Antipsychotic augmentation in the treatment of obsessive-compulsive disorder

Abstract

Most studies suggest that obsessive-compulsive disorder runs a chronic course. Only 40%–70% of patients respond to first-line treatment with selective serotonin reuptake inhibitors (SSRIs). The most common pharmacological strategy used in clinical practice for partial responders to SSRIs is augmentation with an atypical antipsychotic. This article aims to review the efficacy, tolerability, and comparative efficacy of antipsychotics as augmenting agents in patients who showed inadequate response to SSRIs. In addition to case reports and case series, 15 randomized controls trials, 6 meta-analyses, and 3 expert guidelines have been examined. The findings suggest that one in three SSRI nonresponders improve with antipsychotic augmentation. The presence of comorbid tics and/or schizotypal disorder may predict a better response to antipsychotic augmentation. Among antipsychotics, risperidone, and aripiprazole have the best evidence, with haloperidol being considered second in-line owing to its unfavorable side effect profile. Guidelines recommend that antipsychotics be administered at a low-to-medium dosage for a duration not exceeding 3 months, with mandatory discontinuation if there is no response. Larger studies and head-to-head trials are needed to further explore this treatment strategy.

Prescription Pattern and Off-Label Use of Antipsychotics in a Middle Eastern Population

“…Antipsychotics, especially risperidone and aripiprazole, may be used cautiously as first-line pharmacological augmenting agents for OCD patients who are not responding to selective serotonin reuptake inhibitors (SSRI) and cognitive behavioral therapy (CBT), but at low doses and should be monitored at 4 weeks to determine the efficacy ( Veale et al, 2014 ). Current evidence suggests that among patients augmented with antipsychotics, one in three SSRI-resistant OCD patients will show a response ( Thamby and Jaisoorya, 2019 ). However, there is considerable evidence that SGAs can increase the chances of adverse events, including sedation, weight gain and gastrointestinal problems.…”

The use of antipsychotics in obsessive compulsive disorder

“…Therefore, the use of FGAs as adjunctive therapy has to be considered only when the augmentation with SGAs is contraindicated. Moreover, it is advisable that FGAs are introduced at a low dose and with a slow dosage increase (Thamby & Jaisoorya, 2019). Updated evidence on main FGAs involved in OCD treatment is provided below.…”

“…In poor responders different augmentative pharmacological strategies have been tested, including SSRI augmentation with another antidepressant such as clomipramine (a tricyclic antidepressant) or mirtazapine, and with first‐(FGAs) or second‐generation antipsychotics (SGAs; Thamby & Jaisoorya, 2019; Fineberg et al., 2020; Pittenger & Bloch, 2014).…”

Pharmacological augmentation of serotonin reuptake inhibitors in patients with obsessive–compulsive disorder: A network meta‐analysis

“…Amongst pharmacotherapeutic agents, serotonin reuptake inhibitors (SRIs), such as selective serotonin reuptake inhibitors (SSRIs) and clomipramine, are the most recommended first‐line therapy for OCD 7,8 . However, around 40%–60% of patients show a partial response or lack of response after treatment with SSRI or clomipramine 9,10 . For lack of response or resistant cases, the treatment strategy of adding another drug as an augmentation agent is practised 7,11,12 .…”

“…7,8 However, around 40%-60% of patients show a partial response or lack of response after treatment with SSRI or clomipramine. 9,10 For lack of response or resistant cases, the treatment strategy of adding another drug as an augmentation agent is practised. 7,11,12 However, augmentation therapy has been evaluated in non-refractory OCD also with an expectation of better clinical outcomes.…”