Forty chronic obsessive-compulsive ritualizers were randomly assigned to treatment with oral clomipramine or placebo for 8 months. During weeks 4 to 7 these two groups were each randomly split into treatment by relaxation or by exposure in vivo, and during weeks 7 to 10 all patients had exposure in vivo. Double blind assessments were made at weeks 4, 7, 10, 18, 36, 62 and 114. Results are reported to one year. Clomipramine produced significant improvement in rituals, mood and social adjustment, but only in those patients who initially had depressed mood. The clomipramine effect was maximum from weeks 10 to 18 and diminished thereafter. On stopping clomipramine patients often relapsed and improved again on restarting the drug. Relaxation produced little change. Exposure produced significant lasting improvement in rituals, but less change in mood; improvement generalized to social adjustment at follow-up. Clomipramine plus exposure had a slight additive but not interactional effect. Clomipramine enhanced compliance both with exposure and with relaxation. Clomipramine is useful for compulsive ritualizers with depressed mood, but may need continuation for over a year and combination with exposure in vivo. Exposure in vivo remains the treatment of choice for rituals without depressed mood.

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During 2 weeks on a waiting list 12 patients with morbid grief did not improve significantly. They were then randomly allocated either to guided mourning treatment, in which they were encouraged to face cues concerning their bereavement, or to control treatment in which they were asked to avoid such cues. Each treatment comprised six 1 1/2 hour sessions over 2 weeks. At week 4 guided mourning patients had improved significantly more than had controls on 3 measures, with a supportive trend on 4 measures. Improvement, though modest, was maintained to 10-28 weeks follow-up. Control patients did not improve significantly or show any trend to do so.

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