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Obsessive-compulsive disorder (OCD) is characterized by obsessions—recurrent, intrusive, persistent, anxiety-provoking ideas, urges, or images—and by compulsions—repetitive acts usually carried out in response to obsessions. Obsessions and compulsions cause substantial distress and/or interfere with functioning. Common obsession themes include contamination, aggression, sexual identity, morality, and the need to know; common compulsions include washing, checking, counting, praying, repeating and hoarding. OCD affects about 1% to 2% of the population and is about equally common in men and women. It has an early age of onset—about one-third of cases begin before age 15, another third between ages 15 and 25, and the last third between ages 25 and 40. Boys with childhood onset tend to have more severe symptoms.

OCD patients commonly suffer from other psychiatric disorders. About 30% have a comorbid major depression when they present for treatment, and two-thirds experience a major depressive episode at some time in their lives. Other common comorbid conditions include panic disorder, social phobia, alcohol abuse, Tourette’s syndrome, and bipolar II disorder. Imaging studies have revealed rather consistent patterns of hyperactive brain circuitry in OCD, which normalize with treatment.

Pharmacotherapy: An Important Player

Only some selective-serotonin reuptake inhibitors (SSRIs) are FDA-approved for treating OCD, but all have been proven effective in large, multi-center controlled trials. SSRIs don’t cure the disorder, but they do ameliorate symptoms. SSRIs are effective for more than half of OCD patients who try them. Fluvoxamine is the SSRI most studied in the treatment of OCD and may have certain advantages over other agents, including a smaller chance of inducing weight gain and perhaps a lower incidence of sexual side effects. In choosing an anti-OCD medication, physicians must consider not only side-effect profiles, but also the patient’s past treatment trials, potential drug interactions, whether first-degree relatives have responded to the drug, and insurance issues.

The American Psychiatric Association (APA) guideline for the treatment of OCD (available at www.ajp.psychiatryonline.org) recommends three first-line treatments for OCD: 1) SSRIs, 2) cognitive behavioral therapy (CBT), and 3) a combination of SSRIs and CBT. Combining medication and CBT appears to yield better results for some patients but is not required for all, and CBT cannot be implemented with patients who are too depressed or anxious to cooperate in the treatment. About 40% to 50% of patients with OCD, who are unresponsive to SSRI treatment will quickly benefit when an atypical antipsychotic drug is added. Additional augmentation and switching strategies, for which less supporting data are available, are described in the APA guideline. Patient education resources, such as the OC Foundation (www.ocfoundation.org), are useful to help reduce stigma and guilt and to enhance treatment adherence and, thus, treatment effect.

Determining Efficacy of Drugs

Determining whether an SSRI is producing a clinically meaningful response requires 6 to 12 weeks at the maximum easily tolerated dose. A small percentage of OCD patients will start to benefit from SSRI treatment after 3 or 4 weeks. Once the patient starts to improve, symptom severity lessens monthly for about 3 months before severity plateaus. Stopping medication, even after a year of successful treatment, usually leads to relapse; the beneficial effects of CBT may last longer. Adding CBT before slowly tapering medication may lessen relapse chances, but physicians should continue to monitor patients closely since OCD is a chronic condition.

Lorrin M. Koran, MD, has indicated to Physician’s Weekly that he is on the speaker’s bureau for Forest Pharmaceuticals and has received grants from Ortho-McNeil, Eli Lilly and Company, Forest Pharmaceuticals, Somaxon, Jazz and Sepracor.