Pharmacological Treatment of Obsessive-Compulsive Disorder

Abstract

Synopsis Obsessive-compulsive disorder (OCD) affects up to 2.5% of the population of the course of a lifetime and produces substantial morbidity. Approximately 70% of patients can experience significant symptomatic relief with appropriate pharmacotherapy. The selective serotonin reuptake inhibitors (SSRIs) are the main stay of pharmacological treatment. These are typically used at higher doses and for longer periods than in depression. Remission is, unfortunately, uncommon. Proven second-line treatments include the tricyclic clomipramine and the addition of low-dose neuroleptic medications. Other augmentation strategies have been explored for patients refractory to proven interventions, but they are not as of yet robustly supported by controlled studies. The combination of medication with psychotherapy is often used, though careful studies have not documented synergistic benefit in adult patients. OCD refractory to available treatments remains a profound clinical challenge.

Glutamate Modulators in the Treatment of Obsessive-Compulsive Disorder

“…Many early studies have been uncontrolled, and controlled studies have been small and have yielded mixed results. In most cases, it is therefore only appropriate to consider the use of a glutamate modulator once better-proven therapeutic approaches, such as SSRI pharmacotherapy and cognitive-behavioral therapy, have been exhausted 6 .…”

“…Specifically, pharmacotherapy with the SSRI antidepressants, or the older tricyclic drug clomipramine, is effective in 50-60% of cases 6 . Evidence-based psychotherapy is efficacious in a comparable percentage, and combination treatment may be preferable in some cases 5 .…”

Glutamatergic agents for OCD and related disorders

“…In particular, specialized cognitive-behavioral therapy and pharmacotherapy with selective serotonin reuptake inhibitors (SSRIs) are both first-line treatments, and approximately 2 patients in 3 will benefit significantly from these interventions [7, 8]. Evidence-based options after these first-line treatments are exhausted are, however, limited [7, 9, 10]. This leaves approximately 1 patient in 3 without meaningful benefit even after optimal treatment; given the lifetime morbid risk of 2.7% [2], this translates to over 3 million people in the United States.…”

“…It is important to emphasize that in no case has the efficacy of these agents been conclusively proven, in general or in a subset of patients, in multiple well-controlled trials, and thus they should not be considered first-line treatment in place of better-proven approaches such as SSRI pharmacotherapy or expert CBT. But in the substantial fraction of patients who do not respond to conventional treatments – which is regrettably large – glutamate modulators represent an increasingly viable alternative [7, 10, 11]. In the treatment of refractory patients, the evidence of benefit is limited but other therapeutic options are readily exhausted; clinical decisions must be made through careful balancing of risks and uncertain, but plausible, benefits.…”

Evidence-Based Treatments in Treatment-Naïve and Treatment-Resistant Pediatric Obsessive-Compulsive Disorder

“…We also filtered in the terms of Brandomized controlled trials^and Bmeta-analysis^. In addition, we read recent reviews and expert guidelines to find any relevant additional publications [1,[4][5][6][7][8][9][10][11].…”