You may be aware that Cognitive Behavioral Therapy (CBT) is widely accepted as an effective treatment for anxiety disorders, including OCD. However, despite the acceptability and general success of CBT, many patients still struggle to make or maintain progress in outpatient treatment. In those cases, patients can sometimes benefit from a more intensive treatment, such as intensive residential treatment (IRT).
What is Intensive Residential Treatment?
There are varying levels of care for individuals struggling with mental illness. The most common and least intensive level of care is outpatient treatment, in which patients meet weekly with mental healthcare providers. The next most intensive level of care is day treatment, in which patients engage in a structured treatment program, typically Monday through Friday from nine in the morning to five at night, and return home during the evenings. The most intensive level of care is inpatient treatment, which involves admission to a secure hospital unit for treatment and close monitoring. This level of care is generally reserved for patients at high risk for harming themselves or others, or for those who are unable to care for themselves or carry out basic day-to-day activities.
Intensive residential treatment (IRT) is considered an intermediate level of care between inpatient and day treatment in which medically stable, yet severely impaired, patients reside on a unit in a hospital and engage in a structured treatment program. While patients in the IRT setting have access to 24-hour care, they are not restricted to a locked unit as is generally the case for inpatient treatment. There are IRT programs for a variety of mental illnesses, including substance abuse disorders, eating disorders, psychotic disorders, and OCD.
Evaluating IRT for OCD Treatment
The Obsessive Compulsive Disorder Institute at McLean Hospital (OCDI) is one of only three IRT programs in the U.S. dedicated to patients in need of severe OCD treatment. Patients at the OCDI receive individual CBT from behavioral therapists, case management from family therapists, and psychopharmacological consultation from psychiatrists, all of whom specialize in the treatment of severe OCD. Patients engage daily in an average of four hours of individualized exposure and response prevention therapy (ERP), which is the gold-standard behavioral OCD treatment, as well as three hours of group therapy. The average length of stay at the OCDI is approximately 45 days, and some patients remain in treatment for up to 90 days.
A recent study from McLean Hospital, published in the Journal of Psychiatric Research, examined the predictors and overall course of IRT for OCD in an effort to increase our understanding and potentially improve the effectiveness of this method. Over the course of two years, we at the OCDI Office of Clinical Assessment and Research have collected data from over 250 OCD patients receiving treatment at the OCDI in order to determine what factors might predict response to IRT, and understand how OCD symptoms change over the course of IRT. Upon admission to the program, patients completed questionnaires that assessed a number of clinical characteristics, including OCD symptom severity and type (e.g., contamination, symmetry, checking, ordering), severity of depressive symptoms, functional impairment, quality of life, alcohol and drug use, and demographics (e.g., age, gender, education level, marital status). In addition, investigators collected follow-up data on OCD symptom severity, depression severity, functional impairment, and quality of life at monthly intervals and at discharge from the program.
Results revealed that OCD symptom severity, alcohol use, and hoarding symptoms at admission predicted changes in OCD symptom severity, such that patients with more severe OCD symptoms, lower alcohol use, and fewer hoarding symptoms at admission showed better response to treatment. With regard to the time course of change in OCD symptoms following IRT, results showed that OCD symptoms rapidly improved in the first 30 days, with more gradual improvements over the remaining 60 days.
What This Means for OCD Treatment
Altogether, this research suggests that individuals who derive the most benefit from IRT are those who continue to experience severe OCD symptoms and impaired functioning despite attempts at outpatient treatment, and therefore may require a more rapid and targeted intervention, like IRT, in order to accelerate progress. Given the significant personal and financial investment needed for IRT, it’s important to carefully consider this in order to determine if IRT may be the next step for you, your family member, or your patient.
Sources
Journal of Psychiatric Research
Brennan, B.P., Lee, C., Elias, J., Crosby, J. Mathes, B.M., Andre, M.C., Gironda, C.M., Pope, H.G., Jenike, M.A., Fitzmaurice, G.M., Hudson, J.I. (2014). Intensive residential treatment for severe obsessive-compulsive disorder: characterizing treatment course and predictors of response. Journal of Psychiatric Research, 5698-105. doi: 10.1016/j.jpsychires.2014.05.008
Brian P. Brennan, M.D., is an assistant professor of psychiatry at Harvard Medical School and is currently the Director of Medical Research at the Obsessive-Compulsive Disorder Institute at McLean Hospital and the Associate Director of Translational Neuroscience Research in the Biological Psychiatry Laboratory at McLean Hospital. He received his medical degree from the Raymond and Ruth Perelman School of Medicine (formerly known as the University of Pennsylvania School of Medicine) and completed residency training in the combined Massachusetts General Hospital/McLean Hospital Psychiatry Residency Training Program.
The overarching theme of Dr. Brennan’s research is the investigation of novel biological targets for the development of improved pharmacologic therapies for mood and anxiety disorders. Specifically, Dr. Brennan focuses on the use of neuroimaging as a means to better understand the mechanism of action of both standard and novel treatments for mood and anxiety disorders and to identify neurochemical and functional mediators of treatment response.
Dr. Brennan’s clinical and research work has led to grant funding from the National Institute of Mental Health, NARSAD, the Sidney R. Baer, Jr. Foundation, and the Stanley Medical Research Institute and receipt of the Outstanding Professional of the Year Award from the Boston Chapter of the Depression and Bipolar Disorder Support Alliance.
