Enlist the family. Finally, family involvement is often central to the success of CBT. Family members may accommodate the patient’s symptoms by facilitating avoidance, assisting with ritualistic behaviors, or inadvertently facilitating the development of the disorder by participating in rituals (eg, providing reassurance, allowing compulsive avoidance of feared stimuli, and tolerating delays associated with ritual completion). Given this, CBT often includes the patient’s spouse, parents, and significant others.
Pharmacotherapy
Malfunction in the serotonin neurotransmitter system is thought to be the physiologic basis of OCD.8,9 More specifically, OCD patients are believed to have a lower level of serotonin in neural synapses than healthy persons. Given this, seretonergic agents, such as clomipramine (Anafranil), citalopram (Celexa), fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), and fluvoxamine (Luvox) have been used extensively to treat OCD in both adults and youths (SOR: A). The Food and Drug Administration (FDA) has approved only clomipramine, fluoxetine, fluvoxamine, and sertraline for use in youth. Each receives an SOR of A.
Clomipramine: once first choice, now a backup
Until recently, clomipramine—a tricyclic antidepressant—was the most widely prescribed medication for OCD, given its record of providing the greatest and most reliable symptom reduction.10 The efficacy of clomipramine, which has strong seretonergic properties, has not been replicated with other tricyclic antidepressants (eg, desipramine [Norpramin, Pertofrane]) that more directly target other neurotransmitter systems (serotonin, norepinephrine, and dopamine).11 However, clomipramine, like other tricyclic antidepressants, can cause tachycardia, prolongation of QT interval, and other unpleasant side effects (eg, orthostatic hypotension, constipation, and dry mouth are common). As a result, its use is indicated in cases where the patient does not respond to alternative medications.
SSRIs now favored
Given clomipramine’s side effects, selective serotonin reuptake inhibitors (SSRIs), a class of SRIs, have emerged as the first-line medication.12 For patients who need medication, first consider prescribing an SSRI first.
SSRIs, however, are not without side effects. During the initial phase of treatment, nausea, exacerbations of anxiety, jitteriness, and insomnia are experienced by approximately 35% of patients and may persist over the duration of treatment. These side effects may be limited by slow-dose titration. With fluoxetine, for example, start at 20 mg and gradually increase the dose over several weeks to the usual target dose of 40 to 60 mg.
Some patients require even lower initial doses and more prolonged titration. Extended SSRI treatment has been linked to sexual dysfunction, headache, asthenia, and sweating in 25% to 35% of patients.13
Multiple large-scale controlled trials have demonstrated the efficacy and tolerability of SSRIs for adults and youths.13,14 About 40% to 55% of patients generally report significant symptom reduction after 12 weeks. However, typical symptom reduction in clinical practice averages only 20% to 50%, and many patients experience residual symptoms after treatment has stopped.
Course of pharmacotherapy
SSRIs should be gradually titrated. The TABLE displays dosing of commonly used SSRIs in adults with OCD. A 12-week trial of an adequate dosage is the standard of care before considering alternative therapies.9 Initial response to medications may take 6 to 8 weeks, although the maximal response may take up to 20 weeks. Continue medications for 1 year after achieving a therapeutic response and slowly taper thereafter. Evidence suggests that ongoing CBT may be one method to prevent relapse when discontinuing medication.15 Most patients do not fully remit on medication treatment alone, and as many as 60% do not have a substantial reduction of symptoms.16
TABLE
SRI dosing guidelines recommended by the Expert Consensus Panel (1997)
| SRI | INITIAL DOSE/INCREMENT FOR INCREASES* | USUAL TARGET DOSE* | MAXIMUM DOSE* | SOR |
|---|---|---|---|---|
| Clomipramine | 10–25 mg/d | 100–250 mg/d | 250 mg/d | A |
| Fluoxetine | 20 mg/d | 40–60 mg/d | 80 mg/d | A |
| Fluvoxamine | 50 mg/d | 200 mg/d | 300 mg/d | A |
| Paroxetine | 10–20 mg/d | 50 mg/d | 60 mg/d | A |
| Sertraline | 50 mg/d | 150 mg/d | 225 mg/d | A |
For cost-effectiveness, CBT still comes out on top
It is suggested that patients continue medication consistently for 2 years before deciding to stop.9 Medication would therefore be expected to cost more over the long-term than CBT, given the time-limited nature and durability of the latter.3 To date, several trials have examined the relative efficacy of pharmacotherapy alone versus its combination with CBT. In general, results suggest that CBT alone or in combination with pharmacotherapy (an SRI) is the treatment of choice.1,17
CBT plus medication often the better way to go
Given that many patients do not respond adequately to medication alone, augmentation strategies are often necessary. As CBT is considered the most effective approach, this therapy should always be used, particularly when a patient has proven refractory with pharmacological approaches. In cases that are unresponsive to multiple SSRIs and CBT, consider such second-line pharmacological treatments as serotonergic or dopaminergic agents, or adding a second first-line agent.13