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Panminerva Medica 2002 June;44(2):83-91

lingua: Inglese

Management of treatment resistant obsessive-compulsive disorder. Algorithms for pharmacotherapy

Albert U., Bergesio C., Pessina E., Maina G., Bogetto F.

From the Anxiety and Mood Disorders Unit Department of Neurosciences, University of Turin, Turin, Italy


Treatment ­resistant OCD sub­jects, ­defined as ­those ­patients who ­undergo an ade­quate ­trial of SRI (clo­mip­ra­mine or ­SSRI) and do not ­respond or ­show unsat­is­fac­tory ­results, ­account for 40-50% of all ­patients. Once the appro­pri­ate­ness of the ­trial has ­been ­assessed, sev­eral ­options ­exist for the cli­ni­cians. If clo­mip­ra­mine or cital­o­pram ­have ­been ­used, an appro­priate ­strategy con­sists in ­giving the ­same ­drug intra­ve­nously. Double-­blind ­studies ­exist on the effi­cacy of clo­mip­ra­mine IV, ­while ­data are ­missing for cital­o­pram. Another ­option ­that ­should be con­sid­ered ­first, ­although ­data are ­scarce, is the addi­tion of a cog­ni­tive behav­ioral ­therapy, ­when avail­able, in the ­forms of expo­sure and ­response pre­ven­tion. When ­such ­options are not suit­able or avail­able, aug­men­ta­tion of the ­ongoing SRI ­with ­another com­pound rep­re­sents the pref­er­able ­strategy. Double-­blind, pla­cebo-con­trolled ­studies ­have ­shown the effi­cacy of ­adding pin­dolol (7.5 mg/d), ris­per­i­done (2 mg/d) and olan­za­pine (5-10 mg/d). Other ­agents ­have ­been pro­posed, but ­data ­emerging ­from ­double-­blind ­studies ­were neg­a­tive or con­tra­dic­tory. Another ­option avail­able is ­switching ­from CMI to ­SSRI, or ­vice ­versa, or ­from ­SSRI to ­SSRI. Data ­regarding ­such treat­ment ­strategy, how­ever, are ­highly pre­lim­i­nary, ­based on a ­couple of ­open ­label ­reports and on ­studies per­formed in treat­ment ­resistant depres­sion. An unre­solved ques­tion is ­whether aug­men­ta­tion ­should be pre­ferred to ­switching. No ­data ­exist in OCD; a prac­tical ­approach ­would sug­gest aug­men­ta­tion ­first, con­sid­ering ­that ­response ­should be ­obtained ­faster ­than by ­switching com­pound. When all the avail­able and effec­tive strat­e­gies ­prove unef­fec­tive, cli­ni­cians ­should con­sider ­switching the ­patient to ­other com­pounds in mono­therapy, ­such as ven­la­faxine, suma­triptan, inos­itol, ­although ­research is ­strongly ­needed ­before con­clu­sions on the effi­cacy of ­such com­pounds can be ­drawn.

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