Treatment of Obsessive Compulsive Disorder (OCD treatment)
Obsessive-compulsive disorder (OCD) is a common psychiatric illness with lifetime prevalence of 1-3%. It is the fourth-most common psychiatric illness and a leading cause of disability. OCD is associated with significant impairment in functioning, quality of life and disability. If untreated, OCD is a chronic illness with a waxing and waning of symptoms. The hallmarks of OCD are presence of obsessions and compulsions. Obsessions are repetitive, unwanted, intrusive thoughts, images or urges that are mostly ego-dystonic and cause severe distress or anxiety. Compulsions (or rituals) are repetitive behaviours or mental acts that are performed in response to an obsession to reduce anxiety/distress or prevent a dreaded consequence. Obsessions and compulsions are time-consuming, distressing and are often resisted unsuccessfully.
OCD is often comorbid with other psychiatric disorders. It is important to assess all patients with OCD for associated psychiatric comorbidity since they may have an effect on treatment outcomes if left untreated. Depression and anxiety disorders are present in over half of patients seeking treatment for OCD.
Meta-analyses of RCTs show that selective serotonin reuptake inhibitors (SSRIs) are significantly more effective than placebo in the treatment of OCD. SSRIs are associated with many adverse effects but are usually well tolerated. The only other medication which has shown to be consistently effective in OCD is the serotoninergic tricyclic antidepressant clomipramine. Clomipramine has been found to be significantly more effective than placebo in multiple RCTs and meta-analysis of RCTs. Network meta-analysis comparing the efficacy of clomipramine vs. SSRIs failed to find any efficacy advantage over SSRIs. Most head-to-head comparison trials have not found any significant difference between the efficacy of clomipramine and SSRIs.
Meta-analyses comparing the different SSRIs and direct head-to-head comparisons have not shown superiority of anyone SSRI over the other. It is generally recommended that OCD be treated with a higher dose of SSRI than that used in depression.
Guidelines recommend continuation of SSRIs / clomipramine for at least 1-2 years after achieving remission. Clinical experience dictates that discontinuation of medication beyond that period may be associated with increased chance of relapse. Hence discontinuation of medications should be carefully considered based on individual patient factors including severity and duration of illness, past history of relapse on discontinuation, residual symptoms, comorbidities etc. Most patients may require continued pharmacotherapy to prevent relapses. Medications are generally recommended to be continued at the same dose that resulted in improvement, unless the dosage is not tolerated.
Around 20% of patients do not respond to available pharmacological and psychological treatments. Neuromodulatory and neurosurgical treatments targeting the cortico-striato- thalamo-cortical (CSTC) circuits have been tried in resistant patients.
