Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders guidelines for the treatment of adult obsessive-compulsive disorder. Part I: pharmacological treatment

Abstract

Objectives: To summarize evidence-based pharmacological treatments and provide guidance on clinical interventions for adult patients with obsessive-compulsive disorder (OCD). Methods: The American Psychiatric Association (APA) guidelines for the treatment of OCD (2013) were updated with a systematic review assessing the efficacy of pharmacological treatments for adult OCD, comprising monotherapy with selective serotonin reuptake inhibitors (SSRIs), clomipramine, serotonin and norepinephrine reuptake inhibitors (SNRIs), and augmentation strategies with clomipramine, antipsychotics, and glutamate-modulating agents. We searched for the literature published from 2013-2020 in five databases, considering the design of the study, primary outcome measures, types of publication, and language. Selected articles had their quality assessed with validated tools. Treatment recommendations were classified according to levels of evidence developed by the American College of Cardiology and the American Heart Association (ACC/AHA). Results: We examined 57 new studies to update the 2013 APA guidelines. High-quality evidence supports SSRIs for first-line pharmacological treatment of OCD. Moreover, augmentation of SSRIs with antipsychotics (risperidone, aripiprazole) is the most evidence-based pharmacological intervention for SSRI-resistant OCD. Conclusion: SSRIs, in the highest recommended or tolerable doses for 8-12 weeks, remain the first-line treatment for adult OCD. Optimal augmentation strategies for SSRI-resistant OCD include low doses of risperidone or aripiprazole. Pharmacological treatments considered ineffective or potentially harmful, such as monotherapy with antipsychotics or augmentation with ketamine, lamotrigine, or N-acetylcysteine, have also been detailed.

The use of antipsychotics in obsessive compulsive disorder

“…By now, only one case report and one RCT have been published (Angelucci et al., 2009; Storch et al., 2013), the latter showing a partial efficacy in decreasing YBOCS scores, with a mean dose of 4.94 mg/die in a group of 34 patients with treatment‐resistant OCD, not being statistically significant. Overall, there are no recommendation on the usage of paliperidone as augmentative strategy for refractory OCD (de Oliveira et al., 2023).…”

“…No recommendation on the usage of olanzapine nor paliperidone are available, due to the mixed results (de Oliveira et al, 2023) or to the lack of consistent studies (Brakoulias et al, 2019), respectively.…”

“…Other novel antipsychotics, such as lurasidone and cariprazine haven't been included in the latest metanalyses (de Oliveira et al, 2023) as the literature in their regard consists only in case reports (De Berardis et al, 2020;Orsolini et al, 2023).…”

“…No recommendation on the usage of olanzapine nor paliperidone are available, due to the mixed results (de Oliveira et al., 2023) or to the lack of consistent studies (Brakoulias et al., 2019), respectively. Other novel antipsychotics, such as lurasidone and cariprazine haven't been included in the latest metanalyses (de Oliveira et al., 2023) as the literature in their regard consists only in case reports (De Berardis et al., 2020; Orsolini et al., 2023).…”

“…Mean doses used among adults in RCTs ranged between 0.5 and 2.2 mg, however there are no univocal indications either for the augmentation dose or the treatment duration for patients with OCD (Brakoulias & Stockings, 2019). In accordance with the major metanalyses, higher doses of antipsychotics are not associated with better outcomes (Dold et al, 2015) and lower doses seem to be more effective, even though more associated with sedation (de Oliveira et al, 2023;Komossa et al, 2010;Veale et al, 2014). Recently, the Indian Psychiatric Society has recommended dosages of risperidone as augmentation drug between 1 and 3 mg/die, with strength of recommendation A (Thamby & Jaisoorya, 2019).…”