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Levy DM, Arush OB, Carmi L, Wetzler AJ, Zohar J. Off-label higher doses of serotonin reuptake inhibitors in the treatment of obsessive-compulsive disorder: Safety and tolerability. Compr Psychiatry 2024; 133:152486. [PMID: 38703743 DOI: 10.1016/j.comppsych.2024.152486] [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] [Received: 12/26/2023] [Revised: 03/31/2024] [Accepted: 04/13/2024] [Indexed: 05/06/2024] Open
Abstract
OBJECTIVE To examine the long-term safety and tolerability of off-label high-dose serotonin reuptake inhibitors (OLHD-SRIs) in the treatment of obsessive-compulsive disorder (OCD). METHODS A retrospective longitudinal study was performed on 105 randomly selected outpatients diagnosed with OCD and were treated with OLHD-SRIs for at least 6 months. Patients received sertraline >200 mg/day, escitalopram >20 mg/day, fluvoxamine >300 mg/day, and fluoxetine >60 mg/day, combined with exposure and response prevention therapy. Patients were divided into three dosing groups: sertraline equivalent dose (SED) ≤ 200 mg/day (n = 26, 24.7%), 201-400 mg/day (n = 51, 48.5%) and 401-650 mg/day (n = 28, 26.6%). Safety and tolerability were assessed with an electrocardiogram, blood biochemistry, complete blood count, and side-effects monitoring. RESULTS SED ranged from 100 to 650 mg/day and the mean duration of OLHD-SRI treatment was 20.8 months. The most common side-effects reported were sexual dysfunction (n = 36, 34%), weight gain (n = 28, 27%), sedation (n = 27, 26%), hyperhidrosis (n = 20, 19%), and tremor (n = 11, 10%). Abnormal ECG was documented in one patient, and another patient experienced a first-time seizure, whereas elevated liver enzymes were seen in 4.8% of the sample (n = 5). None of the patients had serotonin syndrome or drug-induced liver injury. Side-effects did not differ among the three dosing groups. CONCLUSION OLHD-SRIs appear to be safe and well tolerated in OCD patients in SED ≤ 650 mg/day doses and the side-effects did not differ between the three dosing groups.
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Affiliation(s)
| | - Oded Ben Arush
- Israeli Center for the Treatment of Obsessive-Compulsive and Related Disorders, Modiin, Israel
| | - Lior Carmi
- Israeli Center for the Treatment of Obsessive-Compulsive and Related Disorders, Modiin, Israel; Chaim Sheba Medical Center, Post Trauma Center, Ramat-Gan, Israel
| | | | - Joseph Zohar
- Israeli Center for the Treatment of Obsessive-Compulsive and Related Disorders, Modiin, Israel; Chaim Sheba Medical Center, Post Trauma Center, Ramat-Gan, Israel; Tel Aviv University, Tel Aviv, Israel.
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Bandelow B, Allgulander C, Baldwin DS, Costa DLDC, Denys D, Dilbaz N, Domschke K, Hollander E, Kasper S, Möller HJ, Eriksson E, Fineberg NA, Hättenschwiler J, Kaiya H, Karavaeva T, Katzman MA, Kim YK, Inoue T, Lim L, Masdrakis V, Menchón JM, Miguel EC, Nardi AE, Pallanti S, Perna G, Rujescu D, Starcevic V, Stein DJ, Tsai SJ, Van Ameringen M, Vasileva A, Wang Z, Zohar J. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for treatment of anxiety, obsessive-compulsive and posttraumatic stress disorders - Version 3. Part II: OCD and PTSD. World J Biol Psychiatry 2023; 24:118-134. [PMID: 35900217 DOI: 10.1080/15622975.2022.2086296] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
AIM This is the third version of the guideline of the World Federation of Societies of Biological Psychiatry (WFSBP) Task Force for the Pharmacological Treatment of Anxiety, Obsessive-Compulsive and Posttraumatic Stress Disorders which was published in 2002 and revised in 2008. METHOD A consensus panel of 34 international experts representing 22 countries developed recommendations based on efficacy and acceptability of the treatments. In this version, not only medications but also psychotherapies and other non-pharmacological interventions were evaluated, applying the same rigorous methods that are standard for the assessment of medication treatments. RESULT The present paper (Part II) contains recommendations based on published randomised controlled trials (RCTs) for the treatment of OCD (n = 291) and PTSD (n = 234) in children, adolescents, and adults. The accompanying paper (Part I) contains the recommendations for the treatment of anxiety disorders.For OCD, first-line treatments are selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioural therapy (CBT). Internet-CBT was also superior to active controls. Several second-line medications are available, including clomipramine. For treatment-resistant cases, several options are available, including augmentation of SSRI treatment with antipsychotics and other drugs.Other non-pharmacological treatments, including repetitive transcranial magnetic stimulation (rTMS), deep brain stimulation (DBS) and others were also evaluated.For PTSD, SSRIs and the SNRI venlafaxine are first-line treatments. CBT is the psychotherapy modality with the best body of evidence. For treatment-unresponsive patients, augmentation of SSRI treatment with antipsychotics may be an option. CONCLUSION OCD and PTSD can be effectively treated with CBT and medications.
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Affiliation(s)
- Borwin Bandelow
- Department of Psychiatry and Psychotherapy, University Medical Center, Göttingen, Germany
| | | | - David S Baldwin
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Daniel Lucas da Conceição Costa
- Department and Institute of Psychiatry, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Damiaan Denys
- Afdeling Psychiatrie, Universitair Medische Centra, Amsterdam, The Netherlands
| | - Nesrin Dilbaz
- Psikiyatri Uzmanı, Üsküdar Üniversitesi Tıp Fakültesi Psikiyatri ABD İstanbul, Istanbul, Turkey
| | - Katharina Domschke
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | - Siegfried Kasper
- Clinical Division of General Psychiatry Medical, University of Vienna, Vienna, Austria
| | - Hans-Jürgen Möller
- Department of Psychiatry and Psychotherapy, University of München, München, Germany
| | - Elias Eriksson
- Department of Pharmacology, University of Gothenburg, Gothenburg, Sweden
| | - Naomi A Fineberg
- School of Life and Medical Sciences, University of Hertfordshire, Hertfordshire, United Kingdom
| | | | - Hisanobu Kaiya
- Department of Psychiatry, Kyoto Prefactual Medical College, Kyoto, Japan
| | - Tatiana Karavaeva
- V.M. Bekhterev National Medical Research Center for Psychiatry and Neurology, Ministry of Health, Federal State Budgetary Institution of Higher Education, St. Petersburg State University, St. Petersburg, Russia.,Federal State Budgetary Institution of Higher Education St. Petersburg State Pediatric Medical University, St. Petersburg, Russia
| | - Martin A Katzman
- S.T.A.R.T. CLINIC, Toronto, Ontario, Canada.,Adler Graduate Professional School Toronto, Toronto, Ontario, Canada.,Department of Psychiatry, Northern Ontario School of Medicine Thunder Bay, Thunder Bay, Ontario, Canada.,Department of Psychology, Lakehead University, Thunder Bay, Ontario, Canada
| | - Yong-Ku Kim
- Department of Psychiatry, College of Medicine, Korea University, Seoul, Korea
| | - Takeshi Inoue
- Department of Psychiatry, Tokyo Medical University, Tokyo, Japan
| | - Leslie Lim
- Department of Psychiatry, Singapore General Hospital, Singapore, Singapore
| | - Vasilios Masdrakis
- First Department of Psychiatry, Eginition Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - José M Menchón
- Department of Psychiatry, Bellvitge University Hospital-IDIBELL, Cibersam, University of Barcelona, Barcelona, Spain
| | - Euripedes C Miguel
- Department of Psychiatry, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Antônio E Nardi
- Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Giampaolo Perna
- Department of Biological Sciences, Humanitas University Pieve Emanuele, Milano, Italy
| | - Dan Rujescu
- Clinical Division of General Psychiatry Medical, University of Vienna, Austria
| | - Vladan Starcevic
- Faculty of Medicine and Health, Sydney Medical School, Nepean Clinical School, University of Sydney, Sydney, Australia
| | - Dan J Stein
- SA MRC Unit on Risk & Resilience in Mental Disorders, Department Psychiatry and Neuroscience Institute, University of Cape Town, South Africa
| | - Shih-Jen Tsai
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Michael Van Ameringen
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Anna Vasileva
- V. M. Bekhterev National Medical Research Center for Psychiatry and Neurology, Ministry of Health, I.I. Mechnikov North-Western State Medical University, St. Petersburg, Russia
| | - Zhen Wang
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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van Roessel PJ, Grassi G, Aboujaoude EN, Menchón JM, Van Ameringen M, Rodríguez CI. Treatment-resistant OCD: Pharmacotherapies in adults. Compr Psychiatry 2023; 120:152352. [PMID: 36368186 DOI: 10.1016/j.comppsych.2022.152352] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 09/20/2022] [Accepted: 10/24/2022] [Indexed: 12/13/2022] Open
Abstract
Serotonin reuptake inhibitor (SRI) medications are well established as first-line pharmacotherapeutic treatment for Obsessive-Compulsive Disorder (OCD). However, despite the excellent safety profile and demonstrated efficacy of these medications, a substantial proportion of individuals with OCD fail to attain sufficient benefit from SRIs. In this narrative review, we discuss clinical features of OCD that have been associated with poorer response to SRIs, and we present pharmacotherapeutic interventions that have been explored as augmenting or alternative treatments for treatment-resistant OCD. We additionally highlight non-SRI interventions for OCD that are currently under investigation. Pharmacotherapeutic interventions were identified via expert consensus. To assess the evidence base for individual pharmacotherapies, targeted searches for relevant English-language publications were performed on standard biomedical research databases, including MEDLINE. Information relevant to ongoing registered clinical trials in OCD was obtained by search of ClinicalTrials.gov. Pharmacotherapies are grouped for review in accordance with the general principles of Neuroscience-based Nomenclature (NbN). Clinical features of OCD that may suggest poorer response to SRI treatment include early age of onset, severity of illness, duration of untreated illness, and the presence of symmetry/ordering or hoarding-related symptoms. Based on evolving pathophysiologic models of OCD, diverse agents engaging serotonin, dopamine, norepinephrine, glutamate, and anti-inflammatory pathways have been explored as alternative or adjunctive therapies for treatment-resistant OCD and have at least preliminary evidence of efficacy. Medications with dopamine antagonist activity remain the most robustly evidence-based of augmenting interventions, yet dopamine antagonists benefit only a minority of those who try them and carry elevated risks of adverse effects. Interventions targeting glutamatergic and anti-inflammatory pathways are less well evidenced, but may offer more favorable benefit to risk profiles. Ongoing research should explore whether specific interventions may benefit individuals with particular features of treatment-resistant OCD.
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Affiliation(s)
- Peter J van Roessel
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA; Sierra Pacific Mental Illness Research, Education, and Clinical Center (MIRECC), VA Palo Alto Health Care System, Palo Alto, CA, USA.
| | | | - Elias N Aboujaoude
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - José M Menchón
- Department of Psychiatry, Bellvitge University Hospital-IDIBELL, University of Barcelona, Cibersam, Barcelona, Spain
| | - Michael Van Ameringen
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Carolyn I Rodríguez
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA.
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Soliman G, LaCaze A. Psychotropic medicines are frequently dosed outside recommended ranges: a clinical audit in an Australian mental health hospital. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2022. [DOI: 10.1002/jppr.1840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ghadir Soliman
- Department of Pharmacy St John of God Richmond Hospital North Richmond Australia
| | - Adam LaCaze
- School of Pharmacy and Pharmacology The University of Queensland Brisbane Australia
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Hudepohl N, MacLean JV, Osborne LM. Perinatal Obsessive-Compulsive Disorder: Epidemiology, Phenomenology, Etiology, and Treatment. Curr Psychiatry Rep 2022; 24:229-237. [PMID: 35384553 DOI: 10.1007/s11920-022-01333-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/14/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW We review recent evidence concerning the epidemiology, etiology, and treatment of obsessive-compulsive disorder (OCD) in the perinatal period. We examine studies reporting on rates of both new-onset OCD and exacerbation in both pregnancy and postpartum; explore both biological and psychosocial risk factors for the disorder; and review the latest evidence concerning treatment. RECENT FINDINGS Evidence is limited in all areas, with rates of both OCD and subthreshold obsessive-compulsive symptoms varying widely across studies. Prevalence is likely higher in the perinatal period than in the general population. Clinical features in the perinatal period are more likely than at other times to concern harm to the child, with contamination and aggressive obsessions and cleaning and checking compulsions especially common. Research into the biological etiology is too limited at this time to be definitive. Both observational and randomized controlled trials support cognitive behavioral therapy with exposure and response prevention (CBT with ERP) as a first-line treatment, with limited evidence also supporting the use of selective serotonin reuptake inhibitors (SSRIs). Treatment considerations in the perinatal period must weigh the risks of treatment vs. the risks of untreated illness. Perinatal OCD is common and can be impairing. Clinical features differ somewhat compared to non-perinatal periods. Treatment does not differ from that used in the general population, though evidence pertaining specifically to the perinatal period is sparse.
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Affiliation(s)
- Neha Hudepohl
- University of South Carolina School of Medicine-Greenville Prisma Health, Greenville, South Carolina, US
| | - Joanna V MacLean
- Women's Behavioral Medicine, Women's Medicine Collaborative, Providence, Rhode Island, US
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island, US
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, US
| | - Lauren M Osborne
- Department of Psychiatry & Behavioral Sciences, The Johns Hopkins University School of Medicine, 550 N. Broadway, Baltimore, MD, 21205, US.
- Department of Gynecology & Obstetrics, The Johns Hopkins University School of Medicine, 550 N. Broadway, Baltimore, MD, 21205, US.
- Center for Women's Reproductive Mental Health, The Johns Hopkins University School of Medicine, 550 N. Broadway, Baltimore, MD, 21205, US.
- Advanced Specialty Training Program in Reproductive Psychiatry, The Johns Hopkins University School of Medicine, 550 N. Broadway, Suite 305C, Baltimore, MD, 21205, US.
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Gupta R, Mehan S, Sethi P, Prajapati A, Alshammari A, Alharbi M, Al-Mazroua HA, Narula AS. Smo-Shh Agonist Purmorphamine Prevents Neurobehavioral and Neurochemical Defects in 8-OH-DPAT-Induced Experimental Model of Obsessive-Compulsive Disorder. Brain Sci 2022; 12:brainsci12030342. [PMID: 35326298 PMCID: PMC8946713 DOI: 10.3390/brainsci12030342] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 02/25/2022] [Accepted: 03/01/2022] [Indexed: 02/01/2023] Open
Abstract
Obsessive-compulsive disorder is a mental disorder characterized by repetitive, unwanted thoughts and behavior due to abnormal neuronal corticostriatal-thalamocortical pathway and other neurochemical changes. Purmorphamine is a smoothened-sonic-hedgehog agonist that has a protective effect against many neurological diseases due to its role in maintaining functional connectivity during CNS development and its anti-inflammatory and antioxidant properties. As part of our current research, we investigated the neuroprotective effects of PUR against behavioral and neurochemical changes in 8-hydroxy-2-(di-n-propylamino)-tetralin-induced obsessive-compulsive disorder in rats. Additionally, the effect of PUR was compared with the standard drug for OCD, i.e., fluvoxamine. The intra-dorsal raphe-nucleus injection of 8-OH-DPAT in rats for seven days significantly showed OCD-like repetitive and compulsive behavior along with increased oxidative stress, inflammation, apoptosis, as well as neurotransmitter imbalance. These alterations were dose-dependently attenuated by long-term purmorphamine treatment at 5 mg/kg and 10 mg/kg i.p. In this study, we assessed the level of various neurochemical parameters in different biological samples, including brain homogenate, blood plasma, and CSF, to check the drug’s effect centrally and peripherally. These effects were comparable to the standard oral treatment withfluvoxamine at 10 mg/kg. However, when fluvoxamine was given in combination with purmorphamine, there was a more significant restoration of these alterations than the individualtreatmentswithfluvoxamine and purmorphamine. All the above findings demonstrate that the neuroprotective effect of purmorphamine in OCD can be strong evidence for developing a new therapeutic target for treating and managing OCD.
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Affiliation(s)
- Ria Gupta
- Neuropharmacology Division, Department of Pharmacology, ISF College of Pharmacy, Moga 142001, Punjab, India; (R.G.); (P.S.); (A.P.)
| | - Sidharth Mehan
- Neuropharmacology Division, Department of Pharmacology, ISF College of Pharmacy, Moga 142001, Punjab, India; (R.G.); (P.S.); (A.P.)
- Correspondence:
| | - Pranshul Sethi
- Neuropharmacology Division, Department of Pharmacology, ISF College of Pharmacy, Moga 142001, Punjab, India; (R.G.); (P.S.); (A.P.)
| | - Aradhana Prajapati
- Neuropharmacology Division, Department of Pharmacology, ISF College of Pharmacy, Moga 142001, Punjab, India; (R.G.); (P.S.); (A.P.)
| | - Abdulrahman Alshammari
- Department of Pharmacology and Toxicology, College of Pharmacy, King Saud University, P.O. Box 2455, Riyadh 11451, Saudi Arabia; (A.A.); (M.A.); (H.A.A.-M.)
| | - Metab Alharbi
- Department of Pharmacology and Toxicology, College of Pharmacy, King Saud University, P.O. Box 2455, Riyadh 11451, Saudi Arabia; (A.A.); (M.A.); (H.A.A.-M.)
| | - Haneen A. Al-Mazroua
- Department of Pharmacology and Toxicology, College of Pharmacy, King Saud University, P.O. Box 2455, Riyadh 11451, Saudi Arabia; (A.A.); (M.A.); (H.A.A.-M.)
| | - Acharan S. Narula
- Narula Research, LLC, 107 Boulder Bluff, Chapel Hill, NC 27516, USA;
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Beaulieu AM, Tabasky E, Osser DN. The psychopharmacology algorithm project at the Harvard South Shore Program: An algorithm for adults with obsessive-compulsive disorder. Psychiatry Res 2019; 281:112583. [PMID: 31600606 DOI: 10.1016/j.psychres.2019.112583] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 09/26/2019] [Accepted: 09/26/2019] [Indexed: 12/28/2022]
Abstract
A previous algorithm for the pharmacological treatment of obsessive-compulsive disorder was published in 2012. Developments over the past 7 years suggest an update is needed. The authors conducted searches in PubMed, focusing on new studies and reviews since 2012 that would support or change previous recommendations. We identified exceptions to the main algorithm, including pregnant women and women of child-bearing potential, the elderly, and patients with common medical and psychiatric co-morbidities. Selective serotonin reuptake inhibitors (SSRIs) are still first-line. An adequate trial requires a period at typical antidepressant doses and dose adjustments guided by a plasma level to evaluate for poor adherence or ultra-rapid metabolism. If the response is inadequate, consider a trial of another SSRI this time possibly taken to a very high dose. Clomipramine could be an alternative. If the response to the second trial remains inadequate, the next recommendation is to augment with aripiprazole or risperidone. Alternatively, augmentation with novel agents could be selected, including glutamatergic (memantine, riluzole, topiramate, n-acetylcysteine, lamotrigine), serotonergic (ondansetron), and anti-inflammatory (minocycline, celecoxib) agents. A third option could be transcranial magnetic stimulation. Lastly, after several of these trials, deep brain stimulation and cingulotomy have evidence for a role in the most treatment-refractory patients.
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Affiliation(s)
- Ashley M Beaulieu
- Department of Psychiatry, Harvard Medical School, VA Boston Healthcare System, Brockton Division, 940 Belmont Street, Brockton, MA 02301, United States
| | - Edward Tabasky
- Department of Psychiatry, NYS Psychiatric Institute, Columbia University College of Physicians and Surgeons, 1051 Riverside Drive, Box 111, New York, NY 10032, United States
| | - David N Osser
- Department of Psychiatry, Harvard Medical School, VA Boston Healthcare System, Brockton Division, 940 Belmont Street, Brockton, MA 02301, United States.
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8
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Stein DJ, Costa DLC, Lochner C, Miguel EC, Reddy YCJ, Shavitt RG, van den Heuvel OA, Simpson HB. Obsessive-compulsive disorder. Nat Rev Dis Primers 2019; 5:52. [PMID: 31371720 PMCID: PMC7370844 DOI: 10.1038/s41572-019-0102-3] [Citation(s) in RCA: 287] [Impact Index Per Article: 57.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/27/2019] [Indexed: 12/15/2022]
Abstract
Obsessive-compulsive disorder (OCD) is a highly prevalent and chronic condition that is associated with substantial global disability. OCD is the key example of the 'obsessive-compulsive and related disorders', a group of conditions which are now classified together in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and the International Classification of Diseases, 11th Revision, and which are often underdiagnosed and undertreated. In addition, OCD is an important example of a neuropsychiatric disorder in which rigorous research on phenomenology, psychobiology, pharmacotherapy and psychotherapy has contributed to better recognition, assessment and outcomes. Although OCD is a relatively homogenous disorder with similar symptom dimensions globally, individualized assessment of symptoms, the degree of insight, and the extent of comorbidity is needed. Several neurobiological mechanisms underlying OCD have been identified, including specific brain circuits that underpin OCD. In addition, laboratory models have demonstrated how cellular and molecular dysfunction underpins repetitive stereotyped behaviours, and the genetic architecture of OCD is increasingly understood. Effective treatments for OCD include serotonin reuptake inhibitors and cognitive-behavioural therapy, and neurosurgery for those with intractable symptoms. Integration of global mental health and translational neuroscience approaches could further advance knowledge on OCD and improve clinical outcomes.
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Affiliation(s)
- Dan J. Stein
- Department of Psychiatry, University of Cape Town and SA MRC Unit on Risk & Resilience in Mental Disorders, Cape Town, South Africa
| | - Daniel L. C. Costa
- OCD Research Program, Instituto de Psiquiatria, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Christine Lochner
- Department of Psychiatry, Stellenbosch University and SA MRC Unit on Risk & Resilience in Mental Disorders, Stellenbosch, South Africa
| | - Euripedes C. Miguel
- OCD Research Program, Instituto de Psiquiatria, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Y. C. Janardhan Reddy
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Roseli G. Shavitt
- OCD Research Program, Instituto de Psiquiatria, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Odile A. van den Heuvel
- Department of Psychiatry, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands.,Department of Anatomy & Neurosciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands
| | - H. Blair Simpson
- Department of Psychiatry, Columbia University and New York State Psychiatric Institute, New York, NY, USA
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10
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Uguz F. Pharmacotherapy of obsessive-compulsive disorder during pregnancy: a clinical approach. BRAZILIAN JOURNAL OF PSYCHIATRY 2016; 37:334-42. [PMID: 26692431 DOI: 10.1590/1516-4446-2015-1673] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 04/13/2015] [Indexed: 01/07/2023]
Abstract
Obsessive-compulsive disorder (OCD) is a relatively common psychiatric disorder in the perinatal period. However, specific pharmacological treatment approaches for patients with OCD during pregnancy have not been satisfactorily discussed in the literature. In addition, there are no randomized controlled studies on the treatment of this disorder during pregnancy. The present paper discusses the pharmacological treatment of OCD in the light of data on the safety of antipsychotics and serotonergic antidepressants during pregnancy and their efficacy in the non-perinatal period. Treatment decisions should be individualized because the risk-benefit profile of pharmacotherapy is an important issue in the treatment of pregnant women with any psychiatric diagnosis.
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Affiliation(s)
- Faruk Uguz
- Department of Psychiatry, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
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11
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Mak L, Streiner DL, Steiner M. Is serotonin transporter polymorphism (5-HTTLPR) allele status a predictor for obsessive-compulsive disorder? A meta-analysis. Arch Womens Ment Health 2015; 18:435-45. [PMID: 25896187 DOI: 10.1007/s00737-015-0526-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 03/17/2015] [Indexed: 12/16/2022]
Abstract
The serotonin transporter polymorphism has been implicated in obsessive-compulsive disorder (OCD). However, molecular genetic association studies have yielded inconsistent results. Variation may be due to lack of OCD subtype classification. The goal of this systematic review is to investigate the association of the S-allele of the serotonin transporter polymorphism with OCD and OCD subtypes. A total of 69 studies were initially found through a systematic search of the literature but only 13 with sufficient information to compute odds ratios were suitable for review. A total of 1991 participants with OCD and their 5-HTTLPR allele status were examined. The primary outcome measures were allele frequency and OCD diagnosis. A full meta-analysis was completed comparing the L- and S-alleles using a random effects model in RevMan 5.2.1. Further, a secondary meta-analysis stratified by sex and late-onset was conducted for S- versus L-allele frequency. In the primary meta-analysis, OCD was not associated with the S-allele of the 5-HTTLPR polymorphism (Z = 0.07, p = 0.94). Moreover, late-onset OCD was not associated with the S-allele (Z = 1.45, p = 0.15). However, when stratified by sex, there is an emerging sex-specific relationship. There was a trending association between the S-allele and OCD status in females (Z = 1.62, p = 0.10) but not in males (Z = 0.69, p = 0.49). The findings provide further support for the need of subtype classification of this heterogeneous disorder. Future studies should clearly examine sex differences and OCD age-of-onset. In particular, emphasis should be placed on the effect of female reproductive milestones on OCD onset and symptom exacerbation.
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Affiliation(s)
- Lauren Mak
- MiNDS Neuroscience, McMaster University, Hamilton, ON, Canada
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12
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Fineberg NA, Reghunandanan S, Simpson HB, Phillips KA, Richter MA, Matthews K, Stein DJ, Sareen J, Brown A, Sookman D. Obsessive-compulsive disorder (OCD): Practical strategies for pharmacological and somatic treatment in adults. Psychiatry Res 2015; 227:114-25. [PMID: 25681005 DOI: 10.1016/j.psychres.2014.12.003] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 11/26/2014] [Accepted: 12/04/2014] [Indexed: 12/18/2022]
Abstract
This narrative review gathers together a range of international experts to critically appraise the existing trial-based evidence relating to the efficacy and tolerability of pharmacotherapy for obsessive compulsive disorder in adults. We discuss the diagnostic evaluation and clinical characteristics followed by treatment options suitable for the clinician working from primary through to specialist psychiatric care. Robust data supports the effectiveness of treatment with selective serotonin reuptake inhibitors (SSRIs) and clomipramine in the short-term and the longer-term treatment and for relapse prevention. Owing to better tolerability, SSRIs are acknowledged as the first-line pharmacological treatment of choice. For those patients for whom first line treatments have been ineffective, evidence supports the use of adjunctive antipsychotic medication, and some evidence supports the use of high-dose SSRIs. Novel compounds are also the subject of active investigation. Neurosurgical treatments, including ablative lesion neurosurgery and deep brain stimulation, are reserved for severely symptomatic individuals who have not experienced sustained response to both pharmacological and cognitive behavior therapies.
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Affiliation(s)
- Naomi A Fineberg
- Highly Specialized Obsessive Compulsive and Related Disorders Service, Hertfordshire Partnership University NHS Foundation Trust, Rosanne House,Parkway ,Welwyn Garden City, Hertfordshire, AL8 6HG, UK; Postgraduate Medical School, University of Hertfordshire, College Lane, Hatfield, UK; University of Cambridge School of Clinical Medicine, Addenbrooke׳s Hospital, Box 189, Cambridge CB2 2QQ, UK.
| | - Samar Reghunandanan
- Highly Specialized Obsessive Compulsive and Related Disorders Service, Hertfordshire Partnership University NHS Foundation Trust, Rosanne House,Parkway ,Welwyn Garden City, Hertfordshire, AL8 6HG, UK
| | - Helen B Simpson
- College of Physicians and Surgeons at Columbia University, New York, NY, USA; Anxiety Disorders Clinic and the Centre for OCD and Related Disorders at the New York State Psychiatric Institute, New York, NY, USA
| | - Katharine A Phillips
- Rhode Island Hospital and the Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Margaret A Richter
- Frederick W. Thompson Anxiety Disorders Centre, Sunnybrook Health Sciences Centre and Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Keith Matthews
- Division of Neuroscience, Ninewells Hospital and Medical School, University of Dundee, Dundee DD1 9SY, UK
| | - Dan J Stein
- Department of Psychiatry, University of Cape Town, Cape Town, South Africa
| | - Jitender Sareen
- Departments of Psychiatry, Psychology and Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Angus Brown
- Highly Specialized Obsessive Compulsive and Related Disorders Service, Hertfordshire Partnership University NHS Foundation Trust, Rosanne House,Parkway ,Welwyn Garden City, Hertfordshire, AL8 6HG, UK
| | - Debbie Sookman
- Obsessive Compulsive Disorder Clinic, Department of Psychology, McGill University Health Centre, and Department of Psychiatry, McGill University, Montreal, PQ, Canada
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Veale D, Miles S, Smallcombe N, Ghezai H, Goldacre B, Hodsoll J. Atypical antipsychotic augmentation in SSRI treatment refractory obsessive-compulsive disorder: a systematic review and meta-analysis. BMC Psychiatry 2014; 14:317. [PMID: 25432131 PMCID: PMC4262998 DOI: 10.1186/s12888-014-0317-5] [Citation(s) in RCA: 107] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 10/24/2014] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND In 2006, the National Institute of Clinical and Health Excellence (NICE) guidelines for Obsessive Compulsive Disorder (OCD) recommended anti-psychotics as a class for SSRI treatment resistant OCD. The article aims to systematically review and conduct a meta-analysis on the clinical effectiveness of atypical anti-psychotics augmenting an SSRI. METHODS Studies that were double-blind randomized controlled trials of an atypical antipsychotic against a placebo, for a minimum of 4 weeks, in adults with OCD, were included. Yale-Brown Obsessive Compulsive Scale (Y-BOCS) scores were the primary outcome measure. Inclusion criteria included Y-BOCS score of 16 or more and at least one adequate trial of a SSRI or clomipramine for at least 8 weeks prior to randomization. Data sources included Medline, Embase, PsycINFO, Cochrane Database of Systematic Reviews (CDSR), trial registries and pharmaceutical databases and manufacturers up to September 2013. Forest-plots were drawn to display differences between drug and placebo on the Y-BOCS. RESULTS Two studies found aripiprazole to be effective in the short-term. There was a small effect-size for risperidone or anti-psychotics in general in the short-term. We found no evidence for the effectiveness of quetiapine or olanzapine in comparison to placebo. CONCLUSIONS Risperidone and aripiprazole can be used cautiously at a low dose as an augmentation agent in non-responders to SSRIs and CBT but should be monitored at 4 weeks to determine efficacy.
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Affiliation(s)
- David Veale
- The Institute of Psychiatry, King's College London and South London and Maudsley NHS Foundation Trust, 16 De Crespigny Park, Denmark Hill, London, SE5 8AF, UK. .,Centre for Anxiety Disorders and Trauma, The Maudsley Hospital, 99 Denmark Hill, London, SE5 8AZ, UK.
| | - Sarah Miles
- The Institute of Psychiatry, King's College London and South London and Maudsley NHS Foundation Trust, 16 De Crespigny Park, Denmark Hill, London, SE5 8AF, UK.
| | - Nicola Smallcombe
- Kings College London Medical School, Denmark Hill, London, SE5 9RS, UK.
| | - Haben Ghezai
- The Institute of Psychiatry, King's College London and South London and Maudsley NHS Foundation Trust, 16 De Crespigny Park, Denmark Hill, London, SE5 8AF, UK.
| | - Ben Goldacre
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - John Hodsoll
- The Institute of Psychiatry, King's College London and South London and Maudsley NHS Foundation Trust, 16 De Crespigny Park, Denmark Hill, London, SE5 8AF, UK.
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14
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Van Ameringen M, Simpson W, Patterson B, Dell'Osso B, Fineberg N, Hollander E, Hranov L, Hranov G, Lochner C, Karamustafalioglu O, Marazziti D, Menchon JM, Nicolini H, Pallanti S, Stein DJ, Zohar J. Pharmacological treatment strategies in obsessive compulsive disorder: A cross-sectional view in nine international OCD centers. J Psychopharmacol 2014; 28:596-602. [PMID: 24429223 DOI: 10.1177/0269881113517955] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE It is unknown what next-step strategies are being used in clinical practice for patients with obsessive-compulsive disorder (OCD) who do not respond to first-line treatment. As part of a cross-sectional study of OCD, treatment and symptom information was collected. METHOD Consecutive OCD out-patients in nine international centers were evaluated by self-report measures and clinical/structured interviews. OCD symptom severity was evaluated by the Yale Brown Obsessive Compulsive Scale (YBOCS) and Clinical Global Impression-Severity Scale (CGI-S). Clinical response to current treatment was evaluated by the CGI-Improvement Scale (CGI-I ≤ 2). RESULTS In total, 361 participants reported taking medication; 77.6% were taking a selective serotonin reuptake inhibitor; 50% reported use of at least one augmentation strategy. Antipsychotics were most often prescribed as augmenters (30.3%), followed by benzodiazepines (24.9%) and antidepressants (21.9%). No differences in OCD symptom severity were found between patients taking different classes of augmentation agents. CONCLUSIONS Results from this international cross-sectional study indicate that current OCD treatment is in line with evidence-based treatment guidelines. Although augmentation strategies are widely used, no significant differences in OCD symptom severity were found between monotherapy and augmentation or between different therapeutic agents.
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Affiliation(s)
- Michael Van Ameringen
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
| | - William Simpson
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada MiNDS Neuroscience Graduate Program, McMaster University, St. Joseph's Healthcare, Hamilton, ON, Canada
| | - Beth Patterson
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
| | - Bernardo Dell'Osso
- Department of Psychiatry of the Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico of Milano, Milan, Italy
| | - Naomi Fineberg
- National Obsessive Compulsive Disorders Treatment Service, Hertfordshire Partnership NHS Foundation Trust, Queen Elizabeth II Hospital, Welwyn Garden City, UK; University of Hertfordshire, Postgraduate Medical School, Hatfield, UK
| | - Eric Hollander
- Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Montefiore Medical Center, New York, NY, USA
| | - Luchezar Hranov
- University Hospital of Neurology and Psychiatry, St. Naum of Sofia, Sofia, Bulgaria
| | - Georgi Hranov
- University Hospital of Neurology and Psychiatry, St. Naum of Sofia, Sofia, Bulgaria
| | - Christine Lochner
- MRC Unit on Anxiety and Stress Disorders, Department of Psychiatry, University of Stellenbosch, Stellenbosch, South Africa
| | | | - Donatella Marazziti
- Dipartimento di Psichiatria, Neurobiologia, Farmacologia e Biotecnologie", University of Pisa, Pisa, Italy
| | - Jose M Menchon
- IDIBELL-University Hospital of Bellvitage, CIBERSAM University of Barcelona, Barcelona, Spain
| | - Humberto Nicolini
- Center for Genomic Sciences, Universidad Autónoma de la Ciudad de México and Carracci Medical Group, Mexico City, Mexico
| | - Stefano Pallanti
- Institute of Neuroscience, Università di Firenze, Firenze, Italy
| | - Dan J Stein
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Joseph Zohar
- Chaim Sheba Medical Center, Department of Psychiatry, Tel Aviv, Israel
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Baldwin DS, Anderson IM, Nutt DJ, Allgulander C, Bandelow B, den Boer JA, Christmas DM, Davies S, Fineberg N, Lidbetter N, Malizia A, McCrone P, Nabarro D, O'Neill C, Scott J, van der Wee N, Wittchen HU. Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: a revision of the 2005 guidelines from the British Association for Psychopharmacology. J Psychopharmacol 2014; 28:403-39. [PMID: 24713617 DOI: 10.1177/0269881114525674] [Citation(s) in RCA: 369] [Impact Index Per Article: 36.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This revision of the 2005 British Association for Psychopharmacology guidelines for the evidence-based pharmacological treatment of anxiety disorders provides an update on key steps in diagnosis and clinical management, including recognition, acute treatment, longer-term treatment, combination treatment, and further approaches for patients who have not responded to first-line interventions. A consensus meeting involving international experts in anxiety disorders reviewed the main subject areas and considered the strength of supporting evidence and its clinical implications. The guidelines are based on available evidence, were constructed after extensive feedback from participants, and are presented as recommendations to aid clinical decision-making in primary, secondary and tertiary medical care. They may also serve as a source of information for patients, their carers, and medicines management and formulary committees.
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Affiliation(s)
- David S Baldwin
- 1Faculty of Medicine, University of Southampton, Southampton, UK
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16
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Fineberg NA, Reghunandanan S, Brown A, Pampaloni I. Pharmacotherapy of obsessive-compulsive disorder: evidence-based treatment and beyond. Aust N Z J Psychiatry 2013; 47:121-41. [PMID: 23125399 DOI: 10.1177/0004867412461958] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Obsessive-compulsive disorder (OCD) is a neuropsychiatric disorder associated with a significant degree of functional disability and poor quality of life. Pharmacotherapy may have a substantial impact on the course and outcome of OCD. METHOD We review the evidence supporting available strategies for the pharmacological treatment of OCD. RESULTS Selective serotonin reuptake inhibitors (SSRIs) remain the pharmacological treatment of choice and are associated with improved health-related quality of life. Discontinuation is associated with relapse and loss of quality of life, implying treatment should continue long-term. A substantial minority of patients who fail to respond to SSRI may benefit from dose elevation or adjunctive antipsychotics, though long-term trials validating the effectiveness and tolerability of these strategies are relatively lacking. CONCLUSION The pharmacological evidence-base for the treatment of OCD is becoming increasingly robust. Treatment with SSRIs and clomipramine remains uncontroversial and improvements are sustained over time. Newer compounds targeting serotonin receptor subtypes and other neurotransmitter systems are undergoing evaluation.
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Affiliation(s)
- Naomi A Fineberg
- 1Mental Health Unit, Hertfordshire Partnership Foundation Trust, Queen Elizabeth II Hospital, Welwyn Garden City, UK
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17
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Franz AP, Paim M, Araújo RMD, Rosa VDO, Barbosa ÍM, Blaya C, Ferrão YA. Treating refractory obsessive-compulsive disorder: what to do when conventional treatment fails? TRENDS IN PSYCHIATRY AND PSYCHOTHERAPY 2013; 35:24-35. [DOI: 10.1590/s2237-60892013000100004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Obsessive-compulsive disorder (OCD) is a chronic and impairing condition. A very small percentage of patients become asymptomatic after treatment. The purpose of this paper was to review the alternative therapies available for OCD when conventional treatment fails. Data were extracted from controlled clinical studies (evidence-based medicine) published on the MEDLINE and Science Citation Index/Web of Science databases between 1975 and 2012. Findings are discussed and suggest that clinicians dealing with refractory OCD patients should: 1) review intrinsic phenomenological aspects of OCD, which could lead to different interpretations and treatment choices; 2) review extrinsic phenomenological aspects of OCD, especially family accommodation, which may be a risk factor for non-response; 3) consider non-conventional pharmacological approaches; 4) consider non-conventional psychotherapeutic approaches; and 5) consider neurobiological approaches.
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Affiliation(s)
| | - Mariana Paim
- Universidade Federal de Ciências da Saúde de Porto Alegre, Brazil
| | | | | | | | - Carolina Blaya
- Universidade Federal de Ciências da Saúde de Porto Alegre, Brazil
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18
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Neri V, Cardona F. Clinical Pharmacology of Comorbid Obsessive–Compulsive Disorder in Tourette Syndrome. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2013; 112:391-414. [DOI: 10.1016/b978-0-12-411546-0.00013-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
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Oʼbrien PG, Fleming L. Recognizing anxiety disorders. Nurse Pract 2012; 37:35-42. [PMID: 23014178 DOI: 10.1097/01.npr.0000419299.87440.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The majority of patients with anxiety disorders present in primary care settings, and many are undiagnosed or undertreated-each disorder has defining characteristics. Anxiety disorders are debilitating, and proper treatment can improve quality of life. Preferred treatments are cognitive-behavior therapy and pharmacotherapy with selective serotonin reuptake inhibitors.
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20
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Abstract
Pharmacological strategies for the treatment of obsessive-compulsive disorder (OCD) continue to develop apace but deficiencies remain. We present an updated literature review of the evidence supporting available strategies. We aim to answer key questions including: (1) What are the first-line treatments? (2) Does pharmacotherapy improve health-related quality of life? (3) How do we evaluate clinical response and relapse? (4) How long should treatment continue? (5) Can we predict treatment outcomes? (6) What is the management of treatment-refractory OCD? Selective serotonin reuptake inhibitors (SSRIs) remain the pharmacological treatment of choice for most patients and are associated with improved health-related quality of life. However, discontinuation is associated with relapse and loss of quality of life, implying treatment should continue long term. A substantial minority of patients fail to respond to SSRI. Such patients may respond to strategies such as dose elevation or adjunctive antipsychotic, although long-term trials validating the effectiveness and tolerability of these strategies are relatively lacking. Newer compounds targeting other neurotransmitter systems, such as glutamate, are undergoing evaluation.
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21
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Stein DJ, Koen N, Fineberg N, Fontenelle LF, Matsunaga H, Osser D, Simpson HB. A 2012 evidence-based algorithm for the pharmacotherapy for obsessive-compulsive disorder. Curr Psychiatry Rep 2012; 14:211-9. [PMID: 22527872 DOI: 10.1007/s11920-012-0268-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
There is a need to synthesize the growing body of literature on the pharmacotherapeutic management of patients with obsessive-compulsive disorder for clinicians working at a primary care level. We have aimed to generate a simple, easy-to-follow algorithm for the primary care practitioner. This seven-step algorithm addresses diagnosis of obsessive-compulsive disorder, initiation of pharmacotherapy, monitoring and maintenance treatment, and guidelines for the management of patients who are resistant to initial therapy. In creating this algorithm, we have drawn on the body of published evidence, as well as on expert opinion.
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Affiliation(s)
- Dan J Stein
- University of Cape Town Department of Psychiatry, Groote Schuur Hospital, Cape Town, South Africa.
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22
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Fineberg NA, Chamberlain SR, Hollander E, Boulougouris V, Robbins TW. Translational approaches to obsessive-compulsive disorder: from animal models to clinical treatment. Br J Pharmacol 2012; 164:1044-61. [PMID: 21486280 DOI: 10.1111/j.1476-5381.2011.01422.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Obsessive-compulsive disorder (OCD) is characterized by obsessions (intrusive thoughts) and compulsions (repetitive ritualistic behaviours) leading to functional impairment. Accumulating evidence links these conditions with underlying dysregulation of fronto-striatal circuitry and monoamine systems. These abnormalities represent key targets for existing and novel treatment interventions. However, the brain bases of these conditions and treatment mechanisms are still not fully elucidated. Animal models simulating the behavioural and clinical manifestations of the disorder show great potential for augmenting our understanding of the pathophysiology and treatment of OCD. This paper provides an overview of what is known about OCD from several perspectives. We begin by describing the clinical features of OCD and the criteria used to assess the validity of animal models of symptomatology; namely, face validity (phenomenological similarity between inducing conditions and specific symptoms of the human phenomenon), predictive validity (similarity in response to treatment) and construct validity (similarity in underlying physiological or psychological mechanisms). We then survey animal models of OC spectrum conditions within this framework, focusing on (i) ethological models; (ii) genetic and pharmacological models; and (iii) neurobehavioural models. We also discuss their advantages and shortcomings in relation to their capacity to identify potentially efficacious new compounds. It is of interest that there has been rather little evidence of 'false alarms' for therapeutic drug effects in OCD models which actually fail in the clinic. While it is more difficult to model obsessive cognition than compulsive behaviour in experimental animals, it is feasible to infer cognitive inflexibility in certain animal paradigms. Finally, key future neurobiological and treatment research areas are highlighted.
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Affiliation(s)
- N A Fineberg
- National OCDs Treatment Service, Hertfordshire Partnership NHS Foundation Trust, Welwyn Garden City, UK.
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23
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Abstract
This article aims to highlight current trends in the pharmacologic management of obsessive-compulsive disorder (OCD). A systematic search of the electronic database MEDLINE was conducted. The first case report of clomipramine efficacy in the management OCD more than 40 years ago gave new hope for the treatment of this debilitating disorder. Selective serotonin reuptake inhibitors (SSRIs) proved to have a similar efficacy profile compared with clomipramine but had a superior tolerability profile. While many patients with OCD respond to SSRIs or clomipramine, the treatment of those with refractory OCD remains challenging. Different augmentation agents in treatment-resistant OCD have been explored, with antipsychotic agents having the largest supporting evidence base. Nevertheless, new pharmacologic treatment options are required and are under investigation.
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Affiliation(s)
- Eric H Decloedt
- Department of Internal Medicine, Division of Clinical Pharmacology.
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