Medications May Be Carefully Discontinued If Obsessive-Compulsive Disorder Remits

Obsessive-compulsive disorder (OCD) is a chronic condition that is often treated with both behavioral therapy and selective serotonin reuptake inhibitors (SSRIs).[1] Because SSRIs cause numerous adverse effects, patients often seek to stop using their medication once their OCD symptoms remit; however, there is little data available about the outcomes associated with such drug discontinuance.

A recent clinical trial indicates that many persons with OCD who respond favorably to joint behavioral and SSRI treatment may then safely taper their SSRI use very slowly to elimination, though careful follow-up clinical monitoring is still essential.

Background on OCD

OCD is an often severe and persistent illness characterized by uncontrollable obsessions (repeated thoughts, urges or mental images that cause anxiety) and corresponding compulsions (repetitive behaviors in response to those obsessions) that greatly interfere with day-to-day living.[2] In any year, just over 1% of U.S. adults suffer from OCD, and over half of those sufferers experience serious impairment.[3]

Several SSRIs are approved by the Food and Drug Administration for the treatment of OCD, though they also cause the following common adverse reactions: sexual dysfunction, reduced appetite, diarrhea, tremor, sweating and nausea.[4] Clomipramine (ANAFRANIL), which is chemically similar to tricyclic antidepressants, is also FDA-approved for treating OCD.

The new clinical trial[5]

The new clinical trial, which was published in the March 2022 issue of the Journal of the American Medical Association, Psychiatry, was a randomized, double-blind study of 101 adults with OCD who either continued using SSRI or clomipramine therapy or discontinued that therapy after four weeks of tapering their dose to zero. Those in the taper group received placebo pills after discontinuing the drug so they and the study researchers would not know their medication was being gradually eliminated.

This trial was conducted from 2013 to 2018 at two academically affiliated treatment centers, one in New York at Columbia University and the other in Philadelphia at University of Pennsylvania.

Adults age 18 to 75 years old were eligible for participation if they had 1) an OCD diagnosis for at least one year with moderate symptoms; 2) been on an “adequate” dose of an SSRI or clomipramine (see Table, below) for at least 12 weeks; and 3) attained wellness following up to 25 sessions of a specific behavioral therapy known as exposure/response prevention (EX/RP), which involves safe but challenging exposures to objects or situations that trigger debilitating feelings while discouraging corresponding compulsions. For example, a person with an irrational fear of germs may be coached by their therapist to touch floors or other seemingly contaminated surfaces without immediate hand-cleansing afterwards and work towards comfortably doing so at least three times a day.[6]

Oral Drugs Used to Treat OCD by “Adequate”† Daily Dose

†Per Foa et al, JAMA Psychiatry. 2022;79(3):193-200.
††Brand-name combination products that contain one or more additional active ingredients not listed.
All drugs in this Table are classified as Limited Use by Worst Pills Best Pills News.

Participants were said to achieve wellness after medication and EX/RP treatments if their OCD symptoms declined to a score of 14 or lower on the 40-point Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). This score of 14 is notably lower than the pre-EX/RP treatment score required to enter the trial, which was at least 18 on the same scale.

After wellness was achieved using the combination of medication and EX/RP, the four-week tapering phase followed for those assigned to the medication-taper group; all subjects then continued active medication or placebo for an additional 20 weeks. The primary outcome was the Y-BOCS after those 20 weeks. Secondary endpoints included standardized depression and quality-of-life scale scores.

Subjects had an average age of 31 years, 55% were female and 86% were White. The mean Y-BOCS score at the time medication tapering began was 9.

After 24 weeks, among those who completed the trial, the mean scores between the two groups on the Y-BOCS were statistically indistinguishable and still in the wellness range: 10.7 and 10.8, respectively. Depression and quality-of-life scores also were statistically the same between study completers across groups. However, 45% of the medication-taper group demonstrated marked worsening of their OCD, compared with just 24% of the medication-continuation group, a statistically significant difference.

Accordingly, the researchers concluded that those who achieve wellness on medication and EX/RP therapy on average maintained that wellness without continuing medication. However, the fact that medication tapering resulted in significant clinical worsening in a substantial proportion of subjects further led to the conclusion that OCD patients who attempt drug tapering after achieving therapeutic wellness on medication and EX/RP therapy must be carefully monitored for OCD-symptom relapse.

An April 2022 commentary from a group of clinician researchers published by Comprehensive Psychiatry expressed deep concern that medication discontinuance, even following the achievement of wellness using medication and EX/RP, carries with it a high risk of relapse that may ultimately warrant more gradual or delayed medication tapering.[7]

What You Can Do

If you suffer from OCD and are using an SSRI medication or clomipramine to treat that condition, consider finding a therapist who can additionally treat you with EX/RP. If you achieve wellness with the combination of medication and EX/RP therapy, further consider working closely with your doctors to gradually taper and discontinue your medication, but be careful to maintain regular contact with your therapist and physician during at least the first six months after you begin to taper your medication to monitor for OCD-symptom relapse, which may require resumption of your medication. Never abruptly stop your SSRI or clomipramine.
 

References

[1] Blair Simpson H. Pharmacotherapy for obsessive-compulsive disorder in adults. UpToDate. October 2, 2022.

[2] National Institute of Mental Health. Obsessive Compulsive Disorder: When Unwanted Thoughts or Repetitive Behaviors Take Over. Publication No. 20-MH-4676. Revised 2020. https://www.nimh.nih.gov/sites/default/files/documents/health/publications/obsessive-compulsive-disorder-when-unwanted-thoughts-take-over/20-mh-4676-ocd.pdf. Accessed May 31, 2022.

[3] National Institute of Mental Health. Obsessive-compulsive disorder (OCD). https://www.nimh.nih.gov/health/statistics/obsessive-compulsive-disorder-ocd. Accessed May 31, 2022.

[4] Eli Lilly and Company. Label: fluoxetine (PROZAC). October 2021. https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/018936s111lbl.pdf. Accessed May 31, 2022.

[5] Foa EB, Simpson HB, Gallagher T, et al. Maintenance of wellness in patients with obsessive-compulsive disorder who discontinue medication after exposure/response prevention augmentation: A randomized clinical trial. JAMA Psychiatry. 2022;79(3):193-200.

[6] Drummond L, Edwards L. (2018). Exposure and Response Prevention for OCD. In Obsessive Compulsive Disorder: All You Want to Know about OCD for People Living with OCD, Carers, and Clinicians (pp. 45-68). Cambridge: Cambridge University Press.

[7] Fineberg NA, Hollander E, Grant JE, et al. Commentary on the article: "Maintenance of wellness in patients with obsessive-compulsive disorder who discontinue medication after exposure/response prevention augmentation A randomized clinical trial" Foa EB et al., JAMA Psychiatry. 2022;79(3):193-200 (1). Compr Psychiatry. 2022 Apr 28;116:152323.