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Tundo A, Salvati L, Cieri L, Balestrini V, Di Spigno D, Orazi F, Iommi M, Necci R. Serotonin reuptake inhibitor-cognitive behavioural therapy-second generation antipsychotic combination for severe treatment-resistant obsessive-compulsive disorder. A prospective observational study. Int J Psychiatry Clin Pract 2022; 26:395-400. [PMID: 35323098 DOI: 10.1080/13651501.2022.2054351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Six in ten patients with obsessive-compulsive disorder (OCD) do not respond to the first-line treatments with serotonin reuptake inhibitor (SRI) or cognitive behavioural therapy including exposure and response prevention (CBT/ERP), and several do not respond to second-line treatments, i.e., SRI-second generation antipsychotic (SGA) or SRI-CBT/ERP augmentation. Evidence on third-line treatments is inconsistent. OBJECTIVE We investigated the 1-year response to SRI-CBT/ERP-SGA combination in patients with severe treatment-resistant OCD, who failed to respond to SRI and to SRI-SGA or SRI-CBT/ERP augmentation. METHODS Twenty-eight patients were consecutively recruited and treated with SRI (drug(s) and doses previously administered), SGA (risperidone median dosage 1 mg/day in 14 cases, aripiprazole median dosage 3 mg/day in 14 cases) and CBT/ERP (median hours 32.5). Exclusion criteria: mental retardation and organic brain syndrome. RESULTS The mean Y-BOCS total score reduction at 12 months was 28.2%, 60.7% of patients improved, 46.4% partially responded, 32.1% responded, and 28.6% remitted. Patients previously resistant to SRI-SGA and SRI-CBT/ERP did not significantly differ in the rates of improvement, partial response, response and remission. CONCLUSIONS This study suggests that SRI-SGA-CBT/ERP combination could be useful for severe treatment-resistant OCD. Small sample size is a limitation.Key pointsUp to 6 in 10 patients with OCD do not respond to first line treatments (CBT/ERP or SRIs) and several to second-line treatments (SRI-SGA or SRI CBT/ERP augmentation).In our study, patients with OCD resistant to the first and the second line treatment improved (61%), partially responded (46%), responded (32%), or remitted (29%) combining SRI, SGA and CBT/ERP.In our patients the SRI-SGA-CBT/ERP augmentation improved working/school, social and family impairment.SRI-SGA-CBT/ERP augmentation is easier to use than other treatments for severe treatment-resistant OCD.
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Affiliation(s)
| | | | | | | | | | | | - Marica Iommi
- Dipertimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
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Albert U, Marazziti D, Di Salvo G, Solia F, Rosso G, Maina G. A Systematic Review of Evidence-based Treatment Strategies for Obsessive- compulsive Disorder Resistant to first-line Pharmacotherapy. Curr Med Chem 2019; 25:5647-5661. [PMID: 29278206 DOI: 10.2174/0929867325666171222163645] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 10/19/2017] [Accepted: 11/22/2017] [Indexed: 01/04/2023]
Abstract
BACKGROUND Serotonin reuptake inhibitors (SRIs) and cognitive-behavioral psychotherapy (CBT) are first-line treatments for obsessive-compulsive disorder (OCD). However, a significant proportion of patients do not respond satisfactorily to first-choice treatments. Several options have been investigated for the management of resistant patients. OBJECTIVE The aim of the present paper is to systematically review the available literature concerning the strategies for the treatment of resistant adult patients with OCD. METHOD We first reviewed studies concerning the definition of treatment-resistant OCD; we then analyzed results of studies evaluating several different strategies in resistant patients. We limited our review to double-blind, placebo-controlled studies performed in adult patients with OCD whose resistance to a first adequate (in terms of duration and dosage) SRI trial was documented and where outcome was clearly defined in terms of decrease in Yale-Brown Obsessive-Compulsive Scale (YBOCS) scores and/or response/ remission rates (according to the YBOCS). RESULTS We identified five strategies supported by positive results in placebo-controlled randomized studies: 1) antipsychotic addition to SRIs (16 RCTs, of them 10 positive; 4 head-to-head RCTs); among antipsychotics, available RCTs examined the addition of haloperidol (butyrophenone), pimozide (diphenyl-butylpiperidine), risperidone (SDA: serotonin- dopamine antagonist), paliperidone (SDA), olanzapine (MARTA: multi-acting receptor targeted antipsychotic), quetiapine (MARTA) and aripiprazole (partial dopamine agonist); 2) CBT addition to medication (2 positive RCTs); 3) switch to intravenous clomipramine (SRI) administration (2 positive RCTs); 4) switch to paroxetine (SSRI: selective serotonin reuptake inhibitor) or venlafaxine (SNRI: serotonin-norepinephrine reuptake inhibitor) when the first trial was negative (1 positive RCT); and 5) the addition of medications other than an antipsychotic to SRIs (18 RCTs performed with several different compounds, with only 4 positive studies). CONCLUSION Treatment-resistant OCD remains a significant challenge to psychiatrists. To date, the most effective strategy is the addition of antipsychotics (aripiprazole and risperidone) to SRIs; another effective strategy is CBT addition to medications. Other strategies, such as the switch to another first-line treatment or the switch to intravenous administration are promising but need further confirmation in double-blind studies. The addition of medications other than antipsychotics remains to be studied, as several negative studies exist and positive ones need confirmation (only 1 positive study).
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Affiliation(s)
- Umberto Albert
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy; A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
| | - Donatella Marazziti
- Dipartimento di Medicina Clinica e Sperimentale, Section of Psychiatry, University of Pisa, Pisa, Italy
| | - Gabriele Di Salvo
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy; A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
| | - Francesca Solia
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy; A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
| | - Gianluca Rosso
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy; A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
| | - Giuseppe Maina
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy; A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
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Albert U, Di Salvo G, Solia F, Rosso G, Maina G. Combining Drug and Psychological Treatments for Obsessive- Compulsive Disorder: What is the Evidence, When and for Whom. Curr Med Chem 2019; 25:5632-5646. [PMID: 28707590 DOI: 10.2174/0929867324666170712114445] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 04/11/2017] [Accepted: 05/30/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Serotonin reuptake inhibitors (SRIs) and cognitive-behavioral psychotherapy (CBT) are first-line treatments for obsessive-compulsive disorder (OCD). Since response is often inadequate, in recent years researchers investigated whether combining CBT and SRIs, either ab initio or sequentially, results in a greater reduction of obsessivecompulsive symptoms. OBJECTIVE The aims of the present paper are to assess if combination treatment seems adding benefits as compared to either monotherapy alone and if sequential strategies may be effective in converting partial or non responders to a first-line treatment into responders. METHOD We reviewed available literature on pharmacological and CBT combination and sequential treatments for adult and pediatric OCD patients and then we conducted a separate analysis for studies concerning these two promising strategies. Search results included openlabel trials and randomized controlled trials (RCTs). RESULTS We identified ten controlled studies assessing the efficacy of combination treatments ab initio versus CBT alone and six evaluating combination strategies ab initio versus medications alone. Eleven studies, only two of which were RCTs, have been published on sequential treatments. The combination ab initio of CBT and SRIs has not been found to be clearly superior to either monotherapy alone in most studies conducted on this topic, except for patients with severe depression who might benefit more from the combination versus only CBT. A sequential administration of CBT after medications has been found useful in promoting remission in patients who partially responded to drugs and in promoting response in resistant patients. CONCLUSION OCD patients with comorbid major depression should receive medication firstly, eventually associated with CBT; for all remaining patients there is clear evidence from the literature of no additive benefits of combining ab initio CBT and medication. Therefore, the routine use of a combination approach in all adult patients affected by OCD is not supported by the literature. The available evidence supports the effectiveness of the sequential addition of CBT to SRIs.
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Affiliation(s)
- Umberto Albert
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy, A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
| | - Gabriele Di Salvo
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy, A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
| | - Francesca Solia
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy, A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
| | - Gianluca Rosso
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy, A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
| | - Giuseppe Maina
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy, A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
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Marazziti D, Albert U, Dell'Osso B, Tundo A, Cuniberti F, Maina G, Moroni I, Benatti B, Mucci F, Massimetti G, Piccinni A, Brakoulias V. Italian prescribing patterns in obsessive-compulsive disorder. Hum Psychopharmacol 2017; 32. [PMID: 28967153 DOI: 10.1002/hup.2641] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 08/15/2017] [Accepted: 08/30/2017] [Indexed: 01/03/2023]
Abstract
The aim of the present study was to investigate psychopharmacological prescribing patterns in a large sample (n = 1815) of patients suffering from obsessive-compulsive disorder (OCD) recruited in 4 Italian centers specialized in OCD, in comparison to available national and international guidelines. The centers were asked to complete a specific data sheet questionnaire on patients' therapeutic status. Statistical analyses were carried out by SPSS. The results showed that almost all patients referred to the centers of Milan, Pisa and Rome received psychotropic medications, whereas only 59.9% (313) did so in Turin. Selective serotonin reuptake inhibitors were the most used drugs ranging between 49.0% and 71.5%. Clomipramine was prescribed more often in Rome and Pisa than in Milan and Turin. The same was true for other tricyclic antidepressants. Second-generation antipsychotics were more often prescribed in Pisa and in Milan. Mood stabilizers were almost exclusively used in Pisa. Taken together, the overall findings would suggest that, although the main Italian centers specialized in OCD follow available guidelines, a certain degree of variability does exist. This may depend on the different educational background, availability of other specific therapeutic strategies, as well as varying levels of severity and comorbidity of the patients.
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Affiliation(s)
- Donatella Marazziti
- Dipartimento di Medicina Clinica e Sperimentale, Section of Psychiatry, University of Pisa, Pisa, Italy
| | - Umberto Albert
- Rita Levi Montalcini Department of Neuroscience, University of Turin, and San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
| | - Bernardo Dell'Osso
- Dipartimento di Fisiopatologia-Medico Chirurgica e dei Trapianti, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico.,Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | | | - Francesco Cuniberti
- Rita Levi Montalcini Department of Neuroscience, University of Turin, and San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
| | - Giuseppe Maina
- Rita Levi Montalcini Department of Neuroscience, University of Turin, and San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
| | - Ilenia Moroni
- Dipartimento di Medicina Clinica e Sperimentale, Section of Psychiatry, University of Pisa, Pisa, Italy
| | - Beatrice Benatti
- Dipartimento di Fisiopatologia-Medico Chirurgica e dei Trapianti, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico
| | - Federico Mucci
- Dipartimento di Medicina Clinica e Sperimentale, Section of Psychiatry, University of Pisa, Pisa, Italy
| | - Gabriele Massimetti
- Dipartimento di Medicina Clinica e Sperimentale, Section of Psychiatry, University of Pisa, Pisa, Italy
| | - Armando Piccinni
- Dipartimento di Medicina Clinica e Sperimentale, Section of Psychiatry, University of Pisa, Pisa, Italy
| | - Vlasios Brakoulias
- Department of Psychiatry, Sydney Medical School Nepean, The University of Sydney, Sydney, NSW, Australia
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Janardhan Reddy YC, Sundar AS, Narayanaswamy JC, Math SB. Clinical practice guidelines for Obsessive-Compulsive Disorder. Indian J Psychiatry 2017; 59:S74-S90. [PMID: 28216787 PMCID: PMC5310107 DOI: 10.4103/0019-5545.196976] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Y C Janardhan Reddy
- Department of Psychiatry, OCD Clinic, National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - A Shyam Sundar
- Department of Psychiatry, OCD Clinic, National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - Janardhanan C Narayanaswamy
- Department of Psychiatry, OCD Clinic, National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - Suresh Bada Math
- Department of Psychiatry, OCD Clinic, National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, Karnataka, India
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Arumugham SS, Reddy YCJ. Commonly asked questions in the treatment of obsessive-compulsive disorder. Expert Rev Neurother 2013; 14:151-63. [PMID: 24372473 DOI: 10.1586/14737175.2014.874287] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Obsessive-compulsive disorder (OCD) is a common and often a highly disabling condition that was considered untreatable before the 1960s. The advent of serotonin reuptake inhibitors and exposure and response prevention revolutionized the treatment of OCD. Although they are still the first line treatments for OCD, new treatments like augmentation strategies, brain stimulation techniques, psychosurgery, newer forms of psychotherapy (like cognitive therapy, acceptance and commitment therapy) have been added to the armamentarium. With the available treatment strategies, many patients can achieve at least partial remission of symptoms. Nevertheless, the plethora of information gives rise to many questions on their application for practicing clinicians. We provide evidence-based responses to these questions and suggest a broad guideline for treatment of OCD.
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Affiliation(s)
- Shyam Sundar Arumugham
- Department of Psychiatry, Obsessive-Compulsive Disorder (OCD) Clinic, National Institute of Mental Health and NeuroSciences (NIMHANS), Bangalore, India-560029
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