Antidepressant drugs in the treatment of obsessive-compulsive disorders.

Most reports of drug treatment for obsessivecompulsive neurosis concern one tricyclic antidepressant, namely clomipramine. Early suggestions that the drug might be valuable in this condition were based on uncontrolled and/or short-term studies over only a few weeks (Fernandez and Lopez-Ibor, 1967; Beaumont, 1973; Capstick, 1975; Ananth et al., 1978). A recent controlled study with long-term followup has been reported (Marks et al., 1980; Stern et. al., 1980) in which 40 patients with chronic obsessive compulsive rituals were randomly assigned to treatment with oral clomipramine or placebo for eight months. The two groups were also investigated for the effect of behaviour therapy (given in the form of exposure in vivo) by randomly further splitting them into groups and giving them either behaviour therapy or a control psychological treatment that has no effect on compulsive rituals (relaxation therapy). During the active behaviour therapy the patient would be encouraged to perform a formerly avoided activity and discouraged from carrying out rituals. For instance, a patient who never touched certain clothing and had to wash her hands 35 times to “decontaminate” herself was told to touch this clothing after watching the therapist do likewise. She was then not allowed to wash her hands but encouraged to wait until her anxiety left her. (For details of the behaviour therapy for compulsive rituals see Stern, 1978, Chapter 4.) A large number of measurements were carried out in this controlled study. These can be briefly summarized as: (1) measurement of compulsive rituals, (2) measurement of mood state and (3) measurement of patients’ general adjustment. One of the main measures of ritual was called the behavioural avoidance test (BAT) and was carried out by an assessor who was “blind” both to drug and psychological treatment conditions. Figure 1 shows the effect on this measure of clomipramine and placebo and demonstrates the superiority of clomipramine. Exposure produced significantly more improvement in rituals than the control treatment of relaxation (Fig. 2). However, the active behaviour therapy produced no significant effect on mood or general adjustment.