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Canada’s first intensive residential program for severe OCD

The Frederick W. Thompson Anxiety Disorders Centre at Sunnybrook Health Sciences Centre now provides the country’s first intensive residential treatment program for severe obsessive-compulsive disorder (OCD).

The program offers care for up to 12 patients with refractory (treatment-resistant) OCD, at any one time.

It focuses on treating individuals with severe OCD symptoms who require a more intensive and individualized treatment option, and uses a stepped-care model in order to ensure the most effective treatment is being delivered, at the right time for each person. Residential treatment has been shown to provide a safe and therapeutic environment within which the most severely ill receive the support needed to actively engage and benefit from the therapies provided.

This program focuses on providing intensive cognitive-behavioural therapy to clients, in the context of a holistic approach including occupational therapy, pharmacotherapy, and a social worker who will work with clients’ families to best support recovery. Connections are also developed by the treatment team with the clients’ community care providers to best support transition back to the community at time of discharge. Follow up and/or support of outside care providers can be provided as part of the continuum of care at the Thompson Centre.

As part of the world-leading Hurvitz Brain Sciences program at Sunnybrook, the integration of this leading-edge program within an academic health sciences centre also provides access to the latest innovations and treatments such as high-intensity focused ultrasound (or “scalpel-free”) neurosurgery currently being tested for severe OCD.

The program accepts referrals from family physicians and psychiatrists in Ontario. Eligibility and suitability for the program is determined through a careful assessment process including information packages completed by physicians and clients, and is managed by the Thompson Centre Intake and Patient Navigation Coordinator. All admissions will be reviewed by the team to make the final determination regarding likelihood of benefiting from this treatment approach.

Information regarding the referral process can be found on the Thompson Anxiety Disorders Centre website

About OCD and refractory OCD

Obsessive-Compulsive Disorder (OCD) is a psychiatric disorder that affects approximately 2.5 per cent of the population, and has been cited by the World Health Organization as the 10th most disabling medical condition worldwide.

OCD is characterized by obsessions, or intrusive, unwanted thoughts, images or impulses, which are disturbing, and persist despite efforts to resist them. Obsessions are typically accompanied by compulsions or rituals, which are repetitive behaviours or mental acts which the individual feels driven to perform.

Approximately 20 per cent of those diagnosed with OCD are severely debilitated and rendered gravely disabled, often becoming homebound and isolated, and resulting in poor quality of life and economic hardship. Moreover approximately 13 per cent of individuals with OCD attempt suicide, with 30 per cent reporting suicidal ideation.

These individuals have typically failed treatment at a lower level of care (i.e. medication and/or psychological treatment) and are unable to have their needs met through the current mental health system. This level of illness severity often cannot be effectively treated with outpatient services alone, and current inpatient treatment settings generally do not have the necessary expertise or resource for treating this chronic illness. This may result in no help being received, or some patients seek treatment in the U.S. instead.

Individuals with severe OCD for whom treatment does not work collectively account for most OCD-related psychiatric hospitalizations and remain substantially impaired. Ontario spends an estimated $828 million annually on OCD including direct and indirect healthcare costs, the bulk of which is likely attributable to this very impaired and severe group.

Treatments

Evidence-based treatments for OCD are comprised of drug therapy and a specific type of psychotherapy known as cognitive-behavioural therapy (CBT).

In terms of drug therapy, there is a great deal of evidence for first-line pharmacotherapy, specifically selective serotonin reuptake inhibitor antidepressants (SRIs). Unfortunately, most individuals obtain only a limited response to these medications. Typically only 40-60 per cent of individuals respond to any one medication tried, with an average 25 per cent reduction in symptom severity. This means that many people being treated using this first-line drug therapy often remain significantly debilitated, despite achieving a ‘response’.

Cognitive-behavioural therapy (structured individual or group sessions that typically take place weekly) is more successful, with up to 90 per cent of people responding with more significant improvement. Unfortunately, it is estimated that at least 30 per cent will refuse CBT, drop out prematurely or be deemed inappropriate, often because symptoms are very severe or complex. Additionally, OCD-specific CBT requires specialized skills and knowledge for optimal effectiveness, and there is currently very limited capacity for this treatment in Ontario currently.

For individuals who are resistant to treatment or have extrermely severe illness, there is some evidence for experimental biological therapies (e.g. repetitive transcranial magnetic stimulation [rTMS], deep brain stimulation [DBS], and psychosurgery).

Intensive residential treatment has been successfully used to treat severe OCD in the USA, UK, Germany and Australia, and there is evidence of significant benefit with this approach. For example, a large-scale USA study demonstrated a mean decrease in OCD severity of 30.1 per cent in 403 individuals, while in a recent UK study of 472 treatment-refractory cases, 69 per cent were significantly improved, and almost 50 per cent were asymptomatic by discharge. The core therapeutic component of intensive residential treatment is CBT, delivered intensively in a supportive safe environment.

The establishment of an Ontario intensive residential program modeled on those shown to be effective in other jurisdictions provides an opportunity to address a number of those challenges, in addition to providing other benefits derived from receiving care closer to home including: better transition and stepped care options, improved discharge planning, and coordinated family and health service provider supports.

About the Thompson Centre

The Frederick W. Thompson Anxiety Disorders Centre at Sunnybrook is Canada’s only centre specializing in OCD and related disorders, with a track record of delivering evidence-based, effective treatment with highly specialized staff in an accessible area of Toronto, within the context of a well-recognized and academically affiliated centre.

The Centre is an innovator in research, education and clinical care for obsessive-compulsive and related disorders, currently providing OCD-specific group-based cognitive behavioural therapy, mindfulness-based cognitive therapy, psychopharmacology treatments and consultations.

The Thompson Centre was created in 2013 in response to the unmet needs of people with OCD, and since that time has served hundreds of patients in the GTA and beyond with mild to moderate OCD and related conditions.

In 2015, given the Thompson Centre’s expertise and role in the treatment of OCD, a strategic decision was made to narrow its clinical focus to provide care directly to those with severe OCD, while building capacity in partnering with other health service providers to deliver the evidence-based care needed for those with milder OCD and related disorders.

The Thompson Centre offers a full continuum of care enabling patients to receive the right level of care, in a timely fashion. The complete continuum of care includes: clinical consultation, residential treatment services, day treatment programming and outpatient services.

The intensive residential program is an important addition to the specialized services already being delivered by the Thompson Centre, filling out a full continuum of services for those with treatment-refractory illness.