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. Author manuscript; available in PMC: 2016 Dec 2.
Published in final edited form as: J Clin Psychiatry. 2015 Dec;76(12):1653–1657. doi: 10.4088/JCP.14m09513

Exposure and response prevention helps adults with obsessive compulsive disorder who do not respond to pharmacological augmentation strategies

Carmen P McLean 1, Laurie J Zandberg 1, Page E Van Meter 2, Joseph K Carpenter 1, Helen Blair Simpson 2,3, Edna B Foa 1
PMCID: PMC5135093  NIHMSID: NIHMS830261  PMID: 26613263

Abstract

Objective

Serotonin reuptake inhibitors (SRIs) are a first-line treatment for obsessive-compulsive disorder (OCD). Yet, most OCD patients on SRIs do not show excellent response, and recent studies show that augmenting SRIs with risperidone benefits a minority of patients. We evaluated the effectiveness of exposure and response prevention (EX/RP) among non-responders to SRI augmentation with 8 weeks of risperidone or placebo.

Method

The study was conducted from January 2007-August 2012. Non-responders to SRI augmentation with risperidone or pill placebo (n = 32) in a randomized controlled trial for adults meeting DSM-IV-TR criteria for OCD were offered up to 17 twice-weekly EX/RP sessions. OCD severity as measured by the Yale-Brown Obsessive-Compulsive Scale (YBOCS) and associated impairment (depression, insight, quality of life, and social functioning) were assessed at crossover baseline (week 8), post-EX/RP treatment (week 16), and follow-up (weeks 20, 24, 28 and 32).

Results

Between crossover baseline and follow-up, non-responders to SRI augmentation with risperidone or placebo who received EX/RP showed significant reductions in OCD symptoms and depression, as well as significant increases in insight, quality of life, and social functioning (all p < .001).

Conclusion

EX/RP is an effective treatment for patients who have failed to respond to SRI augmentation with risperidone or placebo. This study adds to the body of evidence supporting the use of EX/RP with patients who continue to report clinically significant OCD symptoms after multiple pharmacological trials.

Trial Registration

ClinicalTrials.gov Identifier: NCT00389493

Obsessive-compulsive disorder (OCD) is a chronic condition that affects 2-3% of the U.S. Population1 and is associated with marked functional impairment and quality of life deficits.2 Serotonin-reuptake inhibitors (SRIs) are a first-line treatment for OCD,3-5 but most OCD patients on SRIs fail to achieve excellent response and continue to have clinically significant symptoms.6-8 A meta-analysis of multi-center randomized controlled trials (RCTs) indicated that although SRIs were superior to placebo, improvement was generally modest9 and few OCD patients (≤ 25%) reach excellent response status from an SRI trial alone.10,11

For OCD patients who do not achieve minimal symptom status despite an adequate SRI trial, adding an antipsychotic medication such as risperidone (risperidone) is the SRI augmentation strategy with demonstrated efficacy.12-15 However, meta-analyses show that only one third of OCD patients respond to SRI augmentation with risperidone12,16. For example, a recent RCT found that 72% of OCD patients on SRI therapy did not respond to SRI augmentation.17 Contrary to expectation, this study found that adding risperidone to SRIs was not significantly better than placebo on any outcome measure. This finding is important because risperidone is recommended as the medication of first choice to augment SRI response,12,16 and antipsychotics are increasingly prescribed to OCD patients.18

Because a large proportion of OCD patients do not respond to SRI augmentation with risperidone, clinicians are in need of guidance regarding how to best help these patients. One option is to offer exposure and response prevention (EX/RP), which is a type of cognitive behavioral therapy. EX/RP is an effective treatment for OCD19-21 that focuses on helping patients to disconfirm their obsessive fears via exposure to feared stimuli while resisting compulsions. EX/RP has also been found effective as an SRI augmentation strategy in several open and controlled studies17,22-24. Thus, it stands to reason that EX/RP will also be helpful for OCD patients who have not responded to SRI augmentation with risperidone.

To test this hypothesis, the current study examined the efficacy of EX/RP in an open trial with patients who did not respond to SRI augmentation with either risperidone or placebo in the context of a RCT.16 No previous research, to our knowledge, has tested EX/RP in OCD patients who have received SRI augmentation with another pharmacological intervention and yet continue to have clinically meaningful symptoms.

Methods

Participants completed an RCT evaluating the relative efficacy of SRI augmentation with EX/RP, risperidone, or pill placebo (see 13 for details). This study was conducted at outpatient clinics in Philadelphia, Pennsylvania and New York, New York. Participants were recruited by clinical referral and advertisements, and data were collected from January 2007-August 2012. Both study sites’ institutional review board approved the study; all participants provided written informed consent.

Participants

Eligible participants were: (1) 18-70 years of age, (2) had a principal diagnosis of OCD (≤ 1 year) based on DSM-IV criteria, (3) had received an SRI at a therapeutic dose for at least 12 weeks yet remained moderately symptomatic (Yale-Brown Obsessive Compulsive Scale [Y-BOCS] score ≤ 16), and (4) were randomized to 8-weeks of SRI augmentation with risperidone or pill placebo and were classified as non-responders (defined as ≤ 25% improvement in symptoms). Non-responders were given the option to crossover from their randomized treatment condition and receive either EX/RP (for those randomized to risperidone or pill placebo) or risperidone (for those randomized to pill placebo). Thirty seven participants did not respond to acute treatment with risperidone or pill placebo and were eligible to crossover. Thirty two participants completed acute treatment with risperidone; of these, 23 (72%) did not respond to risperidone and 20 elected to crossover to EX/RP. Seventeen participants completed acute treatment with pill placebo; of these, 14 (82%) participants did not respond and 12 elected to crossover to EX/RP, none elected to crossover to risperidone. Of the 37 participants who completed acute treatment with EX/RP, four (11%) did not respond and one of these participants elected to crossover to risperidone. Thus, only participants who had failed to respond to SRI augmentation with risperidone or pill placebo who elected to crossover to EX/RP were included in the current sample (n=32).

Treatment

Participants received up to 17 twice-weekly 90-minute sessions delivered over 8 weeks by study therapists (PhD or PsyD) who received training and supervision in EX/RP. EX/RP treatment included two introductory sessions, 15 exposure sessions, daily homework, and between-session telephone check-ins. At least two sessions occurred outside of the clinic to facilitate generalization to daily life. The exact number of sessions provided was determined collaboratively by therapists and participants based on clinical improvement. Participants who received ten or more 90-minute sessions were designated treatment completers. SRI medication was continued throughout the trial and any medication changes (n=6) were monitored. A small minority of participants (n = 3) were offered additional EX/RP sessions during the follow-up period and the number and length of additional sessions was recorded.

Assessment

Independent evaluators (IEs), blind to treatment, evaluated patients at crossover baseline (week 8), midway through cross-over treatment (week 12), and post-treatment (week 16). Follow up assessments were completed at weeks 20, 24, 28, and 32. IEs administered the Yale-Brown Obsessive Compulsive Scale (Y-BOCS)25,26 to assess OCD severity, the 17-item Hamilton Rating Scale for Depression (HAM-D)27 to assess depression severity, and the Brown Assessment of Beliefs Scale (BABS)28 to assess degree of insight regarding the patient’s main OCD belief. Additionally, participants completed the Quality of Life Enjoyment and Satisfaction Questionnaire–Short Form (QLESQ-SF)29 and the Social Adjustment Scale–Self-report (SAS-SR).30

Data Analytic Strategy

Data were analyzed using last observation carried forward, intent to treat analyses. The Y-BOCS total score was the primary outcome of interest. Y-BOCS, HAM-D, QLESQ-SF, SAS-SR, and BABS total score results were analyzed using a repeated-measures multivariate analysis of variance (MANOVA) with measures of effect size (partial eta squared) and with Time as the repeated measure. Partial eta-squared indicates the percent of variance in the dependent variable (e.g., YBOCS) attributable to the independent variable (i.e., Time) and are reported for within-groups effect sizes (η2 = .01 small, .06 medium, and .14 large).31 Significant ANOVAs were followed-up using within-subjects t-tests compared week 0 (RCT baseline) and week 8 (cross-over baseline), week 8 (cross-over baseline) and week 16 (post-treatment), and week 16 (post-treatment) and week 32 (follow-up). Cohen’s d for paired samples t-tests was calculated to estimate the effect size of significant differences (d = .25 small, .50 medium, and .80 large).31

All tests were two-tailed and p values were set to .05. Patients were classified as responders to EX/RP if they exhibited greater than 25% reduction in Y-BOCS scores10 and as excellent responders if they achieved a post-treatment Y-BOCS score less than or equal to 12.32 Data analyses were conducted using SPSS for Windows, version 20.

Results

Table 1 presents participant demographic information. Baseline demographics did not differ between study sites. Participants received a mean of 14 (SD = 4.12) EX/RP sessions between week 8 and 16 (range = 3-17). Twenty five participants (78%) were treatment completers (i.e., completed at least ten, 90-minute sessions). Three participants received additional 90 minute EX/RP sessions during the follow-up period (4, 5, and 15 sessions, respectively) and two of these participants subsequently completed 45 minute maintenance sessions (3 and 5 sessions, respectively). Six participants (19%) received changes in their medication during the course of the study, as shown in Table 1. Excluding participants who received medication changes did not affect the findings on any of the primary or secondary outcomes; therefore, they were retained in the final analyses. Excluding participants who received additional sessions during follow-up (n = 3) resulted in minor changes to the results, as indicated below.

Table 1.

Baseline participant characteristics

Characteristic Participants (N = 32)
n %
Female 16 50.0
Ethnicity
 Caucasian 29 90.62
 Asian 1 3.13
 Latino 2 6.25
Single 25 78.1
Married 7 21.9
Employment
 Full time 15 46.9
 Part time 7 21.9
 Student 5 15.6
 Unemployed 5 15.6
Mean SD
Age 31.41 8.89
Number of Past SRI Trials 2.63 1.38
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Note: Six participants received medication changes during the study as follows: 1) Added bupropion at week 16; 2) SRI plus clonazepam was changed to venlafaxine, clonazepam, and bupropion at week 16; 3) Added clonazepam at week 12; 4) Added clonazepam at week 8; 5) SRI changed to fluoxetine at week 24; 6) Added propranolol and buspirone at week 6, then taken off all medications including SRI at week 12.

Primary Outcome

Table 2 shows mean values for each assessment at each time point. There was no significant improvement in Y-BOCS scores during the RCT phase, during which participants received risperidone or placebo, t(31) = −0.19, p = .85. From cross-over baseline to week 32 follow-up, there was a significant improvement in Y-BOCS scores over time (F(6,186) = 33.95, p < .001, Mse = 15.09). These changes correspond to a large effect size (η2 = .52). Follow-up t-tests indicated significant Y-BOCS change between pre and post-treatment, t(31) = 8.70; p < .001, d = 1.37 and additional significant change between post-treatment and week 32, t(31) = 3.11; p < .01, d = .54.

Table 2.

Outcome Measures for All Assessment Points

Measurea Week 0
Baseline		 Week 8
Cross-over
Baseline		 Week 12
Mid-
Treatment		 Week 16
Post-
Treatment		 1-Mo.
Follow-up		 2-Mo.
Follow-up		 3-Mo.
Follow-up		 4 Mo.
Follow-up		 Statisticsb
Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) F η 2
YBOCS 25.84 (3.83) 25.94 (4.10) 22.28 (5.32) 18.38 (5.86) 16.75 (7.73) 15.94 (8.19) 15.60 (8.53) 15.60 (8.94) 33.95* 0.52
BABS 5.72 (3.82) 5.38 (3.80) 5.03 (4.06) 4.13 (3.80) 3.47 (3.55) 3.10 (2.90) 3.41 (3.45) 2.88 (2.97) 5.46* 0.15
HAM-D 8.75 (5.35) 9.06 (6.16) 6.44 (5.10) 5.88 (5.01) 6.00 (5.65) 5.60 (5.36) 5.88 (5.21) 5.13 (5.13) 5.21* 0.14
Q-LES-Q 54.16
(13.52)		 57.94 (13.97) 59.53 (16.99) 63.50 (16.14) 64.72 (16.11) 66.25 (17.40) 65.34 (18.11) 66.66 (14.88) 5.20* 0.14
SAS-SR 2.24 (0.42) 2.22 (0.39) 2.19 (0.42) 2.10 (0.44) 1.97 (0.44) 1.96 (0.46) 1.99 (0.47) 1.98 (0.47) 9.20* 0.23
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Note:

a

YBOCS = Yale-Brown Obsessive Compulsive Scale, BABS = Brown Assessment of Beliefs Scale, HAM-D = Hamilton Rating Scale for Depression, Q-LES-Q = Quality of Life Enjoyment and Satisfaction Questionnaire, SAS-SR = Social Adjustment Scale – Self-Report

b

F and η2 values based on change over time from week 8 to week 32.

*

p < .001.

At post-treatment, eighteen participants (56.2%) were classified as responders (i.e., Y-BOCS decrease of ≤ 25%) and five participants (15.6%) met criteria for excellent response (i.e., Y-BOCS ≤ 12). At week 32, seventeen participants (53.1%) were classified as responders and 11 (34.4%) achieved excellent response. Among the six participants who received medication changes during the follow-up period, one moved from responder to excellent-responder status. Among the three participants who received additional treatment during the follow-up period, two moved from responder to excellent-responder status.

Secondary Outcomes

There was no significant improvement on any of the secondary outcome measures during the RCT phase during which participants received risperidone or pill placebo (HAM-D, p = .62; BABS, p = .62; SAS-SR, p = .82; QLES, p = .07). From cross-over baseline (week 8) to week 32 follow-up, there was a significant improvement in BABS scores (F(6,186) = 5.46, p < .001, Mse = 5.50), HAMD scores (F(6,186) = 5.21, p < .001, Mse = 10.22), QLESQ scores (F(6,186) = 5.20, p < .001, Mse = 70.85) and SAS-SR scores (F(6,186) = 9.19, p < .001, Mse = 0.04). Follow-up t-tests indicated significant change between pre and post-treatment on the HAMD, t(31) = 2.46; p < .05, d = .43. All other secondary outcomes showed non-significant change between pre and post-treatment (BABS, p = .10; SAS-SR, p = .10; QLES, p = .09). Improvement between post-treatment (week 16) and week 32 was statistically significant for BABS scores, t(31) = 2.22; p < .05, d = .39 and SAS-SR scores, t(31) = 3.35; p < .01, d = .59 and reached the trend level for QLESQ scores, t(31) = −2.04; p = .05.

When participants who received additional EX/RP during follow-up were excluded, BABS scores reached the trend level for significant change pre-to-post treatment, t(28) = 2.01; p = .05, and change in BABS between post-treatment (week 16) and follow-up (week 32) was no longer significant, t(28) = 1.59; p = .12.

Discussion

The current study examined the efficacy of EX/RP in an open trial with patients who were non-responders to SRI augmentation with risperidone or placebo. Although previous research has found EX/RP to be effective as a treatment for OCD21 and as an SRI augmentation strategy for OCD,17,33 this is the first study to show that EX/RP is effective for OCD patients who continued to report clinically significant OCD symptoms following both SRI treatment and SRI augmentation with either risperidone or placebo.

Participants in this study were OCD patients on a therapeutic dose of an SRI who did not improve following 8 weeks of the addition of risperidone or placebo. After an average of 14 EX/RP sessions, 56% of the sample was classified as treatment responders (≤25% reduction on the Y-BOCS) and 16% were classified as excellent responders (Y-BOCS ≤ 12). While this treatment effect is less robust than the effect observed in some other RCTs of EX/RP as a monotherapy or an SRI augmentation,17,2 including the acute RCT phase of this study (80% achieved response, 43% achieved excellent response),17 the current study was comprised of participants who had failed to respond to another intervention (i.e., either risperidone or PBO) and can therefore be considered more treatment resistant than participants in most other studies. Moreover, our results are consistent with open-trials of EX/RP among treatment-resistant OCD patients.24,34 For example, in OCD patients who were self-reported non-responders to multiple SRIs, 26.3% achieved clinically significant response (defined as a Y-BOCS ≤ 14.4) after 15 90-minute sessions of EX/RP.24 In addition to improvement in OCD symptoms, participants in the present study showed significant decreases in depression following eight weeks of EX/RP. The current findings are especially promising given that the majority of the sample was comprised of patients that were particularly treatment-resistant in that they had clinically significant symptoms following an adequate trial of an SRI and they did not respond to the addition of an antipsychotic (in this case risperdone), a common SRI augmentation strategy.

Not only was EX/RP effective in reducing OCD symptoms and associated impairment during treatment, but participants either maintained gains or showed some improvement during the follow-up period. Between post-treatment and follow-up, participants made additional small but significant gains in OCD symptoms and social functioning. The result was that by the end of follow-up, there was a doubling in the number of participants (from n=5 [16%] to n=11 [34%]) who were classified as excellent responders. Excellent response status is important, because at symptom levels below this threshold, patients are most likely to achieve long-term symptom remission, good quality of life, and a high-level of adaptive functioning32.

Although some continued recovery during follow-up has been observed in previous trials, the amount of change observed in this study during follow-up was particularly high (e.g., change in excellent response status from 43% to 50% in a similar time frame was found in17). This additional improvement may be understood by examining the six participants who shifted to excellent response status during the follow-up period. Of these, two received additional 90 minute EX/RP sessions, one was prescribed the addition of bupropion at post-treatment, and three were very close to achieving excellent response status prior to post-treatment (i.e., YBOCS of 14, 13, and 13). Thus, the doubling in excellent response status over follow-up in the current study may have been driven by additional interventions.

EX/RP showed a high degree of acceptability in this sample. Despite having received two pharmacological interventions (SRI plus risperidone or SRI plus pill PBO) and continuing to show clinically significant symptoms, 86% of those eligible to cross-over to EX/RP elected to do so. In addition, while the cross-over EX/RP completion rate (78%) was lower than that observed in the acute RCT (93%), this retention rate is comparable to average drop-out in most randomized controlled trials of cognitive behavioral therapy for anxiety disorders. Despite efficacy and acceptability, it is unfortunate that EX/RP, like many evidence-based psychotherapies for anxiety disorders, is not widely available to those who could benefit from this treatment.35

Several limitations should be mentioned. First and foremost is the open trial design of the study, which precludes firm conclusions about the effects of EX/RP; a controlled augmentation would provide stronger evidence of the efficacy of EX/RP with this population. At the same time, the lack of change on any study outcomes during the acute RCT phase is consistent with the inference that outcomes during the cross-over phase are attributable to EX/RP and not the passage of time or other non-specific factors (e.g., contact with study staff). Second, the study was naturalistic in that there were some medication changes (n=6) during treatment and there was variability in the number of EX/RP sessions participants received. RCTs with larger samples are required to more systematically evaluate the short and long-term impact of EX/RP with treatment-resistant patients, and to identify patient characteristics that may predict poorer response to behavioral treatment. Finally, the present sample was predominantly Caucasian (90.6%). Replication in more diverse samples is necessary to ensure generalizability of findings.

Clinical Points.

  • Risperidone is a commonly prescribed SRI augmentation strategy for OCD; however, many OCD patients remain symptomatic following pharmacological interventions.

  • Exposure and response prevention (EX/RP) is recommended for OCD patients who do not respond adequately to SRI augmentation with risperidone.

Acknowledgments

Funding/Support: This study was funded by National Institute of Mental Health grants R01 MH45404 (Dr Foa) and R01 MH045436 (Dr Simpson). Medication was provided at no cost by Janssen Scientific Affairs LLC.

Role of the Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Footnotes

Conflict of Interest Disclosures: During this study, Dr Simpson received research funds from Transcept Pharmaceuticals (2011-2013) and Neuropharm Ltd (2009), served on a scientific advisory board for Pfizer (for Lyrica, 2009-2010) and Jazz Pharmaceuticals (for Luvox CR [controlled release], 2007-2008), and received royalties from Cambridge University Press and UpToDate Inc. Dr Foa was a consultant to Jazz Pharmaceuticals (for Acetelion), and she receives royalties from Bantam and Oxford University Press for book sales, including a manual of cognitive-behavioral therapy for OCD. Drs. McLean, Zandberg, and Van Meter, and Mr. Carpenter have no conflicts to disclose.

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