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Maiti R, Mishra A, Srinivasan A, Mishra BR. Pharmacological augmentation of serotonin reuptake inhibitors in patients with obsessive-compulsive disorder: A network meta-analysis. Acta Psychiatr Scand 2023. [PMID: 37177823 DOI: 10.1111/acps.13568] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/17/2023] [Accepted: 04/21/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVES The augmentation of serotonin reuptake inhibitors (SRIs) can be achieved by add-on therapy with different pharmacological agents in obsessive-compulsive disorder (OCD) for a better clinical outcome. This network meta-analysis (NMA) was conducted to evaluate and compare the effects of available augmentation agents for SRIs in OCD. METHOD The data was extracted from 59 relevant clinical trials after a literature search on MEDLINE/PubMed, Scopus, Cochrane databases and clinical trial registries. PRISMA guidelines were followed in data extraction, analysis and reporting. Random effects Bayesian NMA was done to pool the effects across the interventions for the change in Yale-Brown Obsessive-Compulsive Scale (YBOCS) scoring from baseline to the end of the study. Network graph was built, consistency model was run, node splitting analysis was performed, treatments were ranked as per SUCRA score and meta-regression was done for refractoriness to SRIs and duration of augmentation therapy as the predictor variables. RESULTS The drugs showing significant reduction in YBOCS scoring were pregabalin (MD:-8.1;95% CrI: -16, -0.43), memantine (MD:-6.2;95% CrI: -9.9, -2.3), lamotrigine (MD:-6;95% CrI: -12, -0.47), ondansetron (MD:-5.7;95% CrI: -11, -0.67), granisetron (MD:-5.6;95% CrI: -11, -0.44), aripiprazole (MD:-5.4;95% CrI:-9.1, -1.6), risperidone (MD:-3.3;95% CrI: -6.4, -0.20) and topiramate (MD:-5.3;95% CrI: -9.6, -0.97). The node-split analysis showed that direct and indirect pooled effect sizes for all comparisons were comparable. Meta-regression showed a statistically non-significant association between YBOCS score reduction with the duration of augmentation therapy, but significant with SRI-refractory status. Finally, the results were sorted based on certainty of evidence. CONCLUSION Memantine was found to be most effective augmentation agent for SRIs in OCD, followed by lamotrigine, ondansetron and granisetron with moderate certainty of evidence. The augmentation agents showed better symptom reduction in patients with SRI-refractory OCD in comparison to non-refractory OCD. PROSPERO REGISTRATION CRD42022360110.
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Affiliation(s)
- Rituparna Maiti
- Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
| | - Archana Mishra
- Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
| | - Anand Srinivasan
- Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
| | - Biswa Ranjan Mishra
- Department of Psychiatry, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
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Pittenger C, Brennan BP, Koran L, Mathews CA, Nestadt G, Pato M, Phillips KA, Rodriguez CI, Simpson HB, Skapinakis P, Stein DJ, Storch EA. Specialty knowledge and competency standards for pharmacotherapy for adult obsessive-compulsive disorder. Psychiatry Res 2021; 300:113853. [PMID: 33975093 PMCID: PMC8536398 DOI: 10.1016/j.psychres.2021.113853] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 03/01/2021] [Indexed: 12/12/2022]
Abstract
Obsessive-compulsive disorder (OCD) affects approximately one person in 40 and causes substantial suffering. Evidence-based treatments can benefit many; however, optimal treatment can be difficult to access. Diagnosis is frequently delayed, and pharmacological and psychotherapeutic interventions often fail to follow evidence-based guidelines. To ameliorate this distressing situation, the International OCD Accreditation Task Force of the Canadian Institute for Obsessive-Compulsive Disorders has developed knowledge and competency standards for specialized treatments for OCD through the lifespan. These are foundational to evidence-based practice and will form the basis for upcoming ATF development of certification/accreditation programs. Here, we present specialty standards for the pharmacological treatment of adult OCD. We emphasize the importance of integrating pharmacotherapy with clear diagnosis, appreciation of complicating factors, and evidence-based cognitive behavioral therapy. Clear evidence exists to inform first- and second-line pharmacological treatments. In disease refractory to these initial efforts, multiple strategies have been investigated, but the evidence is more equivocal. These standards summarize this limited evidence to give the specialist practitioner a solid basis on which to make difficult decisions in complex cases. It is hoped that further research will lead to development of a clear, multi-step treatment algorithm to support each step in clinical decision-making.
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Affiliation(s)
- Christopher Pittenger
- Department of Psychiatry and Yale Child Study Center, Yale University School of Medicine, New Haven, CT, United States.
| | - Brian P Brennan
- Biological Psychiatry Laboratory and Obsessive-Compulsive Disorder Institute, McLean Hospital, Belmont, MA, United States; Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Lorrin Koran
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States
| | - Carol A Mathews
- Department of Psychiatry, University of Florida, Gainesville, FL, United States
| | - Gerald Nestadt
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Michele Pato
- Institute for Genomic Health and Department of Psychiatry, SUNY Downstate College of Medicine, Brooklyn, NY, United States
| | - Katharine A Phillips
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, and Department of Psychiatry, Weill Cornell Medical College, New York, NY, United States
| | - Carolyn I Rodriguez
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, United States
| | - H Blair Simpson
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States; Office of Mental Health, Research Foundation for Mental Hygiene, New York Psychiatric Institute, New York, NY, United States
| | - Petros Skapinakis
- Department of Psychiatry, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Dan J Stein
- Department of Psychiatry and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Eric A Storch
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
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Del Casale A, Sorice S, Padovano A, Simmaco M, Ferracuti S, Lamis DA, Rapinesi C, Sani G, Girardi P, Kotzalidis GD, Pompili M. Psychopharmacological Treatment of Obsessive-Compulsive Disorder (OCD). Curr Neuropharmacol 2020; 17:710-736. [PMID: 30101713 PMCID: PMC7059159 DOI: 10.2174/1570159x16666180813155017] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 07/06/2018] [Accepted: 08/12/2018] [Indexed: 02/07/2023] Open
Abstract
Background: Obsessive-compulsive disorder (OCD) is associated with affective and cognitive symptoms causing personal distress and reduced global functioning. These have considerable societal costs due to healthcare service utilization. Objective: Our aim was to assess the efficacy of pharmacological interventions in OCD and clinical guidelines, providing a comprehensive overview of this field. Methods: We searched the PubMed database for papers dealing with drug treatment of OCD, with a specific focus on clinical guidelines, treatments with antidepressants, antipsychotics, mood stabilizers, off-label medications, and pharmacogenomics. Results: Prolonged administration of selective serotonin reuptake inhibitors (SSRIs) is most effective. Better results can be obtained with a SSRI combined with cognitive behavioral therapy (CBT) or the similarly oriented exposure and response prevention (ERP). Refractory OCD could be treated with different strategies, including a switch to another SSRI or clomipramine, or augmentation with an atypical antipsychotic. The addition of medications other than antipsychotics or intravenous antidepressant administration needs further investigation, as the evidence is inconsistent. Pharmacogenomics and personalization of therapy could reduce treatment resistance. Conclusions: SSRI/clomipramine in combination with CBT/ERP is associated with the optimal response compared to each treatment alone or to other treatments. New strategies for refractory OCD are needed. The role of pharmacogenomics could become preponderant in the coming years.
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Affiliation(s)
- Antonio Del Casale
- Department of Neuroscience, Mental Health, and Sensory Organs (NESMOS), Faculty of Medicine and Psychology, Sapienza University, Unit of Psychiatry, Sant'Andrea University Hospital, Rome, Italy
| | - Serena Sorice
- Residency School in Psychiatry, Faculty of Medicine and Psychology, Sapienza University, Unit of Psychiatry, Sant'Andrea University Hospital, Rome, Italy
| | - Alessio Padovano
- Residency School in Psychiatry, Faculty of Medicine and Psychology, Sapienza University, Unit of Psychiatry, Sant'Andrea University Hospital, Rome, Italy
| | - Maurizio Simmaco
- Department of Neuroscience, Mental Health, and Sensory Organs (NESMOS), Faculty of Medicine and Psychology, Sapienza University, Unit of Psychiatry, Sant'Andrea University Hospital, Rome, Italy
| | | | - Dorian A Lamis
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, United States
| | - Chiara Rapinesi
- Department of Neuroscience, Mental Health, and Sensory Organs (NESMOS), Faculty of Medicine and Psychology, Sapienza University, Unit of Psychiatry, Sant'Andrea University Hospital, Rome, Italy
| | - Gabriele Sani
- Department of Neuroscience, Mental Health, and Sensory Organs (NESMOS), Faculty of Medicine and Psychology, Sapienza University, Unit of Psychiatry, Sant'Andrea University Hospital, Rome, Italy
| | - Paolo Girardi
- Department of Neuroscience, Mental Health, and Sensory Organs (NESMOS), Faculty of Medicine and Psychology, Sapienza University, Unit of Psychiatry, Sant'Andrea University Hospital, Rome, Italy
| | - Georgios D Kotzalidis
- Department of Neuroscience, Mental Health, and Sensory Organs (NESMOS), Faculty of Medicine and Psychology, Sapienza University, Unit of Psychiatry, Sant'Andrea University Hospital, Rome, Italy
| | - Maurizio Pompili
- Department of Neuroscience, Mental Health, and Sensory Organs (NESMOS), Faculty of Medicine and Psychology, Sapienza University, Unit of Psychiatry, Sant'Andrea University Hospital, Rome, Italy
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Velloso P, Piccinato C, Ferrão Y, Perin EA, Cesar R, Fontenelle LF, Hounie AG, do Rosário MC. Clinical predictors of quality of life in a large sample of adult obsessive-compulsive disorder outpatients. Compr Psychiatry 2018; 86:82-90. [PMID: 30086510 DOI: 10.1016/j.comppsych.2018.07.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 07/18/2018] [Accepted: 07/20/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND OCD causes impairment in different areas of the patients' quality of life (QoL), such as sociability, family relationships, and occupational performance. The literature has emphasized the relevance of assessing QoL as a critical outcome in mental health studies. AIMS The aim of this study was to investigate sociodemographic and clinical predictors of QoL, including treatment response, in a large sample of OCD subjects. PROCEDURES 575 adult OCD outpatients were interviewed as part of the Brazilian OCD Consortium (CTOC). A smaller number of subjects (N = 143) participated on a clinical trial conducted by one of the CTOC sites. RESULTS OCD patients were more impaired in their QoL when compared to the Brazilian normative data. Obsessive-compulsive symptoms (OCS) severity had significant correlations with all Medical Outcome Short-Form questionnaire (SF-36) domains. Different OCS dimensions had specific correlations with each SF-36 domain. OCS, depression and anxiety severity significantly increased the impairment risk for the SF-36 domains. Suicidality increased the relative risks for impairment in the Role-Functioning and the Vitality domains by 51% and 17%, respectively. There was a significant improvement in some SF-36 dimensions after treatment. CONCLUSIONS QoL domains are highly compromised in OCD patients. Each SF-36 domain had distinct associations with sociodemographic and clinical variables, including OCS dimensions, suicidality and treatment response. These findings emphasize the OCD heterogeneity and the need for including QoL assessment in clinical practice and research studies.
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Affiliation(s)
- Patricia Velloso
- Child and Adolescent Psychiatry Unit (UPIA), Department of Psychiatry, Federal University of São Paulo, SP, Brazil; Obsessive-Compulsive Spectrum Disorder Research Consortium (C-TOC), Brazil.
| | - Cinthia Piccinato
- Child and Adolescent Psychiatry Unit (UPIA), Department of Psychiatry, Federal University of São Paulo, SP, Brazil; Obsessive-Compulsive Spectrum Disorder Research Consortium (C-TOC), Brazil
| | - Ygor Ferrão
- Obsessive-Compulsive Spectrum Disorder Research Consortium (C-TOC), Brazil; Department of Psychiatry, Health Sciences Federal University of Porto Alegre, Brazil
| | - Eduardo Aliende Perin
- Child and Adolescent Psychiatry Unit (UPIA), Department of Psychiatry, Federal University of São Paulo, SP, Brazil; Obsessive-Compulsive Spectrum Disorder Research Consortium (C-TOC), Brazil
| | - Raony Cesar
- Obsessive-Compulsive Spectrum Disorder Research Consortium (C-TOC), Brazil
| | - Leonardo F Fontenelle
- Obsessive-Compulsive Spectrum Disorder Research Consortium (C-TOC), Brazil; Anxiety, Obsessive, and Compulsive Research Program, Institute of Psychiatry of the Federal University of Rio de Janeiro (IPUB), Rio de Janeiro, Brazil; D'Or Institute for Research and Education (IDOR), Rio de Janeiro, Brazil; Brain and Mental Health Research Hub, Monash Institute of Cognitive and Clinical Neurosciences, MONASH University, Melbourne, Australia
| | - Ana G Hounie
- Child and Adolescent Psychiatry Unit (UPIA), Department of Psychiatry, Federal University of São Paulo, SP, Brazil; Obsessive-Compulsive Spectrum Disorder Research Consortium (C-TOC), Brazil
| | - Maria Conceição do Rosário
- Child and Adolescent Psychiatry Unit (UPIA), Department of Psychiatry, Federal University of São Paulo, SP, Brazil; Obsessive-Compulsive Spectrum Disorder Research Consortium (C-TOC), Brazil; Child Study Center at Yale University, New Haven, CT, USA.
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Uguz F. Pharmacotherapy of obsessive-compulsive disorder during pregnancy: a clinical approach. BRAZILIAN JOURNAL OF PSYCHIATRY 2016; 37:334-42. [PMID: 26692431 DOI: 10.1590/1516-4446-2015-1673] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 04/13/2015] [Indexed: 01/07/2023]
Abstract
Obsessive-compulsive disorder (OCD) is a relatively common psychiatric disorder in the perinatal period. However, specific pharmacological treatment approaches for patients with OCD during pregnancy have not been satisfactorily discussed in the literature. In addition, there are no randomized controlled studies on the treatment of this disorder during pregnancy. The present paper discusses the pharmacological treatment of OCD in the light of data on the safety of antipsychotics and serotonergic antidepressants during pregnancy and their efficacy in the non-perinatal period. Treatment decisions should be individualized because the risk-benefit profile of pharmacotherapy is an important issue in the treatment of pregnant women with any psychiatric diagnosis.
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Affiliation(s)
- Faruk Uguz
- Department of Psychiatry, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
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Abstract
OBJECTIVE To provide a clinically-focused review of the biological treatment of treatment-resistant obsessive compulsive disorder (OCD). CONCLUSIONS There is a paucity of research on how to manage OCD patients who fail to respond adequately to first line therapies. High-dose selective serotonin reuptake inhibitors (SSRIs) and clomipramine have good evidence-based data. Combinations of SSRIs have little support in clinical trials, but the combination of SSRIs and clomipramine can be helpful: careful clinical and cardiac monitoring is required. Certain adjunctive antipsychotics have a reasonable evidence base in OCD, but their use also needs to be weighed against the potential side effect burden. In patients with substantial generalised anxiety symptoms, clonazepam is worth considering. Of the other augmenting strategies, memantine and ondansetron appear useful in some cases, and are well tolerated. Topiramate might ameliorate compulsions to some degree, but it is less well tolerated. If all these strategies, along with expert psychological therapy, fail, careful consideration should be given to deep brain stimulation (DBS), which has an emerging evidence base and which can result in dramatic benefits for some individuals. For some patients, gamma radiosurgery might also still have a place.
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Affiliation(s)
- David Castle
- Professor and Chair of Psychiatry, St. Vincent's Hospital Melbourne, University of Melbourne, Melbourne, VIC, and; Adjunct Professor, Faculty of Health Sciences, Australian Catholic University, Fitzroy, VIC, Australia
| | - Peter Bosanac
- Director of Clinical Services, St Vincent's Mental Health, Fitzroy, VIC, and; Associate Professor, Department of Psychiatry, University of Melbourne, Fitzroy, VIC, Australia
| | - Susan Rossell
- Professor, Swinburne University, Melbourne, VIC, Australia
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Seibell PJ, Hamblin RJ, Hollander E. Obsessive-Compulsive Disorder: Overview and Standard Treatment Strategies. Psychiatr Ann 2015. [DOI: 10.3928/00485713-20150602-04] [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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Barton S, Karner C, Salih F, Baldwin DS, Edwards SJ. Clinical effectiveness of interventions for treatment-resistant anxiety in older people: a systematic review. Health Technol Assess 2015; 18:1-59, v-vi. [PMID: 25110830 DOI: 10.3310/hta18500] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Anxiety and related disorders include generalised anxiety disorder, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder and phobic disorders (intense fear of an object or situation). These disorders share the psychological and physical symptoms of anxiety, but each disorder has its own set of characteristic symptoms. Anxiety disorders can be difficult to recognise, particularly in older people (those aged over 65 years). Older people tend to be more reluctant to discuss mental health issues and there is the perception that older people are generally more worried than younger adults. It is estimated that between 3 and 14 out of every 100 older people have an anxiety disorder. Despite treatment, some people will continue to have symptoms of anxiety. People are generally considered to be 'resistant' or 'refractory' to treatment if they have an inadequate response or do not respond to their first treatment. Older adults with an anxiety disorder find it difficult to manage their day-to-day lives and are at an increased risk of comorbid depression, falls, physical and functional disability, and loneliness. OBJECTIVE To evaluate the effectiveness of pharmacological, psychological and alternative therapies in older adults with an anxiety disorder who have not responded, or have responded inadequately, to treatment. DATA SOURCES Electronic databases (MEDLINE, MEDLINE In-Process and Other Non-Indexed citations, EMBASE, The Cochrane Library databases, PsycINFO and Web of Science) were searched from inception to September 2013. Bibliographies of relevant systematic reviews were hand-searched to identify additional potentially relevant studies. ClinicalTrials.gov was searched for ongoing and planned studies. REVIEW METHODS A systematic review of the clinical effectiveness of treatments for treatment-resistant anxiety in older adults was carried out. RESULTS No randomised controlled trial or prospective comparative observational study was identified meeting the prespecified inclusion criteria. Therefore, it was not possible to draw any conclusions on clinical effectiveness. LIMITATIONS As no study was identified in older adults, there is uncertainty as to which treatments are clinically effective for older adults with an anxiety disorder who have not responded to prior treatment. The comprehensive methods implemented to carry out this review are a key strength of the research presented. However, this review highlights the extreme lack of research in this area, identifying no comparative studies, which is a marked limitation. CONCLUSIONS Specific studies evaluating interventions in older adults with an anxiety disorder who have not responded to first-line treatment are needed to address the lack of evidence. The lack of evidence in this area means that older adults are perhaps receiving inappropriate treatment or are not receiving a particular treatment because there is limited evidence to support its use. At this time there is scope to develop guidance on service provision and, as a consequence, to advance the standard of care received by older adults with a treatment-resistant anxiety disorder in primary and secondary care. Evaluation of the relative clinical effectiveness and acceptability of pharmacological and psychological treatment in older adults with an anxiety disorder that has not responded to first-line treatment is key future research to inform decision-making of clinicians and patients. An important consideration would be the enrolment of older adults who would be representative of older adults in general, i.e. those with multiple comorbid physical and mental disorders who might require polypharmacy. STUDY REGISTRATION The protocol for the systematic review is registered on PROSPERO (registration number CRD42013005612). FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
| | | | | | - David S Baldwin
- Faculty of Medicine, University of Southampton, Southampton, UK
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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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Abstract
Obsessive-compulsive disorder (OCD) is a common heterogeneous psychiatric disorder manifesting with obsessions and compulsions. Obsessions are intrusive, recurrent, and persistent unwanted thoughts. Compulsions are repetitive behaviors or mental acts that an individual feels driven to perform in response to the obsessions. The heterogeneity of OCD includes themes of obsessions, types of rituals, presence or absence of tics, etiology, genetics, and response to pharmacotherapy. Complications of OCD include interpersonal difficulties, unemployment, substance abuse, criminal justice issues, and physical injuries. Areas of the brain involved in the pathophysiology include the orbitofrontal cortex, anterior cingulate gyrus, and basal ganglia. Overall, OCD may be due to a malfunction in the cortico-striato-thalamo-cortical circuit in the brain. Neurotransmitters implicated in OCD include serotonin, dopamine, and glutamate. Numerous drugs such as atypical antipsychotics and dopaminergic agents can cause or exacerbate OCD symptoms. The etiology includes genetics and neurological insults. Treatment of OCD includes psychotherapy, pharmacotherapy, electroconvulsive therapy, transcranial magnetic simulation, and in extreme cases surgery. Exposure and response prevention is the most effective form of psychotherapy. Selective serotonin reuptake inhibitors (SSRIs) are the preferred pharmacotherapy. Higher doses than listed in the package insert and a longer trial are often needed for SSRIs than compared to other psychiatric disorders. Alternatives to SSRIs include clomipramine and serotonin/norepinephrine reuptake inhibitors. Treatment of resistant cases includes augmentation with atypical antipsychotics, pindolol, buspirone, and glutamate-blocking agents.
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Affiliation(s)
- Gyula Bokor
- Staff Psychiatrist, Taunton State Hospital, Taunton, MA, USA
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Arumugham SS, Reddy JYC. Augmentation strategies in obsessive–compulsive disorder. Expert Rev Neurother 2014; 13:187-202; quiz 203. [DOI: 10.1586/ern.12.160] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Jakubovski E, Diniz JB, Valerio C, Fossaluza V, Belotto-Silva C, Gorenstein C, Miguel E, Shavitt RG. Clinical predictors of long-term outcome in obsessive-compulsive disorder. Depress Anxiety 2013; 30:763-72. [PMID: 23109056 DOI: 10.1002/da.22013] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Revised: 09/26/2012] [Accepted: 09/27/2012] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The purpose of this study was to investigate demographic and clinical factors associated with the long-term outcome of obsessive-compulsive disorder (OCD). METHODS A hundred ninety-six previously untreated patients with DSM-IV criteria OCD completed a 12-week randomized open trial of group cognitive-behavioral therapy (GCBT) or fluoxetine, followed by 21 months of individualized, uncontrolled treatment, according to international guidelines for OCD treatment. OCD severity was assessed using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) at different times over the follow-up period. Demographics and several clinical variables were assessed at baseline. RESULTS Fifty percent of subjects improved at least 35% from baseline, and 21.3% responded fully (final Y-BOCS score < or = 8). Worse prognosis was associated with earlier age at onset of OCD (P = 0.045), longer duration of illness (P = 0.001) presence of at least one comorbid psychiatric disorder (P = 0.001), comorbidity with a mood disorder (P = 0.002), higher baseline Beck-Depression scores (P = 0.011), positive family history of tics (P = 0.008), and positive family history of anxiety disorders (P = 0.008). Type of initial treatment was not associated with long-term outcome. After correction for multiple testing, the presence of at least one comorbid disorder, the presence of a depressive disorder, and duration of OCD remained significant. CONCLUSIONS Patients under cognitive-behavioral or pharmacological treatment improved continuously in the long run, regardless of initial treatment modality or degree of early response, suggesting that OCD patients benefit from continuous treatment. Psychiatric comorbidity, especially depressive disorders, may impair the long-term outcome of OCD patients.
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Affiliation(s)
- Ewgeni Jakubovski
- Department of Psychology, University of Heidelberg, Heidelberg, Germany.
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Differential prefrontal gray matter correlates of treatment response to fluoxetine or cognitive-behavioral therapy in obsessive-compulsive disorder. Eur Neuropsychopharmacol 2013; 23:569-80. [PMID: 22841131 DOI: 10.1016/j.euroneuro.2012.06.014] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Revised: 06/28/2012] [Accepted: 06/30/2012] [Indexed: 11/21/2022]
Abstract
Nearly one-third of patients with obsessive-compulsive disorder (OCD) fail to respond to adequate therapeutic approaches such as serotonin reuptake inhibitors and/or cognitive-behavioral therapy (CBT). This study investigated structural magnetic resonance imaging (MRI) correlates as potential pre-treatment brain markers to predict treatment response in treatment-naïve OCD patients randomized between trials of fluoxetine or CBT. Treatment-naïve OCD patients underwent structural MRI scans before randomization to a 12-week clinical trial of either fluoxetine or group-based CBT. Voxel-based morphometry was used to identify correlations between pretreatment regional gray matter volume and changes in symptom severity on the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). Brain regional correlations of treatment response differed between treatment groups. Notably, symptom improvement in the fluoxetine treatment group (n=14) was significantly correlated with smaller pretreatment gray matter volume within the right middle lateral orbitofrontal cortex (OFC), whereas symptom improvement in the CBT treatment group (n=15) was significantly correlated with larger pretreatment gray matter volume within the right medial prefrontal cortex (mPFC). No significant a priori regional correlations of treatment response were identified as common between the two treatment groups when considering the entire sample (n=29). These findings suggest that pretreatment gray matter volumes of distinct brain regions within the lateral OFC and mPFC were differentially correlated to treatment response to fluoxetine versus CBT in OCD patients. This study further implicates the mPFC in the fear/anxiety extinction process and stresses the importance of lateral portions of the OFC in mediating fluoxetine's effectiveness in OCD. Clinical registration information: http://clinicaltrials.gov-NCT00680602.
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Fineberg NA, Reghunandanan S, Brown A, Pampaloni I. Pharmacotherapy of obsessive-compulsive disorder: evidence-based treatment and beyond. Aust N Z J Psychiatry 2013; 47:121-41. [PMID: 23125399 DOI: 10.1177/0004867412461958] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Obsessive-compulsive disorder (OCD) is a neuropsychiatric disorder associated with a significant degree of functional disability and poor quality of life. Pharmacotherapy may have a substantial impact on the course and outcome of OCD. METHOD We review the evidence supporting available strategies for the pharmacological treatment of OCD. RESULTS Selective serotonin reuptake inhibitors (SSRIs) remain the pharmacological treatment of choice and are associated with improved health-related quality of life. Discontinuation is associated with relapse and loss of quality of life, implying treatment should continue long-term. A substantial minority of patients who fail to respond to SSRI may benefit from dose elevation or adjunctive antipsychotics, though long-term trials validating the effectiveness and tolerability of these strategies are relatively lacking. CONCLUSION The pharmacological evidence-base for the treatment of OCD is becoming increasingly robust. Treatment with SSRIs and clomipramine remains uncontroversial and improvements are sustained over time. Newer compounds targeting serotonin receptor subtypes and other neurotransmitter systems are undergoing evaluation.
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Affiliation(s)
- Naomi A Fineberg
- 1Mental Health Unit, Hertfordshire Partnership Foundation Trust, Queen Elizabeth II Hospital, Welwyn Garden City, UK
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Franz AP, Paim M, Araújo RMD, Rosa VDO, Barbosa ÍM, Blaya C, Ferrão YA. Treating refractory obsessive-compulsive disorder: what to do when conventional treatment fails? TRENDS IN PSYCHIATRY AND PSYCHOTHERAPY 2013; 35:24-35. [DOI: 10.1590/s2237-60892013000100004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Obsessive-compulsive disorder (OCD) is a chronic and impairing condition. A very small percentage of patients become asymptomatic after treatment. The purpose of this paper was to review the alternative therapies available for OCD when conventional treatment fails. Data were extracted from controlled clinical studies (evidence-based medicine) published on the MEDLINE and Science Citation Index/Web of Science databases between 1975 and 2012. Findings are discussed and suggest that clinicians dealing with refractory OCD patients should: 1) review intrinsic phenomenological aspects of OCD, which could lead to different interpretations and treatment choices; 2) review extrinsic phenomenological aspects of OCD, especially family accommodation, which may be a risk factor for non-response; 3) consider non-conventional pharmacological approaches; 4) consider non-conventional psychotherapeutic approaches; and 5) consider neurobiological approaches.
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Affiliation(s)
| | - Mariana Paim
- Universidade Federal de Ciências da Saúde de Porto Alegre, Brazil
| | | | | | | | - Carolina Blaya
- Universidade Federal de Ciências da Saúde de Porto Alegre, Brazil
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Abstract
Pharmacological strategies for the treatment of obsessive-compulsive disorder (OCD) continue to develop apace but deficiencies remain. We present an updated literature review of the evidence supporting available strategies. We aim to answer key questions including: (1) What are the first-line treatments? (2) Does pharmacotherapy improve health-related quality of life? (3) How do we evaluate clinical response and relapse? (4) How long should treatment continue? (5) Can we predict treatment outcomes? (6) What is the management of treatment-refractory OCD? Selective serotonin reuptake inhibitors (SSRIs) remain the pharmacological treatment of choice for most patients and are associated with improved health-related quality of life. However, discontinuation is associated with relapse and loss of quality of life, implying treatment should continue long term. A substantial minority of patients fail to respond to SSRI. Such patients may respond to strategies such as dose elevation or adjunctive antipsychotic, although long-term trials validating the effectiveness and tolerability of these strategies are relatively lacking. Newer compounds targeting other neurotransmitter systems, such as glutamate, are undergoing evaluation.
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18
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McGuire JF, Lewin AB, Horng B, Murphy TK, Storch EA. The nature, assessment, and treatment of obsessive-compulsive disorder. Postgrad Med 2012; 124:152-65. [PMID: 22314125 DOI: 10.3810/pgm.2012.01.2528] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Obsessive-compulsive disorder (OCD) is an anxiety disorder that affects between 1% to 2% of individuals and causes considerable impairment and disability. Although > 50% of individuals experience symptom onset in childhood, symptoms can continue to develop throughout adulthood. Accurate and timely assessment of clinical presentation is critical to limit impairment and improve prognosis. Presently, there are 2 empirically supported treatments available for OCD in children and adults, namely cognitive-behavioral therapy and pharmacotherapy with serotonin reuptake inhibitors. This article provides an introduction to the phenomenology, etiology, and clinical course of OCD. Assessment practices used to evaluate symptom severity are described, and evidence-based treatment options are reviewed, with appropriate distinctions drawn between children and adults. Finally, recommendations for assessment and treatment practices for OCD are explicated.
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Affiliation(s)
- Joseph F McGuire
- Department of Psychology, University of South Florida, St. Petersburg, FL 33701, USA
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Hoexter MQ, de Souza Duran FL, D'Alcante CC, Dougherty DD, Shavitt RG, Lopes AC, Diniz JB, Deckersbach T, Batistuzzo MC, Bressan RA, Miguel EC, Busatto GF. Gray matter volumes in obsessive-compulsive disorder before and after fluoxetine or cognitive-behavior therapy: a randomized clinical trial. Neuropsychopharmacology 2012; 37:734-45. [PMID: 22030709 PMCID: PMC3260985 DOI: 10.1038/npp.2011.250] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Serotonin reuptake inhibitors and cognitive-behavior therapy (CBT) are considered first-line treatments for obsessive-compulsive disorder (OCD). However, little is known about their modulatory effects on regional brain morphology in OCD patients. We sought to document structural brain abnormalities in treatment-naive OCD patients and to determine the effects of pharmacological and cognitive-behavioral treatments on regional brain volumes. Treatment-naive patients with OCD (n=38) underwent structural magnetic resonance imaging scan before and after a 12-week randomized clinical trial with either fluoxetine or group CBT. Matched-healthy controls (n=36) were also scanned at baseline. Voxel-based morphometry was used to compare regional gray matter (GM) volumes of regions of interest (ROIs) placed in the orbitofrontal, anterior cingulate and temporolimbic cortices, striatum, and thalamus. Treatment-naive OCD patients presented smaller GM volume in the left putamen, bilateral medial orbitofrontal, and left anterior cingulate cortices than did controls (p<0.05, corrected for multiple comparisons). After treatment with either fluoxetine or CBT (n=26), GM volume abnormalities in the left putamen were no longer detectable relative to controls. ROI-based within-group comparisons revealed that GM volume in the left putamen significantly increased (p<0.012) in fluoxetine-treated patients (n=13), whereas no significant GM volume changes were observed in CBT-treated patients (n=13). This study supports the involvement of orbitofronto/cingulo-striatal loops in the pathophysiology of OCD and suggests that fluoxetine and CBT may have distinct neurobiological mechanisms of action.
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Affiliation(s)
- Marcelo Queiroz Hoexter
- Department and Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil,Interdisciplinary Laboratory for Clinical Neuroscience (LiNC), Department of Psychiatry, Federal University of São Paulo (UNIFESP), São Paulo, Brazil,Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA,Centro de Medicina Nuclear do HC-FMUSP, Laboratório de Neuroimagem em Psiquiatria—LIM21, Rua Ovidio Pires Campos, s/n, 3 andar, CEP: 05403-911, São Paulo, SP, Brazil. Tel: +55 11 3069 7896, Fax: +55 11 3082 1015, E-mail:
| | | | - Carina Chaubet D'Alcante
- Department and Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil
| | - Darin Dean Dougherty
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Roseli Gedanke Shavitt
- Department and Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil
| | - Antonio Carlos Lopes
- Department and Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil
| | - Juliana Belo Diniz
- Department and Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil
| | - Thilo Deckersbach
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Rodrigo Affonseca Bressan
- Interdisciplinary Laboratory for Clinical Neuroscience (LiNC), Department of Psychiatry, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | | | - Geraldo Filho Busatto
- Department and Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil
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A double-blind, randomized, controlled trial of fluoxetine plus quetiapine or clomipramine versus fluoxetine plus placebo for obsessive-compulsive disorder. J Clin Psychopharmacol 2011; 31:763-8. [PMID: 22020357 DOI: 10.1097/jcp.0b013e3182367aee] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Obsessive-compulsive disorder patients who do not improve sufficiently after treatment with a selective serotonin reuptake inhibitor might improve further if other drugs were added to the treatment regimen. The authors present a double-blind, placebo-controlled trial comparing the efficacy of adding quetiapine or clomipramine to a treatment regimen consisting of fluoxetine. Between May 2007 and March 2010, a total of 54 patients with a primary diagnosis of obsessive-compulsive disorder, as defined by Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, and a current Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) score of at least 16, the score having dropped by less than 35% after fluoxetine monotherapy, were allocated to 1 of 3 arms (n = 18 per arm): quetiapine + fluoxetine (≤200 and ≤40 mg/d, respectively), clomipramine + fluoxetine (≤75 and ≤40 mg/d, respectively), or placebo + fluoxetine (≤80 mg/d of fluoxetine). Follow-up was 12 weeks. The Y-BOCS scores were the main outcome measure. No severe adverse events occurred during the trial, and 40 patients (74%) completed the 12-week protocol. The Y-BOCS scores (mean [SD]) were significantly better in the placebo + fluoxetine and clomipramine + fluoxetine groups than in the quetiapine + fluoxetine group (final: 18 [7] and 18 [7], respectively, vs 25 [6], P < 0.001) (reduction from baseline: -6.7 [confidence interval {CI}, -9.6 to -3.8; and -6.5 [CI, -9.0 to -3.9], respectively, vs -0.1 [CI, -2.9 to 2.7], P < 0.001; number needed to treat = 2.4). The clomipramine-fluoxetine combination is a safe and effective treatment for fluoxetine nonresponders, especially those who cannot tolerate high doses of fluoxetine. However, the period of monotherapy with the maximum dose of fluoxetine should be extended before a combination treatment strategy is applied.
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Abstract
This case report describes a 20-year-old man with trichotillomania (TTM). The patient was first treated with paroxetine and carbocisteine without response. Following the addition of aripiprazole (3 mg/d) to the other medications, the TTM was fully alleviated. After stopping treatment, 1.5 to 3.0 mg/d of aripiprazole alone improved TMM symptoms upon recurrence. These findings indicate that further investigation of low-dose aripiprazole for the treatment of TTM is warranted.
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Abudy A, Juven-Wetzler A, Zohar J. Pharmacological management of treatment-resistant obsessive-compulsive disorder. CNS Drugs 2011; 25:585-96. [PMID: 21699270 DOI: 10.2165/11587860-000000000-00000] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Once considered rare and resistant to treatment, obsessive-compulsive disorder (OCD) has now emerged as a common, yet often unrecognized, psychiatric condition. Treatment with selective serotonin reuptake inhibitors (SSRIs) is effective in 40-60% of patients with OCD. Management of the remaining 40-60% of patients with treatment-resistant OCD is challenging. We review up-to-date evidence focusing on strategies for treatment-resistant OCD, including increasing the dose of SSRI, switching to another SSRI, augmentation with antipsychotics, and the use of serotonin noradrenaline (norepinephrine) reuptake inhibitors (SNRIs) and monoamine oxidase inhibitors (MAOIs). Finally, we provide a flow chart, which includes nonpharmacological interventions such as cognitive-behavioural therapy, family interventions and physical interventions such as neurosurgery and deep brain stimulation, alongside the pharmacological strategies.
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Affiliation(s)
- Anat Abudy
- Department of Psychiatry, Chaim Sheba Medical Center, Tel Hashomer, Israel
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Vulink NCC, Figee M, Denys D. Review of atypical antipsychotics in anxiety. Eur Neuropsychopharmacol 2011; 21:429-49. [PMID: 21345655 DOI: 10.1016/j.euroneuro.2010.12.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Revised: 11/30/2010] [Accepted: 12/27/2010] [Indexed: 10/18/2022]
Abstract
Atypical antipsychotics are increasingly used for treatment of anxiety disorders, either in mono- or combination therapy. This is the first review reporting on the use of atypical antipsychotics in monotherapy or augmentation in patients with primary anxiety disorders or anxiety (disorders) comorbid to schizophrenia, bipolar disorder (BPD) and major depressive disorder (MDD). We included 49 open-label trials, 32 randomized, placebo-controlled trials (RCTpls) and five randomized controlled trials without placebo arm with almost 6000 patients (open-label: 1710, randomized: 4145). An increasing number of RCTpls show promising results in 27-71% of patients with primary or comorbid anxiety disorders who were treated with monotherapy atypical antipsychotics or augmentation therapy. However, methodological flaws of included studies may limit conclusions of this review and larger placebo-controlled trials are warranted comparing standard treatment with monotherapy and augmentation therapy of atypical antipsychotics and placebo. In addition, higher dropout rates and side effects from treatment with atypical antipsychotics may limit the use of atypical antipsychotics in patients with anxiety disorders.
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Affiliation(s)
- Nienke C C Vulink
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, The Netherlands.
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Ravindran AV, Al-Subaie A, Abraham G. Quetiapine: novel uses in the treatment of depressive and anxiety disorders. Expert Opin Investig Drugs 2010; 19:1187-204. [DOI: 10.1517/13543784.2010.515586] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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