Aims and Scope
A recent meta-analysis of 17 RCTs found that SSRIs separate from placebo as early as 2 weeks and that majority of improvement occurs early on in the course of treatment [ 20 ]. However, improvements seen early in the course of treatment may not be always clinically meaningful. In many patients, clinically meaningful improvements may be seen only after weeks or months of treatment. It is recommended that an adequate trial of a SSRI or clomipramine should be at least for 12 weeks to account for the lag in the onset of action.
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The APA guidelines recommend upward titration to the maximum FDA-approved doses by weeks and continuation in that dose for another weeks or so to determine efficacy [ 11 ]. Certain clinical and biological predictors of treatment response to SSRIs have been identified but they are not robust predictors Table 7. Venlafaxine, a serotonin-norepinephrine reuptake inhibitor with preferential serotonergic action, has been studied in comparison to paroxetine in a double blinded study and clomipramine in a single blinded study.
The studies found no difference in the efficacy between venlafaxine and the comparator agents in acute control of OCD. Given the absence of evidence from placebo-controlled trials, venlafaxine is not the first-line treatment for OCD. Hence, the guidelines consider venlafaxine as a second-line monotherapy agent in the treatment of OCD. Mirtazapine has been studied as a monotherapy in two small open-label trials with inconsistent findings.
Therefore, mirtazapine cannot be recommended as monotherapy in treatment of OCD. Definitions of treatment outcome [ 21 ] are given in Table 8.
Clinicians often face the subsequent challenge of partial and non-response to SSRIs. Continuing improvement has been noticed with prolonged trial of SSRIs as discussed above. Hence, the initial trial may be continued further if there is evidence of ongoing improvement. Treatment algorithm for treating a patient with OCD. Strategies for non-responders to SSRIs. In partial responders, changing medication may entail loss of the response to the earlier medication. Hence, switching is recommended in partial responders only if there are severe persisting symptoms or upon failure of other augmenting strategies such as CBT and atypical antipsychotics.
The following medications have been commonly tried as augmenters to SSRIs. Atypical antipsychotics, risperidone and aripiprazole have the best evidence. Antipsychotics are the most widely studied augmenting agents of SSRIs [ 23 ]. The literature on antipsychotic augmentation is fraught with methodological limitations including small sample sizes, varying doses and duration of treatment with both antipsychotics and concomitant SSRIs, varying degree of treatment resistance etc. Two recent meta-analyses of 14 RCTs on antipsychotic augmentation found that antipsychotic as a group was significantly more effective than placebo in decreasing YBOCS scores [ 24 , 25 ].
About a third of patients responded to antipsychotic augmentation. Aripiprazole and risperidone are consistently found to be effective as augmenting agents. The evidence for haloperidol should be interpreted with caution as it was based on a single study.
This study has raised questions on the efficacy of risperidone as an augmenter. Quetiapine and olanzapine have not been consistently found to be effective, while other antipsychotics have not been studied adequately.
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Meta-analyses do not throw any light on adequate dose and duration of antipsychotic treatment [ 24 ]. Antipsychotics should be used in low doses e. Use of antipsychotics in the long-run should be considered after weighing the benefits and risks of long-term use. There is a strong theoretical rationale supporting the use of glutamatergic drugs in OCD. The following glutamatergic agents have been studied in OCD [ 23 ]:. However, due to the methodological limitations of the individual studies, 5HT-3 antagonists are recommended as second line augmenting agents along with glutamatergic agents.
Preliminary evidence suggests that clomipramine can be an effective augmenting agent. Clomipramine and SSRI combination should be used cautiously, especially with fluoxetine and fluvoxamine, as they may increase clomipramine related adverse effects including serious events like seizures, cardiac effects, serotonin syndrome due to pharmacokinetic interactions. Clomipramine augmentation of SSRI may be tried but adequate precautions need to be taken keeping in mind the potential adverse effects of the combination. Mirtazapine augmentation has been found to hasten the response with no significant long term benefits [ 23 ] and hence may be considered as an augmenting agent in partial responders and non-responders.
Buspirone, lithium and clonazepam have not been found effective and hence are not recommended as augmenting agents. The safety and efficacy of psychostimulants and opioid drugs have to be systematically studied before they are recommended for routine clinical use. While there appears to be some short-term benefits for intravenous clomipramine in treatment resistant patients, the long term benefits are uncertain.
This formulation is not available in India and is not recommended at present for clinical use. There are a few uncontrolled trials demonstrating the utility of higher than recommended doses of SSRIs up to mg of sertraline, mg of escitalopram in resistant patients. This strategy should be considered experimental and may be used only in resistant patients after exhausting other regular safer options. Neuromodulatory and neurosurgical treatments targeting the cortico-striato- thalamo-cortical CSTC circuits have been tried in resistant patients. Available evidence, in the form of case reports and case series, do not provide evidence for the efficacy of ECT [ 28 ].
Hence, ECT is not recommended as a treatment for OCD and may be considered for the treatment of comorbid conditions like severe mood and psychotic disorders, if indicated.
Hence rTMS has been tried in superficial cortical regions which have connections with other deeper structures implicated in OCD. However, the evidence has not been very consistent. Overall, the findings have to be replicated in larger samples with long term follow-up. There is no convincing evidence that beneficial effects persist for longer than the trial period. The guideline recommends rTMS as an intervention for further research and not for routine clinical use.
It has to be evaluated more systematically before it can be recommended for clinical use in OCD. Ablative neurosurgical procedures involve producing lesions in specific regions of the CSTC circuit, which is hypothesized to be dysfunctional in OCD. Due to the irreversible nature, these procedures are generally employed in treatment refractory patients Table There is some suggestion that capsulotomy may be more effective procedure in OCD [ 30 ] and that its efficacy may be similar to that of deep brain stimulation DBS [ 31 ]. Surgery may be associated with short-term and persistent adverse effects including personality changes, seizures and cognitive adverse effects although rates are not high.
Deep brain stimulation DBS is a potentially reversible procedure involving high frequency stimulation of implanted electrodes in the brain. Although the mechanism of action is poorly understood, it is hypothesized to modify dysfunctional circuits. DBS is an invasive procedure and is associated with short term and long term adverse effects. Further, the battery needs to be replaced periodically which may be quite expensive.
DBS can be recommended in carefully selected refractory OCD patients Table 10 after discussion regarding the pros and cons of the procedure. The neurosurgical procedures are not curative in nature and the procedures are only one aspect of a comprehensive treatment program which should continue following surgery.
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Surgical procedures may be considered only in selective patients after careful evaluation of patients for treatment refractoriness, severity of illness and comorbidities. Patients should be explained about the realistic possibility of benefits and risks.
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They should be evaluated by an independent team consisting of a psychiatrist, a neurologist and a neurosurgeon for suitability for surgery. The treatment should be conducted under close collaboration of a team of psychiatrist, neurosurgeon, radiotherapist, imaging specialist and psychologist with close monitoring of adverse effects. Suggested criteria for suitability to undergo surgery are shown in Table All treatment guidelines have suggested the use of CBT as a first-line treatment option. Patients in the CBT group had significantly greater reductions in OCD symptom severity compared with participants taking risperidone or placebo.
Risperidone was not superior to placebo on any outcome measures. Therapist-guided exposure is better than self-guided exposure. The numbers of CBT sessions have varied between 12 and 20 sessions across various studies. It has ranged from intensive daily 2 hour sessions for 5 days a week for 3 weeks to less intensive twice weekly sessions in other studies.
While a couple of studies have reported comparable efficacy for group and individual forms of CBT, some other studies demonstrated the superiority of individual mode of CBT compared to the group CBT. This therapy aims to improve psychological flexibility through the practice of acceptance and mindfulness in addition to commitment and behavior modification exercises. Preliminary evidence suggests its benefits but it needs to be tested and compared with CBT in larger samples.
These have been conventionally used in many studies as control arm in studies CBT. Stress management and relaxation training may have non-specific effects but there is no evidence suggesting their efficacy in treatment of OCD. Mindfulness based therapy is thought to be useful in OCD. Preliminary data suggests its utility in treating OCD. Protocols for RCT are published but there is no published evidence in the literature in clinical population. Family-inclusive treatment FIT approaches aim to include the family members in the treatment so as to improve the family functioning, facilitate behavioral therapy etc.
Studies targeting family accommodation of obsessive-compulsive symptoms report greater improvements in patient functioning. Family members may be encouraged to participate in CBT since family accommodation of symptoms is associated with poorer treatment outcomes. There is one study examining the role of brief dynamic therapy in OCD with negative result.
In addition, the potential benefits of adding D-cycloserine prior to ERP sessions has been examined in few studies. This includes decision on choice of treatment modality SSRI vs.
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