Treatment-resistant OCD: Pharmacotherapies in adults

New Agents in the Treatment of Psychiatric Disorders: What Innovations and in What Areas of Psychopathology?

Psychiatric disorders are a major cause of illness in the world. Unfortunately, many patients are resistant to treatment and present serious complications. Schizophrenia is refractory to treatment in about one-third of patients. Antidepressants are effective in about half of patients. Suicidal ideation is an increasing issue in patients with mixed features in bipolar disorder (BD). Therefore, there is a need to develop and test new drugs or new indications of available medications for the treatment of psychiatric disorders through evidence-based investigations. This narrative review aims to present the molecules approved by the main drug agencies, the Food and Drug Administration (FDA) and the European Medicines Agency (EMA), from 2018 to date, along with new indications and new formulations of existing medications. We searched PubMed for new drugs approved for schizophrenia, BD, major depressive disorder (MDD), anxiety disorders, and obsessive-compulsive disorder (OCD). We evaluated their clinical benefits, safety, and tolerability profiles. Finally, we considered studies on the main molecules that have shown initial evidence of efficacy and are in the process of obtaining approval. Our search suggested that a new antipsychotic, lumateperone, and two drug combinations, olanzapine/samidorphan (OLZ/SAM) and xanomeline/trospium (KarXT), were approved for schizophrenia. In addition, some new methods of administration-monthly risperidone administration, subcutaneous risperidone administration, and transdermal asenapine administration-obtained approval from the main drug agencies. Lumateperone and OLZ/SAM were also approved in BD. Esketamine, a compound that modulates glutamatergic transmission, was approved to treat treatment-resistant depression and acute suicidal ideation. The dextromethorphan/bupropion combination was approved for MDD. Two new agents, brexanolone and zuranolone, were approved for treatment of postpartum depression. On the other hand, no new drugs received approval for anxiety disorders or OCD. In summary, some new psychotropic medications have been developed, in particular with the aim to improve the symptoms of resistant patients and to decrease the incidence of adverse effects. It is necessary to continue testing the effectiveness of new compounds in methodologically rigorous studies.

Efficacy of Adjunctive Deep Transcranial Magnetic Stimulation in Obsessive-Compulsive Disorder: A Randomized Sham-Controlled Study

OBJECTIVES

Obsessive-compulsive disorder is one of the most common neuropsychiatric disorders with a higher lifetime prevalence than schizophrenia, often showing inadequate response to pharmacological and psychotherapeutic treatments. This study aimed to examine the efficacy of adjunctive deep transcranial magnetic stimulation (dTMS) in a randomized, sham-controlled set-up, addressing inadequate response to standard treatments.

METHODS

Forty-nine obsessive-compulsive disorder patients were randomly allocated to receive either high-frequency dTMS (20 Hz) or sham stimulation and received 10 sessions of treatment using the H7 coil to target the dorsal anterior cingulate cortex and the medial prefrontal cortex over a period of 2 weeks. Change in Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) scores was the primary outcome measure. Secondary efficacy measures were changes in Hamilton Anxiety Rating Scale and Hamilton Depression Rating Scale scores and response rates as measured by Y-BOCS.

RESULTS

The active dTMS group demonstrated a significant reduction in Y-BOCS scores compared with sham (-10.4 vs -2.6 points; P < 0.001), with an effect size of 1.39. Full response rates were 75% in the active group versus 5% in the sham group (P < 0.001). Anxiety and depressive symptoms also improved significantly in the active group (Hamilton Anxiety Rating Scale: -9.1 vs -2.4 points, P < 0.001; Hamilton Depression Rating Scale: -5.9 vs -1.8 points, P < 0.001).

CONCLUSION

Our study demonstrated that dTMS targeting the dorsal anterior cingulate cortex and medial prefrontal cortex significantly improved obsessive-compulsive, anxiety, and depressive symptoms, with faster response rates and fewer sessions compared with previous trials, suggesting that dTMS may serve as an effective early intervention for a wider range of obsessive-compulsive disorder patients.

Remission of OCD and ulcerative colitis with a ketogenic diet: Case Report

Background

There is little research describing the clinical use of a ketogenic diet in obsessive-compulsive disorder (OCD) or inflammatory bowel disease. We describe the first clinical application of a ketogenic diet in adult OCD with ulcerative colitis (UC) resulting in complete remission of OCD, clinical remission of UC, and improved metabolic health.

Methods

A 37-year-old obese woman with longstanding OCD and ulcerative colitis was treated for 12 weeks with a personalized whole-food ketogenic diet (KMT 1:5:1 ratio) in a specialized metabolic psychiatry clinic. Adherence was assessed by capillary beta-hydroxybutyrate (BHB) and photojournaling of food intake. Remission of OCD was assessed by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), Florida Obsessive Compulsive Inventory scale (FOCI), and Clinical Global Impression-Improvement/Severity scale (CGI-S/I). Patient Health Questionnaire-9 (PHQ-9) and Yale Food Addictions Scale 2.0 (YFAS 2.0) assessed depression and food addiction. Remission of UC was assessed by the Partial Mayo Score (PMS) and the Ulcerative Colitis Patient-Reported Outcome (UC-PRO). Metabolic health was assessed by laboratories and bioimpedance. Quality of life was assessed using validated scales for flourishing, resilience, self-compassion, and subjective narrative.

Results

Clinical remission of UC occurred within 3 weeks (PMS 0, UC-PRO 0). Progressive improvement in OCD was inversely related to oscillating BHB, with FOCI 0 at 9 weeks, and complete remission at 12 weeks (Y-BOCS 0, CGI-S 1). Body weight decreased 12.2%, with significant decreases in the percentage of body fat and visceral fat. Flourishing, resilience, and self-compassion improved 2- to 20-fold.

Conclusion

Complete remission of OCD, clinical remission of UC, and marked improvement in metabolic health occurred within 12 weeks using a well-formulated personalized ketogenic diet (KMT ratio 1:5:1) with a meaningful positive impact on quality of life and significant improvements in flourishing, resilience, and self-compassion.

Efficacy and safety of accelerated transcranial magnetic stimulation for obsessive-compulsive disorder: A systematic review and meta-analysis

BACKGROUND

Obsessive-Compulsive Disorder (OCD) is a chronic condition with limited treatment options. Standard transcranial magnetic stimulation (TMS) has shown moderate efficacy but requires 6-8 weeks of daily sessions. This review evaluates the efficacy, safety, and feasibility of accelerated TMS (aTMS) protocols for faster treatment response.

METHODS

We systematically searched PubMed, Web of Science, and Embase databases for randomized controlled trials (RCTs) comparing aTMS to placebo or once-daily TMS, conducting a meta-analysis of clinical and tolerability outcomes. The Cochrane Risk of Bias tool and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach were used to evaluate the quality and strength of evidence.

RESULTS

Of 97 screened records, 7 RCTs were included in the review. Six were analyzed quantitatively, showing that aTMS significantly reduced OCD symptoms (SMD 0.63), depressive symptoms (SMD 0.52), and increased response rate (OR 4.28) compared to sham aTMS. Adverse effects were higher in the aTMS group (OR 5.16), though mild, and dropout rates were similar (OR 0.74). At follow-ups, aTMS sustained significant reductions in depressive symptoms (SMD 0.74), but not in OCD or anxiety symptoms. On risk of bias assessment there were "some concerns" for all included studies. GRADE assessment showed moderate certainty for the primary outcome.

CONCLUSION

Accelerated TMS offers promising, faster treatment for OCD and significantly reduces depressive symptoms, though it has no effect on anxiety. Further studies should explore optimal protocols and long-term effects.

Comparing Different Montages of Transcranial Direct Current Stimulation in Treating Treatment-Resistant Obsessive Compulsive Disorder: A Randomized, Single-Blind Clinical Trial

Background: Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation for treatment-resistant obsessive compulsive disorder (OCD). We aim to compare the treatment outcomes of a newly developed dual-site cathodal tDCS method over the orbitofrontal cortex (OFC) and pre-supplementary motor area (pre-SMA) and two previously reported montages (cerebellum-OFC and pre-SMA) in patients with treatment-resistant OCD. Methods: Eighteen OCD patients were randomly assigned to receive twice-daily 2 mA/20 min sessions for 10 consecutive weekdays, with the active cathode placed on the cerebellum-OFC, bilateral pre-SMA, or OFC-pre-SMA tDCS. The primary outcome was the change in the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). The resting electroencephalogram (EEG) was recorded to obtain the default mode network (DMN) via low-resolution electromagnetic tomography. Each patient received one-week and one-month follow-ups after two weeks of stimulation. Results: At the end of the stimulation, the Y-BOCS scores in the cerebellum-OFC, pre-SMA, and OFC-pre-SMA tDCS groups (n = 6 in each group) were decreased by 14.15 ± 13.31, 7.4 ± 9.59, and 20.75 ± 8.70%, respectively, but no significant differences were found among the groups. In the OFC-pre-SMA tDCS group, OC symptoms significantly decreased by a mean of -20.75% immediately after the 20th tDCS session, and the improvement remained at 1 week and 1 month after tDCS. EEG source functional connectivity analyses revealed increased functional connectivity within the frontal network after OFC-pre-SMA tDCS, whereas decreased functional connectivity within the DMN was observed after cerebellum-OFC tDCS. Conclusions: Dual-site cathodal tDCS over the OFC and pre-SMA might be considered a potential montage to treat patients with treatment-resistant OCD. Future studies using randomized sham-controlled designs are needed.

The deer mouse (Peromyscus maniculatus bairdii) as a model organism to explore the naturalistic psychobiological mechanisms contributing to compulsive-like rigidity: A narrative overview of advances and opportunities

Deer mice (Peromyscus maniculatus bairdii), a wildtype species native to North America, have been investigated for their spontaneous compulsive-like behaviour. The repetitive and persistence nature of three unique compulsive-like phenotypes in deer mice, i.e., high stereotypy (HS), large nesting behaviour (LNB) and high marble burying (HMB), are characterized by behavioural and cognitive rigidity. In this narrative review, we summarize key advances in the model's application to study obsessive-compulsive disorder (OCD), emphasizing how it may be used to investigate neurobiological and neurocognitive aspects of rigidity. Indeed, deer mice provide the field with a unique naturalistic and spontaneous model system of behavioural and cognitive rigidity that is useful for investigating the psychobiological mechanisms that underpin a range of compulsive-like phenotypes. Throughout the review, we highlight new opportunities for future research.

Individualized functional connectome abnormalities obtained using two normative model unveil neurophysiological subtypes of obsessive compulsive disorder

The high heterogeneity observed among patients with obsessive-compulsive disorder (OCD) underscores the need to identify neurophysiological OCD subtypes to facilitate personalized diagnosis and treatment. In this study, our aim was to identify potential OCD subtypes based on individualized functional connectome abnormalities. We recruited a total of 99 patients with OCD and 104 healthy controls (HCs) matched for demographic characteristics. Individualized functional connectome abnormalities were obtained using normative models of functional connectivity strength (FCS) and used as features to unveil OCD subtypes. Sensitivity analyses were conducted to assess the reproducibility and robustness of the clustering outcomes. Patients exhibited significant intersubject heterogeneity in individualized functional connectome abnormalities. Two subtypes with distinct patterns of FCS abnormalities relative to HCs were identified. Subtype 1 patients primarily exhibited significantly decreased FCS in regions including the frontal gyrus, insula, hippocampus, and precentral/postcentral gyrus, whereas subtype 2 patients demonstrated increased FCS in widespread brain regions. When all patients were combined, no significant differences were observed. Additionally, the identified subtypes showed significant differences in age of onset. Furthermore, sensitivity analyses confirmed the reproducibility of our subtyping results. In conclusion, the identified OCD subtypes shed new light on the taxonomy and neurophysiological heterogeneity of OCD.

Naproxen adjunct to fluoxetine for moderate-to-severe obsessive-compulsive disorder: A randomized, double-blind, placebo-controlled trial

AIM

Current treatments for obsessive-compulsive disorder (OCD) encounter resistance and limiting adverse events, necessitating novel therapeutic strategies. This study aimed to investigate the benefits of naproxen, a medication with effects on inflammation and neuronal function, on OCD.

METHODS

One hundred and four OCD outpatients with a Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) score of >21 were equally assigned to receive fluoxetine plus either naproxen 250 mg or matched placebo q12hr. Patients were assessed using the Y-BOCS by recording the subscale scores at baseline and weeks 5 and 10 to evaluate efficacy. They were also assessed in terms of tolerability.

RESULTS

Data from 96 patients were analyzed. The baseline characteristics were comparable between the groups. There were significant time-treatment interaction effects on the obsession subscale (η P 2  = 0.055) and total (η P 2  = 0.043) scores of Y-BOCS. Reductions in the obsession subscale and total scores of Y-BOCS were significantly greater in the fluoxetine plus naproxen group until the endpoint (Cohen's d = 0.560 and Cohen's d = 0.477, respectively). However, the difference in compulsion subscale score changes between the groups was not significant. Respondents with a reduction of ≥35% in Y-BOCS total scores were significantly more in the fluoxetine plus naproxen group (80.0% versus 47.8%). The side effect frequencies were comparable between the groups.

CONCLUSION

Naproxen, adjunct to fluoxetine, outperformed adjunctive placebo in treating obsession and total symptoms of OCD patients in a safe and tolerable manner.

CLINICAL TRIAL REGISTRATION

The study protocol was registered and published in the Iranian Registry of Clinical Trials (http://www.irct.ir; registration number IRCT20090117001556N139).

Assessing the Pharmacotherapy and Clinical Outcomes After Deep Brain Stimulation for Treatment-Refractory Obsessive-Compulsive Disorder: A Case-Cohort Study

Background: In the search for effective treatments for refractive obsessive-compulsive disorder (OCD), deep brain stimulation (DBS) serves as an alternative option for those with minimal response to pharmacotherapy. The rarity of reports regarding DBS use for OCD is attributed to the invasive nature of the procedure: placement of electrodes within targeted areas of the brain to provide neuromodulation. This treatment of last resort may decrease functional impairment and pharmacologic complications for a debilitating mental illness. This study compares the pharmacotherapy utilization and treatment outcomes of five treatment-refractory OCD patients after the placement of DBS with those of a matched cohort. Methods: This retrospective, single-center, case-cohort study reviewed the electronic medical records of five subjects treated with DBS for treatment-refractory OCD and compared them to a similar treatment-refractory cohort whose OCD was treated without the use of DBS. Control subjects were matched by age, sex, years since diagnosis, number of previous medication class trials, and additional clinical factors. Inclusion criteria were defined as those that are at least eighteen years of age, assigned a primary diagnosis of OCD per the ICD-10 classification, and received DBS treatment for refractory OCD. Exclusion criteria included comorbid psychotic disorders, unstable neurological or coagulation disorder(s), and/or an eating disorder diagnosis. The primary endpoint was the change in the number of psychotropic medications two years after implantation for the DBS cohort and two years after psychiatric decompensation for the comparator cohort. Secondary endpoints included: Y-BOCS (the Yale-Brown Obsessive-Compulsive Scale) changes over time, duration quantity of psychotropic medication classes prescribed, and additional symptomology scale changes. Results: Patients receiving DBS were more likely to be on fewer medications and trialed fewer medications after treatment. One out of the five patients was found to be a responder in Y-BOCS scoring after DBS treatment. A reduction in anxiety and depression symptoms was also seen in the HAM-A and HAM-D scales for those that received DBS. Conclusions: A reduction in psychiatric medications trialed during therapy was observed, as well as varying reductions in OCD, anxiety, and depression symptomology following DBS. Results from this study indicate that DBS implantation may contribute to a reduction in polypharmacy while displaying DBS's potential impact on comorbid anxiety and depression symptoms. Given that the small sample size limits generalizability, additional prospective, randomized trials comparing the efficacy of DBS for OCD-specific symptomology and its overall impact on pharmacotherapy are needed in order to further establish the role of DBS as an accepted treatment option for OCD.

Correlation between compulsive behaviors and plastic changes in the dendritic spines of the prefrontal cortex and dorsolateral striatum of male rats

Obsessive-compulsive disorder (OCD) is a mental affliction characterized by compulsive behaviors often manifested in intrusive thoughts and repetitive actions. The quinpirole model has been used with rats to replicate compulsive behaviors and study the neurophysiological processes associated with this pathology. Several changes in the dendritic spines of the medial prefrontal cortex (mPFC) and dorsolateral striatum (DLS) have been related to the occurrence of compulsive behaviors. Dendritic spines regulate excitatory synaptic contacts, and their morphology is associated with various brain pathologies. The present study was designed to correlate the occurrence of compulsive behaviors (generated by administering the drug quinpirole) with the morphology of the different types of dendritic spines in the mPFC and DLS. A total of 18 male rats were used. Half were assigned to the experimental group, the other half to the control group. The former received injections of quinpirole, while the latter rats were injected with physiological saline solution, for 10 days in both cases. After the experimental treatment, the quinpirole rats exhibited all the parameters indicative of compulsive behavior and a significant correlation with the density of stubby and wide neckless spines in both the mPFC and DLS. Dendritic spines from both mPFC and DLS neurons showed plastic changes correlatively with the expression of compulsive behavior induced by quinpirole. Further studies are suggested to evaluate the involvement of glutamatergic neurotransmission in the neurobiology of OCD.

Abnormalities in static and dynamic intrinsic neural activity and neurotransmitters in first-episode OCD

BACKGROUND

Obsessive-compulsive disorder (OCD) is a disabling disorder in which the temporal variability of regional brain connectivity is not well understood. The aim of this study was to investigate alterations in static and dynamic intrinsic neural activity (INA) in first-episode OCD and whether these changes have the potential to reflect neurotransmitters.

METHODS

A total of 95 first-episode OCD patients and 106 matched healthy controls (HCs) were included in this study. Based on resting-state functional magnetic resonance imaging (rs-fMRI), the static and dynamic local connectivity coherence (calculated by static and dynamic regional homogeneity, sReHo and dReHo) were compared between the two groups. Furthermore, correlations between abnormal INA and PET- and SPECT-derived maps were performed to examine specific neurotransmitter system changes underlying INA abnormalities in OCD.

RESULTS

Compared with HCs, OCD showed decreased sReHo and dReHo values in left superior, middle temporal gyrus (STG/MTG), left Heschl gyrus (HES), left putamen, left insula, bilateral paracentral lobular (PCL), right postcentral gyrus (PoCG), right precentral gyrus (PreCG), left precuneus and right supplementary motor area (SMA). Decreased dReHo values were also found in left PoCG, left PreCG, left SMA and left middle cingulate cortex (MCC). Meanwhile, alterations in INA present in brain regions were correlated with dopamine system (D2, FDOPA), norepinephrine transporter (NAT) and the vesicular acetylcholine transporter (VAChT) maps.

CONCLUSION

Static and dynamic INA abnormalities exist in first-episode OCD, having the potential to reveal the molecular characteristics. The results help to further understand the pathophysiological mechanism and provide alternative therapeutic targets of OCD.

A Multicomponent Cognitive-Behavioral Hypnotic Approach for Obsessive-Compulsive Disorder Treatment: A Case Study

This article proposes a multicomponent hypnotherapeutic approach for obsessive-compulsive disorder (OCD) treatment. This new approach combines hypnosis with exposure and response prevention, cognitive reappraisal, principles of acceptance and commitment therapy, and other components. In the presented case study, the patient was treated for four months with both biological and psychological first-line therapy with minor effects; the patient was then treated with hypnotherapy. The patient listened to a recorded hypnosis session, which was constructed according to the new proposed principle. After three weeks of near-daily listening to the session, the patient's Yale-Brown Obsessive-Compulsive Scale score decreased by 38.5%, which helped achieve a 51.5% reduction from the initial score, suggesting that this method might have significantly contributed to the therapeutic outcome. In addition, this article discusses the differences between the proposed approach and previously published hypnotherapeutic methods for OCD treatment and the hypothetical use of such an approach for other disorders characterized by compulsive behavior. Further randomized controlled studies are needed to confirm the efficacy of hypnotic approaches for treating OCD.

New horizons for obsessive-compulsive disorder drug discovery: is targeting glutamate receptors the answer?

INTRODUCTION

Over the past decade, glutamate has emerged as a prominent focus in the field of obsessive-compulsive disorder (OCD) pathophysiology. A convergence of evidence from genetic, preclinical, and clinical studies points to glutamatergic dysfunction as a key feature of this condition. In light of these findings, there has been a growing interest in exploring the potential of glutamatergic agents in the treatment of OCD.

AREAS COVERED

This paper reviews the literature on glutamate transmission in OCD. In addition, the authors examine the results of clinical trials investigating the efficacy of glutamatergic agents in the treatment of OCD patients.

EXPERT OPINION

Along with the recognition of neuroinflammation in the brain in OCD, the evidence of glutamate dysfunction represents one of the most promising recent discoveries for understanding the mechanisms involved in OCD. The importance of this discovery lies primarily in its pharmacological implications and has led to intense research activity in the field of glutamatergic agents. While this research has not yet had a substantial clinical impact, targeting glutamate receptors remains a promising horizon for the successful treatment of OCD patients.

Prescribing patterns in patients with obsessive-compulsive disorder: Retrospective, single-center study

INTRODUCTION

Obsessive-compulsive disorder (OCD) is marked by a high rate of treatment resistance. Patients are often left trialing medications within multiple drug classes with little response, causing heterogeneity to emerge in prescribing patterns. This analysis seeks to investigate the selection and dosing of the pharmacotherapy utilized, to portray an overview of prescribing trends in the United States.

METHODS

This retrospective, single center, review of electronic medical records investigated the pharmacotherapy utilization of patients with a primary diagnosis of OCD. Two hundred and ninety-five patients who received OCD treatment at an urban, academic medical center were included in the study. Patients were included in the review if they were at least eighteen years of age and were assigned a diagnosis of OCD according to DSM-5 criteria.

RESULTS

Psychotropic pharmacotherapy was integrated into the care of 93% of patients. Selective serotonin reuptake inhibitors were the most utilized medication class at 85% followed by benzodiazepines (47%) and second-generation antipsychotics (37%). Tricyclic antidepressants and first-generation antipsychotics were the two medication classes utilized the least at 13% and 2% respectively. Additionally, mood stabilizers and serotonin-norepinephrine reuptake inhibitors were utilized at rates of 8% and 16%, respectively.

CONCLUSIONS

Evidence-based treatment guidelines are being followed with varying augmentation strategies widely prevalent, thus displaying the heterogeneity in treating OCD. A high rate of benzodiazepine utilization highlights a practice trend with potential ties to clinical factors, such as the latency to treatment effect of other first-line pharmacotherapies. Future prospective studies are required to determine the cultural, pharmacoeconomic and pharmacogenomic factors that contribute to the variation in prescribing practices and whether these variations influence treatment outcomes.

Agomelatine efficacy in treatment resistant obsessive-compulsive disorder: A randomized controlled trial

BACKGROUND

Obsessive-compulsive disorder (OCD) is a prevalent and burdensome mental health condition, often resistant to conventional treatments. Agomelatine (Valdoxan), a compound acting on serotonin and melatonin systems, has shown promise in treating those with treatment-resistant OCD based on anecdotal reports and case studies.

METHODS

A randomized, double-blind controlled trial was conducted with 60 patients diagnosed with treatment-resistant OCD. Participants were randomized into an intervention group (receiving agomelatine 50 mg/day) and a control group (receiving placebo). OCD symptoms were assessed using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) over a 12-week period.

RESULTS

There were no significant differences in age, gender, or baseline Y-BOCS scores between intervention and control groups. Agomelatine did not demonstrate a significant improvement in OCD symptoms compared to placebo. Adverse events were comparable between groups, and liver enzyme levels remained within the normal range.

CONCLUSION

This study, while not confirming superior efficacy compared to placebo, underscores the need for continued investigation into agomelatine's potential for treating specific subgroups of OCD patients, underscoring the need for more comprehensive and well-controlled trials in the future.

Early-onset obsessive-compulsive disorder: Sociodemographic and clinical characterization of a large outpatient cohort

INTRODUCTION

Obsessive-compulsive disorder (OCD) is a prevalent and disabling condition characterized by a wide variety of phenotypic expressions. Several studies have reinforced the hypothesis of OCD heterogeneity by proposing subtypes based on predominant symptomatology, course, and comorbidities. Early-onset OCD (EO) could be considered a neurodevelopmental subtype of OCD, with evidence of distinct neurocircuits supporting disease progression. To deepen the heterogeneous nature of the disorder, we analyzed sociodemographic and clinical differences between the EO and late-onset (LO) subtypes in a large outpatient cohort.

METHODS

Two hundred and eighty-four patients diagnosed with OCD were consecutively recruited from the OCD Tertiary Clinic at Luigi Sacco University Hospital in Milan. Sociodemographic and clinical variables were analyzed for the entire sample and compared between the two subgroups (EO, age <18 years [n = 117,41.2 %]; LO: late-onset, age ≥18 years [n = 167, 58.8 %]).

RESULTS

The EO group showed a higher frequency of male gender (65 % vs 42.5 %, p < .001), and a higher prevalence of Tic and Tourette disorders (9.4 % vs 0 %, p < .001) compared to the LO group. Additionally, in the EO subgroup, a longer duration of untreated illness was observed (9.01 ± 9.88 vs 4.81 ± 7.12; p < .001), along with a lower presence of insight (13.8 % vs. 7.5 %, p < .05).

CONCLUSIONS

The early-onset OCD subtype highlights a more severe clinical profile compared to the LO group. Exploring distinct manifestations and developmental trajectories of OCD can contribute to a better definition of homogeneous subtypes, useful for defining targeted therapeutic strategies for treatment.

Ketamine Infusion in a Resistant Obsessive-Compulsive Disorder Patient in Bangladesh with Severe Suicidal Ideation: A Case Report

Treatment of resistant obsessive-compulsive disorder (OCD) typically results in insufficient symptom alleviation, and even long-term medication often fails to have the intended effect. Ketamine is a potent non-competitive antagonist of the N-methyl-D-aspartate (NMDA) receptor. Studies have shown that low-dose ketamine infusion results in a considerable reduction in obsessive-compulsive symptoms and a rapid resolution of suicidal ideation. This is a case report on the effect of intravenous ketamine infusion on a patient with resistant OCD and severe suicidal ideation. Intravenous (IV) ketamine was given once a week over consecutive three weeks with necessary precautions. Psychometric tools such as the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), the Clinical Global Impressions Scale (CGI-S), the Beck Scale for Suicidal Ideations (BSSI), and Depression Anxiety and Stress Scale 21 (DASS-21) were applied before and after infusions. Obsessive-compulsive symptoms and suicidal severity started to decrease rapidly after the first infusion. However, after a transient improvement, these symptoms again began to increase after a stressful incident on the second day of the first infusion. All the symptoms measured by validated rating scales showed continued improvement after the following two infusions. The improvement was sustained until discharge (one week after the last infusion) and subsequent follow-up in the sixth and 12th weeks. The role of ketamine in reducing suicidal thoughts and behavior is already established. Very few studies emphasized its effectiveness in improving severe/resistant obsessive-compulsive symptoms. This pioneering work may offer scope for similar research in the relevant field.

Rethinking Clozapine: Lights and Shadows of a Revolutionary Drug

The current literature globally highlights the efficacy of Clozapine in several psychiatric disorders all over the world, with an FDA indication for reducing the risk of repeated suicidal behavior in patients with schizophrenia or schizoaffective disorder. A growing field of research is also stressing a possible broader beneficial effect of Clozapine in promoting neuroprotection and neurotrophism. However, this drug is linked to several life-threatening side effects, such as agranulocytosis, myocarditis and seizures, that limit its use in daily clinical practice. For this work, a search was performed on PubMed using the terms "Clozapine indications", "Clozapine adverse effects", "Clozapine regenerative effects", and "Clozapine neuroplasticity" with the aim of reviewing the scientific literature on Clozapine's treatment indications, adverse effects and potential regenerative role. The results confirmed the efficacy of clozapine in clinical practice, although limited by its adverse effects. It appears crucial to raise awareness among clinicians about the potential benefits of using Clozapine, as well educating medical personnel about its risks and the early identification of possible adverse effects and their management.

A closer look to neural pathways and psychopharmacology of obsessive compulsive disorder

The intricate neural pathways involved in obsessive-compulsive disorder (OCD) affect areas of our brain that control executive functioning, organization, and planning. OCD is a chronic condition that can be debilitating, afflicting millions of people worldwide. The lifetime prevalence of OCD in the US is 2.3%. OCD is predominantly characterized by obsessions consisting of intrusive and unwanted thoughts, often with impulses that are strongly associated with anxiety. Compulsions with OCD encompass repetitive behaviors or mental acts to satisfy their afflicted obsessions or impulses. While these factors can be unique to each individual, it has been widely established that the etiology of OCD is complex as it relates to neuronal pathways, psychopharmacology, and brain chemistry involved and warrants further exploration.

Implication of microbiota gut-brain axis in the manifestation of obsessive-compulsive disorder: Preclinical and clinical evidence

Recent research has highlighted the key role of gut microbiota in the development of psychiatric disorders. The adverse impact of stress, anxiety, and depression has been well documented on the commensal gut microflora. Thus, therapeutic benefits of gut microbiota-based interventions may not be avoided in central nervous system (CNS) disorders. In this review, we outline the current state of knowledge of gut microbiota with respect to obsessive-compulsive disorder (OCD). We discuss how OCD-generated changes corresponding to the key neurotransmitters, hypothalamic-pituitary-adrenal axis, and immunological and inflammatory pathways are connected with the modifications of the microbiota-gut-brain axis. Notably, administration of few probiotics such as Lactobacillus rhamnosus (ATCC 53103), Lactobacillus helveticus R0052, Bifidobacterium longum R0175, Saccharomyces boulardii, and Lactobacillus casei Shirota imparted positive effects in the management of OCD symptoms. Taken together, we suggest that the gut microbiota-directed therapeutics may open new treatment approaches for the management of OCD.

Will Transcranial Magnetic Stimulation Improve the Treatment of Obsessive-Compulsive Disorder? A Systematic Review and Meta-Analysis of Current Targets and Clinical Evidence

BACKGROUND

Although in 2017 a repetitive transcranial magnetic stimulation (rTMS) protocol received Food and Drug Administration approval for the first time for the treatment of obsessive-compulsive disorder (OCD), which neural target and which protocol should be used for OCD are still debated. The aim of the present study was to perform a systematic review and meta-analysis of the available open and sham-controlled trials.

METHODS

The primary analysis included a pairwise meta-analysis (over 31 trials), and then subgroup analyses were performed for each targeted brain area. Meta-regression analyses explored the possible moderators of effect size.

RESULTS

The pairwise meta-analysis showed a significant reduction in OCD symptoms following active rTMS (g = -0.45 [95%CI: -0.62, -0.29]) with moderate heterogeneity (I² = 34.9%). Subgroup analyses showed a significant effect of rTMS over the bilateral pre-SMA (supplementary motor area), the DLPFC (dorsolateral prefrontal cortex), the ACC/mPFC (anterior cingulate cortex and medial prefrontal cortex), and the OFC (orbitofrontal cortex). No moderators of the effect size emerged.

CONCLUSIONS

TMS of several brain targets represents a safe and effective treatment option for OCD patients. Further studies are needed to help clinicians to individualize TMS protocols and targets for each patient.

A Case Series of Continuous Theta Burst Stimulation Treatment for the Supplementary Motor Area Twice a Day in Patients with Obsessive-Compulsive Disorder: A Real World TMS Registry Study in Japan

Obsessive-compulsive disorder (OCD) is a psychiatric disorder characterized by patterns in which unwanted thoughts and fears are evoked as obsessions and furthermore, compulsive behaviors are provoked repeatedly, with a prevalence rate of 2% of the population. These obsessive-compulsive symptoms disrupt daily life and cause great distress to the individual. At present, OCD is treated with antidepressants, mainly selective serotonin reuptake inhibitors, and psychotherapy, including the exposure and response prevention method. However, these approaches may only show a certain level of efficacy, and approximately 50% of patients with OCD show treatment resistance. This situation has led to the research and development of neuromodulation therapies, including transcranial magnetic stimulation treatment, for OCD worldwide in recent years. In this case series, we retrospectively analyzed the TMS registry data of continuous theta burst stimulation (cTBS) therapy targeting the bilateral supplementary motor cortex for six patients with OCD whose obsessive-compulsive symptoms had not improved with pharmacotherapy. The results suggest that treatment with cTBS for the bilateral supplementary motor area may reduce obsessive-compulsive symptoms in patients with OCD, despite the limitations of an open-label preliminary case series. The present findings warrant further validation with a randomized, sham-controlled trial with a larger sample size in the future.

Clinical Effectiveness of N-Methyl-D-Aspartate (NMDA) Receptor Antagonists in Adult Obsessive-Compulsive Disorder (OCD) Treatment: A Systematic Review

Obsessive-compulsive disorder (OCD) is a neuropsychiatric disorder that affects approximately 2% of the human population. Traditional treatment of OCD includes selective serotonin reuptake inhibitor (SSRI) or serotonin reuptake inhibitor (SRI) treatment along with cognitive behavioral therapy (CBT). Nearly 25%-30% of OCD patients do not respond to SSRIs. Glutamatergic agents are currently being studied for the treatment of OCD due to the glutamatergic pathway in the brain, related to OCD, and the role of the cortico-striato-thalamic circuit (CSTC). This review assesses the clinical effectiveness of N-methyl-D-aspartate (NMDA) antagonists, ketamine/esketamine, memantine, and amantadine, for adult patients with OCD. Inclusion criteria include human studies published within the last 15 years, with patients diagnosed with OCD, aged over 18 years, with only psychiatric comorbidities, and full-text articles. Papers that included interventions other than CBT, exposure with response prevention (ERP), and SSRI/SRI were excluded. Articles were searched for using PubMed, PubMed Central, Medical Literature Analysis and Retrieval System Online, GeorgiA LIbrary LEarning Online, EBSCO Information Services, OpenAthens, Multidisciplinary Digital Publishing Institute, and Google Scholar databases, last searched on December 2, 2022. The risk of bias was assessed using Cochrane Risk of Bias tools, the Scale for the Assessment of Narrative Review Articles (SANRA) checklist for literature reviews, and the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for quasi-experimental studies. Results were presented and synthesized by Excel spreadsheet analysis. The database search yielded 4,221 articles, which was cut down to 18 articles by inclusion/exclusion criteria, including duplications. 80% of the ketamine studies resulted in a significant reduction of obsessions and compulsions based on the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), and each of the memantine and amantadine studies displayed clinical effectiveness, also. Limitations include the small number of amantadine studies and the limited availability of other NMDA receptor (NMDAR) antagonist-focused studies. This systematic review shows that ketamine is an effective drug for the treatment of non-refractory, mild to moderate OCD, and memantine and amantadine are effective augmentation agents for the treatment of mild to severe OCD.