Are Antipsychotic Medications a Helpful Adjunct for Treating Obsessive-Compulsive Disorder?

Among people with whom I work, a practice that’s grown more common in the last few years but with iffy research support is the addition of an antipsychotic medication when an antidepressant medication doesn’t seem to be working. This is done in an attempt to augment the effect of the antidepressant. The practice concerns me because there’s a lot of research evidence showing that the side effects of antipsychotics can be pretty awful (e.g., weight gain, high blood pressure). It concerned me enough that I wrote an editorial about it that the Oregonian published in 2012.

Now new data has been published that clearly suggests antipsychotics should not be added to antidepressants for people with OCD.

Another study showing that CBT does the best with OCD

As I’ve written before, the most effective treatment for OCD is cognitive behavioral therapy (CBT) with exposure and response (or ritual) prevention (ERP).

A 2013 study examined a group of people with moderate to severe OCD who were already taking an antidepressant. They were divided into three groups.

  1. One group received psychotherapy—cognitive behavioral therapy with ERP.
  2. One group was prescribed an antipsychotic—Risperidone—in addition to the antidepressant.
  3. One group was prescribed a placebo (i.e., inactive) pill.

What did they find?—CBT was much more effective

The results are pretty striking. For those that were given an antipsychotic, only 23% of people showed improvement. This might suggest there is some benefit to adding an antipsychotic; however, this finding is not very impressive because those given the placebo (e.g., sugar pill) showed a 15% improvement. Moreover, the researcher found no statistically significant different between the effectiveness of the antipsychotic and that of the placebo. What this means is that, statistically speaking, the antipsychotic was no better than the placebo; that is, the 23% improvement (i.e., antipsychotic) is not more meaningful than the 15% improvement (i.e., placebo).

By contrast to those who received a pill, 80% of people who received cognitive behavioral therapy with ERP showed improvement! This is 3-4x the rate of improvement compared to those taking an antipsychotic—and without the extensive side effects that are common with antipsychotics.

Antipsychotic medication should not be considered for people with OCD

I think this is an important study because it makes it clear that adding antipsychotic medication is unlikely to really benefit someone with OCD. However, that cognitive behavioral therapy with ERP is more effective than medication for OCD is not a new finding

There’s already a solid base of research that suggests the ERP is superior to antidepressant medication for OCD. Giving an antidepressant to someone receiving EX/RP for OCD neither helps nor hinders treatment. This study is evidence that antipsychotics should not be considered for people with OCD.

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