Treatment with Antidepressants
Although OCD symptoms have been described for centuries, effective treatments have not been available, and the long-term outcome of patients has been generally chronic. The treatment of obsessive-compulsive disorder (OCD), perhaps more than for any other disorder, has changed dramatically in the last two decades. At present two treatments have evolved: pharmacotherapy with SSRIs and CBT.
Clomipramine, a serotonin reuptake inhibitor (SRI), was the first agent shown to be useful in the treatment of OCD 20 years ago (Fernandez-Cordoba et al., 1967) and the efficacy of this tricyclic antidepressant in OCD is now well documented (DeVaugh-Geiss et al., 1991; Stein et al., 1996b; Greist et al., 1995b). The treatment of OCD has a significantly better response to serotonin reuptake inhibitors, such as clomipramine compared to noradrenaline reuptake inhibitors, such as desipramine (Zohar and Insel, 1987; Leonard et al., 1989; Deakin JFW, 1996). The efficacy and availability of clomipramine for investigational study of OCD prompted the development and use of the new SSRIs in the treatment of OCD.
Treatment with SSRIs
The development of serotonin specific reuptake inhibitors (SSRIs) was an important step in OCD management, as these agents have not only proven to be effective in the disorder (Greist et al., 1995b; Piccinelli et al., 1995; Gunasekara et al., 1998; Ravizza et al., 1996; Stein et al., 1995b; Zohar et al., 1988), but they also demonstrate relatively few side effects compared to the older tricyclics (Jenike et al., 1990; Leonard, 1997).
In recent years, new antidepressants with potent serotonin transport-inhibiting properties have been shown conclusively to have both short-term and long-term efficacy in reducing OCD symptomatology (Greist et al., 1995a; Greist et al., 1995b; Greist et al., 1995c; Greist et al., 1995d; Wheadon et al., 1993; Tollefson et al., 1994; Fontaine and Chouinard, 1986; Liebowitz et al., 1989; Goodman et al., 1989; Chouinard et al., 1990). Direct comparison studies between the SSRIs have not shown differences in efficacy (Pigott et al., 1990; Tamini et al., 1991) despite the variations in potency and selectivity. Neither potency nor selectivity profile appears to be correlated with clinical anti-obsessional efficacy. These are, however, important issues for considering dosages, side effects and drug interactions (Leonard, 1997).
The issue of how long to continue an OCD patient, who has responded to an SSRI, on medication maintenance is unresolved. Many responders require long-term maintenance pharmacotherapy. Lane (1996) reports on the need for long-term treatment and suggests and that sertraline and citalopram may be the SSRIs of choice due to their low risk for drug interactions.
The initial response to pharmacotherapy is not evident until 4-6 weeks of treatment have elapsed and patients continue to improve for up to 3-4 months. Treatment after full remission of the symptoms should be continued long enough so that the neuronal dysfunction is fully treated before the medication is discontinued (Koponen, 1997).
Pato et al (1988) reported that 89% of subjects who had clomipramine substituted with placebo during the maintenance phase of treatment, relapsed within 7 weeks, and the majority of patients on fluoxetine maintenance treatment relapsed within 12 weeks of discontinuing medication (Pato et al., 1991). These studies suggest that long-term maintenance treatment is required in OCD for most patients. However, there are suggestions that cognitive-behavioural therapy (CBT) may decrease the need for long-term pharmacotherapy.
Numerous studies have now clearly shown that behaviour therapy and serotonergic antidepressants are effective in the treatment of OCD (de Haan et al., 1997). However, approximately 50% of the patients who request treatment do not benefit from it as some of them ultimately refuse the treatment offered, some of them discontinue the treatment themselves and therefore little or no change is seen in many of them, despite psychotherapeutic and pharmacologic intervention. This raises the question of whether it is possible to identify factors that can predict these non-responders or non-compliers. Research into predictive factors is mostly centred on the group of patients who do not improve despite therapy. Various researchers have attempted to predict outcome on the basis of factors which can already be discerned before treatment begins. However, there may also be predictive factors, such as the short-term effect, which become apparent during treatment.
In a survey of research into predictive factors for behaviour therapy outcome, (Steketee and Shapiro, 1995) the conclusion was reached that, in most cases, age, sex, marital status, education, living environment, type, duration and severity of complaints and degree of anxiety had little effect on outcome. The same was found in the treatment strategies that employed antidepressants alone or in combination with behaviour therapy. In general, no relationship was found between these factors and treatment outcome (DeVaugh-Greiss et al., 1990; Castle et al., 1994).
There are other factors which play a role in the success of treatment but are more difficult to study and therefore little is known about their effect. “Motivation for therapy” is one of these little known entities which deserve to be studied further. Studies have suggested that motivation is one of the factors that predict behaviour therapy outcome. Research into the predictive value of personality disorders has been increasing and in studies where personality disorders were determined prospectively, a negative correlation with treatment outcome was found (de Haan et al., 1997).
Therefore the combination of the serotonin reuptake inhibitors (SSRIs) class and of the specialised cognitive-behavioural therapies, coupled with an increasing neurobiological line of study into underlying mechanisms, has revolutionised our understanding about the causes and the treatment of OCD. With the development of these new pharmacotherapeutic strategies, attention has now focused on the need for long-term maintenance, on the safety and efficacy of the SSRIs in the paediatric ages, and their applicability in other compulsive-like (spectrum) disorders (Leonard, 1997; Stein and Hollander, 1996).
The role of psychological interventions must not be underestimated in the treatment of children with anxiety.
A study in Australia illustrates this point: 79 children suffering from separation anxiety, overanxious disorder and social anxiety disorder were randomly assigned to one of three treatment groups; cognitive-behavioural therapy (CBT), CBT and family management, or a waiting list. At 12 month follow-up 70% of the children in the CBT group no longer met their diagnostic criteria, as compared to 96% in the CBT and family management group, and 26% for the waiting-list group (Barrett et al., 1996).
The creation of specialised child and adolescent anxiety centres will facilitate the research that is needed to improve the pharmacological., and therefore total, care of these patients.
It has been suggested that a diagnosis of OCD will increase demand for treatment, increasing managed care costs. On the contrary, more rapid diagnosis and appropriate treatment of OCD and spectrum disorders, could reduce the costs of management. With early, appropriate treatment, the number of providers, visits, and total outpatient fees can be significantly reduced and suffering significantly alleviated. With this goal in mind, we need to support continued research into the nature, causes and treatment of OCD and its related disorders.
Last updated: 20.12.2011