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Swierkosz-Lenart K, Dos Santos JFA, Elowe J, Clair AH, Bally JF, Riquier F, Bloch J, Draganski B, Clerc MT, Pozuelo Moyano B, von Gunten A, Mallet L. Therapies for obsessive-compulsive disorder: Current state of the art and perspectives for approaching treatment-resistant patients. Front Psychiatry 2023; 14:1065812. [PMID: 36873207 PMCID: PMC9978117 DOI: 10.3389/fpsyt.2023.1065812] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 01/25/2023] [Indexed: 02/18/2023] Open
Abstract
Even though obsessive compulsive disorder (OCD) is one of the ten most disabling diseases according to the WHO, only 30-40% of patients suffering from OCD seek specialized treatment. The currently available psychotherapeutic and pharmacological approaches, when properly applied, prove ineffective in about 10% of cases. The use of neuromodulation techniques, especially Deep Brain Stimulation, is highly promising for these clinical pictures and knowledge in this domain is constantly evolving. The aim of this paper is to provide a summary of the current knowledge about OCD treatment, while also discussing the more recent proposals for defining resistance.
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Affiliation(s)
- Kevin Swierkosz-Lenart
- Department of Psychiatry, Service Universitaire de Psychiatrie de l’Age Avancé (SUPAA), Centre Hospitalier Universitaire Vaudois, Prilly, Switzerland
| | | | - Julien Elowe
- Department of Psychiatry, Lausanne University Hospital, University of Lausanne, West Sector, Prangins, Switzerland
- Department of Psychiatry, Lausanne University Hospital, University of Lausanne, North Sector, Yverdon-les-Bains, Switzerland
| | - Anne-Hélène Clair
- Sorbonne University, UPMC Paris 06 University, INSERM, CNRS, Institut du Cerveau et de la Moelle Épinière, Paris, France
| | - Julien F. Bally
- Department of Clinical Neurosciences, Service of Neurology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Françoise Riquier
- Department of Clinical Neuroscience, Service of Neurosurgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Jocelyne Bloch
- Department of Clinical Neuroscience, Service of Neurosurgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Bogdan Draganski
- Laboratory for Research in Neuroimaging (LREN), Department of Clinical Neurosciences, Centre for Research in Neurosciences, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
- Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
| | - Marie-Thérèse Clerc
- Department of Psychiatry, Service Universitaire de Psychiatrie de l’Age Avancé (SUPAA), Centre Hospitalier Universitaire Vaudois, Prilly, Switzerland
| | - Beatriz Pozuelo Moyano
- Department of Psychiatry, Service Universitaire de Psychiatrie de l’Age Avancé (SUPAA), Centre Hospitalier Universitaire Vaudois, Prilly, Switzerland
| | - Armin von Gunten
- Department of Psychiatry, Service Universitaire de Psychiatrie de l’Age Avancé (SUPAA), Centre Hospitalier Universitaire Vaudois, Prilly, Switzerland
| | - Luc Mallet
- Department of Mental Health and Psychiatry, Geneva University Hospital, Geneva, Switzerland
- Univ Paris-Est Créteil, DMU IMPACT, Département Médical-Universitaire de Psychiatrie et d’Addictologie, Hôpitaux Universitaires Henri Mondor - Albert Chenevier, Assistance Publique-Hôpitaux de Paris, Créteil, France
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Paris, France
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Pepper J, Zrinzo L, Hariz M. Anterior capsulotomy for obsessive-compulsive disorder: a review of old and new literature. J Neurosurg 2019; 133:1595-1604. [PMID: 31604328 DOI: 10.3171/2019.4.jns19275] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 04/29/2019] [Indexed: 12/16/2022]
Abstract
Over the last two decades, deep brain stimulation (DBS) has gained popularity as a treatment of severe and medically refractory obsessive-compulsive disorder (OCD), often using brain targets informed by historical lesional neurosurgical procedures. Paradoxically, the use of DBS in OCD has led some multidisciplinary teams to revisit the use of lesional procedures, especially anterior capsulotomy (AC), although significant aversion still exists toward the use of lesional neurosurgery for psychiatric disorders. This paper aims to review all literature on the use of AC for OCD to examine its effectiveness and safety profile.All publications on AC for OCD were searched. In total 512 patients were identified in 25 publications spanning 1961-2018. In papers where a Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score was available, 73% of patients had a clinical response (i.e., > 35% improvement in Y-BOCS score) and 24% patients went into remission (Y-BOCS score < 8). In the older publications, published when the Y-BOCS was not yet available, 90% of patients were deemed to have had a significant clinical response and 39% of patients were considered symptom free. The rate of serious complications was low.In summary, AC is a safe, well-tolerated, and efficacious therapy. Its underuse is likely a result of historical prejudice rather than lack of clinical effectiveness.
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Affiliation(s)
- Joshua Pepper
- 1Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Ludvic Zrinzo
- 2Unit of Functional Neurosurgery, Queen Square, London, United Kingdom; and
| | - Marwan Hariz
- 3Department of Clinical Neuroscience, Umeå University, Umeå, Sweden
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Naguy A, Alamiri B, Al-Khadhari S, Francis K. Lamotrigine Augmentation in Treatment-Resistant Pediatric Obsessive-Compulsive Disorder with a 16 Month Follow-up. J Child Adolesc Psychopharmacol 2016; 26:769-772. [PMID: 26465832 DOI: 10.1089/cap.2015.0083] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Ahmed Naguy
- 1 Child and Adolescent Psychiatry, Kuwait Center for Mental Health , Alamanara Unit, Kuwait City, Kuwait
| | - Bibi Alamiri
- 1 Child and Adolescent Psychiatry, Kuwait Center for Mental Health , Alamanara Unit, Kuwait City, Kuwait .,2 Department of Psychiatry, Tufts University School of Medicine , Boston, Massachusetts
| | - Souleiman Al-Khadhari
- 1 Child and Adolescent Psychiatry, Kuwait Center for Mental Health , Alamanara Unit, Kuwait City, Kuwait .,3 Department of Psychiatry, Kuwait University , Kuwait City, Kuwait
| | - Konstantinos Francis
- 1 Child and Adolescent Psychiatry, Kuwait Center for Mental Health , Alamanara Unit, Kuwait City, Kuwait .,4 Department of Child Psychiatry, Athens University , Chalandri, Greece
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Storch EA, Bussing R, Small BJ, Geffken GR, McNamara JP, Rahman O, Lewin AB, Garvan CS, Goodman WK, Murphy TK. Randomized, placebo-controlled trial of cognitive-behavioral therapy alone or combined with sertraline in the treatment of pediatric obsessive-compulsive disorder. Behav Res Ther 2013; 51:823-9. [PMID: 24184429 PMCID: PMC3908957 DOI: 10.1016/j.brat.2013.09.007] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Revised: 09/18/2013] [Accepted: 09/19/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND To examine the efficacy of sequential sertraline and cognitive-behavioral therapy (CBT) treatment relative to CBT with pill placebo over 18 weeks in children and adolescents with obsessive-compulsive disorder (OCD). METHODS Forty-seven children and adolescents with OCD (Range = 7-17 years) were randomized to 18-weeks of treatment in one of three arms: 1) sertraline at standard dosing + CBT (RegSert + CBT); 2) sertraline titrated slowly but achieving at least 8 weeks on the maximally tolerated daily dose + CBT (SloSert + CBT); or 3) pill placebo + CBT (PBO + CBT). Assessments were conducted at screening, baseline, weeks 1-9, 13, and 17, and post-treatment. Raters and clinicians were blinded to sertraline (but not CBT) randomization status. Primary outcomes included the Children's Yale-Brown Obsessive-Compulsive Scale, and response and remission status. Secondary outcomes included the Child Obsessive Compulsive Impact Scale-Parent/Child, Children's Depression Rating Scale-Revised, Multidimensional Anxiety Scale for Children, and Clinical-Global Impressions-Severity. RESULTS All groups exhibited large within-group effects across outcomes. There was no group by time interaction across all outcomes suggesting that group changes over time were comparable. CONCLUSIONS Among youth with OCD, there was no evidence that sequentially provided sertraline with CBT differed from those receiving placebo with CBT. CLINICALTRIALSGOV IDENTIFIER NCT00382291.
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Affiliation(s)
- Eric A Storch
- Department of Pediatrics and Psychiatry, University of South Florida, USA.
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van Balkom AJLM, Emmelkamp PMG, Eikelenboom M, Hoogendoorn AW, Smit JH, van Oppen P. Cognitive therapy versus fluvoxamine as a second-step treatment in obsessive-compulsive disorder nonresponsive to first-step behavior therapy. PSYCHOTHERAPY AND PSYCHOSOMATICS 2013; 81:366-74. [PMID: 22964609 DOI: 10.1159/000339369] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Accepted: 05/04/2012] [Indexed: 12/21/2022]
Abstract
BACKGROUND To compare the effectiveness of second-step treatment with cognitive therapy (CT) versus fluvoxamine in patients with obsessive-compulsive disorder (OCD) who are nonresponsive to exposure in vivo with response prevention (ERP). METHODS A 12-week randomized controlled trial at an outpatient clinic in the Netherlands comparing CT with fluvoxamine in OCD. Of 118 subjects with OCD treated with 12 weeks of ERP, 48 appeared to be nonresponders (Y-BOCS improvement score of less than one third). These nonresponders were randomized to CT (n = 22) or fluvoxamine (n = 26). The main outcome measure was the Y-BOCS severity scale. Statistical analyses were conducted in the intention-to-treat sample (n = 45) on an 'as randomized basis' and in the per-protocol sample (n = 30). Due to selective dropout in the fluvoxamine group, two additional sensitivity analyses were performed. RESULTS Complete data could be obtained from 45 subjects (94%) after 12 weeks. Fifty percent of the patients refused fluvoxamine after randomization compared to 13% who refused CT [χ(2)(1) = 7.10; p = 0.01]. CT as a second-step treatment did not appear to be effective in this sample of nonresponders. Fluvoxamine was significantly superior to CT in the intention-to-treat sample, in the per-protocol sample and in the two separately defined samples in which the sensitivity analyses were performed. CONCLUSIONS OCD patients who are nonresponsive to ERP may benefit more from a switch to treatment with an antidepressant instead of switching to CT. In clinical practice, it may be important to motivate this subgroup of patients to undergo psychopharmacological treatment, as this may improve their outcome considerably.
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Affiliation(s)
- Anton J L M van Balkom
- Department of Psychiatry and EMGO Institute, VU University Medical Center, Academic Outpatient Clinic for Anxiety Disorders, GGZinGeest, Amsterdam, The Netherlands.
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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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Uzun O. Lamotrigine as an augmentation agent in treatment-resistant obsessive-compulsive disorder: a case report. J Psychopharmacol 2010; 24:425-7. [PMID: 19010977 DOI: 10.1177/0269881108098809] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Obsessive-compulsive disorder (OCD) is a relatively common, often chronic and disabling disorder with high rates of partial and/or absent response to standard, recommended treatments. We report a case of treatment-resistant OCD that was successfully treated with a pharmacological augmentation of lamotrigine plus clomipramine. The patient, a 59-year-old woman, was on a stable dose of clomipramine (225 mg/day) when she was started on lamotrigine (up to 150 mg/day). After 10 weeks of this treatment, her clinical condition remarkably improved, as indicated by a significant decrease of the Yale-Brown Obsessive-Compulsive Scale. This case suggests some preliminary evidence that the addition of glutamatergic agent lamotrigine may be useful in treatment-resistant OCD. However, further controlled studies are needed to support this finding.
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Affiliation(s)
- O Uzun
- Department of Psychiatry, Gulhane School of Medicine, Ankara, Turkey.
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Atmaca M. A case of problematic internet use successfully treated with an SSRI-antipsychotic combination. Prog Neuropsychopharmacol Biol Psychiatry 2007; 31:961-2. [PMID: 17321659 DOI: 10.1016/j.pnpbp.2007.01.003] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2006] [Revised: 01/04/2007] [Accepted: 01/04/2007] [Indexed: 01/05/2023]
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Fontenelle LF, Nascimento AL, Mendlowicz MV, Shavitt RG, Versiani M. An update on the pharmacological treatment of obsessive-compulsive disorder. Expert Opin Pharmacother 2007; 8:563-83. [PMID: 17376013 DOI: 10.1517/14656566.8.5.563] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The purpose of this article is to introduce the reader to an updated evidence-based drug treatment algorithm to be employed in patients with obsessive-compulsive disorder (OCD). Relevant studies were identified through a comprehensive review and classified according to the type of patients enrolled, the quality of the study design and the invasiveness, availability and complexity of the therapeutic approach. When ineffective, therapeutic trials with first-line strategies (such as the selective serotonin re-uptake inhibitors [SSRIs] and venlafaxine) should be followed by treatment approaches such as clomipramine, augmentation with antipsychotics or pindolol, SSRI megadoses or cognitive behavioral therapy. These therapeutic strategies are expected to help most patients with OCD. Additional approaches include intravenous clomipramine, oral morphine, 'heroic drug strategies', deep brain stimulation and functional neurosurgery. Independent studies are urgently needed to help identify the most promising drug treatment sequences for OCD.
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Affiliation(s)
- Leonardo F Fontenelle
- Anxiety and Depression Research Program, Institute of Psychiatry, Universidade Federal of Rio de Janeiro (IPUB/UFRJ), Icaraí, Niterói, RJ, Brazil.
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Kemp DE, Gilmer WS, Fleck J, Dago PL. An association of intrusive, repetitive phrases with lamotrigine treatment in bipolar II disorder. CNS Spectr 2007; 12:106-11. [PMID: 17277710 DOI: 10.1017/s1092852900020617] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Bipolar disorder is frequently associated with obsessional symptoms. However, no reports have identified a pattern of obsessionality that is associated with a specific mood stabilizer treatment. METHODS A chart review was conducted on five patients with bipolar II disorder who spontaneously reported a form of obsessionality characterized by intrusive, recurrent phrases after taking lamotrigine. RESULTS Development of the phrases occurred from 7-42 years after mood disorder onset and occurred only after initiation of lamotrigine treatment. The phrases improved with lamotrigine discontinuation or dose reduction and recurred with lamotrigine re-challenge or upon dose escalation. CONCLUSION A possible mechanism for the development of the intrusive phrases involves the influence of lamotrigine on glutamatergic regulation in a bipolar II disorder population vulnerable to the expression of obsessionality. Limitations of this report include its observational nature, small number of cases reported, and confound of concomitant medication use.
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Affiliation(s)
- David E Kemp
- Bipolar Disorder Research Center, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA.
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O'Connor KP, Aardema F, Robillard S, Guay S, Pélissier MC, Todorov C, Borgeat F, Leblanc V, Grenier S, Doucet P. Cognitive behaviour therapy and medication in the treatment of obsessive-compulsive disorder. Acta Psychiatr Scand 2006; 113:408-19. [PMID: 16603032 DOI: 10.1111/j.1600-0447.2006.00767.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To compare cognitive behaviour therapy (CBT) with CBT plus medication; medication alone; and placebo in the treatment of adult obsessive-compulsive disorder (OCD). METHOD Forty-eight participants (43 completers) were recruited into two protocols. In the first protocol, 21 people with OCD were randomly allocated to either a standard medication (fluvoxamine) or standard placebo condition for a 5-month period. Both these groups subsequently received CBT for a further 5 months. In the second protocol, 22 people with OCD received CBT, one group was already stabilized on an antidepressant of choice; the second group was drug naïve. RESULTS All active treatments, but not the placebo, showed clinical improvement. There was no difference in treatment response to CBT regardless of whether participants had previously received medication or placebo. CONCLUSION CBT has a more specific antiobsessional effect than medication but CBT plus medication shows greatest overall clinical improvement in mood.
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Affiliation(s)
- K P O'Connor
- Fernand-Seguin Research Centre, Louis-H. Lafontaine Hospital, Montreal, QC, Canada.
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Pallanti S, Quercioli L. Treatment-refractory obsessive-compulsive disorder: methodological issues, operational definitions and therapeutic lines. Prog Neuropsychopharmacol Biol Psychiatry 2006; 30:400-12. [PMID: 16503369 DOI: 10.1016/j.pnpbp.2005.11.028] [Citation(s) in RCA: 228] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/02/2005] [Indexed: 01/20/2023]
Abstract
While controlled trials with SRIs have demonstrated a selective efficacy in obsessive-compulsive disorder (OCD), up to 40-60% of patients do not have a satisfactory outcome. Non-response to treatment in OCD is associated with serious social disability. There are a large number of non-responsive patients, and they are difficult to cluster due to ambiguities in diagnostic criteria, possibility of subtypes and a high rate of comorbidity. Moreover, the findings of current studies of "so-called" non-responsive cases are currently non-generalizable because of the lack of an operational definition of non-response. The result has been that a cumulative body of data on a reasonably homogeneous sample of non-responders has not been developed. The aims of the research in this area are to clarify some of the obstacles in defining stages of response and levels of non-response and, through a comprehensive analysis, to propose a systematic nosology for this rather common condition. Better characterization of which patients respond and do not respond to various treatments will enable more accurate clustering of patients, and help facilitate multisite data collection for future research trials. The authors reviewed also the more recent therapeutic pharmacological and psychological lines for the treatment of refractoriness in OCD.
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Fontenelle LF, Mendlowicz MV, Miguel EC, Versiani M. Citalopram plus reboxetine in treatment-resistant obsessive-compulsive disorder. World J Biol Psychiatry 2005; 6:57-9. [PMID: 16097406 DOI: 10.1080/15622970510029740] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
While serotonin reuptake inhibitors (SRIs) are the first-line treatment of obsessive compulsive disorder (OCD), as many as 40-60% of patients fail to respond to adequate trials with these drugs. In this study, we describe the case of a patient with an SRI-resistant OCD who was successfully treated with a combination of citalopram (a selective SRI) and reboxetine (a selective noradrenaline reuptake inhibitor (SNRI)). This report suggests that future studies accessing the efficacy of the SRI SNRI combination in treatment resistant OCD are needed.
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Affiliation(s)
- Leonardo F Fontenelle
- Anxiety and Depression Research Program, Institute of Psychiatry of the Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
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