Longitudinal course of pharmacotherapy in obsessive–compulsive disorder

Abstract

Background Although data fully support the use of serotonin reuptake inhibitors (SRIs) in the treatment of obsessive–compulsive disorder (OCD), investigations on pharmacotherapy discontinuation during the course of OCD are lacking. This 5-year prospective study sought to better understand the long-term course of SRI utilization among individuals with OCD. Methods A total of 252 adult outpatients with Diagnostic and Statistical Manual of Mental Disorders, 4th ed. OCD, treated with medication in the community, were examined for discontinuation and resumption of SRIs. Data on weekly OCD symptoms, medications, and dosage changes were obtained annually using the Longitudinal Interval Follow-up Evaluation. Results During the 5-year follow-up period, 151 patients had at least one trial of an SRI for 12 weeks or more. A total of 110 patients (43.7%) discontinued their medication (i.e. ceased taking medication for ≥4 weeks) at least once during the follow-up period. In patients symptomatic at the time of discontinuation, the cumulative incidence of worsening of OCD after SRI discontinuation was 9.8%, whereas in patients in partial or full remission at the time of discontinuation, the corresponding cumulative incidence was 33.3%. Among patients with worsening of OCD upon SRI discontinuation, the median time to worsening was 39 weeks. Conclusion This first longitudinal study on the use of SRIs in OCD found that patients who had achieved partial or full remission on SRIs were less likely to discontinue medication, and the cumulative incidence of worsening of OCD after discontinuation was negatively associated with OCD severity at the time of SRI discontinuation.

Metabolic and Cardiovascular Complications in Obsessive-Compulsive Disorder: A Total Population, Sibling Comparison Study With Long-Term Follow-up

“…High doses of SRIs have been consistently associated with greater reductions in OCD symptoms, compared with low doses or placebo, in multiple clinical trials and meta-analyses (37). Similarly, it is well established that relapse rates are high in patients who discontinue their SRI treatment too soon (38)(39)(40). As this is not a randomized controlled study, we are cautious to attribute the observed risk reductions to medication alone.…”

Trichotillomania

“…Trichotillomania occurs with a variety of other disorders such as major depressive (39-65%), anxiety (27-32%), and substance use (15-19%) disorders (11,16–17). Where data regarding age of onset are available, trichotillomania generally begins at an earlier age than these co-occurring disorders (18). A study of 894 individuals with trichotillomania found that 6.0% used illegal drugs, 17.7% used tobacco products, and 14.1% used alcohol to relieve negative feelings associated with pulling (2).…”

Unified protocol for the discontinuation of long-term serotonin reuptake inhibitors in obsessive compulsive disorder: Study protocol and methods

“…Urn randomization is used to assign participants [30] in a 1:1 allocation while stratifying treatment assignment on baseline level of OCD severity (cutoff on the YBOCS ≥ 16) [31]. Level of OCD symptomatology at baseline (pre-intervention) is likely a prognostic factor affecting severity and discontinuation outcomes [7] and therefore is controlled during randomization.…”

“…[3,4] Despite increased recognition of its public health significance, surprisingly little is known about how to optimize long-term treatment of the disorder. Serotonin reuptake inhibitors (SRIs) are the most commonly prescribed medications for OCD [5] with large observational studies estimating lifetime utilization at over 90% in treatment-seeking populations [6,7]. Although widely used and efficacious [8–10], SRI use long-term is associated with adverse side effects [11–14], as well as problems with adherence and financial burden [15,16].…”

“…Controlled short-term SRI discontinuation studies highlight a moderate-to-high risk of OCD symptom reoccurrence following abrupt or rapid discontinuation [18–20]. These findings, however, are inconsistent with naturalistic observations suggesting that the majority of OCD patients discontinue maintenance SRIs without significant symptom worsening [7]. Furthermore, abrupt discontinuation of SRIs is at odds with clinical practice and American Psychiatric Association guidelines recommending slow taper [21].…”