Adjunctive CBT First Choice for Refractory OCD

Megan Brooks

September 11, 2013

For patients with obsessive-compulsive disorder (OCD) that is not adequately controlled with a serotonin reuptake inhibitor (SRI), adjunctive cognitive-behavioral therapy (CBT) is better than adding an antipsychotic, a new study shows.

SRIs are effective at reducing OCD symptoms, but many patients will have ongoing symptoms that will require additional treatment. Existing guidelines currently recommend 2 options: adding an antipsychotic medication such as risperidone, or adding CBT consisting of exposure and ritual prevention (EX/RP).

"We found that adding EX/RP to SRIs was superior to risperidone and pill placebo in reducing OCD symptoms and improving insight, functioning, and quality of life," study investigator H. Blair Simpson, MD, PhD, who led the study, told Medscape Medical News.

The study was published online September 11 in JAMA Psychiatry.

Superior Efficacy, Fewer Side Effects

The investigators compared the effects of these 2 SRI augmentation strategies (vs pill placebo) in 100 adults from 2 outpatient OCD clinics. The patients had OCD of at least moderate severity despite receiving a therapeutic SRI dose for at least 12 weeks.

For 8 weeks, 40 patients received risperidone, 40 received twice-weekly EX/RP sessions with a therapist (17 sessions), and 20 received pill placebo in addition to their existing SRI.

At week 8, patients who had had EX/RP added to their regimen saw significantly greater reduction in OCD severity, as determined on the basis of the Yale-Brown Obsessive Compulsive Scale (Y- BOCS), compared with those for whom risperidone or placebo was added (both P < .001). Patients receiving risperidone did not significantly differ from those receiving placebo (P = .83).

A decline in Y-BOCS score of at least 25% was achieved in 80% of patients for whom EX/RP was added; it was achieved in 23% of those for whom risperidone was added; and it was achieved in 15% of those for whom placebo was added (P < .001). More patients receiving EX/RP achieved minimal symptoms (Y-BOCS score of 12 or less; 43% for EX/RP, 13% for risperidone, and 5% for placebo, P = .001).

Dr. Simpson, who is professor of clinical psychiatry in the College of Physicians and Surgeons at Columbia University and is director of the Anxiety Disorders Clinic and the Center for OCD and Related Disorders at the New York State Psychiatric Institute in New York City, said that these data have 2 important clinical implications.

Dr. H. Blair Simpson

"First, OCD patients on SRIs should be offered EX/RP before antipsychotics, given its superior efficacy and lower rate of side effects. Second, if risperidone is tried, clinicians should know that it is likely only to help a small subset, and it should be discontinued after 4 weeks if there is no obvious benefit."

"These data also show that many patients with OCD who have a partial response to an SRI medication can improve further when EX/RP is added, and some can become well with minimal symptoms."

The investigators have received additional funding from the National Institute of Mental Health to study whether those who become well after the combination of SRIs and EX/RP can maintain their wellness, even if some discontinue SRIs, Dr. Simpson said.

"We are actively recruiting patients both here at Columbia University and at the University of Pennsylvania and hope that people will call us if they might be interested in participating," she said.

Intriguing Data

In an accompanying editorial, Kerry J. Ressler, MD, PhD, and Barbara O. Rothbaum, PhD, of Emory University School of Medicine, Atlanta, describe the data as "intriguing and thought provoking. They remind us that there are likely unique aspects of brain function that are differentially targeted by medication and psychotherapeutic approaches."

"As the neurology of OCD and other disorders are further dissected, we can hope for progress with targeted combined pharmacotherapy and psychotherapy in which rationally designed therapeutics can be fully derived from our understanding of the brain, its dysfunction, and mechanisms of recovery," they conclude.

The study by Dr. Simpson's team supports another recent study that found that adding CBT to maintenance SRI treatment can significantly improve OCD symptoms in children and adolescents, as reported by Medscape Medical News.

The study was funded by National Institute of Mental Health grants. Medication was provided at no cost by Janssen Scientific Affairs. The authors and editorialists report no relevant financial relationships.

JAMA Psychiatry. Published online September 11, 2013. Full article

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