Is Medication Needed to Treat Obsessive-Compulsive Disorder?
Exposure and response prevention may be enough to treat OCD.
Exposure and response (or ritual) prevention (ERP) alone is as effective as ERP with psychiatric medication.
Exposure homework compliance is extremely important for treatment success.
It's important to continue ERP until a client is confident that they can manage their OCD on their own.
People who struggle with obsessive-compulsive disorder (OCD) experience intrusive thoughts accompanied by urges to engage in repeated behaviors to ward off something bad from happening or to relieve distress. For example, someone might check that their front door is locked when they leave so often that they are late for work, and they may jiggle the door handle so frequently that they damage the hardware.
The treatment with the most research support for OCD is exposure and response (or ritual) prevention (ERP). In ERP, people learn to trigger obsessive thoughts and resist the urges to engage in compulsive behaviors or rituals. In the example above, someone might practice turning the lock once and walking away no matter how strong the urge they feel to return and double-check. There are different therapy models for guiding exposure. Traditional exposure focuses on symptom reduction, while newer models with strong research support, such as acceptance and commitment therapy and inhibitory learning, do not. Psychiatric medication—mainly antidepressants—is also an effective treatment for OCD. Psychiatric medication tends to reduce the intensity of OCD thoughts and urges.
When clients come into treatment for ERP for OCD, a frequent question they ask me is whether they should also be on medication. My response has been that ERP is effective with or without medication and that ERP may be even a little more potent than medication alone. My recommendations were based on a meta-analysis Cuijpers and colleagues published in 2013. As that study is over 10 years old, I was excited when I came across a more recent study from 2023 by Wheaton and colleagues asking similar questions. The researchers wanted to know whether ERP alone or ERP-plus-medication is more effective.
Study design
For this study, the researchers combined data from two separate clinical trials of ERP for OCD. One study involved participants who were already taking an antidepressant before beginning ERP. The other study consisted of participants who were not taking medication before or during ERP. As both trials used the same manualized ERP protocol, participants in each received comparable versions of ERP for OCD.
The manualized ERP protocol involved 17 sessions, meeting twice weekly with phone calls between sessions. As once-weekly sessions without phone calls are more typical in most practice settings, this manualized version of ERP is more intensive than one is likely to find in the community. One limitation of this protocol is that most OCD therapists use as many sessions as needed for clients to graduate treatment rather than limit treatment to 17, as in the study protocol.
What did they find?
Participants appeared to improve about equally as well from ERP, whether they were taking psychiatric medication or not. One important factor was what the authors called homework adherence. In ERP, people complete exposure exercises regularly—usually daily—between appointments. The researchers defined “homework adherence” as consisting of 3 parts: (a) quantity of practice (e.g., how often they engaged in exposure); (b) quality of practice (e.g., how well they engage in exposure); (c) and ritual prevention (e.g., resisting urges to engage in compulsions between sessions).
Participants with higher OCD symptom severity and/or worse quality of life at the start of treatment showed less improvement overall. The researchers suggest these individuals may need more intensive treatment or more sessions than permitted in the study. As noted above, the study protocol was limited to 17 sessions of ERP. While 17 sessions may be enough for many clients, it's important to engage in as many sessions as necessary to work through relevant exposure exercises until someone can engage in daily life without compulsions. Consequently, limiting the number of sessions may mean treatment ends prematurely for some people. Here is one example where something that strengthens the integrity of a research study design is less applicable in a real-world setting. As I tell my clients, we will continue ERP until they are confident that they can manage their OCD on their own, without the structure of regular meetings.
Conclusions
This study supports what I’ve told clients all along: ERP is an effective treatment whether they are taking psychiatric medication or not. Anecdotally, if someone is struggling with ERP, sometimes psychiatric medication may help to reduce OCD symptoms just enough that they can better engage in exposure work.
I want to stress another important conclusion of the study: how crucial it is that people complete ERP homework outside of session. Typically, an ERP therapist assigns daily exposure practice. For example, I might ask a client with health-related obsessions to spend 30 minutes repeatedly reading a triggering medical article (e.g., young people dying of cancer) each day between appointments until they can read the article more objectively and without engaging in compulsions. For someone afraid of accidentally hitting someone with their car without realizing it, they might practice driving through a heavy pedestrian area each day, perhaps on their way to or from work, resisting any urges to turn around and check that they did not hit someone. Regular and consistent practice is extremely important in ERP. I liken it to a musician practicing scales or a basketball player practicing free throws. Deliberate practice helps to reinforce learning so that people can respond more effectively in the moment, even under duress. As this study's authors note, improving homework adherence is an important target for improving outcomes in ERP.
Brian Thompson, Ph.D., - Website -
References
Cuijpers, P., Sijbrandij, M., Koole, S. L., Andersson, G., Beekman, A. T., & Reynolds III, C. F. (2013). The efficacy of psychotherapy and pharmacotherapy in treating depressive and anxiety disorders: A meta‐analysis of direct comparisons. World Psychiatry, 12(2), 137-148.
Jacoby, R. J., & Abramowitz, J. S. (2016). Inhibitory learning approaches to exposure therapy: A critical review and translation to obsessive-compulsive disorder. Clinical Psychology Review, 49, 28-40.
Twohig, M. P., Abramowitz, J. S., Smith, B. M., Fabricant, L. E., Jacoby, R. J., Morrison, K. L., ... & Ledermann, T. (2018). Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial. Behavior Research and Therapy, 108, 1-9.
Wheaton, M. G., Rosenfield, B., Rosenfield, D., Marsh, R., Foa, E. B., & Simpson, H. B. (2023). Predictors of EX/RP alone versus EX/RP with medication for adults with OCD: Does medication status moderate outcomes? Journal of Obsessive-Compulsive and Related Disorders, 39, 1-9.
