Treatment of risperidone-induced obsessive-compulsive symptoms with sertraline

The association of HTR2A polymorphisms with obsessive-compulsive disorder and its subtypes: A meta-analysis

BACKGROUND

Genetic risk factors that contribute to obsessive-compulsive disorder (OCD) have yet to be elucidated. Historically, serotonergic dysfunction has been implicated. Evidence from the literature points towards the serotonin receptor 2A gene (HTR2A) as a primary candidate. Our meta-analysis investigated whether polymorphisms in HTR2A are associated with OCD or its subtypes, based on sex and age of onset.

METHODS

Studies employing case-control or family-based designs were systematically searched, and those meeting eligibility underwent quality assessment, resulting in 18 studies. A random-effects meta-analysis using standard inverse-variance weighting to compute odds ratio (OR) was conducted. To examine sensitivity, results were also obtained using a more conservative statistical method.

RESULTS

Three HTR2A variants were identified: T102C, G-1438A, and C516T. T102C and G-1438A were analyzed together due to strong linkage disequilibrium, where the 102T allele co-occurs with -1438A allele. Results reported as OR [95%CI] showed that the T/A allele were significantly associated with OCD, 1.14 [1.01, 1.29]. After stratification, results remained significant for females, 1.20 [1.00, 1.45], and early-onset OCD, 1.27 [1.02, 1.58], but not males, 1.06 [0.91, 1.23]. No associations were found for late-onset OCD, 0.98 [0.70, 1.37], or C516T, 1.22 [0.14, 10.37], but conclusions cannot be drawn from two studies.

LIMITATIONS

Associations no longer reached significance with the conservative statistical approach. HTR2A alone cannot explain OCD complexity and limited samples reporting genetic data according to subtypes.

CONCLUSIONS

These results suggest a possible association of HTR2A polymorphisms with OCD, but further investigations considering sex and age of onset with larger samples is needed.

Suicidality in clozapine-treated patients with schizophrenia: role of obsessive-compulsive symptoms

Patients with schizophrenia have an increased lifetime risk of comorbid obsessive-compulsive symptoms. Up to 30% of these patients experience such symptoms and 12% may be diagnosed with obsessive-compulsive disorder. The presence of these symptoms in schizophrenia seems to be associated with poor outcomes including a greater suicidal risk. A subgroup of patients develops this symptomatology after the initiation with Second Generation Antipsychotics (SGA). Also, there is evidence of a causal relationship for this association, particularly for clozapine. The primary aim of this study was to investigate the association of this comorbidity with suicidality in a population of clozapine-medicated schizophrenic and schizoaffective patients (N=65). The prevalence of obsessive-compulsive symptoms in our sample was 29.2% (N=19) and the prevalence of obsessive-compulsive disorder was 13.8% (N=9). Significant positive correlations between suicidality and total Y-BOCS score and between Y- BOCS score and depressive symptoms were found. Further analysis indicated that a Y-BOCS score greater or equal than 8 was an independent predictor of suicide attempt during clozapine treatment. Routine screening for this adverse event should be warranted for this population.

Second generation antipsychotic-induced obsessive-compulsive symptoms in schizophrenia: a review of the experimental literature

Second generation antipsychotics (SGAs) have been implicated in the de novo emergence and exacerbation of obsessive-compulsive symptoms (OCS) in patients with schizophrenia. Among SGAs, clozapine, olanzapine, and risperidone are the most prominent agents associated with these sequelae, according to case reports. Comorbid OCS can impede recovery by compromising treatment benefits, medication compliance, and clinical prognoses. Previous reviews of SGA-induced OCS have predominantly focused on descriptive case reports, with limited attention paid toward experimental findings. To address this paucity of data, we sought to review the effects of SGAs on OCS in schizophrenia in the experimental literature, while addressing the role of different treatment (duration, dose, serum levels) and pharmacogenetic factors. Our findings suggest that clozapine confers the greatest risk of OCS in schizophrenia, with 20 to 28% of clozapine-treated patients experiencing de novo OCS, in addition to 10 to 18% incurring an exacerbation of pre-existing OCS. Clozapine can also yield full threshold obsessive-compulsive disorder (OCD), in some cases. Olanzapine is another high risk drug for secondary OCS which occurs in 11 to 20% of schizophrenic patients receiving olanzapine therapy. At this time, there is insufficient experimental evidence to characterize the effects of other SGAs on OCS. Despite some experimental support for the involvement of longer treatment duration and genetic factors in mediating drug-induced OCS, more research is needed to clearly elucidate these associations. Based on these results, schizophrenic patients should be routinely monitored for OCS throughout the course of SGA treatment, particularly when clozapine or olanzapine is administered.

Management of schizophrenia with obsessive-compulsive features

Although obsessive-compulsive symptoms (OCS) in schizophrenia have been conceptually controversial and clinically challenging, recent evidence suggests that schizophrenia with OCS may constitute a distinct schizophrenic subgroup. Recent epidemiological and clinical findings have shown that the subgroup obsessive-compulsive (OC) schizophrenia is associated with poor outcome and is more frequent than previously realized. Emerging biological evidence suggests that OCS in schizophrenia has more than one pathogenesis, with distinct mechanisms that may require different treatment interventions. Therefore, the management of OCS in patients with schizophrenia requires an individualized treatment approach based on the pathogenesis and clinical status of the patient. For example, the atypical antipsychotics that are potent serotonin antagonists sometimes induce de novo or exacerbate preexisting OCS, which resolves if the patient is switched to an antipsychotic with a different profile or if adjunctive treatment with serotonin reuptake inhibitors (SSRIs) is undergone. Regarding OC schizophrenia, SSRIs are often a necessary part of treatment, with knowledge of potential pharmacokinetic interactions with antipsychotic drugs essential. In this article, recent progress and current knowledge of OC schizophrenia is reviewed and treatment guidelines are offered for this complex and challenging subgroup of schizophrenic patients.

Obsessive compulsive symptoms in schizophrenia: frequency and clinical features

OBJECTIVE

Prior studies have evaluated the occurrence and clinical effects of obsessive-compulsive (OC) symptoms in schizophrenia with varied results. This study systematically assessed the frequency and clinical impact of OC symptoms among outpatients with schizophrenia and schizoaffective disorder.

METHOD

One hundred subjects with schizophrenia or schizoaffective disorder were evaluated with a 20-question detailed screen for the presence of OC symptoms. The severity of OC symptoms was assessed with the Yale Brown Obsessive-Compulsive Scale (Y-BOCS). Fifty-eight patients participated in subsequent assessments comparing schizophrenia severity (Positive and Negative Syndrome Scale) functional status (Social and Occupational Functioning Scale) and resource utilization (psychiatric hospitalization) of OC (N=21) and non-OC (N=37) patients.

RESULTS

Thirty percent of patients exhibited two or more OC symptoms, and 19% had at least moderate OC symptoms (Y-BOCS score >or= 16). Twenty-three percent met full DSM-IV criteria for OCD. There were no differences observed between the OC and non-OC groups on any of the clinical outcomes. OC symptoms were developed prior to the onset of schizophrenia in only 28% of patients.

CONCLUSIONS

Nearly one-third of patients exhibited clinically significant OC symptoms in this systematic, cross-sectional assessment. However, OC symptoms did not appear to impact the clinical outcome of patients. In most cases, OC symptoms began concurrently with or after the onset of the psychotic disorder. Studies are needed to define the relevance and pathological basis for the co-occurrence of OC symptoms in persons with schizophrenia.

[Obsessive-compulsive symptoms treatment in: schizophrenia]

Obsessive-compulsive symptoms (OCSs) frequently occur in schizophrenia and seem to worsen prognosis. Many case studies suggest that OCSs appear or worsen with an atypical antipsychotic agent treatment (that is, with risperidone, olanzapine, and clozapine). Therefore, family or personal history of OCS should be investigated before initiating such treatment, and OCS onset should be monitored during treatment. Clozapine is involved in most such cases. When OCSs appear with clozapine, dosage can be reduced and a serotonin reuptake inhibitor treatment added. Current studies suggest that patients with schizophrenia and OCSs should benefit from treatment with an antipsychotic and an antiobsessive medication. Two controlled trials deal with OCS treatment in schizophrenia: the first, with clomipramine; and the second, with fluvoxamine. Both have proven their efficacy, but these trials include a small number of patients with heterogeneous characteristics.

The paradox of quetiapine in obsessive-compulsive disorder

Schizophrenia and obsessive-compulsive disorder (OCD) have historical, clinical, and epidemiological links. The clinical use of atypical neuroleptics (ie, dual serotonin-dopamine antagonists) to treat both conditions sheds a new light on them. We report the first two cases of obsessive-compulsive symptoms (OCS) induced by quetiapine in schizophrenia patients. A case of successful augmentation by quetiapine in refractory OCD is also presented. A review of the literature on OCS induced by atypical neuroleptics follows. This paradoxically induced OCD symptomology in schizophrenia patients administered atypical neuroleptics is discussed from new pathophysiological and clinical perspectives. The discussion emphasizes the prognostic implications of OCS in schizophrenia and available therapies for this comorbidity.

Obsessive-compulsive disorder in schizophrenia: clinical characteristics and treatment

There is a considerable overlap of schizophrenia and obsessive-compulsive disorder (OCD) in the structural and functional brain abnormalities involved, role of the dopamine/serotonin neurotransmitter systems, and some demographic and clinical characteristics. Although OCD co-occurs in a substantial proportion of schizophrenia patients, a systematic evaluation of the clinical features and treatment of this population is lacking. This review critically evaluates findings of recent studies pertaining to the rate of occurrence of OCD or obsessive-compulsive symptoms (OCS) in schizophrenia and the clinical characterisation of the schizo-obsessive subtype. Specifically, interrelationships between obsessive-compulsive and schizophrenic symptoms in terms of temporal relationships and their association with specific schizophrenia subtypes and the effect of OCS on the severity of schizophrenia symptoms are addressed. In the absence of evidence-based data, tentative therapeutic approaches in this difficult-to-treat patient subgroup are suggested. These include monotherapy with atypical antipsychotic agents or a combination of either typical or atypical antipsychotics with SSRIs or clomipramine. The clinical characteristics of antipsychotic-induced OCS/OCD are also presented to facilitate identification and management of this rare but clinically significant adverse effect. Finally, future directions of research in schizophrenia-OCD comorbidity relevant to clinical practice are discussed.

Obsessive-compulsive symptoms associated with clozapine and risperidone treatment: three case reports and review of the literature

Treatment-emergent obsessive-compulsive symptoms (OCSs) have raised concern since the widespread introduction of serotonin-dopamine antagonists (SDAs) for the treatment of schizophrenia. Further investigations of SDA-emergent OCSs and their response to anti-obsessional agents will be beneficial for clinicians in helping patients who suffer from this problem. We present three cases of schizophrenia in which distressing OCSs occurred during clozapine or risperidone treatment. OCSs were assessed consecutively using the Yale-Brown Obsessive-Compulsive Scale. The OCSs of these three patients were responsive to anti-obsessional agents, including fluvoxamine, clomipramine, and paroxetine. We also review the current literature and discuss the possible pathophysiology and psychopathology of SDA-emergent OCSs.

[Pharmacotherapy of compulsive disorders in childhood and adolescence]

OBJECTIVES

The review addresses the issue of the extent to which pharmacological treatment of obsessive-compulsive disorders (OCD) in childhood and adolescence is based on empirical studies.

METHODS

Current literature is evaluated, including studies of adult cohorts if these contain approaches relevant for the pharmacological treatment of children and adolescents.

RESULTS

The number of qualified empirical studies is few. These studies have shown clomipramine and serotonin-reuptake inhibitors to be very effective in the therapy of obsessive-compulsive disorders in childhood and adolescence. On the basis of the studies available, no specific recommendation can be made with regard to pharmacological dosage. For clomipramine the effective daily dose probably ranges somewhere between 75-150 mg, for fluoxetin between 20-60 mg, and for fluvoxamine between 100-250 mg. However, it must be kept in mind that in individual cases, improvement sometimes will not be noticeable until after 8 to 10 weeks of treatment have elapsed.

CONCLUSION

Clomipramine and serotonin-reuptake inhibitors are effective in the treatment of obsessive-compulsive disorders in children and adolescents. There is an urgent need for therapy studies of obsessive-compulsive disorders in childhood and adolescence. Placebo-controlled studies of pharmacological treatment, controlled studies of psychotherapeutic treatment, and comparative studies of pharmacological and psychotherapeutic approaches are necessary.

Obsessive-compulsive symptoms induced by atypical antipsychotics. A review of the reported cases

Atypical antipsychotics (APs) are now widely in use in clinical practice. They exert a beneficial effect in patients with schizophrenic disorders, including cases resistant to traditional APs and negative symptoms. They have also enhanced the ratio of therapeutic efficacy to adverse effects. Atypical APs, mainly risperidone and olanzapine, have been used as adjunctive treatment in (selective) serotonin reuptake inhibitor [(S)SRI]-refractory cases with obsessive symptoms. However, de novo emergence or exacerbation of obsessive-compulsive (OC) symptoms during treatment with clozapine, risperidone, olanzapine and quetiapine has been described in the literature. The reported cases and the possible pathogenetic mechanisms involved in their occurrence are discussed and reviewed.

A neural network approach to the outcome definition on first treatment with sertraline in a psychiatric population

Therapy decision is one of the most important tasks clinicians have to perform in their clinical practice. The decision process requires taking into account many different factors. The Authors have proposed a neural computing approach for supporting clinical decision analysis. The mathematical model of artificial neural network (ANN) has been applied on a pool of clinical information gathered through case description freely filled by senior psychiatrists into 416 clinical charts. Sertraline, as drug for treatment, has been chosen since its clinical uses range from treatment of depression to that of many other psychiatric clinical conditions so that it has been thought to be a good candidate to this type of study. The ANN performance in forecasting successful and unsuccessful treatment cases showed an overall accuracy of classification of 97.35%. This result suggests a possible future application of this method to obtain a reliable prediction of a given psychiatric patient outcome during a specific psychopharmacological therapy, optimising the decisional making process.

On the role of prefrontal cortex glutamate for the antithetical phenomenology of obsessive compulsive disorder and attention deficit hyperactivity disorder

1. The objective of the present study was to compare the phenomenology and pathophysiology of obsessive compulsive disorder (OCD) and attention deficit hyperactivity disorder/deficits in attention, motor control and perception (ADHD/DAMP). 2. Through detailed studies of the literature on OCD and ADHD/DAMP, the phenomenology of these two conditions is compared, and possible underlying pathophysiological mechanisms involving interactions between glutamate, dopamine, serotonin and acetylcholine are discussed, with emphasis on OCD. The present paper also discusses possible mechanisms of action for current pharmacological treatments of OCD and ADHD, as well as possible future treatment strategies for these disorders. 3. OCD and ADHD/DAMP are common neuropsychiatric conditions which in many regards appear to be each other's antipodes with respect to clinical manifestations, associated personality traits and brain biochemistry, notably prefrontal cortical glutamate activity. Future pharmacological treatments of these disorders may involve manipulations with glutamate, dopamine D , serotonin 2A and nicotine receptors. 4. It appears that OCD is a hyperglutamatergic and ADHD a hypoglutamatergic condition, with prefrontal brain regions being especially affected.

The selective serotonin reuptake inhibitor sertraline: its profile and use in psychiatric disorders

The naphthylamine derivative sertraline is a potent and selective inhibitor of serotonin reuptake into presynaptic terminals. Sertraline has a linear pharmacokinetic profile and a half-life of about 26 h. Its major metabolite, desmethylsertraline does not appear to inhibit serotonin reuptake. Sertraline mildly inhibits the CYP2D6 isoform of the cytochrome P450 system but has little effect on CYP1A2, CYP3A3/4, CYP2C9, or CYP2C19. It is, however, highly protein bound and may alter blood levels of other highly protein bound agents. Sertraline is a widely used serotonin reuptake inhibitor that has been shown to have both antidepressant and antianxiety effects. Many clinical trials have demonstrated its efficacy in depression compared with both placebo and other antidepressant drugs. Its efficacy has also been demonstrated in randomized, controlled trials of patients with obsessive-compulsive disorder, panic disorder, social phobia, and premenstrual dysphoric disorder. In short-term, open-label studies it has appeared efficacious and tolerable in children and adolescents and in the elderly, and data are positive for its use in pregnant or lactating women. Typical side effects include gastrointestinal and central nervous system effects as well as treatment-emergent sexual dysfunction; withdrawal reactions may be associated with abrupt discontinuation of the agent. The safety profile of sertraline in overdose is very favorable. Sertraline's efficacy for both mood and anxiety disorders, relatively weak effect on the cytochrome P450 system, and tolerability profile and safety in overdose are factors that contribute to make it a first-line agent for treatment in both primary and tertiary care settings.

Obsessive-compulsive disorder in schizophrenia

OBJECTIVE

To examine the differences in demographic and clinical features of patients with schizophrenia, with or without comorbid obsessive-compulsive disorder (OCD).

METHODS

Fifty-two subjects were recruited from clinical services in the city of Edmonton, Alberta and assessed for schizophrenia and OCD with structured clinical interviews and standardized clinical rating scales.

RESULTS

The prevalence of OCD in individuals meeting criteria for schizophrenia was 25%. Those subjects having both schizophrenia and OCD scored significantly higher on the Y-BOCS, Hollingshead scale, and GAF; plus significantly lower PANSS negative symptoms and a trend in increased Parkinsonian symptoms compared with individuals with schizophrenia alone.

CONCLUSION

Our preliminary findings indicate that patients with schizophrenia and OCD vary in selected demographic and clinical measures when compared to patients with schizophrenia alone. Patients with schizophrenia and OCD appear to have less negative symptoms, which may thus be reflected in the decreased GAF scores. It is speculated that patients with schizophrenia and OCD may have a greater propensity to basal ganglia dysfunction than those with schizophrenia alone resulting in increased Parkinsonian symptoms.

Demographics, Prevalence, and Clinical Features of the Schizo-obsessive Subtype of Schizophrenia

The schizo-obsessive subtype of schizophrenia has been proposed to describe the condition of patients with chronic psychotic disorders and prominent obsessive-compulsive (OC) symptoms. These patients differ from others with schizophrenia not only in their psychopathology, but perhaps also in their prognosis and pharmacotherapeutic response. Potent serotonin reuptake blockers, such as clomipramine, fluvoxamine, and fluoxetine, in conjunction with antipsychotics, can prove helpful in improving these patients' OC symptoms. The current study to access the demographics, prevalence, and clinical features of the schizo-obsessive subtype included established outpatients with a principal diagnosis of schizophrenia or schizoaffective disorder treated at a large urban public hospital. More than 50% of the hospital's psychiatric population is Hispanic. The Modified Maudsley Obsessive Compulsive Inventory (MMOCI) was used to identify prominent compulsive symptoms. Of the 52 patients who fulfilled the specific screening criteria, 17 (33%) also had prominent OC symptoms. Surprisingly, there was a statistical trend (P=0.06) for Hispanic patients to meet our threshold for the schizo-obsessive subtype. The MMOCI proved to be an adequate and efficient self-rated screening tool. The prevalence of the schizo-obsessive subtype, especially among Hispanic patients, highlights the importance for mental health professionals working with this population to identify and appropriately treat this group of patients.

An open trial of risperidone in young autistic children

OBJECTIVE

To assess the benefits and side effects of risperidone in young autistic children.

METHOD

In this open, prospective trial, subjects were treated with risperidone for 12 weeks. All subjects were started at 0.5 mg daily with individual titration to a maximum of 6 mg or 0.1 mg/kg daily. Behavioral ratings, completed by the investigators and the children's parents, included the Clinical Global Impressions (CGI), Children's Psychiatric Rating Scale, Conners Parent-Teacher Questionnaire, Childhood Autism Rating Scale, and Abnormal Involuntary Movement Scale.

RESULTS

Ten boys, aged 4.5 to 10.8 years, were enrolled in the study and all completed the 12-week protocol. The mean final dose was 1.3 mg/day (range = 1 to 2.5 mg/day). On the basis of CGI-rated improvement, 8 of the 10 children were considered to be responders. Improvement was also demonstrated on the other scales. Transient sedation was common, and the children gained an average of 3.5 kg over the 12 weeks of the study. There was no evidence of either extrapyramidal symptoms or tardive dyskinesia.

CONCLUSIONS

These results suggest that risperidone may be safe and leads to improvements in several behavioral symptoms in young children with autism. Controlled studies of risperidone in young autistic children are warranted.