Tapering From SRIs After Successful Exposure/Responsive Prevention Augmentation

After achieving wellness following exposure/response prevention (EX/RP) therapy, patients can taper to discontinuation of serotonin reuptake inhibitors (SRIs) and maintain their decreased symptoms of obsessive-compulsive disorder (OCD), according to new research from JAMA Psychiatry.

Researchers conducted a trial from May 2013 to June 2018 at the Center for the Treatment and Study of Anxiety and the Center for OCD and Related Disorders.

Patients were excluded if they had experienced recurrent major depressive disorder or major depressive episode with psychotic features, history of bipolar or psychotic disorders, substance use disorder in the past 3 months, prominent suicidal ideation, or had experienced EX/RP therapy in the past 5 years while on SRIs. Patients were also excluded if they were currently pregnant or nursing.

Patients received up to 25 sessions of EX/RP. If they gained a score less than or equal to 14 on the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), they could enter the study.

The researchers randomly, double-blinded matched patients (n=101 aged 31.0±11.2 years, 55 women, 86% White) to a 4-week taper (n=51) or continuation of SRI dose (n=50). The taper group’s SRI dose was decreased 25% weekly, substituted with placebo, and participants met every 2 weeks with a study psychiatrist and alternate weeks with a therapist.

Y-BOCS, Hamilton Depression Rating Scale (HDRS), and Quality-of-Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF) in both groups worsened by 24 weeks, without significant differences between groups in slopes or scores at the end of the study. Taper was considered noninferior to continuation of medications in each test.

The groups’ percentages of patients who retained wellness at 24 weeks did not change. More patients in the taper group showed clinical worsening compared with the continuation group (45% vs 24% Fisher exact test P =.04), when taking SRIs with half-lives of 26 hours or fewer (fluvoxamine, paroxetine, sertraline, 70% taper, 27% continuation, Fisher exact test P =.007).

Taper group participants taking SRIs with longer half-lives did not have higher clinical worsening rates compared with their peers in the continuation group.

Limitations of the study included a lack of measure of OCD severity prior to SRI treatment, exclusion of patients with at least 3 episodes of depression, demographic diversity, and SRI discontinuation after EX/RP only after wellness scores.

“In summary, results from this randomized clinical trial indicate that after successful SRI augmentation with EX/RP, patients who achieve wellness after EX/RP could, on average, discontinue their SRI with noninferior outcomes on measures of OCD, depression, and quality of life compared with those who continued their SRI,” the researchers noted. “However, those who tapered their SRI had higher rates of clinical worsening. Thus, tapering may require careful monitoring.”

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures. 

Reference

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. Published online January 26, 2022. doi:10.1001/jamapsychiatry.2021.3997