Possible solutions to the shortcomings of the Yale-Brown Obsessive-Compulsive Scale / Possíveis soluções para as deficiências da escala de Yale-Brown para avaliação do transtorno obsessivo-compulsivo

OBJECTIVE: The Yale-Brown Obsessive-Compulsive Scale is the most frequently used instrument to measure obsessive-compulsive symptom severity. We describe its shortcomings and propose new methods of evaluating current severity and treatment response. METHOD: The Yale-Brown Obsessive-Compulsive Scale total and subscale scores were pooled from one cross-sectional study database containing information on 1,000 obsessive-compulsive disorder patients from seven specialized mental health care centers. Additional longitudinal data were pooled for 155 patients who participated in a 12-week trial that evaluated the effectiveness of fluoxetine vs. cognitive-behavior therapy as first-line treatment options. All patients were followed by a clinician who provided a clinical opinion of improvement. Neither patients nor clinicians were aware of the classifications proposed in this study. New methods for using the severity scores were compared with the clinical opinion of improvement. RESULTS: In the Yale-Brown Obsessive-compulsive scale, the summing-up of subscale scores to compose a total score does not accurately reflect clinical severity. In addition, the reduction of scores with treatment does not usually reach score zero in either subscale. To overcome such problems, we suggest (a) use of the maximum score of any of the subscales; (b) use of a minimum score of 4 in each subscale or 5 for the maximum in any subscale as the goal after treatment. This method performed better than traditional ones regarding sensitivity and specificity against the gold standard represented by the clinical opinion of improvement. CONCLUSION: The new proposed response criteria are coherent with the clinical opinion of improvement and perform better than the traditional methodology.

RESUMO OBJETIVO: A escala de Yale-Brown para avaliação do transtorno obsessivo-compulsivo é o instrumento mais utilizado para medir a gravidade desse transtorno. Descrevemos as deficiências dessa escala e propomos novos métodos de cálculo dos escores para avaliação de gravidade e resposta ao tratamento. MÉTODO: Os escores totais e subtotais da escala de Yale-Brown foram recuperados de um banco de dados de um estudo transversal com informações sobre 1.000 pacientes com transtorno obsessivo-compulsivos atendidos em sete centros especializados em saúde mental. Foram acrescentados os dados longitudinais de 155 pacientes participantes de um ensaio clínico de 12 semanas que avaliou a eficácia da fluoxetina ou da terapia cognitivo-comportamental como opções de tratamento de primeira linha. Todos os pacientes foram acompanhados por um médico que forneceu um parecer clínico de melhora. Nem os pacientes nem os médicos estavam conscientes das classificações propostas neste estudo. Novos métodos para avaliar os escores de gravidade foram comparados com o parecer clínico de melhora. RESULTADOS: Na escala obsessivo-compulsiva Yale-Brown, a soma de sub-escalas para compor a pontuação total não reflete com precisão a gravidade clínica. Além disso, a redução da pontuação com o tratamento, normalmente, não atinge o valor zero em qualquer das sub-escalas. Para superar esses problemas, sugerimos (a) o uso da pontuação máxima de qualquer das sub-escalas antes do tratamento; (b) o uso de um score mínimo de 4 em cada sub-escala ou um escore mínimo de 5 como o máximo de qualquer das sub-escalas como a meta para o pós-tratamento. Os novos métodos propostos tiveram melhor desempenho do que os tradicionais quanto a sensibilidade e especificidade contra o padrão ouro representado pelo parecer clínico de melhora. CONCLUSÃO: Os novos critérios propostos são coerentes com o parecer clínico de melhora e desempenham melhor do que a metodologia tradicional.

Risk factors for early treatment discontinuation in patients with obsessive-compulsive disorder

INTRODUCTION: In obsessive-compulsive disorder, early treatment discontinuation can hamper the effectiveness of first-line treatments. OBJECTIVE: This study aimed to investigate the clinical correlates of early treatment discontinuation among obsessive-compulsive disorder patients. METHODS: A group of patients who stopped taking selective serotonin reuptake inhibitors (SSRIs) or stopped participating in cognitive behavioral therapy before completion of the first twelve weeks (total n = 41; n = 16 for cognitive behavioral therapy and n = 25 for SSRIs) were compared with a paired sample of compliant patients (n = 41). Demographic and clinical characteristics were obtained at baseline using structured clinical interviews. Chisquare and Mann-Whitney tests were used when indicated. Variables presenting a p value <0.15 for the difference between groups were selected for inclusion in a logistic regression analysis that used an interaction model with treatment dropout as the response variable. RESULTS: Agoraphobia was only present in one (2.4 percent) patient who completed the twelve-week therapy, whereas it was present in six (15.0 percent) patients who dropped out (p = 0.044). Social phobia was present in eight (19.5 percent) patients who completed the twelve-week therapy and eighteen (45 percent) patients who dropped out (p = 0.014). Generalized anxiety disorder was present in eight (19.5 percent) patients who completed the twelve-week therapy and twenty (50 percent) dropouts (p = 0.004), and somatization disorder was not present in any of the patients who completed the twelveweek therapy; however, it was present in six (15 percent) dropouts (p = 0.010). According to the logistic regression model, treatment modality (p = 0.05), agoraphobia, the Brown Assessment of Beliefs Scale scores (p = 0.03) and the Beck Anxiety Inventory (p = 0.02) scores were significantly associated with the probability of treatment discontinuation irrespective of interactions with other variables. DISCUSSION AND CONCLUSION: Early treatment discontinuation is a common phenomenon in obsessive-compulsive disorder patients from our therapeutic setting. Psychiatric comorbidities were associated with discontinuation rates of specific treatments. Future studies might use this information to improve management for increased compliance and treatment effectiveness.

The drug-naïve OCD patients imaging genetics, cognitive and treatment response study: methods and sample description / Estudo de genética, imagem, cognição e resposta a tratamento em pacientes com TOC virgens de tratamento: métodos e descrição da amostra

OBJECTIVE: To describe a protocol that was based on an integrative neurobiological model of scientific investigation to better understand the pathophysiology of obsessive-compulsive disorder and to present the clinical and demographic characteristics of the sample. METHOD: A standardized research protocol that combines different methods of investigation (genetics, neuropsychology, morphometric magnetic resonance imaging and molecular neuroimaging of the dopamine transporter) obtained before and after treatment of drug-naïve adult obsessive-compulsive disorder patients submitted to a sequentially allocated 12-week clinical trial with a selective serotonin reuptake inhibitor (fluoxetine) and group cognitive-behavioral therapy. RESULTS: Fifty-two treatment-naïve obsessive-compulsive disorder patients entered the clinical trial (27 received fluoxetine and 25 received group cognitive-behavioral therapy). At baseline, 47 blood samples for genetic studies, 50 neuropsychological evaluations, 50 morphometrical magnetic resonance images and 48 TRODAT-1 single-photon emission computed tomography (SPECT) exams were obtained. After 12 weeks, 38 patients completed the protocol (fluoxetine = 20 and GCBT = 18). Thirty-eight neuropsychological evaluations, 31 morphometrical magnetic resonance images and 34 TRODAT-1 SPECT exams were obtained post-treatment. Forty-one healthy controls matched for age, gender, socioeconomic status, level of education and laterality were submitted to the same research procedures at baseline. CONCLUSION: The comprehensive treatment response protocol applied in this project allowing integration on genetic, neuropsychological, morphometrical and molecular imaging of the dopamine transporter data in drug-naïve patients has the potential to generate important original information on the neurobiology of obsessive-compulsive disorder, and at the same time be clinically meaningful.

OBJETIVO: Descrever um protocolo integrativo de investigação neurobiológica para melhor compreender as bases patofisiológicas do transtorno obsessivo-compulsivo e apresentar as características clínicas e demográficas da amostra. MÉTODO: Protocolo padronizado que combina diferentes modalidades de investigação (genética, neuropsicologia, ressonância magnética cerebral e imagem molecular do transportador de dopamina) obtidas antes e depois do tratamento em pacientes com transtorno obsessivo-compulsivo nunca expostos à medicação submetidos a um ensaio clínico comparando um inibidor seletivo da recaptação de serotonina (fluoxetina) e terapia cognitivo-comportamental em grupo. RESULTADOS: Cinquenta e dois pacientes com transtorno obsessivo-compulsivo entraram no ensaio clínico (27 no grupo fluoxetina e 25 no grupo de terapia). No início, foram realizadas 47 coletas de sangue para genética, 50 avaliações neuropsicológicas, 50 ressonâncias magnéticas cerebrais e 48 exames de tomografia computadorizada por emissão de fóton único (SPECT) com TRODAT-1. Depois de 12 semanas, 38 pacientes terminaram o protocolo (20 no grupo de fluoxetina e 18 no grupo de terapia). Trinta e oito reavaliações neuropsicológicas, 31 ressonâncias magnéticas de crânio e 34 exames de SPECT foram obtidos após o tratamento. Quarenta e um controles pareados foram submetidos ao mesmo protocolo inicial. CONCLUSÃO: Os dados genéticos, neuropsicológicos, volumétricos e moleculares do transportador de dopamina aliados à resposta a tratamento podem tanto gerar informações importantes a respeito da neurobiologia do transtorno obsessivo-compulsivo quanto ter uma aplicação clínica.