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New research published this week (11th September) provides evidence that patients with OCD for whom SSRIs have not resolved their problem respond better when psychological treatment (CBT with ERP) is added to the SSRI antidepressant compared to those that were prescribed an augmentation of a SSRI medication and Risperidone, a form of antipsychotic drug.
These findings led researchers to conclude that patients with OCD receiving SSRIs who continue to have clinically significant symptoms should be offered CBT before antipsychotics are prescribed, especially given its superior efficacy and less negative adverse effects.
Here in the UK, since the launch of the National Institute for Health and Care Excellence (NICE) Guidelines for the treatment of OCD back in 2005, if a patient failed to respond to SSRI or Clomipramine, NICE have recommended adding antipsychotic medication (eg, haloperidol, risperidone, olanzapine, quetiapine fumarate, or aripiprazole). The use of antipsychotics has also been, in the opinion of OCD-UK, a controversial barrier that in some cases could prevent patients with OCD accessing one of the specialist national treatment services. At present referral criteria states that patients should have had ‘augmentation of SSRI treatment either with first or second generation antipsychotic drugs’, which OCD-UK would like to see changed from mandatory to desired in the referral crtieria.
The new randomised clinical research, conducted between January 2007 and August 2012, is the first randomised clinical trial to compare two recommended SSRI augmentation strategies for adults with OCD. The research team had originally hypothesised that Risperidone and CBT would each reduce OCD symptoms more than placebo and that Risperidone and CBT would not differ in efficacy. The research aimed to find out if the drug combination did indeed work and also if it proved better than antidepressants and CBT.
Patients (aged 18-70 years) were eligible if they had OCD of at least moderate severity despite a therapeutic SSRI dose for at least 12 weeks prior to entry. Of 163 patients that were eligible, 100 were randomised (risperidone, n = 40; CBT (17 x twice weekly sessions), n = 40; and placebo, n = 20), and 86 completed the trial.
After two months, 43% of patients who took an antidepressant plus CBT had minimal symptoms of OCD, compared with 13% who added Risperidone and 5% who took the placebo. Significantly more patients receiving CBT (32 of 40[80%]) than those receiving Risperidone (9 of 40 [22.5%]) or placebo (3 of 20 [15%]) responded to treatment.
What the researchers concluded was that adding CBT was also superior to Risperidone and placebo in improving insight, functioning, and quality of life for patients with OCD, although some data does suggest that antipsychotic augmentation is most helpful in patients with comorbid OCD and tic disorders. It is worth noting that the CBT offered during this clinical trial was high quality CBT provided by specialists in the field of OCD, something that OCD-UK would like to see made more easily accessible to patients with OCD here in the UK.
In light of this clear new research SSRI/CBT augmentation offers more likely effective treatment advantages over SSRI/Risperidone augmentation, OCD-UK call upon NICE to review their recommendations to ensure that patients are given access to high quality CBT before health clinicians prescribe antipsychotic medications.
Paul Salkovskis, an OCD specialist and a professor of clinical psychology and applied science at the University of Bath, in England, praised the study and said the findings confirm that exposure and cognitive behavioural therapy "has a substantial effect."
"It's about as strong a study as can be -- properly conducted, properly reported and analysed. It is world-changing for OCD patients" Salkovskis said. "It would seem appropriate for people taking antipsychotic medication purely as augmentation of SSRIs in OCD to ask their doctor to review this prescription with a possible view to being helpedto discontinue it. The other implication is that there is an urgent need to make good quality specialist Cognitive Behaviour Therapy (CBT), including in some cases intensively delivered, more available to people who have not responded to conventional first-line treatment."
OCD-UK welcomes this new research, and will be contacting NICE and the National Specialised Commissioning Team (NSCT) to ask them to review the new evidence .
For those patients already being prescribed an antipsychotic medication we advise caution before sudden discontinuing the medication, and recommend patients talk this through carefully with their GP and/or Psychiatrist to agree continuation or withdrawal plan before any further action is taken.