A systematic review: antipsychotic augmentation with treatment refractory obsessive-compulsive disorder

Abstract

As many as half of obsessive-compulsive disorder (OCD) patients treated with an adequate trial of serotonin reuptake inhibitors (SRIs) fail to fully respond to treatment and continue to exhibit significant symptoms. Many studies have assessed the effectiveness of antipsychotic augmentation in SRI-refractory OCD. In this systematic review, we evaluate the efficacy of antipsychotic augmentation in treatment-refractory OCD. The electronic databases of PubMed, PsychINFO (1967PsychINFO ( -2005, Embase (1974Embase ( -2000 and the Cochrane Central Register of Controlled Trials (CENTRAL, as of 2005, Issue 3) were searched for relevant double-blind trials using keywords 'antipsychotic agents' or 'neuroleptics' and 'obsessive-compulsive disorder'. Search results and analysis were limited to double-blind, randomized control trials involving the adult population. The proportion of subjects designated as treatment responders was defined by a greater than 35% reduction in Yale Brown Obsessive-Compulsive Scale (Y-BOCS) rating during the course of augmentation therapy. Nine studies involving 278 participants were included in the analysis. The meta-analysis of these studies demonstrated a significant absolute risk difference (ARD) in favor of antipsychotic augmentation of 0.22 (95% confidence interval (CI): 0.13, 0.31). The subgroup of OCD patients with comorbid tics have a particularly beneficial response to this intervention, ARD = 0.43 (95% CI: 0.19, 0.68). There was also evidence suggesting OCD patients should be treated with at least 3 months of maximaltolerated therapy of an SRI before initiating antipsychotic augmentation owing to the high rate of treatment response to continued SRI monotherapy (25.6%). Antipsychotic augmentation in SRI-refractory OCD is indicated in patients who have been treated for at least 3 months of maximal-tolerated therapy of an SRI. Unfortunately, only one-third of treatment-refractory OCD patients show a meaningful treatment response to antipsychotic augmentation. There is sufficient evidence in the published literature, demonstrating the efficacy of haloperidol and risperidone, and evidence regarding the efficacy of quetiapine and olanzapine is inconclusive. Patients with comorbid tics are likely to have a differential benefit to antipsychotic augmentation.

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Pharmacological Treatment of Anxiety, Obsessive-Compulsive and Post-Traumatic Stress Disorders – First Revision

“…A comparison of risperidone and olanzapine augmentation to an SSRI revealed no difference between the two drugs (Maina et al 2008). Altogether, meta-analyses demonstrated positive effects of antipsychotic augmentation (Bloch et al 2006;Fineberg et al 2006;Skapinakis et al 2007). The subgroup of OCD patients with comorbid tics had a particularly beneficial response to this intervention.…”

“…However, only one-third of treatment-refractory OCD patients showed a meaningful treatment response to antipsychotic augmentation. In summary, there was sufficient evidence demonstrating the efficacy of haloperidol and risperidone; however, evidence regarding the efficacy of quetiapine and olanzapine is inconclusive, according to a review (Bloch et al 2006). Notably, there have been several case reports on OCD symptoms in schizophrenic patients induced by antipsychotics (Zohar et al 2006).…”

Tourette syndrome and obsessive–compulsive disorder

“…For these individuals, it is possible that augmentation strategies may be tried. To date, the addition of an antipsychotic medication is the most effective class of medications for augmentation [44]. In addition, cognitive-behavioral therapies deserve consideration either as an adjunct or as a first line treatment for children and adolescents with OCD.…”

Probing Compulsive and Impulsive Behaviors, from Animal Models to Endophenotypes: A Narrative Review

“…OCD typically responds to serotonin reuptake inhibitors (SRIs; clomipramine and selective SRIs, SSRIs) and to SSRIs combined with antipsychotic agents . Antipsychotics represent first-line treatment for Tourette's syndrome, and it is, therefore, interesting that their combination with SSRIs shows greater efficacy in ticrelated OCD (Bloch et al, 2006). Compulsions associated with autistic disorders may also respond to low-dose SSRI and to antipsychotics (Kolevzon et al, 2006).…”