Diagnosis and Treatment of Obsessive-Compulsive Disorder - Term Paper Example

SRI IN THE TREATMENT OF OBSESSIVE COMPULSIVE DISORDER Obsessive compulsive disorder (OCD) is one of the most common psychiatric disorders aswell as one of the most disabling of all medical disorders. Several studies have reported that Serotonin Reuptake Inhibitors (SRIs) provide clinically meaningful relief for 40 -60% OCD patients. The medications along with psychotherapy should be the first line of intervention for patients with OCD. The five drugs approved by the Food and Drug Administration (FDA) for the treatments of adults with OCD are clomipramine, fluoxamine, fluoxetine, sertraline and paroxetine. The essay reviews the various studies of the SRIs in the treatment of OCD. Introduction Obsessive compulsive disorder (OCD) is characterized by recurrent obsessions and compulsions that cause marked distress and significant functional impairment (Dell’Osso, 2007). OCD is one of the more common serious mental illnesses. The shame and secrecy associated with it, as well as lack of recognition of its characteristic symptoms, can lead to delay in diagnosis and treatment. Effective psychological and drug treatments are available for the distressing, time-consuming, repetitive thoughts and rituals and the associated functional impairment. Obsessions are unwanted ideas, images or impulses that repeatedly enter a person’s mind. Although recognized as being self-generated, they are experienced as “egodystonic” (out of character, unwanted, and distressing). Compulsions are repetitive stereotyped behaviors or mental acts driven by rules that must be applied rigidly. They are not inherently enjoyable and do not result in the completion of any useful task. To qualify for the diagnosis, the symptoms must be disabling. OCD occurs throughout the life span and children as young as six or seven present with the characteristic-impairing symptoms. Recent epidemiological studies report prevalence rates of 0.8% in adults and 0.25% in 5-10 year old children, although earlier studies suggested rates as high as 1-3% in adults and 1-2% in children and adolescents. The World Health Organization rates OCD as one of the top 20 most disabling diseases. The current best validated instrument is the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), which exists both in adults and children (Heymann, 2006). OCD responds selectively to inhibit the synaptic reuptake of serotonin (SRIs). This was stated by Dell’Osso et al. (2007) in a review of an intensive pharmacological investigations. Randomized, controlled trials have shown that such medications that lack these properties are ineffective. Though remissions with such medications are rare, a single SRI trial generally provides clinically meaningful relief for 40-60% OCD patients. Response in OCD research is a reduction of 25-35% in OCD symptoms. Differences in side-effects profile, half-life, available formulations and cost helps in selecting a SRI which will be more effective for a given patient. An adequate SRI trial in OCD should extend to a period of 10-12 weeks with at least 4-6 at the maximum tolerated dose. The first line of intervention for patients with OCD include the medications along with psychotherapy. The Food and Drug Administration has approved 5 drugs for the treatment adult OCD which are: clomipramine, fluvoxamine, fluoxetine, sertraline, and paroxetine OCD can be treated effectively with higher doses of SRIs than those used for depression as stated by Heymann et al (2006). Treatment OCD by a nationally representative sample of psychiatrists was examined by Blanco et al. (2006) Physician reported data from the period of 1997 to 1999 by the American Psychiatric Institute for Research and Education Practice Research Network (PRN) Study of Psychiatric Patients and Treatments were analyzed in order to describe demographic, clinical and treatment characteristics of patients with a diagnoses of OCD. Since the study included data from both surveys, the sample size and associated statistical power was high. In both surveys, were assigned, each participant psychiatrist collected data using an extensive instrument for 3 patients who had been randomly preselected from the patient log. Socio-demographic characteristics, health plan features, DSM-IV diagnoses and clinical features, including co-occurring mental disorders and treatments provided by the PRN psychiatrists and other providers at the time of the survey were the important patient-level information obtained during the study. In a detailed information on a total of 3071 patients, the response rate was 78% for both the years. Though 65% of the patients received an SRI, only 31.4% of the sample patients were prescribed an SRI at an effective dose for treating OCD. Cognitive Behavioral Therapy (CBT) was received by 7.5% of the patients with or without medication. Prescription of benzodiazepines or antipsychotic was found to be common, often in the absence of an SRI. The study showed that the Global Assessment of Functioning (GAF) Scale scores were high in patients receiving CBT. Other demographic or treatment characteristics were not associated with the type of treatment received by the patients. But the study has several limitations. The diagnoses were not subjected to expert validation and were based on independent judgment of the participating psychiatrist. The authors also stated that there was no published information on patient treatment preferences and the constraints they imposed on the selection and provision of evidence based treatments. The only standard measure of illness severity collected by the surveys was the GAF, rather than the more disorder-specific Yale-Brown Obsessive Compulsive Scale (YBOCS). The study also lacked the analytical power to stratify the analysis by ethnicity. The authors concluded that the future researches should pilot approaches to increase the use of evidence-based treatment. Sousa et al. (2006) conducted a study to evaluate the efficacy of Cognitive Behavioral Group Therapy (CBGT) as compared to that of sertraline in reducing OCD symptoms. Fifty-six patients with OCD participated in randomized 12 week trial to receive of sertraline or CBGT. Participants were female or male outpatients, aged between 18 and 65 years, who were diagnosed with OCD according to DSM-IV criteria. Patients were evaluated by clinical interview and by the Brazilian version of the Mini-International Neuropsychiatric Interview (MINI). Other inclusion criteria included a YBOCS score > 16 and being motivated and ready to accept the random assignment of CBGT sessions and sertraline use. Twenty-eight patients were randomly assigned to CBGT treatment group and the other 28 patients were treated with 100 mg per day of sertraline for the same length of time. The authors reported that though both treatment s were effective, patients treated with CBGT obtained mean YBOCS reduction of symptoms of 44%, while those treated with sertraline obtained only a 28% reduction (p= 0.033). Such result demonstrated higher improvement rate for CBGT, with significant reduction in the intensity of compulsions (p=0.030). There were no significant differences at study endpoint in the YBOCS scores of patients who used serotonergic antidepressants before the trial compared with those who did not in the CBGT (p= 0.384) or sertraline (p= 0.829) groups. Eight patients (32%) who underwent CBGT reached the improvement level, while only one (4%) among those taking sertraline had the same result (p=0.023). CBGT and sertraline have shown to be effective in reducing OCD symptoms , though the rate of symptom reduction, intensity reduction of compulsions, and percentage of patients who obtained full remission were significantly higher in patients treated with CBGT. Participants demostrated a higher degree of medication compliance during the study. The main limitation of the study was the small sample size that could cause type II errors. Another limitation was though fixed doses of sertraline (100mg/day) were used for all subjects, a higher dose would have had a different outcome in some patients. As the study did not employ a placebo control group, it was not possible to compare the efficacy of each treatment to the association of both. The percentage of patients who obtained full remission was significantly higher in patients treated with CBGT, though CBGT ant sertraline have shown to be effective in reducing OCD symptoms. The effectiveness of CBGT and sertraline in the treatment of naïve children and adolescents with OCD was compared by Asbahr et al. (2005). Forty subjects between 9 and 17 years old were randomized to receive CBGT (n=20) or sertraline (n=20), between 2000 and 2002. CBGT included manual based 12 week cognitive-behavioral protocol for one group, and the other group was treated with sertraline for 12 weeks. Subjects were assessed before, during and after treatment (at 1, 3, 6, and 9 months after treatment conclusion). Primary outcome measure was the Children’s YBOCS. Repeated measures analysis of variance was also carried out. The results showed that both the groups were similar according to sex, age and duration of symptoms. Subjects in the CBGT condition had significantly low rate of symptom relapse than those in sertraline group after the 9 month follow up period. The reliability of the outcome measures may have been influenced since the subjects were assessed 11 times by the same raters along the study. The study did not use a placebo controlled group. They concluded that the treatment with CBGT may be effective in decreasing obsessive-compulsive symptoms in childhood OCD and should be considered as an alternative to either CBT or a medication such as sertraline. Results support the effectiveness and the maintenance of gains in the treatment of youngsters with OCD. It can therefore be concluded that children and adults with OCD may be offered SRIs; this should be a second line treatment in young people. Mild cases may be helped by guided self-help. Most people with OCD should be offered CBT incorporating exposure and response prevention. References Asbahr, F. R., Ana, R. C., Ligia, M. I., & Lotufo-Neto. (2005). Group Cognitive Therapy Versus Sertraline for the Treatment of Children and Adolescents with Obsessive-Compulsive Disorder. J.am.acad. Child adolesc. Psychiatry, 44, (11), 1128-1136. Blanco, C., Mark, O., Dan, J. S., Helen, B. S, Marc, J. G. & William, H. N. (2006) Treatment of Obsessive-Compulsive Disorder. J Clin Psychiatry, 67, (6), 946-951. Dell’Osso, B., Altamura, A. C., Mundo, E., Marazziti, D., & Hollander, E. (2007). Diagnosis and treatment of Obsessive-Compulsive Disorder and Related Disorder. Int J Clin Prac, 61, (1), 98-104. Heyman, I. D., Mataix-Cols., & Fineberg, N.A. (2006). Obsessive-Compulsive Disorder. BMJ 333,424-429. Sousa, M. B., LuRenata, R.O., Gisele, G.M., & Aristides, V.C. (2006). A Randomized Clinical Trial of Cognitive-Behavioral Group Therapy and Sertraline in the Treatment of Obsessive-Compulsive Disorder. J Clin Psychiatry, 67, (7), 1133-1139. Read More