OCD

Treatment-refractory OCD

Both pharmacological and psychotherapeutic treatments have been proven to be effective in the treatment of OCD, but preliminary data suggest that OCD is a life-long disease. There are also treatment refractory cases emerging despite the known effective treatment options (Rasmussen and Eisen, 1997).

A treatment refractory patient in OCD is considered when a patient has failed both adequate trials of an SSRI and psychotherapy treatment. An “adequate trial” is defined as 10 to 12 weeks of continuous treatment at the maximum tolerated dose of the SSRI. “Adequate psychotherapy” is at least 30 hours of behaviour therapy with no improvement (Rasmussen and Eisen, 1997). The clinician should always check compliance and then consider using another SSRI. Evidence from multi-centre trials has suggested that 20% of patients who fail to respond to an initial SSRI will go on to respond to a second trial with another SSRI (Rasmussen and Eisen, 1997).

Thereafter pharmacological augmentation should be considered. Two primary lines of approach have been taken in the development of pharmacologic augmentation treatments for the SSRI-refractory OCD patient. Another option is to use of DA receptor  antagonists, such as haloperidol, risperidone, olanzapine and pimozide, to the treatment regimen of SSRI-refractory OCD patients (McDougle et al., 1994). This combination treatment strategy has been shown to be effective in reducing OCD symptoms primarily in SSRI-refractory patients who have co-morbid personal or family histories of chronic tics.

Preliminary reports describing the effectiveness of risperidone addition to SSRIs are encouraging, as this drug has been associated with fewer acute and chronic extrapyramidal side effects than typical neuroleptics (McDougle and Potenza, 1998).

The addition of TCAs to SSRI treatment has been successful where neither of the two drugs were successful in controlling the OCD individually (Simoen et al., 1990).

Finally, the addition of other drugs with demonstrated efficacy for reducing tics, such as the a2-adrenoceptor agonists clonidine and possibly guanfacine, may be worthy of study as adjuncts to SSRIs in the treatment of tic-related forms of OCD (McDougle, 1997).