Medication Treatment of Obsessive-Compulsive Disorders

The absence of previous therapies, moderate baseline severity of obsessive-compulsive symptoms (Y-BOCS score < 23), and low Hamilton Depressive Rating Scale scores (6-15) were found to be prognostic determinants of good response to pharmacotherapy. Int Clin Psychopharmacol. 2003 Nov;18(6):315-22.

Cognitive Behavior Therapy As Good for OCD as Combination: In a random assignment study, 37 OCD patients were treated with Cognitive Behavior Therapy (CBT) alone, and 37 with combined CBT and SRI treatment. Of the latter, 17 discontinued SRI treatment during follow-up (1 and 2 years after inpatient treatment). During the initial treatment, scores for Y-BOCS (p < 0.001), HDRS (p < 0.001) and the Global Assessment of Functioning Scale (GAF) (p < 0.001) improved significantly in all groups. Two years later, OCD symptom severity and depression scores were similar between the groups and discontinuation of SRI did not prompt by a recurrence. Clinical outcome in patients with obsessive-compulsive disorder after discontinuation of SRI treatment: results from a two-year follow-up. Kordon A, Kahl KG, et al. Universitaetsklinikum Schleswig-Holstein, Luebeck, Germany. Eur Arch Psychiatry Clin Neurosci. 2004 Nov 12

Clonazepam (Klonopin) No Benefit in OCD Study: In a 12-week DB PC study of 37 adults with OCD, all received sertraline (Zoloft) while half also received clonazepam. Clonazepam was of no benefit over placebo. A double-blind combination study of clonazepam with sertraline in obsessive-compulsive disorder. Crockett BA, Churchill E, Davidson JR. Duke University. Ann Clin Psychiatry. 2004 Jul-Sep;16(3):127-32

SSRI Plus Cognitive Behavior Therapy Best Results for Child OCD: In a 12-week DB PC study of 112 OCD children ages 7-17 with Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) scores of 16 or higher given CBT alone, sertraline (Zoloft) alone, combined CBT and sertraline, or pill placebo, an intent-to-treat analyses indicated a statistically significant advantage for CBT alone (P = .003), sertraline alone (P = .007), and combined treatment (P = .001) over placebo. Combined treatment proved superior to CBT alone (P = .008) and to sertraline alone (P = .006), which did not differ from each other. Clinical remission for combined treatment was 54%; for CBT alone, 39%; for sertraline alone, 21%; and for placebo, 4%. Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: the Pediatric OCD Treatment Study (POTS) randomized controlled trial.  JAMA. 2004 Oct 27;292(16):1969-76

Clomipramine Causes More Weight Gain; Prozac, Zoloft Least: 138 OCD patients who responded to 6-month acute treatment were followed for 2 years while receiving open-label clomipramine, citalopram, fluoxetine, fluvoxamine, paroxetine, or sertraline. Patients gained an average of 3.4 pounds with 14.5% gaining more. Clomipramine patients gained the most with 35% gaining over 3.4 pounds. Sertraline and fluoxetine patients had the least significant weight gain (4.5% and 8.7%), Weight gain during long-term treatment of obsessive-compulsive disorder: a prospective comparison between serotonin reuptake inhibitors. Maina G, Albert U, Salvi V, Bogetto F. University of Turin, Torino, Italy. J Clin Psychiatry. 2004 Oct;65(10):1365-71

Dissociation Common in OCD and TTM: 110 OCD and 32 trichotillomania (TTM) patients were compared with respect to the degree of dissociation and childhood trauma. 16% of OCD and 19% of TTM patients were high dissociators. More high dissociators than low dissociators reported a lifetime history of tics (P <.001), Tourette's syndrome (P =.019), bulimia nervosa (P =.003), and borderline personality disorder (P =.027). In the TTM group, significantly more high dissociators than low dissociators reported (lifetime) kleptomania (P =.005) and depersonalisation disorder (P =.005). The study showed a link between childhood trauma and dissociation in patients with OCD and TTM. Dissociative experiences in obsessive-compulsive disorder and trichotillomania: clinical and genetic findings. Lochner C, Seedat S, et al, University of Stellenboch, Cape Town, South Africa. Compr Psychiatry. 2004 Sep-Oct;45(5):384-91.

CBT Helps Even Some Multiple Medication Non-Responders: 20 OCD adults with inadequate response to multiple medications received 15 sessions of outpatient CBT incorporating exposure and ritual prevention.  OCD severity decreased significantly (p <.05) after treatment, and improvement was maintained over a 6-month follow-up period. Significant benefit was found in 40% at 6-month follow-up. Cognitive-behavioral therapy for medication nonresponders with obsessive-compulsive disorder: a wait-list-controlled open trial. Tolin DF, Maltby N, et al. The Institute of Living/Hartford Hospital, CT. J Clin Psychiatry. 2004 Jul;65(7):922-31

Co-Morbid OCD with ADHD, Tics, or Oppositional Defiant Do More Poorly: In one study, 193 of 335 (57.6%) patients had at least one psychiatric disorder in addition to OCD, and 102 of 335 (30.4%) had multiple other disorders. Although the response rate to paroxetine in the overall population was high (71%), the response rates in patients with comorbid attention deficit hyperactivity disorder, tic disorder, or oppositional defiant disorder (56%, 53%, and 39%, respectively) were significantly less than in patients with OCD only (75%). MGH. Impact of comorbidity on treatment response to paroxetine in pediatric obsessive-compulsive disorder: is the use of exclusion criteria empirically supported in randomized clinical trials? Geller DA, Biederman J, Stewart SE, Mullin B, Farrell C, Wagner KD, Emslie G, Carpenter D. J Child Adolesc Psychopharmacol. 2003;13 Suppl 1:S19-29

Clomipramine Found Better, But SSRIs All Equally Good: In a meta-analysis by MGH-Harvard covering 12 studies with 1044 patients, these were the conclusions. Which SSRI? A meta-analysis of pharmacotherapy trials in pediatric obsessive-compulsive disorder. Geller DA, Biederman J, Stewart SE, Mullin B, Martin A, Spencer T, Faraone SV. Am J Psychiatry. 2003 Nov;160(11):1919-28. 

Clomipramine better than Desipramine for Body Dysmorphic Disorder: 29 pt DB. 16 weeks crossover study. Even among those patients who are delusional. Clomipramine vs desipramine crossover trial in body dysmorphic disorder: selective efficacy of a serotonin reuptake inhibitor in imagined ugliness. Hollander E, Allen A, Kwon J, Aronowitz B, Schmeidler J, Wong C, Simeon D. Arch Gen Psychiatry 1999 Nov;56(11):1033-9

Clomipramine better than Fluoxetine; Side-Effects Associated with Positive Response: 2 multi-center DB industry trials clomipramine v fluoxetine. Response = >35% reduction.58% clomipramine (133/230) and 34% fluoxetine (72/210) responded. Placebo 3% and 8%. Clomipramine side-effects constipation, dry mouth, dizzy each associated with good response. Fluoxetine sex dysfunction associated with 2- to 3-fold increase in response. Comparable in men and women. Initial Fluoxetine nervousness associated with 2-fold increase in response. Nervousness is transient and easily detectable. UCLA, Ackerman, J Clin Psychoph 99;19:459

Clomipramine = Fluvoxamine: Author says meta-analyses favor clomipramine. This 227 patient DB with both medicines given at 150-300 mg/day. Equal efficacy but more side-effects and dropouts with clomipramine, especially dry mouth, constipation, tremor. Fluvoxamine in obsessive-compulsive disorder: similar efficacy but superior tolerability in comparison with clomipramine. Mundo E, Rouillon F, Figuera ML, Stigler M. Hum Psychopharmacol 2001 Aug;16(6):461-468

Clomipramine as Good as or Better than Venlafaxine: Random assignment single blind 26 patients venlafaxine 225-350mg/d, 46 clomipramine. 35% improvement=response. Placebo 6% response vs. 36% venlafaxine vs. 50% clomipramine. More clomipramine side-effects. Venlafaxine versus clomipramine in the treatment of obsessive-compulsive disorder: a preliminary single-blind, 12-week, controlled study. Albert U, Aguglia E, Maina G, Bogetto F. J Clin Psychiatry 2002 Nov;63(11):1004-9

Clomipramine Helps OCD Pets: 2:1 male dogs and female cats. not appear to be associated with lack of training, lack of household stimulation, or social confinement. In cats, OCD may be associated with environmental and social stress. Obsessive-compulsive disorder appears at the time of social maturity and may have sporadic and heritable forms. With behavior therapy and med, most 50% decrease. Clinical features and outcome in dogs and cats with obsessive-compulsive disorder: 126 cases (1989-2000). Overall KL, Dunham AE. J Am Vet Med Assoc 2002 Nov 15;221(10):1445-52

Clonazepam No Added Benefit for OCD: In a 12-week DB PC study of 37 OCD adult outpatients, clonazepam was of no added benefit to sertraline alone.  A double-blind combination study of clonazepam with sertraline in obsessive-compulsive disorder. Crockett BA, Churchill E,  Davidson JR. Duke University. Ann Clin Psychiatry. 2004 Jul-Sep;16(3):127-32

Citalopram 20, 40, 60/d All Help OCD: DB PC 401 pt. Response defined as 25% improvement on Y-BOCS. 57%, 52%, and 65% responders vs. 37% with placebo. Citalopram 20 mg, 40 mg and 60 mg are all effective and well tolerated compared with placebo in obsessive-compulsive disorder. Montgomery SA, Kasper S, Stein DJ, Bang Hedegaard K, Lemming OM. Imperial College of Science-London: Int Clin Psychopharmacol 2001 Mar;16(2):75-86

Fluvoxamine Helps Some in DB: A PC DB study of 256 OCD adults treated with 100-300 mg/d fluvoxamine or placebo for 12 weeks found 32% decrease in OCD scores with fluvoxamine and 21% with placebo. A double-blind, placebo-controlled study of the efficacy and safety of controlled-release fluvoxamine in patients with obsessive-compulsive disorder. Hollander E, Koran LM, Goodman WK, Greist JH, Ninan PT, Yang H, Li D, Barbato LM. J Clin Psychiatry. 2003 Jun;64(6):640-7

Imipramine = Sertraline: 10 week DB study of just 19 patients starting with 25 mg sertraline or 10 mg/day imipramine and then increased. No difference in benefit although sertraline reportedly had fewer side-effects. J Benzo, APA 5/17/99

Inositol Helps Depression, OCD, Panic: DB PC studies found no benefit schizophrenia, Alzheimer's, ADHD, or autism but did find benefit for 12 g/day for 4 weeks for 28 depressed pts, for 12 g/day for 21 panic patients, and 18 g/day for 13 OCD patients. Minimal S-E. Levine, Ben Gurion U, Eur Neuropharm ’97;7:14. Ed: Inositol is available on line (iHerb.com) for $12 for 8 oz. or 227 g. That's roughly $1 per day for OCD and not covered by insurance.  For more on inositol, see Inositol.

Inositol Helps Trichotillomania, Skin Picking, OCD: 3 cases, one as adjunct for SSRI. Other two refused SSRI. 6 g three times a day. improvement at 4-8 week and all much improved. J Clin Psychiatry 01;672:60

Tramadol Probably Best and Safest Opiate to Try: Atypical antipsychotic drugs, which block 5-HT2A receptors, are used in augmentation strategies. Opiate drugs might be effective in treatment-refractory OCD and Tourette syndrome. The 5-HT2A-related behavior (i.e., head twitch) has been related with tics, stereotypes, and compulsive symptoms observed in Tourette syndrome and OCD. Head-twitch response was induced in mice by administration of either 5-hydroxytryptophan (5-HTP) or the 5-HT2A/C agonist (+/-)-1-(2,5-dimethoxy-4-iodophenyl)-2-aminopropane (DOI). Dose-effect curves of atypical opiate drugs [tramadol, methadone and levorphanol], morphine, and other psychoactive drugs (fluvoxamine, desipramine, nefazodone, and clozapine) were performed. All the opiates tested reduced both 5-HTP and DOI-induced behavior in a naloxone-reversible fashion, atypical opiates being more effective. The effects of the other drugs depended on the protocol, clozapine being the most effective. Role of atypical opiates in OCD. Experimental approach through the study of 5-HT(2A/C) receptor-mediated behavior. Rojax-Corrales MO, et al. University of Cadiz, Spain, . Psychopharm (Berlin) 2006 Nov 11.

Morphine: Stanford Pushes Morphine for Obsessive-Compulsive Disorder in Flimsy Study with Minimal Possible Benefit: In a small and supposedly double-blind crossover study of 23 OCD patients, the authors claim that once-weekly oral morphine was effective in for some SRI-resistant OCD patients. Patients were randomly assigned to random-order, 2-week blocks of once-weekly morphine, lorazepam, and placebo. However, the authors didn't check to see whether patients could accurately guess whether they had been given the morphine or not. The OCD ( Y-BOCS) score after the highest dose of morphine decreased by an average of 13% vs. 6% with lorazepam and 7% with placebo. Double-blind treatment with oral morphine in treatment-resistant obsessive-compulsive disorder. Koran LM, et al. Stanford University. . J Clin Psychiatry. 2005 Mar;66(3):353-9. Ed: This is an incredibly irresponsible article. To promote the equivalent of heroin for a possible 6% improvement in OCD scores is unethical. In addition to this, it is extremely likely that patients could tell which drug they had been given, yet researchers never asked the patients.  If the patients figured out more often than not which drug they received, that knowledge may have influenced their answers in a way to favor the morphine. When someone feels like that have taken a real medicine they are much more likely to feel better than if they are pretty sure that they just took a placebo sugar pill.  Wouldn't you be disappointed if you realized that your doctor gave you sugar pills for two weeks?

Nicotine Used in OCD: After one patient with obsessive-compulsive disorder (OCD) improved following self-medication with nicotine, another four OCD were treated with nicotine for eight weeks in an open study. Four of five had decreases in YBOCS scores while on nicotine chewing gum. Nicotine treatment of obsessive-compulsive disorder. Lundberg S, Carlsson A, et al. Kungalv, Sweden. Prog Neuropsychopharmacol Biol Psychiatry. 2004 Nov;28(7):1195-9. Ed: Open trials are extremely prone to wishful-thinking, nicotine is quite addictive, and it could lead to tobacco use.  I doubt this approach is going to succeed.

SSRIs said Better than Clomipramine: Two meta-analyses favor clomipramine but in 5 of 6 head-to-head comparisons, SSRIs did just as well with fewer side-effects. J Clin Psychiatry 2/99;60:101 (Ed: Some of the clomipramine side-effects are easily treatable); Sertraline safe and effective for childhood OCD. JAMA 11/25/98; Behavioral therapy helps when obsessions dominant. Br J Psychiatry ’98 Suppl

SSRI In a 12-week DB PC study of fluoxetine 60 adults with body dysmorphic disorder, fluoxetine led to a significantly greater improvement in impaired functioning (LIFE-RIFT and SOFAS scores) and with improvement on the mental health subscale of the SF-36 that approached significance. Decrease in the severity of body dysmorphic disorder, as measured by the Yale-Brown Obsessive Compulsive Scale Modified for Body Dysmorphic Disorder, was significantly correlated with improvement. Change in psychosocial functioning and quality of life of patients with body dysmorphic disorder treated with fluoxetine: a placebo-controlled study. Phillips KA, Rasmussen SA. Butler Hospital, Providence, RI. Psychosomatics. 2004 Sep-Oct;45(5):438-44.

Sertraline (Zoloft) Follow-up in Children: 12-week acute treatment trial, only 23% of the sample achieved full remission. 124 children and teens. The value of longer-term treatment is validated by the finding that more than 85% of patients completing a year of treatment had full (51%) or partial remissions (31%). Remission Status After Long-term Sertraline Treatment of Pediatric Obsessive-Compulsive Disorder. Wagner KD, Cook EH, Chung H, Messig M. Journal of Child and Adolescent Psychopharmacology. 2003;13(Supp 1):S53-60. Two thirds of patients with severe OCD at baseline (CY-BOCS of 26 or greater) achieved full or partial remission. Children were more likely to achieve a full remission than adolescents. Univ Texas. Remission status after long-term sertraline treatment of pediatric obsessive-compulsive disorder. Wagner KD, Cook EH, Chung H, Messig M. J Child Adolesc Psychopharmacol. 2003;13 Suppl 1:S53-60

Venlafaxine Not as Good as SSRI (Paroxetine-Paxil): In a DB study of 150 patients, 79% improved while on paroxetine up to 60 mg/day vs. 64% on venlafaxine up to 300 mg/day. Non-improvers were switched to the opposite medicine, with 56% of venlafaxine non-responders improved on paroxetine, but only 19% of paroxetine non-responders improved while on venlafaxine. Utrecht. A double-blind switch study of paroxetine and venlafaxine in obsessive-compulsive disorder. Denys D, Van Megen HJ, Van Der Wee N, Westenberg HG. J Clin Psychiatry. 2004 Jan;65(1):37-43

Venlafaxine (Effexor) Almost as Good as Clomipramine for OCD: A small DB study of 73 OCD patients found that by three months 36% had a response (35% decrease in Y-BOCS score) with venlafaxine (225-350mg/d) vs. 50% with clomipramine (150-225mg/d). There were more side-effects with clomipramine due to anti-cholinergic effects, but bethanechol use was not permitted in the study. Albert U, et al. Univ Turin. Venlafaxine versus clomipramine in the treatment of obsessive-compulsive disorder: a preliminary single-blind, 12-week, controlled study. J Clin Psychiatry 2002;63:1004-9.

Venlafaxine as Good as Paroxetine (Paxil) for OCD: A 150-patient 12-week DB study of venlafaxine 300 mg/d vs. paroxetine 60mg/d found them equally effective. There were 40% responders in both groups. A double blind comparison of venlafaxine and paroxetine in obsessive-compulsive disorder. Denys D, van der Wee N, van Megen HJ, Westenberg HG. J Clin Psychopharmacol. 2003 Dec;23(6):568-75

Subtypes of OCD

Compulsive Buying Placebo=Fluvoxamine: 23 patient DB PC both groups did well in 9 week trial. Placebo actually did better! Black, Ann Clin Psychiatry 00;12:205

Compulsive Gamblers with Bipolar Disorders: Selective serotonin reuptake inhibitors may be effective for some patients with pathological gambling, but those with bipolar spectrum disorders may relapse during treatment. In a 10-week DB PC study of 40 pathological gambling patients with bipolar spectrum disorders, those given lithium carbonate significantly improved compared to placebo on total pathological gambling scores on the Yale-Brown Obsessive Compulsive Scale, including both thoughts/urges and behavior, as well as on the Clinical Global Impression severity of pathological gambling scale. Affective instability (the Clinician-Administered Rating Scale for Mania score) was also lower in the group treated with sustained-release lithium carbonate compared to placebo. Ten (83%) of 12 completers were rated as responders in the sustained-release lithium group versus five (29%) of 17 in the placebo group. Does sustained-release lithium reduce impulsive gambling and affective instability versus placebo in pathological gamblers with bipolar spectrum disorders? Hollander E, Pallanti S, et al. Mount Sinai School of Medicine, New York, NY. Am J Psychiatry. 2005 Jan;162(1):137-45.

Hoarding forms a distinctive OCD category: Fifteen patients with hoarding symptoms in the Y-BOCS checklist (15.6% of the total sample) were compared and contrasted with 82 patients without. Hoarders were characterized by (1) higher educational levels (P =.02); (2) earlier age at onset (P =.003); (3) higher rates of symmetry obsessions (P =.01); (4) greater frequency of ordering (P =.004); (5) rituals repetition (P =.03); (6) counting compulsions (P =.02); and (7) significantly higher rates of comorbidity with bipolar II disorder (P =.02) and (8) with eating disorders (P =.02). Patients with obsessive-compulsive disorder and hoarding symptoms: a distinctive clinical subtype? Fontenelle LF, Mendlowicz MV, et al. Federal University of Rio de Janiero, Brazil Compr Psychiatry. 2004 Sep-Oct;45(5):375-83 

Hoarding Predicts Poor Response: In a DB PC 12-week study with an SSRI, only 45% improved on the medication. Black, Univ Iowa, J Clin Psychiatry ’98;59:420 

Skin Picking: Fluoxetine (Prozac) Helps: DB PC 21 pt. Simeon, Mt Sinai, J Clin Psychiatry ’97;58:341

Med Augmentation

Atypical Anti-Psychotic Quetiapine (Seroquel) Helped as an Add-On to SSRI: In a meta-analysis of three DB PC studies of 102 OCD patients on SSRI treatment, adjunctive quetiapine (<400 mg/day) was more successful than placebo in total Yale-Brown Obsessive Compulsive Scale scores (P=0.008). Adjunctive quetiapine for serotonin reuptake inhibitor-resistant obsessive-compulsive disorder: a meta-analysis of randomized controlled treatment trials. Fineberg NA, et al. University of Hertfordshire, UK. Int Clin Psychopharm 2006 Nov;21(6):337-343.

Atypical Anti-Psychotic Quetiapine (Seroquel) Helps as an Add-On to SSRI: In an 8-week, 40-patient DB PC study of OCD unresponsive to at 2 SRI meds, quetiapine increased up to 300 mg/day in intent-to-treat, last-observation-carried-forward analysis showed a 31% decrease in Y-BOCS score vs. a 7% for the placebo ( p <.001). The most common side effects in the quetiapine group were somnolence, dry mouth, weight gain, and dizziness. A double-blind, randomized, placebo-controlled trial of quetiapine addition in patients with obsessive-compulsive disorder refractory to serotonin reuptake inhibitors. Denys D, de Geus F, van Megen HJ, Westenberg HG. University Medical Center Utrecht, Netherlands. J Clin Psychiatry. 2004 Aug;65(8):1040-8

Atypical: Low Dose Anti-Psychotic Helped As OCD Adjunct: 45 OCD patients were given 12 weeks of fluvoxamine (Luvox) and then continued for 6 weeks in a DB PC study of risperidone 0.5 mg/day. Resperidone helped only fluvoxamine-refractory patients. Five patients on risperidone (50%) and two (20%) on placebo became responders, with Y-BOCS decreases of at least 35%. Low-dose risperidone augmentation of fluvoxamine treatment in obsessive-compulsive disorder: a double-blind, placebo-controlled study. Erzegovesi S, Guglielmo E, et al, San Raffaele Hospital, Milan, Italy. Eur Neuropsychopharmacol. 2005 Jan;15(1):69-74

Atypical: Risperidone (Risperdal) Augmentation Helps in DB: In a DB PC 8-week study, 16 patients who had failed to respond while on each of two SSRI medications were randomly assigned to risperidone or placebo. While on risperidone 40% improved, but 0% improved while on placebo. Mt. Sinai. Risperidone augmentation in treatment-resistant obsessive-compulsive disorder: a double-blind, placebo-controlled study. Hollander E, Rossi NB, Sood E, Pallanti S. Int J Neuropsychopharmacol. 2003 Dec;6(4):397-401

Atypical: Risperidone Augmention Helps In DB:  A DB PC study using an SSRI plus risperidone found the combination to be of benefit. McDougle, Arch Gen Psych 1999. Olanzepine also helped one case. J Clin Psychopharm 98;18:423. Olanzapine augmentation helped 1 of 10 dramatically (68% improvement) and five more a little. However, weight gain averaged 17 pounds!

Atypical: Risperidone Augmentation Modest Benefit: In an open trial of 20 patients who did not respond to an SSRI given for 8 weeks had risperidone added. Y-BOCS decreased an average of 26%. Pfanner, University of Pisa, Int Clin Psychoph 00;15:297

Atypical: 3 Trichotillomania SSRI-Failures Helped by Added Risperidone: SSRIs were continued but traditional anti-psychotics were stopped. Epperson, Yale, J Child Adol Psychopharm 99;9:43

Atypical Antipsychotic Olanzapine (Zyprexa) Augmentation of SSRI Helpful: In a 6-week DB PC trial of 26 OCD patients who had not responded on an SSRI, the atypical anti-psychotic olanzapine (average dose 11 mg/day) was helpful with a mean decrease of 4.2 in Y-BOCS score compared with a mean increase in score of 0.54 for subjects in the placebo group (p =.04). Six (46%) of 13 subjects in the olanzapine group showed a 25% or greater improvement in Y-BOCS score compared with none in the placebo group. Two (15%) of 13 subjects who received olanzapine discontinued because of side effects: sedation (N = 1) or weight gain (N = 1). Augmentation of Serotonin Reuptake Inhibitors in Refractory Obsessive-Compulsive Disorder Using Adjunctive Olanzapine: A Placebo-Controlled Trial. Bystritsky A, Ackerman DL, Rosen RM, Vapnik T, Gorbis E, Maidment KM, Saxena S. UCLA. J Clin Psychiatry. 2004 Apr;65(4):565-568. Ed: I greatly prefer ziprasidone (Geodon) to olanzapine due to much lower cost when using once a day dosing and considerably fewer serious side-effects.

Carbamazepine Added to Clomipramine Case: A 27-year-old with a 15 year history of not being helped by clomipramine even with added benzodiazepines or typical or atypical anti-psychotics did well with carbamazepine increased to 500mg/day. Iwata, Japan, J Clin Psych 00;61:528

Clomipramine-Nortriptyline Helpful: Clomipramine less specific for serotonin than SSRI but may be more effective. Norepinepherine may play a role in OCD. 30 OCD patients without depression were treated in a DB PC study for 8 weeks receiving clomipramine 150 mg/day with or without nortriptyline 50 mg/day. The combination did better. Noorbala, Tehran, Combination of clomipramine and nortriptyline in the treatment of obsessive-compulsive disorder: a double-blind, placebo-controlled trial. Noorbala AA, Hosseini SH, Mohammadi MR, Akhondzadeh S. J Clin Pharmacy & Therpeutics 98;23:155 

Inosital Augmentation of SSRI: 10 patients failing to improve while taking 12 weeks of SSRI medication had 18 g/day inositol added for 4-6 weeks with 3 of the 10 benefiting. Seeday, University of Stellenbosch, APA 5/99

Lithium & Thyroid Not Helpful Add-ons: DB PC. NIMH, J Clin Psychopharm ’91;11:242

Mirtazapine Little Benefit as OCD Add-On: In a 12-week DB PC study of 49 adult OCD patients, citalopram (20-80 mg/day) was compared to citalopram plus mirtazapine (15-30 mg/day). The citalopram plus mirtazapine group had a reduction of at least 35% in YBOCS score and a "much improved" or "very much improved" rating on the Clinical Global Impressions-Improvement scale from the 4^th week, while the citalopram plus placebo group obtained these results only from the eighth week. No difference between groups in the response rate was noted at the eighth and twelfth weeks of treatment. Response acceleration with mirtazapine augmentation of citalopram in obsessive-compulsive disorder patients without comorbid depression: a pilot study. Pallanti S, Quercioli L, Bruscoli M. Institute for Neurosciences, Florence, Italy.  J Clin Psychiatry. 2004 Oct;65(10):1394-9. Ed: To expose patients to the cost and side-effects (including weight gain) of mirtazapine for such a brief possible benefit seem foolish.

Thomas E. Radecki, M.D., J.D.

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