Access to OCD Treatments and When to Seek Them with Dr Peggy Richter

Dr. Peggy Richter: Such a great question, and before I launch into it, I just also want to say thank you to you and Anxiety Canada for doing this. I think it’s such a valuable service to people. So you’re starting off with a really good initial question, which is, how do you know if you need help? But when is it right to get help?

And the answer is a pretty straightforward one, I would say, for almost any psychiatric issue, which is if you are being distressed by thoughts of any sort or intense emotions that seem disproportionate to your circumstances or having other difficulties with behaviors that are leading to problems with functioning in your life and maintaining relationships and doing well at work or school the way you normally would, that’s a signal to get help. So those same general principles apply to OCD.

In the case of OCD, my advice would be anybody who thinks they may have OCD, namely because they have obsessions or intrusive, unwanted sticky thoughts that seem to persist that they can’t somehow move on from, or rituals and compulsions, which are the actions people engage in typically to try and alleviate their concerns. If anybody is troubled by these and it’s beginning to interfere with their ability to function or causing them distress, that’s a good sign that maybe getting help is a good idea because nothing is ever harmed by getting some help and getting another opinion.

Mark Antczak: And a couple of things you mentioned there really stand out. So it sounds like when we have these kind of persistent thoughts that are quite distressing in nature or when we have a lot of these compulsions that really take up a lot of our time or detract from our quality of life or functioning, is there a threshold that you need to meet, or as you’re mentioning just at any given point, if you feel it’s distressing to you, that’s the time to get that help?

Dr. Peggy Richter: It’s a great question, and, ultimately, I would say an individual needs to make that decision for themselves subjectively based on how they’re feeling. The yardsticks that we use for diagnosis, though, are basically exactly that. We would call somebody as having OCD, being diagnosable with OCD if they themselves define it as causing them subjective distress. “So I’m getting these thoughts. They’re upsetting to me. They actually are really quite disturbing.” That’s enough. If they are interfering with your ability to function in any way, that is enough. Or, in the case of OCD, the one little unique option as well is if these symptoms aren’t so distressing, maybe aren’t really preventing you from doing things normally, but slow you down enough that they may waste an hour a day or so. That would be another threshold we look at for diagnosis.

Mark Antczak: Okay. Yeah, because we kind of acknowledge that OCD lies on a spectrum, and although there’s a lot of chronicity with it, we also know that the main kind of measure is severity, as you had put once. And it really, I think too, I often see a lot of folks come in when they say, “I don’t think it’s bad enough. I don’t know if it warrants the support.” But what you’re advocating for is if it bothers you, if it’s distressing, if it meets any of these kind of thresholds, go ahead and get some support.

Dr. Peggy Richter: Exactly.

Mark Antczak: Yeah. Okay. So let’s say someone is kind of at that point. They want to get some support. They want to get some help. Where do they start? What are some of the first steps you can take?

Dr. Peggy Richter: So great question. My usual starting point would be to say call your family doctor. Now, in Canada, I have to be realistic and recognize that that may not be quite as easy as it used to be, but seeing a family physician at a walk-in clinic may also be a good way to get started. Any general physician should be able to recognize the signs and symptoms of OCD and give you at least some guidance around what next steps are.

The other thing I can’t speak to strongly enough is becoming your own best informant, your own best caregiver, by learning about the illness. And that means going to resources. There are some fabulous online resources that will give people a lot of information if they’re wondering if what they’re dealing with might be OCD. So, for example, websites such as the one run by the International OCD Foundation at iocdf.org has a wealth of information. Similarly, Anxiety Canada at AnxietyCanada.com has fabulous resources now for the whole spectrum of anxiety disorders, including OCD.

And I guess the last resource I’ll just highlight, although it is slimmer than the others, but has other materials, is our own website at the Thompson Centre, which can be found at sunnybrook.ca/thompsoncentre, one word, because we also highlight support groups for example, and list other websites as well as some of the wonderful self-help books that are out there. And there was a lot of evidence actually that for people with mild issues, simply attending self-help books and or what we would call self-help therapy bibliotherapy reading about it may often be enough to help get them on the right path.

Mark Antczak: Okay. So I’m really hearing almost kind of like a proactive approach where if you even start to kind of notice little whispers of it, being able to take some of that decision-making power in your own hands, looking at some of these resources that we’ll certainly share on our link here, that could almost prevent it from getting worse. That could be an early intervention of sorts that prevents it from becoming more severe.

Dr. Peggy Richter: That’s a lovely way to put it. And we do know that seeking treatment earlier is always better than later on. Most people will do better the earlier in the course of illness that they seek help.

Mark Antczak: Mm-hmm. No, such an important point, and I want to go back to this piece around a family physician or a walk-in doctor. It is true that it is getting increasingly more difficult to find that kind of support.

And I’ve also heard a number of folks, for example, with specific type of obsessions, for example, one that may be a bit more taboo in nature, often involving either self-harm, harming of others, any kind of paraphilic kind of components.

I’ve heard occasional stories where sometimes clinicians may not be able to recognize that as OCD. Do you kind of have any thoughts on what to fear with folks that may be ambivalent to seek out help if they worry about that?

Dr. Peggy Richter: I’m really glad you raised that, and I wish it weren’t so, but what you raise is a valid point and, unfortunately, we all hear the occasional really unfortunate story because OCD commonly can involve what we call taboo thoughts.

So violent thoughts, images or impulses of stabbing people or other ways of harming people, driving cars into people and traffic, intrusive sexual thoughts that are very disturbing, not pleasurable in any way, whether they involve family members, people of the gender one doesn’t view oneself as attracted to, children or other subjects or topics, and what we often call scrupulosity or religiosity.

So thoughts about having acted in immoral ways or going against religious beliefs. And these cause tremendous anxiety for good reasons. Sometimes, people who aren’t familiar with OCD may misunderstand them.

So having said that, your question is a really important one, and I can’t give any one answer beyond this, which is if you have a good relationship with your family physician and you know them to be somebody who is open to mental health, then I advise your listeners to go and just be upfront and ask about it. And a sensitive and reasonably knowledgeable doctor may say, “This isn’t my expertise, but let’s get you seen by somebody who does have that knowledge,” and refer you onto a psychiatrist.

If you don’t have that kind of a relationship and you’re seeing a doctor for the first time and you are concerned, it is also perhaps a reasonable consideration to talk about other OCD symptoms that are not as likely to be misunderstood. Keeping in mind that most people with OCD have multiple types of symptoms. So one could talk about one’s checking symptoms, for example, and even in the case of people whose primary concerns are perhaps around being responsible for harm to others, they may have all kinds of checking rituals they would feel comfortable talking about.

“I have to check when I drive the car that I didn’t hit someone. I have to check that my family members are safe and didn’t come to harm.” There are lots of other ways of disclosing symptoms without necessarily volunteering those elements and then asking themselves for a referral to a mental health provider who will better understand OCD.

Mark Antczak: Right. So even just recognizing, even if the nature of my thoughts feels really vulnerable, it feels really terrifying to talk about, I can talk about the way that it comes out. So I excessively track. I can’t get certain thoughts out of my brain. I feel really stuck. I feel like I lose hours to all of these different kinds of things that I have to do to get relief. Even if they don’t know OCD very well, that in and of itself should be at least recognizable or a safer way that [inaudible 00:12:42] care that you’re struggling.

Dr. Peggy Richter: I love the way you put that. Exactly.

Mark Antczak: Yeah. It is unfortunate, right. Because, I mean, I hear a lot of these stories, especially kind of more recently, a lot of moms, for example, brand new moms, we have a lot of narratives, and we have a lot of education on postpartum depression. But postnatal OCD, as an example, is something that I feel like is becoming more prominent, but it’s still very much missing. So, we’ll sometimes get these moms that are having these thoughts about harming their kids in different ways for a year or a couple of years before severe enough where they seek help for it.

Dr. Peggy Richter:  Yes, that is such a vulnerable time in women’s life. I mean, I will just as an aside mentioned, men are also more vulnerable with the arrival of a child. They may not have the biological factors going on that women are experiencing in terms of hormonal and other bodily changes. But the emotional stress of adapting to a new little one for whom you feel responsible is going to be triggering to anybody.

And we know that this is among the most common time points in women’s lives for OCD to announce itself or to become worse. And usually, at that time, the content does revolve around horrible concerns the women have that they will somehow deliberately harm their child or be responsible for harm to the child. Totally, understandably. I think most people who’ve had children can probably relate to some extent to that feeling of, “Oh my gosh, I am now responsible for this new person.”

But for people with OCD, it goes above and beyond, and getting help is so important because there is good treatment, and this can be helped.

Mark Antczak: Absolutely. No such an important message, and truly, I think even anytime that I have someone come in and they share those words for the first time, “I’m having thoughts about this really taboo thing,” and I say, “It kind of sounds like this really is OCD.”

Often times, it’s almost like this wave of relief that often is accompanied by just people crying, just emoting so intensely because of that palpable relief of saying, “Oh, a professional just told me that this isn’t me wanting to do something abhorrent or terrible.”

Dr. Peggy Richter: I’d like to follow up on that point and just say when we do psychoeducation with patients, to that point precisely, it’s sometimes a huge sigh that you see going through them when I share that, in fact, we… none of us can control our thoughts, and we all get bizarre, disturbing, sometimes, frankly, repugnant, or inappropriate thoughts. That’s the human condition. So people with OCD may be attaching more importance to it. The thoughts may be stickier, but they’re thoughts we all get.

Mark Antczak: Absolutely. Yeah. It’s how we make meaning from these very normalized thoughts versus whether we have them at all because we can’t ultimately control them, as you’ve said. So you mentioned psychoeducation, so kind of segueing into how we’re navigating finding a therapist that knows how to educate on OCD, a therapist that knows how to work with OCD, what are some of the things that you can do as someone that’s looking for a clinician to basically verify that they’re trained in treating it?

Dr. Peggy Richter: That’s a great question. So I think it depends on whether we’re talking about psychiatrists or other mental health professionals to some extent in the sense that if medication is somebody’s preferred treatment choice at that point, then any psychiatrist and, in fact, in general, any family physician should be familiar with how to initiate the starting medications for OCD, what we would call our first line medications or those that have the best balance between evidence of benefit and possible adverse events or side effects, which are the SSRI antidepressants, frankly, the selective serotonin reuptake inhibitors, which are the most commonly prescribed antidepressants in any event.

Now, if we’re talking, however, about psychological therapy, CBT typically being what we call our first-line psychological treatment with the strongest evidence by far, then that’s where it does get trickier because it is very reasonable for anyone as a consumer to ensure that their person they’re seeing has had specific training in OCD. One of the painful lessons we know from research studies out there is that a very large percentage of mental health practitioners, including psychiatrists who say they do cite CBT, psychologists and others, whether they be social workers, nurses, other mental health professionals, if they haven’t had treatment specifically in CBT for OCD, we know that generic CBT, the kind of CBT we are generally taught first to be used for depression and to some extent anxiety is ineffective for OCD.

And I want to make sure that was very clear to people. General CBT not targeting OCD is ineffective for OCD. So it is really reasonable and important to ask your prospective therapist what experience they’ve had with OCD. Have they had any specialized training, whether it was during the formal education they had to get their degree, whether it was subsequently as an intern or practicum or in a work setting where they were supervised specifically with OCD cases? Those are fair questions, and frankly, my own perspective is that if a therapist is uncomfortable answering them, then that, to me, is a good sign they probably don’t have that specialized training. And while they may be wonderful therapists and great people, I will just not feel as confident that they know how to directly target OCD.

There is one other thing I will mention, and that is something called the BTTI, the Behavior Therapy Institutes that are run by the International OCD Foundation. These are not essential by any means, but they are one type of educational initiative that has been developed by the major public group that supports people with OCD. And they do a very good job of giving mental health practitioners basic grounding in CBT for OCD, really a lovely job. They’re pretty available, and that would be another type of training people might seek out.

Mark Antczak: Such an important point. So I’m hearing just a couple summary points there. So finding a therapist that’s willing to even answer the question here’s the kind of experience I had, acknowledging whether or not they’re willing to actually talk about the extensive experience they have, how many hours perhaps they’ve trained in it.

The BTTI program, having done a number myself, such a foundational program because it just gives you all of the basics plus some because there’s different levels of it, if memory serves, where you can come at a beginner’s level or do more advanced training as a clinician. You mentioned all these different trainings. Would you mind kind of sharing some of the specific modalities that you could even tell folks to look out for? So I’m asking about training. What kind of training do they need specifically besides the BTTI? What do they teach in that?

Dr. Peggy Richter: So I should also just say there are lots of other groups around the world that offer trainings intermittently or occasionally, and I don’t mean in any way to disparage any others. It’s just that the BTI has been a steady offering so it’s one easy one to recognize. In terms of what you’re looking for. You’re looking for somebody who has specific skills in exposure and response prevention as an absolute starting point. That is a form of cognitive behavioral therapy. It actually comes under the B of CBT, standing for the behavioral. It’s our basic behavioral approach to OCD is evidence-based. It was the first first-line treatment to be recognized for OCD.

Now, many will also have cognitive therapy training, and usually, that is integrated in, and that’s when we use that full-term CBT. But CBT for OCD typically still includes that exposure and response prevention element, what we consider to be the behavioral part of the treatment. There are lots of other types of psychotherapies, and there is really a lot of interest and research going on into looking at them, but none of the others have attained what we would call first-line evidence yet.

So, for example, to name just a few, mindfulness-based cognitive therapy is a very helpful intervention for depression and a host of other issues and has been researched for OCD with good outcomes. There is a newer version of CBT called inference-based CBT, I-CBT for short, which has also gained a lot of attention and looks very good, but again, these would not yet be considered first-line treatments.

Mark Antczak: Mm-hmm. Okay. Yeah, so we’re kind of seeing a little bit of a hierarchy based on the amount of evidence that’s been collected, looking at the efficacy rates about how well that modality works. So I’m hearing, ask if they have specific training in ERP, asking if they have some training in cognitive components or cognitive work, not general CBT because that is deemed ineffective for OCD specifically.

And if they say they primarily work through things like mindfulness-based cognitive therapy, if they work through things like I-CBT or ACT, that they should have some caution because it’s not considered first-line treatment at this point.

Dr. Peggy Richter: Exactly. They can be wonderful add-ons, but I would want to be seeing a therapist who is still familiar with the basic CBT approach who then is able to use some of these other techniques to enhance it.

Mark Antczak: Mm-hmm. Okay. Excellent. Excellent points. And yeah, I think you see so much of the trends that happen. Like I-CBT is really having a moment right now where people are saying, “It’s OCD treatment without the ERP,” and there’s so many folks I think you could attest to that don’t do therapy because they’re so terrified of doing any kind of ERP or any kind of exposure at the end of the day.

So, acknowledging that medication piece because I think that that may segway into how challenging it could be to do therapy sometimes. How would you help someone determine whether they are at a point where medication is appropriate, and if so, you’ve already mentioned a psychiatrist? What can they kind of expect from that?

Dr. Peggy Richter: Okay, such a good question. So I think my first starting point usually would be to say does the patient have a strong preference and to explore the reasons why they may have that strong preference to make sure it’s based on what we know to be true rather than perhaps some misinformation they picked up from a relative or friend who may have had an unusually difficult experience for some reason with one or the other.

So that’s my first starting point is, “Did you come in with a specific idea?” Because people’s preferences are important. Now, having said that, both medication and CBT as I mentioned before, would be absolutely considered first-line based treatments because of the excellent evidence showing that they benefit most people who receive them.

They have very significant pros and cons, though, which are things to consider by the individual. So something you mentioned would be many people being somewhat fearful of doing exposure-based work, which, as I mentioned, is the main state traditionally of any CBT approach which incorporates exposure and response prevention.

If people are fearful of it. Again, I want to go into why and see whether we can work around that, but something to consider is that with medication, people don’t need to necessarily begin by challenging their fears at all. With medication, you are taking a pill. That is an easy step for most people. Now, for some people, OCD may get in the way. But generally speaking, taking a pill once a day is not going to be all that challenging.

It doesn’t involve dealing with heightened levels of anxiety, and medication will be quite effective for the majority of people as long as they appreciate that the first pill alone will very likely not be sufficient in that only about 50% of people show a good response to the first medication they try.

So one of my first bits of information around medication is be patient, be willing to try a few different medications in order to find one that for you specifically has a good balance in terms of helping your OCD and not causing significant side effects that are going to interfere with your quality of life in any way.

Another thing about medication that is worth considering is that if people have multiple illnesses that come… that came on with their OCD, so, perhaps they have some significant burden of depression. They may have some panic attacks or panic-like episodes when their anxiety is really high and triggered. Perhaps they have another anxiety difficulty in the background that’s not as significant but nonetheless part of that picture. As the presentation gets more challenging in that way, that can also be a reason sometimes why we might favour medication.

And certainly, if the OCD is very severe in and of itself, in other words, as that burden of illness increases, that’s when our emphasis will increasingly be on making sure that we get some medication aboard if the person is willing to consider it because it may really ease their burden and open the door to more effective psychological treatment.

Now, on the other side, CBT has some very significant advantages that can’t be understated. Number one being that it is the most effective intervention for the majority of people. Some early studies have suggested, and some of the more recent ones as well, support at least 70%, if not 90%, of people benefiting from CBT when they actually engage in it and are doing the work.

And the work is the second big issue. It’s like learning any new skill and learning to think differently. And just as you wouldn’t expect to master piano with one lesson a week or become fantastic at hitting home runs in baseball if you only attended a practice once a week, the more you practice, the more you improve. And that means willingness to experience anxiety and face those triggers without doing the rituals. So CBT requires that huge commitment, but the reward is better likelihood of greater benefit and more long-lasting benefits.

Mark Antczak:Mm-hmm. So that reduction in potential relapse, unlike meds, for example, really kind of  provides you with a skill set that gives you some of those longer or more improved outcomes from the sounds of it?

Dr. Peggy Richter: Absolutely.

Mark Antczak: Yeah. There’s so many folks that I think I’ll do an intake with, and they will have all this motivation. They’ll have so much of this willingness to try and create this change to try and do the work. And then, once we get past the psychoeducation piece, there’s a lot of folks that really kind of freeze up because when they’re asked to start ERP, it’s just so overwhelming that they cannot even remotely comprehend the concept.

And I think in these kinds of instances, the way that I often describe is meds are there to kind of reduce the intensity of how those worries impact you. They make the thoughts a little bit less sticky in a sense, and once they get on some kind of medication that works for them, generally they have more capacity, they have more ability to regulate some of that anxiety so they can utilize the skills and the tools that they learn in therapy.

Dr. Peggy Richter:I couldn’t say it better, Mark. Exactly. I think, though, an important point I just want to mention because sometimes I hear misunderstandings about that is just to say once, again though, that although for more severe illness, absolutely medication can be crucial in opening the door to allow somebody to really invest in psychological treatment. At the mild to moderate end of the spectrum, many people will do beautifu lly without medication at all, and so we shouldn’t overestimate either the need for it.

Mark Antczak: Of course. No, absolutely. Such a good point. So just to kind of briefly touch up or add a few more details to the medication piece, so you mentioned SSRIs are kind of like the standard first line for any kind of medication support. Are there additional types of medications that people will sometimes try? Because we know there’s a lot of different classifications of medications, and what can folks kind of expect from those?

Dr. Peggy Richter: So there are quite a number of classes, although only the SSRI type of antidepressants are what we call first line. Again, just to come back to it, that’s based on a very high level of evidence from many studies which have been looked at in tandem supporting that the effects are real, typically what we call randomized, double-blind controlled studies, where people may be getting a placebo or other controlled medication to compare it with and don’t know in advance what they’re getting. So people’s expectations, including the doctors who are rating them, don’t cloud the findings of the study.

So when we have that level of evidence, and we know that the drugs are very safe as well as effective, that’s when we call them first line, and that is the SSRI group of antidepressants. There are a few other types of antidepressants that also have good evidence but not quite at the same level or with more side effects.

So those include the serotonin and norepinephrine reuptake inhibitors or SNRIs, as their classes know. And clearly, as you might tell by the title, they overlap in those serotonergic effects, which is one of the brain neurotransmitter systems, as well as also impacting the norepinephrine transmitter system. And these drugs are very safe, good antidepressants, just lower-level evidence for OCD.

The other type of antidepressants in this group is actually just one unique agent called clomipramine, which is an older type of antidepressant called a tricyclic. It has primarily serotonergic effects again and is actually relatively selective for serotonin, but does act on a number of other neurotransmitter systems. Interestingly, that may contribute to some of the benefit people may experience with it, but also does lead to more significant side effects with it.

And because of that, even though it’s been clearly shown to be extremely effective, we would also call it second line because those side effects can include a host of things, including orthostatic hypotension or dizziness when you stand up too rapidly, significant constipation, significant hesitancy when urinating and in a very small minority of cases, even a small risk of seizures. So we need to think about it a little more carefully because of that burden. And we typically reserve both the SNRIs and clomipramine until people have tried at least two SSRIs.

Mark Antczak: Okay.

Dr. Peggy Richter: I think a rule of thumb I’d also like to share is that treating OCD with antidepressants is not the same as treating depression. And there are two distinct rules patients, clients should be aware of, as well as their doctors. And that is that with OCD, while low doses may work, in general, statistically, the best odds of getting a good response are seen with much higher doses. And so, for most people, that will mean pushing up the dose if the low doses don’t work. So that’s number one, higher doses.

Rule number two is that it can take much longer to see a response to antidepressants in OCD than for depression. And so, a typical drug trial in OCD will require about three months of building up the dose and then giving it some time, at least six weeks or longer, at the maximum dose people tolerate or their doctor is willing to prescribe that they think will be helpful for their OCD. And that’s very different from depression, where often people would switch medications after six weeks.

Mark Antczak: Mm-hmm. So much nuance there. I’m really hearing that so much… so many of these decisions involve kind of like a cost-benefit analysis of, “Here are the different things that I can benefit from meds, but here are the tangible side effects that we might have to deal with versus am I willing to push through the initial discomfort in psychotherapy to be able to get the really palpable and tangible effects that come from that.”

Really such important pieces for folks to consider. And I guess when we talk about SSRI use, we can maybe start with that one, but can you briefly talk about what folks can expect? You mentioned it can take up to three months, so a little bit longer for OCD. But what’s the typical kind of trajectory for folks, or what do they experience on any kind of medication?

Dr. Peggy Richter: So typically, these medications are really well tolerated, as I mentioned, Mark, and very, very safe, but that doesn’t mean they won’t have any side effects. So it’s pretty typical for people to experience some mild side effects at least, and those could range between some GI symptoms such as a mild degree of constipation or nausea, perhaps a bit of a sense of sedation.

Or in some people’s cases, they may feel slightly more wired initially on the medications, and based on that, they may decide to take it morning or night to suit their schedule best. It’s not uncommon to have perhaps a bit of a fine tremor or a little bit of shakiness or a little increase in sweating. And unfortunately, sexual side effects, although usually mild, are pretty common for most people. So some drop in libido or slightly more difficulty getting aroused sexually. These are not permanent. All of these side effects tend to be dose-related, and most will get better over time.

Now, when people start feeling benefit, typically, what they’ll experience is a feeling that the intensity of the thoughts has just diminished a bit. So the thoughts are still there. “I’m still worried about contamination in germs when I touch these objects, but I found I’m a little more able to move past it.

And maybe instead of washing my hands three times in a row, I’ve lately said, ‘Oh, I’m in a hurry, I’ll just wash them twice or maybe even once,’ and then I went on with my day, and that’s a real change.” So it’s not that symptoms disappear for most people, but they will come down in that intensity, and that allows people to begin to challenge and limit them a bit more. And that will take, as I mentioned, anywhere from six to 12 weeks typically.

Mark Antczak: Okay. And so I’m really hearing it makes the thoughts less sticky, no pun intended, if with the contamination component. What would you say to someone who’s kind of going through the trial and error of meds? Because I think this is a common issue. It’s a common issue for folks when they’re struggling to decide, “Do I need to push through on this one? Do I need to just stay on this one and see if it gets easier?” At what point can folks make the decision to pivot and try something different?

Dr. Peggy Richter: That’s a great question. If the side effects are getting in the way of your quality of life, they’re unpleasant, they’re on your mind or in your body quite a bit of the time, then that, to me, is more than good enough reason to say, “This may not be the right fit,” particularly if you haven’t tried many medications yet.

Now, that equation may begin to change in somebody who’s had perhaps 3, 4, 5 medications or more without success. And then people may want to try and persist a little longer, not necessarily pushing the dose of any higher, but keeping it at whatever dose they find is manageable in the hope that, one, the side effects will diminish over time because they often do, or two, the medication is of so much benefit that it’s worth it to them.

Mark Antczak: Right. Right. Again, kind of doing that cost-benefit analysis, again, because I know, for a lot of folks, they’ll kind of go to their physician, they’ll get prescribed a med, and we typically do see more of that prominence of a side effect initially, and a lot of it subsides, but a lot of folks I find just have a hard time kind of deciding,  “How hard is it? Is it worth staying on this?”

And that’s kind of where I encourage them to go back and reflect and say, “Is the… Is any of the benefit problematic enough, or rather are any of these side effects rather problematic enough that are impacting your quality of life?” Going back to that original definition of OCD, “Are these thoughts problematic enough in my life? Are they preventing me from doing things that are important to me?”

Dr. Peggy Richter: Yeah. And I would take the same approach, the side effects, particularly in somebody who’s only tried one or two or maybe three medications because there are so many options out there. It’s very likely that another medication in the same class may be better tolerated.

Mark Antczak: Okay, so let’s say someone’s on meds. They’ve been filing different pieces out. They’ve kind of found one that they work well on. They are in psychotherapy. They’re doing ERP. They’re doing the cognitive work for OCD, and OCD is still resilient enough, and it’s sticking around. What are the options for folks like that, people in those positions?

Dr. Peggy Richter: Okay, so first off, there are certainly other drug therapy options we haven’t covered, and maybe this podcast isn’t the one to go in huge detail, but there are other kinds of drugs we use, such as antipsychotic medication, which I think is often confusing to people, but these are medications that just happen to work on other brain transmitter systems, specifically the dopamine system, in addition to serotonin. You’ll hear serotonin coming up again and again.

And these drugs can be very helpful as add-on medications or augmentation of antidepressants for OCD. There’s also another class of medications that are increasingly a group of interest in research, which are medications that work on glutamate, yet another brain transmitter system, and some reasonable but still limited evidence that a number of drugs in that class can also help people as add-on drugs. So, first of all, people should be trying multiple antidepressants and considering those add-on medications.

I think something else to keep in mind is that even if people have an excellent family physician who’s managed things really well while they tried their first three or four drugs, at some point around then certainly by the fifth, if not earlier, it makes sense to seek out a specialist such as a psychiatrist, ideally someone who feels they have some familiarity with OCD to get another opinion and just ensure first of all, that OCD is the problem and that the medications being used are the best choices and have been used at appropriate dosages. So that’s kind of my starting point before we talk about resistance.

Mark Antczak: Yeah. No, great point.

Dr. Peggy Richter: If somebody, however, has had good drug therapy, multiple drugs not working the way they would like, they’ve tried good CBT, they’ve given it their best, and they really aren’t able to make those gains, that’s when we begin to call it the illness treatment-resistant. And fortunately, things are a lot better than they were 20 years ago for people in that position.

So we actually have pretty good evidence that intensive CBT can work extremely well even for people who have failed routine outpatient CBT. What do I mean by that? So there are a number of different definitions, but most people would say treatment that is at least twice a week. More commonly, though, we use it to refer to treatment in a hospital setting or as a day hospital patient.

So whether or not you stay in a residential treatment setting or a hospital setting, or you’re coming and going five days a week, nine to four, nine to five, you’re getting very intensive treatment at least five days of the week from a team that has more significant expertise in OCD. And this can work for actually the majority of people, even with resistant or refractory OCD, at least in terms of seeing some benefits if not attaining remission. So that’s number one.

Now, there are a number of these centers in the US that could be a bit of a challenge for many people. Some provinces will cover that more readily than others. There’s only one centre in Canada, so I know this sounds perhaps a little like I’m beating my own drum, but at the Thompson Centre, we do run the only publicly funded intensive treatment program right now where we offer both live-in care or day treatment depending on the individual, and that is available to people from across the country at present. So that’s one option.

Beyond that, we get into other types of biological treatments, which can range from non-invasive to more invasive. So, for example, some of your listeners may have heard about repetitive transcranial magnetic stimulation or deep transcranial magnetic stimulation. TMS is the acronym for these, and these are a form of treatment in which an individual is subjected simply to a high-powered magnet over their head. Sounds pretty simple, pretty harmless, and it is. It’s very safe.

There are, of course, more specifics to it. But it turns out that a high-powered magnetic field over the head will induce changes in electrical activity in the underlying brain areas and change that brain activity in ways very similarly to the way medication and CBT affect changes in the brain. The catch with this is that although there is pretty good evidence for both rTMS and dTMS at present, neither are funded publicly generally in Canada, which makes both very difficult to access other than privately.

Mark Antczak: Right. Right.

Dr. Peggy Richter: So they are an option depending on your situation, whether you happen to live near a hospital that may be willing to give it to people with OCD despite not being funded for it or if you are able to pay for private course of treatment, which can be quite costly. Just to be very clear, we’re talking about four to five digits of funding needed for people. After that-

Mark Antczak: Really acknowledging just the amount of barriers in place, whether it’s cost availability. There’s… And just to intersect on this too, how often would you say what percentage of cases warrant past the medication n and psychotherapy component because I think that’s an important piece to note there too.

Dr. Peggy Richter: Well, our best estimates are that at least 20 to 30% of people with OCD become treatment-resistant. And so that’s when I would say, first of all, think about more intensive CBT always because that doesn’t involve any risks.

It is publicly funded, although limited accessibility right now, and that’s a really great option for gaining those long-term skills. But otherwise, we then need to think about these options. Now, rTMS is lovely, and dTMS is lovely. I will also point out that we don’t have as much evidence about how helpful they are in people who have failed multiple previous treatments. There is limited evidence.

Mark Antczak: Okay. Okay.

Dr. Peggy Richter: After that, though, there are a couple of more invasive biological treatment options that I don’t want to spend much time on today, but just to make your listeners aware that they exist. So the two major types of treatment we know that can work by directly changing the activity in the brain is something called deep brain stimulation or DBS for short and psychosurgery.

Mark Antczak: Okay.

Dr. Peggy Richter: Now, in brief, DBS involves drilling two burr holes in the skull to drop two little thin wires called electrodes deep into the brain that are then connected to a controller device that’s implanted on the chest wall, just like people have if they have a pacemaker for the heart. You could actually think of this as akin to a pacemaker for the brain circuit involved in OCD.

And by changing the degree of stimulation and the type of stimulation, we can change again that electrical activity in that brain circuit. And about 70% of people with severe resistant OCD see some benefit. But this is long-term. It is invasive and really requires regular follow-up and proximity to a center with advanced OCD expertise that offers this kind of care.

Mark Antczak: Right. Right.

Dr. Peggy Richter: The last category of options I want to touch on are perhaps, in some ways, more frightening, maybe for some people less so, and that is what we call psychosurgery, by which we’re talking about creating lesions in the brain circuit responsible for OCD. So again, our target is those same areas of the brain.

The difference here is that traditionally, it would be done by literally burning or cauterizing two very small specific lesions in the OCD circuit on each side of the brain. That’s done in an operating room, one day, in and out. The wires don’t remain. There’s nothing that remains behind. But once those lesions are created, they’re long-lasting. Now, that has been around since the 60s in its contemporary form for OCD, but had significant side effects.

There are other methodologies that have been looked at, including what we call Gamma Knife radiation, which uses a form of radiation that was developed frankly for people with inoperable brain lesions, for example, and allows us to still burn those areas of the brain with exposure to radiation, but without cutting into any tissue. That’s also an option. And the most recent technology that is still emerging and being researched is something called Focused Ultrasound. And this is available at just a few sites around the world, Sunnybrook being one of them, in which individuals are basically exposed under live MRI imaging guidance.

So we see the brain and its activity in real-time to about a thousand beams of ultrasound, which converge on a single spot and will raise the temperature in that spot to burn and create those lesions. So, the same end result, but no cutting, no risk of an invasive surgery, and so far, the outcomes look excellent. So these are all means to a same end. Now, I want to just end with a brief caution about these, which is that all of these treatments, when I talk about, well, certainly deep brain stimulation and any form of psychosurgery, regardless of how it’s done, typically right now, we think of as treatments of last resort.

These are never a starting point, and these should never be entertained lightly, and they should typically involve talking to a number of care providers with specific expertise in these treatments because we want to reserve them for people for whom other less invasive options have been exhausted. But they do offer hope for that group of people.

Mark Antczak: Absolutely. It’s such an aggressive range of different interventions that you’ve listed and shared in the last half hour here. It’s really showcasing the importance of kind of going through the steps, looking at how those early interventions have the least amount of risk. And as you get into more treatment-resistant territory, you’re getting into more of that risky territory. We’re still offering that hope and offering the different options.

Really, really appreciate all this insight. One of the final questions I just want to ask, because you work in a center where you see a lot of that kind of treatment-resistant OCD. For those that may be feeling a lot of hopelessness right now, that their OCD is unmanageable, that it’s never going to get better, what are some words that you can share with them? What could you leave them with at this point?

Dr. Peggy Richter: Okay. I think that’s a very important question, Mark. I’m so glad you asked that too. I think first of all, for anybody who feels they’re in that situation, I want them to be sure that they are seeing a team with really deep expertise in OCD that, frankly, that they’ve sought out several opinions, not just one provider, whether it be me or any of my colleagues across the country like me because any of us are capable of overlooking something and having a bit of tunnel vision. So you really want to make sure that nothing perhaps really helpful has been overlooked and that the diagnosis is accurate. The treatment has been the best treatment possible.

After that, I want people to really give some thought to some of these more invasive treatment options I’ve mentioned. They do tend to be underutilized. Well, I think I’ve emphasized that we think of them and position them as treatments of last resort. The point is they are there, and I have seen some people make really substantial recoveries after receiving one of these types of treatments when everything is left hopeless. So that is also an option to consider. And thirdly, is that OCD is still a mystery, and we know that some people spontaneously, over time, will change.

There are also other types of psychological treatment, which, rather than targeting the OCD directly, may target focusing on having a good quality of life, even if OCD continues to be there. And while this may sound to some people like a pipe dream, it is not. I have seen these types of treatment work. And so I really do encourage people to think more broadly, to seek out those multiple opinions and to think about some of these other treatment alternatives and to always try to have some hope and focus on having the best quality of life and doing those things that give their life meaning regardless of OCD.

Mark Antczak: Right. Right. So we’re seeing making sure you have a good team, making sure you have a team that has a lot of expertise, making sure you’re getting those second opinions to make sure nothing’s been overlooked, making sure that you don’t negate those kind of more severe interventions. If it warrants that or those professionals that you’re working alongside with, I think it would be a good intervention at that point.

And also acknowledging that we do have a broad spectrum of different therapies, that even if traditional ERP and cognitive therapy for OCD may not be working wonders, doing a little bit more radical acceptance value-based action and living with some degree of OCD, even if it is leading to some dysfunction or a lot of distress, could still be very worthwhile as well.

Dr. Peggy Richter: Yes, exactly.

Mark Antczak: Peggy, thank you so, so much for your time today. You’ve given me so much to think about and for our listeners. I think so much of this information is hard to be able to disseminate and to create in such a succinct way as you did today. So, really, from the bottom of my heart, thank you so much for being here, and we appreciate your time.

Dr. Peggy Richter: Thank you so much, Mark.

Outro:  Thank you for listening to #OurAnxietyStories, the Anxiety Canada podcast. To share your own story or to find resources and support this podcast, visit us at anxietycanada.com.