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Grassi G, Scillitani E, Cecchelli C. New horizons for obsessive-compulsive disorder drug discovery: is targeting glutamate receptors the answer? Expert Opin Drug Discov 2024:1-11. [PMID: 39105546 DOI: 10.1080/17460441.2024.2387127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Accepted: 07/29/2024] [Indexed: 08/07/2024]
Abstract
INTRODUCTION Over the past decade, glutamate has emerged as a prominent focus in the field of obsessive-compulsive disorder (OCD) pathophysiology. A convergence of evidence from genetic, preclinical, and clinical studies points to glutamatergic dysfunction as a key feature of this condition. In light of these findings, there has been a growing interest in exploring the potential of glutamatergic agents in the treatment of OCD. AREAS COVERED This paper reviews the literature on glutamate transmission in OCD. In addition, the authors examine the results of clinical trials investigating the efficacy of glutamatergic agents in the treatment of OCD patients. EXPERT OPINION Along with the recognition of neuroinflammation in the brain in OCD, the evidence of glutamate dysfunction represents one of the most promising recent discoveries for understanding the mechanisms involved in OCD. The importance of this discovery lies primarily in its pharmacological implications and has led to intense research activity in the field of glutamatergic agents. While this research has not yet had a substantial clinical impact, targeting glutamate receptors remains a promising horizon for the successful treatment of OCD patients.
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Affiliation(s)
- Giacomo Grassi
- Department of Psychiatry, Brain Center Firenze, Florence, Italy
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2
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Younus S, Havel L, Stiede JT, Rast CE, Saxena K, Goodman WK, Storch EA. Pediatric Treatment-Resistant Obsessive Compulsive Disorder: Treatment Options and Challenges. Paediatr Drugs 2024; 26:397-409. [PMID: 38877303 DOI: 10.1007/s40272-024-00639-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/22/2024] [Indexed: 06/16/2024]
Abstract
Pediatric obsessive-compulsive disorder (OCD) is a chronic, potentially debilitating psychiatric condition. Although effective treatments exist, at least 10% of youth do not achieve remission despite receiving first-line treatments. This article reviews the extant, albeit limited, evidence supporting treatment approaches for youth with treatment-resistant OCD. A literature search for articles addressing pediatric treatment-resistant OCD was conducted through April 11, 2024. These results were augmented by searching for treatment-resistant OCD in adults; treatment strategies discovered for the adult population were then searched in the context of children and adolescents. In general, intensive treatment programs and antipsychotic augmentation of an antidepressant had the most substantial and consistent evidence base for treatment-resistant youth with OCD, although studies were limited and of relatively poor methodological quality (i.e., open trials, naturalistic studies). Several pharmacological approaches (clomipramine, antipsychotics [e.g., aripiprazole, risperidone], riluzole, ketamine, D-cycloserine, memantine, topiramate, N-acetylcysteine, ondansetron), largely based on supporting data among adults, have received varying levels of investigation and support. There is nascent support for how to treat pediatric treatment-resistant OCD. Future treatment studies need to consider how to manage the significant minority of youth who fail to benefit from first-line treatment approaches.
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Affiliation(s)
- Sana Younus
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1977 Butler Blvd, Suite 4-400, Houston, TX, 77030, USA
- Texas Children's Hospital, Houston, TX, USA
| | - Lauren Havel
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1977 Butler Blvd, Suite 4-400, Houston, TX, 77030, USA
- Texas Children's Hospital, Houston, TX, USA
| | - Jordan T Stiede
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1977 Butler Blvd, Suite 4-400, Houston, TX, 77030, USA
| | - Catherine E Rast
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1977 Butler Blvd, Suite 4-400, Houston, TX, 77030, USA
| | - Kirti Saxena
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1977 Butler Blvd, Suite 4-400, Houston, TX, 77030, USA
- Texas Children's Hospital, Houston, TX, USA
| | - Wayne K Goodman
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1977 Butler Blvd, Suite 4-400, Houston, TX, 77030, USA
| | - Eric A Storch
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1977 Butler Blvd, Suite 4-400, Houston, TX, 77030, USA.
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3
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Kawashima Y, Yamada M, Furuie H, Kuniishi H, Akagi K, Kawashima T, Noda T, Yamada M. Effects of riluzole on psychiatric disorders with anxiety or fear as primary symptoms: A systematic review. Neuropsychopharmacol Rep 2023; 43:320-327. [PMID: 37463744 PMCID: PMC10496048 DOI: 10.1002/npr2.12364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/31/2023] [Accepted: 06/19/2023] [Indexed: 07/20/2023] Open
Abstract
AIM Previous behavioral pharmacology studies involving rodents suggested riluzole had potential to be an ideal psychotropic drug for psychiatric disorders with anxiety or fear as primary symptoms. Several clinical studies have recently been conducted. The purpose of this study was to gather information about the efficacy and tolerability of riluzole for patients with those symptoms. METHODS We searched PubMed, PsycINFO, CINAHL, EMBASE, and the Cochrane database from inception until April 2021, and performed manual searches for additional relevant articles. This review included: (1) studies involving participants that were patients with generalized anxiety disorder (GAD), social anxiety disorder, panic disorder, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), acute stress disorder, or phobias; and (2) randomized controlled trials (RCTs) or intervention studies (e.g., single arm trials) examining the effects and safety of riluzole. RESULTS Of the 795 identified articles, four RCTs, one RCT subgroup-analysis, and three open-label trials without control groups met the inclusion criteria. Most trials evaluated the efficacy of riluzole as an augmentation therapy with selective serotonin reuptake inhibitors and other antidepressants for PTSD, OCD, or GAD. However, there was insufficient evidence to confirm the effects of riluzole for patients with these psychiatric disorders. Most trials demonstrated adequate study quality. CONCLUSIONS This review found insufficient evidence to confirm the effects of riluzole for psychiatric disorders with anxiety or fear as primary symptoms. It would be worthwhile to conduct studies that incorporate novel perspectives, such as examining the efficacy of riluzole as a concomitant medication for psychotherapy.
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Affiliation(s)
- Yoshitaka Kawashima
- Department of Neuropsychopharmacology, National Institute of Mental HealthNational Center of Neurology and PsychiatryTokyoJapan
- Clinical Psychology Course, Department of Psycho‐Social Studies, School of Arts and LettersMeiji UniversityTokyoJapan
| | - Misa Yamada
- Department of Neuropsychopharmacology, National Institute of Mental HealthNational Center of Neurology and PsychiatryTokyoJapan
| | - Hiroki Furuie
- Department of Neuropsychopharmacology, National Institute of Mental HealthNational Center of Neurology and PsychiatryTokyoJapan
| | - Hiroshi Kuniishi
- Department of Neuropsychopharmacology, National Institute of Mental HealthNational Center of Neurology and PsychiatryTokyoJapan
| | - Kie Akagi
- Department of Neuropsychopharmacology, National Institute of Mental HealthNational Center of Neurology and PsychiatryTokyoJapan
| | - Tomoko Kawashima
- Department of Neuropsychopharmacology, National Institute of Mental HealthNational Center of Neurology and PsychiatryTokyoJapan
| | - Takamasa Noda
- Department of Psychiatry, National Center HospitalNational Center of Neurology and PsychiatryTokyoJapan
| | - Mitsuhiko Yamada
- Department of Neuropsychopharmacology, National Institute of Mental HealthNational Center of Neurology and PsychiatryTokyoJapan
- Department of Pathophysiology, Faculty of Human NutritionTokyo Kasei Gakuin UniversityTokyoJapan
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Pittenger C. The Pharmacological Treatment of Obsessive-Compulsive Disorder. Psychiatr Clin North Am 2023; 46:107-119. [PMID: 36740347 DOI: 10.1016/j.psc.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Pharmacological treatment is a mainstay of the care of individuals with obsessive-compulsive disorder. Robust evidence supports the use of the selective serotonin reuptake inhibitors and the older tricyclic drug clomipramine. Other antidepressants are less effective (or have been insufficiently studied). When first-line treatment with these agents, and with appropriate psychotherapy, is ineffective, several augmentation strategies are available, though their evidentiary support is weaker. A substantial minority of patients have persistent symptoms despite optimal evidence-based treatment. Further work and more treatment options are needed.
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Affiliation(s)
- Christopher Pittenger
- Departments of Psychiatry, Psychology, and Child Study Center, and Center for Brain and Mind Health, Yale University.
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Suhas S, Malo PK, Kumar V, Issac TG, Chithra NK, Bhaskarapillai B, Reddy YCJ, Rao NP. Treatment strategies for serotonin reuptake inhibitor-resistant obsessive-compulsive disorder: A network meta-analysis of randomised controlled trials. World J Biol Psychiatry 2023; 24:162-177. [PMID: 35615998 DOI: 10.1080/15622975.2022.2082525] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Treatment-resistant obsessive-compulsive disorder is a chronic debilitating illness. We conducted a network meta-analysis [NMA] to compare the efficacy of all interventions in SRI-resistant OCD from published Randomised controlled trials [RCT]. METHODS We performed an NMA of RCTs in SRI resistant OCD from all modalities of treatments; pharmacological, psychological, neuromodulation, neurosurgery including deep brain stimulation. The design-by-treatment interaction inconsistency model within the frequentist framework was adopted with a change in Yale-Brown Obsessive-Compulsive Scale score as the primary outcome. We conducted sensitivity analyses excluding studies examining neurosurgical interventions, deep brain stimulation, studies in the paediatric population, and studies from a single geographical region. We also conducted analyses of interventions categorised into treatment groups. RESULTS 55 RCTs examining 19 treatments or placebo involving 2011 participants were included in the NMA. Ondansetron [Standardised mean difference -2.01 (95% CI: -3.19, -0.83)], deep TMS [- 1.95 (-3.25, -0.65)], therapist administered Cognitive Behavioural Therapy [CBT-TA] [-1.46 (-2.93, 0.01)] and aripiprazole [-1.36 (-2.56, -0.17)] were ranked as the best four treatments on using the Surface Under the Cumulative Ranking [SUCRA] percentage values (85.4%, 83.2%, 80.3%, 67.9% respectively). While all four interventions had large effect sizes, CBT[TA] narrowly missed statistical significance in our analysis. In sensitivity analyses, deep TMS was ranked as the best treatment strategy for SRI-resistant OCD. The small number of subjects in individual studies, higher confidence interval limits, and wider prediction interval for most agents warrant a cautious interpretation. CONCLUSIONS Considering the principal analysis and sensitivity analyses together, deep TMS, ondansetron, CBT[TA], and aripiprazole may be considered a first-line intervention for SRI-resistant OCD in adults. OTHER This work was not funded. The NMA has been registered with PROSPERO, [Registration number: CRD42020173589].
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Affiliation(s)
- Satish Suhas
- Department of Psychiatry, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India
| | - Palash Kumar Malo
- Department of Biostatistics, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India
| | - Vijay Kumar
- Department of Psychiatry, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India
| | - Thomas Gregor Issac
- Department of Psychiatry, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India
| | - Nellai K Chithra
- Department of Psychiatry, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India
| | - Binukumar Bhaskarapillai
- Department of Biostatistics, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India
| | - Y C Janardhan Reddy
- Department of Psychiatry, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India
| | - Naren P Rao
- Department of Psychiatry, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India
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van Roessel PJ, Grassi G, Aboujaoude EN, Menchón JM, Van Ameringen M, Rodríguez CI. Treatment-resistant OCD: Pharmacotherapies in adults. Compr Psychiatry 2023; 120:152352. [PMID: 36368186 DOI: 10.1016/j.comppsych.2022.152352] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 09/20/2022] [Accepted: 10/24/2022] [Indexed: 12/13/2022] Open
Abstract
Serotonin reuptake inhibitor (SRI) medications are well established as first-line pharmacotherapeutic treatment for Obsessive-Compulsive Disorder (OCD). However, despite the excellent safety profile and demonstrated efficacy of these medications, a substantial proportion of individuals with OCD fail to attain sufficient benefit from SRIs. In this narrative review, we discuss clinical features of OCD that have been associated with poorer response to SRIs, and we present pharmacotherapeutic interventions that have been explored as augmenting or alternative treatments for treatment-resistant OCD. We additionally highlight non-SRI interventions for OCD that are currently under investigation. Pharmacotherapeutic interventions were identified via expert consensus. To assess the evidence base for individual pharmacotherapies, targeted searches for relevant English-language publications were performed on standard biomedical research databases, including MEDLINE. Information relevant to ongoing registered clinical trials in OCD was obtained by search of ClinicalTrials.gov. Pharmacotherapies are grouped for review in accordance with the general principles of Neuroscience-based Nomenclature (NbN). Clinical features of OCD that may suggest poorer response to SRI treatment include early age of onset, severity of illness, duration of untreated illness, and the presence of symmetry/ordering or hoarding-related symptoms. Based on evolving pathophysiologic models of OCD, diverse agents engaging serotonin, dopamine, norepinephrine, glutamate, and anti-inflammatory pathways have been explored as alternative or adjunctive therapies for treatment-resistant OCD and have at least preliminary evidence of efficacy. Medications with dopamine antagonist activity remain the most robustly evidence-based of augmenting interventions, yet dopamine antagonists benefit only a minority of those who try them and carry elevated risks of adverse effects. Interventions targeting glutamatergic and anti-inflammatory pathways are less well evidenced, but may offer more favorable benefit to risk profiles. Ongoing research should explore whether specific interventions may benefit individuals with particular features of treatment-resistant OCD.
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Affiliation(s)
- Peter J van Roessel
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA; Sierra Pacific Mental Illness Research, Education, and Clinical Center (MIRECC), VA Palo Alto Health Care System, Palo Alto, CA, USA.
| | | | - Elias N Aboujaoude
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - José M Menchón
- Department of Psychiatry, Bellvitge University Hospital-IDIBELL, University of Barcelona, Cibersam, Barcelona, Spain
| | - Michael Van Ameringen
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Carolyn I Rodríguez
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA.
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Purushotham SS, Reddy NMN, D'Souza MN, Choudhury NR, Ganguly A, Gopalakrishna N, Muddashetty R, Clement JP. A perspective on molecular signalling dysfunction, its clinical relevance and therapeutics in autism spectrum disorder. Exp Brain Res 2022; 240:2525-2567. [PMID: 36063192 DOI: 10.1007/s00221-022-06448-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 08/18/2022] [Indexed: 11/29/2022]
Abstract
Intellectual disability (ID) and autism spectrum disorder (ASD) are neurodevelopmental disorders that have become a primary clinical and social concern, with a prevalence of 2-3% in the population. Neuronal function and behaviour undergo significant malleability during the critical period of development that is found to be impaired in ID/ASD. Human genome sequencing studies have revealed many genetic variations associated with ASD/ID that are further verified by many approaches, including many mouse and other models. These models have facilitated the identification of fundamental mechanisms underlying the pathogenesis of ASD/ID, and several studies have proposed converging molecular pathways in ASD/ID. However, linking the mechanisms of the pathogenic genes and their molecular characteristics that lead to ID/ASD has progressed slowly, hampering the development of potential therapeutic strategies. This review discusses the possibility of recognising the common molecular causes for most ASD/ID based on studies from the available models that may enable a better therapeutic strategy to treat ID/ASD. We also reviewed the potential biomarkers to detect ASD/ID at early stages that may aid in diagnosis and initiating medical treatment, the concerns with drug failure in clinical trials, and developing therapeutic strategies that can be applied beyond a particular mutation associated with ASD/ID.
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Affiliation(s)
- Sushmitha S Purushotham
- Neuroscience Unit, Jawaharlal Nehru Centre for Advanced Scientific Research, Bengaluru, 560064, India
| | - Neeharika M N Reddy
- Neuroscience Unit, Jawaharlal Nehru Centre for Advanced Scientific Research, Bengaluru, 560064, India
| | - Michelle Ninochka D'Souza
- Centre for Brain Research, Indian Institute of Science Campus, CV Raman Avenue, Bangalore, 560 012, India.,The University of Trans-Disciplinary Health Sciences and Technology (TDU), Bangalore, 560064, India
| | - Nilpawan Roy Choudhury
- Neuroscience Unit, Jawaharlal Nehru Centre for Advanced Scientific Research, Bengaluru, 560064, India
| | - Anusa Ganguly
- Neuroscience Unit, Jawaharlal Nehru Centre for Advanced Scientific Research, Bengaluru, 560064, India
| | - Niharika Gopalakrishna
- Neuroscience Unit, Jawaharlal Nehru Centre for Advanced Scientific Research, Bengaluru, 560064, India
| | - Ravi Muddashetty
- Centre for Brain Research, Indian Institute of Science Campus, CV Raman Avenue, Bangalore, 560 012, India.,The University of Trans-Disciplinary Health Sciences and Technology (TDU), Bangalore, 560064, India
| | - James P Clement
- Neuroscience Unit, Jawaharlal Nehru Centre for Advanced Scientific Research, Bengaluru, 560064, India.
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Farhat LC, Vattimo EFQ, Ramakrishnan D, Levine JLS, Johnson JA, Artukoglu BB, Landeros-Weisenberger A, Asbahr FR, Cepeda SL, Comer JS, Fatori D, Franklin ME, Freeman JB, Geller DA, Grant PJ, Goodman WK, Heyman I, Ivarsson T, Lenhard F, Lewin AB, Li F, Merlo LJ, Mohsenabadi H, Peris TS, Piacentini J, Rosa-Alcázar AI, Rosa-Alcázar À, Rozenman M, Sapyta JJ, Serlachius E, Shabani MJ, Shavitt RG, Small BJ, Skarphedinsson G, Swedo SE, Thomsen PH, Turner C, Weidle B, Miguel EC, Storch EA, Mataix-Cols D, Bloch MH. Systematic Review and Meta-analysis: An Empirical Approach to Defining Treatment Response and Remission in Pediatric Obsessive-Compulsive Disorder. J Am Acad Child Adolesc Psychiatry 2022; 61:495-507. [PMID: 34597773 DOI: 10.1016/j.jaac.2021.05.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 05/05/2021] [Accepted: 09/21/2021] [Indexed: 02/01/2023]
Abstract
OBJECTIVE A lack of universal definitions for response and remission in pediatric obsessive-compulsive disorder (OCD) has hampered the comparability of results across trials. To address this problem, we conducted an individual participant data diagnostic test accuracy meta-analysis to evaluate the discriminative ability of the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) in determining response and remission. We also aimed to generate empirically derived cutoffs on the CY-BOCS for these outcomes. METHOD A systematic review of PubMed, PsycINFO, Embase and CENTRAL identified 5,401 references; 42 randomized controlled clinical trials were considered eligible, and 21 provided data for inclusion (N = 1,234). Scores of ≤2 in the Clinical Global Impressions Improvement and Severity scales were chosen to define response and remission, respectively. A 2-stage, random-effects meta-analysis model was established. The area under the curve (AUC) and the Youden Index were computed to indicate the discriminative ability of the CY-BOCS and to guide for the optimal cutoff, respectively. RESULTS The CY-BOCS had sufficient discriminative ability to determine response (AUC = 0.89) and remission (AUC = 0.92). The optimal cutoff for response was a ≥35% reduction from baseline to posttreatment (sensitivity = 83.9, 95% CI = 83.7-84.1; specificity = 81.7, 95% CI = 81.5-81.9). The optimal cutoff for remission was a posttreatment raw score of ≤12 (sensitivity = 82.0, 95% CI = 81.8-82.2; specificity = 84.6, 95% CI = 84.4-84.8). CONCLUSION Meta-analysis identified empirically optimal cutoffs on the CY-BOCS to determine response and remission in pediatric OCD randomized controlled clinical trials. Systematic adoption of standardized operational definitions for response and remission will improve comparability across trials for pediatric OCD.
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Affiliation(s)
- Luis C Farhat
- Faculdade de Medicina FMUSP, Universidade de São Paulo, Brazil
| | | | - Divya Ramakrishnan
- Yale Child Study Center, Yale School of Medicine, New Haven, Connecticut
| | - Jessica L S Levine
- Yale Child Study Center, Yale School of Medicine, New Haven, Connecticut
| | - Jessica A Johnson
- Columbia University New York, New York; Columbia School of Nursing, New York
| | | | | | | | | | - Jonathan S Comer
- Center for Children and Families, Florida International University, Miami, Florida
| | - Daniel Fatori
- Faculdade de Medicina FMUSP, Universidade de São Paulo, Brazil
| | - Martin E Franklin
- University of Pennsylvania, Philadelphia; Rogers Memorial Hospital, Oconomowoc, Wisconsin
| | - Jennifer B Freeman
- Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Daniel A Geller
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | - Isobel Heyman
- Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
| | - Tord Ivarsson
- Regional Center for Child and Youth Mental Health and Child Welfare, Faculty of Medicine and Health Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Fabian Lenhard
- Centre for Psychiatry Research, Karolinska Institutet, Stockholm Health Care Services, Region Stockholm, Sweden
| | - Adam B Lewin
- University of South Florida, Hillsborough County
| | - Fenghua Li
- Yale Child Study Center, Yale School of Medicine, New Haven, Connecticut
| | | | - Hamid Mohsenabadi
- Tehran Institute of Psychiatry, Iran University of Medical Sciences, Tehran, IR
| | - Tara S Peris
- Semel Institute for Neuroscience and Human Behavior, University of California at Los Angeles
| | - John Piacentini
- Semel Institute for Neuroscience and Human Behavior, University of California at Los Angeles
| | | | | | | | | | - Eva Serlachius
- Centre for Psychiatry Research, Karolinska Institutet, Stockholm Health Care Services, Region Stockholm, Sweden
| | - Mohammad J Shabani
- Tehran Institute of Psychiatry, Iran University of Medical Sciences, Tehran, IR
| | | | - Brent J Small
- School of Aging Studies, University of South Florida, Hillsborough County
| | | | | | - Per Hove Thomsen
- Regional Center for Child and Youth Mental Health and Child Welfare, Faculty of Medicine and Health Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Aarhus University Hospital, Skejby, Denmark
| | - Cynthia Turner
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Bernhard Weidle
- Regional Center for Child and Youth Mental Health and Child Welfare, Faculty of Medicine and Health Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; St. Olav's University Hospital, Trondheim, Norway
| | | | | | - David Mataix-Cols
- Centre for Psychiatry Research, Karolinska Institutet, Stockholm Health Care Services, Region Stockholm, Sweden
| | - Michael H Bloch
- Yale Child Study Center, Yale School of Medicine, New Haven, Connecticut.
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Abstract
INTRODUCTION First-line treatment for obsessive-compulsive disorder (OCD) includes exposure and response prevention behavioral therapy and serotonin reuptake inhibitors, particularly in combination. New and more effective treatments are needed, give that recent studies suggest that glutamatergic neurotransmission contributes to the pathophysiology of the disorder. In these circumstances, ketamine, as a potent N-methyl-D-aspartate receptor antagonist and glutamate modulator, offers alternative possibilities for OCD treatment. METHODS This systematic review aims to investigate the effects of ketamine in OCD, following the Preferred Reporting Items for Systematic Review and Meta-analyses Protocols (PRISMA-P). Searches were carried out using the PubMed/MEDLINE, Embase, and PsycINFO databases. RESULTS Nine articles were included, of which three were randomized controlled trials, three case reports, two open-label trials, and one a retrospective chart review. Reported data have shown a potential for fast onset of action and good tolerability of ketamine for OCD, even though the principal studies used only single-session racemic ketamine treatments, administered intravenously, and the results have been erratic. In addition, none of the available evidence demonstrates whether racemic ketamine, S-ketamine, or R-ketamine has the best efficacy in controlling OCD symptoms, and only sparse evidence suggests that a combination of ketamine and psychotherapy could benefit patients with OCD. CONCLUSION In order to advance clinical practice regarding the use of ketamine in treating OCD, future randomized, double-blind, placebo-controlled trials are required. These trials need to use larger samples to explore ketamine and its enantiomers, with different methods of administration, multiple sessions, and appropriate washout periods.
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Maraone A, Tarsitani L, Pinucci I, Pasquini M. Antiglutamatergic agents for obsessive-compulsive disorder: Where are we now and what are possible future prospects? World J Psychiatry 2021; 11:568-580. [PMID: 34631461 PMCID: PMC8474998 DOI: 10.5498/wjp.v11.i9.568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 07/25/2021] [Accepted: 08/06/2021] [Indexed: 02/06/2023] Open
Abstract
Recent data suggest that obsessive-compulsive disorder (OCD) is driven by an imbalance among the habit learning system and the goal-directed system. The frontostriatal loop termed cortico-striatal-thalamo-cortical (CSTC) circuitry loop is involved in habits and their dysfunction plays an important role in OCD. Glutamatergic neurotransmission is the principal neurotransmitter implicated in the CSTC model of OCD. Hyperactivity in the CSTC loop implies a high level of glutamate in the cortical-striatal pathways as well as a dysregulation of GABAergic transmission, and could represent the pathophysiology of OCD. Moreover, the dysregulation of glutamate levels can lead to neurotoxicity, acting as a neuronal excitotoxin. The hypothesis of a role of neurotoxicity in the pathophysiology of OCD clinically correlates to the importance of an early intervention for patients. Indeed, some studies have shown that a reduction of duration of untreated illness is related to an earlier onset of remission. Although robust data supporting a progression of such brain changes are not available so far, an early intervention could help interrupt damage from neurotoxicity. Moreover, agents targeting glutamate neurotransmission may represent promising therapeutical option in OCD patients.
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Affiliation(s)
- Annalisa Maraone
- Department of Human Neurosciences, Sapienza University of Rome, Rome 00185, Lazio, Italy
| | - Lorenzo Tarsitani
- Department of Human Neurosciences, Sapienza University of Rome, Rome 00185, Lazio, Italy
| | - Irene Pinucci
- Department of Human Neurosciences, Sapienza University of Rome, Rome 00185, Lazio, Italy
| | - Massimo Pasquini
- Department of Human Neurosciences, Sapienza University of Rome, Rome 00185, Lazio, Italy
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11
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Specialty knowledge and competency standards for pharmacotherapy for pediatric obsessive-compulsive disorder. Psychiatry Res 2021; 299:113858. [PMID: 33770712 DOI: 10.1016/j.psychres.2021.113858] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 03/06/2021] [Indexed: 12/28/2022]
Abstract
Evidence based treatments for pediatric Obsessive-Compulsive Disorder (OCD) are delivered with varying levels of expertise. This paper is part of the phase two series by the International OCD Accreditation Task Force (ATF) to advance a standardized high level of care globally. This paper presents specific knowledge and competencies recommended for specialized practice for pediatric psychopharmacologists working with OCD, developed by an international group of clinicians with extensive expertise in assessment and treatment of OCD. Tabulated knowledge and competency standards are operationalized as clinician abilities with specification of evidence for each standard. The distinction between current practice guidelines and ATF standards is discussed. Drug treatment has a solid evidence base. However, it should not be applied isolated, but informed by broad competence in general child and adolescent psychiatry and pediatrics. Other treatment relevant areas such as specialty CBT, family functioning, developmental issues, and neurobiology require consideration. Drug treatment includes several phases with varying degrees of evidence: Starting up medication, titration to maximum tolerated dose, maintenance, termination, and relapse prevention. In complex cases, pharmacotherapy with weak evidence may be needed to target symptoms and/or co-morbidity. The ATF knowledge and competency standards presented will be reviewed and updated commensurate with research.
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Tidball AM, Lopez-Santiago LF, Yuan Y, Glenn TW, Margolis JL, Clayton Walker J, Kilbane EG, Miller CA, Martina Bebin E, Scott Perry M, Isom LL, Parent JM. Variant-specific changes in persistent or resurgent sodium current in SCN8A-related epilepsy patient-derived neurons. Brain 2021; 143:3025-3040. [PMID: 32968789 DOI: 10.1093/brain/awaa247] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 05/27/2020] [Accepted: 06/19/2020] [Indexed: 12/12/2022] Open
Abstract
Missense variants in the SCN8A voltage-gated sodium channel gene are linked to early-infantile epileptic encephalopathy type 13, also known as SCN8A-related epilepsy. These patients exhibit a wide spectrum of intractable seizure types, severe developmental delay, movement disorders, and elevated risk of sudden unexpected death in epilepsy. The mechanisms by which SCN8A variants lead to epilepsy are poorly understood, although heterologous expression systems and mouse models have demonstrated altered sodium current properties. To investigate these mechanisms using a patient-specific model, we generated induced pluripotent stem cells from three patients with missense variants in SCN8A: p.R1872>L (Patient 1); p.V1592>L (Patient 2); and p.N1759>S (Patient 3). Using small molecule differentiation into excitatory neurons, induced pluripotent stem cell-derived neurons from all three patients displayed altered sodium currents. Patients 1 and 2 had elevated persistent current, while Patient 3 had increased resurgent current compared to controls. Neurons from all three patients displayed shorter axon initial segment lengths compared to controls. Further analyses focused on one of the patients with increased persistent sodium current (Patient 1) and the patient with increased resurgent current (Patient 3). Excitatory cortical neurons from both patients had prolonged action potential repolarization. Using doxycycline-inducible expression of the neuronal transcription factors neurogenin 1 and 2 to synchronize differentiation of induced excitatory cortical-like neurons, we investigated network activity and response to pharmacotherapies. Both small molecule differentiated and induced patient neurons displayed similar abnormalities in action potential repolarization. Patient induced neurons showed increased burstiness that was sensitive to phenytoin, currently a standard treatment for SCN8A-related epilepsy patients, or riluzole, an FDA-approved drug used in amyotrophic lateral sclerosis and known to block persistent and resurgent sodium currents, at pharmacologically relevant concentrations. Patch-clamp recordings showed that riluzole suppressed spontaneous firing and increased the action potential firing threshold of patient-derived neurons to more depolarized potentials. Two of the patients in this study were prescribed riluzole off-label. Patient 1 had a 50% reduction in seizure frequency. Patient 3 experienced an immediate and dramatic seizure reduction with months of seizure freedom. An additional patient with a SCN8A variant in domain IV of Nav1.6 (p.V1757>I) had a dramatic reduction in seizure frequency for several months after starting riluzole treatment, but then seizures recurred. Our results indicate that patient-specific neurons are useful for modelling SCN8A-related epilepsy and demonstrate SCN8A variant-specific mechanisms. Moreover, these findings suggest that patient-specific neuronal disease modelling offers a useful platform for discovering precision epilepsy therapies.
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Affiliation(s)
- Andrew M Tidball
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | | | - Yukun Yuan
- Department of Pharmacology, University of Michigan, Ann Arbor, MI, USA
| | - Trevor W Glenn
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | | | - J Clayton Walker
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Emma G Kilbane
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | | | - E Martina Bebin
- Department of Neurology, University of Alabama Birmingham School of Medicine, Birmingham, AL, USA.,Department of Pediatrics, University of Alabama Birmingham School of Medicine, Birmingham, AL, USA
| | - M Scott Perry
- Cook Children's Health Care System, Fort Worth, Texas, USA
| | - Lori L Isom
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Department of Pharmacology, University of Michigan, Ann Arbor, MI, USA.,Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI, USA
| | - Jack M Parent
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Ann Arbor VA Healthcare System, Ann Arbor, MI, USA
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Grassi G, Cecchelli C, Vignozzi L, Pacini S. Investigational and Experimental Drugs to Treat Obsessive-Compulsive Disorder. J Exp Pharmacol 2021; 12:695-706. [PMID: 33447096 PMCID: PMC7801912 DOI: 10.2147/jep.s255375] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/12/2020] [Indexed: 12/13/2022] Open
Abstract
Treatment-resistance is a frequent condition for obsessive-compulsive disorder (OCD). Over the past decades, a lot of effort has been made to address this issue, and several augmentation strategies of serotonergic drugs have been investigated. Antidopaminergic drugs are considered the first choice as augmentation strategy for treatment-resistant OCD patients, but they seem to work only for a subset of patients, and none of them have been officially approved for OCD. Recently, the role of glutamate and inflammation in OCD pathophysiology clearly emerged, and this has led to several investigations on glutamatergic and anti-inflammatory agents. Results seem promising but still inconclusive. Probiotic interventions (considered to modulate the immune systems and the brain activity) are gaining attention in several psychiatric fields but are still at their early stages in the OCD field. Research on new treatment approaches for OCD is moving forward, and more than one hundred interventional trials are ongoing around the world. While the vast majority of these trials involve neuromodulation and psychotherapeutic approaches, only a small proportion (around 20%) involve the investigation of new pharmacological approaches (tolcapone, nabilone, psilocybin, troriluzole, nitrous oxide, rituximab, naproxen, and immunoglobulins). Here, we provide a comprehensive review of investigational and experimental drugs to treat OCD.
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Affiliation(s)
- Giacomo Grassi
- Neuroscience Department, Brain Center Firenze, Florence, Italy
| | | | - Luisa Vignozzi
- Neuroscience Department, Brain Center Firenze, Florence, Italy
| | - Silvia Pacini
- Neuroscience Department, Brain Center Firenze, Florence, Italy
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Abstract
Effective pharmacological and psychotherapeutic treatments are well established for obsessive-compulsive disorder (OCD). Serotonin reuptake inhibitors (SRIs) are first-line treatment and are of benefit to about half of patients. Augmentation of SRI treatment with low-dose neuroleptics is an evidence-based second-line strategy. Specialty psychotherapy is also used as both first-line and second-line treatment and can benefit many. However, a substantial number of patients do not respond to these treatments. New alternatives are urgently needed. This review summarizes evidence for these established pharmacotherapeutic strategies, and for others that have been investigated in refractory disease but are not supported by the same level of evidence. We focus on three neurotransmitter systems in the brain: serotonin, dopamine, and glutamate. We summarize evidence from genetic, neuroimaging, animal model, and other lines of investigation that probe these three systems in patients with OCD. We also review recent work on predictors of response to current treatments. While many studies suggest abnormalities that may provide insight into the pathophysiology of the disorder, most studies have been small, and non-replication of reported findings has been common. Nevertheless, the gradual accrual of evidence for neurotransmitter dysregulation may in time lead the way to new pharmacological strategies.
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Abstract
Obsessive-compulsive disorder (OCD) is a common, chronic, and oftentimes disabling disorder. The only established first-line treatments for OCD are exposure and response prevention, and serotonin reuptake inhibitor medications (SRIs). However, a subset of patients fails to respond to either modality, and few experience complete remission. Beyond SRI monotherapy, antipsychotic augmentation is the only medication approach for OCD with substantial empirical support. Our incomplete understanding of the neurobiology of OCD has hampered efforts to develop new treatments or enhance extant interventions. This review focuses on several promising areas of research that may help elucidate the pathophysiology of OCD and advance treatment. Multiple studies support a significant genetic contribution to OCD, but pinpointing the specific genetic determinants requires additional investigation. The preferential efficacy of SRIs in OCD has neither led to discovery of serotonergic abnormalities in OCD nor to development of new serotonergic medications for OCD. Several lines of preclinical and clinical evidence suggest dysfunction of the glutamatergic system in OCD, prompting testing of several promising glutamate modulating agents. Functional imaging studies in OCD show consistent evidence for increased activity in brain regions that form a cortico-striato-thalamo-cortical (CSTC) loop. Neuromodulation treatments with either noninvasive devices (e.g., transcranial magnetic stimulation) or invasive procedures (e.g., deep brain stimulation) provide further support for the CSTC model of OCD. A common substrate for various interventions (whether drug, behavioral, or device) may be modulation (at different nodes or connections) of the CSTC circuit that mediates the symptoms of OCD.
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Affiliation(s)
- Wayne K. Goodman
- Menninger Department of Psychiatry and Behavioral Sciences (all authors) and Department of Neurosurgery (Sheth), Baylor College of Medicine, Houston
| | - Eric A. Storch
- Menninger Department of Psychiatry and Behavioral Sciences (all authors) and Department of Neurosurgery (Sheth), Baylor College of Medicine, Houston
| | - Sameer A. Sheth
- Menninger Department of Psychiatry and Behavioral Sciences (all authors) and Department of Neurosurgery (Sheth), Baylor College of Medicine, Houston
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Spangler PT, West JC, Dempsey CL, Possemato K, Bartolanzo D, Aliaga P, Zarate C, Vythilingam M, Benedek DM. Randomized Controlled Trial of Riluzole Augmentation for Posttraumatic Stress Disorder: Efficacy of a Glutamatergic Modulator for Antidepressant-Resistant Symptoms. J Clin Psychiatry 2020; 81:20m13233. [PMID: 33113596 PMCID: PMC7673650 DOI: 10.4088/jcp.20m13233] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 05/18/2020] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Current pharmacologic treatments for posttraumatic stress disorder (PTSD) have shown limited efficacy, prompting a call to investigate new classes of medications. The current study investigated the efficacy of glutamate modulation with riluzole augmentation for combat-related PTSD symptoms resistant to treatment with selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). METHODS A randomized, double-blind, placebo-controlled, parallel trial was conducted at Walter Reed National Military Medical Center and Syracuse VA Medical Center between December 2013 and November 2017. Veterans and active duty service members with combat-related PTSD (per the Clinician Administered PTSD Scale [CAPS]) who were not responsive to SSRI or SNRI pharmacotherapy were randomized to 8-week augmentation with a starting dose of 100 mg/d of riluzole (n = 36) or placebo (n = 38) and assessed weekly for PTSD symptoms, anxiety, depression, disability, and side effects. RESULTS Intent-to-treat analyses (N = 74) of the primary outcome (CAPS for DSM-IV) showed no significant between-group difference in change in overall PTSD symptoms (F = 0.64, P = .422), with a small effect size (d = 0.25). There was clinically significant within-group improvement in overall PTSD symptoms in both groups, with a greater mean (SD) decrease in CAPS score in the riluzole group (-21.1 [18.9]) than in the placebo group (-16.7 [17.2]). Exploratory analyses of PTSD symptom clusters showed significantly greater improvement on hyperarousal symptoms in the riluzole group as measured by the PTSD Checklist-Specific-Subscale D (d = 0.48) and near-significant findings on the CAPS Subscale D. Riluzole augmentation was not superior to placebo on change in depression, anxiety, or disability severity. CONCLUSIONS Although preliminary, the exploratory findings of this study offer some evidence that riluzole augmentation of an SSRI or SNRI may selectively improve PTSD hyperarousal symptoms without changes in overall PTSD symptoms, depression, anxiety, or disability. Additional investigation of the mechanism of the efficacy of riluzole for hyperarousal symptoms is warranted. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02155829.
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Affiliation(s)
- Patricia T. Spangler
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University, Bethesda, MD
| | - James C. West
- Department of Psychiatry, Uniformed Services University, Bethesda, MD
| | - Catherine L. Dempsey
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University, Bethesda, MD
| | - Kyle Possemato
- Veterans Administration Center for Integrated Healthcare, Syracuse, NY
| | - Danielle Bartolanzo
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University, Bethesda, MD
| | - Pablo Aliaga
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University, Bethesda, MD
| | - Carlos Zarate
- Experimental Therapeutics & Pathophysiology Branch, National Institute of Mental Health, Bethesda, MD
| | | | - David M. Benedek
- Department of Psychiatry, Uniformed Services University, Bethesda, MD
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Sonmez AI, Almorsy A, Ramsey LB, Strawn JR, Croarkin PE. Novel pharmacological treatments for generalized anxiety disorder: Pediatric considerations. Depress Anxiety 2020; 37:747-759. [PMID: 32419335 PMCID: PMC7584375 DOI: 10.1002/da.23038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 03/16/2020] [Accepted: 04/27/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Pediatric anxiety disorders such as generalized anxiety disorder (GAD) are common, impairing, and often undertreated. Moreover, many youth do not respond to standard, evidence-based psychosocial or psychopharmacologic treatment. An increased understanding of the gamma-aminobutyric acid (GABA) and glutamate neurotransmitter systems has created opportunities for novel intervention development for pediatric GAD. METHODS This narrative review examines potential candidates for pediatric GAD: eszopiclone, riluzole, eglumegad (LY354740), pimavanserin, agomelatine. RESULTS The pharmacology, preclinical data, clinical trial findings and known side effects of eszopiclone, riluzole, eglumegad (LY354740), pimavanserin, agomelatine, are reviewed, particularly with regard to their potential therapeutic relevance to pediatric GAD. CONCLUSION Notwithstanding numerous challenges, some of these agents represent potential candidate drugs for pediatric GAD. Further treatment development studies of agomelatine, eszopiclone, pimavanserin and riluzole for pediatric GAD also have the prospect of informing the understanding of GABAergic and glutamatergic function across development.
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Affiliation(s)
- A. Irem Sonmez
- Department of Psychiatry and Psychology Mayo Clinic, Rochester, Minnesota, USA
| | - Ammar Almorsy
- Department of Psychiatry and Psychology Mayo Clinic, Rochester, Minnesota, USA
| | - Laura B. Ramsey
- Division of Research in Patient Services and Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine Cincinnati, Ohio, USA
| | - Jeffrey R. Strawn
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, Ohio, USA
| | - Paul E. Croarkin
- Department of Psychiatry and Psychology Mayo Clinic, Rochester, Minnesota, USA
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Pregabalin augmentation for resistant obsessive-compulsive disorder: a double-blind placebo-controlled clinical trial. CNS Spectr 2020; 25:552-556. [PMID: 31648655 DOI: 10.1017/s1092852919001500] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVE Glutamate dysfunction has been shown to be associated with pathophysiology of obsessive-compulsive disorder (OCD). Our objective is to survey the effects of pregabalin (a glutamate-modulating agent) as an augmenting treatment for resistant OCD. PATIENTS AND METHODS In this 12-week double-blind placebo-controlled clinical trial, 56 patients with resistant OCD were randomly allocated to receive either pregabalin or placebo plus their current medication (sertraline). Yale-Brown Obsessive Compulsive Scale (Y-BOCS) was used to evaluate the outcomes. Adverse effects were also registered. RESULTS Of the 56 patients with resistant OCD who were randomly allocated in 2 groups of pregabalin (n = 28) and placebo group (n = 28), 42 patients (22 in pregabalin group and 20 in placebo group) completed the trial. Throughout the trial, the mean score decreased from 26.13± 7.03 to 8.81 ± 3.47 in the pregabalin group (p < 0) and from 26.85 ± 4.34 to 17.63 ± 4.22 in the placebo group (p < 0). At the end of trial, 16 (57.14%) patients in the pregabalin group and 2 (7.14%) patients in the placebo group showed more than 35% decline in YBOCS (p < .01). The pregabalin group showed good tolerability and safety. CONCLUSIONS Our study revealed that pregabalin, as an augmenting medication, is more effective than placebo in the treatment of patients with resistant OCD.
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Nazeer A, Latif F, Mondal A, Azeem MW, Greydanus DE. Obsessive-compulsive disorder in children and adolescents: epidemiology, diagnosis and management. Transl Pediatr 2020; 9:S76-S93. [PMID: 32206586 PMCID: PMC7082239 DOI: 10.21037/tp.2019.10.02] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Obsessive-compulsive disorder (OCD) can be found in about 4% of the general population and is characterized by various compulsions and obsessions that interfere with the person's quality of life from a mild to severe degree. The following discussion reflects on current concepts in this condition, including its epidemiology and etiologic underpinnings (behavioral, neurological, immunological, gastroenterological, as well as genetic). The interplay of PANS and PANDAS are included in this review. In addition, the core concepts of OCD diagnosis, differential diagnosis, and co-morbidities are considered. It is stressed that the quality of life for persons with pediatric OCD as well as for family members can be quite limited and challenged. Thus, principles of management are presented as a guide to improve the quality of life for these persons as much as possible.
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Affiliation(s)
- Ahsan Nazeer
- Department of Psychiatry, Division of Child and Adolescent Psychiatry, Sidra Medicine, Doha, Qatar
| | - Finza Latif
- Division of Psychiatry and Behavioral Sciences, George Washington University, Children's National Medical Center, Washington, DC, USA
| | - Aisha Mondal
- Division of Psychiatry and Behavioral Sciences, George Washington University, Children's National Medical Center, Washington, DC, USA
| | | | - Donald E Greydanus
- Department of Pediatric and Adolescent Medicine, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
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Kotzalidis GD, Del Casale A, Simmaco M, Pancheri L, Brugnoli R, Paolini M, Gualtieri I, Ferracuti S, Savoja V, Cuomo I, De Chiara L, Mosca A, Sani G, Girardi P, Pompili M, Rapinesi C, On Behalf Of The Sapienza Group For The Study Of The Placebo Effect In Psychiatric Disorders. Placebo Effect in Obsessive-Compulsive Disorder (OCD). Placebo Response and Placebo Responders in OCD: The Trend Over Time. Curr Neuropharmacol 2020; 17:741-774. [PMID: 30370851 PMCID: PMC7059157 DOI: 10.2174/1570159x16666181026163922] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 07/16/2018] [Accepted: 10/17/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Placebo response appears to be increasing in antidepressant, antipsychotic and various internal medicine trials. A similar trend has been reported for OCD during 1989-1999. Placebo response is generally considered as the extent to which placebo treatment is associated with core symptom improvement. In this analysis, we used Joinpoint regression to assess the time trend of both placebo response and placebo responder rates according to the year of publication with no time restriction in OCD drug trials. METHODS We included drug and/or psychotherapy trials vs. placebo from PubMed, Embase, CINAHL, and PsycINFO retrieved through the search (placebo OR sham) AND (obsessive* OR OCD). We included studies through investigator consensus. We then performed on data of included studies log-linear joinpoint segmented regression models using a p<0.05 cutoff. RESULTS We included 113 studies from 112 published papers. Placebo mean annual response rates in OCD studies significantly increased from 1991 to 2017 with an annual percent change (APC) of 0.66%, while placebo mean annual responder rates also significantly increased from 2010 to 2017, with an APC of 5.45%. Drug mean annual response rates in OCD studies significantly increased from 1987 to 2012 with an APC of 0.72%, while the corresponding responder rates did not show statistically significant APC changes between 1984 and 2017. CONCLUSION We observed a tendency for placebo to increase both measures of response in OCD clinical drug trials through the years that tend to approximate the responses shown by drugs. Changes in the type of study (moving from classical head to head comparisons to add-on studies in treatmentresistant populations) and countries involved in experimentation may partially account for some portion of these results. It appears that placebo effects are becoming more elusive and out of control.
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Affiliation(s)
- Georgios D Kotzalidis
- Neurosciences, Mental Health, and Sensory Organs (NESMOS) Department, Faculty of Medicine and Psychology, Sapienza University, Sant'Andrea Hospital, Rome, Italy
| | - Antonio Del Casale
- Neurosciences, Mental Health, and Sensory Organs (NESMOS) Department, Faculty of Medicine and Psychology, Sapienza University, Sant'Andrea Hospital, Rome, Italy
| | - Maurizio Simmaco
- Neurosciences, Mental Health, and Sensory Organs (NESMOS) Department, Faculty of Medicine and Psychology, Sapienza University, Sant'Andrea Hospital, Rome, Italy
| | | | - Roberto Brugnoli
- Neurosciences, Mental Health, and Sensory Organs (NESMOS) Department, Faculty of Medicine and Psychology, Sapienza University, Sant'Andrea Hospital, Rome, Italy
| | - Marco Paolini
- Residency School in Psychiatry, Faculty of Medicine and Psychology, Sapienza University, Sant'Andrea Hospital, Rome, Italy
| | - Ida Gualtieri
- Residency School in Psychiatry, Faculty of Medicine and Psychology, Sapienza University, Sant'Andrea Hospital, Rome, Italy
| | - Stefano Ferracuti
- Department of Human Neuroscience, Sapienza University, Sant'Andrea Hospital, Rome, Italy
| | | | - Ilaria Cuomo
- ASL Roma 1, Istituto Penitenziario Regina Caeli, Rome, Italy
| | - Lavinia De Chiara
- Neurosciences, Mental Health, and Sensory Organs (NESMOS) Department, Faculty of Medicine and Psychology, Sapienza University, Sant'Andrea Hospital, Rome, Italy
| | - Alessio Mosca
- Neurosciences, Mental Health, and Sensory Organs (NESMOS) Department, Faculty of Medicine and Psychology, Sapienza University, Sant'Andrea Hospital, Rome, Italy
| | - Gabriele Sani
- Neurosciences, Mental Health, and Sensory Organs (NESMOS) Department, Faculty of Medicine and Psychology, Sapienza University, Sant'Andrea Hospital, Rome, Italy
| | - Paolo Girardi
- Neurosciences, Mental Health, and Sensory Organs (NESMOS) Department, Faculty of Medicine and Psychology, Sapienza University, Sant'Andrea Hospital, Rome, Italy
| | - Maurizio Pompili
- Neurosciences, Mental Health, and Sensory Organs (NESMOS) Department, Faculty of Medicine and Psychology, Sapienza University, Sant'Andrea Hospital, Rome, Italy
| | - Chiara Rapinesi
- Neurosciences, Mental Health, and Sensory Organs (NESMOS) Department, Faculty of Medicine and Psychology, Sapienza University, Sant'Andrea Hospital, Rome, Italy
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Albert U, Marazziti D, Di Salvo G, Solia F, Rosso G, Maina G. A Systematic Review of Evidence-based Treatment Strategies for Obsessive- compulsive Disorder Resistant to first-line Pharmacotherapy. Curr Med Chem 2019; 25:5647-5661. [PMID: 29278206 DOI: 10.2174/0929867325666171222163645] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 10/19/2017] [Accepted: 11/22/2017] [Indexed: 01/04/2023]
Abstract
BACKGROUND Serotonin reuptake inhibitors (SRIs) and cognitive-behavioral psychotherapy (CBT) are first-line treatments for obsessive-compulsive disorder (OCD). However, a significant proportion of patients do not respond satisfactorily to first-choice treatments. Several options have been investigated for the management of resistant patients. OBJECTIVE The aim of the present paper is to systematically review the available literature concerning the strategies for the treatment of resistant adult patients with OCD. METHOD We first reviewed studies concerning the definition of treatment-resistant OCD; we then analyzed results of studies evaluating several different strategies in resistant patients. We limited our review to double-blind, placebo-controlled studies performed in adult patients with OCD whose resistance to a first adequate (in terms of duration and dosage) SRI trial was documented and where outcome was clearly defined in terms of decrease in Yale-Brown Obsessive-Compulsive Scale (YBOCS) scores and/or response/ remission rates (according to the YBOCS). RESULTS We identified five strategies supported by positive results in placebo-controlled randomized studies: 1) antipsychotic addition to SRIs (16 RCTs, of them 10 positive; 4 head-to-head RCTs); among antipsychotics, available RCTs examined the addition of haloperidol (butyrophenone), pimozide (diphenyl-butylpiperidine), risperidone (SDA: serotonin- dopamine antagonist), paliperidone (SDA), olanzapine (MARTA: multi-acting receptor targeted antipsychotic), quetiapine (MARTA) and aripiprazole (partial dopamine agonist); 2) CBT addition to medication (2 positive RCTs); 3) switch to intravenous clomipramine (SRI) administration (2 positive RCTs); 4) switch to paroxetine (SSRI: selective serotonin reuptake inhibitor) or venlafaxine (SNRI: serotonin-norepinephrine reuptake inhibitor) when the first trial was negative (1 positive RCT); and 5) the addition of medications other than an antipsychotic to SRIs (18 RCTs performed with several different compounds, with only 4 positive studies). CONCLUSION Treatment-resistant OCD remains a significant challenge to psychiatrists. To date, the most effective strategy is the addition of antipsychotics (aripiprazole and risperidone) to SRIs; another effective strategy is CBT addition to medications. Other strategies, such as the switch to another first-line treatment or the switch to intravenous administration are promising but need further confirmation in double-blind studies. The addition of medications other than antipsychotics remains to be studied, as several negative studies exist and positive ones need confirmation (only 1 positive study).
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Affiliation(s)
- Umberto Albert
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy; A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
| | - Donatella Marazziti
- Dipartimento di Medicina Clinica e Sperimentale, Section of Psychiatry, University of Pisa, Pisa, Italy
| | - Gabriele Di Salvo
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy; A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
| | - Francesca Solia
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy; A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
| | - Gianluca Rosso
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy; A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
| | - Giuseppe Maina
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy; A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
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Efficacy and tolerability of riluzole in psychiatric disorders: A systematic review and preliminary meta-analysis. Psychiatry Res 2019; 278:294-302. [PMID: 31254879 DOI: 10.1016/j.psychres.2019.06.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 06/16/2019] [Accepted: 06/16/2019] [Indexed: 12/15/2022]
Abstract
There is a pressing need for better pharmacological treatment strategies for psychiatric disorders as current treatment often results in partial symptom remission and unwanted side effects. A point of entry may be the glutamatergic system since glutamatergic dysregulation contributes to multiple psychiatric disorders. We evaluated the evidence from randomized controlled trials (RCTs) regarding the use of the glutamatergic drug riluzole in mental illnesses; and conducted preliminary meta-analyses of its effectiveness in treating obsessive-compulsive disorder (OCD) and depression. A systematic search was performed using PubMed (Medline), Embase, Cochrane Database of Systematic Reviews and PsycINFO. Meta-analyses were performed using Comprehensive Meta-Analysis software. Twenty-three RCTs were included for qualitative analysis and showed positive effects of adjunctive/monotherapy riluzole in patients with OCD, depression, autism, substance abuse and schizophrenia. Seven studies were also used for quantitative analysis, which revealed positive but non-significant effects on OCD and depression. Riluzole was generally well tolerated with few serious adverse events. The studies included in this systematic review were highly heterogeneous and the number of studies was limited per diagnostic condition. Moreover, few studies have examined riluzole as a single treatment. We suggest carrying out further work to provide definitive evidence for the benefit of riluzole in psychiatric illness.
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Farahzadi MH, Moazen-Zadeh E, Razaghi E, Zarrindast MR, Bidaki R, Akhondzadeh S. Riluzole for treatment of men with methamphetamine dependence: A randomized, double-blind, placebo-controlled clinical trial. J Psychopharmacol 2019; 33:305-315. [PMID: 30526230 DOI: 10.1177/0269881118817166] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Riluzole is a glutamate regulator and effective in treatment of neuropsychiatric conditions. AIMS We assessed riluzole for treatment of methamphetamine dependence. METHODS In this randomized, double-blind, placebo-controlled clinical trial, male outpatients with methamphetamine dependence who were 18-65 years old received either 50 mg riluzole ( n=34) or placebo ( n=54) twice daily for 12 weeks. Patients were excluded in case of comorbid serious medical conditions or neurologic disorders, comorbid psychiatric disorders other than methamphetamine dependence requiring specific treatment interventions, simultaneous positive urine test result for substances of abuse other than methamphetamine, smoking >3 days per week, simultaneous consumption of medications which are contraindicated or have interaction with riluzole. RESULTS Concerning primary outcomes, the cumulative mean number of attended weekly visits was higher in the riluzole arm compared with the placebo arm approaching a statistically significant difference (riluzole, median (range)=13.00 (2.00-13.00); placebo=4.00 (2.00-13.00); Mann-Whitney U=505.00, p-value=0.073), and the weekly measured rate of positive methamphetamine urine test results was significantly lower in the riluzole arm by the end of the study (riluzole=1 (5.00%), placebo=9 (45.00%), p-value=0.004). Patients in the riluzole arm experienced significantly greater improvement on all the craving, withdrawal, and depression measures regarding mean score changes from baseline to endpoint. No significant difference was detected between the two arms in terms of incidence of adverse events. CONCLUSION Future randomized clinical trials are needed to investigate proper dosing strategy in a more inclusive sample.
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Affiliation(s)
- Mohammad-Hadi Farahzadi
- 1 Department of Neuroscience and Addiction Studies, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Ehsan Moazen-Zadeh
- 2 Psychiatric Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Emran Razaghi
- 3 Department of Psychiatry, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad-Reza Zarrindast
- 1 Department of Neuroscience and Addiction Studies, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Bidaki
- 4 Research Center of Addiction and Behavioral Sciences, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Shahin Akhondzadeh
- 2 Psychiatric Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Abstract
Proven treatment strategies for obsessive-compulsive disorder (OCD) include pharmacotherapy with serotonin reuptake inhibitors and cognitive behavior therapy (CBT). A significant proportion of patients (25%-30%) fail to respond to these treatment options, necessitating the need for additional treatment options to improve treatment outcomes and quality of life in patients with OCD. Augmentation strategies using various glutamatergic agents have been explored, with diverse outcomes. The aim of this review is to give an overview of the glutamatergic system in the brain with a focus on glutamatergic abnormalities in OCD and to review the existing evidence for various glutamatergic agents used for augmentation.
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Affiliation(s)
- Karthik Sheshachala
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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Burchi E, Pallanti S. Diagnostic Issues in Early-Onset Obsessive-Compulsive Disorder and their Treatment Implications. Curr Neuropharmacol 2019; 17:672-680. [PMID: 29701156 PMCID: PMC7059152 DOI: 10.2174/1570159x16666180426151746] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 03/16/2018] [Accepted: 04/24/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The lifespan approach and recent shift in the conceptualization of Obsessive- Compulsive Disorder (OCD) promoted by the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM5) along with novel insights into the pathogenesis of this heterogeneous disorder are driving the development of new outcome measures and new treatments for a disease that, on the other hand, is characterized by high rates of refractoriness. OBJECTIVE AND METHODS The aim of this review is to provide a discussion of the translational evidence about Early Onset OCD (EO) in compliance with a neurodevelopmental and RdoC perspective. RESULTS AND CONCLUSION EO might be considered the neurodevelopmental subtype of OCD. Indeed there is evidence that different clusters of symptoms and dimensions at an early stage predict different trajectories in phenotype and that distinct neurocircuit pathways underpin the progression of the disorder. Despite the development of high refractoriness in the course of the disorder, evidence suggests that EO may be particularly treatment responsive in the early stages, thus showing the need for early recognition and additional recovery oriented studies in this subgroup. Consistent with the neurodevelopmental perspective, immunity and glutamate neurotransmission are emerging as novel pathways for parsing out the neurobiology of OCD, the EO form, in particular, supporting the implementation of new multisystemic models of the OCD phenotype. Brain connectivity patterns, immune and microbiome profiles are standing out as promising areas for biomarkers with the potential for targeted personalized therapies in EO.
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Affiliation(s)
- Elisabetta Burchi
- Address correspondence to this author at the Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine and Montefiore Medical Center 111 East 210th street, Bronx, NY, 10467, USA;, Tel: 929-308-6669; E mail:
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Grassi G, Pallanti S. Current and up-and-coming pharmacotherapy for obsessive-compulsive disorder in adults. Expert Opin Pharmacother 2018; 19:1541-1550. [PMID: 30321070 DOI: 10.1080/14656566.2018.1528230] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Only 40-60% of obsessive-compulsive patients respond to first line treatments, such as selective serotonin reuptake inhibitors (SSRIs) and cognitive-behavioral therapy. Several second-line treatments have been investigated in the last two decades, and most of them seem to work, at least in a subset of patients. However, since there is still a lack of treatment predictors, the treatment of obsessive-compulsive disorder (OCD) is still empirical and non-evidence based. AREAS COVERED In this paper, we review current and up-and-coming pharmacotherapy for OCD in adults, focusing on two emerging fields of research, inflammation and glutamate systems, since they have attracted the greatest attention in recent years in OCD pharmacological research. EXPERT OPINION Most of the investigated second-line agents seem to work at least in a subset of patients with OCD. These results raise an open question: what works for who? In our opinion, this question should be answered in a precision medicine perspective or, in other words, individualizing diagnostic processes and treatment approaches. In a precision medicine approach, OCD treatment should be sub-type specific, phase specific, multimodal and sequential, and, more importantly, dimensional.
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Affiliation(s)
- Giacomo Grassi
- a Department of Neuroscience, Psychology, Drug Research and Child Health, Neurofarba , University of Florence , Florence , Italy.,b Institute of Neuroscience , Florence , Italy
| | - Stefano Pallanti
- b Institute of Neuroscience , Florence , Italy.,c Department of Psychiatry and Behavioral Science , Stanford University Medical Center , Stanford , CA , USA
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A Randomized Placebo-Controlled Cross-Over Pilot Study of Riluzole for Drug-Refractory Irritability in Autism Spectrum Disorder. J Autism Dev Disord 2018; 48:3051-3060. [DOI: 10.1007/s10803-018-3562-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Hoffman KL, Cano-Ramírez H. Lost in translation? A critical look at the role that animal models of obsessive compulsive disorder play in current drug discovery strategies. Expert Opin Drug Discov 2017; 13:211-220. [DOI: 10.1080/17460441.2018.1417379] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Kurt Leroy Hoffman
- Centro de Investigación en Reproducción Animal, CINVESTAV-Universidad Autónoma de Tlaxcala, Tlaxcala, México
| | - Hugo Cano-Ramírez
- Centro de Investigación en Reproducción Animal, CINVESTAV-Universidad Autónoma de Tlaxcala, Tlaxcala, México
- Doctorado en Ciencias Biológicas, Universidad Autónoma de Tlaxcala, Tlaxcala, México
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Grant P, Farmer C, Song J, Kish T, Swedo S. Riluzole Serum Concentration in Pediatric Patients Treated for Obsessive-Compulsive Disorder. J Clin Psychopharmacol 2017; 37:713-716. [PMID: 29045303 PMCID: PMC5679444 DOI: 10.1097/jcp.0000000000000797] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE/BACKGROUND The goals of this study were to determine whether pediatric serum concentration of riluzole is similar to that observed in adults and to determine whether riluzole serum concentration is associated with adverse effects or efficacy in children and adolescents with treatment-refractory obsessive-compulsive disorder. METHODS/PROCEDURES Data were drawn from previously published studies: 1 open-label trial and 1 randomized controlled trial with an open-label extension phase. Serum was drawn at 24, 36, and 52 weeks in 37 patients who were taking approximately 100 mg riluzole daily (mean dose at 24 weeks, 99 ± 28 mg). FINDINGS/RESULTS Across all samples, serum riluzole concentration ranged from 7 to 963 ng/mL. At week 24 (n = 37), the median concentration was 76 ng/mL (interquartile range, 53-172 ng/mL). Within-patient concentration was relatively stable. One subject who had the highest serum concentration levels during the study developed pancreatitis after exiting the study. The patient had recently added fluvoxamine to the riluzole regimen. Controlling for concomitant fluvoxamine (in 6 participants) and time of draw, serum riluzole concentration was not associated with obsessive-compulsive disorder symptom severity, nor was it associated with adverse effect profile. IMPLICATIONS/CONCLUSIONS The dose of riluzole used in these pediatric subjects seems to have achieved serum concentration levels similar to those observed in adults. However, as previously reported in adults, the serum concentration had no discernable relationship to efficacy or adverse effects.
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Affiliation(s)
- Paul Grant
- From the Section on Behavioral Pediatrics, National Institute of Mental Health, Bethesda, MD
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Albanna A, Bazaid K, Azeem MW. Obsessive-Compulsive Disorder in Children and Adolescents: An Overview. Psychiatr Ann 2017. [DOI: 10.3928/00485713-20170908-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Aripiprazole and Riluzole treatment alters behavior and neurometabolites in young ADHD rats: a longitudinal 1H-NMR spectroscopy study at 11.7T. Transl Psychiatry 2017; 7:e1189. [PMID: 28763063 PMCID: PMC5611734 DOI: 10.1038/tp.2017.167] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 05/20/2017] [Accepted: 05/30/2017] [Indexed: 01/13/2023] Open
Abstract
Attention deficit hyperactivity disorder (ADHD), Tourette syndrome (TS) as well as obsessive compulsive disorder (OCD) are co-occurring neurodevelopmental diseases that share alterations of frontocortical neurometabolites. In this longitudinal study we investigated the behavioral and neurochemical effects of aripiprazole and riluzole treatment in juvenile spontaneously hypertensive rats (SHR), a model for ADHD. For neurochemical analysis we employed in vivo magnetic resonance spectroscopy (MRS). Spectra from voxels located at the central striatum and prefrontal cortex were acquired postnatally from day 35 to 50. In the SHR strain only, treatments reduced repetitive grooming and climbing behavior. The absolute quantification of cerebral metabolites in vivo using localized 1H-MRS at 11.7T showed significant alterations in SHR rats compared to controls (including glutamine, aspartate and total NAA). In addition, drug treatment reduced the majority of the detected metabolites (glutamate and glutamine) in the SHR brain. Our results indicate that the drug treatments might influence the hypothesized 'hyperactive' state of the cortico-striatal-thalamo-cortical circuitries of the SHR strain. Furthermore, we could show that behavioral changes correlate with brain region-specific alterations in neurometabolite levels in vivo. These findings should serve as reference for animal studies and for the analysis of neurometabolites in selected human brain regions to further define neurochemical alterations in neuropsychiatric diseases.
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Ajram LA, Horder J, Mendez MA, Galanopoulos A, Brennan LP, Wichers RH, Robertson DM, Murphy CM, Zinkstok J, Ivin G, Heasman M, Meek D, Tricklebank MD, Barker GJ, Lythgoe DJ, Edden RAE, Williams SC, Murphy DGM, McAlonan GM. Shifting brain inhibitory balance and connectivity of the prefrontal cortex of adults with autism spectrum disorder. Transl Psychiatry 2017; 7:e1137. [PMID: 28534874 PMCID: PMC5534939 DOI: 10.1038/tp.2017.104] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 04/10/2017] [Indexed: 02/02/2023] Open
Abstract
Currently, there are no effective pharmacologic treatments for the core symptoms of autism spectrum disorder (ASD). There is, nevertheless, potential for progress. For example, recent evidence suggests that the excitatory (E) glutamate and inhibitory (I) GABA systems may be altered in ASD. However, no prior studies of ASD have examined the 'responsivity' of the E-I system to pharmacologic challenge; or whether E-I modulation alters abnormalities in functional connectivity of brain regions implicated in the disorder. Therefore, we used magnetic resonance spectroscopy ([1H]MRS) to measure prefrontal E-I flux in response to the glutamate and GABA acting drug riluzole in adult men with and without ASD. We compared the change in prefrontal 'Inhibitory Index'-the GABA fraction within the pool of glutamate plus GABA metabolites-post riluzole challenge; and the impact of riluzole on differences in resting-state functional connectivity. Despite no baseline differences in E-I balance, there was a significant group difference in response to pharmacologic challenge. Riluzole increased the prefrontal cortex inhibitory index in ASD but decreased it in controls. There was also a significant group difference in prefrontal functional connectivity at baseline, which was abolished by riluzole within the ASD group. Our results also show, for we believe the first time in ASD, that E-I flux can be 'shifted' with a pharmacologic challenge, but that responsivity is significantly different from controls. Further, our initial evidence suggests that abnormalities in functional connectivity can be 'normalised' by targeting E-I, even in adults.
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Affiliation(s)
- L A Ajram
- Department of Forensic and Neurodevelopmental Sciences, The Sackler Centre for Translational Neurodevelopment, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - J Horder
- Department of Forensic and Neurodevelopmental Sciences, The Sackler Centre for Translational Neurodevelopment, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - M A Mendez
- Department of Forensic and Neurodevelopmental Sciences, The Sackler Centre for Translational Neurodevelopment, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- Behavioural and Developmental Psychiatry Clinical Academic Group, South London and Maudsley NHS Trust, London, UK
| | - A Galanopoulos
- Department of Forensic and Neurodevelopmental Sciences, The Sackler Centre for Translational Neurodevelopment, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- Behavioural and Developmental Psychiatry Clinical Academic Group, South London and Maudsley NHS Trust, London, UK
| | - L P Brennan
- Department of Forensic and Neurodevelopmental Sciences, The Sackler Centre for Translational Neurodevelopment, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- Behavioural and Developmental Psychiatry Clinical Academic Group, South London and Maudsley NHS Trust, London, UK
| | - R H Wichers
- Department of Forensic and Neurodevelopmental Sciences, The Sackler Centre for Translational Neurodevelopment, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- Behavioural and Developmental Psychiatry Clinical Academic Group, South London and Maudsley NHS Trust, London, UK
| | - D M Robertson
- Behavioural and Developmental Psychiatry Clinical Academic Group, South London and Maudsley NHS Trust, London, UK
| | - C M Murphy
- Department of Forensic and Neurodevelopmental Sciences, The Sackler Centre for Translational Neurodevelopment, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- Behavioural and Developmental Psychiatry Clinical Academic Group, South London and Maudsley NHS Trust, London, UK
| | - J Zinkstok
- Behavioural and Developmental Psychiatry Clinical Academic Group, South London and Maudsley NHS Trust, London, UK
| | - G Ivin
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
| | - M Heasman
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
| | - D Meek
- Behavioural and Developmental Psychiatry Clinical Academic Group, South London and Maudsley NHS Trust, London, UK
| | - M D Tricklebank
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - G J Barker
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - D J Lythgoe
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - R A E Edden
- Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - S C Williams
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - D G M Murphy
- Department of Forensic and Neurodevelopmental Sciences, The Sackler Centre for Translational Neurodevelopment, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- Behavioural and Developmental Psychiatry Clinical Academic Group, South London and Maudsley NHS Trust, London, UK
| | - G M McAlonan
- Department of Forensic and Neurodevelopmental Sciences, The Sackler Centre for Translational Neurodevelopment, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- Behavioural and Developmental Psychiatry Clinical Academic Group, South London and Maudsley NHS Trust, London, UK
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Vloet TD, Herpertz-Dahlmann B, Simons M. [New developments in the psychotherapeutic and pharmacological treatment of pediatric obsessivecompulsive disorder]. ZEITSCHRIFT FUR KINDER- UND JUGENDPSYCHIATRIE UND PSYCHOTHERAPIE 2017; 45:9-22. [PMID: 27299378 DOI: 10.1024/1422-4917/a000445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Den Goldstandard in der Behandlung von Zwangsstörungen im Kindes- und Jugendalter stellen die kognitiv-behaviorale Therapie sowie die Medikation mit selektiven Serotonin-Wiederaufnahmehemmern dar. In den letzten Jahren wurden vermehrt auch alternative psychotherapeutische und v. a. psychopharmakologische Behandlungsstrategien untersucht, die möglicherweise bei therapieresistenten Zwangsstörungen erfolgreich sein könnten. Die vorliegende Übersichtsarbeit fasst diese neuen Entwicklungen zusammen, wobei ein Schwerpunkt auf expositionsbezogene psychotherapeutische bzw. pharmakologische Ansätze im glutamatergen System gelegt wurde. Hinsichtlich neuer pharmakologischer Behandlungsoptionen bei Kindern und Jugendlichen unterstreicht die derzeitige Datenlage, v. a. im Hinblick auf den Grad der nachgewiesenen Evidenz sowie mögliche unerwünschte Nebenwirkungen, die Bedeutung einer optimal durchgeführten Kombinationstherapie. Dabei kann diese einer Monotherapie mit kognitiv-behavioraler Therapie im Einzelfall überlegen sein. Eine grundsätzliche Überlegenheit der Kombinationstherapie ist derzeit allerdings nicht nachgewiesen.
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Affiliation(s)
- Timo D Vloet
- 1 Klinik für Psychiatrie, Psychosomatik und Psychotherapie des Kindes- und Jugendalters, Universitätsklinikum der RWTH Aachen
- 2 Lehr- und Forschungsgebiet Klinische Neuropsychologie des Kindes- und Jugendalters an der Klinik für Psychiatrie, Psychosomatik und Psychotherapie des Kindes und Jugendalters, Universitätsklinikum der RWTH Aachen
| | - Beate Herpertz-Dahlmann
- 1 Klinik für Psychiatrie, Psychosomatik und Psychotherapie des Kindes- und Jugendalters, Universitätsklinikum der RWTH Aachen
| | - Michael Simons
- 1 Klinik für Psychiatrie, Psychosomatik und Psychotherapie des Kindes- und Jugendalters, Universitätsklinikum der RWTH Aachen
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Marinova Z, Chuang DM, Fineberg N. Glutamate-Modulating Drugs as a Potential Therapeutic Strategy in Obsessive-Compulsive Disorder. Curr Neuropharmacol 2017; 15:977-995. [PMID: 28322166 PMCID: PMC5652017 DOI: 10.2174/1570159x15666170320104237] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 12/27/2016] [Accepted: 03/15/2017] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Obsessive-compulsive disorder (OCD) is a mental disease commonly associated with severe distress and impairment of social functioning. Serotonin reuptake inhibitors and/or cognitive behavioural therapy are the therapy of choice, however up to 40% of patients do not respond to treatment. Glutamatergic signalling has also been implicated in OCD. The aim of the current study was to review the clinical evidence for therapeutic utility of glutamate-modulating drugs as an augmentation or monotherapy in OCD patients. METHODS We conducted a search of the MEDLINE database for clinical studies evaluating the effect of glutamate-modulating drugs in OCD. RESULTS Memantine is the compound most consistently showing a positive effect as an augmentation therapy in OCD. Anti-convulsant drugs (lamotrigine, topiramate) and riluzole may also provide therapeutic benefit to some OCD patients. Finally, ketamine may be of interest due to its potential for a rapid onset of action. CONCLUSION Further randomized placebo-controlled trials in larger study populations are necessary in order to draw definitive conclusions on the utility of glutamate-modulating drugs in OCD. Furthermore, genetic and epigenetic factors, clinical symptoms and subtypes predicting treatment response to glutamate-modulating drugs need to be investigated systematically.
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Affiliation(s)
- Zoya Marinova
- Department of Psychosomatic Medicine, Clinic Barmelweid, Barmelweid, Switzerland
| | - De-Maw Chuang
- National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland, United States
| | - Naomi Fineberg
- Hertfordshire Partnership University NHS Foundation Trust and University of Hertfordshire, Welwyn Garden City, AL8 6HG, United Kingdom
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Averill LA, Purohit P, Averill CL, Boesl MA, Krystal JH, Abdallah CG. Glutamate dysregulation and glutamatergic therapeutics for PTSD: Evidence from human studies. Neurosci Lett 2016; 649:147-155. [PMID: 27916636 DOI: 10.1016/j.neulet.2016.11.064] [Citation(s) in RCA: 118] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 11/18/2016] [Accepted: 11/30/2016] [Indexed: 12/20/2022]
Abstract
Posttraumatic stress disorder (PTSD) is a chronic and debilitating psychiatric disorder afflicting millions of individuals across the world. While the availability of robust pharmacologic interventions is quite lacking, our understanding of the putative neurobiological underpinnings of PTSD has significantly increased over the past two decades. Accumulating evidence demonstrates aberrant glutamatergic function in mood, anxiety, and trauma-related disorders and dysfunction in glutamate neurotransmission is increasingly considered a cardinal feature of stress-related psychiatric disorders including PTSD. As part of a PTSD Special Issue, this mini-review provides a concise discussion of (1) evidence of glutamatergic abnormalities in PTSD, with emphasis on human subjects data; (2) glutamate-modulating agents as potential alternative pharmacologic treatments for PTSD; and (3) selected gaps in the literature and related future directions.
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Affiliation(s)
- Lynnette A Averill
- Clinical Neurosciences Division, United States Department of Veterans Affairs, National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA; Department of Psychiatry, Yale University School of Medicine, 300 George Street, Suite 901, New Haven, CT, 06511, USA.
| | - Prerana Purohit
- Clinical Neurosciences Division, United States Department of Veterans Affairs, National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA; Department of Psychiatry, Yale University School of Medicine, 300 George Street, Suite 901, New Haven, CT, 06511, USA
| | - Christopher L Averill
- Clinical Neurosciences Division, United States Department of Veterans Affairs, National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA; Department of Psychiatry, Yale University School of Medicine, 300 George Street, Suite 901, New Haven, CT, 06511, USA
| | - Markus A Boesl
- Clinical Neurosciences Division, United States Department of Veterans Affairs, National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA; Department of Psychiatry, Yale University School of Medicine, 300 George Street, Suite 901, New Haven, CT, 06511, USA
| | - John H Krystal
- Clinical Neurosciences Division, United States Department of Veterans Affairs, National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA; Department of Psychiatry, Yale University School of Medicine, 300 George Street, Suite 901, New Haven, CT, 06511, USA
| | - Chadi G Abdallah
- Clinical Neurosciences Division, United States Department of Veterans Affairs, National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA; Department of Psychiatry, Yale University School of Medicine, 300 George Street, Suite 901, New Haven, CT, 06511, USA
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Esalatmanesh S, Abrishami Z, Zeinoddini A, Rahiminejad F, Sadeghi M, Najarzadegan MR, Shalbafan MR, Akhondzadeh S. Minocycline combination therapy with fluvoxamine in moderate-to-severe obsessive-compulsive disorder: A placebo-controlled, double-blind, randomized trial. Psychiatry Clin Neurosci 2016; 70:517-526. [PMID: 27488081 DOI: 10.1111/pcn.12430] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 07/16/2016] [Accepted: 07/31/2016] [Indexed: 01/12/2023]
Abstract
AIM Several lines of evidence implicate glutamatergic dysfunction in the pathophysiology of obsessive-compulsive disorder (OCD), presenting this neurotransmitter as a target for the development of novel pharmacotherapy. The objective of this study was to assess the efficacy of minocycline as an augmentative agent to fluvoxamine in the treatment of patients with OCD. METHODS One hundred and two patients with the diagnosis of moderate-to-severe OCD were recruited to this study. A randomized double-blind trial was designed and patients received either L-carnosine or placebo as adjuvant to fluvoxamine for 10 weeks. The patients randomly received either minocycline 100 mg twice per day or placebo for 10 weeks. All patients received fluvoxamine (100 mg/day) for the first 4 weeks, followed by 200 mg/day for the rest of the trial, regardless of their treatment groups. Participants were evaluated using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). The main outcome measure was to assess the efficacy of minocycline in improving the OCD symptoms. RESULTS General linear model repeated measures demonstrated significant effect for time × treatment interaction on the Y-BOCS total scores, F(1.49, 137.93) = 7.1, P = 0.003, and Y-BOCS Obsession subscale score, F(1.54, 141.94) = 9.72, P = 0.001, and near significant effect for the Y-BOCS Compulsion subscale score, F(1.27, 117.47) = 2.92, P = 0.08. A significantly greater rate of partial and complete response was observed in the minocycline group (P < 0.001). The frequency of side-effects was not significantly different between the treatment arms. CONCLUSION The results of this study suggest that minocycline could be a tolerable and effective adjuvant in the management of patients with OCD.
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Affiliation(s)
- Sophia Esalatmanesh
- Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Zoha Abrishami
- Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Atefeh Zeinoddini
- Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Rahiminejad
- Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Majid Sadeghi
- Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Mohammad-Reza Shalbafan
- Mental Health Research Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Shahin Akhondzadeh
- Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Grabb MC, Gobburu JVS. Challenges in developing drugs for pediatric CNS disorders: A focus on psychopharmacology. Prog Neurobiol 2016; 152:38-57. [PMID: 27216638 DOI: 10.1016/j.pneurobio.2016.05.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 05/05/2016] [Accepted: 05/08/2016] [Indexed: 02/03/2023]
Abstract
Many psychiatric and behavioral disorders manifest in childhood (attention deficit hyperactivity disorder, obsessive compulsive disorder, anxiety, depression, schizophrenia, autism spectrum disorder, etc.) and the opportunity for intervening early may attenuate full development of the disorder and lessen long term disability. Yet, pediatric drug approvals for CNS indications are limited, and pediatric testing generally occurs only after establishing adult efficacy, more as an afterthought rather than with the initial goal of developing the medication for a pediatric CNS indication. With pharmaceutical companies decreasing funding of their neuroscience research divisions overall, the prospects for moving promising investigational drugs forward into pediatrics will only decline. The goal of this review is to highlight important challenges around pediatric drug development for psychiatric disorders, specifically during clinical development, and to present opportunities for filling these gaps, using new strategies for de-risking investigational drugs in new clinical trial designs/models. We will first present the current trends in pediatric drug efficacy testing in academic research and in industry trials, we will then discuss the regulatory landscape of pediatric drug testing, including policies intended to support and encourage more testing. Obstacles that remain will then be presented, followed by new designs, funding opportunities and considerations for testing investigational drugs safely.
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Affiliation(s)
- Margaret C Grabb
- National Institute of Mental Health, NIH, Rockville, MD, United States.
| | - Jogarao V S Gobburu
- School of Pharmacy University of Maryland, Baltimore, MD, United States; School of Medicine University of Maryland, Baltimore, MD, United States
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Khalkhali M, Aram S, Zarrabi H, Kafie M, Heidarzadeh A. Lamotrigine Augmentation Versus Placebo in Serotonin Reuptake Inhibitors-Resistant Obsessive-Compulsive Disorder: A Randomized Controlled Trial. IRANIAN JOURNAL OF PSYCHIATRY 2016; 11:104-14. [PMID: 27437007 PMCID: PMC4947218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Serotonin reuptake inhibitors are frequently used in first-line treatments for patients with obsessive-compulsive disorder. Nevertheless, many of these patients do not respond well to initial therapy. The hypothesis of glutamatergic dysfunction in specific brain regions has been proposed in the pathophysiology of obsessive-compulsive disorder. This study was designed to evaluate the possible efficacy of lamotrigine, a glutamatergic agent in Serotonin reuptake inhibitors-resistant patients with obsessive-compulsive disorder. METHOD This study was a 12-week, double blind, randomized, placebo-controlled trial of adjunctive fixed-doses of lamotrigine (100 mg) to Serotonin reuptake inhibitors therapy in obsessive-compulsive disorder. Eligible subjects who had a total Y-BOCS of 21 or above were randomly assigned to receive adjunctive treatment with either lamotrigine (n = 26), or placebo (n = 27). Response to lamotrigine was defined as clinical improvement (>25% decrease in the total Y-BOCS score), which was administered at weeks 0, 8 and 12. RESULTS At the endpoint (week 12), significant differences were observed in obsession, compulsion, and total Y-BOCS scores comparing lamotrigine to placebo (P = 0.01, 0.005 and 0.007 respectively). The mean reduction in obsession, compulsion and total scores in lamotrigine group was about 4.15, 4.50 and 8.73, respectively. Similarly, the mean reductions in the placebo group were 2.52, 2.56 and 5.07. Effect sizes for efficacy measureswerecalculatedbyCohen'sd, and it was calculated as 0.54 for the total YBOCS. CONCLUSION Our findings provide evidence that this augmentation is well tolerated and may be an effective strategy for patients with refractory obsessive-compulsive disorder.
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Affiliation(s)
| | - Setareh Aram
- Department of Psychiatry, Guilan University of Medical Sciences, Rasht, Iran.
| | - Homa Zarrabi
- Department of Psychiatry, Guilan University of Medical Sciences, Rasht, Iran.
| | - Moosa Kafie
- Department of Psychology, Guilan University, Rasht, Iran.
| | - Abtin Heidarzadeh
- Department of Community Medicine, Guilan University of Medical Sciences, Rasht, Iran.
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Pittenger C. Glutamatergic agents for OCD and related disorders. CURRENT TREATMENT OPTIONS IN PSYCHIATRY 2015; 2:271-283. [PMID: 26301176 PMCID: PMC4540409 DOI: 10.1007/s40501-015-0051-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Pharmacotherapy remains inadequate for many patients with OCD; there is an urgent need for alternative pharmacological strategies. Convergent evidence suggests imbalance in glutamate, the brain's primary excitatory neurotransmitter, in some patients. This has motivated interest in glutamate modulators in patients who are unresponsive to standard pharmacotherapeutic approaches. While no glutamate modulator can be considered proven as an efficacious treatment of OCD, promising suggestions of benefit have been reported for memantine and riluzole. The evidence is thinner for N-acetylcysteine, but this agent's low cost and benign side effect profile make it a reasonable consideration in certain patients. Intriguing research on D-cycloserine and ketamine suggest potential benefit as well. It is notable that these agents all work by different, and in some cases opposite, mechanisms; this suggests that we have much to learn about the role of glutamate dysregulation in the etiology of OCD, and of glutamate modulators in its treatment.
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Affiliation(s)
- Christopher Pittenger
- Child Study Center Yale University 34 Park Street, W315 New Haven, CT 06519 203-974-7675 (phone) 203-974-7805 (fax)
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Van Ameringen M, Patterson B. Topiramate augmentation in a patient with obsessive-compulsive disorder. J Psychiatry Neurosci 2015; 40:E31-2. [PMID: 26290064 PMCID: PMC4543099 DOI: 10.1503/jpn.150100] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Michael Van Ameringen
- From the MacAnxiety Research Centre, McMaster University, and Hamilton Health Sciences, Hamilton, Ont., Canada
| | - Beth Patterson
- From the MacAnxiety Research Centre, McMaster University, and Hamilton Health Sciences, Hamilton, Ont., Canada
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Pittenger C, Bloch MH, Wasylink S, Billingslea E, Simpson R, Jakubovski E, Kelmendi B, Sanacora G, Coric V. Riluzole augmentation in treatment-refractory obsessive-compulsive disorder: a pilot randomized placebo-controlled trial. J Clin Psychiatry 2015; 76. [PMID: 26214725 PMCID: PMC4560666 DOI: 10.4088/jcp.14m09123] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Obsessive-compulsive disorder (OCD) affects approximately 2.5% of the population and is associated with significant morbidity. Many patients receive little benefit from the best available treatments, and even those who do respond often suffer from significant residual symptoms. Convergent evidence suggests that abnormalities in glutamate homeostasis and neurotransmission may contribute to OCD and that glutamate-modulating medications may be of benefit in patients whose symptoms are refractory to standard interventions. Small open-label trials of augmentation of serotonin reuptake inhibitor (SRI) pharmacotherapy with the glutamate modulator riluzole have suggested benefit in adults with refractory symptoms. We report a pilot randomized placebo-controlled trial of riluzole augmentation of ongoing SRI treatment in SRI-refractory patients. METHOD Outpatients (n = 27) and inpatients (n = 11) with DSM-IV OCD on stable SRI pharmacotherapy were randomized between November 2006 and December 2012 to receive riluzole 50 mg or placebo twice a day and followed for 12 weeks after a 2-week placebo lead-in phase. RESULTS Riluzole was well tolerated; 1 patient experienced moderate nausea, but none discontinued treatment due to side effects. While there was nominally greater Y-BOCS improvement in the riluzole group (our primary outcome) compared to placebo, it did not reach statistical significance. In the outpatient subsample, a trend suggesting benefit from riluzole augmentation for obsessions (P = .056, 2-tailed, uncorrected) was found in a secondary analysis. Among outpatients, more achieved at least a partial response (> 25% improvement) with riluzole than with placebo (P = .02 in a secondary analysis). CONCLUSIONS Riluzole may be of benefit to a subset of patients. Larger samples would be required to detect effects of the order suggested by the nominal improvement in our outpatient subsample. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00523718.
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Affiliation(s)
| | - Michael H. Bloch
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT,Yale Child Study Center, Yale University School of Medicine, New Haven, CT
| | - Suzanne Wasylink
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT
| | - Eileen Billingslea
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT
| | - Ryan Simpson
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT
| | - Ewgeni Jakubovski
- Yale Child Study Center, Yale University School of Medicine, New Haven, CT
| | - Ben Kelmendi
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT
| | - Gerard Sanacora
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT
| | - Vladimir Coric
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT
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Evidence-Based Treatments in Treatment-Naïve and Treatment-Resistant Pediatric Obsessive-Compulsive Disorder. Curr Behav Neurosci Rep 2015. [DOI: 10.1007/s40473-015-0047-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Abstract
Established treatments for obsessive-compulsive disorder (OCD) are of benefit in approximately 3 of every 4 patients, but refractory disease remains distressingly common, and many treatment responders continue to experience considerable morbidity. This motivates a search for new insights into pathophysiology that may inform novel treatment strategies. Much recent work has focused on the neurotransmitter glutamate. Several lines of neurochemical and genetic evidence suggests that glutamate dysregulation may contribute to OCD, although much remains unclear. The off-label use of a number of pharmacological agents approved for other indications has been investigated in refractory OCD. We summarize investigations of memantine, riluzole, ketamine, D-cycloserine, glycine, N-acetylserine, topiramate, and lamotrigine. Evidence exists for benefit from each of these in some patients; though none has been proven effective with sufficient clarity to be considered part of standard care, these agents are options in individuals whose symptoms are refractory to better-established therapeutic strategies.
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Affiliation(s)
- Christopher Pittenger
- Departments of Psychiatry and Psychology, Child Study Center, and Interdepartmental Neuroscience Program, Yale University School of Medicine
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Fineberg NA, Reghunandanan S, Simpson HB, Phillips KA, Richter MA, Matthews K, Stein DJ, Sareen J, Brown A, Sookman D. Obsessive-compulsive disorder (OCD): Practical strategies for pharmacological and somatic treatment in adults. Psychiatry Res 2015; 227:114-25. [PMID: 25681005 DOI: 10.1016/j.psychres.2014.12.003] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 11/26/2014] [Accepted: 12/04/2014] [Indexed: 12/18/2022]
Abstract
This narrative review gathers together a range of international experts to critically appraise the existing trial-based evidence relating to the efficacy and tolerability of pharmacotherapy for obsessive compulsive disorder in adults. We discuss the diagnostic evaluation and clinical characteristics followed by treatment options suitable for the clinician working from primary through to specialist psychiatric care. Robust data supports the effectiveness of treatment with selective serotonin reuptake inhibitors (SSRIs) and clomipramine in the short-term and the longer-term treatment and for relapse prevention. Owing to better tolerability, SSRIs are acknowledged as the first-line pharmacological treatment of choice. For those patients for whom first line treatments have been ineffective, evidence supports the use of adjunctive antipsychotic medication, and some evidence supports the use of high-dose SSRIs. Novel compounds are also the subject of active investigation. Neurosurgical treatments, including ablative lesion neurosurgery and deep brain stimulation, are reserved for severely symptomatic individuals who have not experienced sustained response to both pharmacological and cognitive behavior therapies.
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Affiliation(s)
- Naomi A Fineberg
- Highly Specialized Obsessive Compulsive and Related Disorders Service, Hertfordshire Partnership University NHS Foundation Trust, Rosanne House,Parkway ,Welwyn Garden City, Hertfordshire, AL8 6HG, UK; Postgraduate Medical School, University of Hertfordshire, College Lane, Hatfield, UK; University of Cambridge School of Clinical Medicine, Addenbrooke׳s Hospital, Box 189, Cambridge CB2 2QQ, UK.
| | - Samar Reghunandanan
- Highly Specialized Obsessive Compulsive and Related Disorders Service, Hertfordshire Partnership University NHS Foundation Trust, Rosanne House,Parkway ,Welwyn Garden City, Hertfordshire, AL8 6HG, UK
| | - Helen B Simpson
- College of Physicians and Surgeons at Columbia University, New York, NY, USA; Anxiety Disorders Clinic and the Centre for OCD and Related Disorders at the New York State Psychiatric Institute, New York, NY, USA
| | - Katharine A Phillips
- Rhode Island Hospital and the Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Margaret A Richter
- Frederick W. Thompson Anxiety Disorders Centre, Sunnybrook Health Sciences Centre and Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Keith Matthews
- Division of Neuroscience, Ninewells Hospital and Medical School, University of Dundee, Dundee DD1 9SY, UK
| | - Dan J Stein
- Department of Psychiatry, University of Cape Town, Cape Town, South Africa
| | - Jitender Sareen
- Departments of Psychiatry, Psychology and Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Angus Brown
- Highly Specialized Obsessive Compulsive and Related Disorders Service, Hertfordshire Partnership University NHS Foundation Trust, Rosanne House,Parkway ,Welwyn Garden City, Hertfordshire, AL8 6HG, UK
| | - Debbie Sookman
- Obsessive Compulsive Disorder Clinic, Department of Psychology, McGill University Health Centre, and Department of Psychiatry, McGill University, Montreal, PQ, Canada
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Grados MA, Atkins EB, Kovacikova GI, McVicar E. A selective review of glutamate pharmacological therapy in obsessive-compulsive and related disorders. Psychol Res Behav Manag 2015; 8:115-31. [PMID: 25995654 PMCID: PMC4425334 DOI: 10.2147/prbm.s58601] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Glutamate, an excitatory central nervous system neurotransmitter, is emerging as a potential alternative pharmacological treatment when compared to gamma-aminobutyric acid (GABA)-, dopamine-, and serotonin-modulating treatments for neuropsychiatric conditions. The pathophysiology, animal models, and clinical trials of glutamate modulation are explored in disorders with underlying inhibitory deficits (cognitive, motor, behavioral) including obsessive–compulsive disorder, attention deficit hyperactivity disorder, Tourette syndrome, trichotillomania, excoriation disorder, and nail biting. Obsessive–compulsive disorder, attention deficit hyperactivity disorder, and grooming disorders (trichotillomania and excoriation disorder) have emerging positive data, although only scarce controlled trials are available. The evidence is less supportive for the use of glutamate modulators in Tourette syndrome. Glutamate-modulating agents show promise in the treatment of disorders of inhibition.
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Affiliation(s)
- Marco A Grados
- Division of Child and Adolescent Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Bloch MH, Storch EA. Assessment and management of treatment-refractory obsessive-compulsive disorder in children. J Am Acad Child Adolesc Psychiatry 2015; 54:251-62. [PMID: 25791142 PMCID: PMC4460245 DOI: 10.1016/j.jaac.2015.01.011] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 01/14/2015] [Accepted: 01/26/2015] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To review the assessment and treatment of treatment-refractory pediatric obsessive-compulsive disorder (OCD). METHOD A PubMed search was conducted to identify controlled trials in pediatric OCD. In addition, practice guidelines for the treatment of adults and children were further reviewed for references in treatment-refractory OCD across the lifespan. RESULTS Pharmacotherapy with selective serotonin reuptake inhibitors (SSRIs) and cognitive-behavioral therapy (CBT) were found to be effective treatments for pediatric OCD. Evidence suggests that CBT is also effective even in pediatric patients with refractory OCD symptoms. Antipsychotic augmentation, raising SSRI dosage, and several glutamate-modulating agents have some evidence of efficacy in adults with treatment-refractory OCD but have not been studied in pediatric populations. CONCLUSION Several pharmacological treatment options exist for children with refractory OCD symptoms. However, little evidence-based data exist to guide treatment for our most challenging pediatric OCD patients. Further research is needed to evaluate the efficacy/side effect profile of commonly used interventions in treatment-refractory pediatric OCD.
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Skarphedinsson G, Weidle B, Thomsen PH, Dahl K, Torp NC, Nissen JB, Melin KH, Hybel K, Valderhaug R, Wentzel-Larsen T, Compton SN, Ivarsson T. Continued cognitive-behavior therapy versus sertraline for children and adolescents with obsessive-compulsive disorder that were non-responders to cognitive-behavior therapy: a randomized controlled trial. Eur Child Adolesc Psychiatry 2015; 24:591-602. [PMID: 25239489 PMCID: PMC4419185 DOI: 10.1007/s00787-014-0613-0] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 08/27/2014] [Indexed: 11/25/2022]
Abstract
Expert guidelines recommend cognitive-behavior therapy (CBT) as a first-line treatment in pediatric obsessive-compulsive disorder (OCD) and the addition of selective serotonin reuptake inhibitors when CBT is not effective. However, the recommendations for CBT non-responders are not supported by empirical data. Our objective was to investigate the effectiveness of sertraline (SRT) versus continued CBT in children and adolescents that did not respond to an initial course of CBT. Randomized controlled trial conducted in five sites in Denmark, Sweden and Norway, 54 children and adolescents, age 7-17 years, with DSM-IV primary OCD were randomized to SRT or continued CBT for 16 weeks. These participants had been classified as non-responders to CBT following 14 weekly sessions. Primary outcomes were the CY-BOCS total score and clinical response (CY-BOCS <16). The study was a part of the Nordic Long-Term OCD Treatment Study (NordLOTS). Intent-to-treat sample included 50 participants, mean age 14.0 (SD = 2.7) and 48 (n = 24) males. Twenty-one of 28 participants (75%) completed continued CBT and 15 of 22 participants (69.2%) completed SRT. Planned pairwise comparison of the CY-BOCS total score did not reveal a significant difference between the treatments (p = .351), the response rate was 50.0% in the CBT group and 45.4% in the SRT group. The multivariate χ (2) test suggested that there were no statistically significant differences between groups (p = .727). Within-group effect sizes were large and significant across both treatments. These large within-group effect sizes suggest that continued treatment for CBT non-responders is beneficial. However, there was no significant between-group differences in SRT or continued CBT at post-treatment.
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Affiliation(s)
- Gudmundur Skarphedinsson
- Center for Child and Adolescent Mental Health, Eastern and Southern Norway, Gullhaugveien 1-3, 0484, Oslo, Norway,
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