Exposure and Ritual Prevention Therapy for OCD

Adding cognitive behavioral therapy (CBT) consisting of exposure and ritual prevention (EX/RP) to an antidepressant regimen is more effective than adding an antipsychotic or taking an antidepressant alone in adults with obsessive-compulsive disorder (OCD), according to a recent study.

These results indicate that “OCD patients on serotonin reuptake inhibitors (SRIs) should be offered the addition of EX/RP before being offered the addition of antipsychotic medications, given the greater efficacy and safety of EX/RP,” said Helen Blair Simpson, MD, PhD, lead study author, Professor of Psychiatry at Columbia University Medical College, Columbia University, and Director of the Anxiety Disorders Clinic and the Center for Obsessive-Compulsive and Related Disorders at the New York State Psychiatric Institute, New York, New York.

“We hope that these data will impact clinical practice and help more patients with OCD achieve wellness,” she added.

Few patients with OCD achieve minimal symptoms from taking SRIs alone, the only medications approved by the US Food and Drug Administration for the treatment of OCD. In those individuals who experience some SRI response, adding antipsychotics or CBT is recommended in practice guidelines.

“This is the first randomized controlled trial to directly compare two recommended strategies for augmenting SRI response: the addition of an antipsychotic medication like risperidone and the addition of CBT consisting of EX/RP,” noted Simpson.

Patients were eligible for study participation if they had OCD of at least moderate severity and were receiving a therapeutic SRI dose for at least 12 weeks prior to the start of the study.

While continuing the SRI treatment at the same dose, researchers randomized 100 patients to the addition of 8 weeks of risperidone treatment (up to 4 mg/d if clinically indicated; n=40), 17 twice-weekly EX/RP therapy sessions over 8 weeks (n=40), or placebo (n=20); 86 individuals completed the trial.

Researchers conducted assessments on the participants’ progress every 4 weeks using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) to measure OCD severity.

Simpson and colleagues found that after 8 weeks, 80% of patients receiving EX/RP experienced a Y-BOCS score decrease of ≥25% as compared with 23% of risperidone patients and 15% of placebo patients. Further, 43% of patients randomized to EX/RP achieved OCD symptoms reduced to a minimal level (Y-BOCS score of ≤12) as compared with 13% of risperidone patients and 5% of placebo patients.

The authors also reported that adding EX/RP to SRI therapy was superior to both risperidone and placebo in improving insight, functioning, and quality of life.

Risperidone was not superior to placebo on any outcome.

Some limitations of the study as noted by the authors include the following: (1) there are no measures of the patients’ OCD severity prior to SRI treatment to quantify the degree of SRI response; (2) factors such as differential expectancy could have contributed to the study outcomes; (3) because only a small percentage of the study population (5%) reported a lifetime tic disorder, these data could not address the question of whether antipsychotic augmentation is most helpful in those with OCD and tic disorders; and (4) the study design could not address whether individuals with OCD who are taking SRIs and do not respond to EX/RP might benefit from risperidone augmentation. 

According to Simpson, future research should focus on whether patients with OCD who are taking SRIs and achieving wellness from the addition of EX/RP therapy need to then continue with their SRI medications and on treatments to help patients with OCD who do not respond to the combination of SRIs and EX/RP.

This study, published online in JAMA Psychiatry on September 11, 2013, was funded by National Institute of Mental Health grants R01 MH045436 and R01 MH45404; medication was provided by Janssen Scientific Affairs LLC. Additional disclosure and funding information is available in the study.

For more information, visit www.ocdtreatmentstudy.com or www.columbia-ocd.org. 

-Meredith Edwards White

Reference

Simpson HB, Foa EB, Liebowitz MR, et al. Cognitive-behavioral therapy vs risperidone for augmenting serotonin reuptake inhibitors in obsessive-compulsive disorder: a randomized clinical trial. JAMA Psychiatry. 2013 Sep 11. doi: 10.1001/jamapsychiatry.2013.1932. [Epub ahead of print]