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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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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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Fineberg NA, Hollander E, Pallanti S, Walitza S, Grünblatt E, Dell’Osso BM, Albert U, Geller DA, Brakoulias V, Janardhan Reddy Y, Arumugham SS, Shavitt RG, Drummond L, Grancini B, De Carlo V, Cinosi E, Chamberlain SR, Ioannidis K, Rodriguez CI, Garg K, Castle D, Van Ameringen M, Stein DJ, Carmi L, Zohar J, Menchon JM. Clinical advances in obsessive-compulsive disorder: a position statement by the International College of Obsessive-Compulsive Spectrum Disorders. Int Clin Psychopharmacol 2020; 35:173-193. [PMID: 32433254 PMCID: PMC7255490 DOI: 10.1097/yic.0000000000000314] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 03/16/2020] [Indexed: 11/25/2022]
Abstract
In this position statement, developed by The International College of Obsessive-Compulsive Spectrum Disorders, a group of international experts responds to recent developments in the evidence-based management of obsessive-compulsive disorder (OCD). The article presents those selected therapeutic advances judged to be of utmost relevance to the treatment of OCD, based on new and emerging evidence from clinical and translational science. Areas covered include refinement in the methods of clinical assessment, the importance of early intervention based on new staging models and the need to provide sustained well-being involving effective relapse prevention. The relative benefits of psychological, pharmacological and somatic treatments are reviewed and novel treatment strategies for difficult to treat OCD, including neurostimulation, as well as new areas for research such as problematic internet use, novel digital interventions, immunological therapies, pharmacogenetics and novel forms of psychotherapy are discussed.
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Affiliation(s)
- Naomi A. Fineberg
- University of Hertfordshire, Hatfield
- Hertfordshire Partnership University NHS Foundation Trust, Welwyn Garden City, Hertfordshire
- University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Eric Hollander
- Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Stefano Pallanti
- Istituto di Neuroscienze, University of Florence, Firenze, Italy
- Albert Einstein College of Medicine, Bronx, New York, USA
| | - Susanne Walitza
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry Zurich, University of Zurich
- Neuroscience Center Zurich, University of Zurich and ETH Zurich
- Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
| | - Edna Grünblatt
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry Zurich, University of Zurich
- Neuroscience Center Zurich, University of Zurich and ETH Zurich
- Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
| | - Bernardo Maria Dell’Osso
- University of Milan, Department of Biomedical and Clinical Sciences Luigi Sacco, Ospedale Sacco-Polo Universitario, ASST Fatebenefratelli-Sacco, Milan, Italy
- Department of Psychiatry and Behavioural Sciences, Stanford University, California, USA
- CRC ‘Aldo Ravelli’ for Neurotechnology and Experimental Brain Therapeutics, University of Milan, Milan
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford
| | - Umberto Albert
- Department of Medicine, Surgery and Health Sciences, UCO Clinica Psichiatrica, University of Trieste, Trieste, Italy
| | - Daniel A. Geller
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vlasios Brakoulias
- Western Sydney Obsessive-Compulsive and Related Disorders Service, Western Sydney Local Health District, Blacktown Hospital, Blacktown, New South Wales
- Translational Research Health Institute (THRI), Clinical and Health Psychology Research Initiative (CaHPRI) and School of Medicine, Western Sydney University, Sydney, Australia
| | - Y.C. Janardhan Reddy
- OCD Clinic, Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, India
| | - Shyam Sundar Arumugham
- OCD Clinic, Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, India
| | - Roseli G. Shavitt
- OCD Spectrum Disorders Program, Institute and Department of Psychiatry, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo-SP, Brazil
| | - Lynne Drummond
- Consultant Psychiatrist, SW London and St George’s NHS Trust and St George’s, University of London, London
| | - Benedetta Grancini
- Hertfordshire Partnership University NHS Foundation Trust, Welwyn Garden City, Hertfordshire
- University of Milan, Department of Biomedical and Clinical Sciences Luigi Sacco, Ospedale Sacco-Polo Universitario, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Vera De Carlo
- Hertfordshire Partnership University NHS Foundation Trust, Welwyn Garden City, Hertfordshire
- University of Milan, Department of Biomedical and Clinical Sciences Luigi Sacco, Ospedale Sacco-Polo Universitario, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Eduardo Cinosi
- University of Hertfordshire, Hatfield
- Hertfordshire Partnership University NHS Foundation Trust, Welwyn Garden City, Hertfordshire
| | - Samuel R. Chamberlain
- Department of Psychiatry, University of Cambridge, Cambridge
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
| | - Konstantinos Ioannidis
- Department of Psychiatry, University of Cambridge, Cambridge
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
| | - Carolyn I. Rodriguez
- Department of Psychiatry and Behavioural Sciences, Stanford University, California, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Kabir Garg
- Hertfordshire Partnership University NHS Foundation Trust, Welwyn Garden City, Hertfordshire
| | - David Castle
- St. Vincent’s Hospital Melbourne and The University of Melbourne, Melbourne, Australia
| | - Michael Van Ameringen
- Department of Psychiatry and Behavioural Neurosciences, McMaster University
- Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Dan J. Stein
- SA MRC Unit on Risk and Resilience in Mental Disorders, Department of Psychiatry and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Lior Carmi
- The Post Trauma Center, Chaim Sheba Medical Center, Ramat Gan
- The Data Science Institution, The Interdisciplinary Center, Herzliya
| | - Joseph Zohar
- The Post Trauma Center, Chaim Sheba Medical Center, Ramat Gan
- Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Jose M. Menchon
- Department of Psychiatry, Bellvitge University Hospital-IDIBELL, University of Barcelona, Cibersam, Barcelona, Spain
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Factors associated with obsessive-compulsive symptoms in people with epilepsy. Epilepsy Behav 2020; 102:106723. [PMID: 31805509 DOI: 10.1016/j.yebeh.2019.106723] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 11/15/2019] [Accepted: 11/15/2019] [Indexed: 11/22/2022]
Abstract
PURPOSE Obsessive-compulsive disorder (OCD) is a common but underrecognized psychiatric condition comorbid with epilepsy. We thus investigated clinical factors associated with obsessive-compulsive symptoms (OCS) in adults with epilepsy. METHODS This was a cross-sectional multicenter study in Republic of Korea. Obsessive-compulsive symptoms were assessed using the Obsessive-Compulsive Inventory-Revised (OCI-R). Clinical factors that were assessed included age, sex, seizure-related variables, and the number and use of antiepileptic drugs (AEDs) prescribed. Data were analyzed by stepwise linear regression and adjusted according to anxiety and depressive symptoms as assessed by Hospital Anxiety Depression Scale (HADS). RESULTS The study population comprised 221 adults with epilepsy (42.1% male, 39.7 ± 11.9 years of age). The mean OCI-R score was 18.0 (standard deviation, 12.7), and an OCI-R score of ≥21 was obtained for 40.3% of the study sample. On a stepwise linear regression analysis, epilepsy severity, temporal lobe seizures, the use of topiramate, and the use of lamotrigine were identified as independent factors associated with OCI-R score after adjusting for anxiety according to the HADS. All factors except topiramate usage were positively associated with OCS. The total explained variance was 37.3%. CONCLUSIONS Obsessive-compulsive symptoms are common in persons with epilepsy and are associated with severe epilepsy, temporal lobe seizures, and the use of topiramate and lamotrigine. Specifically, the use of lamotrigine may aggravate OCS, whereas the use of topiramate may have beneficial effects on OCS.
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