Maintenance of Wellness in Patients With Obsessive-Compulsive Disorder Who Discontinue Medication After Exposure/Response Prevention Augmentation

Abstract

IMPORTANCESerotonin reuptake inhibitors (SRIs) are the only medications approved for obsessive-compulsive disorder (OCD), yet most patients taking SRIs exhibit significant symptoms. Adding exposure/response prevention (EX/RP) therapy improves symptoms, but it is unknown whether patients maintain wellness after discontinuing SRIs. OBJECTIVE To assess whether patients with OCD who are taking SRIs and have attained wellness after EX/RP augmentation can discontinue their SRI with noninferior outcomes compared with those who continue their SRI therapy. DESIGN, SETTING, AND PARTICIPANTSA 24-week, double-blind, randomized clinical trial was performed from May 3, 2013, to June 25, 2018. The trial took place at US academic medical centers. Participants included 137 adults with a principal diagnosis of OCD (Ն1 year) who were taking an SRI (Ն12 weeks), had at least moderate symptoms (defined as Yale-Brown Obsessive-Compulsive Scale [Y-BOCS] score Ն18 points), and received as many as 25 sessions of EX/RP therapy. Those who attained wellness (Y-BOCS score Յ14 points; 103 patients [75.2%]) were study eligible. Data were analyzed from June 29, 2019, to October 2, 2021.INTERVENTION Participants were randomly assigned either to receive taper to placebo (taper group) or to continue their SRI (continuation group) and monitored for 24 weeks. MAIN OUTCOME AND MEASURESThe Y-BOCS score (range, 0-40 points) was the primary outcome; the Hamilton Depression Rating Scale (HDRS; range, 0-52 points) and the Quality-of-Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF; range, 0%-100%) scores were secondary outcomes. Outcomes were assessed at 8 time points by independent evaluators who were blinded to randomization. The taper regimen was hypothesized to be noninferior to continuation at 24 weeks using a 1-sided α value of .05. RESULTS A total of 101 patients (mean [SD] age, 31.0 [11.2] years; 55 women [54.5%]) participated in the trial: 51 patients (50.5%) in the taper group and 50 patients (49.5%) in the continuation group. At 24 weeks, patients in the taper group had noninferior results compared with patients in the continuation group (mean [SD] Y-BOCS score: taper group, 11.47 [6.56] points; continuation group: 11.51 [5.97] points; difference, −0.04 points; 1-sided 95% CI, −ϱ to 2.09 points [below the noninferiority margin of 3.0 points]; mean [SD] HDRS score: taper group, 5.69 [3.84] points; continuation group, 4.61 [3.46] points; difference, 1.08 points; 1-sided 95% CI, −ϱ to 2.28 points [below the noninferiority margin of 2.5 points]; mean [SD] Q-LES-Q-SF score: taper group, 68.01% [15.28%]; continuation group, 70.01% [15.59%]; difference, 2.00%; 1-sided 95% CI, −ϱ to 6.83 [below the noninferiority margin of 7.75]). However, the taper group had higher rates of clinical worsening (23 of 51 [45%] vs 12 of 50 [24%]; P = .04).CONCLUSIONS AND RELEVANCE Results of this randomized clinical trial show that patients with OCD who achieve wellness after EX/RP therapy could, on average, discontinue their SRI with noninferior outco...

Willingness to experience unpleasant thoughts, emotions, and bodily sensations at admission does not predict treatment outcome in inpatients with obsessive–compulsive disorder

“…Footnotes 1 As some patients had unexpectedly low Y-BOCS scores at admission, we re-ran analyses with patients that had a Y-BOCS score ≥ 18, similar to other studies (e.g., 27). Yet, results were very similar to those with the full sample (Table S1 in the supplementary material).…”

The role of between‐session homework in cognitive‐behavioral therapy for comorbid obsessive‐compulsive disorder and autism: A case vignette

“…CBT with ERP demonstrates large treatment effect sizes shown in multiple meta‐analyses (e.g., Öst et al, 2015) and support from healthcare organizations that identify CBT as a first‐line psychotherapeutic intervention for OCD (Tolin et al, 2015). Treatment gains are durable over extended periods (Foa et al, 2022), particularly when paired with ongoing personalized support in regard to bolstering behavior change via between‐session homework. However, some research has suggested that standard CBT treatment may be associated with attenuated outcomes for individuals with autism (Murray et al, 2015; Weston et al, 2016).…”

Promoting OCD WEllness and resilience (POWER) study: Rationale, design, and methods

“…Patients who were taking an adequate dose of SRI, who received up to 25 sessions of EX/RP and achieved wellness (YBOCS ≤14) following EX/RP were eligible for the study. Participants were randomized into the SRI continuation or SRI discontinuation groups ( Foa et al, 2022 ). This study found that SRI discontinuation was noninferior to SRI continuation in terms of OCD symptom recurrence ( Foa et al, 2022 ).…”

“…Participants were randomized into the SRI continuation or SRI discontinuation groups ( Foa et al, 2022 ). This study found that SRI discontinuation was noninferior to SRI continuation in terms of OCD symptom recurrence ( Foa et al, 2022 ). However, there were increased rates of clinical worsening in 45% of adults in the SRI discontinuation arm compared to 24% of adults in the SRI maintenance arm.…”