A double-blind comparison of sertraline and clomipramine in outpatients with obsessive-compulsive disorder

Pharmacological and Psychotherapeutic Interventions for Management of Obsessive-compulsive Disorder in Adults: A Systematic Review and Network Meta-analysis

Reprinted under Creative Commons CC-BY license.

Obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a highly prevalent and chronic condition that is associated with substantial global disability. OCD is the key example of the 'obsessive-compulsive and related disorders', a group of conditions which are now classified together in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and the International Classification of Diseases, 11th Revision, and which are often underdiagnosed and undertreated. In addition, OCD is an important example of a neuropsychiatric disorder in which rigorous research on phenomenology, psychobiology, pharmacotherapy and psychotherapy has contributed to better recognition, assessment and outcomes. Although OCD is a relatively homogenous disorder with similar symptom dimensions globally, individualized assessment of symptoms, the degree of insight, and the extent of comorbidity is needed. Several neurobiological mechanisms underlying OCD have been identified, including specific brain circuits that underpin OCD. In addition, laboratory models have demonstrated how cellular and molecular dysfunction underpins repetitive stereotyped behaviours, and the genetic architecture of OCD is increasingly understood. Effective treatments for OCD include serotonin reuptake inhibitors and cognitive-behavioural therapy, and neurosurgery for those with intractable symptoms. Integration of global mental health and translational neuroscience approaches could further advance knowledge on OCD and improve clinical outcomes.

A systematic review of the clinical effectiveness and cost-effectiveness of pharmacological and psychological interventions for the management of obsessive-compulsive disorder in children/adolescents and adults

BACKGROUND

Obsessive-compulsive disorder (OCD) is a relatively common and disabling condition.

OBJECTIVES

To determine the clinical effectiveness, acceptability and cost-effectiveness of pharmacological and psychological interventions for the treatment of OCD in children, adolescents and adults.

DATA SOURCES

We searched the Cochrane Collaboration Depression, Anxiety and Neurosis Trials Registers, which includes trials from routine searches of all the major databases. Searches were conducted from inception to 31 December 2014.

REVIEW METHODS

We undertook a systematic review and network meta-analysis (NMA) of the clinical effectiveness and acceptability of available treatments. Outcomes for effectiveness included mean differences in the total scores of the Yale-Brown Obsessive-Compulsive Scale or its children's version and total dropouts for acceptability. For the cost-effectiveness analysis, we developed a probabilistic model informed by the results of the NMA. All analyses were performed using OpenBUGS version 3.2.3 (members of OpenBUGS Project Management Group; see www.openbugs.net ).

RESULTS

We included 86 randomised controlled trials (RCTs) in our systematic review. In the NMA we included 71 RCTs (54 in adults and 17 in children and adolescents) for effectiveness and 71 for acceptability (53 in adults and 18 in children and adolescents), comprising 7643 and 7942 randomised patients available for analysis, respectively. In general, the studies were of medium quality. The results of the NMA showed that in adults all selective serotonin reuptake inhibitors (SSRIs) and clomipramine had greater effects than drug placebo. There were no differences between SSRIs, and a trend for clomipramine to be more effective did not reach statistical significance. All active psychological therapies had greater effects than drug placebo. Behavioural therapy (BT) and cognitive therapy (CT) had greater effects than psychological placebo, but cognitive-behavioural therapy (CBT) did not. BT and CT, but not CBT, had greater effects than medications, but there are considerable uncertainty and methodological limitations that should be taken into account. In children and adolescents, CBT and BT had greater effects than drug placebo, but differences compared with psychological placebo did not reach statistical significance. SSRIs as a class showed a trend for superiority over drug placebo, but the difference did not reach statistical significance. However, the superiority of some individual drugs (fluoxetine, sertraline) was marginally statistically significant. Regarding acceptability, all interventions except clomipramine had good tolerability. In adults, CT and BT had the highest probability of being most cost-effective at conventional National Institute for Health and Care Excellence thresholds. In children and adolescents, CBT or CBT combined with a SSRI were more likely to be cost-effective. The results are uncertain and sensitive to assumptions about treatment effect and the exclusion of trials at high risk of bias.

LIMITATIONS

The majority of psychological trials included patients who were taking medications. There were few studies in children and adolescents.

CONCLUSIONS

In adults, psychological interventions, clomipramine, SSRIs or combinations of these are all effective, whereas in children and adolescents, psychological interventions, either as monotherapy or combined with specific SSRIs, were more likely to be effective. Future RCTs should improve their design, in particular for psychotherapy or combined interventions.

STUDY REGISTRATION

The study is registered as PROSPERO CRD42012002441.

FUNDING DETAILS

The National Institute for Health Research Health Technology Assessment programme.

Pharmacological and psychotherapeutic interventions for management of obsessive-compulsive disorder in adults: a systematic review and network meta-analysis

BACKGROUND

Several interventions are available for management of obsessive-compulsive disorder in adults, but few studies have compared their relative efficacy in a single analysis. We aimed to simultaneously compare all available treatments using both direct and indirect data.

METHODS

In this systematic review and network meta-analysis, we searched the two controlled trials registers maintained by the Cochrane Collaboration Common Mental Disorders group for trials published up to Feb 16, 2016. We selected randomised controlled trials in which an active psychotherapeutic or pharmacological intervention had been used in adults with obsessive-compulsive disorder. We allowed all comorbidities except for schizophrenia or bipolar disorder. We excluded studies that focused exclusively on treatment-resistant patient populations defined within the same study. We extracted data from published reports. The primary outcome was symptom severity as measured by the Yale-Brown Obsessive Compulsive Scale. We report mean differences with 95% credible intervals compared with placebo. This study is registered with PROSPERO, number CRD42012002441.

FINDINGS

We identified 1480 articles in our search and included 53 articles (54 trials; 6652 participants) in the network meta-analysis. Behavioural therapy (mean difference -14·48 [95% credible interval -18·61 to -10·23]; 11 trials and 287 patients), cognitive therapy (-13·36 [-18·40 to -8·21]; six trials and 172 patients), behavioural therapy and clomipramine (-12·97 [-19·18 to -6·74]; one trial and 31 patients), cognitive behavioural therapy and fluvoxamine (-7·50 [-13·89 to -1·17]; one trial and six patients), cognitive behavioural therapy (-5·37 [-9·10 to -1·63]; nine trials and 231 patients), clomipramine (-4·72 [-6·85 to -2·60]; 13 trials and 831 patients), and all SSRIs (class effect -3·49 [95% credible interval -5·12 to -1·81]; 37 trials and 3158 patients) had greater effects than did drug placebo. Clomipramine was not better than were SSRIs (-1·23 [-3·41 to 0·94]). Psychotherapeutic interventions had a greater effect than did medications, but a serious limitation was that most psychotherapeutic trials included patients who were taking stable doses of antidepressants (12 [80%] of the 15 psychotherapy trials explicitly allowed antidepressants).

INTERPRETATION

A range of interventions is effective in the management of obsessive-compulsive disorder, but considerable uncertainty and limitations exist regarding their relative efficacy. Taking all the evidence into account, the combination of psychotherapeutic and psychopharmacological interventions is likely to be more effective than are psychotherapeutic interventions alone, at least in severe obsessive-compulsive disorder.

FUNDING

National Institute for Health Research.

Interventions for enhancing medication adherence

BACKGROUND

People who are prescribed self administered medications typically take only about half their prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications.

OBJECTIVES

The primary objective of this review is to assess the effects of interventions intended to enhance patient adherence to prescribed medications for medical conditions, on both medication adherence and clinical outcomes.

SEARCH METHODS

We updated searches of The Cochrane Library, including CENTRAL (via http://onlinelibrary.wiley.com/cochranelibrary/search/), MEDLINE, EMBASE, PsycINFO (all via Ovid), CINAHL (via EBSCO), and Sociological Abstracts (via ProQuest) on 11 January 2013 with no language restriction. We also reviewed bibliographies in articles on patient adherence, and contacted authors of relevant original and review articles.

SELECTION CRITERIA

We included unconfounded RCTs of interventions to improve adherence with prescribed medications, measuring both medication adherence and clinical outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive findings at earlier time points.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data and a third author resolved disagreements. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Pooling results according to one of these characteristics still leaves highly heterogeneous groups, and we could not justify meta-analysis. Instead, we conducted a qualitative analysis with a focus on the RCTs with the lowest risk of bias for study design and the primary clinical outcome.

MAIN RESULTS

The present update included 109 new RCTs published since the previous update in January 2007, bringing the total number of RCTs to 182; we found five RCTs from the previous update to be ineligible and excluded them. Studies were heterogeneous for patients, medical problems, treatment regimens, adherence interventions, and adherence and clinical outcome measurements, and most had high risk of bias. The main changes in comparison with the previous update include that we now: 1) report a lack of convincing evidence also specifically among the studies with the lowest risk of bias; 2) do not try to classify studies according to intervention type any more, due to the large heterogeneity; 3) make our database available for collaboration on sub-analyses, in acknowledgement of the need to make collective advancement in this difficult field of research. Of all 182 RCTs, 17 had the lowest risk of bias for study design features and their primary clinical outcome, 11 from the present update and six from the previous update. The RCTs at lowest risk of bias generally involved complex interventions with multiple components, trying to overcome barriers to adherence by means of tailored ongoing support from allied health professionals such as pharmacists, who often delivered intense education, counseling (including motivational interviewing or cognitive behavioral therapy by professionals) or daily treatment support (or both), and sometimes additional support from family or peers. Only five of these RCTs reported improvements in both adherence and clinical outcomes, and no common intervention characteristics were apparent. Even the most effective interventions did not lead to large improvements in adherence or clinical outcomes.

AUTHORS' CONCLUSIONS

Across the body of evidence, effects were inconsistent from study to study, and only a minority of lowest risk of bias RCTs improved both adherence and clinical outcomes. Current methods of improving medication adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. The research in this field needs advances, including improved design of feasible long-term interventions, objective adherence measures, and sufficient study power to detect improvements in patient-important clinical outcomes. By making our comprehensive database available for sharing we hope to contribute to achieving these advances.

Commonly asked questions in the treatment of obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a common and often a highly disabling condition that was considered untreatable before the 1960s. The advent of serotonin reuptake inhibitors and exposure and response prevention revolutionized the treatment of OCD. Although they are still the first line treatments for OCD, new treatments like augmentation strategies, brain stimulation techniques, psychosurgery, newer forms of psychotherapy (like cognitive therapy, acceptance and commitment therapy) have been added to the armamentarium. With the available treatment strategies, many patients can achieve at least partial remission of symptoms. Nevertheless, the plethora of information gives rise to many questions on their application for practicing clinicians. We provide evidence-based responses to these questions and suggest a broad guideline for treatment of OCD.

Pharmacotherapy of obsessive-compulsive disorder: evidence-based treatment and beyond

BACKGROUND

Obsessive-compulsive disorder (OCD) is a neuropsychiatric disorder associated with a significant degree of functional disability and poor quality of life. Pharmacotherapy may have a substantial impact on the course and outcome of OCD.

METHOD

We review the evidence supporting available strategies for the pharmacological treatment of OCD.

RESULTS

Selective serotonin reuptake inhibitors (SSRIs) remain the pharmacological treatment of choice and are associated with improved health-related quality of life. Discontinuation is associated with relapse and loss of quality of life, implying treatment should continue long-term. A substantial minority of patients who fail to respond to SSRI may benefit from dose elevation or adjunctive antipsychotics, though long-term trials validating the effectiveness and tolerability of these strategies are relatively lacking.

CONCLUSION

The pharmacological evidence-base for the treatment of OCD is becoming increasingly robust. Treatment with SSRIs and clomipramine remains uncontroversial and improvements are sustained over time. Newer compounds targeting serotonin receptor subtypes and other neurotransmitter systems are undergoing evaluation.

Psychopharmacology of anxiety disorders

Exposure of the general population to a 1:4 lifetime risk of disabling anxiety has inspired generations of fundamental and clinical psychopharmacologists, from the era of the earliest benzodiazepines (BZ) to that of the selective serotonin reuptake inhibitors (SSRIs) and related compounds, eg, the serotonin and norepinephrine reuptake inhibitors (SNRIs). This comprehensive practical review summarizes current therapeutic research across the spectrum of individual disorders: generalized anxiety disorder (GAD), panic disorder (PD) and agoraphobia (social anxiety disorder), compulsive disorder (OCD), phobic disorder (including social phobia), and posttraumatic stress disorder (PTSD). Specific diagnosis is a precondition to successful therapy: despite substantial overlap, each disorder responds preferentially to specific pharmacotherapy. Comorbidity with depression is common; hence the success of the SSRIs, which were originally designed to treat depression. Assessment (multidomain measures versus individual end points) remains problematic, as-frequently-do efficacy and tolerability The ideal anxiolytic remains the Holy Grail of worldwide psychopharmacologic research.

Pharmacological management of treatment-resistant obsessive-compulsive disorder

Once considered rare and resistant to treatment, obsessive-compulsive disorder (OCD) has now emerged as a common, yet often unrecognized, psychiatric condition. Treatment with selective serotonin reuptake inhibitors (SSRIs) is effective in 40-60% of patients with OCD. Management of the remaining 40-60% of patients with treatment-resistant OCD is challenging. We review up-to-date evidence focusing on strategies for treatment-resistant OCD, including increasing the dose of SSRI, switching to another SSRI, augmentation with antipsychotics, and the use of serotonin noradrenaline (norepinephrine) reuptake inhibitors (SNRIs) and monoamine oxidase inhibitors (MAOIs). Finally, we provide a flow chart, which includes nonpharmacological interventions such as cognitive-behavioural therapy, family interventions and physical interventions such as neurosurgery and deep brain stimulation, alongside the pharmacological strategies.

Current management of obsessive and phobic states

Obsessional states show an average point prevalence of 1%-3% and a lifetime prevalence of 2%-2.5%. Most treatment-seeking patients with obsessions continue to experience significant symptoms after 2 years of prospective follow-up. A significant burden of impairment, distress, and comorbidity characterize the course of the illness, leading to an increased need for a better understanding of the nature and management of this condition. This review aims to give a representation of the current pharmacological and psychotherapeutic strategies used in the treatment of obsessive-compulsive disorder. Antidepressants (clomipramine and selective serotonin reuptake inhibitors) are generally the first-line choice used to handle obsessional states, showing good response rates and long-term positive outcomes. About 40% of patients fail to respond to selective serotonin reuptake inhibitors. So far, additional pharmacological treatment strategies have been shown to be effective, ie, administration of high doses of selective serotonin reuptake inhibitors, as well as combinations of different drugs, such as dopamine antagonists, are considered efficacious and well tolerated strategies in terms of symptom remission and side effects. Psychotherapy also plays an important role in the management of obsessive-compulsive disorder, being effective for a wide range of symptoms, and many studies have assessed its long-term efficacy, especially when added to appropriate pharmacotherapy. In this paper, we also give a description of the clinical and psychological features likely to characterize patients refractory to treatment for this illness, with the aim of highlighting the need for greater attention to more patient-oriented management of the disease.

Current trends in drug treatment of obsessive-compulsive disorder

This article aims to highlight current trends in the pharmacologic management of obsessive-compulsive disorder (OCD). A systematic search of the electronic database MEDLINE was conducted. The first case report of clomipramine efficacy in the management OCD more than 40 years ago gave new hope for the treatment of this debilitating disorder. Selective serotonin reuptake inhibitors (SSRIs) proved to have a similar efficacy profile compared with clomipramine but had a superior tolerability profile. While many patients with OCD respond to SSRIs or clomipramine, the treatment of those with refractory OCD remains challenging. Different augmentation agents in treatment-resistant OCD have been explored, with antipsychotic agents having the largest supporting evidence base. Nevertheless, new pharmacologic treatment options are required and are under investigation.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of anxiety, obsessive-compulsive and post-traumatic stress disorders - first revision

In this report, which is an update of a guideline published in 2002 (Bandelow et al. 2002, World J Biol Psychiatry 3:171), recommendations for the pharmacological treatment of anxiety disorder, obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) are presented. Since the publication of the first version of this guideline, a substantial number of new randomized controlled studies of anxiolytics have been published. In particular, more relapse prevention studies are now available that show sustained efficacy of anxiolytic drugs. The recommendations, developed by the World Federation of Societies of Biological Psychiatry (WFSBP) Task Force for the Pharmacological Treatment of Anxiety, Obsessive-Compulsive and Post-traumatic Stress Disorders, a consensus panel of 30 international experts, are now based on 510 published randomized, placebo- or comparator-controlled clinical studies (RCTs) and 130 open studies and case reports. First-line treatments for these disorders are selective serotonin reuptake inhibitors (SSRIs), serotonin-noradrenaline reuptake inhibitors (SNRIs) and the calcium channel modulator pregabalin. Tricyclic antidepressants (TCAs) are equally effective for some disorders, but many are less well tolerated than the SSRIs/SNRIs. In treatment-resistant cases, benzodiazepines may be used when the patient does not have a history of substance abuse disorders. Potential treatment options for patients unresponsive to standard treatments are described in this overview. Although these guidelines focus on medications, non-pharmacological were also considered. Cognitive behavioural therapy (CBT) and other variants of behaviour therapy have been sufficiently investigated in controlled studies in patients with anxiety disorders, OCD, and PTSD to support them being recommended either alone or in combination with the above medicines.

The medical treatment of obsessive-compulsive disorder and anxiety

Selective serotonin reuptake inhibitors (SSRIs) are first-line pharmacotherapy treatments for obsessive-compulsive disorder (OCD). Clomipramine is effective in OCD but associated with more adverse events. Typically, higher doses of antidepressants are required for OCD. Up to 50% of patients do not respond to initial treatment of OCD. Treatment options for nonresponders include augmentation of antidepressants with atypical antipsychotics, among other strategies. First-line treatments for anxiety disorders include SSRIs, serotonin norepinephrine reuptake inhibitors, and pregabalin. Tricyclic antidepressants are equally effective as SSRIs, but are less well tolerated. In treatment-resistant cases, benzodiazepines may be used when the patient does not have a history of dependency and tolerance. Other treatment options include irreversible and reversible monoamine oxidase inhibitors, the atypical antipsychotic quetiapine, and other medications. Cognitive-behavioral therapy has been sufficiently investigated in controlled studies of OCD and anxiety disorders and is recommended alone or in combination with the above medications.

Interventions for enhancing medication adherence

BACKGROUND

People who are prescribed self-administered medications typically take less than half the prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications, but also might increase their adverse effects.

OBJECTIVES

To update a review summarizing the results of randomized controlled trials (RCTs) of interventions to help patients follow prescriptions for medications for medical problems, including mental disorders but not addictions.

SEARCH STRATEGY

We updated searches of The Cochrane Library, MEDLINE, CINAHL, EMBASE, International Pharmaceutical Abstracts (IPA), PsycINFO (all via OVID) and Sociological Abstracts (via CSA) in January 2007 with no language restriction. We also reviewed bibliographies in articles on patient adherence and articles in our personal collections, and contacted authors of relevant original and review articles.

SELECTION CRITERIA

Articles were selected if they reported an unconfounded RCT of an intervention to improve adherence with prescribed medications, measuring both medication adherence and treatment outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive initial findings.

DATA COLLECTION AND ANALYSIS

Study design features, interventions and controls, and results were extracted by one review author and confirmed by at least one other review author. We extracted adherence rates and their measures of variance for all methods of measuring adherence in each study, and all outcome rates and their measures of variance for each study group, as well as levels of statistical significance for differences between study groups, consulting authors and verifying or correcting analyses as needed. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Therefore, we did not feel that quantitative analysis was scientifically justified; rather, we conducted a qualitative analysis.

MAIN RESULTS

For short-term treatments, four of ten interventions reported in nine RCTs showed an effect on both adherence and at least one clinical outcome, while one intervention reported in one RCT significantly improved patient adherence, but did not enhance the clinical outcome. For long-term treatments, 36 of 81 interventions reported in 69 RCTs were associated with improvements in adherence, but only 25 interventions led to improvement in at least one treatment outcome. Almost all of the interventions that were effective for long-term care were complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counseling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up, and supportive care. Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes.

AUTHORS' CONCLUSIONS

For short-term treatments several quite simple interventions increased adherence and improved patient outcomes, but the effects were inconsistent from study to study with less than half of studies showing benefits. Current methods of improving adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term medical disorders.

An update on the pharmacological treatment of obsessive-compulsive disorder

The purpose of this article is to introduce the reader to an updated evidence-based drug treatment algorithm to be employed in patients with obsessive-compulsive disorder (OCD). Relevant studies were identified through a comprehensive review and classified according to the type of patients enrolled, the quality of the study design and the invasiveness, availability and complexity of the therapeutic approach. When ineffective, therapeutic trials with first-line strategies (such as the selective serotonin re-uptake inhibitors [SSRIs] and venlafaxine) should be followed by treatment approaches such as clomipramine, augmentation with antipsychotics or pindolol, SSRI megadoses or cognitive behavioral therapy. These therapeutic strategies are expected to help most patients with OCD. Additional approaches include intravenous clomipramine, oral morphine, 'heroic drug strategies', deep brain stimulation and functional neurosurgery. Independent studies are urgently needed to help identify the most promising drug treatment sequences for OCD.

New treatment options for OCD

Pharmacological management of obsessive-compulsive disorder (OCD) is achieved using drugs that inhibit the synaptic uptake of serotonin, such as clomipramine, a tricyclic antidepressant, and the selective serotonin reuptake inhibitors (SSRIs). Recent studies suggest that the improved tolerability profile of the SSRIs relative to clomipramine may offer a more suitable treatment choice. Escitalopram, the therapeutically active S-enantiomer of citalopram, is the most selective SSRI currently available. In a 24-week randomized, placebo-controlled, double-blind study, escitalopram (20 mg) was associated with significantly lower symptom scores at 12 weeks (P<0.01) and increased response rate (Yale-Brown Obsessive-compulsive Scale [Y-BOCS]) (70.2%) compared with placebo (50.4%). Escitalopram (10 mg) was more effective in reducing symptom scores than placebo at 24 weeks (P=0.052). Escitalopram 20 mg was also associated with improved remitter status (Y-BOCS total score ≤10) compared with paroxetine (40 mg) or placebo from week 12. In a relapse-prevention study, 10 and 20 mg escitalopram showed a statistically significant superior effect relative to placebo on time to relapse of OCD with a hazard ratio of 2.74. Escitalopram was well-tolerated by patients with OCD. In conclusion, escitalopram provides significant symptom relief and prevention of relapse during long-term use and deserves consideration as a first-line agent in the long-term pharmacotherapy of OCD.

Pharmacotherapies in the management of obsessive-compulsive disorder

Few medications are effective in treating obsessive-compulsive disorder (OCD). As monotherapy, only potent serotonin (5-HT) reuptake inhibitors (SRIs) consistently exert an intrinsic therapeutic action in OCD. Their use in OCD, however, differs from their use in depression. This paper first reviews the evidence supporting the key role of 5-HT as a pivotal neurotransmitter in the anti-OCD response. Then, we describe the practicalities of SRI use, followed by the steps that can be taken when these medications do not produce an adequate clinical response. We provide specifics for the treatment of children and adolescents with OCD. We include a brief description of the brain circuitry involved in OCD and the mechanisms of action of the pharmacologic agents reported to be effective in this disorder, as well as those that are useful in depression but not in OCD. We present this information to promote better understanding of the research endeavours needed to develop new pharmacotherapeutic approaches.

Are placebo-controlled trials still important for obsessive compulsive disorder?

The use of placebos as reference agents in randomised controlled trials for psychiatric disorders has come under question for ethical reasons. Alternative methods for validating the efficacy of new treatments exist, but may not be as reliable as placebo. In this paper we examine arguments for and against the ongoing use of placebo agents in the development of new treatments for obsessive compulsive disorder in the context of evidence from randomised controlled trials.

Fluvoxamine: a selective serotonin re-uptake inhibitor for the treatment of obsessive-compulsive disorder

Fluvoxamine is the selective serotonin re-uptake inhibitor with the largest database in the treatment of obsessive-compulsive disorder, a severe, and often chronic, anxiety disorder associated with substantial impairment in functioning. The selective serotonin re-uptake inhibitors represent a first-line treatment in patients with obsessive-compulsive disorder. These agents work primarily by blocking the re-uptake of serotonin into the presynaptic nerve terminal, which is believed to be mediated by their effects on the serotonin transport system. In the last two decades, the anti-obsessional effect of fluvoxamine has been tested in several double-blind, placebo-controlled and active-comparison studies, demonstrating its superior efficacy over obsessions and compulsions compared with non-serotonergic antidepressants (i.e., desipramine) and equal efficacy to clomipramine (a tricyclic antidepressant with potent serotonin re-uptake inhibition) and other selective serotonin re-uptake inhibitors (paroxetine and citalopram). However, compared with clomipramine, the selective serotonin re-uptake inhibitor fluvoxamine showed fewer side effects and better tolerability. This reflects the poor affinity of this compound for adrenergic, muscarinic, cholinergic or histaminergic receptors.

Interventions to enhance medication adherence

BACKGROUND

People who are prescribed self-administered medications typically take less than half the prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications, but also might increase their adverse effects.

OBJECTIVES

To update a review summarizing the results of randomized controlled trials (RCTs) of interventions to help patients follow prescriptions for medications for medical problems, including mental disorders but not addictions.

SEARCH STRATEGY

Computerized searches were updated to September 2004 without language restriction in MEDLINE, EMBASE, CINAHL, The Cochrane Library, International Pharmaceutical Abstracts (IPA), PsycINFO and SOCIOFILE. We also reviewed bibliographies in articles on patient adherence and articles in our personal collections, and contacted authors of original and review articles on the topic.

SELECTION CRITERIA

Articles were selected if they reported an unconfounded RCT of an intervention to improve adherence with prescribed medications, measuring both medication adherence and treatment outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive initial findings.

DATA COLLECTION AND ANALYSIS

Study design features, interventions and controls, and results were extracted by one reviewer and confirmed by at least one other reviewer. We extracted adherence rates and their measures of variance for all methods of measuring adherence in each study, and all outcome rates and their measures of variance for each study group, as well as levels of statistical significance for differences between study groups, consulting authors and verifying or correcting analyses as needed.

MAIN RESULTS

For short-term treatments, four of nine interventions reported in eight RCTs showed an effect on both adherence and at least one clinical outcome, while one intervention reported in one RCT significantly improved patient compliance, but did not enhance the clinical outcome. For long-term treatments, 26 of 58 interventions reported in 49 RCTs were associated with improvements in adherence, but only 18 interventions led to improvement in at least one treatment outcome. Almost all of the interventions that were effective for long-term care were complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counseling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up, and supportive care. Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes. Six studies showed that telling patients about adverse effects of treatment did not affect their adherence.

AUTHORS' CONCLUSIONS

Improving short-term adherence is relatively successful with a variety of simple interventions. Current methods of improving adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term medical disorders.

Combining Pharmacotherapy with Cognitive‐Behavioral Interventions for Obsessive‐Compulsive Disorder

This paper reviews the evidence-based literature concerning the efficacy and effectiveness of cognitive behavior therapy (CBT), drug treatment and their combination for obsessive compulsive disorder (OCD). After a brief outline of the seminal studies, the state of the art is presented with reference to the consensual recommendations proposed in the last 10 years. Management of OCD rests on potent selective serotonin reuptake inhibitors and CBT, used separately, sequentially, or concurrently. A hierarchical model for clinical decision-making is reported. With greater severity of OCD, it is recommended to add medications. However, the response rate is still too low in many patients, and some patients remain refractory to any kind of treatment. This stresses the importance of joint efforts of psychological and biological teams to develop new treatments.

A multidimensional meta-analysis of psychotherapy and pharmacotherapy for obsessive-compulsive disorder

A number of qualitative and meta-analytic reviews point to the efficacy of psychotherapeutic and pharmacological interventions for obsessive-compulsive disorder (OCD). In this article, we report a multidimensional meta-analysis of psychological and pharmacological treatment studies for OCD published between 1980 and 2001, examining a range of variables not previously meta-analyzed, including exclusion rates and exclusion criteria, percent of patients improved or recovered post-treatment, mean post-treatment symptomatology, and long-term outcome. These additional metrics provide a more nuanced view of the strengths and limitations of the existing data and their implications for clinical practice. Behavioral and cognitive-behavioral therapy, and a range of pharmacological interventions, lead to substantial improvement for the average patient, with individual psychotherapies and clomipramine and other Serotonin reuptake inhibitors faring best across multiple metrics. However, OCD symptoms persist at moderate levels even following adequate treatment course, and no replicable data are available on maintenance of gains for either form of treatment at 1 year or beyond. Future research should track recruitment and exclusion of study participants, include more comorbid patients, and focus on longer-term follow-up using multiple indices of outcome. More research on combined pharmacological and psychotherapeutic interventions is also indicated.

WCA recommendations for the long-term treatment of obsessive-compulsive disorder in adults

What are the latest psychotherapeutic and pharmacotherapeutic treatment recommendations for obsessive-compulsive disorder (OCD)? OCD is a relatively common disorder with a lifetime prevalence of approximately 2% in the general population. It often has an early onset, usually in childhood or adolescence, and frequently becomes chronic and disabling if left untreated. High associated healthcare utilization and costs, and reduced productivity resulting in loss of earning, pose a huge economic burden to OCD patients and their families, employers, and society. OCD is characterized by the presence of obsessions and compulsions that are time-consuming, cause marked distress, or significantly interfere with a person's functioning. Most patients with OCD experience symptoms throughout their lives and benefit from long-term treatment. Both psychotherapy and pharmacotherapy are recommended, either alone or in combination, for the treatment of OCD. Cognitive-behavioral therapy is the psychotherapy of choice. Pharmacologic treatment options include the tricyclic antidepressant clomipramine and the selective serotonin reuptake inhibitors (SSRIs) citalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline. These have all shown benefit in acute treatment trials; clomipramine, fluvoxamine, fluoxetine, and sertraline have also demonstrated benefit in long-term treatment trials (at least 24 weeks), and clomipramine, sertraline, and fluvoxamine have United States Food and Drug Administration approvals for use in children and adolescents. Available treatment guidelines recommend first-line use of an SSRI (ie, fluoxetine, fluvoxamine, paroxetine, sertraline, or citalopram) in preference to clomipramine, due to the latter's less favorable adverse-event profile. Further, pharmacotherapy for a minimum of 1-2 years is recommended before very gradual withdrawal may be considered.

How to treat OCD in patients with Tourette syndrome

Obsessive-compulsive disorder (OCD) constitutes an etiologically heterogeneous set of conditions, including a subtype that seems etiologically related to Tourette syndrome (TS). In order to treat OCD patients optimally, the clinician needs to integrate educational, psychological and pharmacological approaches. The most effective psychological intervention is cognitive-behavior therapy (CBT). Drug treatment includes clomipramine and all selective serotonin reuptake inhibitors (SSRIs). A subgroup of OCD patients, however, shows no significant improvement. Few studies suggest that the presence of tics is associated to a worse treatment response to SSRIs and that such patients benefit from combined therapy of serotonin-reuptake inhibitors plus neuroleptics. Independently of the presence of tics, there are several different augmentation strategies for resistant cases with drugs that interfere in the dopamine, serotonin, opioid and gonadal hormone systems. In addition, new therapies are now being tested against presumed postinfectious autoimmune processes. Finally, new developments are promising in neural circuit-based therapies, including neurosurgery for refractory patients.

Current and potential pharmacological treatments for obsessive-compulsive disorder

In the past 20 years, several effective treatments have been developed for obsessive-compulsive disorder. Despite this, it is a disorder that is often inadequately treated by available therapies. Recent advances in neuroimaging and neurophysiology have provided some clues to possible treatments that may be more effective in treating this disorder. Serotonin agents remain the cornerstone of pharmacological treatment for obsessive-compulsive disorder. The development of agents that target specific serotonin receptor subtypes may improve the effectiveness of drug treatment. Other possible future treatment approaches are also discussed.

Pharmacotherapy of anxious disorders

The present paper is a review of the treatment of anxious disorders by the current pharmaceutical medications; a short epidemiological survey is given for anxious disorders including: general anxiety disorder, panic disorder, obsessive compulsive disorder, social anxiety and post-traumatic stress disorder. For all these disorders there are proposals of treatment built on literature data mainly on meta-analysis as well on personal experience.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of anxiety, obsessive-compulsive and posttraumatic stress disorders

In this report, recommendations for the pharmacological treatment of anxiety and obsessive-compulsive disorders are presented, based on available randomized, placebo- or comparator-controlled clinical studies. Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for panic disorder. Tri2-cyclic antidepressants (TCAs) are equally effective, but they are less well tolerated than the SSRIs. In treatment-resistant cases, benzodiazepines like alprazolam may be used when the patient does not have a history of dependency and tolerance. Due to possible serious side effects and interactions with other drugs and food components, the irreversible monamine oxidase inhibitor (MAOI) phenelzine should be used only when first-line drugs have failed. In generalised anxiety disorder, venlafaxine and SSRIs can be recommended, while buspirone and imipramine may be alternatives. For social phobia, SSRIs are recommended for the first line, and MAOIs, moclobemide and benzodiazepines as second line. Obsessive-compulsive disorder is best treated with SSRIs or clomipramine.

Sertraline treatment of obsessive-compulsive disorder: efficacy and tolerability of a rapid titration regimen

The objective of this study was to compare in a single blind manner, over a period of 12 weeks, the efficacy and tolerability of two different titration regimens of sertraline in the treatment of OCD: 150 mg/day reached at day five from the beginning of therapy (rapid titration regimen) versus 150 mg/day reached at day 15 from the beginning (slow titration regimen). Patients with a DSM-IV diagnosis of OCD and a Y-BOCS greater or equal to 16 were randomly assigned to receive one of the two dosing regimens; an upper target dose of 150 mg/day was selected on the basis of a review of mean dosages used in flexible-dose sertraline studies. The primary efficacy measure was the Y-BOCS, which was completed at baseline and every 2 weeks. Thirty-two patients referred to the Anxiety and Mood Disorders Unit of the University of Turin were included in the study. Seventeen were assigned to the rapidly escalating dose regimen and 15 to the other titration regimen. Twenty-seven (84.4%) patients completed the 12 weeks of the study: 14 (82.4%) patients in the rapid and 13 (86.7%) in the slow titration regimen. The ANOVA analysis showed a significant difference between treatment groups at week 4 and 6 in favor of the rapid titration regimen group; this difference faded afterwards. Both titration regimens were effective in reducing OC symptoms and were well tolerated: no differences in drop-out or in adverse event rates emerged between the two groups. Limitations of the present study are the single-blind design and the lack of power to detect differences in tolerability.

Sertraline and fluoxetine treatment of obsessive-compulsive disorder: results of a double-blind, 6-month treatment study

The purpose of this study was to evaluate the comparative efficacy and tolerability of sertraline and fluoxetine in the treatment of obsessive-compulsive disorder (OCD). Outpatients meeting DSM-IV criteria for OCD, with a Yale-Brown Obsessive-Compulsive (Y-BOCS) total score >or= 17, an NIMH Global Obsessive-Compulsive (NIMH-OC) scale score >or= 7, and a CGI-Severity score >or= 4 were randomized to 24 weeks of double-blind treatment with sertraline (N = 77) or fluoxetine (N = 73). Primary efficacy measures consisted of the Y-BOCS, the NIMH-OC scale, and the CGI-Severity (CGI-S) and Improvement (CGI-I) scales. Equivalent and significant (p < 0.001) improvement was found at week 24 in Y-BOCS and NIMH-OC scale scores for sertraline and fluoxetine. After 12 weeks, 49.2% of patients on sertraline were rated on the CGI-S scale as being mildly ill or not ill compared to 24.6% on fluoxetine (p < 0.01). A Cox analysis found patients on sertraline to have a statistically nonsignificant 42% greater likelihood of achieving a response by week 12 (CGI-I, much or very much improved; 95% CI, 0.85, 2.38; p = 0.18). Sertraline treatment also resulted in a higher proportion of remissions than fluoxetine (defined as a CGI-I <or= 2 and a Y-BOCS score <or= 11), both at week 12 (20% vs. 8%; chi2, 3.95; df 1; p = 0.047) and week 24 (36% vs. 22%; chi2, 3.18; df, 1; p = 0.075). Both medications were well-tolerated and demonstrated significant efficacy in the treatment of outpatients with moderate to severe OCD with the subjects treated with sertraline showing a greater likelihood of remission as well as an earlier improvement on some but not all efficacy measures

Long-term sertraline treatment of children and adolescents with obsessive-compulsive disorder

OBJECTIVE

To evaluate the safety and effectiveness of sertraline in the long-term treatment of pediatric obsessive-compulsive disorder (OCD).

METHOD

Children (6-12 years; n= 72) and adolescents (13-18 years; n = 65) with DSM-III-R-defined OCD who had completed a 12-week, double-blind, placebo-controlled sertraline study were given open-label sertraline 50 to 200 mg/day in this 52-week extension study. Concomitant psychotherapy was allowed during the extension study Outcome was evaluated by the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), National Institute of Mental Health Global Obsessive-Compulsive Scale, and Clinical Global Impression Severity (CGI-S) and Improvement (CGI-I) scores.

RESULTS

Significant improvement (p < .0001) was demonstrated on all four outcome parameters on an intent-to-treat analysis for the overall study population (n = 132), as well as the child and the adolescent samples. At endpoint, 72% of children and 61% of adolescents met response criteria (>25% decrease in CY-BOCS and a CGI-I score of 1 or 2). Significant (p < .05) improvements were also demonstrated from the extension study baseline to endpoint on all outcome parameters in those patients who received sertraline during the 12-week, double-blind acute study. Long-term sertraline treatment was well tolerated, and there were no discontinuations due to changes in vital signs, laboratory values, or electrocardiograms.

CONCLUSION

Sertraline (50-200 mg/day) was effective and generally well tolerated in the treatment of childhood and adolescent OCD for up to 52 weeks. Improvement was seen with continued treatment.

Long-term experience with citalopram in the treatment of adolescent OCD

OBJECTIVE

The primary purpose of the study was to describe tolerability and effectiveness of citalopram in the treatment of adolescent obsessive-compulsive disorder (OCD).

METHOD

Thirty nondepressed patients (15 females, 15 males) with a mean age of 13.7 years (range 13-18 years) were treated for their OCD with citalopram in an open-label, flexible-dose study (range of dose 20-70 mg; mean dose 46.5 mg). All patients were referred to Aarhus University Hospital. The patients were monitored for 1 to 2 years. The mean total score on the Yale-Brown Obsessive Compulsive Scale (child or adult version) was 28.7 at base-line, 23.3 after 10 weeks of treatment, 20.0 after 6 months, 18.4 after 1 year, and 17.9 after 2 years (from baseline to 2 years of treatment: t = 11.65; p < .001).

RESULTS

Seventy percent showed a decrease in total Yale-Brown Obsessive Compulsive Scale score in excess of 35% from baseline to 1 year of treatment. Twenty percent still had a score of greater than 20 after 1 year of treatment, indicating that clinically they still had OCD. Side effects were similar to those reported from the use of other selective serotonin reuptake inhibitors (SSRIs). No patient was excluded because of serious side effects during the 1 year of observation.

CONCLUSIONS

The clinical effectiveness and tolerability of citalopram in the long-term treatment seem to be comparable with the observations of other SSRIs in childhood and adolescent OCD. A further, statistically significant reduction is provided by an extended treatment period of up to 1 year.

Neurobiology and clinical pharmacology of obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a brain disorder with recognizable periods of onset, course, familial occurrence, epidemiology, phenomenology, and treatment response. Several manifestations of pathophysiology are beginning to be defined, although they may represent intermediate pathophysiology rather than primary etiology. Positron emission tomography studies have consistently identified hypermetabolism in the orbitofrontal cortex, caudate nucleus, and, sometimes, anterior cingulate cortex. Neuropsychologic testing frequently identifies abnormalities in visuospatial function. Abnormal levels of cerebrospinal fluid neurotransmitters and neuromodulators are identifiable in untreated patients with OCD and return toward normal levels after effective treatment. The most consistent pathophysiologic finding in OCD points toward an abnormality in serotonin neurotransmission. Therapeutic response to selective serotonin reuptake inhibitors and the absence of improvement with norepinephrine reuptake inhibitors and dopamine antagonists argue strongly for a role of serotonin in the pathophysiology and treatment of OCD. Despite this clear indication from treatment trials, probes and manipulations of the serotonin system and its specific receptors have not provided a useful understanding of specific abnormalities. Clomipramine or potent selective serotonin reuptake inhibitors are the pharmacotherapy of choice for OCD, with a more limited role reserved for monoamine oxidase inhibitors. If one selective serotonin reuptake inhibitor is ineffective, others may be beneficial, in addition to the different proserotonergic and nonserotonergic augmentation strategies that could be useful in treatment of resistant OCD patients. Nondrug therapies are also important in OCD: behavioral therapy is frequently helpful and neurosurgery is sometimes helpful when other treatments fail.

Sertraline in the treatment of anxiety disorders

Sertraline was first developed and approved for the treatment of depression. However, considerable research has been conducted on its use in anxiety disorders. This paper reviews the data emerging from controlled and open trials of the use of sertraline in anxiety disorders. Sertraline has been tested extensively in the treatment of panic and obsessive-compulsive disorders. Less extensive testing has been completed on social phobia and post-traumatic stress disorder. The reviewed studies show that sertraline is an effective and well-tolerated treatment of all of these disorders. A comparison of sertraline with other pharmacotherapeutic options shows it to be at least equivalent to other medications for anxiety disorders.

Obsessions: the impact and treatment of obsessive-compulsive disorder in children and adolescents

In the development of the majority of children, ritualistic behaviour may be seen as a normal phenomenon. In some children and adolescents, however, these rituals become time-consuming, interfering, irritating and annoying. The most common obsessions in both children and adults with obsessive-compulsive disorder (OCD) are related to a fear of dirt and contamination, fear of some terrible happening, and the fear of harming a loved one. The most common compulsions are washing fixations, checking behaviour and rituals (including mental rituals). Prevalence studies show that OCD in children and adolescents is far more common than previously thought. It is estimated that up to 2% of this population have symptoms fulfilling OCD criteria. The impact of early OCD onset can be profound, with long-term studies indicating that approximately 50% of these patients will also suffer from OCD in early adulthood. These patients tend to remain socially isolated, to have fewer relationships than their non-OCD peers, and have a tendency to remain within the family home during early adulthood. In addition, childhood OCD is associated with comorbid psychiatric disorders, in particular depression, anxiety and panic disorders, Tourette's syndrome and eating disorders. Treatment strategies for childhood OCD reflect those used in adult psychiatry. The most effective psychotherapeutic approach is based on cognitive-behavioural therapy with exposure and prevention. In contrast to pharmacotherapeutic agents without serotonin activity, the serotonin-specific antidepressants appear to be effective and well-tolerated in the treatment of OCD in children.

The selective serotonin reuptake inhibitor sertraline: its profile and use in psychiatric disorders

The naphthylamine derivative sertraline is a potent and selective inhibitor of serotonin reuptake into presynaptic terminals. Sertraline has a linear pharmacokinetic profile and a half-life of about 26 h. Its major metabolite, desmethylsertraline does not appear to inhibit serotonin reuptake. Sertraline mildly inhibits the CYP2D6 isoform of the cytochrome P450 system but has little effect on CYP1A2, CYP3A3/4, CYP2C9, or CYP2C19. It is, however, highly protein bound and may alter blood levels of other highly protein bound agents. Sertraline is a widely used serotonin reuptake inhibitor that has been shown to have both antidepressant and antianxiety effects. Many clinical trials have demonstrated its efficacy in depression compared with both placebo and other antidepressant drugs. Its efficacy has also been demonstrated in randomized, controlled trials of patients with obsessive-compulsive disorder, panic disorder, social phobia, and premenstrual dysphoric disorder. In short-term, open-label studies it has appeared efficacious and tolerable in children and adolescents and in the elderly, and data are positive for its use in pregnant or lactating women. Typical side effects include gastrointestinal and central nervous system effects as well as treatment-emergent sexual dysfunction; withdrawal reactions may be associated with abrupt discontinuation of the agent. The safety profile of sertraline in overdose is very favorable. Sertraline's efficacy for both mood and anxiety disorders, relatively weak effect on the cytochrome P450 system, and tolerability profile and safety in overdose are factors that contribute to make it a first-line agent for treatment in both primary and tertiary care settings.

Serotonergic drugs in the treatment of depressive and anxiety disorders

Serotonergic dysfunction has been implicated in the aetiology of several psychiatric conditions, including depressive and anxiety disorders. Much of the evidence for the role of serotonin (5-HT) in these disorders comes from treatment studies with serotonergic drugs, including selective serotonin reuptake inhibitors (SSRIs), 5-HT(1A) agonists and 5-HT antagonists. This review considers the place of these drugs in the treatment of panic disorder, obsessive-compulsive disorder (OCD), social phobia, and generalized anxiety disorder (GAD). Among these agents, the SSRIs stand out with proven efficacy in the treatment of a spectrum of disorders, such as depression, panic disorder, OCD and social phobia. They may also be a suitable treatment for GAD. 5-HT(1A) agonists have been used extensively for the treatment of depression and GAD but evidence of their efficacy in other anxiety disorders is equivocal. 5-HT antagonists are the least well studied of these agents: while they may have activity in depression, their efficacy has not been fully investigated in anxiety disorders. However, preliminary reports suggest that they may be useful as adjuvants to SSRIs in treatment-refractory OCD. The high incidence of comorbidity amongst psychiatric disorders means that pharmacotherapy that is effective against a range of disorders, such as the SSRIs, is of considerable use to clinicians. Future research into the biological mechanisms underlying such disorders is likely to further enhance pharmacotherapy. Copyright 2000 John Wiley & Sons, Ltd.

Biological therapies for obsessive-compulsive disorder

Two treatments have demonstrated efficacy in OCD, exposure and response (ritual) prevention (EX/RP) and pharmacotherapy with serotonin reuptake inhibitors (SRIs). In this article, which is the third in a three-part series, the authors present an overview of the role of biological treatments for OCD. The evidence for the efficacy of the serotonin reuptake inhibitors (clomipramine and the five selective serotonin reuptake inhibitors "SSRIs" fluvoxamine, fluoxetine, paroxetine, sertraline, and citalopram) as monotherapy for OCD is reviewed. The authors also discuss the rationale for choosing among these agents for specific patients. Research on other types of medication monotherapies for OCD is also discussed. The authors then cover strategies for treatment-resistant OCD, including combining EX/RP and SRI medication treatment, combining clomipramine and an SSRI, use of augmenting medications, and use of intravenous clomipramine. Findings concerning the use of other somatic therapies for treatment-resistant OCD, including electroconvulsive therapy, neurosurgery, plasma exchange/IV immunoglobulin/maintenance antibiotics, and transcranial magnetic stimulation, are also reviewed. Finally, the authors discuss what is known about matching treatments to patients with certain specific symptom clusters, how long to continue maintenance medication treatment, and how to terminate treatment.

On the pharmacotherapy of obsessive-compulsive disorder: is a consensus possible?

OBJECTIVE

To examine the efficacy and tolerability of clomipramine compared with the selective serotonin reuptake inhibitors (SSRIs) in the treatment of obsessive-compulsive disorder (OCD), bearing in mind the recent Expert Consensus Guidelines recommendation to use clomipramine after 2 to 3 failed SSRI trials.

METHOD

The literature on the pharmacotherapy of OCD was critically examined.

RESULTS

The available research evidence is not conclusive but suggests that clomipramine possesses greater anti-obsessional efficacy than do the SSRIs. In addition, when clomipramine is presented to patients in a positive way, and properly used in small initial doses with gradual increases, it seems to be tolerated as well as the SSRIs.

CONCLUSION

Recently expressed opinions that clomipramine should be used to treat OCD after 2 to 3 failed SSRI trials are not supported by research evidence. Both clomipramine and the SSRIs may be used as first-line treatments for OCD.

Side effects as predictors of drug response in obsessive-compulsive disorder

Differences between the side effect profiles of clomipramine (CMI) and the selective serotonin reuptake inhibitors may be important factors in both treatment outcome and patient selection in obsessive-compulsive disorder (OCD). Safety and efficacy data from an industry-sponsored, multicenter clinical trial of CMI were analyzed previously using tabular and multiple regression methods. Good response, defined as at least a 35% drop in final scores on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), was associated with a later age of OCD onset and certain early side effects that may reflect a sensitivity of responders to CMI's serotonergic actions. The authors conducted a similar analysis of data from an industry-sponsored clinical trial of fluoxetine in OCD. Fluoxetine response did not seem to be associated with age of OCD onset. Good response to both drugs was associated with initial nervousness and sexual complaints. The common side effects of fluoxetine (headache, nausea, and gastrointestinal complaints) did not seem to be associated with treatment response. Slight differences in the protocols of the two clinical trials yielded patient populations that were different in factors found to be associated with treatment outcome: subjects in the fluoxetine study had lower scores on the Y-BOCS, higher scores on the Hamilton Rating Scale for Depression, and an earlier age of OCD onset.

Effects of SSRIs on sexual function: a critical review

Sexual problems are highly prevalent in both men and women and are affected by, among other factors, mood state, interpersonal functioning, and psychotropic medications. The incidence of antidepressant-induced sexual dysfunction is difficult to estimate because of the potentially confounding effects of the illness itself, social and interpersonal comorbidities, medication effects, and design and assessment problems in most studies. Estimates of sexual dysfunction vary from a small percentage to more than 80%. This article reviews current evidence regarding sexual side effects of selective serotonin reuptake inhibitors (SSRIs). Among the sexual side effects most commonly associated with SSRIs are delayed ejaculation and absent or delayed orgasm. Sexual desire (libido) and arousal difficulties are also frequently reported, although the specific association of these disorders to SSRI use has not been consistently shown. The effects of SSRIs on sexual functioning seem strongly dose-related and may vary among the group according to serotonin and dopamine reuptake mechanisms, induction of prolactin release, anticholinergic effects, inhibition of nitric oxide synthetase, and propensity for accumulation over time. A variety of strategies have been reported in the management of SSRI-induced sexual dysfunction, including waiting for tolerance to develop, dosage reduction, drug holidays, substitution of another antidepressant drug, and various augmentation strategies with 5-hydroxytryptamine-2 (5-HT2), 5-HT3, and alpha2 adrenergic receptor antagonists, 5-HT1A and dopamine receptor agonists, and phosphodiesterase (PDE5) enzyme inhibitors. Sexual side effects of SSRIs should not be viewed as entirely negative; some studies have shown improved control of premature ejaculation in men. The impacts of sexual side effects of SSRIs on treatment compliance and on patients' quality of life are important clinical considerations.

Selective serotonin reuptake inhibitors in affective disorders--II. Efficacy and quality of life

Since their introduction, the selective serotonin reuptake inhibitors (SSRIs) have become one of the most widely used classes of medication in psychiatry. Their popularity is based on apparent efficacy over a wide range of disorders and a favorable side-effect profile. However, as with any psychotropic medication, considerable data are required to define where a drug works and where it does not. There is now a wealth of evidence demonstrating that SSRIs may differ in their efficacy profiles in certain depressive symptoms, in different subtypes of depression, with respect to their ability to maintain efficacy over time, on broader outcomes such as quality of life, and in the consistency of the usually effective minimum therapeutic dose across the age spectrum and across indications. Although this review includes data on all SSRIs, it focuses on fluoxetine and sertraline, which in addition to being the most widely used SSRIs are also the most widely studied. The relative quantity and quality of data on these two SSRIs means that it is possible to make relatively firm inferences regarding their differential effects on affective symptoms and quality of life.