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Foa EB, Simpson HB, Gallagher T, Wheaton MG, Gershkovich M, Schmidt AB, Huppert JD, Imms P, Campeas RB, Cahill S, DiChiara C, Tsao SD, Puliafico A, Chazin D, Asnaani A, Moore K, Tyler J, Steinman SA, Sanches-LaCay A, Capaldi S, Snorrason Í, Turk-Karan E, Vermes D, Kalanthroff E, Pinto A, Hamlett GE, Middleton R, Hahn CG, Xu B, Van Meter PE, Katechis M, Rosenfield D. Maintenance of Wellness in Patients With Obsessive-Compulsive Disorder Who Discontinue Medication After Exposure/Response Prevention Augmentation: A Randomized Clinical Trial. JAMA Psychiatry 2022; 79:193-200. [PMID: 35080598 PMCID: PMC8792795 DOI: 10.1001/jamapsychiatry.2021.3997] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 11/04/2021] [Indexed: 01/28/2023]
Abstract
IMPORTANCE Serotonin 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 PARTICIPANTS A 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 (≥1 year) who were taking an SRI (≥12 weeks), had at least moderate symptoms (defined as Yale-Brown Obsessive-Compulsive Scale [Y-BOCS] score ≥18 points), and received as many as 25 sessions of EX/RP therapy. Those who attained wellness (Y-BOCS score ≤14 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 MEASURES The 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, -∞ 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, -∞ 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, -∞ 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 outcomes compared with those who continued their SRI. Those who tapered the SRI had higher clinical worsening rates. Future research should evaluate if SRI half-life alters these rates. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01686087.
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Affiliation(s)
- Edna B. Foa
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Helen Blair Simpson
- Department of Psychiatry, Columbia University, New York, New York
- New York State Psychiatric Institute, New York
- Associate Editor, JAMA Psychiatry
| | - Thea Gallagher
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Michael G. Wheaton
- New York State Psychiatric Institute, New York
- Barnard College, Columbia University, New York, New York
| | - Marina Gershkovich
- Department of Psychiatry, Columbia University, New York, New York
- New York State Psychiatric Institute, New York
| | - Andrew B. Schmidt
- Department of Psychiatry, Columbia University, New York, New York
- New York State Psychiatric Institute, New York
| | | | - Patricia Imms
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Raphael B. Campeas
- Department of Psychiatry, Columbia University, New York, New York
- New York State Psychiatric Institute, New York
| | | | - Christina DiChiara
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Anxiety and Behavior Therapy, Bryn Mawr, Pennsylvania
| | - Steven D. Tsao
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Anxiety and Behavior Therapy, Bryn Mawr, Pennsylvania
| | - Anthony Puliafico
- Department of Psychiatry, Columbia University, New York, New York
- New York State Psychiatric Institute, New York
| | - Daniel Chazin
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Anu Asnaani
- Department of Psychology, University of Utah, Salt Lake City
| | - Kelly Moore
- Rutgers University/Biomedical Health Sciences, New Brunswick, New Jersey
| | - Jeremy Tyler
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | | | - Sandy Capaldi
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - Elizabeth Turk-Karan
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Donna Vermes
- Department of Psychiatry, Columbia University, New York, New York
- New York State Psychiatric Institute, New York
| | - Eyal Kalanthroff
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Psychiatry, Columbia University, New York, New York
- University of Wisconsin, Milwaukee
| | - Anthony Pinto
- Department of Psychiatry, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, The Zucker Hillside Hospital, Glen Oaks, New York
| | - Gabriella E. Hamlett
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - Chang-Gyu Hahn
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Bin Xu
- Department of Psychiatry, Columbia University, New York, New York
| | - Page E. Van Meter
- Department of Psychiatry, Columbia University, New York, New York
- New York State Psychiatric Institute, New York
| | | | - David Rosenfield
- Department of Psychology, Southern Methodist University, Dallas, Texas
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Simpson HB, Foa EB, Wheaton MG, Gallagher T, Gershkovich M, Schmidt AB, Huppert JD, Campeas RB, Imms PA, Cahill SP, DiChiara C, Tsao SD, Puliafico AC, Chazin D, Asnaani A, Moore K, Tyler J, Steinman SA, Sanchez-LaCay A, Capaldi S, Snorrason I, Turk-Karan E, Vermes D, Kalanthroff E, Pinto A, Hahn CG, Xu B, Van Meter PE, Katechis M, Scodes J, Wang Y. Maximizing remission from cognitive-behavioral therapy in medicated adults with obsessive-compulsive disorder. Behav Res Ther 2021; 143:103890. [PMID: 34089924 DOI: 10.1016/j.brat.2021.103890] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 03/31/2021] [Accepted: 05/18/2021] [Indexed: 12/27/2022]
Abstract
Practice guidelines for adults with obsessive-compulsive disorder (OCD) recommend augmenting serotonin reuptake inhibitors (SRIs) with exposure and ritual prevention (EX/RP). However, fewer than half of patients remit after a standard 17-session EX/RP course. We studied whether extending the course increased overall remission rates and which patient factors predicted remission. Participants were 137 adults with clinically significant OCD (Yale-Brown Obsessive Compulsive Scale [Y-BOCS] score ≥18) despite an adequate SRI trial (≥12 weeks). Continuing their SRI, patients received 17 sessions of twice-weekly EX/RP (standard course). Patients who did not remit (Y-BOCS ≤12) received up to 8 additional sessions (extended course). Of 137 entrants, 123 completed treatment: 49 (35.8%) remitted with the standard course and another 46 (33.6%) with the extended course. Poorer patient homework adherence, more Obsessive-Compulsive Personality Disorder (OCPD) traits, and the Brain-Derived Neurotrophic Factor (BDNF) Val66MET genotype were associated with lower odds of standard course remission. Only homework adherence differentiated non-remitters from extended course remitters. Extending the EX/RP course from 17 to 25 sessions enabled many (69.3%) OCD patients on SRIs to achieve remission. Although behavioral (patient homework adherence), psychological (OCPD traits), and biological (BDNF genotype) factors influenced odds of EX/RP remission, homework adherence was the most potent patient factor overall.
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Affiliation(s)
- Helen B Simpson
- Department of Psychiatry, Columbia University, New York, NY, 10032, USA; New York State Psychiatric Institute, New York, NY, 10032, USA.
| | - Edna B Foa
- Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Michael G Wheaton
- New York State Psychiatric Institute, New York, NY, 10032, USA; Barnard College, Columbia University, New York, NY, 10027, USA
| | - Thea Gallagher
- Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Marina Gershkovich
- Department of Psychiatry, Columbia University, New York, NY, 10032, USA; New York State Psychiatric Institute, New York, NY, 10032, USA
| | - Andrew B Schmidt
- Department of Psychiatry, Columbia University, New York, NY, 10032, USA; New York State Psychiatric Institute, New York, NY, 10032, USA
| | | | - Raphael B Campeas
- Department of Psychiatry, Columbia University, New York, NY, 10032, USA; New York State Psychiatric Institute, New York, NY, 10032, USA
| | - Patricia A Imms
- Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Shawn P Cahill
- University of Wisconsin-Milwaukee, Milwaukee, WI, 53201, USA
| | - Christina DiChiara
- Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, 19104, USA; Center for Anxiety and Behavior Therapy, Bryn Mawr, PA, 19010, USA
| | - Steven D Tsao
- Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, 19104, USA; Center for Anxiety and Behavior Therapy, Bryn Mawr, PA, 19010, USA
| | - Anthony C Puliafico
- Department of Psychiatry, Columbia University, New York, NY, 10032, USA; New York State Psychiatric Institute, New York, NY, 10032, USA
| | - Daniel Chazin
- Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Anu Asnaani
- Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, 19104, USA; Department of Psychology, University of Utah, Salt Lake City, UT, 84112, USA
| | - Kelly Moore
- Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, 19104, USA; Rutgers University/Biomedical Health Sciences New Brunswick, NJ, 08854, USA
| | - Jeremy Tyler
- Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Shari A Steinman
- Department of Psychiatry, Columbia University, New York, NY, 10032, USA; New York State Psychiatric Institute, New York, NY, 10032, USA; Department of Psychology, WVU, Morgantown, WV, 26506, USA
| | - Arturo Sanchez-LaCay
- Department of Psychiatry, Columbia University, New York, NY, 10032, USA; New York State Psychiatric Institute, New York, NY, 10032, USA
| | - Sandy Capaldi
- Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Ivar Snorrason
- Department of Psychiatry, Columbia University, New York, NY, 10032, USA; New York State Psychiatric Institute, New York, NY, 10032, USA; McLean Hospital/Harvard Medical School, Belmont, MA, 02478, USA
| | - Elizabeth Turk-Karan
- Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Donna Vermes
- Department of Psychiatry, Columbia University, New York, NY, 10032, USA; New York State Psychiatric Institute, New York, NY, 10032, USA
| | | | - Anthony Pinto
- Department of Psychiatry, Columbia University, New York, NY, 10032, USA; New York State Psychiatric Institute, New York, NY, 10032, USA; Department of Psychiatry, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, The Zucker Hillside Hospital, Glen Oaks, NY, 11004, USA
| | - Chang-Gyu Hahn
- Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Bin Xu
- Department of Psychiatry, Columbia University, New York, NY, 10032, USA
| | - Page E Van Meter
- Department of Psychiatry, Columbia University, New York, NY, 10032, USA; New York State Psychiatric Institute, New York, NY, 10032, USA
| | - Martha Katechis
- Department of Psychiatry, Columbia University, New York, NY, 10032, USA; New York State Psychiatric Institute, New York, NY, 10032, USA
| | - Jennifer Scodes
- New York State Psychiatric Institute, New York, NY, 10032, USA
| | - Yuanjia Wang
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, 10032, USA
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