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

Abstract

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 points

• Up 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.

Keywords:

• Obsessive compulsive disorder
• treatment resistance
• cognitive behavioural therapy
• serotonin reuptake inhibitor
• second generation antipsychotic

Acknowledgments

Authors declare to have no acknowledgments.

Disclosure statement

Antonio Tundo: consultant from Janssen. Loretta Salvati, Luca Cieri, Viviana Balestrini, Daniela Di Spigno, Marica Iommi, Floriana Orazi, and Roberta Necci: no conflicts of interest to declare.

Data availability statement

Due to the nature of this research, participants of this study did not agree for their data to be shared publicly, so supporting data is not available.

Additional information

Funding

This study was funded by the Fondazione dell’Istituto di Psicopatologia Onlus, Rome, Italy [Grant no. 01/2019]. The founding source had no role in the study design; in the collection, analysis and interpretation of the data; in the writing of the manuscript; and in the decision to submit the paper for publication.