Bupropion for patients with obsessive-compulsive disorder: an open-label, fixed-dose study

Global prevalence of smoking among individuals with obsessive-compulsive disorder and symptoms: a systematic review and meta-analysis

Disease from nicotine dependency continues to be a leading cause of preventable death worldwide, and therefore research that elucidates potential correlates of tobacco use may facilitate the advancement of research, clinical practice, and policy in this area to target this public health challenge. One potential tobacco use correlate is obsessive-compulsive disorder (OCD) phenomena. The growing research evidence on the association between tobacco use and OCD phenomena is mixed, making it difficult to synthesize extant findings into meaningful conclusions. Indeed, there has never been a systematic review or meta-analysis of this area of research. To this end, a systematic review was carried out with studies between 1988 and 2021, and from this review, 71 independent estimations (n = 10,475; Females = 51.95%; mean age = 37.29, SD = 13.78) were extracted for meta-analysis. We found that about three in ten participants with OCD are likely to use tobacco, which is higher than the general population. The prevalence was the same among OCD participants at all levels (those with symptomology but no confirmed diagnosis, those surpassing a clinical cutoff for OCD but no confirmed diagnosis, and those with a confirmed OCD diagnosis). The results also indicated considerable variability across study results and a wide confidence interval associated with the tobacco use prevalence rate among those with OCD phenomena. The findings provide support for continued study of this comorbidity, perhaps with longitudinal and experimental designs to test for reciprocal associations between tobacco use and OCD phenomena in the service of targeting nicotine dependence as a substantial global public health concern.

Psilocybin for the Treatment of Obsessive-Compulsive Disorders

Obsessive-compulsive disorder (OCD) is a highly prevalent and disabling condition for which currently available treatments are insufficiently effective and alternatives merit priority attention. Psilocybin may represent a safe and effective avenue for treatment of individuals affected by this condition. In this chapter we briefly introduce OCD symptoms, epidemiology, as well as relevant hypotheses on the mechanism of disease that may inform treatment interventions. We briefly describe currently available treatments, mechanisms of action, and efficacy limitations, as preamble to the potential use of psilocybin and perhaps similar compounds in the treatment of OCD and related conditions. Although much is reviewed throughout this book about the mechanisms of action of psychedelic agents, a focused discussion of psilocybin effects as they pertain to OCD is also included. Our experience with incidental observation, prospective research, and current explorations of psilocybin in OCD are also described.

Pharmacotherapeutic Strategies and New Targets in OCD

Effective pharmacological and psychotherapeutic treatments are well established for obsessive-compulsive disorder (OCD). Serotonin reuptake inhibitors (SRIs) are first-line treatment and are of benefit to about half of patients. Augmentation of SRI treatment with low-dose neuroleptics is an evidence-based second-line strategy. Specialty psychotherapy is also used as both first-line and second-line treatment and can benefit many. However, a substantial number of patients do not respond to these treatments. New alternatives are urgently needed. This review summarizes evidence for these established pharmacotherapeutic strategies, and for others that have been investigated in refractory disease but are not supported by the same level of evidence. We focus on three neurotransmitter systems in the brain: serotonin, dopamine, and glutamate. We summarize evidence from genetic, neuroimaging, animal model, and other lines of investigation that probe these three systems in patients with OCD. We also review recent work on predictors of response to current treatments. While many studies suggest abnormalities that may provide insight into the pathophysiology of the disorder, most studies have been small, and non-replication of reported findings has been common. Nevertheless, the gradual accrual of evidence for neurotransmitter dysregulation may in time lead the way to new pharmacological strategies.

The psychopharmacology algorithm project at the Harvard South Shore Program: An algorithm for adults with obsessive-compulsive disorder

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.

An exploratory dimensional approach to premenstrual manifestation of obsessive-compulsive disorder symptoms: a multicentre study

OBJECTIVE

In women with obsessive-compulsive disorder (OCD), symptom severity appears to fluctuate over the course of the menstrual cycle. The objective of this paper was to compare female OCD patients with and without premenstrual worsening of obsessive-compulsive symptoms (OCS), in terms of the clinical characteristics of OCD.

METHODS

This was a cross-sectional study involving 455 women with OCD, of whom 226 (49.7%) had experienced premenstrual OCS worsening and 229 (50.3%) had not (PMOCS-worse and PMOCS-same groups, respectively). Data were collected with the original and dimensional versions of the Yale-Brown obsessive-compulsive scale, as well as with the Beck Depression Inventory (BDI) and Beck anxiety inventory (BAI).

RESULTS

We found significant differences between the PMOCS-same and PMOCS-worse groups, the latter showing a higher frequency of suicidal ideation (P<.001), suicide attempts (P=.027), current use of selective serotonin reuptake inhibitors (P=.022), lifetime use of mood stabilisers (P=.015), and sexual/religious obsessions (P<.001; OR=1.90), as well as higher scores on the BDI (P<.001) and BAI (P<.001).

CONCLUSION

Underscoring the fact that OCD is a heterogeneous disorder, there appears to be a subgroup of female OCD patients in whom the premenstrual period is associated with a higher frequency of sexual/religious obsessions, depression, anxiety, and suicidality. This might be attributable to hormonal fluctuations. Further studies are warranted in order to investigate this hypothesis by evaluating such patients at different phases of the menstrual cycle, as well as measuring hormonal levels.

Effects of ketamine in treatment-refractory obsessive-compulsive disorder

BACKGROUND

Treatments for obsessive-compulsive disorder (OCD) usually lead to incomplete symptom relief and take a long-time to reach full effect. Convergent evidence suggests that glutamate abnormalities contribute to the pathogenesis of OCD. Ketamine is a potent noncompetitive antagonist of the N-methyl-D-aspartate glutamate receptor. Trials have reported rapid antidepressant effects after low-dose ketamine infusion.

METHODS

We conducted an open-label trial of ketamine (.5 mg/kg IV over 40 min) in 10 subjects with treatment-refractory OCD. Response was defined as >35% improvement in OCD symptoms and >50% improvement in depression symptoms from baseline at any time between 1 and 3 days after infusion.

RESULTS

None of 10 subjects experienced a response in OCD symptoms in the first 3 days after ketamine. Four of seven patients with comorbid depression experienced an antidepressant response to ketamine in the first 3 days after infusion. Both OCD and depression symptoms demonstrated a statistically significant improvement in the first 3 days after infusion compared with baseline, but the OCD response was <12%. The percentage reduction in depressive symptoms in the first 3 days after ketamine infusion was significantly greater than the reduction in OCD symptoms.

CONCLUSIONS

Ketamine effects on OCD symptoms, in contrast to depressive symptoms, did not seem to persist or progress after the acute effects of ketamine had dissipated.

The potent inhibitory effect of tipepidine on marble-burying behavior in mice

Our previous study revealed that centrally acting non-narcotic antitussives inhibited G-protein-coupled inwardly rectifying K(+) (GIRK) channel currents in brain neurons, and that the tipepidine antitussives had a novel antidepressive-like effect on rats. Furthermore, the antitussives revealed multiplexed ameliorating actions on intractable brain disease models. This study evaluated the therapeutic potential of tipepidine in obsessive-compulsive disorder (OCD) subjects using marble-burying behavior (MBB) tests in mice. In fact, OCD is classified as an anxiety disorder characterized by obsession or compulsion. Although selective 5-HT reuptake inhibitors (SSRIs) are considered first choice agents for the pharmacological treatment of OCD, 50% of patients with OCD failed to respond to SSRIs. The burying of harmless objects such as marbles by mice might reflect the formation of compulsive behavior. The results show that tipepidine reduced MBB in a dose-dependent manner. The effect of tipepidine was significant even at a dosage as small as 5 mg/kg. The tipepidine at 10 mg/kg s.c. nearly abolished MBB without reducing the locomotor activity in mice. It is particularly interesting that the dopamine D₂ antagonist or 5-HT(1A) antagonist partly inhibited the effect of tipepidine on MBB. The results suggest that tipepidine has more of a potent inhibitory effect on MBB, compared with known drugs used for the treatment of OCD, and that the tipepidine action mechanism might differ from that of known drugs.

Volitional disorders: a proposal for DSM-V

In the DSM-IV-TR, specific impulse control disorders not elsewhere classified (ICD) have been designated following four principles: (1) through the addition of an adjective that emphasizes the aberrant character of an otherwise normal behaviour (e.g., pathological gambling); (2) by means of metaphors (such as in intermittent explosive disorder); (3) according to the presumably quintessential nature of their main signs and symptoms, such as impulsive (e.g., impulse control disorders not elsewhere classified), compulsive (e.g., compulsive shopping), or addictive (e.g., internet addiction); or (4) using Greek suffix mania (e.g., kleptomania, pyromania, and trichotillomania). Given this flagrant inconsistency, we argue that time has come to adopt a less arbitrary way of describing these disorders, at least until it becomes clearer whether they are really impulsive, compulsive or addictive or if the preoccupation with this distinction is valid. In keeping with DSM's emphasis on descriptive phenomenology rather than on unsupported theory, a less biased terminology is in order. Therefore, we would like to suggest: (1) the substitution of the term ICD by the more neutral expression 'volitional disorders not elsewhere classified'; (2) the use of the classical Greek suffix mania, already present in some DSM-IV-TR ICDs, as the main naming principle to be adopted in the DSM-V; and (3) the creation of compulsive, impulsive, and mixed subtypes of the 'volitional disorders not elsewhere classified', since they are beginning to be validated by treatment trials.

Dopamine D1 receptor binding in the striatum of patients with obsessive-compulsive disorder

BACKGROUND

Obsessive-compulsive disorder (OCD) is a chronic anxiety disorder of unknown aetiology. Psychopharmacological studies have suggested a role for the neurotransmitter serotonin however further evidence for serotonin in the aetiology of OCD is conflicted. The authors used positron emission tomography (PET) to examine the binding of the dopamine D(1) receptor antagonist [(11)C]-SCH23390 to D(1) receptors in the striatum of drug-free OCD patients compared with healthy controls.

METHODS

Seven drug-free patients (two drug naïve) with OCD and seven age, gender and education matched healthy controls underwent positron emission tomography with [(11)C]-SCH23390. Binding Potentials (BP) at D(1) receptors were calculated for the caudate nucleus and putamen. Correlations between BP values for basal ganglia regions and clinical measures were performed in OCD patients.

RESULTS

The BP for [(11)C]-SCH23390 at D(1) receptors in OCD patients was significantly reduced in both caudate nucleus (0.59+/-0.06 vs 0.88+/-0.06, p<0.05) and putamen (0.89+/-0.06 vs 1.14+/-0.06, p<0.05) compared with healthy controls. No correlations were found between D(1) BP and symptom measures.

LIMITATIONS

The main limitations of this study are the small sample size and the PET methodology which does not allow for disaggregation of Bmax and Kd values for D(1) receptor binding of [(11)C]-SCH23390.

CONCLUSIONS

The finding of downregulation of D(1) receptors in the striatum of OCD patients suggests increased nigrostriatal dopaminergic drive in OCD. If confirmed, this finding provides support for trials of novel treatments in OCD based on dopaminergic system blockade.

An update on the pharmacological treatment of obsessive-compulsive disorder

The purpose of this article is to introduce the reader to an updated evidence-based drug treatment algorithm to be employed in patients with obsessive-compulsive disorder (OCD). Relevant studies were identified through a comprehensive review and classified according to the type of patients enrolled, the quality of the study design and the invasiveness, availability and complexity of the therapeutic approach. When ineffective, therapeutic trials with first-line strategies (such as the selective serotonin re-uptake inhibitors [SSRIs] and venlafaxine) should be followed by treatment approaches such as clomipramine, augmentation with antipsychotics or pindolol, SSRI megadoses or cognitive behavioral therapy. These therapeutic strategies are expected to help most patients with OCD. Additional approaches include intravenous clomipramine, oral morphine, 'heroic drug strategies', deep brain stimulation and functional neurosurgery. Independent studies are urgently needed to help identify the most promising drug treatment sequences for OCD.

Pharmacotherapy of obsessive-compulsive disorder and obsessive-compulsive spectrum disorders

This article reviews new developments of pharmacotherapy in obsessive-compulsive disorder (OCD) and OC spectrum disorders of the past five years. New developments primarily involved the ex-tension of evidence of efficacy of serotonin reuptake inhibitors(SRIs), the use of atypical antipsychotics in addition to SRIs for treatment refractory patients, the combination of pharmacotherapy with behavior therapy, and studies assessing predictors of response. Today, frontline pharmacological treatment of OCD still consists of drugs with potent serotonin reuptake inhibition proper-ties. In case of non-response, treatment options comprise adding another drug, increasing the dose, switching drugs, or changing the mode of delivery.

Female hormones affect symptom severity in obsessive-compulsive disorder

There is circumstantial evidence that reproductive events can influence symptom severity of obsessive-compulsive disorder (OCD). We sent self-report questionnaires to 350 female outpatients with OCD to examine the relationship between the menstrual cycle, pregnancy, menopause, hormonal contraceptives, selective serotonin reuptake inhibitors and symptom severity of OCD. Yale-Brown Obsessive-Compulsive Scale scores were used at three serial time points during the menstrual cycle to assess symptom severity. One hundred and one out of 350 questionnaires (29%) were returned and completed. Forty-nine patients reported an exacerbation of OCD symptoms during the premenstrual period, nine during the menopause and 17 patients during pregnancy, whereas 11 patients mentioned improvement of OCD symptoms during pregnancy. Premenstrual dysphoric disorder could only partly explain a premenstrual exacerbation of OCD symptoms. Exacerbation of OCD could be related to reproductive events in a considerable number of patients, especially the premenstrum. Because reproductive cycle events influence the symptom severity of OCD, the menstrual cycle should be taken into account when assessing the severity of OCD symptoms during pharmacological studies.