. 2021 Aug:143:103890.

doi: 10.1016/j.brat.2021.103890. Epub 2021 May 29.

Maximizing remission from cognitive-behavioral therapy in medicated adults with obsessive-compulsive disorder

Helen B Simpson¹, Edna B Foa², Michael G Wheaton³, Thea Gallagher², Marina Gershkovich⁴, Andrew B Schmidt⁴, Jonathan D Huppert⁵, Raphael B Campeas⁴, Patricia A Imms², Shawn P Cahill⁶, Christina DiChiara⁷, Steven D Tsao⁷, Anthony C Puliafico⁴, Daniel Chazin², Anu Asnaani⁸, Kelly Moore⁹, Jeremy Tyler², Shari A Steinman¹⁰, Arturo Sanchez-LaCay⁴, Sandy Capaldi², Ivar Snorrason¹¹, Elizabeth Turk-Karan², Donna Vermes⁴, Eyal Kalanthroff⁵, Anthony Pinto¹², Chang-Gyu Hahn², Bin Xu¹³, Page E Van Meter⁴, Martha Katechis⁴, Jennifer Scodes¹⁴, Yuanjia Wang¹⁵

Affiliations

¹ Department of Psychiatry, Columbia University, New York, NY, 10032, USA; New York State Psychiatric Institute, New York, NY, 10032, USA. Electronic address: Blair.Simpson@nyspi.columbia.edu.
² Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, 19104, USA.
³ New York State Psychiatric Institute, New York, NY, 10032, USA; Barnard College, Columbia University, New York, NY, 10027, USA.
⁴ Department of Psychiatry, Columbia University, New York, NY, 10032, USA; New York State Psychiatric Institute, New York, NY, 10032, USA.
⁵ The Hebrew University of Jerusalem, Israel.
⁶ University of Wisconsin-Milwaukee, Milwaukee, WI, 53201, USA.
⁷ Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, 19104, USA; Center for Anxiety and Behavior Therapy, Bryn Mawr, PA, 19010, USA.
⁸ Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, 19104, USA; Department of Psychology, University of Utah, Salt Lake City, UT, 84112, USA.
⁹ Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, 19104, USA; Rutgers University/Biomedical Health Sciences New Brunswick, NJ, 08854, USA.
¹⁰ Department of Psychiatry, Columbia University, New York, NY, 10032, USA; New York State Psychiatric Institute, New York, NY, 10032, USA; Department of Psychology, WVU, Morgantown, WV, 26506, USA.
¹¹ Department of Psychiatry, Columbia University, New York, NY, 10032, USA; New York State Psychiatric Institute, New York, NY, 10032, USA; McLean Hospital/Harvard Medical School, Belmont, MA, 02478, USA.
¹² Department of Psychiatry, Columbia University, New York, NY, 10032, USA; New York State Psychiatric Institute, New York, NY, 10032, USA; Department of Psychiatry, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, The Zucker Hillside Hospital, Glen Oaks, NY, 11004, USA.
¹³ Department of Psychiatry, Columbia University, New York, NY, 10032, USA.
¹⁴ New York State Psychiatric Institute, New York, NY, 10032, USA.
¹⁵ Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, 10032, USA.

PMID: 34089924
PMCID: PMC8241471
DOI: 10.1016/j.brat.2021.103890

Maximizing remission from cognitive-behavioral therapy in medicated adults with obsessive-compulsive disorder

Helen B Simpson et al. Behav Res Ther. 2021 Aug.

. 2021 Aug:143:103890.

doi: 10.1016/j.brat.2021.103890. Epub 2021 May 29.

Authors

Affiliations

¹ Department of Psychiatry, Columbia University, New York, NY, 10032, USA; New York State Psychiatric Institute, New York, NY, 10032, USA. Electronic address: Blair.Simpson@nyspi.columbia.edu.
² Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, 19104, USA.
³ New York State Psychiatric Institute, New York, NY, 10032, USA; Barnard College, Columbia University, New York, NY, 10027, USA.
⁴ Department of Psychiatry, Columbia University, New York, NY, 10032, USA; New York State Psychiatric Institute, New York, NY, 10032, USA.
⁵ The Hebrew University of Jerusalem, Israel.
⁶ University of Wisconsin-Milwaukee, Milwaukee, WI, 53201, USA.
⁷ Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, 19104, USA; Center for Anxiety and Behavior Therapy, Bryn Mawr, PA, 19010, USA.
⁸ Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, 19104, USA; Department of Psychology, University of Utah, Salt Lake City, UT, 84112, USA.
⁹ Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, 19104, USA; Rutgers University/Biomedical Health Sciences New Brunswick, NJ, 08854, USA.
¹⁰ Department of Psychiatry, Columbia University, New York, NY, 10032, USA; New York State Psychiatric Institute, New York, NY, 10032, USA; Department of Psychology, WVU, Morgantown, WV, 26506, USA.
¹¹ Department of Psychiatry, Columbia University, New York, NY, 10032, USA; New York State Psychiatric Institute, New York, NY, 10032, USA; McLean Hospital/Harvard Medical School, Belmont, MA, 02478, USA.
¹² Department of Psychiatry, Columbia University, New York, NY, 10032, USA; New York State Psychiatric Institute, New York, NY, 10032, USA; Department of Psychiatry, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, The Zucker Hillside Hospital, Glen Oaks, NY, 11004, USA.
¹³ Department of Psychiatry, Columbia University, New York, NY, 10032, USA.
¹⁴ New York State Psychiatric Institute, New York, NY, 10032, USA.
¹⁵ Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, 10032, USA.

PMID: 34089924
PMCID: PMC8241471
DOI: 10.1016/j.brat.2021.103890

Abstract

Practice guidelines for adults with obsessive-compulsive disorder (OCD) recommend augmenting serotonin reuptake inhibitors (SRIs) with exposure and ritual prevention (EX/RP). However, fewer than half of patients remit after a standard 17-session EX/RP course. We studied whether extending the course increased overall remission rates and which patient factors predicted remission. Participants were 137 adults with clinically significant OCD (Yale-Brown Obsessive Compulsive Scale [Y-BOCS] score ≥18) despite an adequate SRI trial (≥12 weeks). Continuing their SRI, patients received 17 sessions of twice-weekly EX/RP (standard course). Patients who did not remit (Y-BOCS ≤12) received up to 8 additional sessions (extended course). Of 137 entrants, 123 completed treatment: 49 (35.8%) remitted with the standard course and another 46 (33.6%) with the extended course. Poorer patient homework adherence, more Obsessive-Compulsive Personality Disorder (OCPD) traits, and the Brain-Derived Neurotrophic Factor (BDNF) Val66MET genotype were associated with lower odds of standard course remission. Only homework adherence differentiated non-remitters from extended course remitters. Extending the EX/RP course from 17 to 25 sessions enabled many (69.3%) OCD patients on SRIs to achieve remission. Although behavioral (patient homework adherence), psychological (OCPD traits), and biological (BDNF genotype) factors influenced odds of EX/RP remission, homework adherence was the most potent patient factor overall.

Keywords: CBT; Cognitive-behavioral therapy; EX/RP; Exposure and ritual prevention; OCD; Obsessive-compulsive disorder.

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Conflict of interest statement

During the conduct of this study and in the prior 36 months, Dr. Simpson has received research support from Biohaven, royalties from Cambridge University Press and UpToDate, Inc, and a stipend from JAMA for her role as Associate Editor at JAMA Psychiatry. Dr. Puliafico has received royalties from UpToDate, Inc. Dr. Foa has received support for research from Pfizer, Solvay, Eli Lilly, SmithKline Beecham, GlaxoSmithKline, Cephalon, Bristol Myers Squibb, Forest, Ciba Geigy, Kali-Duphar, American Psychiatric Association, NIDA, NIAAA, NIH, DOJ and DoD, speaking fees from Pfizer, GlaxoSmithKline, Forest Pharmaceuticals, American Psychiatric Association and Jazz Pharmaceuticals, consulted for Actelion Pharmaceuticals and royalties from Bantam and Oxford University Press for book sales, including a manual of cognitive behavioral therapy for OCD. She also receives payment for training she conducts on obsessive-compulsive disorder. All other authors report no financial relationships with commercial interests.

Figures

**Figure 1:. Consort Diagram**
EX/RP = Exposure and Ritual Prevention; NY=New York site; OCD=Obsessive Compulsive Disorder; PA=Pennsylvania site; SRI = Serotonin Reuptake Inhibitor; Y-BOCS = Yale-Brown Obsessive Compulsive Scale

**Figure 2:. Observed OCD Severity Across Time by Remission Status**
Observed OCD Severity (as measured by the Yale-Brown Obsessive Compulsive Scale [Y-BOCS]) is presented by remission status. Error bars are 1 standard deviation.

**Figure 3:. Model-estimated Odds-ratios Predicting Remission Status after Standard or Extended Course^a,b**
Multinomial logistic regression models examined which hypothesized predictors were associated with remission status. Odds-ratios were computed for all contrasts: extended course remission compared to standard course remission (left panel), no-remission compared to standard course remission (middle panel), and no-remission compared to extended course remission (right panel). As a result, odds-ratios greater than 1 indicate higher odds of extended course remission or no remission compared to those with standard course remission (left and middle panel, respectively) and higher odds of no remission compared to those with extended course remission (right panel) for every one standard deviation unit increase in the predictor. Hypothesized predictors included: baseline OCD severity (measured by the Yale-Brown Obsessive Compulsive Scale [Y-BOCS]), patient homework adherence (measured by the PEAS), psychological traits (measured by the POPS and MCQ), and specific genotypes (BDNF, COMT, SLC6A4). See text for details. ^a Values greater than 8 are not shown. ^b The BDNF T/T vs C/C contrast is not estimated in the no-remission versus standard course and extended course remission comparisons because no subjects in the no-remission group had the T/T genotype. This contrast is estimated in the extended course versus standard course remission comparison, though only one subject in the extended course remission group had the T/T genotype.

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Maximizing remission from cognitive-behavioral therapy in medicated adults with obsessive-compulsive disorder

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Maximizing remission from cognitive-behavioral therapy in medicated adults with obsessive-compulsive disorder

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