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Original Research

Six-Month Follow-Up of a Randomized Controlled Trial Augmenting Serotonin Reuptake Inhibitor Treatment With Exposure and Ritual Prevention for Obsessive-Compulsive Disorder

Edna B. Foa, PhD; Helen Blair Simpson, MD, PhD; Michael R. Liebowitz, MD; Mark B. Powers, PhD; David Rosenfield, PhD; Shawn P. Cahill, PhD; Raphael Campeas, MD; Martin Franklin, PhD; Chang-Gyu Hahn, MD, PhD; Elizabeth A. Hembree, PhD; Jonathan D. Huppert, PhD; Andrew B. Schmidt, PhD; Donna Vermes, MS, NPP; and Monnica T. Williams, PhD

Published: May 15, 2013

Article Abstract

Objective: This article describes the long-term effects of augmenting serotonin reuptake inhibitors (SRIs) with exposure and ritual prevention or stress management training in patients with DSM-IV obsessive-compulsive disorder (OCD).

Method: Between November 2000 and November 2006, 111 OCD patients from 2 academic outpatient centers with partial SRI response were randomized to the addition of exposure and ritual prevention or stress management training, delivered twice weekly for 8 weeks (acute phase); 108 began treatment. Responders (38 of 52 in the exposure and ritual prevention condition, 11 of 52 in the stress management training condition) entered a 24-week maintenance phase. The Yale-Brown Obsessive Compulsive Scale (YBOCS) was the primary outcome measure.

Results: After 24 weeks, patients randomized to and receiving exposure and ritual prevention versus stress management training had significantly better outcomes (mean YBOCS scores of 14.69 and 21.37, respectively; t = 2.88, P = .005), higher response rates (decrease in YBOCS scores ≥ 25%: 40.7% vs 9.3%, Fisher exact test P < .001), and higher rates of excellent response (YBOCS score ≤ 12: 24.1% vs 5.6%, Fisher exact test P = .01). During the maintenance phase, the slope of change in YBOCS scores was not significant in either condition (all P values ≥ .55), with no difference between exposure and ritual prevention and stress management training (P > .74). Better outcome was associated with baseline variables: lower YBOCS scores, higher quality of life, fewer comorbid Axis I diagnoses, and male sex.

Conclusions: Augmenting SRIs with exposure and ritual prevention versus stress management training leads to better outcome after acute treatment and 24 weeks later. Maintenance outcome, however, was primarily a function of OCD severity at entrance. Greater improvement during the acute phase influences how well patients maintain their gains, regardless of treatment condition.

Trial Registration: identifier: NCT00045903

J Clin Psychiatry 2013;74(5):464-469

Submitted: July 13, 2012; accepted October 25, 2012(doi:10.4088/JCP.12m08017).

Corresponding author: Edna B. Foa, PhD, Center for the Treatment and Study of Anxiety, University of Pennsylvania School of Medicine, Department of Psychiatry, 3535 Market St, 6th Floor, Philadelphia, PA 19104 (

Volume: 74

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