Exposure/Ritual Prevention Therapy Boosts Antidepressant Treatment of OCD
Trumps antipsychotic, amending current guidelines
September 12, 2013—Grantees at the National Institute of Mental Health have demonstrated that a form of behavioral therapy can augment antidepressant treatment of obsessive compulsive disorder (OCD) better than an antipsychotic. The researchers recommend that this specific form of cognitive behavior therapy (CBT)—exposure and ritual prevention (ERT) —be offered to OCD patients who don't respond adequately to treatment with an antidepressant alone, which is often the case. Current guidelines favor augmentation with antipsychotics.
In the controlled trial with 100 antidepressant-refractory OCD patients, 80 percent of those who received CBT responded, compared to 23 percent of those who received the antipsychotic risperidone, and 15 percent of those who received placebo pills. Forty-three percent experienced symptoms reduced to a minimal level following CBT treatment, compared to 13 percent for risperidone and 5 percent for placebo.
The study, published September 11, 2013 in JAMA Psychiatry, was led by Helen Blair Simpson, M.D., of Columbia University, in New York City; and Edna Foa, Ph.D., of the University of Pennsylvania, Philadelphia.
In an accompanying editorial, grantees Kerry Ressler, M.D., and Barbara Rothbaum, Ph.D., of Emory University, Atlanta, note that antidepressants are effective in treating only a subset of OCD patients. They add that the targeted form of CBT works via different mechanisms—such as retraining the brain's habit-forming circuitry to unlearn compulsive rituals.
Matthew Rudorfer, M.D., chief of the NIMH Somatic Treatments Program, which funded the study, said that in demonstrating how different patients respond best to different approaches, it helps to move the field toward the goal of more personalized treatment.
ARTICLES:
"Cognitive-Behavioral Therapy vs Risperidone for Augmenting Serotonin Reuptake Inhibitors in Obsessive-Compulsive Disorder – A Randomized Clinical Trial." Simpson, H.B.; Foa, E.B.; Liebowitz, M.R.; Huppert, J.D.; Cahil,l S; Maher, M.J.; McLean, C.P.; Bender, Jr., J; Marcus, S.M.; Williams, M.T.; Weaver, J.; Vermes, D.; Van Meter, P.E.; Rodriquez, C.I.; Powers, M.; Pinto, A.; Imms, P.; Hahn, C-G; Campeas, R. JAMA Psychiatry, Sept. 11, 2013.
"Augmenting Obsessive-Compulsive Disorder Treatment – From Brain to Mind." Ressler, K.J.; Rothbaum, B.O. JAMA Psychiatry, Sept. 11, 2013.
RELATED RESEARCH:
UCLA research psychiatrist Jeffrey Schwartz's book notes in his book "Brain Lock:
"If you are familiar with a specific cognitive-behavioral therapy technique known as exposure and response prevention (ERP), Refocus with Progressive Mindfulness may seem similar. In some of the mechanics, it is—you are entering situations that distress you. However, the important distinction lies it what you do once you are in that distressing situation. The major difference between the two approaches is that exposure and response prevention asks you to enter a situation and then sit with—but do nothing about—your uncomfortable sensations. You do not focus your attention on a healthy behavior or attempt to regulate your sensations in any way. . . .
In contrast, Refocus with Progressive Mindfulness encourages you to first face situations you currently are avoiding or to continue in an activity that causes you distress and then focus your attention on constructive, healthy activities while you are in that situation. This process results in your brain rewiring itself in ways that are beneficial to you and that adaptively retrain your Habit Center to work toward your true goals and values."
Mindfulness Based Cognitive Therapy (MBCT) for OCD:
"Mindfulness-Based Cognitive Therapy in Obsessive-Compulsive Disorder—A Qualitative Study on Patients’ Experiences." Hertenstein et al. BMC Psychiatry 2012, 12:185.
