Treatments for ocd

SSRIs are the first-line recommendation for patients with OCD

• – Approved agents include fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil)

Second-line agents are considered off-label but have at least a minimum evidence base to support their use

• – SNRI agents (venlafaxine-XR [EffexorXR], duloxetine [Cymbalta], and desvenlafaxine [Pristiq]) all have potent serotonin reuptake inhibitor (SRI) activity, which may account for their anti-obsessive properties

• – MAOI agents cannot be added to SSRI or SNRI treatments safely, but may be used as monotherapy trials in more resistant OCD cases

  • The risk of serotonin syndrome or tyramine-induced hypertensive crises limits the safety and tolerability of this class, hence a second-tier rating

• The TCA clomipramine (Anafranil) was actually the first approved agent

  • Its side-effect profile includes more sedation, weight gain, and anticholinergic effects than that of the SSRIs

  • Its cardiotoxicity in overdose limits it to second-tier use

  • This agent is considered the gold standard from outcomes-based trials

Several medications may be used as adjuncts for residual symptoms or treatment-resistant OCD

• – Buspirone (BuSpar) and the atypical antipsychotics are often mentioned in treatment guidelines

• – The BZ anxiolytics and hypnotics are noted in some studies to lower agitation associated with obsessive thinking, but often do little to limit compulsive behaviors

• – Deep Brain Stimulation (DBS) is approved for compassionate use for treatment-resistant OCD patients

  • DBS is less surgically invasive than traditional or gamma knife anterior capsulotomy psychosurgery for truly refractory cases of OCD

Posttest-self assessment question and answer

Obsessive compulsive disorder (OCD) may develop postpartum in some cases, which is not true of postpartum OCD

A. It is less common than postpartum blues

B. It is less common than postpartum depression

C. It occurs in up to 5% of postpartum women

D. Obsessions are most frequently related to contamination fears

Answer: D

Obsessions most frequently noted are images or impulses about causing harm to the newborn or being unable to intervene and stop harm from involving the infant. Contamination was predominant in this case, but is not the most typical presentation postpartum.

References

1.Saxena S, Rauch SL. Functional neuroimaging and the neuroanatomy of obsessive-compulsive disorder. Psychiatr Clin North Am 2000; 23:563–86.

2.Hollander E, Kim S, Khanna S, Pallanti S. Obsessive-compulsive disorder and obsessive-compulsive spectrum disorders: diagnostic and dimensional issues. CNS Spectr 2007; 12:5–13.

3.Stahl SM. Stahl’s Essential Psychopharmacology: The Prescriber’s Guide, 5th edn. New York, NY: Cambridge University Press, 2014.

4.American Psychiatric Association Work Group on Obsessive-Compulsive Disorder. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Am J Psychiatry 2007; 164:1–56.

5.Greenberg BD, Malone DA, Friehs GM, et al. Three-year outcomes in deep brain stimulation for highly resistant obsessive-compulsive disorder. Neuropsychopharmacology 2006; 31:2384–93.

6.Greist JH, Jefferson JW, Kobak KA, Katzelnick DJ, Serlin RC. Efficacy and tolerability of serotonin transport inhibitors in obsessive-compulsive disorder. A meta-analysis. Arch Gen Psychiatry 1995; 52:53–60.

7.Kobak KA, Greist JH, Jefferson JW, Katzelnick DJ, Henk HJ. Behavioral versus pharmacological treatments of obsessive compulsive disorder: a meta-analysis. Psychopharmacology (Berl) 1998; 136:205–16.

8.Bloch MH, Landeros-Weisenberger A, Kelmendi B, et al. A systematic review: antipsychotic augmentation with treatment refractory obsessive-compulsive disorder. Mol Psychiatry 2006; 11:622–32.

9.Bauer M, Pretorius HW, Constant EL, et al. Extended-release quetiapine as adjunct to an antidepressant in patients with major depressive disorder: results of a randomized, placebo-controlled, double-blind study. J Clin Psychiatry 2009; 70:540–9.

Patient file

The Case:

The woman who liked late-night TV

The Question:

What to do when comorbid depression and sleep disorders are resistant to treatment

The Dilemma:

Continuous positive airway pressure (CPAP) may not be a reasonable option for treating apnea; polypharmacy is needed but complicated by adverse effects

Pretest self-assessment question (answer at the end of the case)

Which of the following hypnotic agents is less likely to be addictive, impair psychomotor function, or cause respiratory suppression?

A. Ramelteon (Rozerem)

B. Zolpidem (Ambien)

C. Doxepin (Silenor)

D. Temazepam (Restoril)

E. A and C

F. B and D

G. None of the above