Treatment Strategies for Refractory OCD: Cost-Effectiveness Analysis

Specialized treatment protocols may be more effective at treating refractory obsessive-compulsive disorder than pharmacotherapy alone.

Partial hospitalization followed by step-down intensive outpatient treatment was the most cost-effective strategy in addressing treatment-refractory obsessive-compulsive disorder (OCD), according to data published in the Journal of Clinical Psychiatry.

Researchers developed a decision analytical model to stratify outpatient treatment strategies and a Markov model to accumulate benefits, costs, and mortality for a hypothetical cohort of 100,000 adults (18-64 years old) with treatment-resistant OCD. Researchers identified 7 treatment strategies from existing literature, beginning with 2 pharmacology-only models: antidepressant medication (ADM) monotherapy and ADM therapy augmented with antipsychotic medications. Investigators then identified 5 strategies for polytherapy with ADMs and cognitive behavioral therapy (ADM-CBT). 

Two similar ADM-CBT treatment models extracted from the literature varied in CBT dosage and fidelity, with 1 parameterized by trial-based efficacy (ADM+CBT) and the other by real-world practice-based effectiveness (ADM+CBT [effectiveness]). Of the 3 final ADM-CBT strategies, 1 included intensive outpatient treatment (IOP), 1 included partial hospitalization (PHP), and 1 included a step-down strategy that guided the transition from PHP to IOP (PHP/IOP).

The PHP/IOP strategy resulted in the highest net health benefits level of the 7 strategies, with a mean value of 10.96 quality-adjusted life-years remaining posttreatment. This result was 2.2 quality-adjusted life-years greater than that of the next highest-scoring strategy (ADM+CBT), representing a greater mean improvement in life-years remaining for the average individual in PHP/IOP compared with the average individual in ADM+CBT.

Scientists then calculated an incremental cost-effectiveness ratio for each strategy at $7983, PHP/IOP had the highest incremental cost-effectiveness ratio value of all treatment methods, offset by the greatest effectiveness score. The additional ADM-CBT strategies were not found to be statistically significantly different from each other (P >.05), although all ADM-CBT strategies outperformed both pharmacotherapy-only strategies. In the simulation model, CBT provided in an IOP, PHP, or clinical trial scenario (ADM+CBT) was superior to real-world CBT (ADM+CBT [effectiveness]). 

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Given the limited availability of high-quality CBT in real-world scenarios, investigators concluded that specialized treatment programs involving partial hospitalization and a step-down strategy may offer greater effectiveness in achieving wellness for this patient population.

These analyses reinforce current knowledge that ADM-CBT combination therapies are typically more effective than pharmaceutical monotherapy and indicate that specialized treatment protocols may be more effective regarding refractory OCD. The cost-effectiveness data may also provide clinicians with useful information in developing individualized intervention strategies for patients with treatment-resistant OCD.


Gregory ST, Kay B, Smith J, et al. Treatment-refractory obsessive-compulsive disorder in adults: a cost-effectiveness analysis of treatment strategies. J Clin Psychiatry. 2018;79(2):17m11552.