Treatment resistant OCD Unit 1 Topic Presentation Nov 17, 2009
Attribution <ul><li>Information for this presentation is entirely drawn from  “Management of treatment resistant obsessive...
Introduction <ul><li>Prevalence of OCD 1-3% </li></ul><ul><li>1 st   treatment  tricyclic drug- clomipramine </li></ul><ul...
Treatment Non response <ul><li>40% – 60 % do not respond to treatment with either SRIs or CBT </li></ul><ul><li>Instrument...
Definition <ul><li>‘Treatment resistance’ – failure to respond to one adequate SRI trial </li></ul><ul><li>Assessment – to...
Optimum Dose Ranges <ul><li>Fluoxetine </li></ul><ul><li>Sertaline </li></ul><ul><li>Fluvoxamine </li></ul><ul><li>Paroxet...
Predictors of treatment non response <ul><li>Early age at onset </li></ul><ul><li>Longer duration of OCD </li></ul><ul><li...
Therapeutic Approach Fleck and Horwath <ul><li>Optimization </li></ul><ul><li>Switching </li></ul><ul><li>Augmentation </l...
Switching Strategies <ul><li>One SSRI to another </li></ul><ul><li>Clomipramine </li></ul><ul><li>Venlafaxine </li></ul>
Augmentation Strategies <ul><li>Risperidone </li></ul><ul><li>Augmentation trial 8 weeks </li></ul>
Combination strategies <ul><li>SSRI and clomipramine. </li></ul><ul><li>SSRI/ SRI and behavior therapy. </li></ul>
Other Strategies <ul><li>Intensive residential therapy </li></ul><ul><li>Family therapy </li></ul><ul><li>High dose SSRI t...
Recommendations for Management   <ul><li>Nonresponders to single trial– add BT or switch to alternate SSRI. </li></ul><ul>...
Management   <ul><li>Not tolerating switch to clomipramine – switch to venlafaxine. </li></ul><ul><li>Non responding to BT...
Summary <ul><li>Treatment of treatment resistance is challenging. </li></ul><ul><li>Though 1 st  line is effective substan...
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Treatment Resistant Ocd

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Treatment Resistant Ocd

  1. 1. Treatment resistant OCD Unit 1 Topic Presentation Nov 17, 2009
  2. 2. Attribution <ul><li>Information for this presentation is entirely drawn from “Management of treatment resistant obsessive compulsive compulsive disorder” chapter 9 written by </li></ul><ul><li>Sumanth Khanna and Ravi Philip Rajkumar in the book “ Obsessive compulsive disorder current understanding and future directions” Editors Y C Janardhan Reddy, Shoba Srinath Nimhans publications no 63. 2007 </li></ul>
  3. 3. Introduction <ul><li>Prevalence of OCD 1-3% </li></ul><ul><li>1 st treatment tricyclic drug- clomipramine </li></ul><ul><li>SRI – 1 st line medication for OCD </li></ul><ul><li>Psychological treatment based on learning model </li></ul><ul><li>ERP – 1 st line treatment for OCD </li></ul><ul><li>CBT </li></ul>
  4. 4. Treatment Non response <ul><li>40% – 60 % do not respond to treatment with either SRIs or CBT </li></ul><ul><li>Instruments used in assessing treatment response is Y- BOCS symptoms severity scale and the CGI severity and improvement scale. </li></ul><ul><li>Response –decrease in more than 25% </li></ul>
  5. 5. Definition <ul><li>‘Treatment resistance’ – failure to respond to one adequate SRI trial </li></ul><ul><li>Assessment – to exclude ‘pseudo resistance’ </li></ul><ul><li>An adequate trial of SRI – 10/12 weeks </li></ul><ul><li>Ensure optimum dose of medication used </li></ul><ul><li>Ensure drug adherence </li></ul>
  6. 6. Optimum Dose Ranges <ul><li>Fluoxetine </li></ul><ul><li>Sertaline </li></ul><ul><li>Fluvoxamine </li></ul><ul><li>Paroxetine </li></ul><ul><li>Citalopram </li></ul><ul><li>Escitalopram </li></ul><ul><li>Clomipramine </li></ul><ul><li>40-80 mg/day </li></ul><ul><li>150-250 </li></ul><ul><li>200-300 </li></ul><ul><li>40-60 </li></ul><ul><li>40-60 </li></ul><ul><li>10-20 </li></ul><ul><li>150-225 </li></ul>
  7. 7. Predictors of treatment non response <ul><li>Early age at onset </li></ul><ul><li>Longer duration of OCD </li></ul><ul><li>Mixed subtype of OCD </li></ul><ul><li>Presence of sexual obsessions </li></ul><ul><li>Presence of washing compulsions </li></ul><ul><li>Hoarding, poor insight, prior treatment </li></ul><ul><li>Personality disorders, Tic disorders </li></ul>
  8. 8. Therapeutic Approach Fleck and Horwath <ul><li>Optimization </li></ul><ul><li>Switching </li></ul><ul><li>Augmentation </li></ul><ul><li>Combination </li></ul>
  9. 9. Switching Strategies <ul><li>One SSRI to another </li></ul><ul><li>Clomipramine </li></ul><ul><li>Venlafaxine </li></ul>
  10. 10. Augmentation Strategies <ul><li>Risperidone </li></ul><ul><li>Augmentation trial 8 weeks </li></ul>
  11. 11. Combination strategies <ul><li>SSRI and clomipramine. </li></ul><ul><li>SSRI/ SRI and behavior therapy. </li></ul>
  12. 12. Other Strategies <ul><li>Intensive residential therapy </li></ul><ul><li>Family therapy </li></ul><ul><li>High dose SSRI therapy </li></ul><ul><li>Monotherapy with drugs other than SSRI </li></ul><ul><li>Psychosurgery </li></ul><ul><li>rTMS </li></ul><ul><li>Deep brain stimulation </li></ul>
  13. 13. Recommendations for Management <ul><li>Nonresponders to single trial– add BT or switch to alternate SSRI. </li></ul><ul><li>Nonresponder to BT – add SSRI </li></ul><ul><li>Non response to 2 trials of SSRI- add BT or switch to clomipramine or augment with respiridone. </li></ul>
  14. 14. Management <ul><li>Not tolerating switch to clomipramine – switch to venlafaxine. </li></ul><ul><li>Non responding to BT+ SSRI switch to clomipramine, venlaflaxine or other SRI or try augmentation </li></ul><ul><li>Failure of all above 1 st line– go for intensive residential treatment, 2 nd line augmentation with pindolol etc </li></ul>
  15. 15. Summary <ul><li>Treatment of treatment resistance is challenging. </li></ul><ul><li>Though 1 st line is effective substantial proportion do not respond to it </li></ul><ul><li>Combination, switching, augmentation </li></ul><ul><li>Research is ongoing………. </li></ul>

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