The Pharmacological Treatment of Obsessive-Compulsive Disorder

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.

Safety considerations for prescribing SSRI antidepressants to patients at increased cardiovascular risk

INTRODUCTION

With the development of selective serotonin reuptake inhibitors (SSRI), a relatively uncomplicated treatment of depression and a safer alternative to tricyclic antidepressants was introduced. Any medical treatment has potential safety risks, however, and these risks should also be considered when prescribing SSRIs.

AREAS COVERED

The present review focuses on safety considerations when prescribing SSRIs to patients with previous stroke and myocardial infarction, as depression, and the need for antidepressant treatment, is common in these patients. At the same time, patients with stroke and myocardial infarction may be at increased risk of developing adverse events due to higher age, comorbidity, and co-medication. Specifically, the evidence of the risk of QT prolongation and bleeding versus thrombotic events will be discussed in the present review.

EXPERT OPINION

No medical treatment comes without risk and SSRIs are no exception. Depression, a common complication after vascular events, is a potentially life-threatening condition in itself and relevant and sufficient treatment is imperative. SSRIs are often the first medical treatment choice in the ambulatory setting, also in patients at increased cardiovascular risk. Relevant comorbidity and co-medication, however, should always be taken into account when initiating treatment and when choosing a specific SSRI.

Body dysmorphic disorder: a treatment synthesis and consensus on behalf of the International College of Obsessive-Compulsive Spectrum Disorders and the Obsessive Compulsive and Related Disorders Network of the European College of Neuropsychopharmacology

Body dysmorphic disorder (BDD) is characterized by a preoccupation with a perceived appearance flaw or flaws that are not observable to others. BDD is associated with distress and impairment of functioning. Psychiatric comorbidities, including depression, social anxiety, and obsessive-compulsive disorder are common and impact treatment. Treatment should encompass psychoeducation, particularly addressing the dangers associated with cosmetic procedures, and may require high doses of selective serotonin reuptake inhibitors* (SSRI*) and protracted periods to establish full benefit. If there is an inadequate response to SSRIs, various adjunctive medications can be employed including atypical antipsychotics*, anxiolytics*, and the anticonvulsant levetiracetam*. However, large-scale randomized controlled trials are lacking and BDD is not an approved indication for these medications. Oxytocin* may have a potential role in treating BDD, but this requires further exploration. Cognitive-behavioural therapy has good evidence for efficacy for BDD, and on-line and telephone-assisted forms of therapy are showing promise. CBT for BDD should be customized to address such issues as mirror use, perturbations of gaze, and misinterpretation of others' emotions, as well as overvalued ideas about how others view the individual.

Pharmacotherapeutic Strategies and New Targets in OCD

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.

Considerations and Current Trends in the Management of the Geriatric Patient on a Consultation-Liaison Service

PURPOSE OF REVIEW

To provide consultation-liaison psychiatrists with an updated resource that can assist in the treatment and management of geriatric patients.

RECENT FINDINGS

The current available literature has not shown any differences in efficacy between haloperidol and second-generation antipsychotics in patients with delirium. When considering relative advantages of forms of antipsychotic administration, there is no support for a superior safety profile of oral compared to intramuscular or intravenous administration. A recent meta-analysis of four randomized controlled trials concluded that when melatonin was administered to older age patients on medical wards, it significantly prevented the incidence of delirium when compared with the control group. While suvorexant administered nightly to elderly patients in acute care settings may lower the incidence of delirium, larger studies are needed to confirm this finding. Despite the black box warning of increased mortality risk in older patients with dementia, antipsychotics may be used with caution by the consultation-liaison (CL) psychiatrist to treat the neuropsychologic symptoms of dementia including hallucinations and psychosis in the hospital setting. While antidepressant studies have focused primarily on citalopram and escitalopram in the treatment of agitation in the setting of dementia, these two medications have not been adequately compared directly to other SSRIs for this condition. It is therefore not clear whether citalopram and escitalopram are more efficacious in treating agitation in the setting of dementia when compared to other SSRIs. While the evidence supporting trazodone's use is limited, it is generally well tolerated and is an option as a PRN for irritability and agitation in patients with Alzheimer's and mixed dementia. While there is some evidence to support the use of acetylcholinesterase inhibitors for treating cognitive impairments and hallucinations in Lewy body dementia, the usefulness of these agents in other forms of dementia is not well studied, and those studies did not show any benefit in the management of acute agitation. It is important to note that memantine can cause or exacerbate agitation and may be the cause of behavioral dysregulation. There is no evidence to support the routine use of benzodiazepines for behavioral improvement in patients with dementia. Escitalopram and citalopram do have a unique pharmacokinetic properties in the sense that they have been found to have 50-56% plasma protein binding, compared to sertraline, fluoxetine, and paroxetine (95% or more). Pooled analyses suggest that antidepressants are more effective than placebo in reducing the symptoms of post-stroke depression. SSRIs are considered first-line antidepressants in stroke patients, who are often elderly with underlying cardiovascular problems. Although treatment with SSRIs is recommended for post-stroke depression, there are no studies providing conclusive data on the superiority of a specific drug. Older age is associated with a better outcome from ECT, with remission rates of approximately 73% to 90% in patients over 65 years. ECT is the treatment of choice for patients with psychotic depression, and elderly patients with psychotic depression have been shown to have a higher remission rate and faster time to response than depressed patients without psychotic symptoms. With the average life expectancy increase, it is projected that 19 million people will reach the age of 85 or higher, an increase from 5.5 million in 2010. With an increasing older population, psychiatric consultation in the management of geriatric patients is becoming more necessary. Psychiatrists must be aware of the unique considerations in elderly patients. In this article, we provide evidence-based guidance to the CL psychiatrist on major issues relating to the older age patient, highlighting recent trends in treatment. First, we provide background on the evaluation of the medically hospitalized geriatric patient. As rates of medical and psychiatric illnesses increase with advancing age, elderly patients are more likely to be taking a higher number of medications as compared to younger patients, and physicians must pay special attention to polypharmacy, including side effects and drug interactions in this group. Next, we focus on the diagnosis, management, and unique needs of the geriatric patient presenting with common clinical syndromes of delirium, dementia, and depression. Delirium and dementia are among the most common causes of cognitive impairment in clinical settings yet are often either unrecognized or misdiagnosed as they may have similar signs and symptoms. In addition, depression is prevalent in older adults, especially in those with comorbid medical illness. Depression can be fatal as the rates of suicide are higher in later life than in any other age group. Consultation can improve the management of elderly patients and prevent unnecessary nursing home placement.

Treatment of posttraumatic stress disorder: Focus on pharmacotherapy

Current clinical practice guidelines for the treatment of posttraumatic stress disorder offer varying recommendations regarding the use of pharmacotherapy. Many direct head-to-head comparisons of pharmacotherapy are lacking, and recommendations are based on meta-analyses and small trials. While selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors are considered first-line pharmacotherapy, clear distinctions do not exist when considering other classes of psychotropic medications. Ultimately, when selecting an appropriate medication for a patient diagnosed with posttraumatic stress disorder, the clinician needs to consider the current symptomatology being experienced, comorbid conditions, and evidence for efficacy of specific treatments prior to initiating medications.

Assessing Responsiveness of Health Systems to Drug Safety Warnings

OBJECTIVE

In 2011-2012 the U.S. Food and Drug Administration (FDA) issued safety announcements cautioning providers against prescribing high doses of citalopram given concerns for QT prolongation. The authors evaluated Veterans Affairs (VA) national trends in citalopram use and dose compared with alternative antidepressants after the FDA warnings.

METHODS

Time series analyses estimated the effect of the FDA warnings on citalopram and other antidepressant across three periods: before the first FDA warning in August 2011, after the 2011 FDA warning until the second warning in March 2012, and after the 2012 FDA warning. In a National VA health system, adult VA outpatients prescribed citalopram or alternative antidepressants from February 2010 to September 2013 were studied. Outpatient use of high-dose citalopram (>40 or >20 mg daily in adults aged > 60 years) including the proportion of patients prescribed citalopram and difference between study periods.

RESULTS

Between the first and second FDA warnings, among patients aged 18-60, high-dose citalopram use decreased by 2.0% per month (p < 0.001) and by 1.9% per month (p < 0.001) for older adults. After the second FDA warning in 2012, 30.7% of older patients remained on doses higher than the newly recommended dose of 20 mg. Reductions in overall use of citalopram were accompanied by significant increases in prescriptions of alternative antidepressants, with sertraline most widely prescribed.

CONCLUSION

Although trends in high-dose citalopram use declined after the 2011-2012 FDA warnings, roughly one-third of older adults still remained on higher than recommended doses. Concomitant increases in sertraline and other antidepressant prescriptions suggest potential substitution of these medications for citalopram.

Real Patient and its Virtual Twin: Application of Quantitative Systems Toxicology Modelling in the Cardiac Safety Assessment of Citalopram

A quantitative systems toxicology (QST) model for citalopram was established to simulate, in silico, a 'virtual twin' of a real patient to predict the occurrence of cardiotoxic events previously reported in patients under various clinical conditions. The QST model considers the effects of citalopram and its most notable electrophysiologically active primary (desmethylcitalopram) and secondary (didesmethylcitalopram) metabolites, on cardiac electrophysiology. The in vitro cardiac ion channel current inhibition data was coupled with the biophysically detailed model of human cardiac electrophysiology to investigate the impact of (i) the inhibition of multiple ion currents (I_Kr, I_Ks, I_CaL); (ii) the inclusion of metabolites in the QST model; and (iii) unbound or total plasma as the operating drug concentration, in predicting clinically observed QT prolongation. The inclusion of multiple ion channel current inhibition and metabolites in the simulation with unbound plasma citalopram concentration provided the lowest prediction error. The predictive performance of the model was verified with three additional therapeutic and supra-therapeutic drug exposure clinical cases. The results indicate that considering only the hERG ion channel inhibition of only the parent drug is potentially misleading, and the inclusion of active metabolite data and the influence of other ion channel currents should be considered to improve the prediction of potential cardiac toxicity. Mechanistic modelling can help bridge the gaps existing in the quantitative translation from preclinical cardiac safety assessment to clinical toxicology. Moreover, this study shows that the QST models, in combination with appropriate drug and systems parameters, can pave the way towards personalised safety assessment.