A Randomized, Controlled Trial of Cognitive-Behavioral Therapy for Augmenting Pharmacotherapy in Obsessive-Compulsive Disorder

Abstract

Objective-Although serotonin reuptake inhibitors (SRIs) are approved for the treatment of obsessive-compulsive disorder (OCD), most OCD patients who have received an adequate SRI trial continue to have clinically significant OCD symptoms. The purpose of this study was to examine the effects of augmenting SRIs with exposure and ritual prevention, an established cognitive-behavioral therapy (CBT) for OCD.Method-A randomized, controlled trial was conducted at two academic outpatient clinics to compare the effects of augmenting SRIs with exposure and ritual prevention versus stress management training, another form of CBT. Participants were adult outpatients (N=108) with primary OCD and a Yale-Brown Obsessive Compulsive Scale total score ≥16 despite a therapeutic SRI dose for at least 12 weeks prior to entry. Participants received 17 sessions of CBT (either exposure and ritual prevention or stress management training) twice a week while continuing SRI pharmacotherapy.Results-Exposure and ritual prevention was superior to stress management training in reducing OCD symptoms. At week 8, significantly more patients receiving exposure and ritual prevention than patients receiving stress management training had a decrease in symptom severity of at least 25% (based on Yale-Brown Obsessive Compulsive Scale scores) and achieved minimal symptoms (defined as a Yale-Brown Obsessive Compulsive Scale score ≤12).Conclusions-Augmentation of SRI pharmacotherapy with exposure and ritual prevention is an effective strategy for reducing OCD symptoms. However, 17 sessions were not sufficient to help most of these patients achieve minimal symptoms.Obsessive-compulsive disorder (OCD) is a severe and disabling illness (1). Serotonin reuptake inhibitors (SRIs) (e.g., clomipramine and various selective serotonin re-uptake inhibitors [SSRIs]) and cognitive-behavioral therapy (CBT) involving exposure and ritual NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript prevention have both been found to be efficacious in randomized, controlled trials (2). In clinical practice, SRIs are used most frequently (3), but because they typically yield only a 20%-40% reduction in OCD symptoms (4), many SRI responders continue to have clinically significant symptoms.The only SRI augmentation strategy with proven efficacy in multiple randomized, placebocontrolled trials involves the addition of antipsychotics (e.g., haloperidol, risperidone, olanzapine, or quetiapine) (5). However, at most only half of the patients respond (i.e., experience ≥25% reduction in OCD severity) (6, 7) and antipsychotics can cause significant adverse effects (8).Because of the efficacy of exposure and ritual prevention as monotherapy for OCD (9) and promising findings from our open SRI augmentation trial using exposure and ritual prevention (10), we conducted a randomized, controlled trial to compare the effects of augmenting SRIs with exposure and ritual prevention versus stress management training, another form of CBT. Stress management training teache...

Sensitivity to change in the Obsessive Compulsive Inventory: Comparing the standard and revised versions in two cohorts of different severity

“…The effect size on the OCI-R was 1.47 in our IAPT sample and this compares with 1.27 in Abramowitz et al (2005) and 0.85 in Simpson et al (2008). The cut-off score for achieving clinically significant change on the OCI-R was ≥ 22, which is comparable to cut-off reported in Abramowitz et al (2005) of ≥ 21.…”

Effectiveness of Cognitive-Behavioral Therapy Addition to Pharmacotherapy in Resistant Obsessive-Compulsive Disorder: A Multicenter Study

“…Antipsychotics’ side effects, mainly the metabolic ones [8], however, limit this option. The second strategy consists of sequentially adding CBT; the efficacy of this strategy is suggested by open-label reports [9,10,11,12,13,14] and a single randomized, controlled trial [15]. …”

“…In the study by Simpson et al [15], for example, comorbid diagnoses were allowed only if secondary; mania, psychosis, suicidal ideation, and substance abuse/dependence in the previous 6 months were exclusion criteria. Moreover, ERP protocol consisted of 17 twice-weekly sessions (90–120 min each), daily homework assignments, and between-session phone calls and included ≥2 sessions in the patients’ home.…”

“…One might ask if patients in the real world can follow this intensive CBT format. So, it could be useful for clinicians to know if the results of Simpson et al [15] have been confirmed in large multicenter effectiveness studies.…”

“…Our multicenter, prospective, naturalistic study indicates that the positive results of the controlled study concerning the efficacy of CBT addition to medication in partial responder OCD patients [15] can be generalized, although to a lesser degree, to routine clinical practice. The demonstration of the effectiveness of CBT addition in this clinical population is of high clinical relevance.…”