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Pharmacotherapy for obsessive-compulsive disorder in adults

Author
Helen Blair Simpson, MD, PhD
Section Editor
Murray B Stein, MD, MPH
Deputy Editor
Richard Hermann, MD

INTRODUCTION

Obsessive-compulsive disorder (OCD) is characterized by recurrent, intrusive, and distressing thoughts, images, or impulses (ie, obsessions) and repetitive mental or behavioral acts that the individual feels driven to perform (ie, compulsions) to prevent or reduce distress.

OCD can be effectively treated with serotonergic antidepressants as well as cognitive-behavioral therapy. However, patients frequently experience a partial response to treatment. A number of augmentation strategies have been studied.

Pharmacotherapy for OCD in adults is discussed here. The epidemiology, clinical manifestations, and diagnosis of OCD are discussed separately. Psychotherapy for OCD, deep brain stimulation for OCD, and OCD in pregnant and postpartum women are also discussed separately. (See "Obsessive-compulsive disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis" and "Psychotherapy for obsessive-compulsive disorder in adults" and "Obsessive-compulsive disorder in pregnant and postpartum women" and "Deep brain stimulation for treatment of obsessive-compulsive disorder".)

MONOTHERAPY

Efficacy — Two classes of serotonergic antidepressants are strongly supported by randomized trials for OCD, while evidence for the third is weaker:

Selective serotonin reuptake inhibitor (SSRI) antidepressants: Fluoxetine, fluvoxamine, sertraline, paroxetine, citalopram, and escitalopram

                        

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Literature review current through: Nov 2016. | This topic last updated: Wed Jan 21 00:00:00 GMT+00:00 2015.
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References
Top
  1. Soomro GM, Altman D, Rajagopal S, Oakley-Browne M. Selective serotonin re-uptake inhibitors (SSRIs) versus placebo for obsessive compulsive disorder (OCD). Cochrane Database Syst Rev 2008; :CD001765.
  2. Ackerman DL, Greenland S. Multivariate meta-analysis of controlled drug studies for obsessive-compulsive disorder. J Clin Psychopharmacol 2002; 22:309.
  3. Freeman CP, Trimble MR, Deakin JF, et al. Fluvoxamine versus clomipramine in the treatment of obsessive compulsive disorder: a multicenter, randomized, double-blind, parallel group comparison. J Clin Psychiatry 1994; 55:301.
  4. Koran LM, McElroy SL, Davidson JR, et al. Fluvoxamine versus clomipramine for obsessive-compulsive disorder: a double-blind comparison. J Clin Psychopharmacol 1996; 16:121.
  5. Mundo E, Maina G, Uslenghi C. Multicentre, double-blind, comparison of fluvoxamine and clomipramine in the treatment of obsessive-compulsive disorder. Int Clin Psychopharmacol 2000; 15:69.
  6. Pigott TA, Pato MT, Bernstein SE, et al. Controlled comparisons of clomipramine and fluoxetine in the treatment of obsessive-compulsive disorder. Behavioral and biological results. Arch Gen Psychiatry 1990; 47:926.
  7. López-Ibor JJ Jr, Saiz J, Cottraux J, et al. Double-blind comparison of fluoxetine versus clomipramine in the treatment of obsessive compulsive disorder. Eur Neuropsychopharmacol 1996; 6:111.
  8. Zohar J, Judge R. Paroxetine versus clomipramine in the treatment of obsessive-compulsive disorder. OCD Paroxetine Study Investigators. Br J Psychiatry 1996; 169:468.
  9. Bisserbe J, Lane R, Flament M, Franco-Belgian OCD Study Group. A double-blind comparison of sertraline and clomipramine in outpatients with obsessive-compulsive disorder. Eur Psychiatry 1997; 12:82.
  10. Decloedt EH, Stein DJ. Current trends in drug treatment of obsessive-compulsive disorder. Neuropsychiatr Dis Treat 2010; 6:233.
  11. Pigott TA, Seay SM. A review of the efficacy of selective serotonin reuptake inhibitors in obsessive-compulsive disorder. J Clin Psychiatry 1999; 60:101.
  12. Greist JH, Jefferson JW, Kobak KA, et al. Efficacy and tolerability of serotonin transport inhibitors in obsessive-compulsive disorder. A meta-analysis. Arch Gen Psychiatry 1995; 52:53.
  13. Yaryura-Tobias JA, Neziroglu FA. Venlafaxine in obsessive-compulsive disorder. Arch Gen Psychiatry 1996; 53:653.
  14. Denys D, van der Wee N, van Megen HJ, Westenberg HG. A double blind comparison of venlafaxine and paroxetine in obsessive-compulsive disorder. J Clin Psychopharmacol 2003; 23:568.
  15. Albert U, Aguglia E, Maina G, Bogetto F. Venlafaxine versus clomipramine in the treatment of obsessive-compulsive disorder: a preliminary single-blind, 12-week, controlled study. J Clin Psychiatry 2002; 63:1004.
  16. Denys D, van Megen HJ, van der Wee N, Westenberg HG. A double-blind switch study of paroxetine and venlafaxine in obsessive-compulsive disorder. J Clin Psychiatry 2004; 65:37.
  17. Dell'osso B, Mundo E, Marazziti D, Altamura AC. Switching from serotonin reuptake inhibitors to duloxetine in patients with resistant obsessive compulsive disorder: a case series. J Psychopharmacol 2008; 22:210.
  18. Dell'Osso B, Nestadt G, Allen A, Hollander E. Serotonin-norepinephrine reuptake inhibitors in the treatment of obsessive-compulsive disorder: A critical review. J Clin Psychiatry 2006; 67:600.
  19. Koran LM, Hanna GL, Hollander E, et al. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Am J Psychiatry 2007; 164:5.
  20. Stein DJ, Andersen EW, Tonnoir B, Fineberg N. Escitalopram in obsessive-compulsive disorder: a randomized, placebo-controlled, paroxetine-referenced, fixed-dose, 24-week study. Curr Med Res Opin 2007; 23:701.
  21. Hollander E, Allen A, Steiner M, et al. Acute and long-term treatment and prevention of relapse of obsessive-compulsive disorder with paroxetine. J Clin Psychiatry 2003; 64:1113.
  22. Montgomery SA, McIntyre A, Osterheider M, et al. A double-blind, placebo-controlled study of fluoxetine in patients with DSM-III-R obsessive-compulsive disorder. The Lilly European OCD Study Group. Eur Neuropsychopharmacol 1993; 3:143.
  23. Montgomery SA, Kasper S, Stein DJ, et al. Citalopram 20 mg, 40 mg and 60 mg are all effective and well tolerated compared with placebo in obsessive-compulsive disorder. Int Clin Psychopharmacol 2001; 16:75.
  24. Greist J, Chouinard G, DuBoff E, et al. Double-blind parallel comparison of three dosages of sertraline and placebo in outpatients with obsessive-compulsive disorder. Arch Gen Psychiatry 1995; 52:289.
  25. Bloch MH, McGuire J, Landeros-Weisenberger A, et al. Meta-analysis of the dose-response relationship of SSRI in obsessive-compulsive disorder. Mol Psychiatry 2010; 15:850.
  26. FDA Drug Safety Communication: Abnormal heart rhythms associated with high doses of Celexa (citalopram hydrobromide). http://www.fda.gov/Drugs/DrugSafety/ucm269086.htm (Accessed on August 25, 2011).
  27. Ninan PT, Koran LM, Kiev A, et al. High-dose sertraline strategy for nonresponders to acute treatment for obsessive-compulsive disorder: a multicenter double-blind trial. J Clin Psychiatry 2006; 67:15.
  28. Pato MT, Zohar-Kadouch R, Zohar J, Murphy DL. Return of symptoms after discontinuation of clomipramine in patients with obsessive-compulsive disorder. Am J Psychiatry 1988; 145:1521.
  29. Koran LM, Hackett E, Rubin A, et al. Efficacy of sertraline in the long-term treatment of obsessive-compulsive disorder. Am J Psychiatry 2002; 159:88.
  30. Romano S, Goodman W, Tamura R, Gonzales J. Long-term treatment of obsessive-compulsive disorder after an acute response: a comparison of fluoxetine versus placebo. J Clin Psychopharmacol 2001; 21:46.
  31. Fineberg NA, Tonnoir B, Lemming O, Stein DJ. Escitalopram prevents relapse of obsessive-compulsive disorder. Eur Neuropsychopharmacol 2007; 17:430.
  32. Koran LM, Gamel NN, Choung HW, et al. Mirtazapine for obsessive-compulsive disorder: an open trial followed by double-blind discontinuation. J Clin Psychiatry 2005; 66:515.
  33. Shapira NA, Keck PE Jr, Goldsmith TD, et al. Open-label pilot study of tramadol hydrochloride in treatment-refractory obsessive-compulsive disorder. Depress Anxiety 1997; 6:170.
  34. Insel TR, Hamilton JA, Guttmacher LB, Murphy DL. D-amphetamine in obsessive-compulsive disorder. Psychopharmacology (Berl) 1983; 80:231.
  35. Joffe RT, Swinson RP, Levitt AJ. Acute psychostimulant challenge in primary obsessive-compulsive disorder. J Clin Psychopharmacol 1991; 11:237.
  36. Joffe RT, Swinson RP. Methylphenidate in primary obsessive-compulsive disorder. J Clin Psychopharmacol 1987; 7:420.
  37. McDougle CJ, Barr LC, Goodman WK, et al. Lack of efficacy of clozapine monotherapy in refractory obsessive-compulsive disorder. Am J Psychiatry 1995; 152:1812.
  38. Connor KM, Payne VM, Gadde KM, et al. The use of aripiprazole in obsessive-compulsive disorder: preliminary observations in 8 patients. J Clin Psychiatry 2005; 66:49.
  39. Tenneij NH, van Megen HJ, Denys DA, Westenberg HG. Behavior therapy augments response of patients with obsessive-compulsive disorder responding to drug treatment. J Clin Psychiatry 2005; 66:1169.
  40. Simpson HB, Foa EB, Liebowitz MR, et al. A randomized, controlled trial of cognitive-behavioral therapy for augmenting pharmacotherapy in obsessive-compulsive disorder. Am J Psychiatry 2008; 165:621.
  41. Simpson HB, Foa EB, Liebowitz MR, et al. Cognitive-behavioral therapy vs risperidone for augmenting serotonin reuptake inhibitors in obsessive-compulsive disorder: a randomized clinical trial. JAMA Psychiatry 2013; 70:1190.
  42. Carey PD, Vythilingum B, Seedat S, et al. Quetiapine augmentation of SRIs in treatment refractory obsessive-compulsive disorder: a double-blind, randomised, placebo-controlled study [ISRCTN83050762]. BMC Psychiatry 2005; 5:5.
  43. Fineberg NA, Sivakumaran T, Roberts A, Gale T. Adding quetiapine to SRI in treatment-resistant obsessive-compulsive disorder: a randomized controlled treatment study. Int Clin Psychopharmacol 2005; 20:223.
  44. Shapira NA, Ward HE, Mandoki M, et al. A double-blind, placebo-controlled trial of olanzapine addition in fluoxetine-refractory obsessive-compulsive disorder. Biol Psychiatry 2004; 55:553.
  45. McDougle CJ, Goodman WK, Leckman JF, et al. Haloperidol addition in fluvoxamine-refractory obsessive-compulsive disorder. A double-blind, placebo-controlled study in patients with and without tics. Arch Gen Psychiatry 1994; 51:302.
  46. McDougle CJ, Epperson CN, Pelton GH, et al. A double-blind, placebo-controlled study of risperidone addition in serotonin reuptake inhibitor-refractory obsessive-compulsive disorder. Arch Gen Psychiatry 2000; 57:794.
  47. Bystritsky A, Ackerman DL, Rosen RM, et al. Augmentation of serotonin reuptake inhibitors in refractory obsessive-compulsive disorder using adjunctive olanzapine: a placebo-controlled trial. J Clin Psychiatry 2004; 65:565.
  48. Denys D, de Geus F, van Megen HJ, Westenberg HG. A double-blind, randomized, placebo-controlled trial of quetiapine addition in patients with obsessive-compulsive disorder refractory to serotonin reuptake inhibitors. J Clin Psychiatry 2004; 65:1040.
  49. 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.
  50. Komossa K, Depping AM, Meyer M, et al. Second-generation antipsychotics for obsessive compulsive disorder. Cochrane Database Syst Rev 2010; :CD008141.
  51. Sayyah M, Sayyah M, Boostani H, et al. Effects of aripiprazole augmentation in treatment-resistant obsessive-compulsive disorder (a double blind clinical trial). Depress Anxiety 2012; 29:850.
  52. Muscatello MR, Bruno A, Pandolfo G, et al. Effect of aripiprazole augmentation of serotonin reuptake inhibitors or clomipramine in treatment-resistant obsessive-compulsive disorder: a double-blind, placebo-controlled study. J Clin Psychopharmacol 2011; 31:174.
  53. Marder SR, Essock SM, Miller AL, et al. Physical health monitoring of patients with schizophrenia. Am J Psychiatry 2004; 161:1334.
  54. Maina G, Albert U, Ziero S, Bogetto F. Antipsychotic augmentation for treatment resistant obsessive-compulsive disorder: what if antipsychotic is discontinued? Int Clin Psychopharmacol 2003; 18:23.
  55. Andrade C. Augmenting selective serotonin reuptake inhibitors with clomipramine in obsessive-compulsive disorder: benefits and risks. J Clin Psychiatry 2013; 74:e1128.
  56. Szegedi A, Wetzel H, Leal M, et al. Combination treatment with clomipramine and fluvoxamine: drug monitoring, safety, and tolerability data. J Clin Psychiatry 1996; 57:257.
  57. Transcept Pharmaceuticals Announces that a Phase 2 Clinical Trial of TO-2061 as Adjunctive Therapy for Obsessive Compulsive Disorder Did Not Meet Primary Endpoint. http://ir.transcept.com/releasedetail.cfm?ReleaseID=728327 (Accessed on December 12, 2014).
  58. Pallanti S, Bernardi S, Antonini S, et al. Ondansetron augmentation in treatment-resistant obsessive-compulsive disorder: a preliminary, single-blind, prospective study. CNS Drugs 2009; 23:1047.
  59. Soltani F, Sayyah M, Feizy F, et al. A double-blind, placebo-controlled pilot study of ondansetron for patients with obsessive-compulsive disorder. Hum Psychopharmacol 2010; 25:509.
  60. Koran LM, Aboujaoude E, Gamel NN. Double-blind study of dextroamphetamine versus caffeine augmentation for treatment-resistant obsessive-compulsive disorder. J Clin Psychiatry 2009; 70:1530.
  61. Bruno A, Micò U, Pandolfo G, et al. Lamotrigine augmentation of serotonin reuptake inhibitors in treatment-resistant obsessive-compulsive disorder: a double-blind, placebo-controlled study. J Psychopharmacol 2012; 26:1456.
  62. Oulis P, Mourikis I, Konstantakopoulos G. Pregabalin augmentation in treatment-resistant obsessive-compulsive disorder. Int Clin Psychopharmacol 2011; 26:221.
  63. Pittenger C, Bloch MH, Williams K. Glutamate abnormalities in obsessive compulsive disorder: neurobiology, pathophysiology, and treatment. Pharmacol Ther 2011; 132:314.
  64. Lafleur DL, Pittenger C, Kelmendi B, et al. N-acetylcysteine augmentation in serotonin reuptake inhibitor refractory obsessive-compulsive disorder. Psychopharmacology (Berl) 2006; 184:254.
  65. Poyurovsky M, Weizman R, Weizman A, Koran L. Memantine for treatment-resistant OCD. Am J Psychiatry 2005; 162:2191.
  66. Pasquini M, Biondi M. Memantine augmentation for refractory obsessive-compulsive disorder. Prog Neuropsychopharmacol Biol Psychiatry 2006; 30:1173.
  67. Aboujaoude E, Barry JJ, Gamel N. Memantine augmentation in treatment-resistant obsessive-compulsive disorder: an open-label trial. J Clin Psychopharmacol 2009; 29:51.
  68. Feusner JD, Kerwin L, Saxena S, Bystritsky A. Differential efficacy of memantine for obsessive-compulsive disorder vs. generalized anxiety disorder: an open-label trial. Psychopharmacol Bull 2009; 42:81.
  69. Stewart SE, Jenike EA, Hezel DM, et al. A single-blinded case-control study of memantine in severe obsessive-compulsive disorder. J Clin Psychopharmacol 2010; 30:34.
  70. Coric V, Taskiran S, Pittenger C, et al. Riluzole augmentation in treatment-resistant obsessive-compulsive disorder: an open-label trial. Biol Psychiatry 2005; 58:424.
  71. Rodriguez CI, Bender J Jr, Marcus SM, et al. Minocycline augmentation of pharmacotherapy in obsessive-compulsive disorder: an open-label trial. J Clin Psychiatry 2010; 71:1247.
  72. Foa EB, Liebowitz MR, Kozak MJ, et al. Randomized, placebo-controlled trial of exposure and ritual prevention, clomipramine, and their combination in the treatment of obsessive-compulsive disorder. Am J Psychiatry 2005; 162:151.
  73. Chasson GS, Buhlmann U, Tolin DF, et al. Need for speed: evaluating slopes of OCD recovery in behavior therapy enhanced with d-cycloserine. Behav Res Ther 2010; 48:675.
  74. Kushner MG, Kim SW, Donahue C, et al. D-cycloserine augmented exposure therapy for obsessive-compulsive disorder. Biol Psychiatry 2007; 62:835.
  75. Storch EA, Merlo LJ, Bengtson M, et al. D-cycloserine does not enhance exposure-response prevention therapy in obsessive-compulsive disorder. Int Clin Psychopharmacol 2007; 22:230.
  76. Wilhelm S, Buhlmann U, Tolin DF, et al. Augmentation of behavior therapy with D-cycloserine for obsessive-compulsive disorder. Am J Psychiatry 2008; 165:335.