Shorter communicationChanges in quality of life following cognitive-behavioral therapy for obsessive-compulsive disorder
Introduction
Cognitive-behavioral therapy (CBT) incorporating exposure and response prevention is a first line treatment for obsessive-compulsive disorder (OCD) (March, Frances, Carpenter, & Kahn, 1997). Although research has consistently demonstrated the beneficial effects of CBT on OCD symptoms (Foa et al., 2005; Lindsay, Crino, & Andrews, 1997; Tolin, Diefenbach, Maltby, & Hannan, 2005; Tolin et al., 2007; van Balkom et al., 1998), the picture is less clear regarding the extent to which patients also undergo improvement in quality of life (QOL) following treatment. Some data suggest statistically significant improvements in QOL following CBT for OCD (Bystritsky et al., 1999; Cordioli et al., 2003; Moritz et al., 2005), although continued functional impairment has been noted despite improvements in OCD symptoms (e.g., Bystritsky et al., 2001; Norberg, Calamari, Jones, & Riemann, in press).
Most studies exploring changes in QOL following treatment have been conducted in settings that typically serve the most severely impaired patients (e.g., inpatient, partial hospitalization programs) (e.g., Bystritsky et al., 1999; Moritz et al., 2005), who likely present with more severe, chronic, and potentially treatment resistant functional disability than patients receiving treatment in outpatient settings. Thus, results might not generalize to routine outpatient clinical practice where the majority of patients receive treatment. Moreover, many existing studies examining treatment effects on QOL have explored the outcome of pharmacotherapy either alone or in combination with unstandardized CBT for OCD (e.g., Bystritsky et al., 1999; Tenney, Denys, van Megen, Glas, & Westenberg, 2003). One exception is a study reported by Cordioli et al. (2003) who found that 12 weekly sessions of group CBT were effective in improving QOL as assessed using a multidimensional instrument of QOL. These results are promising, yet need to be replicated in individual outpatient samples.
Toward this end, Norberg et al. (in press) explored the relation between QOL (as assessed using a life satisfaction measure) and OCD severity changes among outpatients completing CBT. Three outcome patterns were identified: (1) significant symptom reduction and improvement in life satisfaction, (2) moderate symptom reduction and less consistent improvement in life satisfaction, and (3) minimal symptom reduction and no improvement in life satisfaction. However, treatment did not follow a standardized protocol and assessment relied solely on a life satisfaction instrument to measure QOL. Given the differences in QOL conceptualizations, the use of a specific measure of functional disability may produce different results. Results of the Norberg et al. (in press) study also underscore the importance of exploring the correspondence between symptom and QOL changes, which has not been conducted consistently in previous research.
Thus, further research is needed to clarify whether OCD symptom improvement following CBT is related to improved QOL. In the current study we (a) conducted archival data analysis of outpatients with a range of OCD symptom severity and related impairment to improve upon generalizability issues in most previous work; (b) administered a standardized CBT protocol and controlled for the impact of adjunctive treatments by precluding additional psychotherapy and requesting a stable type of dose of medications be maintained throughout treatment, and (c) determined the relationship between changes in OCD symptoms and QOL following CBT using dimensional measures and as categorized by clinically significant change criteria. We assessed OCD symptom severity with the gold standard Yale–Brown Obsessive-Compulsive Scale (Y-BOCS, Goodman, Price, Rasmussen, Mazure, Fleischmann et al., 1989) and QOL with the Sheehan Disability Scale (SDS, Sheehan, 1986), a measure of impairment in occupational, social, and family functioning. The SDS is commonly used to assess QOL in the anxiety disorders, and is recommended as a concise measure to assess the primary domains of impairment associated with anxiety disorders (Quilty, Van Ameringen, Mancini, Oakman, & Farvolden, 2003).
We predicted that OCD symptom severity would correlate positively with functional impairment at pre-treatment and that QOL would improve after CBT. We hypothesized that the change in OCD symptom severity would contribute significantly to predicting changes in functional impairment from pre- to post-treatment. Because depression is a significant predictor of CBT outcome in OCD (Abramowitz, Franklin, Street, Kozak, & Foa, 2000) and also is related to QOL for patients with this disorder (Moritz et al., 2005), we controlled for the impact of changes in depression over treatment in these analyses. We also predicted there would be correspondence between clinically significant change on the Y-BOCS and SDS.
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Participants
We conducted archival data analysis for 70 adult outpatients (age M=36.79, SD=11.22), who met inclusion/exclusion criteria below, completed treatment, and completed all study materials at pre- and post-treatment. Data were combined from two outpatient treatment centers: the Institute of Living in Hartford, Connecticut (n=28, 40%), and the Mayo Clinic in Rochester, Minnesota (n=42, 60%). All participants were diagnosed with OCD (American Psychiatric Association, 2000) as the primary problem.
Relationships between symptoms and QOL at pre-treatment
As expected, correlations among the SDS subscales were in the moderate to strong range (r range=0.535–0.704), justifying the use of the SDS total score as a global measure. To examine the individual domains of functional impairment, however, we also report exploratory analyses using the three single-item SDS subscales. Pre-treatment group means and standard deviations for the Y-BOCS and BDI-II, as well as correlations between these measures and the SDS, are presented in Table 1. The sample
Discussion
The aim of the present study was to investigate the extent to which patients with OCD exhibit improvements in QOL following CBT. We observed statistically significant and substantial improvements in QOL from pre- to post-treatment. Our exploratory analyses revealed that the largest effect occurred for family functioning, followed by social and then work functioning. In addition, 40% of participants met criteria for clinically significant improvement on QOL. The average participant experienced
Acknowledgments
This research was supported by grants from the Obsessive Compulsive Foundation awarded to Jonathan Abramowitz, Stefanie Schwartz, and Stephen Whiteside; a grant from Hartford Hospital to David Tolin, and a grant from the Patrick and Catherine Weldon Donaghue Medical Research Foundation to David Tolin.
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