Stopping SRIs in OCD may be noninferior to continuing, but monitoring needed

Patients with obsessive-compulsive disorder who were well after exposure/response prevention therapy often could discontinue a serotonin reuptake inhibitor and have similar outcomes to those who continued an SRI.

Researchers published these results in a randomized clinical trial in JAMA Psychiatry.

“OCD practice guidelines do not address how to manage SRIs after effective [exposure/response prevention therapy (EX/RP)],” Edna B. Foa, PhD, of the department of psychiatry at the University of Pennsylvania’s Perelman School of Medicine, and colleagues wrote. “However, some patients want to discontinue their SRI for various reasons (eg, plan to become pregnant, adverse effects). Thus, it is important to examine whether patients with OCD can discontinue medication and retain wellness after effective EX/RP therapy.”

Foa and colleagues conducted the 24-week, double-blind, randomized clinical trial between May 3, 2013, and June 25, 2018, at U.S. academic medical centers. They included adults with a principal OCD diagnosis for 1 year or longer and who were on an SRI for at least 12 weeks, had at least moderate symptoms according to a Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) score of 18 points and received up to 25 sessions of EX/RP therapy. A further eligibility criterion included attaining wellness or a Y-BOCS score of 14 points.

Researchers randomly assigned participants to receive taper to placebo or to continue their SRI and monitored them for 24 weeks. Y-BOCS score, which ranged from zero to 40 points, served as the primary outcome. Secondary outcomes included the Hamilton Depression Rating Scale (HDRS), which ranged from zero to 52 points, and the Quality-of-Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF), which ranged from 0% to 100%. Independent evaluators who were blinded to random assignment examined outcomes at eight time points.

Foa and colleagues included 101 patients (mean age, 31 years; 54.5% women), of whom 51 (50.5%) participated in the taper group and 50 (49.5%) in the continuation group. Results showed noninferior results at 24 weeks between those in the taper group and those in the continuation group, with a difference of 0.04 points between the groups on Y-BOCS score, 1.08 points on HDRS score and 2% on Q-LES-Q-SF score. However, patients in the taper group exhibited higher rates of clinical worsening (45% vs. 24%; P = .04).

“Tapering may require careful monitoring,” Foa and colleagues wrote. “Future research should investigate the individual factors that determine who can and who cannot taper SRIs and whether moderators such as SRI half-life or speed of taper can alter worsening rates.”