International prescribing practices in obsessive-compulsive disorder (OCD)

Prescribing patterns in patients with obsessive-compulsive disorder: Retrospective, single-center study

INTRODUCTION

Obsessive-compulsive disorder (OCD) is marked by a high rate of treatment resistance. Patients are often left trialing medications within multiple drug classes with little response, causing heterogeneity to emerge in prescribing patterns. This analysis seeks to investigate the selection and dosing of the pharmacotherapy utilized, to portray an overview of prescribing trends in the United States.

METHODS

This retrospective, single center, review of electronic medical records investigated the pharmacotherapy utilization of patients with a primary diagnosis of OCD. Two hundred and ninety-five patients who received OCD treatment at an urban, academic medical center were included in the study. Patients were included in the review if they were at least eighteen years of age and were assigned a diagnosis of OCD according to DSM-5 criteria.

RESULTS

Psychotropic pharmacotherapy was integrated into the care of 93% of patients. Selective serotonin reuptake inhibitors were the most utilized medication class at 85% followed by benzodiazepines (47%) and second-generation antipsychotics (37%). Tricyclic antidepressants and first-generation antipsychotics were the two medication classes utilized the least at 13% and 2% respectively. Additionally, mood stabilizers and serotonin-norepinephrine reuptake inhibitors were utilized at rates of 8% and 16%, respectively.

CONCLUSIONS

Evidence-based treatment guidelines are being followed with varying augmentation strategies widely prevalent, thus displaying the heterogeneity in treating OCD. A high rate of benzodiazepine utilization highlights a practice trend with potential ties to clinical factors, such as the latency to treatment effect of other first-line pharmacotherapies. Future prospective studies are required to determine the cultural, pharmacoeconomic and pharmacogenomic factors that contribute to the variation in prescribing practices and whether these variations influence treatment outcomes.

Online group therapies for anxiety, obsessive-compulsive, and trauma-related disorders: a systematic review

Background

This systematic review examined the existing literature to determine the evidence supporting the efficacy of online group treatments for anxiety-, obsessive-compulsive- and trauma-related disorders (AOTDs).

Methods

A systematic review using the PUBMED, PsycInfo, Web of Science, and ClinicalTrials databases with no language, date, or study design filters was performed. The inclusion criteria comprised studies that examined individuals who had received a formal diagnosis of AOTDs, were aged 18 years or older, and had baseline and endpoint assessments of symptom severity using formal tools.

Results

Five studies on social anxiety disorder (SAD), four on post-traumatic stress disorder (PTSD) and one on tic disorders (TDs) were found. The studies were open-label (n = 2) and randomized controlled trials (RCTs) (n = 8), with five of the RCTs being non-inferiority trials. Most studies were conducted in the US and investigated psychological CBT based interventions via internet-based therapies (IBT: n = 4), video teleconferencing (VTC: n = 5) or a combination of both (n = 1). In SAD, IBT studies associated with a clinician assisted web-based forum (here termed "forum-enhanced" studies) were superior to waiting lists and not inferior to similar versions that were also "forum enhanced" but self-guided, "telephone enhanced" by a contact with a non-specialist, and "email enhanced" by a contact with a clinician individually. Studies involving VTC have shown comparable effectiveness to in-person interventions across some online group CBT based treatments for PTSD. Two open trials also demonstrated symptoms reductions of social anxiety and tics through VTC.

Conclusion

There is evidence supporting the effectiveness of online group treatments for SAD and PTSD. Further studies from different research groups may be needed to replicate the use of these and other forms of online treatments in individuals with SAD, PTSD, and other clinical populations, such as OCD, panic disorder, agoraphobia and specific phobias.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42023408491.

Systematic review of studies using platelet serotonin content to assess bioeffect of serotonin reuptake inhibitors at the serotonin transporter

RATIONALE

Assessment of the bioeffect of serotonin reuptake inhibitors (SRIs, including both selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs)) at the serotonin transporter (SERT) in patients and healthy controls can have important theoretical and clinical implications.

OBJECTIVES

Bioeffect at SERT has been assessed by neuroimaging of brain SERT occupancy, through in vitro measurements of platelet serotonin (5-HT) uptake, and by measuring platelet 5-HT content pre- and post-initiation of SRI administration. Studies of platelet 5-HT content were reviewed in order to (1) determine the overall apparent bioeffect of SRIs; (2) compare bioeffect across types of SRIs; (3) compare the three approaches to assessing SRI bioeffect; and (4) determine how the findings might inform clinical practice.

METHODS

We performed a systematic review of the published studies that measured platelet 5-HT content to assess SRI bioeffect at the platelet SERT. Studies using neuroimaging and in vitro platelet 5-HT uptake to assess SRI bioeffect were reviewed for comparison purposes.

RESULTS

Clinical doses of SRIs typically resulted in 70-90% reductions in platelet 5-HT content. The observed bioeffect at the platelet SERT appeared similar among different SSRIs and SNRIs. The bioeffect estimations based on platelet 5-HT content were consistent with those obtained using neuroimaging to assess brain SERT occupancy and those based on the in vitro measurement of platelet 5-HT uptake.

CONCLUSIONS

In general, excellent agreement was seen in the apparent SRI bioeffect (70-90% inhibition) among the platelet 5-HT content studies and across the three bioeffect approaches. Theoretical and practical clinical implications are discussed.

Neurobiological outcomes of cognitive behavioral therapy for obsessive-compulsive disorder: A systematic review

Introduction

Obsessive-compulsive disorder (OCD) is characterized by recurrent distressing thoughts and repetitive behaviors, or mental rituals performed to reduce anxiety. Recent neurobiological techniques have been particularly convincing in suggesting that cortico-striatal-thalamic-cortico (CSTC) circuits, including orbitofrontal cortex (OFC) and striatum regions (caudate nucleus and putamen), are responsible for mediation of OCD symptoms. However, it is still unclear how these regions are affected by OCD treatments in adult patients. To address this yet open question, we conducted a systematic review of all studies examining neurobiological changes before and after first-line psychological OCD treatment, i.e., cognitive-behavioral therapy (CBT).

Methods

Studies were included if they were conducted in adults with OCD and they assessed the neurobiological effects of CBT before and after treatment. Two databases were searched: PsycINFO and PubMed for the time frame up to May 2022.

Results

We obtained 26 pre-post CBT treatment studies performed using different neurobiological techniques, namely functional magnetic resonance imaging (fMRI), Positron emission tomography (PET), regional cerebral blood flow (rCBF), 5-HT concentration, magnetic resonance imaging (MRI), magnetic resonance spectroscopy (MRS), Electroencephalography (EEG). Neurobiological data show the following after CBT intervention: (i) reduced activations in OFC across fMRI, EEG, and rCBF; (ii) decreased activity in striatum regions across fMRI, rCBF, PET, and MRI; (iii) increased activations in cerebellum (CER) across fMRI and MRI; (iv) enhanced neurochemical concentrations in MRS studies in OFC, anterior cingulate cortex (ACC) and striatum regions. Most of these neurobiological changes are also accompanied by an improvement in symptom severity as assessed by a reduction in the Y-BOCS scores.

Conclusion

Cognitive-behavioral therapy seems to be able to restructure, modify, and transform the neurobiological component of OCD, in addition to the clinical symptoms. Nevertheless, further studies are necessary to frame the OCD spectrum in a dimensional way.

Early intervention in obsessive-compulsive disorder: From theory to practice

Obsessive-compulsive disorder (OCD) is frequent and often disabling. Yet, correct diagnosis and appropriate treatment implementation are usually delayed, with undesirable consequences. In this paper we review the rationale for early intervention in OCD and provide recommendations for early intervention services. Two scenarios are discussed, i.e., subclinical (prodromal) obsessive-compulsive symptoms (OCS) and full-blown OCD. Although the typical patient with OCD reports a long history of subclinical OCS, longitudinal studies suggest most individuals with OCS in the community do not convert to full-blown OCD. Thus, research on "at risk" phenotypes for OCD and how they should incorporate different risk factors (e.g., polygenic risk scores) are badly needed. For this specific scenario, preventative treatments that are cheap, well tolerated and highly scalable (e.g., lifestyle interventions) are of major interest. On the other hand, increasing evidence suggests OCD to be a progressive disorder and the severity and duration of illness to be associated with both biological changes and increased clinical complexity, including greater number of physical and psychiatric comorbidities, increased family accommodation and worse treatment response. Therefore, prompt identification and early treatment implementation for full-blown OCD are also critical for ethical, clinical and therapeutic reasons. Based on the existing findings, we argue that, regardless of focusing on subclinical OCS or clinical OCD, early intervention services need to target a childhood age group. In addition to delivering well established treatments to people with full-blown OCD early on their illness, early intervention services also need to provide psychoeducation for patients, families and teachers.

Latency to treatment seeking in patients with obsessive-compulsive disorder: Results from a large multicenter clinical sample

This study aimed to identify the factors associated with a delay in treatment-seeking among patients with obsessive-compulsive disorder (OCD), a disabling neuropsychiatric disorder. To achieve this purpose, we conducted a cross-sectional study examining latency to treatment (LTT) and its associated correlates in 863 patients with OCD. We defined LTT as the time lag between the awareness of discomfort and/or impairment caused by symptoms and the beginning of OCD-specific treatment. To determine the socio-demographic and clinical characteristics associated with LTT, we built an interval-censored survival model to simultaneously assess the relationship between all variables, representing the best fit to our data format. The results of our study showed that approximately one-third of OCD patients sought treatment within two years of symptom awareness, one-third between two and nine years, and one-third after ten or more years. Median LTT was 4.0 years (mean = 7.96, SD = 9.54). Longer LTT was associated with older age, early onset of OCD symptoms, presence of contamination/cleaning symptoms and full-time employment. Shorter LTT was associated with the presence of aggression symptoms and comorbidity with hypochondriasis. The results of our study confirm the understanding that LTT in OCD is influenced by several interdependent variables - some of which are modifiable. Strategies for reducing LTT should focus on older patients, who work in a full-time job, and on individuals with early onset of OCD and contamination/cleaning symptoms.

Therapists’ Emotional Reactions to Patients with Obsessive–Compulsive Disorder: The Role of Therapists’ Orientation and Perfectionism

Therapist’s emotional response towards patients with obsessive–compulsive disorder (OCD) is under-investigated. This aspect might provide valuable information about therapists’ difficulties during sessions and support supervisory practice, since a proportion of OCD patients drop out due to issues related to the therapeutic relationship. In a sample of therapists, we explored the effects of therapists’ orientation (cognitive behavioural versus psychodynamic) and perfectionistic traits on their emotional responses towards patients with OCD, controlling for other variables potentially related to emotional response towards patients (i.e., therapists’ gender/age and patient’s comorbid personality disorders). Ninety-four therapists (74 women and 20 men; mean age = 42.07 ± 10.17 years), of which 47 (50%) had a cognitive behavioural therapy (CBT) and 47 (50%) a psychodynamic orientation matched on gender and age, completed the Therapist Response Questionnaire and Frost Multidimensional Perfectionism Scale. Therapists with a CBT orientation reported less negative emotional responses, i.e., lower overwhelmed/disorganized, hostile/angry, criticised/devalued, parental/protective and special/over-involved emotions towards patients than therapists with a psychodynamic orientation. Therapists with higher perfectionistic traits (i.e., parents’ expectations/evaluation) had higher hostile/angry reactions, those with higher concerns over mistakes and doubts about actions had more intense criticised/devalued emotions, while those with stronger concerns with precision, order and organization had lower disengagement responses. The present study is the first investigation which sheds some light on the emotional responses of therapists towards OCD patients. Therapists’ CBT orientation and lower perfectionistic traits might be associated with better emotions. Therapists’ emotional responses, their psychotherapeutic orientation and levels of perfectionism should be considered during supervisory practice.

Sexual response in obsessive-compulsive disorder: the role of obsessive beliefs

BACKGROUND

Sexual response in obsessive-compulsive disorder (OCD) research and practice is overlooked. According to the Dual Control Model, satisfactory sexual response is based upon a balance of sexual excitation and inhibition. The assessment of sexual response in OCD may have clinical implications, such as the integration of sex therapy in psychotherapeutic intervention. The present study was aimed at comparing sexual excitation and inhibition levels between OCD patients and matched control subjects, and investigating whether obsessive beliefs might predict sexual excitation/inhibition.

METHODS

Seventy-two OCD patients (mean age ± standard deviation [SD]: 34.50 ± 10.39 years) and 72 matched control subjects (mean age ± SD: 34.25 ± 10.18) were included (62.50% men and 37.50% women in both groups). The Obsessive Compulsive Inventory-Revised (OCI-R), the Obsessive Beliefs Questionnaire-46 (OBQ-46), and the Sexual Inhibition/Sexual Excitation Scales (SIS/SES) were administered.

RESULTS

Patients with OCD showed significantly higher levels of sexual excitation, inhibition due to threat of performance failure, and inhibition due to threat of performance consequences than the controls. In addition, the patients with more severe symptoms showed lower excitation than those with less severe symptoms, and those with higher perfectionism had stronger inhibition due to threat of performance failure than those with lower perfectionism.

CONCLUSIONS

This is the first study exploring sexual response in OCD according to the Dual Control Model. Sexual response is an impaired quality of life outcome in OCD that should be assessed in routine clinical practice. These findings support the importance of addressing specific obsessive beliefs to improve sexuality in OCD patients.

The increasing challenge of the possible impact of ethnicity on psychopharmacology

Ethnic differences may significantly influence the outcome of psychopharmacological treatment, in terms of prescription, adherence, clinical response, emergence of side effects, as well as pharmacokinetics and pharmacodynamics. The purpose of this review was to explore the available literature in order to provide general suggestions to help clinicians in choosing the best therapeutic option for patients, taking into account ethnicity. Although findings are sometimes controversial, the overall published studies suggest that ethnicities other than Caucasians tend to show a lower response to antidepressants and a reduced compliance. Africans tend to be more prescribed with antipsychotics, probably due to cultural stereotypes, except with clozapine, probably for their chronic benign neutropenia. Asians usually require less antipsychotic dosages than Caucasians. The differential response and side effect profile of antidepressants and antipsychotics have been related to individual intrinsic factors, to genetic make-up, but also to cultural and contextual variables. Interestingly, albeit limited data suggest ethnic-related genetic heterogeneity at the level of the serotonin transporters, the cytochromes and some neuroreceptors. Taken together, no conclusive findings are available about the role and impact of ethnicity in psychopharmacology. One of the main problems is that the majority of the studies in psychopharmacology have been conducted on Caucasians, so that there is an urgent need to have data in other populations. Furthermore, in the era of precision medicine, the role of ethnicity may be also supported by genetic analysis.

Psychopharmacological Treatment of Obsessive-Compulsive Disorder (OCD)

Background:

Obsessive-compulsive disorder (OCD) is associated with affective and cognitive symptoms causing personal distress and reduced global functioning. These have considerable societal costs due to healthcare service utilization.

Objective:

Our aim was to assess the efficacy of pharmacological interventions in OCD and clinical guidelines, providing a comprehensive overview of this field.

Methods:

We searched the PubMed database for papers dealing with drug treatment of OCD, with a specific focus on clinical guidelines, treatments with antidepressants, antipsychotics, mood stabilizers, off-label medications, and pharmacogenomics.

Results:

Prolonged administration of selective serotonin reuptake inhibitors (SSRIs) is most effective. Better results can be obtained with a SSRI combined with cognitive behavioral therapy (CBT) or the similarly oriented exposure and response prevention (ERP). Refractory OCD could be treated with different strategies, including a switch to another SSRI or clomipramine, or augmentation with an atypical antipsychotic. The addition of medications other than antipsychotics or intravenous antidepressant administration needs further investigation, as the evidence is inconsistent. Pharmacogenomics and personalization of therapy could reduce treatment resistance.

Conclusions:

SSRI/clomipramine in combination with CBT/ERP is associated with the optimal response compared to each treatment alone or to other treatments. New strategies for refractory OCD are needed. The role of pharmacogenomics could become preponderant in the coming years.

Early intervention for obsessive compulsive disorder: An expert consensus statement

Obsessive-compulsive disorder (OCD) is common, emerges early in life and tends to run a chronic, impairing course. Despite the availability of effective treatments, the duration of untreated illness (DUI) is high (up to around 10 years in adults) and is associated with considerable suffering for the individual and their families. This consensus statement represents the views of an international group of expert clinicians, including child and adult psychiatrists, psychologists and neuroscientists, working both in high and low and middle income countries, as well as those with the experience of living with OCD. The statement draws together evidence from epidemiological, clinical, health economic and brain imaging studies documenting the negative impact associated with treatment delay on clinical outcomes, and supporting the importance of early clinical intervention. It draws parallels between OCD and other disorders for which early intervention is recognized as beneficial, such as psychotic disorders and impulsive-compulsive disorders associated with problematic usage of the Internet, for which early intervention may prevent the development of later addictive disorders. It also generates new heuristics for exploring the brain-based mechanisms moderating the 'toxic' effect of an extended DUI in OCD. The statement concludes that there is a global unmet need for early intervention services for OC related disorders to reduce the unnecessary suffering and costly disability associated with under-treatment. New clinical staging models for OCD that may be used to facilitate primary, secondary and tertiary prevention within this context are proposed.

Treatments used for obsessive-compulsive disorder-An international perspective

OBJECTIVE

The objective of this study was to characterise international trends in the use of psychotropic medication, psychological therapies, and novel therapies used to treat obsessive-compulsive disorder (OCD).

METHODS

Researchers in the field of OCD were invited to contribute summary statistics on the characteristics of their samples. Consistency of summary statistics across countries was evaluated.

RESULTS

The study surveyed 19 expert centres from 15 countries (Argentina, Australia, Brazil, China, Germany, Greece, India, Italy, Japan, Mexico, Portugal, South Africa, Spain, the United Kingdom, and the United States) providing a total sample of 7,340 participants. Fluoxetine (n = 972; 13.2%) and fluvoxamine (n = 913; 12.4%) were the most commonly used selective serotonin reuptake inhibitor medications. Risperidone (n = 428; 7.3%) and aripiprazole (n = 415; 7.1%) were the most commonly used antipsychotic agents. Neurostimulation techniques such as transcranial magnetic stimulation, deep brain stimulation, gamma knife surgery, and psychosurgery were used in less than 1% of the sample. There was significant variation in the use and accessibility of exposure and response prevention for OCD.

CONCLUSIONS

The variation between countries in treatments used for OCD needs further evaluation. Exposure and response prevention is not used as frequently as guidelines suggest and appears difficult to access in most countries. Updated treatment guidelines are recommended.

A systematic review of the use of risperidone, paliperidone and aripiprazole as augmenting agents for obsessive-compulsive disorder

INTRODUCTION

Obsessive-compulsive disorder (OCD) is often viewed as a difficult to treat disorder. In some patients, antipsychotics are used to augment the action of serotonin reuptake inhibitors (SRIs), particularly when there is only a partial response to treatment.

AREAS COVERED

This comprehensive literature review aims to assess the effectiveness and tolerability of three commonly used atypical antipsychotic agents: risperidone, paliperidone and aripiprazole, as augmentation agents in the treatment of OCD.

EXPERT OPINION

Antipsychotic augmentation should only be trialed once treatment with selective SRIs at high dose and exposure and response prevention therapy have failed. Currently, there is evidence to support the use of risperidone, paliperidone and aripiprazole as augmentation agents for OCD in adult samples but more studies with larger samples are needed to assess predictors of response to antipsychotic augmentation and to detect any differential effects between the three agents. At this point in time, the choice of antipsychotic is best determined by the side effect profile of the drug and a patient's medication history.

Descriptive Phenotype of Obsessive Compulsive Symptoms in Males With Duchenne Muscular Dystrophy

Increased rates of clinically significant internalizing disorders (obsessive compulsive disorder, anxiety, and depression) have been demonstrated in males with Duchenne muscular dystrophy, and a Duchenne muscular dystrophy neuropsychiatric syndrome has been suggested. Although symptoms of depression are widely recognized, some of the other internalizing symptoms are less frequently identified. Through a retrospective chart review of 107 males with Duchenne muscular dystrophy, we identified 15 patients with obsessive compulsive disorder spectrum symptoms; 11 of those also had anxiety symptoms. Many of these patients received selective serotonin reuptake inhibitor treatment, commonly noting improvement in symptoms. Here we describe the clinical features of several patients in detail to facilitate early recognition and consideration for treatment for patients with Duchenne muscular dystrophy and internalizing psychiatric symptoms. The results of this cohort showed a significantly increased rate of obsessive compulsive disorder spectrum symptoms (14%) compared to the general population.

Ethnopharmacology of Love

Background: Elixirs conferring eternal youth or inducing amatory and erotic attraction have been searched for without success. Lovesickness is a widespread affliction resulting from unrequited love and/or the impossibility for physical and emotional union. The symptoms are reflections of altered dopamine, serotonin, noradrenaline, testosterone and cortisol levels and range from frenzy and intrusive thinking to despair and depression, sharing traits with the neurochemistry of addiction and compulsive behavior disorder. Although it can seriously impact the quality of life, lovesickness is currently not considered in official disease classification systems. Consequently, no official therapeutic guidelines exist, leaving subjects to seek the cure on their own. Methods: We review literature of the past 2000 years dealing with the concept, diagnosis and the healing of lovesickness and contextualize it with neurochemical, ethnomedical, and ethnographic data. Since neurobiological and pharmacological connections between the love drive and the sex drive exist, we review also the literature about herbal an- and aphrodisiacs, focusing on their excitatory or calmative potential. Results: An overall consensus regarding socio-behavioral regimes exists for dealing with lovesickness from historical through contemporary literature. The herbal drugs used for treating lovesickness or inducing love passion do not possess the alleged properties. The pharmacological effects of aphrodisiacs are heterogeneous, including dopaminergic and adrenergic activities, but there is no evidence for any serotonergic effects. The libido-regulating properties of anaphrodisiacs seem to be associated with sedative and toxic effects or decreasing testosterone levels. CB2 receptors expressed on dopaminergic neurons of the ventral tegmental area, part of the brain's reward circuit, implicated with addiction, orgasm and strong emotions such as love, might constitute a new therapeutic target. Conclusion: The common food additive and CB2 agonist β-caryophyllene might have the potential to attenuate dopaminergic firing, quenching the reward and thus motivation associated with romantic love. From Greek mythology to modern history, cultural expressions and implications of love, sex and procreation is and was organized along hierarchical lines that put men on top. The neuronal predispositions and activities associated with falling in love will probably forever remain nature's and Eros' secret.

Predictors of benzodiazepine use in a transdiagnostic sample of panic disorder, social anxiety disorder, and obsessive-compulsive disorder patients

We investigated the rates of current and past benzodiazepine (BZD) use in a sample of 102 subjects attending specialized anxiety disorder clinics, including panic disorder (PD; N = 36), social anxiety disorder (SAD; N = 28) and obsessive-compulsive disorder (OCD; N = 38) patients. Almost 56% of the entire sample was using BZDs at the moment of the assessment, and 74.5% described having used them at some point during their lifetimes. The duration of psychiatric treatment and a lifetime history of PD, but not any other "transdiagnostic" measure of severity (such as the Panic and Agoraphobia Scale, the Social Phobia Inventory, the Dimensional Obsessive-Compulsive Scale, the Anxiety Sensitivity Index-36, and the Beck Inventories) were independent risk factors for current prescription of BZDs. Patients who continued to use BZDs differed from patients who stopped them by being older (both currently and when firstly seen in the clinic), by having a later age at onset of their most significant anxiety disorder, by being more agoraphobic/avoidant, and by believing to be less capable of stopping their BZDs for the fear of not being able to sleep.

Influence of Culture in Obsessive-compulsive Disorder and Its Treatment

Background

The aspects of cultural identity and its impact on obsessive-compulsive disorder (OCD) have been un-derstudied. There are different opinions, ranging from the idea that culture does not affect the symptoms of this condition to the idea that cultures with high religiosity may have more severity of OCD. Also, the concept of OCD has considerably var-ied across history and cultures, from being considered an issue related to lack of control of blasphemous ideas, and a part of anxious issues, to the description of complex neurobiological systems in its causation.

Objective

The aim of this review was to address OCD as a well-characterized disorder with a proposed neurobiological ba-sis which may or may not have variations depending on cultural diversity. The question that was asked in this review is whether or not there are cultural differences in the manifestations of the OCD symptomatology and which factors of cultural diversity have a major influence on such manifestations along with the differences among some cultures regarding OCD is-sues, where the difference among countries has also been highlighted.

Methods

A review of the literature was conducted that includes the following words: obsessive-compulsive disorder, cul-ture, cultural identity and religion in a period of 10 years.

Conclusion

Cultural variations do not seem to differ from symptomatic clusters of OCD, which may be indicating that a se-ries of adaptive behaviors is evolutionarily evolving to be constantly altered, perhaps by well-determined pathophysiological mechanisms. Some aspects that have been related to some dimensions of OCD symptomatology are religion and religiosity, affecting the content of obsessions and the severity of manifestations. Properly evaluating the education background, access to health services, food, and the genetic structure of populations, using investigational instruments sensitive to these cultural elements, will increase our understanding of the importance of culture on OCD and its treatment.

Italian prescribing patterns in obsessive-compulsive disorder

The aim of the present study was to investigate psychopharmacological prescribing patterns in a large sample (n = 1815) of patients suffering from obsessive-compulsive disorder (OCD) recruited in 4 Italian centers specialized in OCD, in comparison to available national and international guidelines. The centers were asked to complete a specific data sheet questionnaire on patients' therapeutic status. Statistical analyses were carried out by SPSS. The results showed that almost all patients referred to the centers of Milan, Pisa and Rome received psychotropic medications, whereas only 59.9% (313) did so in Turin. Selective serotonin reuptake inhibitors were the most used drugs ranging between 49.0% and 71.5%. Clomipramine was prescribed more often in Rome and Pisa than in Milan and Turin. The same was true for other tricyclic antidepressants. Second-generation antipsychotics were more often prescribed in Pisa and in Milan. Mood stabilizers were almost exclusively used in Pisa. Taken together, the overall findings would suggest that, although the main Italian centers specialized in OCD follow available guidelines, a certain degree of variability does exist. This may depend on the different educational background, availability of other specific therapeutic strategies, as well as varying levels of severity and comorbidity of the patients.

A cross-cultural clinical comparison between subjects with obsessive-compulsive disorder from the United States and Brazil

Although OCD is a global problem, the literature comparing, in a direct and standardized way, the manifestations across countries is scarce. Therefore, questions remain as to whether some important clinical findings are replicable worldwide, especially in the developing world. The objective of this study was to perform a clinical comparison of OCD patients recruited in the United States (U.S.) and Brazil. Our sample consisted of 1187 adult, treatment-seeking OCD outpatients from the U.S. (n=236) and Brazil (n=951). With regards to the demographics, U.S. participants with OCD were older, more likely to identify as Caucasian, had achieved a higher educational level, and were less likely to be partnered when compared to Brazilians. Concerning the clinical variables, after controlling for demographics the two samples presented largely similar profiles. Brazilian participants with OCD, however, endorsed significantly greater rates of generalized anxiety disorder and post-traumatic stress disorder, whereas U.S. subjects were significantly more likely to endorse a lifetime history of addiction (alcohol-use and substance-use disorders). This is the largest direct cross-cultural comparison to date in the OCD field. Our results provide much needed insight regarding the development of culture-sensitive treatments.