Treatment resistant OCDTreatment resistant OCD

Unit 1 Topic PresentationUnit 1 Topic Presentation

Nov 17, 2009Nov 17, 2009

AttributionAttribution Information for this presentation is Information for this presentation is

entirely drawn from entirely drawn from “Management of “Management of treatment resistant obsessive compulsive treatment resistant obsessive compulsive compulsive disorder” compulsive disorder” chapter 9 written bychapter 9 written by

Sumanth Khanna and Ravi Philip Rajkumar Sumanth Khanna and Ravi Philip Rajkumar in the bookin the book“ Obsessive compulsive disorder “ Obsessive compulsive disorder current understanding and future current understanding and future directions” directions” Editors Y C Janardhan Reddy, Editors Y C Janardhan Reddy, Shoba Srinath Nimhans publications no 63. Shoba Srinath Nimhans publications no 63. 20072007

IntroductionIntroduction

Prevalence of OCD 1-3%Prevalence of OCD 1-3% 11stst treatment tricyclic drug- treatment tricyclic drug-

clomipramineclomipramine SRI – 1SRI – 1stst line medication for OCD line medication for OCD Psychological treatment based on Psychological treatment based on

learning modellearning model ERP – 1ERP – 1stst line treatment for OCD line treatment for OCD CBTCBT

Treatment Non responseTreatment Non response

40% – 60 % do not respond to 40% – 60 % do not respond to treatment with either SRIs or CBTtreatment with either SRIs or CBT

Instruments used in assessing Instruments used in assessing treatment response is Y- BOCS treatment response is Y- BOCS symptoms severity scale and the CGI symptoms severity scale and the CGI severity and improvement scale.severity and improvement scale.

Response –decrease in more than Response –decrease in more than 25%25%

DefinitionDefinition ‘‘Treatment resistance’ – failure to Treatment resistance’ – failure to

respond to one adequate SRI trialrespond to one adequate SRI trial Assessment – to exclude ‘pseudo Assessment – to exclude ‘pseudo

resistance’resistance’

An adequate trial of SRI – 10/12 weeksAn adequate trial of SRI – 10/12 weeks Ensure optimum dose of medication usedEnsure optimum dose of medication used Ensure drug adherenceEnsure drug adherence

Optimum Dose RangesOptimum Dose Ranges

FluoxetineFluoxetine SertalineSertaline FluvoxamineFluvoxamine ParoxetineParoxetine CitalopramCitalopram EscitalopramEscitalopram ClomipramineClomipramine

40-80 mg/day40-80 mg/day 150-250150-250 200-300200-300 40-6040-60 40-6040-60 10-2010-20 150-225150-225

Predictors of treatment non Predictors of treatment non responseresponse

Early age at onsetEarly age at onset Longer duration of OCDLonger duration of OCD Mixed subtype of OCDMixed subtype of OCD Presence of sexual obsessionsPresence of sexual obsessions Presence of washing compulsionsPresence of washing compulsions Hoarding, poor insight, prior treatmentHoarding, poor insight, prior treatment Personality disorders, Tic disordersPersonality disorders, Tic disorders

Therapeutic ApproachTherapeutic ApproachFleck and HorwathFleck and Horwath

OptimizationOptimization

SwitchingSwitching

AugmentationAugmentation

CombinationCombination

Switching StrategiesSwitching Strategies

One SSRI to anotherOne SSRI to another

ClomipramineClomipramine

VenlafaxineVenlafaxine

Augmentation StrategiesAugmentation Strategies

RisperidoneRisperidone

Augmentation trial 8 weeksAugmentation trial 8 weeks

Combination strategiesCombination strategies

SSRI and clomipramine.SSRI and clomipramine.

SSRI/ SRI and behavior therapy.SSRI/ SRI and behavior therapy.

Other StrategiesOther Strategies

Intensive residential therapyIntensive residential therapy Family therapyFamily therapy High dose SSRI therapyHigh dose SSRI therapy Monotherapy with drugs other than SSRIMonotherapy with drugs other than SSRI PsychosurgeryPsychosurgery rTMSrTMS Deep brain stimulationDeep brain stimulation

Recommendations for Recommendations for

ManagementManagement Nonresponders to single trial– add BT Nonresponders to single trial– add BT

or switch to alternate SSRI.or switch to alternate SSRI. Nonresponder to BT – add SSRINonresponder to BT – add SSRI

Non response to 2 trials of SSRI- add Non response to 2 trials of SSRI- add BT or switch to clomipramine or BT or switch to clomipramine or augment with respiridone.augment with respiridone.

ManagementManagement

Not tolerating switch to clomipramine Not tolerating switch to clomipramine – switch to venlafaxine.– switch to venlafaxine.

Non responding to BT+ SSRI switch Non responding to BT+ SSRI switch to clomipramine, venlaflaxine or to clomipramine, venlaflaxine or other SRI or try augmentationother SRI or try augmentation

Failure of all above 1Failure of all above 1stst line– go for line– go for intensive residential treatment, 2intensive residential treatment, 2ndnd line augmentation with pindolol etcline augmentation with pindolol etc

SummarySummary

Treatment of treatment resistance is Treatment of treatment resistance is challenging.challenging.

Though 1Though 1stst line is effective substantial line is effective substantial proportion do not respond to itproportion do not respond to it

Combination, switching, augmentationCombination, switching, augmentation Research is ongoing……….Research is ongoing……….