Obsessive-compulsive disorder medical therapy

Revision as of 22:59, 29 July 2020 by WikiBot (talk | contribs) (Bot: Removing from Primary care)
Jump to navigation Jump to search

Obsessive-compulsive disorder Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Obsessive-Compulsive Disorder from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Substance/Medication-induced Obsessive-Compulsive Disorder

Obsessive-Compulsive Disorder due to Another Medical Condition

Diagnosis

Diagnostic Study of Choice

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X-ray

Echocardiography and Ultrasound

CT scan

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Interventions

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Obsessive-compulsive disorder medical therapy On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Obsessive-compulsive disorder medical therapy

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Obsessive-compulsive disorder medical therapy

CDC on Obsessive-compulsive disorder medical therapy

Obsessive-compulsive disorder medical therapy in the news

Blogs on Obsessive-compulsive disorder medical therapy

Directions to Hospitals Treating Obsessive-compulsive disorder

Risk calculators and risk factors for Obsessive-compulsive disorder medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sonya Gelfand, Usama Talib, BSc, MD [2]

Overview

According to the Expert Consensus Guidelines for the Treatment of obsessive-compulsive disorder, behavioral therapy (BT), cognitive therapy (CT), medications, or any combination of the three are first-line treatments for OCD. Psychodynamic psychotherapy may help in managing some aspects of the disorder, but there are no controlled studies that demonstrate effectiveness of psychoanalysis or dynamic psychotherapy in OCD.[1] Though there is no known treatment for full remission of OCD yet, there are a number of successful treatment options available to promote significant improvement.

Treatment

Medical Therapy

One may be referred by their doctor to a mental health specialist, such as a psychiatrist, psychologist, social worker, or counselor for evaluation of treatment, however OCD is usually medically managed by psychological and pharmacological interventions.[2]

Medication

  • Medications as treatment include the following:
  • SSRIs prevent excess serotonin from being pumped back into the original neuron that released it. Serotonin can then bind to the receptor sites of nearby neurons and send chemical messages or signals that can help regulate the excessive anxiety and obsessive-compulsive thoughts.
  • In some treatment-resistant cases, a combination of clomipramine and an SSRI has shown to be effective even when neither drug on its own has been efficacious. Serotonergic antidepressants typically take longer to show benefit in OCD than with most other disorders which they are used to treat, as it is common for 2–3 months to elapse before any tangible improvement is noticed.
  • In addition, the treatment usually requires high doses. Fluoxetine, for example, is usually prescribed in doses of 20 mg per day for clinical depression, whereas with OCD the dose will often range from 20 mg to 80 mg or higher, if necessary.
  • In most cases antidepressant therapy alone will only provide a partial reduction in symptoms, even in cases that are not deemed treatment-resistant. Other medications such as riluzole, memantine, gabapentin (Neurontin), lamotrigine (Lamictal), and low doses of the newer atypical antipsychotics olanzapine (Zyprexa), quetiapine (Seroquel) and risperidone (Risperdal) have also been found to be useful as adjuncts in the treatment of OCD. The use of antipsychotics in OCD must be undertaken carefully, however, since, although there is very strong evidence that at low doses they are beneficial (most likely due to their dopamine receptor antagonism), at high doses these same antipsychotics have proven to cause dramatic obsessive-compulsive symptoms even in those patients who do not normally have OCD. This is most likely due to the antagonism of 5-HT2A receptors becoming very prominent at these doses and outweighing the benefits of dopamine antagonism.
  • Another point that must be noted with antipsychotic treatment is that SSRIs inhibit the chief enzyme that is responsible for metabolising antipsychoticsCYP2D6 — so the dose will be effectively higher than expected when these are combined with SSRIs.
  • The naturally occurring sugar inositol may be an effective treatment for OCD. Inositol appears to modulate the actions of serotonin and has been found to reverse desensitisation of the neurotransmitter's receptors.[3]
  • St John's Wort has been claimed to be of benefit due to its (non-selective) serotonin re-uptake inhibiting qualities, and studies have emerged that have shown positive results. However, a double-blind study, using a flexible-dose schedule(600-1800 mg/day), found no difference between St John's Wort and the placebo.[4]
  • Recent research has found increasing evidence that opioids may significantly reduce OCD symptoms, though the addictive property of these drugs likely stands as an obstacle to their sanctioned approval for OCD treatment. Anecdotal reports suggest that some OCD sufferers have successfully self-medicated with opioids such as Ultram and Vicodin, though the off-label use of such painkillers is not widely accepted, again because of their addictive qualities. Tramadol is an atypical opioid that may be a viable option as it has a low potential for abuse and addiction, mild side effects, and shows signs of rapid efficacy in OCD. Tramadol not only provides the anti-OCD effects of an opiate, but also inhibits the re-uptake of serotonin (in addition to norepinephrine). This may provide additional benefits, but should not be taken in combination with antidepressant medication unless under careful medical supervision due to potential serotonin syndrome.[5]
  • Studies have also been done that show nutrition deficiencies may also contribute to OCD and other mental disorders. Certain vitamin and mineral supplements may aid in such disorders and provide the nutrients necessary for proper mental functioning. [3]
  • Research has generally shown that psychotherapy, in combination with psychotropic medication, is more effective than either option alone.
  • Recent studies at the University of Arizona using the tryptamine alkaloid psilocybin have shown promising results. There are reports that other hallucinogens such as LSD and peyote have produced similar benefits. It has been hypothesised that this effect may be due to stimulation of 5-HT2A receptors and, less importantly, 5-HT2C receptors. This causes, among many other effects, an inhibitory effect on the orbitofrontal cortex, an area of the brain in which hyperactivity has been strongly associated with OCD.[6][7]
  • Emerging evidence has suggested that regular nicotine treatment may be helpful in improving symptoms of OCD, although the pharmacodynamical mechanism by which this improvement is achieved is not yet known, and more detailed studies are needed to fully confirm this hypothesis. Anecdotal reports suggest OCD can worsen when cigarettes are smoked.[8]

Dosing of Medications for OCD treatment

Medication Starting Dose

(mg/d)

Target Dose

(mg/d)

SSRIs Fluoxetine 20 80
Fluvoxamine 50 300
Sertraline 50 200
Paroxetine 20 60
Citalopram 20 40
Escitalopram 10 40
Tricyclic

Antidepressants

Clomipramine 25 250

*Adopted from JAMA[9]

References

  1. Koran LM, Hanna GL, Hollander E, Nestadt G, Simpson HB; American Psychiatric Association. Template:PDFlink Am J Psychiatry 2007; 164(7 Suppl): 5-53. PMID 17849776.
  2. Hirschtritt ME, Bloch MH, Mathews CA (2017). "Obsessive-Compulsive Disorder: Advances in Diagnosis and Treatment". JAMA. 317 (13): 1358–1367. doi:10.1001/jama.2017.2200. PMID 28384832.
  3. "Inositol in psychiatry". Retrieved 2007-06-28.
  4. Kobak KA; et al. (2005). "St John's wort versus placebo in obsessive-compulsive disorder: results from a double-blind study". Int Clin Psychopharmacol. 20 (6): 299–304. doi:10.1097/00004850-200511000-00003. PMID 16192837.
  5. Goldsmith TB, Shapira NA, Keck PE (1999). "Rapid remission of OCD with tramadol hydrochloride". The American journal of psychiatry. 156 (4): 660–1. PMID 10200754.
  6. "Hallucinogens and Obsessive-Compulsive Disorder -- PERRINE 156 (7): 1123 -- Am J Psychiatry". Retrieved 2007-06-28.
  7. "Psilocybin in the Treatment of Obsessive Compulsive Disorder". Retrieved 2007-06-28.
  8. Lundberg S, Carlsson A, Norfeldt P, Carlsson ML (2004). "Nicotine treatment of obsessive-compulsive disorder". Prog. Neuropsychopharmacol. Biol. Psychiatry. 28 (7): 1195–9. doi:10.1016/j.pnpbp.2004.06.014. PMID 15610934.
  9. Hirschtritt ME, Bloch MH, Mathews CA (2017). "Obsessive-Compulsive Disorder: Advances in Diagnosis and Treatment". JAMA. 317 (13): 1358–1367. doi:10.1001/jama.2017.2200. PMID 28384832.

Template:WikiDoc Sources