Metacognitive beliefs predict early response to pharmacological treatment in patients with obsessive-compulsive disorder

Predictors of clinical worsening during a discontinuation trial of serotonin reuptake inhibitors for obsessive compulsive disorder

OBJECTIVE

To explore predictors and moderators of clinical worsening during a double-blind trial in which patients with obsessive-compulsive disorder (OCD) were randomized to either continue or discontinue their Serotonin Reuptake Inhibitor (SRI) medication after achieving wellness from the addition of exposure and response prevention (EX/RP) therapy.

METHOD

The data came from a double-blind discontinuation trial that included N = 101 participants, 35 of whom were removed from the study due to clinical worsening. We first used LASSO logistic regression to identify which of the 34 potential baseline variables of interest (including demographics, diagnoses, other relevant clinical constructs, and specific genotypes), might moderate or predict this clinical worsening. Then logistic regression was used to examine which of these identified variables were significantly related to later clinical worsening. We verified the validity of our final prediction model using k-fold cross-validation.

RESULTS

There was one significant predictor of clinical worsening: In both groups, those with more past diagnoses had a greater likelihood of clinical worsening (p = .015). There were several moderators. Rates of clinical worsening were higher in the Discontinuation group compared to the Continuation group for participants who were taking a shorter half-life SRI (p = .044), were female (p = .022), had higher baseline levels of maladaptive metacognitions (p < .001), had fewer sleep problems at baseline (p = .001), and/or had more years of education (p < .001).

CONCLUSIONS

Our results identified several factors that may predict the development of clinical worsening in OCD patients discontinuing SRI medication following successful EX/RP treatment.

Treatment-resistant OCD: Pharmacotherapies in adults

Serotonin reuptake inhibitor (SRI) medications are well established as first-line pharmacotherapeutic treatment for Obsessive-Compulsive Disorder (OCD). However, despite the excellent safety profile and demonstrated efficacy of these medications, a substantial proportion of individuals with OCD fail to attain sufficient benefit from SRIs. In this narrative review, we discuss clinical features of OCD that have been associated with poorer response to SRIs, and we present pharmacotherapeutic interventions that have been explored as augmenting or alternative treatments for treatment-resistant OCD. We additionally highlight non-SRI interventions for OCD that are currently under investigation. Pharmacotherapeutic interventions were identified via expert consensus. To assess the evidence base for individual pharmacotherapies, targeted searches for relevant English-language publications were performed on standard biomedical research databases, including MEDLINE. Information relevant to ongoing registered clinical trials in OCD was obtained by search of ClinicalTrials.gov. Pharmacotherapies are grouped for review in accordance with the general principles of Neuroscience-based Nomenclature (NbN). Clinical features of OCD that may suggest poorer response to SRI treatment include early age of onset, severity of illness, duration of untreated illness, and the presence of symmetry/ordering or hoarding-related symptoms. Based on evolving pathophysiologic models of OCD, diverse agents engaging serotonin, dopamine, norepinephrine, glutamate, and anti-inflammatory pathways have been explored as alternative or adjunctive therapies for treatment-resistant OCD and have at least preliminary evidence of efficacy. Medications with dopamine antagonist activity remain the most robustly evidence-based of augmenting interventions, yet dopamine antagonists benefit only a minority of those who try them and carry elevated risks of adverse effects. Interventions targeting glutamatergic and anti-inflammatory pathways are less well evidenced, but may offer more favorable benefit to risk profiles. Ongoing research should explore whether specific interventions may benefit individuals with particular features of treatment-resistant OCD.

Dysfunctional Metacognitive Beliefs in Patients With Obsessive-Compulsive Disorder and Pattern of Their Changes Following a 3-Month Treatment

Introduction: Metacognitions are considered to be crucial factors for the development and maintenance of pathologic anxiety. The present case-control study aimed to examine how metacognitive beliefs are associated with the diagnostic status and subtypes of obsessive-compulsive disorder (OCD). In addition, we examined the pattern of changes in metacognitive beliefs after a 3-month pharmacological treatment in patients with OCD. Methods: A total of 562 cases with OCD and 236 healthy controls were assessed with the Metacognitions Questionnaire (MCQ) and various measures of OC symptom severity. Multivariate analyses of variance (MANOVAs) with covariates were conducted to explore the relationship between subdimensions of metacognitive beliefs and OCD disease status. In addition, for the OCD patients, Pearson's correlation was performed between baseline MCQ subdimensions and Obsessive-Compulsive Inventory-Revised-Korean subscales (OCI-R-K). Finally, in a subset of drug-free OCD patients (n = 144), the MCQ was reassessed after 3 months of treatment and patterns of changes in subdimensions of the MCQ were examined. Results: Patients with OCD scored significantly higher on the four dimensions of the MCQ. There were significant associations between all MCQ subdimensions and OCI-R-K subscales. In the repeated-measure MANOVA, a significant group (non-responders vs. responders)-by-time interaction effect was found only for the negative beliefs about the uncontrollability and danger of worry (NB) subdimension (F = 10.75; η² = 0.072; p = 0.001). Conclusion: The presence of dysfunctional metacognitive beliefs in OCD subjects and their association with OCD characteristics suggest that dysfunctional metacognitions may play a crucial role in the pathophysiology of OCD. Improvement of metacognitive beliefs in the NB dimension may be a clinically meaningful correlate of good treatment response in the pharmacological treatment of OCD.