For OCD patients, taking the antipsychotic drug risperidone (Risperdal) as an add-on drug is no more effective than placebo in those who failed to respond to a serotonin reuptake inhibitor (SRI) alone, according to a new study.

On the other hand, adding cognitive behavioral therapy (CBT) — particularly one with exposure and ritual prevention — was significantly more effective than either placebo or risperidone.

“The big message is not that antipsychotic augmentation of SRIs never works, but that it only works in a small subset.

“So if you as a clinician try it and you don’t see effects in four to six weeks, you should take your patient off of it so they don’t wind up on an antipsychotic for no reason while having all the bad side effects,” said lead author H. Blair Simpson, M.D., Ph.D., professor of clinical psychiatry at Columbia University and director of the Anxiety Disorders Clinic at the New York State Psychiatric Institute.

“It’s important for clinicians to know that not only should they go to CBT therapy before antipsychotic use, they should go to exposure and ritual prevention therapy and not something like stress management, which is very different and would not be as effective,” she added.

According to the researchers, few patients with OCD achieve remission with an SRI alone, and doctors are often faced with the challenge of what to do next. Since CBT requires time, access, and a commitment from patients, many clinicians find it easier to simply add another drug — usually an antipsychotic.

For the study, researchers randomly assigned 100 patients who had received 12 weeks of SRIs but who were still at least moderately ill to receive either eight weeks of risperidone, exposure and ritual prevention, or pill placebo, while still taking the SRI.

Exposure and ritual prevention involves confronting thoughts or situations that trigger anxiety (exposure) and then choosing not to respond compulsively after coming in contact with the fearful situation.

At week eight, the patients receiving the exposure and ritual prevention CBT had a significantly greater reduction of symptoms, compared with patients receiving risperidone and those receiving placebo.

As many as 80 percent of patients receiving CBT had a symptom decrease of 25 percent or more, compared with 23 percent of patients receiving risperidone and 15 percent receiving placebo.

Furthermore, 43 percent in the CBT group achieved remission, compared with only 13 percent in the risperidone group and 5 percent in the placebo group.

Interestingly, patients receiving risperidone showed no greater improvement than those receiving placebo.

“Based on previous smaller studies, we expected risperidone to be effective in about a third of patients, but this was a surprise — our sample showed it didn’t differ from pill placebo.”

Although this study involves the largest sample of patients receiving risperidone in comparison with CBT, Simpson cautioned that previous research should also be considered in drawing the correct conclusions.

“I think the careful message is that in our sample, it [risperidone] didn’t work, but in prior, smaller studies, it worked for some,” she said.

In one of Simpson’s prior studies, OCD patients on SRIs who also received CBT and improved after eight weeks were likely to maintain those gains at six months. With that in mind, the team is working on a six-month followup of the current study.

“My prediction is patients who continue to be their own therapists during the follow-up period and follow the instruction that their therapist taught them will be the ones to maintain their gains, but we don’t know that yet. It’s still a hypothesis,” she said.

The findings were presented at the Anxiety and Depression Association of America (ADAA) 33rd Annual Conference.

Source: Columbia University

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For OCD, CBT May Be More Effective Than Add-On Antipsychotic