eMedicine Specialties > Psychiatry > Adult

Obsessive-Compulsive Disorder: Treatment & Medication

Author: William M Greenberg, MD, Associate Director, Clinical Development, Forest Research Institute, Forest Laboratories, Inc; Visiting Scientist, Nathan S Kline Institute for Psychiatric Research; Private Practice
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Updated: May 31, 2009

Treatment

Medical Care

The mainstays of treatment of obsessive-compulsive disorder (OCD) include pharmacotherapy, particular forms of behavior therapy (exposure and response prevention and some forms of CBT), education and family interventions, and neurosurgical treatment in extremely refractory cases. A practice guideline for the treatment of OCD has recently been published by the American Psychiatric Association.²²

• Pharmacotherapy
  • First-line pharmacologic treatments are potent 5-HT reuptake inhibitors, such as the SSRIs (fluoxetine, fluvoxamine, sertraline, paroxetine, citalopram, escitalopram) and clomipramine (Anafranil), with possible alternatives including venlafaxine, a serotonin norepinephrine reuptake inhibitor (SNRI). All of these are commonly used to treat OCD, although not all have received an FDA indication for this disorder. Unlike in the case of major depression, complete or near-complete remission of OCD symptoms is rare with only serotonergic antidepressant treatment. More typically, perhaps half of patients may experience symptom reductions of 30-50%, as measured by the Y-BOCS, with many others failing to even achieve this degree of relief.
  • Doses above those needed for treatment of depression may be more effective for some patients. A therapeutic dose for 6-10 weeks may be required to observe a clinical response (see Medication). Response tends to be slow and continue for at least 12 weeks (the common duration of OCD pharmacologic clinical trials), unlike the use of these same antidepressants in the treatment of major depressive episodes, where responses are more often seen somewhat earlier.
  • Several treatment studies suggest a possible role for norepinephrine (NE) in cases of OCD. A subset of patients reportedly show greater clinical improvement with a combination of 5-HT and NE reuptake inhibition as compared to treatment with SSRIs alone. These have included patients treated with clomipramine (a tricyclic antidepressant [TCA] with both 5-HT and NE reuptake inhibition) and those whose SSRI treatment was augmented with an NE reuptake inhibitor such as desipramine.
• Behavior therapy
  • This is a first-line treatment that should be undertaken with a psychotherapist who has specific training and experience in behavior therapy (most commonly behaviorally-trained psychologists). Some patients will not undertake this therapy, with perhaps 25% rejecting it and 25% dropping out of behavioral therapy, but it should definitely be encouraged if a competent behavioral therapist is available.
  • Exposure and response (or ritual) prevention (ERP) is the important and specific core element in behavior therapy for OCD. The patient rank orders OCD situations he or she perceives as threatening, and then the patient is systematically exposed to symptom triggers of gradually increasing intensity, while the patient is to suppress his or her usual ritualized response. This is generally challenging and often quite distressing for the patient, but when effectively done, promotes unlearning of the strong link that has existed between having an urge and giving into the urge. When a patient does not respond in the face of a potent trigger, extinction of the response can take place. Significant others should be involved when possible, and they may have to be willing to change their responses to the patient (eg, not provide requested reassurance to irrational doubts).
  • ERP is now usually administered as part of a broader program of CBT, specifically designed for OCD. Other elements of CBT that are used include identifying and challenging the cognitive distortions of OCD symptoms (eg, intolerance of uncertainty, black and white thinking, focusing on unlikely extreme possibilities instead of viewing the future in a balanced manner, ascribing overimportance to thoughts, excessive concern about the importance of one's thoughts, inflated sense of responsibility). After making the patient aware of his or her irrational thoughts, the therapist works to have the patient counter them with more rational thoughts and do cost/benefit analyses regarding performing his or her rituals. 
    
    Meditation and relaxation techniques may be useful, but not during active ERP, as the effectiveness of these exercises requires that the patient experience a significant level of discomfort and then not respond with his or her characteristic rituals. A patient may benefit from a self-help book in conducting ERP (eg, Foa and Reid, 2001²³ ), and workbooks are available for CBT as well. When recommending such a book, the treating physician should be familiar with its content.
  • Another related approach described by Dr. Jonathan Grayson focuses on getting the patient to accept living with uncertainty, as it relates to his or her obsessional ideas, and prepare an individualized script to reinforce this attitude.²⁴
  • Psychodynamic psychotherapy alone has generally not been found helpful in ameliorating OCD symptoms. It may, however, be useful in working on a patient's resistance to accepting recommended treatments, or in appreciating the interpersonal effects that a patient's OCD symptoms are having on others.²²
• Strategies for treatment resistance
  • Strategies should always include an assessment of complicating diagnoses, medication compliance, drug dose, and duration of therapy.
  • The presence of a comorbid diagnosis that has not been addressed, such as depression or panic disorder, can interfere with clinical recovery and identification may guide the choice of interventions. Targeted interventions might include, for example, lithium or antipsychotic augmentation or ECT for depression.
• Interventions for patients with treatment resistance include the following:
  • Change or increase in medication (eg, increase dose or prescribe different SSRI or clomipramine)
  • More intensive CBT
• Other interventions, which have not received an FDA indication for OCD include the following:
  • Addition of an NE reuptake inhibitor, such as desipramine, to an SSRI, or a trail of venlafaxine
  • Addition of a typical or atypical antipsychotic, especially in patients with a history of tics
  • Augmentation with buspirone
  • Addition of inositol
  • Sole or augmented use of selected glutamatergic agents^10,11
  • Deep brain stimulation (DBS)^25,26 or cingulotomy neurosurgery²⁷ for severe and intractable cases

Some clinicians feel that individuals with comorbid Tourette disorder or with hoarding as their principal OCD symptom may be more likely to be treatment resistant, although there is significant variation in treatment response, regardless of the particular presenting symptomatology.

Surgical Care

• Neurosurgical treatment of OCD is performed at a limited number of centers and is reserved for patients with severe and refractory symptoms. The most common small series use a specific small lesion (eg, cingulotomy) or deep brain stimulation. Current clinical trials are also exploring the application of transcranial magnetic stimulation (TMS) for OCD, a noninvasive treatment approach.
• One surgical technique involves the stereotactic placement of bilateral lesions in the anterior cingulate cortex. A case series of 18 patients showed a 28% response rate, with an additional 17% showing a partial response. No significant adverse neurologic or cognitive sequelae were noted.
• A deep brain stimulation technique consists of implanting a device to electrically stimulate the subthalamic nucleus. A crossover study in 17 patients with severe, refractory OCD in which patients received 3 months of active stimulation and 3 months of sham stimulation in randomized order, found that there was significantly more improvement during the active stimulation periods. However, serious adverse events were substantial and included intracerebral hemorrhage and infection.²⁶
• In February 2009, the FDA approved the use of Reclaim Deep Brain Stimulation Therapy for individuals with chronic, severe OCD. This device is an implanted medical device that is designed to target a region called the ventral capsule/ventral striatum, which is in the anterior limb of the internal capsule of the brain.

Consultations

• While treatment approaches for OCD are now well described in the literature, many clinicians remain unfamiliar with the features and management of this disorder. Consultation should be sought if the treating physician is unfamiliar or uncomfortable with the diagnosis, or if they feel they have exhausted the interventions with which they feel comfortable.
• Neurosurgical treatment of OCD is available at only a limited number of medical centers. The Obsessive Compulsive Foundation can provide a listing of centers with experience in this area.

Medication

Only antidepressants that potently inhibit presynaptic reuptake of serotonin appear to be effective in treating OCD. Clomipramine (Anafranil) is the only TCA with this quality. The SSRIs are also effective. SSRIs have the advantages of ease of dosing and low toxicity in overdose. Available SSRIs include fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexapro), and sertraline (Zoloft).

The dual serotonin-norepinephrine reuptake inhibitor antidepressants (SNRIs) venlafaxine (Effexor) and duloxetine (Cymbalta) may also have efficacy in OCD, and they have safety and tolerability profiles comparable to those of the SSRIs, but neither has yet been FDA-approved specifically for treatment of OCD.

SSRIs are generally preferred over clomipramine in treating OCD. The adverse effect profiles of SSRIs are less prominent, so improved compliance is promoted. SSRIs do not have the cardiac arrhythmia risk associated with TCAs. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered when treating a child or adolescent with mood disorder.

Physicians are advised to be aware of the following information and use appropriate caution when considering treatment with SSRIs in the pediatric population.

In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweighed the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appeared to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.

In October 2003, the FDA issued a public health advisory regarding reports of suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.

Upon further analysis of pooled clinical trial data suicidality was reportedly increased in children and adolescents being treated with SSRIs for depression (approximately 2% for those treated with placebo vs 4% for those on SSRIs, although no actual suicides occurred in either group). These clinical trials were unfortunately not designed to specifically and clearly assess suicidal thoughts and behaviors, and therefore included events not readily classified. The FDA issued a public health advisory in October of 2004²⁸ , mandating a black box warning for antidepressants. Antidepressant treatment of children and adolescents with depression then significantly decreased over the next 2 years, although apparently so did suicides for this population. In 2007, the FDA extended its warning to young adults.²⁹

Currently, evidence does not exist to associate an increased risk of suicide in patients with OCD and/or other anxiety disorders being treated with SSRIs. However, physicians should closely attend to whether treated patients have unusual uncomfortable adverse reactions (eg, akathisia), or if they might have comorbid bipolar disorder (which may involve only subtle hypomanic episodes), as occasionally antidepressant use seems to be associated with triggering dysphoria and sometimes manic episodes in such individuals. Children, adolescents, and young adults being treated with antidepressants should be closely and frequently monitored, particularly early in treatment, for any suicidal ideation or actions.

Antidepressants

SSRIs are used commonly. The tricyclic antidepressant clomipramine is also used, although often attended by more uncomfortable adverse effects.

Fluoxetine (Prozac)

Enhances serotonin activity due to selective reuptake inhibition at neuronal membrane. Highly protein-bound and metabolized by CYP450 2D6.

Paroxetine (Paxil)

Enhances serotonin activity due to selective reuptake inhibition at the neuronal membrane.

Sertraline (Zoloft)

Enhances serotonin activity due to selective reuptake inhibition at the neuronal membrane.

Citalopram (Celexa)

Enhances serotonin activity due to selective reuptake inhibition at the neuronal membrane. Also has the advantage of fewer potential drug interactions. Citalopram is a 50:50 racemate of r- and s-citalopram.

Fluvoxamine (Luvox)

Enhances serotonin activity because of selective reuptake inhibition at the neuronal membrane.

Clomipramine (Anafranil)

Tricyclic antidepressant with potent NE and 5-HT reuptake inhibition.

Escitalopram (Lexapro)

SSRI and S-enantiomer of citalopram. Used for the treatment of depression. Mechanism of action is thought to be potentiation of serotonergic activity in CNS resulting from inhibition of CNS neuronal reuptake of serotonin. Onset of depression relief may be obtained after 1-2 wk, which is sooner than other antidepressants.

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