Serotonin reuptake inhibitor-cognitive behavioural therapy-second generation antipsychotic combination for severe treatment-resistant obsessive-compulsive disorder. A prospective observational study.

INTRODUCTION: Six in ten patients with obsessive-compulsive disorder (OCD) do not respond to the first-line treatments with serotonin reuptake inhibitor (SRI) or cognitive behavioural therapy including exposure and response prevention (CBT/ERP), and several do not respond to second-line treatments, i.e., SRI-second generation antipsychotic (SGA) or SRI-CBT/ERP augmentation. Evidence on third-line treatments is inconsistent. OBJECTIVE: We investigated the 1-year response to SRI-CBT/ERP-SGA combination in patients with severe treatment-resistant OCD, who failed to respond to SRI and to SRI-SGA or SRI-CBT/ERP augmentation. METHODS: Twenty-eight patients were consecutively recruited and treated with SRI (drug(s) and doses previously administered), SGA (risperidone median dosage 1 mg/day in 14 cases, aripiprazole median dosage 3 mg/day in 14 cases) and CBT/ERP (median hours 32.5). Exclusion criteria: mental retardation and organic brain syndrome. RESULTS: The mean Y-BOCS total score reduction at 12 months was 28.2%, 60.7% of patients improved, 46.4% partially responded, 32.1% responded, and 28.6% remitted. Patients previously resistant to SRI-SGA and SRI-CBT/ERP did not significantly differ in the rates of improvement, partial response, response and remission. CONCLUSIONS: This study suggests that SRI-SGA-CBT/ERP combination could be useful for severe treatment-resistant OCD. Small sample size is a limitation.Key pointsUp to 6 in 10 patients with OCD do not respond to first line treatments (CBT/ERP or SRIs) and several to second-line treatments (SRI-SGA or SRI CBT/ERP augmentation).In our study, patients with OCD resistant to the first and the second line treatment improved (61%), partially responded (46%), responded (32%), or remitted (29%) combining SRI, SGA and CBT/ERP.In our patients the SRI-SGA-CBT/ERP augmentation improved working/school, social and family impairment.SRI-SGA-CBT/ERP augmentation is easier to use than other treatments for severe treatment-resistant OCD.

Addition of cognitive-behavioral therapy for nonresponders to medication for obsessive-compulsive disorder: a naturalistic study.

OBJECTIVE: The best currently available treatments for obsessive-compulsive disorder (OCD) are serotonin reuptake inhibitors (SRIs) and cognitive-behavioral therapy (CBT). It is generally recommended that patients who have been unsuccessfully treated with SRIs should receive supplementary CBT, although few studies have yet to investigate the proposal's validity. The purpose of the present study is to examine the effectiveness of CBT on a sample of nonselected, pharmacologically treatment-resistant OCD patients. METHOD: Thirty-six OCD patients (based on DSM-IV criteria) who had not responded to at least 1 adequate SRI trial conducted in our outpatient clinic were treated from January 2000 through April 2004 with CBT, incorporating exposure and ritual prevention. The therapy was conducted in a naturalistic setting and manualized guidelines were adapted to each patient. Pharmacologic treatment underwent no changes during the trial period. Outcome measures included the Yale-Brown Obsessive Compulsive Scale, the Clinical Global Impressions-Severity of Illness scale, and the Global Assessment of Functioning scale. The primary outcome measure was a rating of "much improved" or "very much improved" on the Clinical Global Impressions-Improvement scale (CGI-I). RESULTS: Two patients (5%) refused CBT after 1 session, and 10 patients (28%) dropped out of the study. Three of the 24 remaining patients completed the trial at 6 months (T1) but did not follow through up to 12 months (T2). The 21 patients completing CBT showed statistically significant improvement (p < .0001) during follow-up on all outcome measures. At T2, 15 (42%) of 36 patients were rated as being "much improved" or "very much improved," as measured by the CGI-I. Symptom reduction was clinically modest but important, with nearly all patients presenting residual symptoms. CONCLUSION: CBT could be usefully added to pharmacologic treatments for severe, real-world, medication-resistant OCD patients.