Jurnal OCD

Journal Reading
Hari/ tanggal: Kamis/ 28 Desember 2017
RAWAT INAP INTENSIF UNTUK GANGGUAN

OBSESIF-KOMPULSIF YANG BERAT:
MENJELASKAN KARAKTERISTIK PERJALANAN
PENGOBATAN DAN PREDIKSI RESPON
Nama Dokter Muda : Fatma Jauhar P 2282 A

Silma Farraha P 2292 A
Nama Perseptor : dr. Taufik Ashal, Sp.KJ
BAGIAN PSIKIATRI FAKULTAS KEDOKTERAN

UNIVERSITAS ANDALAS
2017
RAWAT INAP INTENSIF UNTUK GANGGUAN OBSESIF-KOMPULSIF
YANG BERAT: MENJELASKAN KARAKTERISTIK PERJALANAN
PENGOBATAN DAN PREDIKSI RESPON
Abstrak
Latar Belakang
Rawat inap intensif (IRT) efektif untuk gangguan obsesif-kompulsif
(OCD) yang berat dan resisten pengobatan. Kami berusaha untuk menjelaskan
karakteristik perkiraan respon dan perjalanan dari IRT
Metode
Data pada saat masuk, bulanan, dan pada saat keluar dikumpulkan dari
individu yang mendapatkan terapi IRT. Kami meneliti hubungan antara
karakteristik awal dan persentase perubahan gejala OCD yang diukur
menggunakan skala Yale-Brown Obsessive-Compulsive (Y-BOCS) dengan
menggunakan regresi linear. Kami membandingkan karakteristik awal responden
IRT (pengurangan ≥ 35% pada Y-BOCS) dibandingkan dengan yang bukan
responden dan pasien yang sembuh dengan yang tidak sembuh (Y-BOCS ≤ 12)
menggunakan uji non parametrik. Untuk mengukur perjalanan tingkat keparahan
OCD dari waktu ke waktu, kami menggunakan model efek-linear campuran
dengan memvariasikan secara acak faktor penghambat dan faktor miring.
Hasil
Kami mengevaluasi 281 individu yang masuk ke dalam program IRT. Skor
awal Y-BOCS yang lebih besar dikaitkan dengan persen pengurangan yang lebih
besar pada skor Y-BOCS (β= -1.49 [95% interval kepercayaan: -2.06 sampai
-0.93]; P<0.001). Responden IRT menunjukkan skor awal Y-BOCS yang lebih
besar secara signifikan dibandingkan dengan yang bukan responden (rata-rata
(SD) 28 ( 5.2) banding 25.6 (5.8) ; P=0.003) dan skor konsumsi alkohol di masa
lalu yang lebih rendah dibandingkan yang bukan responden. (1.4 (1.9) banding
2.1 (2.2); P=0.01). Partisipan yang mencapai kesembuhan menunjukkan skor
faktor kumpulan yang lebih rendah dibandingkan yang tidak (5 (4.6) banding 9.53
(6.3); P=0.03). Gejala OCD menurun dengan cepat selama bulan pertama namun
lebih lambat selama dua bulan berikutnya.
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Kesimpulan
Tingkat keparahan OCD yang lebih tinggi, konsumsi alkohol di masa lalu
yang lebih rendah, dan lebih sedikit gejala faktor kumpulan diprediksi memiliki
respon terhadap IRT yang lebih baik. IRT menghasilkan penurunan cepat gejala
OCD pada fase awal, diikuti oleh penurunan yang lebih lambat pada fase setelah
bulan pertama.
Kata Kunci
Gangguan obsesif-kompulsif; OCD; rawat inap intensif; IRT; prediksi,
penimbunan
LATAR BELAKANG
Gangguan obsesif-kompulsif (OCD) adalah penyakit kejiwaan yang kronis dan
sering melemahkan, yang mempengaruhi antara 2% dan 3% populasi Amerika
Serikat pada suatu waktu dalam hidup mereka (Karno et al., 1988). Pengobatan
lini pertama saat ini untuk OCD mencakup pendekatan farmakologis seperti
inhibitor reuptake selektif serotonin dan perawatan perilaku seperti terapi
pencegahan respons paparan. Bagi sebagian besar pasien OCD, perawatan ini
sendiri atau dalam kombinasi menghasilkan setidaknya pengurangan gejala
moderat (Jenike, 2004). Namun, sebagian pasien OCD hanya mendapatkan sedikit
atau tidak ada bantuan dari terapi ini dan memerlukan pendekatan pengobatan
yang lebih intensif. Bagian kasus yang parah dan tahan-perawatan ini
menyumbang hampir semua rawat inap psikiatri yang terkait dengan OCD di
Amerika Serikat, serta sebagian besar gangguan sosial dan fungsional (Ruscio et
al., 2010). Dengan demikian, penting untuk mengembangkan pendekatan
perawatan khusus yang menargetkan populasi pasien yang unik dan menantang
ini.
Salah satu pendekatan tersebut adalah rawat inap intensif (IRT). IRT
menggunakan strategi pengobatan multidimensional yang menggabungkan
perlakuan perilaku, pengobatan, dan pengobatan intensif yang dilakukan di
lingkungan perumahan. Sampai sekarang, beberapa penelitian tentang IRT telah
menunjukkan penurunan gejala OCD yang signifikan (Bjorgvinsson et al., 2013;
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Bjorgvinsson et al., 2008; Boschen et al., 2008; Drummond, 1993; Stewart et al.,
2005) yang menetap setelah rawatn (Stewart et al., 2009), menunjukkan bahwa
pendekatan ini adalah pilihan pengobatan yang tepat untuk pasien OCD dengan
penyakit berat dan refrakter. Namun, mengingat investasi pribadi dan finansial
yang signifikan yang dibutuhkan untuk IRT, penting untuk mencari prediksi
respon terhadap perawatan ini. Saat ini, tiga penelitian IRT telah menguji prediksi
hasil untuk pasien dengan OCD (Bjorgvinsson et al., 2013; Bjorgvinsson et al.,
2008; Stewart et al., 2006), namun dua di antaranya (Bjorgvinsson et al., 2013;
Bjorgvinsson et al., 2008) menggunakan ukuran sampel sederhana (N <50) dan
satu (Bjorgvinsson et al., 2008) hanya memeriksa remaja dengan OCD. Selain itu,
tidak satu pun studi ini yang meneliti respons pengobatan longitudinal. Studi
semacam itu penting untuk memperbaiki dan mengoptimalkan pendekatan IRT.
Institut Gangguan Obsesif-Kompulsif di Rumah Sakit McLean (OCDI), sebuah
program IRT yang representatif, menggunakan staf multidisiplin untuk
memberikan perawatan perilaku, farmakologis, dan kelompok intensif, baik pada
tingkat perawatan di rumah sakit maupun di tempat layanan kesehatan lain. Rata-
rata, IRT melibatkan sekitar 2-4 jam terapi pencegahan penanggulangan paparan
setiap hari, kemudian pertemuan mingguan dengan psikiater yang khusus dalam
pengelolaan terapi farmakologis OCD, dan manajemen kasus dengan pekerja
sosial untuk menangani dinamika keluarga dan perencanaan setelah perawatan.
Rata-rata lama tinggal di OCDI adalah sekitar 45 hari, dan sekitar 25% pasien
tinggal minimal 3 bulan.
Dalam penelitian terhadap pasien OCDI sebelumnya, kelompok kami menemukan
bahwa tingkat keparahan awal OCD yang lebih rendah, jenis kelamin perempuan,
dan fungsi psikososial dasar yang lebih baik diprediksikan tingkat keparahan
OCD yang lebih rendah saat dipulangkan (Stewart et al., 2006). Namun,
penelitian ini tidak meneliti lintasan keparahan OCD selama data IRT - yang dapat
memandu keputusan mengenai pendekatan pengobatan dan lama tinggal yang
optimal. Oleh karena itu, tujuan dari penelitian ini adalah 1) untuk mereplikasi
dan memperluas temuan sebelumnya dari prediksi awal tanggapan terhadap IRT
dan 2) untuk mengetahui karakteristik perjalanan tingkat keparahan OCD dari
waktu ke waktu selama pengobatan IRT. Berdasarkan penelitian kami
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sebelumnya, kami berhipotesis bahwa pasien wanita dengan OCD yang kurang
parah, fungsi psikososial awal yang lebih baik, dan lebih sedikit gejala depresi
awal akan paling responsif terhadap IRT. Kami juga berhipotesis bahwa pasien
dengan gejala kontaminasi / pencucian primer akan merespons IRT lebih baik
daripada pasien lain, karena menurut pengalaman kami, gejala pencemaran /
pencucian umumnya tampak lebih sesuai dengan pendekatan pencegahan respons
paparan. Selain itu, berdasarkan pengalaman anekdotal, kami berhipotesis bahwa
pasien yang menerima IRT membaik dengan cepat selama bulan pertama, namun
secara bertahap setelahnya.
BAHAN DAN METODE

Populasi Penelitian
Partisipan penelitian yang pertama kali masuk ke OCDI antara bulan Mei
2011 dan Mei 2013 yang memberikan informed consent untuk berpartisipasi
dalam studi database penelitian yang disetujui oleh Dewan Peninjau Kelembagaan
Rumah Sakit McLean. Setiap peserta memenuhi kriteria penerimaan untuk OCDI,
yang mencakup gejala OCD yang parah, secara signifikan membahayakan fungsi
sosial dan pekerjaan, dan bukti adanya resistensi terhadap pengobatan sebelumnya
atau terapi perilaku rawat jalan. Selain itu, setiap pasien memiliki diagnosis OCD
yang dikonfirmasi berdasarkan penilaian masuk oleh ahli terapi perilaku dan
psikiater dengan keahlian di OCD.
Penilaian Klinis
Setiap partisipan penelitian secara perorangan dinilai keadaan klinisnya
saat masuk, yang dijelaskan di bawah, yang diulang setiap bulan dan saat pulang.
Peserta juga menyelesaikan kuesioner demografi penerimaan yang mencakup usia
gejala OCD, riwayat keluarga OCD, status perkawinan, latar belakang pendidikan,
status pekerjaan, dan diagnosis awal dari gangguan stres pascatrauma.
Skala Obsesif Kompulsif Yale-Brown (Y-BOCS), ukuran utama tingkat
keparahan OCD kami, adalah skala 10 item dengan reliabilitas yang ditunjukkan
untuk menilai tingkat keparahan obsesi dan kompulsif, dengan masing-masing
item dinilai pada skala antara 0 ( tingkat keparahan terendah) dan 4 (tingkat
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keparahan tertinggi) (Goodman et al., 1989). Versi self-report dari Y-BOCS telah
terbukti sangat berkorelasi dengan versi yang diberikan oleh dokter (Federici et
al., 2010). Skala tingkat gejala obsesif-kompulsif (OCSRS) adalah ukuran laporan
perorangan yang menilai adanya 67 gejala OCD spesifik dan gejala obsesif
kompulsif yang dikelompokkan menjadi 22 kategori termasuk obsesi (misalnya,
agresi, kontaminasi, penimbunan, seksual, religius, simetri, somatik), dorongan
(misalnya pembersihan, pengecekan, pengulangan, penghitungan, pemesanan,
penimbunan), dan beberapa kategori lain-lain (Wilhelm dan Steketee, 2006).
Individu kemudian dinilai tingkat keparahan masing-masing kategori dalam skala
dari 0 (tidak masalah) sampai 10 (sangat parah). Skor kategori ini terbukti dapat
diandalkan dan valid dengan konsistensi internal yang baik (Yovel et al., 2012).
Quick Inventory of Depressive Symptomatology-Self Report Version (QIDS-
SR16), skala laporan perorangan 16 item yang banyak digunakan dengan
konsistensi internal dan validitas internal yang tinggi (Rush et al., 2003), menilai
tingkat keparahan gejala depresi. Work and Social Adjustment Scale (WSA),
mengukur 5 poin laporan perorangan dari gangguan fungsional, menunjukkan
reliabilitas dan validitas yang baik (Mundt et al., 2002) Setiap item dinilai dalam
skala dari 0 (tidak sama sekali) dengan 8 (sangat parah). 10-item Schwartz
Outcome Scale (SOS-10) adalah ukuran kualitas hidup yang dapat diandalkan dan
konsisten (Blais et al., 1999) dengan skor lebih tinggi yang menunjukkan fungsi
yang lebih baik. Uji Identifikasi Gangguan Penggunaan Alkohol - Pertanyaan
Konsumsi (AUDIT-C), dan Tes Penyalahgunaan Narkoba (DAST-10) adalah
kuesioner skrining singkat dengan reliabilitas dan validitas wajah yang
ditunjukkan (Bush et al., 1998; Skinner, 1982) menilai masa lalu - tahun
penggunaan alkohol dan narkoba, masing-masing, dengan skor yang lebih tinggi
menunjukkan bukti penyalahgunaan atau ketergantungan yang lebih besar.
Dengan menggunakan kriteria yang telah ditetapkan (Farris et al., 2013),
kami mendefinisikan "respon" sebagai penurunan skor Y-BOCS ≥ 35% dari awal
dirawat sampai pulang dan "sembuh" sebagai skor Y-BOCS ≤ 12 pada penilaian
terakhir. Untuk peserta yang pulang sebelum melakukan tindakan pelepasan dapat
diperoleh, kami menggunakan penilaian akhir yang telah selesai dalam
pendekatan observasi terakhir yang diikuti (LOCF).
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Analisis Statistik
Prediksi Univariat dari Respon dan Kesembuhan
Kami memeriksa hubungan antara karakteristik awal dan persentase perubahan
total skor Y-BOCS antara penilaian pada saat masuk dan pulang dengan
menggunakan regresi linier. Selain itu, kami membandingkan karakteristik dasar
responden dan non-responden, dan pasien yang mencapai kesembuhan dan yang
tidak, menggunakan uji Wilcoxon rank-sum untuk data kontinu dan uji pasti
Fisher untuk data kategoris. Semua karakteristik dasar minat dipilih sebelum
melakukan analisis dan semua hasil (keduanya signifikan dan tidak signifikan)
dilaporkan dalam manuskrip ini.
Kami juga menilai tingkat dimensi gejala OCD, diperoleh saat masuk, sebagai
prediktor respons. Dengan menggunakan solusi empat faktor yang dapat diterima
secara luas untuk gejala OCD, yang meliputi: 1) pikiran terlarang (agresif,
seksual, dan obsesi religius) dan pemeriksaan kompulsif; 2) obsesi simetri dan
dorongan pemesanan; 3) obsesi kontaminasi dan kompulsif pencucian; dan 4)
penimbunan obsesi dan kompulsif, (Bloch et al., 2008) kami menghitung nilai
faktor untuk masing-masing dari empat faktor domain dengan menambahkan
peringkat kategori gejala dalam setiap faktor. Hanya pengamatan dengan nilai
faktor yang lebih besar dari nol yang dipertimbangkan dalam analisis. Untuk
setiap dimensi faktor, korelasi antara skor faktor dan persentase perubahan Y-
BOCS dihitung dan skor faktor untuk responden versus non-responden dan untuk
mereka yang mencapai tingkat kesembuhan dibandingkan dengan yang tidak.
Pemodelan Perjalanan Tingkat Keparahan OCD dari Waktu ke Waktu

Untuk memodelkan jalannya keparahan OCD dari waktu ke waktu, kami
mempertimbangkan model intercept and slope secara acak (RIS) untuk lintasan
total Y-BOCS dari waktu ke waktu disesuaikan dengan usia dan jenis kelamin, di
mana modelnya adalah sebagai berikut:
dimana b0i adalah faktor penghambat acak, b1i adalah kemiringan acak, dan ξij
adalah kesalahan dalam subjek acak, untuk subjek diberi nomor i = 1, ..., 287
dengan penilaian j = 1, ..., ni, di mana jumlah maksimum penilaian ini bervariasi
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berdasarkan pasien dan dapat mengambil nilai dari 1 sampai 4. Efek tetap kuadrat
kemudian ditambahkan ke model di atas, diikuti oleh efek kubik. Efek acak
kuadrat dan kubik tidak dianggap karena terlalu berlebih, karena subjek dalam
dataset memiliki maksimum empat penilaian, dan mayoritas memiliki dua
penilaian atau kurang (lihat hasilnya di bawah). Analisis sekunder dilakukan
dengan menggunakan transformasi waktu, khususnya log (waktu + 1) dan √waktu,
untuk menilai kecocokan model.
Akhirnya, kami melakukan analisis eksploratif dengan menggunakan
metode non-parametrik untuk lebih memahami hubungan antara tingkat
keparahan dan waktu OCD. Pertama, kami menggunakan smoothing scatterplot
berbobot lokal (LOESS) agar sesuai dengan kehalusan kurva yang bervariasi
melalui scatterplot skor Y-BOCS dibandingkan dengan waktu sejak masuk.
Selanjutnya, kami menggunakan pemulusan terakhir (garis linear untuk data
longitudinal) untuk memodelkan lintasan keparahan OCD, dengan
mempertimbangkan variabilitas dalam subjek dari penilaian berulang. Model yang
terakhir dipasang mengambil simpulan pada setiap 5, 10, 20, dan 30 hari.
Terakhir, untuk menyelidiki kemungkinan hubungan antara durasi rawatan dan
lintasan keparahan OCD, kami membandingkan plot profil peserta yang penilaian
terakhirnya paling sedikit 30 hari setelah masuk. Kami melakukan hal yang sama
untuk peserta yang penilaian terakhirnya paling sedikit 45, 60, dan 75 hari setelah
pendaftaran.
HASIL
Karakteristik Dasar
Kami menilai 287 pasien yang dirawat untuk pertama kalinya di OCDI antara Mei
2011 dan Mei 2013. Enam dari pasien ini dikeluarkan dari analisis karena
memiliki nilai Y-BOCS masuk di bawah kriteria kesehatan (≤ 12). Karakteristik
dasar sampel disajikan pada Tabel 1. Lebih dari setengah (56%) peserta telah
menerima pengobatan sebelumnya dengan kombinasi terapi perilaku dan
pengobatan, dan tambahan 32% dilaporkan menerima terapi perilaku (14%) atau
obat-obatan (18 %) sebelum masuk. Meskipun demikian, peserta biasanya
melaporkan gejala yang parah dan melemahkan saat masuk, seperti yang
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ditunjukkan oleh nilai Y-BOCS awal (rata-rata (SD) 26,7 (5,6)) dan nilai WSA
(rata-rata 27,3 (7,7)), yang menyiratkan tingkat refraksi pengobatan yang tinggi.
Dari 281 peserta yang dianalisis, hanya 58 (21%) memiliki data masuk, 101
(36%) memiliki data penerimaan dengan satu penilaian tindak lanjut, 87 (31%)
memiliki dua penilaian tindak lanjut, dan 35 (12%) memiliki tiga penilaian tindak
lanjut. Penilaian pasien yang pulang diperoleh pada 202 dari 281 peserta awal
(72%).
Respon Prediksi dan Kesembuhan

Dari berbagai karakteristik dasar yang dianalisis (Tabel 2), hanya skor Y-BOCS
awal yang secara signifikan memprediksi persentase perubahan pada Y-BOCS
pada debit (β = -1,49 ([95% confidence interval: -2.06, -0.93]; P <.001 ; effect size
= -2.79 (slope / MSE)), namun beberapa perhatian dilakukan dalam menafsirkan
asosiasi ini karena tentu saja ada hubungan part-whole (negatif) antara baseline
dan change. Pada karakteristik yang sama, responden menunjukkan skor Y-BOCS
baseline yang jauh lebih besar (P = 0,003; ukuran efek = 0,43 ((perbedaan mean
sampel) / (pooled SD)) dan nilai AUDIT-C yang lebih rendah (P = .01; ukuran
efek = 0,34 ((perbedaan mean sampel) / pooled SD)), namun tidak berbeda secara
signifikan pada karakteristik lainnya (Tabel 3). Tidak ada perbedaan signifikan
antara peserta yang mencapai kesehatan dan peserta yang gagal mencapai
kesehatan (Tabel 4).
Tidak satu pun dari faktor skor empat dimensi tersebut dikaitkan secara signifikan
dengan perubahan persentase skor Y-BOCS (Tabel 5), atau tidak ada faktor skor
yang berbeda secara signifikan antara responden dan non-penanggap. Namun,
peserta yang mencapai tingkat kesehatan memiliki skor faktor penimbunan yang
jauh lebih rendah daripada peserta yang tidak mencapai kesehatan (P= .03; ukuran
efek = 0,94 ((perbedaan mean sampel) / pooled SD)) (Tabel 5).
Waktu Perjalanan Tingkat Keparahan Obsesif Kompulsif

Tes yang sesuai harapan menunjukkan bahwa model waktu terbaik adalah RIS
dengan efek tetap kubik, keduanya saat menggunakan waktu yang berubah atau
tidak dapat diubah. Plot profil dari 100 peserta yang dipilih secara acak
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menunjukkan perjalanan serupa untuk tiga model utama yang disesuaikan
(Gambar 1) selama 60 hari pertama, dengan model efek tetap kuadrat yang
berbeda dari yang lain sesudahnya. Mengingat kemungkinan bahwa perjalanan
setelah 60 hari sangat dipengaruhi oleh subset kecil pasien yang tinggal selama
lebih dari 60 hari, kami mengulangi analisis yang sama dengan menggunakan data
yang dibatasi hingga 60 hari atau kurang, namun kurva tetap tidak berubah dari 90
hari. Oleh karena itu, analisis eksploratori lebih lanjut dengan menggunakan
metode non parametrik dilakukan dengan menggunakan data hingga 90 hari.
Analisis menggunakan LOESS menunjukkan bahwa perbaikan terjadi dengan
cepat selama 30 hari pertama namun secara bertahap (Gambar 2). Analisis
menggunakan penalized smoothing dengan t pada 20 dan 30 hari menghasilkan
kurva serupa (Gambar 3a dan 3b). Penalized smoothing dengan menggunakan
simpulan 5 dan 10 hari menyarankan kemungkinan adanya lonjakan gejala OCD
pada hari 20-40 dan lonjakan singkat yang lebih kecil di sekitar tanda 60 hari
(Gambar 3c dan 3d). Akhirnya, ketika semua waktu kursus analisis diulang tanpa
penyesuaian untuk usia dan jenis kelamin, mereka menghasilkan hasil yang sama.
DISKUSI
Hasil Prediksi
Kami menemukan bahwa tingkat keparahan awal OCD yang lebih rendah
memprediksi penurunan gejala OCD yang lebih besar setelah IRT. Karena
beberapa komponen dari asosiasi ini adalah karena "regresi terhadap mean",
implikasi klinis dari hasil ini harus ditafsirkan dengan hati-hati. Demikian pula,
kami menemukan bahwa responden IRT menunjukkan tingkat keparahan OCD
awal yang lebih besar daripada non-penanggap. Temuan ini sesuai dengan
Bjorgvinsson dkk. (Bjorgvinsson et al., 2008) yang melaporkan hubungan yang
sama antara tingkat keparahan awal OCD yang lebih besar dan respons terhadap
IRT pada remaja dengan OCD, namun berbeda dengan penelitian selanjutnya oleh
kelompok yang sama pada orang dewasa yang menerima IRT (Bjorgvinsson et al.,
2013) dan dengan penelitian kami sebelumnya (Stewart et al., 2006). Studi yang
meneliti pasien rawat jalan dengan OCD secara konsisten menunjukkan hubungan
antara tingkat keparahan OCD yang rendah dan respon terhadap terapi perilaku
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kognitif (CBT) (Keeley dkk.,2008; Knopp dkk, 2013) dan obat-obatan (Denys et
al., 2003; Shetti et al., 2005; Stein et al.,2001; Storch et al., 2006; Tukel et al.,
2006). Dengan demikian, temuan kami saat ini menunjukkan bahwa IRT rawat
inap mungkin sangat sesuai untuk OCD berat walaupun diperlukan penyelidikan
yang lebih ketat.
Kami juga menemukan bahwa responden memiliki skor dasar penggunaan
alkohol tahun lalu yang jauh di bawah standar AUDIT-C daripada non-responden.
Namun, nilai rata-rata pada kelompok ini di bawah 3 (ambang batas yang dapat
diterima secara umum untuk kemungkinan penyalahgunaan atau ketergantungan
(Bush et al, 1998)), menyarankan sedikit bukti tentang permasalahan minum
dalam sampel kita secara keseluruhan.
Meskipun kami tidak menemukan hubungan yang signifikan antara dimensi gejala
dan perubahan persentase pada Y-BOCS atau tanggapan pengobatan setelah IRT,
peserta yang mendapat gejala penimbunan lebih sedikit mencapai kesehatan
(Tabel 5). Sesuai dengan temuan ini, penelitian sebelumnya terhadap penimbun
kompulsif telah menunjukkan hasil pengobatan yang lebih buruk pada berbagai
pendekatan pengobatan termasuk CBT (Abramowitz et al., 2003b; Rufer et
al.,2006), terapi perilaku (Mataix-Cols et al., 2002), farmakologis (Mataix-Cols et
al.,1999), perawatan multimodal intensif dalam konteks program rawat inap
parsial (Saxena et al., 2002), dan operasi limbik (Gentil et al., 2014). Secara
keseluruhan, temuan ini mendukung pandangan baru-baru ini tentang penimbunan
kompulsif sebagai gangguan berbeda dari OCD yang mungkin memerlukan
pendekatan pengobatan yang berbeda (Pertusa et al., 2010).
Berbeda dengan penelitian sebelumnya, kami tidak menemukan hubungan antara
jenis kelamin atau tingkat fungsi psikososial dan respons IRT. Dengan demikian,
penting untuk memperluas penelitian ini untuk memasukkan populasi IRT ke luar
program kami dalam upaya untuk lebih memahami temuan-temuan yang
bertentangan ini.
Karakteristik Fokus Pengobatan
10
Kami menemukan peningkatan cepat dalam gejala OCD selama 20-30 hari
pertama pengobatan IRT. Temuan ini konsisten dengan penelitian sebelumnya
yang menunjukkan pengurangan OCD secara cepat gejala di antara pasien yang
menerima perawatan pencegahan paparan rawat jalan harian intensif selama
periode 3-4 minggu (Abramowitz et al., 2003a; Foa et al., 2005; Storch et
al.,2008) - sebuah pendekatan yang sangat mirip dengan komponen perilaku IRT.
Kami juga menemukan penurunan gejala OCD yang lebih bertahap selama 2
bulan berikutnya dari IRT, sesuai dengan hipotesis awal dan pengalaman klinis
kami.
Tanpa diduga, kami menemukan kemungkinan adanya gejala OCD dari hari ke 20
dan sekitar hari ke 60 pengobatan. Meskipun lonjakan ini mungkin mewakili
artefak statistik, ada pengalaman klinis anekdotal untuk mendukung lonjakan
gejala pertama. Beberapa mekanisme dapat berkontribusi pada apa yang disebut
"fase rebound" ini. Pertama, karena pasien berubah lingkungan untuk memasuki
IRT, yang mungkin berarti meninggalkan lingkungan rumah yang jauh lebih
memicu, ada kemungkinan beberapa orang mengalami "periode bulan madu"
selama beberapa minggu pertama pengobatan. Saat pemicu baru terbentuk di
lingkungan IRT, pasien ini mungkin mengalami gejala yang memburuk. Kedua,
karena komponen psikoedukognitif pengobatan IRT yang signifikan, ada
kemungkinan pasien menemukan obsesi dan / atau dorongan yang sebelumnya
tidak dikenali selama pengobatan karena mereka menjadi lebih mahir dalam
mengenali gejala OCD. Ketiga, mengingat kebijakan hirarki dari perawatan ERP
yang dimulai dengan eksposur yang lebih mudah dan secara bertahap berkembang
menjadi yang lebih menantang, ada kemungkinan pasien tidak terbiasa dengan
eksposur yang lebih sulit seperti yang mereka lakukan sebelumnya dalam
perawatan. Namun, karena pasien tidak menerima timeline ERP standar, yang
memindahkan pasien ke hierarki hanya antara hari ke 20-40 dan setelah hari ke
60, penjelasan ini kemungkinannya kecil.
Implikasi Terhadap Pengobatan
11
Beberapa temuan dari penelitian ini dapat menginformasikan pengiriman IRT ke
depan. Pertama, kami menemukan bahwa pasien dengan OCD paling parah
menghasilkan penurunan gejala terbanyak setelah IRT. Temuan ini sangat kontras
dengan penelitian yang melibatkan modalitas pengobatan rawat jalan,
menunjukkan bahwa IRT mungkin mewakili pengobatan pilihan untuk pasien
dengan refrakter yang parah. Kedua, sementara dimensi gejala OCD tidak
mempengaruhi keseluruhan pengurangan gejala atau respons pengobatan, pasien
dengan gejala penimbunan lebih sedikit mencapai kesehatan setelah IRT. Ketiga,
penggunaan alkohol di masa lalu yang lebih baik dapat memprediksi respons yang
lebih buruk terhadap IRT. Namun, temuan ini tampaknya tidak terkait dengan
masalah minum. Keempat, IRT tampaknya menghasilkan pengurangan gejala
OCD yang cepat selama bulan pertama pengobatan, berbeda dengan perawatan
perilaku rawat jalan dan farmakologis untuk OCD, yang biasanya memerlukan 8-
12 minggu dan sering menghasilkan pengurangan gejala sederhana (Jenike,2004).
Dengan demikian, IRT dapat diindikasikan secara khusus untuk pasien dengan
OCD berat yang memerlukan intervensi akut untuk segera menghilangkan gejala
ketidakmampuan. Kelima, data kami menunjukkan bahwa sementara pasien
menunjukkan peningkatan pesat selama bulan pertama IRT, perbaikan ini
melambat di bulan-bulan berikutnya dan mungkin terganggu oleh periode
memburuk. Temuan ini menimbulkan pertanyaan apakah kemiringan perbaikan
setelah satu bulan cukup untuk membenarkan biaya IRT melampaui batas 30 hari.
Penelitian selanjutnya juga harus menilai apakah intervensi tambahan, yang
diperkenalkan di awal perawatan, dapat mempertahankan lintasan yang lebih
curam dari pengurangan gejala di luar bulan pertama. Salah satu kemungkinan
yang menarik adalah penggunaan d- sikloserin, yang telah menunjukkan bukti
awal sebagai peningkat farmakologis dari terapi pencegahan respon pencegahan
untuk OCD (Kushner et al., 2007; Wilhelm et al., 2008)- terutama melalui proses
habituasi yang cepat (Chasson et al., 2010).
Keterbatasan
12
Kami mengakui beberapa keterbatasan dalam penelitian ini. Pertama, kami tidak
memasukkan wawancara klinis terstruktur saat masuk, dan karenanya tidak
termasuk diagnosis komorbid selain depresi, gangguan stres pasca trauma, dan
gangguan penggunaan obat dalam analisis prediktor hasil kami. Mengingat bahwa
gangguan mental komorbid mempengaruhi hasil pada terapi perilaku kognitif
(Keeley et al., 2008) dan pengobatan (Baer et al., 1992; Cavedini et al., 1997;
Ravizza et al., 1995) di OCD, studi masa depan Prediktor pengobatan IRT harus
menilai kondisi komorbid ini. Kedua, kita tidak dapat menilai respons "plasebo"
potensial (yaitu, efek harapan yang tidak spesifik) dalam sampel kita tanpa
dimasukkan kelompok perlakuan kontrol. Kelompok kontrol juga akan
mempertahankan terhadap kekhawatiran "regresi terhadap rata-rata" yang
disebutkan sebelumnya. Ketiga, sementara sampel awal kami adalah 281 peserta,
jumlah peserta yang memberikan data tindak lanjut terus menurun selama
pengobatan, menghasilkan sampel yang lebih kecil dengan 2 dan 3 penilaian
setelah masuk. Selanjutnya,Data yang hilang saat debit berpotensi untuk bias
mempengaruhi perlakuan terhadap kesehatan dan respons. Dengan demikian,
penelitian IRT di masa mendatang yang memeriksa data klinis longitudinal dalam
sampel yang lebih besar akan diperlukan. Model longitudinal yang
dipresentasikan dalam penelitian awal saat ini dapat membantu memandu
penyelidikan di masa depan. Keempat, kami tidak benar untuk beberapa
perbandingan statistik sehingga temuan kami bersifat eksploratif dan harus
ditafsirkan dengan hati-hati. Kelima, kami tidak mengukur variabel lain yang
berpotensi secara klinis penting yang telah ditunjukkan sebelumnya sebagai
prediktor hasil yang signifikan (seperti gejala komorbid, tingkat wawasan,
harapan pengobatan, dan jumlah pengobatan dan uji coba CBT terakhir) dan oleh
karena itu tidak dapat memeriksa variabel-variabel ini sebagai prediktor hasil.
Penelitian selanjutnya harus diteliti prediktor potensial ini sekaligus
mengkonfirmasi hasil signifikan dari penelitian ini.
Kesimpulan
13
Pada pasien dengan OCD tahan-pengobatan yang parah, perawatan rawat inap
(IRT) dikaitkan dengan pengurangan gejala OCD yang cepat selama 30 hari
pertama pengobatan dan penurunan gejala yang lebih bertahap selama 60 hari
yang tersisa. Individu dengan tingkat keparahan awal OCD yang lebih rendah dan
penggunaan alkohol yang kurang sebelumnya merespons IRT dengan lebih baik
sedangkan mereka yang memiliki gejala penimbunan lebih sedikit lebih mungkin
mencapai kesehatan. Penyelidikan di masa depan mengenai isu-isu ini dapat
membantu menjelaskan panjang tinggal yang optimal dalam setting IRT, serta
kemungkinan intervensi untuk meningkatkan respons IRT dan mencapai
kesehatan secara keseluruhan.
14
NIH Public Access
Author Manuscript
J Psychiatr Res. Author manuscript; available in PMC 2015 September 01.
Published in final edited form as:
NIH-PA Author Manuscript
J Psychiatr Res. 2014 September ; 56: 98–105. doi:10.1016/j.jpsychires.2014.05.008.
INTENSIVE RESIDENTIAL TREATMENT FOR SEVERE

OBSESSIVE-COMPULSIVE DISORDER: CHARACTERIZING
TREATMENT COURSE AND PREDICTORS OF RESPONSE
Brian P. Brennan, MD, MMSc1,2,6, Catherine Lee, PhD3, Jason A. Elias, PhD2,6, Jesse M.
Crosby, PhD2, Brittany M. Mathes, BA2, Marie-Christine Andre, MA2,5, Christina M. Gironda,
BA2, Harrison G. Pope Jr., MD1,6, Michael A. Jenike, MD2,6, Garrett M. Fitzmaurice, ScD3,4,
and James I. Hudson, MD, ScD1,6
1
Biological Psychiatry Laboratory, McLean Hospital, Belmont, MA 2Obsessive-
Compulsive Disorder Institute, McLean Hospital, Belmont, MA 3Department of

Biostatistics, Harvard School of Public Health, Boston, MA 4Laboratory for
Psychiatric Biostatistics, McLean Hospital, Belmont, MA 5Psychology

Department, Suffolk University, Boston, MA
6
Department of Psychiatry, Harvard Medical School, Boston, MA
Abstract
Background—Intensive residential treatment (IRT) is effective for severe, treatment-resistant
obsessive-compulsive disorder (OCD). We sought to characterize predictors and course of response to
IRT.
Methods—Admission, monthly, and discharge data were collected on individuals receiving IRT. We
examined the association between baseline characteristics and percent change in OCD symptoms as
measured by the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) using linear regression. We
compared baseline characteristics of IRT responders (≥35% reduction in Y-BOCS) versus non-responders,
and of patients who did versus those who did not achieve wellness (Y-
© 2014 Elsevier Ltd. All rights reserved.

Address correspondence to: Dr. Brennan; address: McLean Hospital, 115 Mill Street, Belmont, MA 02478; telephone: 617-855-2911; fax:
617-855-3585; bbrennan@partners.org.
CONTRIBUTORS
BPB and JIH designed the study. CL and GMF undertook the statistical analyses. JAE, JMC, BMM, MCA, CMG, and MAJ wrote the
protocol for data collection and oversaw all data management. HGP contributed to data analysis and manuscript preparation. BPB wrote the
first draft of the manuscript. All authors contributed to and have approved the final manuscript.
CONFLICT OF INTEREST
Dr. Brennan has received research grant support from Eli Lilly and Transcept Pharmaceuticals. Dr. Hudson has received consulting fees
from Genentech, HealthCore, Roche, and Shire; and has received research grant support from Genentech, Otsuka, and Shire. None of the
other authors report any potential conflicts of interest.
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15
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16
Brennan et al. Page 2
BOCS ≤12) using non-parametric tests. To examine the course of OCD severity over time, we used
linear mixed-effects models with randomly varying intercepts and slopes.
Results—We evaluated 281 individuals admitted to an IRT program. Greater baseline Y-BOCS scores
were associated with a significantly greater percent reduction in Y-BOCS scores (β = −1.49 ([95%
confidence interval: −2.06 to −0.93]; P<.001). IRT responders showed significantly greater baseline Y-
BOCS scores than non-responders (mean (SD) 28 (5.2) vs. 25.6 (5.8); P=.003) and lower past-year alcohol
use scores than non-responders (1.4 (1.9) vs. 2.1 (2.2); P=.01).
Participants who achieved wellness displayed lower hoarding factor scores than those who did not (5 (4.6)
vs. 9.53 (6.3); P=.03). OCD symptoms declined rapidly over the first month but more slowly over the
remaining two months.
Conclusions—Higher baseline OCD severity, lower past-year alcohol use, and fewer hoarding
symptoms predicted better response to IRT. IRT yielded an initial rapid reduction in OCD symptoms,
followed by a slower decline after the first month.
Keywords
obsessive-compulsive disorder; OCD; intensive residential treatment; IRT; predictors; hoarding
BACKGROUND
Obsessive-compulsive disorder (OCD) is a chronic and often debilitating psychiatric illness, affecting between
2% and 3% of the United States population at some time in their lives (Karno et al., 1988). The current first-
line treatments for OCD include both pharmacologic approaches such as the selective serotonin reuptake
inhibitors and behavioral treatment such as exposure response prevention therapy. For most OCD patients,
these treatments alone or in combination produce at least moderate symptom reduction (Jenike, 2004).
However, a subset of OCD patients derives little or no relief from these therapies and requires more intensive
treatment approaches. This severe, treatment-refractory subset of cases accounts for nearly all of the OCD-
related psychiatric hospitalizations in the United States, as well as the vast majority of social and functional
impairment (Ruscio et al., 2010). Thus, it is important to develop specialized treatment approaches targeting
this unique and challenging patient population.
One such approach is intensive residential treatment (IRT). IRT utilizes a multidimensional treatment strategy
incorporating intensive behavioral, medication, and milieu treatment administered in a residential setting. To
date, several studies of IRT have demonstrated a significant reduction in OCD symptoms (Bjorgvinsson et al.,
2013; Bjorgvinsson et al., 2008; Boschen et al., 2008; Drummond, 1993; Stewart et al., 2005) that persists post-
discharge (Stewart et al., 2009), suggesting that this approach is a viable treatment option for OCD patients with
severe and refractory illness. However, given the significant personal and financial investment required for IRT,
it is important to seek predictors of response to this treatment. Currently, three studies of IRT have examined
outcome predictors for patients with OCD (Bjorgvinsson et al., 2013; Bjorgvinsson et al., 2008; Stewart et al.,
2006), but two of these (Bjorgvinsson et al., 2013; Bjorgvinsson et al., 2008) employed modest sample sizes (N
< 50) and one (Bjorgvinsson et al., 2008) examined only adolescents with OCD.

Moreover, none of these studies examined the longitudinal course of treatment response. Such studies are
critical for refining and optimizing the IRT approach.
The Obsessive-Compulsive Disorder Institute at McLean Hospital (OCDI), a representative IRT program,
utilizes a multidisciplinary staff to provide intensive behavioral, pharmacologic, and group treatment at both
residential and partial hospital levels of care. On average, IRT involves about 2–4 hours of daily exposure
response prevention therapy, weekly meetings with psychiatrists who specialize in the pharmacologic
management of OCD, and case management with a social worker to address family dynamics and aftercare
planning. The average length of stay in the OCDI is approximately 45 days, and about 25% of patients stay at
least 3 months.
In a previous study of OCDI patients, our group found that lower initial OCD severity, female sex, and better
baseline psychosocial functioning predicted less severe OCD at discharge (Stewart et al., 2006). However, this
study did not examine the trajectory of OCD severity over the course of IRT – data that could guide decisions
on optimal treatment approaches and length of stay. Therefore, the aims of this study were 1) to replicate and
expand upon our previous findings of baseline predictors of response to IRT and 2) to characterize the course
of OCD severity over time during IRT treatment. Based on our previous study, we hypothesized that female
patients with less severe OCD, better baseline psychosocial functioning, and fewer baseline depressive
symptoms would respond best to IRT. We also hypothesized that patients with primary contamination/washing
symptoms would respond better to IRT than other patients, since in our experience, contamination/ washing
symptoms generally appear more amenable to the exposure response prevention approach. Additionally, based
on anecdotal experience, we hypothesized that patients receiving IRT improve rapidly over the first month, but
more gradually thereafter.
MATERIALS AND METHODS

Study Population
Study participants were first time-admissions to the OCDI between May 2011 and May 2013 who gave written
informed consent to participate in a research database study approved by the McLean Hospital Institutional
Review Board. Each participant met admission criteria to the OCDI, which included having severe OCD
symptoms, significantly compromised social and occupational functioning, and evidence of treatment
resistance to previous medication trials or outpatient behavioral therapies. In addition, each patient had a
confirmed diagnosis of OCD based on admission assessments by both a behavioral therapist and a psychiatrist
with expertise in OCD.
Clinical Assessments
Each study participant was administered a battery of self-report clinical rating scales upon admission, detailed
below, which were repeated monthly and at discharge. Participants also completed an admission demographic
questionnaire covering age of onset of OCD symptoms, family history of OCD, marital status, educational
background, employment status, and prior diagnosis of post-traumatic stress disorder.

The Yale-Brown Obsessive Compulsive Scale (Y-BOCS), our primary measure of OCD severity, is a 10-item
scale with demonstrated reliability used to assess the severity of both obsessions and compulsions, with each
item rated on a scale between 0 (lowest severity) and 4 (highest severity) (Goodman et al., 1989). The self-
report version of the Y-BOCS has been shown to correlate highly with the clinician-administered version
(Federici et al., 2010). The Obsessive Compulsive Symptoms Rating Scale (OCSRS) is a self-report measure
that assesses the presence of 67 specific OCD and obsessive-compulsive spectrum symptoms grouped into 22
categories including obsessions (e.g., aggression, contamination, sexual, hoarding, religious, symmetry,
somatic), compulsions (e.g., cleaning, checking, repeating, counting, ordering, hoarding), and several
miscellaneous categories (Wilhelm and Steketee, 2006). Individuals then rate the severity of each category on a
scale from 0 (no problem) to 10 (very severe). These category scores have been shown to be reliable and valid
with good internal consistency (Yovel et al., 2012). The Quick Inventory of Depressive Symptomatology – Self
Report Version (QIDS-SR16), a widely used 16-item self-report scale with demonstrated high internal
consistency and validity (Rush et al., 2003), assesses the severity of depressive symptoms. The Work and Social
Adjustment Scale (WSA), a 5- item self-report measure of functional impairment, demonstrates good reliability
and validity (Mundt et al., 2002) Each item is rated on a scale from 0 (not at all) to 8 (very severe). The 10-item
Schwartz Outcome Scale (SOS-10) is a reliable and internally consistent (Blais et al., 1999) quality-of-life
measure with higher scores indicating better functioning. The Alcohol Use Disorders Identification Test –
Consumption Questions (AUDIT-C), and the Drug Abuse Screening Test (DAST-10) are brief screening
questionnaires with demonstrated reliability and face validity (Bush et al., 1998; Skinner, 1982) assessing past-
year alcohol and drug use, respectively, with higher scores indicating greater evidence of abuse or dependence.
Using established criteria (Farris et al., 2013), we defined “response” as a decrease in Y- BOCS score of ≥ 35%
from admission to discharge and “wellness” as a Y-BOCS score of ≤ 12 at last assessment. For participants
discharged before discharge measures could be obtained, we used the final completed assessment in a last-
observation-carried-forward (LOCF) approach.
Statistical Analyses
Univariate Predictors of Response and Wellness—We examined the association between baseline
characteristics and percent change in total Y-BOCS scores between admission and discharge assessments using
linear regression. Additionally, we compared the baseline characteristics of responders versus non-responders,
and of patients who did and did not achieve wellness, using the Wilcoxon rank-sum test for continuous data and
Fisher’s exact test for categorical data. All baseline characteristics of interest were chosen prior to conducting
any analyses and all results (both significant and non-significant) are reported in this manuscript.
We also assessed OCD symptom dimension ratings, obtained at admission, as predictors of response. Using
the widely accepted four-factor solution for OCD symptoms, which includes: 1) forbidden thoughts
(aggressive, sexual, and religious obsessions) and checking

compulsions; 2) symmetry obsessions and ordering compulsions; 3) contamination obsessions and washing
compulsions; and 4) hoarding obsessions and compulsions, (Bloch et al., 2008) we calculated factor scores for
each of the four factor domains by adding the symptom category ratings within each factor. Only observations
with factor scores greater than zero were considered in the analysis. For each factor dimension, the correlation
between factor scores and percent change in Y-BOCS was calculated and the factor scores for responders versus
non-responders and for those who achieved wellness versus those who did not were compared.
Modeling the Course of OCD Severity Over Time—To model the course of OCD severity over time, we
considered a random intercept and slope (RIS) model for the trajectory of total Y-BOCS over time adjusted for
age and sex, where the model is given by:
where b0i is the random intercept, b1i is the random slope, and ξij is the random within- subject error, for
subjects numbered i = 1, …, 287 with assessments j = 1, …, ni, where the maximum number of assessments
ni varies by patient and can take on values from 1 to 4. Quadratic fixed effects were then added to the above
models, followed by cubic effects.
Quadratic and cubic random effects were not considered due to over-fitting, since subjects in the dataset had a
maximum of four assessments, and a majority had two assessments or fewer (see results below). Secondary
analyses were conducted using transformations of time, specifically log(time + 1) and √time, to assess model
fit.
Finally, we performed exploratory analyses using non-parametric methods to better understand the relationship
between OCD severity and time. First, we used locally weighted scatterplot smoothing (LOESS) to fit curves of
varying smoothness through the scatterplot of Y-BOCS scores versus time since admission. Next, we used
penalized smoothing (linear splines for longitudinal data) to model the trajectory of OCD severity, taking into
consideration the within-subject variability of the repeated assessments. The latter models were fitted taking
knots at every 5, 10, 20, and 30 days. Last, to investigate the possible relationship between length of stay and
OCD severity trajectory, we compared the profile plots of participants whose last assessments were at least 30
days post-admission. We did the same for participants whose last assessments were at least 45, 60, and 75 days
post- admission.
RESULTS
Baseline Characteristics
We assessed 287 patients admitted for the first time to the OCDI between May 2011 and May 2013. Six of
these patients were removed from the analysis for having admission Y- BOCS scores below the wellness
criterion (≤ 12). Baseline characteristics of the sample are presented in Table 1. Over half (56%) of participants
had received prior treatment with a combination of behavioral therapy and medications, and an additional 32%
reported receiving either behavioral therapy (14%) or medications (18%) prior to admission. Despite

this, participants typically reported severe and debilitating symptoms at admission, as indicated by initial Y-
BOCS scores (mean (SD) 26.7 (5.6)) and WSA scores (mean 27.3 (7.7)), implying a high degree of
treatment-refractoriness.
Of the initial 281 participants analyzed, 58 (21%) had admission data only, 101 (36%) had admission data
with one follow-up assessment, 87 (31%) had two follow-up assessments, and 35 (12%) had three follow-up
assessments. Discharge measures were obtained on 202 out of the initial 281 participants (72%).
Predictors of Response and Wellness

Of the various baseline characteristics analyzed (Table 2), only baseline Y-BOCS scores significantly predicted
percent change in Y-BOCS at discharge (β = −1.49 ([95% confidence interval: −2.06, −0.93]; P <.001; effect
size = −2.79 (slope/MSE)); however, some caution must be exercised in interpreting this association because
there is necessarily a part-whole (negative) relationship between baseline and change. On the same
characteristics, responders showed significantly greater baseline Y-BOCS scores (P = .003; effect size =
0.43 ((difference of sample means)/(pooled SD)) and lower AUDIT-C scores (P = .01; effect size = 0.34
((difference of sample means)/pooled SD)), but did not differ significantly on any other characteristics (Table
3). There were no significant differences between participants who achieved wellness and participants who
failed to achieve wellness (Table 4).
None of the four dimensional factor scores was significantly associated with percent change in Y-BOCS scores
(Table 5), nor did any factor scores differ significantly between responders and non-responders. However,
participants who achieved wellness had significantly lower hoarding factor scores than participants who did not
achieve wellness (P
= .03; effect size = 0.94 ((difference of sample means)/pooled SD)) (Table 5).
Time Course of OCD Severity

Goodness-of-fit tests suggested that the best-fitting model of time course was the RIS with cubic fixed effects,
both when using transformed or untransformed time. Profile plots of 100 randomly selected participants showed
similar trajectories for the three primary adjusted models (Figure 1) over the first 60 days, with the quadratic
fixed effects model diverging from the others thereafter. Given the possibility that the trajectory after 60 days
was strongly influenced by the small subset of patients staying for more than 60 days, we repeated the same
analyses using data restricted to 60 days or less, but the curves remained virtually unchanged from the 90-day
model. Therefore, further exploratory analyses using non- parametric methods were performed using data up to
90 days. Analyses using LOESS suggested that improvement occurred rapidly during the first 30 days but more
gradually thereafter (Figure 2). Analyses using penalized smoothing with knots at 20 and 30 days yielded
similar curves (Figure 3a and 3b). Penalized smoothing using knots of 5 and 10 days suggested a possible
temporary spike in OCD symptoms from days 20–40 and another smaller brief spike around the 60-day mark
(Figure 3c and 3d). Finally, when all of the time course analyses were repeated without adjustment for age and
sex, they yielded identical results.

DISCUSSION
Outcome Predictors
We found that greater baseline OCD severity predicted greater percent reduction in OCD symptoms following
IRT. Because some component of this association is due to “regression to the mean”, the clinical implications
of this result must be interpreted with some care.
Similarly, we found that IRT responders exhibited greater baseline OCD severity than non- responders. These
findings accord with Bjorgvinsson et al. (Bjorgvinsson et al., 2008) who reported a similar association between
greater baseline OCD severity and response to IRT in adolescents with OCD, but contrast with a later study by
the same group in adults receiving IRT (Bjorgvinsson et al., 2013) and with our previous study (Stewart et al.,
2006). Studies examining outpatients with OCD have consistently demonstrated an association between lower
OCD severity and response to cognitive behavioral therapy (CBT) (Keeley et al., 2008; Knopp et al., 2013) and
medication (Denys et al., 2003; Shetti et al., 2005; Stein et al., 2001; Storch et al., 2006; Tukel et al., 2006).
Thus, our present findings suggest that inpatient IRT may be particularly suited for severe OCD although more
rigorous investigation is necessary.
We also found that responders had significantly lower baseline past-year alcohol use scores on the AUDIT-C
than non-responders. However, mean scores in these groups were below 3 (the generally accepted threshold for
possible abuse or dependence (Bush et al., 1998)), suggesting little evidence of problematic drinking in our
sample overall.
While we found no significant association between symptom dimensions and percent change in Y-BOCS or
treatment response following IRT, participants who presented with fewer hoarding symptoms were more likely
to achieve wellness (Table 5). In agreement with these findings, prior studies of compulsive hoarders have
demonstrated poorer treatment outcomes to a variety of treatment approaches including CBT (Abramowitz et
al., 2003b; Rufer et al., 2006), behavioral therapy (Mataix-Cols et al., 2002), pharmacologic (Mataix-Cols et al.,
1999), intensive multimodal treatment in the context of a partial hospitalization program (Saxena et al., 2002),
and limbic surgery (Gentil et al., 2014). Taken together, these findings support the recent view of compulsive
hoarding as a distinct disorder separate from OCD that may require different treatment approaches (Pertusa et
al., 2010).
In contrast to our prior study, we found no association between sex or level of psychosocial functioning and
IRT response. As such, it will be important to expand this research to include IRT populations outside our
program in an effort to better understand these contradictory findings.
Characterization of Treatment Course

We found rapid improvement in OCD symptoms over the first 20–30 days of IRT treatment. This finding is
consistent with previous studies showing a rapid reduction in OCD symptoms among patients receiving
intensive daily outpatient exposure response prevention treatment over a 3–4 week period (Abramowitz et al.,
2003a; Foa et al., 2005; Storch et al., 2008) – an approach that closely resembles the behavioral component of
IRT. We also found

a more gradual decline in OCD symptoms over the subsequent 2 months of IRT, consistent with our initial
hypothesis and clinical experience.
Unexpectedly, we found a possible spike in OCD symptoms from days 20–40 and again around day 60 of
treatment. Although these spikes may represent statistical artifacts, there is anecdotal clinical experience to
support the first spike in symptoms. Several mechanisms could contribute to this so-called “rebound phase”.
First, since patients are changing environment to enter IRT, which may mean leaving a home environment that
is much more triggering, it is possible that some may experience a “honeymoon period” during the first few
weeks of treatment. As new triggers are established in the IRT environment, these patients may experience a
worsening of symptoms. Second, due to the significant psychoeducational component of IRT treatment, it is
possible that patients uncover previously unrecognized obsessions and/or compulsions over the course of
treatment as they become more adept at identifying OCD symptoms. Third, given the step-wise hierarchical
nature of ERP treatment which begins with easier exposures and gradually progresses to more challenging ones,
it is possible that patients are not habituating as quickly to more difficult exposures as they did earlier in
treatment. However, since patients were not receiving a standardized timeline of ERP, which moved patients up
their exposure hierarchy only between days 20–40 and after day 60, this explanation is less likely.
Implications for Treatment

Several findings from this study may inform the future delivery of IRT. First, we found that patients with the
most severe OCD derived the greatest reduction in symptoms following IRT. This finding contrasts sharply with
studies involving outpatient treatment modalities, suggesting that IRT may represent the treatment of choice for
severe, treatment-refractory patients. Second, while OCD symptom dimensions do not influence overall
symptom reduction or treatment response, patients with fewer hoarding symptoms are more likely to achieve
wellness following IRT. Third, greater past-year alcohol use may predict a poorer response to IRT. However,
this finding appears unrelated to problematic drinking. Fourth, IRT appears to produce a rapid reduction in
OCD symptoms over the first month of treatment, in contrast to outpatient behavioral and pharmacologic
treatments for OCD, which typically require 8–12 weeks and often yield modest symptom reduction (Jenike,
2004). As such, IRT may be particularly indicated for patients with severe OCD who require acute intervention
to rapidly relieve incapacitating symptoms. Fifth, our data suggest that while patients show rapid improvement
over the first month of IRT, this improvement slows in subsequent months and might be disrupted by brief
periods of worsening. This finding raises the question of whether the slope of improvement after one month is
sufficient to justify the cost of IRT beyond the 30-day mark. Future studies should also assess whether
additional interventions, introduced early in treatment, might maintain the steeper trajectory of symptom
reduction beyond the first month. One intriguing possibility is the use of d- cycloserine, which has shown
preliminary evidence as a pharmacologic enhancer of exposure response prevention therapy for OCD (Kushner
et al., 2007; Wilhelm et al., 2008)
– primarily through a hastening of the habituation process (Chasson et al., 2010).


Limitations
We acknowledge several limitations to this study. First, we did not include a structured
clinical interview on admission, and thus could not include comorbid diagnoses other than
depression, post-traumatic stress disorder, and substance use disorders in our analyses of
outcome predictors. Given that comorbid mental disorders impact outcome in both cognitive
behavior therapy (Keeley et al., 2008) and medication treatment (Baer et al., 1992; Cavedini
et al., 1997; Ravizza et al., 1995) in OCD, future studies of IRT treatment predictors should
assess for these comorbid conditions. Second, we cannot assess potential “placebo” response
(that is, non-specific effects of expectation) in our sample without the inclusion of a control
treatment group. A control group would also defend against the “regression to the mean”
concern mentioned earlier. Third, while our initial sample was 281 participants, the number
of participants providing follow-up data declined steadily over the course of treatment,
resulting in a smaller sample with 2 and 3 assessments post-admission. Furthermore, missing
data at discharge have the potential to bias the effect of treatment on wellness and response.
Thus, future IRT studies examining longitudinal clinical data in larger samples will be
necessary. The longitudinal models presented in the present initial study may help to guide
such future investigations. Fourth, we did not correct for multiple statistical comparisons so
our findings are exploratory and must be interpreted with some caution.
Fifth, we did not measure other potentially clinically important variables that have been
shown previously to be significant predictors of outcome (such as comorbid tics, level of
insight, treatment expectancy, and past number of medication and CBT trials) and therefore
could not examine these variables as predictors of outcome. Future research should examine
these potential predictors as well as confirm the significant results of this study.
Conclusions
In patients with severe, treatment-refractory OCD, inpatient residential treatment (IRT) was
associated with a rapid reduction of OCD symptoms over the first 30 days of treatment and
a more gradual decline in symptoms over the remaining 60 days. Individuals with greater
baseline OCD severity and less prior alcohol use responded better to IRT while those with
fewer hoarding symptoms were more likely to achieve wellness. Future investigations of
these issues may help to elucidate the optimal length of stay in the IRT setting, as well as
possible interventions to enhance IRT response and achieve overall wellness.
Acknowledgments
We thank Diane Davey, RN, MBA and Evelyn Stewart, MD who played an important role in the conceptualization and initiation of data
collection. We also thank Jordan Cattie, Justin Clark, Christina Albano, and Lily Motta who assisted with data collection and management.
ROLE OF THE FUNDING SOURCE
This work was funded in part by Grant 1K23-MH092397 from the National Institute of Mental Health (BPB) and the David Judah Fund
at Massachusetts General Hospital (BPB).

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Figure 1.
Profile plots from 100 randomly selected individuals receiving intensive residential treatment for obsessive-
compulsive disorder showing the mean trajectories of total Y-BOCS scores over time for the primary adjusted
RIS models considered. RIS, Random intercept and random slope; Y-BOCS, Yale-Brown Obsessive-
Compulsive Scale.
Figure 2.
Scatterplot of total Y-BOCS scores versus time for individuals receiving intensive residential treatment for
obsessive-compulsive disorder with LOESS curves of varying degrees of smoothness and mean trajectories
for the primary adjusted RIS models considered. RIS, Random intercept and random slope; Y-BOCS, Yale-
Brown Obsessive- Compulsive Scale.
Figure 3.
Mean trajectories of total Y-BOCS scores over time using penalized smoothing for knots at every (a) 30 days,
(b) 20 days, (c) 10 days, and (d) 5 days for individuals receiving intensive residential treatment for obsessive-
compulsive disorder. Y-BOCS, Yale-Brown Obsessive- Compulsive Scale.
TABLE 1
Demographic and Clinical Characteristics of the Subjects at Admission

Characteristic N (%) Mean (SD) Range

Age, years (N = 281) 33.5 (13.8) 16–78
Sex (N = 281)
Male 143 (51)
Female 138 (49)
Education (N = 274)
High School Diploma/GED 88 (32)
Some College or Associates Degree 57 (21)
Bachelors Degree 89 (32)
Graduate Degree 40 (15)
Employment (N = 275)
Employed 81(29)
Unemployed or On Leave 194 (71)
Marital status (N = 275)
Single 202 (73)
Married or Partner 54 (20)

Divorced or Separated 19 (7)
Payment method (N = 275)
Managed care 215 (78)
Medicare/Medi-caid 48 (18)
Self-pay 12 (4)
Past treatment (N = 270)
Behavioral therapy 38 (14)
Medication 49 (18)
Behavioral therapy and medication 151 (56)
Other treatment method 18 (7)
Never received treatment 14 (5)
Age of OCD Onset, years (N = 235) 14.3 (9.6) 0–61
Duration of OCD, years (N = 235) 18.8 (13.4) 1–64
Yale-Brown Obsessive Compulsive Scale (N = 281) 26.7 (5.6) 13–40
Quick Inventory of Depressive Symptomatology (N = 280) 13.3 (5.4) 1–26

Work and Social Adjustment Scale (N = 204) 27.3 (7.7) 0–40
Schwartz Outcome Scale (N = 204) 23.6 (10.5) 0–54
Time between admission and last assessment, days (N = 223) 52.5 (22.7) 6–101
Table 2
Association Between Clinical Characteristics at Admission and Percent Change in Total Y-BOCS Between Last and First Assessments
Brennan et al.
Characteristic Slope Slope SE Slope p-value Slope 95% CI
Age 0.06 0.12 0.64 (−0.18, 0.30)
Age of OCD onset −0.12 0.18 0.50 (−0.47, 0.23)
Alcohol Use Disorders Test - Consumption 1.59 0.84 0.06 (−0.06, 3.24)
Drug Abuse Screening Test-10 −0.06 1.36 0.96 (−2.75, 2.62)
Yale-Brown Obsessive Compulsive Scale −1.49 0.29 <.001 (−2.06, −0.93)

Quick Inventory of Depressive Symptomatology-16 0.42 0.32 0.19 (−0.21, 1.04)
Work and Social Adjustment Scale −0.13 0.27 0.64 (−0.66, 0.41)
Schwarz Outcome Scale, 10 item −0.17 0.19 0.37 (−0.55, 0.21)
Duration of illness −0.06 0.14 0.69 (−0.34, 0.22)
Male 2.50 3.42 0.47 (−4.25, 9.24)
Married/partner −6.82 4.43 0.13 (−15.56, 1.92)
Currently employed −1.14 3.74 0.76 (−8.51, 6.23)
Family history of OCD −0.30 3.48 0.93 (−7.16, 6.55)
History of posttraumatic stress disorder −7.33 5.72 0.20 (−18.6, 3.95)
Payment methoda
Managed care −7.6 9.21 0.41 (−25.8, 10.5)
Medicare/Medi-caid −9.0 9.98 0.37 (−28.7, 10.7)
Past treatmentb
Behavioral therapy −1.20 8.60 0.89 (−18.1, 15.8)
Medication 0.71 8.60 0.94 (−16.2, 17.7)
Behavioral therapy and medication −2.14 7.78 0.78 (−17.5, 13.2)
Other treatment method 3.75 9.67 0.70 (−15.3, 22.8)
Educationc
Some college or Associates degree 4.88 4.93 0.32 (−4.85, 14.6)
Bachelors degree −0.84 4.19 0.84 (−9.1, 7.42)
Graduate degree −9.77 5.42 0.07 (−20.5, 0.91)
a
Reference group = Self-pay
Page 17
Reference group = High school diploma or GED

Reference group = Never received treatment
b
c

Table 3
Clinical Characteristics at Admission of Responders Versus Non-responders
Brennan et al.
Non-responders (N = 110) Responders (N = 113)
Characteristic N Mean (SD) N Mean (SD) p-value

Age 110 33.4 (14.5) 113 33.4 (13.4) 0.81
Age of OCD onset 88 13.6 (7.9) 98 15.6 (12.1) 0.53
Alcohol Use Disorders Test - Consumption 108 2.1 (2.2) 109 1.4 (1.9) 0.01
Drug Abuse Screening Test-10 110 0.8 (1.0) 113 0.8 (1.5) 0.33
Yale-Brown Obsessive Compulsive Scale 110 25.6 (5.8) 113 28 (5.2) 0.003
Quick Inventory of Depressive Symptoms-16 110 13.6 (5.3) 113 13.4 (5.5) 0.81
Work and Social Adjustment scale 84 26.9 (7.9) 76 28.1 (7.3) 0.3
Schwartz Outcome Scale-10 84 24.6 (11.4) 76 22.5 (10.2) 0.15
Duration of illness 88 18.8 (13.8) 98 18.2 (12.4) 0.96
Characteristic N N (%) N N (%) p-value
Male 110 58 (52.7) 113 60 (53.1) 1

Married/partner 108 15 (13.9) 109 25 (22.9) 0.12
Currently employed 108 30 (27.8) 109 37 (33.9) 0.38
Family history of OCD 108 56 (51.9) 108 62 (57.4) 0.49
PTSD history 106 10 (9.4) 108 12 (11.1) 0.82
Payment method
Managed care 108 86 (79.6) 109 88 (80.7) 0.87
Medicare/Medi-caid 108 18 (16.7) 109 17 (15.6) 0.86
Self-pay 108 4 (3.7) 109 4 (3.7) 1
Past treatment
Behavioral therapy 106 16 (15.1) 108 17 (15.7) 1
Medication 106 16 (15.1) 108 17 (15.7) 1
Behavioral therapy and medication 106 59 (55.7) 108 62 (57.4) 0.89
Other treatment method 106 9 (8.5) 108 7 (6.5) 0.61
Never received treatment 106 6 (5.7) 108 5 (4.6) 0.77
Education
Page 19
Non-responders (N = 110) Responders (N = 113)
Brennan et al.
High school diploma or GED 108 36 (33.3) 109 36 (33.0) 1
Some college or Associates degree 108 24 (22.2) 109 17 (15.6) 0.23
Bachelors degree 108 38 (35.2) 109 35 (32.1) 0.67
Graduate degree 108 10 (9.3) 109 21 (19.3) 0.051
Page 20
Table 4
Clinical Characteristics at Admission of Participants Who Achieved “Wellness” Versus Participants Who Did Not
Brennan et al.
Wellness not acheived (N = 174) Wellness achieved (N = 53)

Age 173 33.3 (14.1) 50 33.7 (13.4) 0.83
Age of OCD onset 141 14.2 (9.2) 45 16.1 (13.2) 0.36
Alcohol Use Disorders Test - Consumption 167 1.9 (2.1) 50 1.4 (1.8) 0.14
Drug Abuse Screening Test-10 173 0.8 (1.3) 50 0.6 (1.2) 0.38
Yale-Brown Obsessive Compulsive Scale 173 27.1 (5.4) 50 25.7 (6.5) 0.16
Quick Inventory of Depressive Symptoms-16 173 13.8 (5.5) 50 12.5 (4.9) 0.11
Work and Social Adjustment scale 130 27.6 (7.8) 30 26.5 (7.1) 0.46
Schwartz Outcome Scale-10 130 23.3 (10.8) 30 25.1 (11.1) 0.43
Duration of illness 141 18.5 (13.4) 45 18.2 (11.7) 0.86
Characteristic N N (%) N N (%) p-value
Male 173 92 (53.2) 50 26 (52.0) 1

Married/partner 170 33 (19.4) 47 7 (14.9) 0.53
Currently employed 170 53 (31.2) 47 14 (29.8) 1
Family history of OCD 170 94 (55.3) 46 24 (52.2) 0.74
PTSD history 168 14 (8.3) 46 8 (17.4) 0.1
Payment method
Managed care 170 135 (79.4) 47 39 (83.0) 0.68
Medicare/Medi-caid 170 27 (15.9) 47 8 (17.0) 0.83
Self-pay 170 8 (4.7) 47 0 (0) 0.21
Past treatment
Behavioral therapy 168 27 (16.1) 46 6 (13.0) 0.82
Medication 168 26 (15.5) 46 7 (15.2) 1
Behavioral therapy and medication 168 93 (55.4) 46 28 (60.9) 0.62
Other treatment method 168 13 (7.7) 46 3 (6.5) 1
Never received treatment 168 9 (5.4) 46 2 (4.3) 1
Education
Page 21
Wellness not acheived (N = 174) Wellness achieved (N = 53)
Brennan et al.
High school diploma or GED 170 55 (32.4) 47 17 (36.2) 0.73
Some college or Associates degree 170 36 (21.2) 47 5 (10.6) 0.14
Bachelors degree 170 59 (34.7) 47 14 (29.8) 0.60
Graduate degree 170 20 (11.8) 47 11 (23.4) 0.058
Page 22
Table 5
Symptom Dimension Factor Scores of Participants Who Achieved “Wellness” Versus Participants Who Did Not
Brennan et al.
Wellness not acheived Wellness achieved
Symptom dimension N Mean factor score (SD) N Mean factor score (SD) p-value
Symmetry (N =109) 56 11.1 (7.2) 53 10.1 (8.3) 0.36
Forbidden thoughts (N =134) 110 15.2 (10.6) 24 11.9 (10.1) 0.07
Contamination (N =115) 93 10.7 (5.9) 22 11.2 (6.8) 0.81
Hoarding (N =65) 57 9.53 (6.3) 8 5 (4.6) 0.03
Page 23

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J Psychiatr Res. 2014 September ; 56: 98–105. doi:10.1016/j.jpsychires.2014.05.008.

INTENSIVE RESIDENTIAL TREATMENT FOR SEVERE

Compulsive Disorder Institute, McLean Hospital, Belmont, MA 3Department of

Biostatistics, Harvard School of Public Health, Boston, MA 4Laboratory for

Psychiatric Biostatistics, McLean Hospital, Belmont, MA 5Psychology

© 2014 Elsevier Ltd. All rights reserved.

J Psychiatr Res. Author manuscript; available in PMC 2015 September 01.

MATERIALS AND METHODS

J Psychiatr Res. Author manuscript; available in PMC 2015 September 01.

J Psychiatr Res. Author manuscript; available in PMC 2015 September 01.

J Psychiatr Res. Author manuscript; available in PMC 2015 September 01.

Predictors of Response and Wellness

Time Course of OCD Severity

J Psychiatr Res. Author manuscript; available in PMC 2015 September 01.

Characterization of Treatment Course

J Psychiatr Res. Author manuscript; available in PMC 2015 September 01.

Implications for Treatment

J Psychiatr Res. Author manuscript; available in PMC 2015 September 01.

J Psychiatr Res. Author manuscript; available in PMC 2015 September 01.

ROLE OF THE FUNDING SOURCE

J Psychiatr Res. Author manuscript; available in PMC 2015 September 01.

Demographic and Clinical Characteristics of the Subjects at Admission

Characteristic N (%) Mean (SD) Range

Married or Partner 54 (20)

Quick Inventory of Depressive Symptomatology (N = 280) 13.3 (5.4) 1–26

Yale-Brown Obsessive Compulsive Scale −1.49 0.29 <.001 (−2.06, −0.93)

Reference group = High school diploma or GED

J Psychiatr Res. Author manuscript; available in PMC 2015 September 01.

Clinical Characteristics at Admission of Responders Versus Non-responders

Characteristic N Mean (SD) N Mean (SD) p-value

Characteristic N N (%) N N (%) p-value

Male 110 58 (52.7) 113 60 (53.1) 1

Characteristic N Mean (SD) N Mean (SD) p-value

Characteristic N Mean (SD) N Mean (SD) p-value

Characteristic N N (%) N N (%) p-value

Male 173 92 (53.2) 50 26 (52.0) 1

Characteristic N Mean (SD) N Mean (SD) p-value

Hoarding (N =65) 57 9.53 (6.3) 8 5 (4.6) 0.03

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