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CBT decreased OCD severity better than antipsychotics

Adding exposure and ritual prevention therapy to serotonin reuptake inhibitor treatment decreased obsessive-compulsive disorder severity more than an antipsychotic or placebo, according to research published in JAMA Psychiatry.

Compared with risperidone, cognitive-behavioral therapy increased the number of patients who experienced minimal symptoms and improved insight, functioning and quality of life, according to researchers.

Antipsychotics vs. therapy

From January 2007 to August 2012, researchers at two clinics — in New York City and Philadelphia — conducted a randomized controlled trial to determine whether adding exposure and ritual prevention therapy (EX/RP) or antipsychotics to standard serotonin reuptake inhibitor (SRI) therapy improved OCD symptoms. Patients were aged 18 to 70 years and had moderately severe OCD, at least, after 12 weeks of treatment with an SRI. One hundred patients were randomly assigned to risperidone (n=40), exposure and ritual prevention (n=40), or placebo (n=20), but only 86 completed the trial.

SRI treatment was maintained, and psychiatric visits occurred every 4 weeks in the EX/RP group and weekly for the first 4 weeks, then every other week in the risperidone and placebo groups. The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) was used to measure OCD severity throughout the study.

EX/RP treatment consisted of two introductory sessions, 15 exposure sessions, daily homework and between-session telephone check-ins for 8 weeks. Both risperidone and placebo were administered at 0.25 mg/day for 3 days then 0.5 mg/day for 1 week; subsequently, the dose increased by 0.5 mg per week to reach a maximum of 4 mg/day, if necessary.

Improved OCD symptoms

Compared with risperidone and placebo, EX/RP therapy was associated with a significantly greater reduction in Y-BOCS scores after 8 weeks (P<.001 for both). Response rates also were higher, defined as a Y-BOCS score ≥25%, among those assigned to EX/RP (80%) vs. risperidone (23%) or placebo (15%; P<.001). Similarly, minimal symptoms (Y-BOCS score ≤12) were achieved by more patients in the EX/RP group (43%) vs. risperidone (13%) or placebo (5%; P=.001).

However, the risperidone and placebo groups did not differ significantly in terms of Y-BOCS score reduction (P=.83).

In the EX/RP group, Hamilton Depression Scale (HAM-D), Brown Assessment of Beliefs Scale (BABS) and Social Adjustment Scale-Self-report (SAS-SR) scores were all lower after 8 weeks vs. risperidone (P=.007, P=.03 and P=.009, respectively), and Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form scores were improved (P<.001).

"Patients with OCD receiving SRIs should be offered EX/RP before antipsychotics, given EX/RPs superior efficacy and less negative adverse effect profile," researchers wrote.

They added that further data are needed to determine who benefits from EX/RP and whether these patients could potentially discontinue SRI treatment.

Similarly, it is unknown whether EX/RP nonresponders might benefit from treatment with risperidone. What is known, however, is that alternative strategies for medication augmentation are needed in this patient population, they wrote.

Disclosure: See the study for a full list of all researchers’ relevant financial disclosures.