To critically review the antiobsessional properties of serotonin-norepinephrine reuptake inhibitors (SNRIs) (venlafaxine and clomipramine) in the treatment of obsessive-compulsive disorder (OCD) as an alternative to selective serotonin reuptake inhibitors (SSRIs), which are currently considered the first-line treatment of OCD.
A MEDLINE search was performed to identify clinical trials with the SNRIs venlafaxine and clomipramine published from 1996 to 2004 (keywords: SNRIs, venlafaxine, duloxetine, and clomipramine, each matched individually with the term OCD), focusing on the best-designed studies for inclusion.
Much of the literature about SNRIs in OCD supports the efficacy of these compounds in the treatment of OCD. However, double-blind, placebo-controlled studies with venlafaxine are lacking, and the most relevant studies consist of active comparison trials between SNRIs and SSRIs. In these studies, SNRIs seem to be as effective as SSRIs in OCD; SNRIs might be preferred for patients with certain types of treatment-resistant OCD or those with particular comorbid conditions. A large number of placebo-controlled and active comparison trials with clomipramine document efficacy in OCD, and meta-analytic studies suggest a small superiority over SSRIs. Compared with clomipramine, the SNRI venlafaxine showed fewer side effects and better tolerability.
The SNRIs may represent a valid alternative to the SSRIs, particularly in specific cases. Double-blind, placebo-controlled studies are, however, needed to confirm the positive findings reported by several studies with venlafaxine.
"This suggests that SSRIs and exposure therapy improve the function of the frontal and temporal lobes in OCD. SSRI has already established its efficacy in obsessive-compulsive disorder . OCD has been attributed to dysfunction in the interaction between basal ganglia and the cerebral cortex, specifically the lack of cortical control over the striatum . "
[Show abstract][Hide abstract] ABSTRACT: Drug therapy with selective serotonin reuptake inhibitors (SSRIs) has been used as a treatment for obsessive-compulsive disorder (OCD). In the present case report, exposure therapy was used in addition to escitalopram (20 mg) to treat a 28-year-old female patient with OCD for 6 months. Her obsessive-compulsive symptoms comprised thoughts of words such as rape, crematorium, neck hanging, unhappy, death, die, and kill and images such as a shelf of gods, a shrine, a Buddhist altar, the sun, the sky, and the faces of her parents, siblings, and relatives. As exposure therapy, she was asked to view the images associated with these symptoms three times a day along with drug therapy. With the combination of drug and exposure therapies, her obsessive-compulsive symptoms improved within 6 months, with no interference in her daily life. Multichannel near-infrared spectroscopy (NIRS) showed improvement of brain function in the temporal and frontal lobes after treatment. These results suggest that NIRS can be used as an indicator of brain function improvement in patients with OCD.
"However, due to the absence of double-blind placebo-controlled trials, venlafaxine should not be considered a first line medication treatment for patients with OCD at this time. Perhaps venlafaxine might be considered in specific clinical situations such as OCD with comorbid attention/deficit/hyperactivity disorder (ADHD) (Dell'Osso et al., 2006). One placebo-controlled trial supports the efficacy of phenelzine (MAO inhibitor) (Vallejo et al., 1992). "
"A 1997 meta-analysis comparing clomipramine with fluoxetine and sertraline found larger effect sizes for clomipramine; however, there were relatively few studies of fluoxetine and sertraline, and a large contrast in side effect profiles between clomipramine and placebo may have inflated the effect size for clomipramine (Abramowitz 1997). More recently, other work also has found that clomipramine tends to be slightly superior to other SSRIs in OCD (Ackerman and Greenland 2002; Dell’Osso et al 2006). Using meta-regression to control for factors such as clinical-trial length and OCD severity in their meta-analysis of placebo-controlled trials of clomipramine, fluvoxamine, sertraline, and paroxetine, Ackerman and Greenland (2002) found superiority for clomipramine. "
[Show abstract][Hide abstract] ABSTRACT: Obsessive-compulsive disorder (OCD) is a common and severe neuropsychiatric disorder treated by both behavioral and pharmacologic techniques. Despite the availability of treatments for OCD, including the selective serotonin reuptake inhibitors (SSRIs), many OCD patients have an inadequate response to current treatments. As such, additional approaches to the management of OCD are required. A potential but little studied treatment for OCD is the SSRI escitalopram. Escitalopram is the S-enantiomer of citalopram, the preparation containing both S and R enantiomers of citalopram. Not only is escitalopram the most selective of the SSRIs, it is also devoid of R-citalopram, which may interfere with the effects of the S enantiomer. Escitalopram appears to be effective in depression and several anxiety disorders, including social anxiety disorder and generalized anxiety disorder, conditions in which it also appears reasonably well tolerated. Enantiomeric specificity, high serotonin reuptake selectivity, comparatively good tolerability and favorable pharmacokinetics, and preliminary evidence of efficacy in OCD suggest a potential role for the use of escitalopram in the treatment of OCD. Nevertheless, additional work including evaluating the use of escitalopram with behavioral interventions and in long-term treatment of OCD is needed to clarify its overall role in managing OCD.
Neuropsychiatric Disease and Treatment 09/2007; 3(4):455-61. · 1.74 Impact Factor
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