Research paper
Pharmacotherapy for obsessive compulsive disorder in clinical practice – Data of 842 inpatients from the International AMSP Project between 1994 and 2012

https://doi.org/10.1016/j.jad.2016.04.035Get rights and content

Highlights

  • Pharmacotherapy of OCD in 842 inpatients was investigated using prescription data.

  • 90% of the patients received at least 1 psychotropic drug, about 70% at least 2.

  • SSRIs (58%) and clomipramine (11%) were the antidepressants (78%) mostly used.

  • Dosages of SSRIs were rather low compared with evidence-based recommendations.

  • The most common augmentation strategy consisted of SGAs.

Abstract

Background

Specific treatment of obsessive compulsive disorder (OCD) is based on cognitive-behavioral therapy, serotonin reuptake inhibitors (SRIs) or their combination. Treatment strategies do not always follow evidence-based guidelines in outpatient settings. Data on pharmacotherapy in inpatient settings are lacking.

Methods

Prescription data for inpatients suffering from OCD in the time period 1994–2012 were obtained from the database of the Drug Safety Program in Psychiatry (AMSP). Data were collected on two index dates per year; the prescription patterns and changes over time were analysed.

Results

Of 842 patients 89.9% received at least one psychotropic drug and 67.6% a combination of at least two psychotropic drugs. The drug groups prescribed most often were antidepressants (78.0%), antipsychotics (46.7%), and tranquilizers (19.7%). In 58.0% of all cases selective serotonin reuptake inhibitors (SSRIs) were used as antidepressants, followed by tricyclic antidepressants (TCAs, 17.8%), mainly clomipramine (10.9%). Second-generation antipsychotics (SGAs) were administered in 37.8% of all cases, first-generation antipsychotics (FGAs) in 13.7%. While the use over time significantly increased for psychotropic drugs, antidepressants, antipsychotics, tranquilizers, SSRIs and SGAs, it remained stable for FGAs and decreased for TCAs.

Limitations

Observational cross-sectional study without follow-up or additional information.

Conclusions

In clinical practice, most OCD patients received pharmacological treatment. The high prescription rate of SSRIs and their preference over clomipramine as well as the augmentation of this therapy with SGAs comply with the guidelines. Administration of tranquilizers as well as sedative FGAs and the choice of single SGAs are not in line with expert recommendations.

Introduction

Obsessive compulsive disorder (OCD) is a severe and disabling mental disorder with an estimated lifetime prevalence of 1.0–2.3% and a 12-month prevalence of 0.7–1.2% in adults (Adam et al., 2012, Hauschildt et al., 2010, Ruscio et al., 2010). The clinical picture of OCD is characterized by obsessions and/or compulsions. Obsessions are defined as recurrent, persistent and intrusive thoughts, images or urges that cause anxiety. Compulsions are defined as repetitive behaviors or mental acts that the patient feels driven to perform in order to reduce the obsession-related anxiety (DSM-IV; ICD-10; American Psychiatric Assosication, 1994; World Health Organisation, 1994).

Treatment guidelines recommend cognitive behavioral therapy (CBT), serotonin reuptake inhibitors (SRIs), or their combination as first-line treatments (Cuijpers et al., 2013, Fineberg et al., 2015, Katzman et al., 2014; Rosa-Alcázar et al., 2008; Hohagen et al., 2015). Cognitive behavioral therapy with exposure exercises can be considered superior to medication for acute treatment and over the long run (Cuijpers et al., 2013, Fineberg et al., 2015, Katzman et al., 2014; Rosa-Alcázar et al., 2008; Hohagen et al., 2015). The pharmacological management of OCD is regarded as second-line treatment except in the case of comorbid depression or predominant obsessions (Hohagen et al., 1998). There is a large body of evidence for the efficacy of SRIs, i.e., selective serotonin reuptake inhibitors (SSRIs) and the tricyclic antidepressant (TCA) clomipramine in high dosages (Bloch et al., 2010, Foa et al., 2005, Soomro et al., 2008). A reduction of OCD symptomatology by 20–40% can be expected after 6–8 weeks. The SRI clomipramine – in contrast to other TCA (non-SRI)-has an efficacy similar to that of SSRI, but it is generally less tolerated. Therefore, primarily SSRIs are recommended in accordance with the guidelines (Cuijpers et al., 2013, Fineberg et al., 2015, Katzman et al., 2014; Rosa-Alcázar et al., 2008; Hohagen et al., 2015).

A substantial number of OCD patients (25–60%) either do not respond to a first treatment trial with an SSRI or show only partial response despite an adequate dosage or length of treatment (Bloch et al., 2010, Soomro et al., 2008). Different strategies are generally taken in such cases, such as switching from one SSRI to another or to clomipramine, or vice versa (Hohagen et al., 2015), augmenting the medication with another class of agents (Bloch et al., 2006, Komossa et al., 2010) or with CBT (Anand et al., 2011). Antipsychotics are not effective as monotherapy in OCD, but meta-analyses have demonstrated that adding various second-generation antipsychotics (SGAs) achieved a significant efficacy compared to placebo. The highest efficacy was shown for risperidone and aripiprazole as well as for the first generation antipsychotic (FGA) haloperidol (Bloch et al., 2006, Dold et al., 2015, Komossa et al., 2010; Pessina et al. 2009; Sayah et al. 2012).

Despite the disabling character of OCD, community-based studies in western countries have reported help-seeking rates of only 10–40% among OCD patients, depending on the total number of OCD symptoms and the presence of severe and violent obsessions (Ruscio et al., 2010, Schwartz et al., 2013, Torres et al., 2007). Apparently the tolerance of obsessive compulsive problems might be relatively high as long as distress and impairment in private relationships and work are not too disruptive. Even when patients contact the health system, OCD often remains undetected and OCD target therapy is rarely induced (Wahl et al., 2010, Ruscio et al., 2010). In outpatient settings, about 43–65% of all OCD patients receive pharmacological treatment consisting of an SRI, but only half of them at a dosage that is effective for OCD (Denys et al., 2002, Van Ameringen et al., 2014). Augmentation therapy is common, mostly with SGAs, followed by benzodiazepines, and antidepressants (Van Ameringen et al., 2014).

Until now, the existing studies on treatment practice in OCD were all based on self-reports from relatively small samples of patients in secondary or tertiary outpatient centers (Denys et al., 2002, Ruscio et al., 2010, Schwartz et al., 2013, Van Ameringen et al., 2014). Little is known about treatment practice in primary care centers and inpatient settings. This study analysed the actual prescription patterns of pharmacotherapy for OCD in a large psychiatric inpatient population treated during routine clinical practice between 1994 and 2012. We used prescription data based on medical records, examined prescription patterns over time, and compared the results with the guideline recommendations.

Section snippets

Data source

For the present study prescription data were used that had been collected through the International Drug Safety Program in Psychiatry (Arzneimittelsicherheit in der Psychiatrie, AMSP). AMSP is an ongoing international multicenter drug safety program which has collected data on psychopharmacotherapy and adverse drug reactions from psychiatric hospitals in a naturalistic setting since 1993. Its methods have been described in detail elsewhere (Engel et al., 2004, Grohmann et al., 2004). Briefly,

Characteristics of study population

Characteristics of the study population are presented in Table 1. A total of 842 patients with a leading admission diagnosis of OCD based on ICD-10 codes were identified. Most cases showed a mixed symptomatology with obsessions and compulsions (50.5%). According to the clinical picture, obsessions dominated in 13.9% of the cases, compulsions in 13.5%. In 16.5% of the cases further information was missing which would have allowed differentiation between these subgroups. More patients were

Discussion

To the best of our knowledge, the present study is the first to investigate pharmacotherapy for OCD in a large population of 842 inpatients who had a leading admission diagnosis of OCD based on ICD-10. The data are of special interest because they were collected in primary care centers including 78 psychiatric hospitals in three German-speaking countries in Europe. The quality of the data is high as they are based on medical records and not only on self-reports. Thus, the dosages of the

Statement of interest

Since 1993 educational and research grants have been given by the following pharmaceutical companies to the three local non-profit associations of the AMSP:

  • (1)

    Austrian companies: AESCA Pharma GmbH, AstraZeneca Österreich GmbH, Boehringer Ingelheim Austria, Bristol–Myers Squibb GmbH, CSC Pharmaceuticals GmbH, Eli Lilly GmbH, Germania Pharma GmbH, GlaxoSmithKline Pharma GmbH, Janssen-Cilag Pharma GmbH, Lundbeck GmbH, Novartis Pharma GmbH, Pfizer Med Inform, Servier Austria GmbH, and Wyeth Lederle

Conflict of interest

The authors declare that no conflict of interest exists.

Contributors

CP, WG and SS initiated and planned the conception of the study.

CP, STM and WG managed the literature searches.

CP drafted the various versions of the manuscript.

CP and WG designed figures and tables.

AW, CP, RG, SS, STM and WG revised the manuscript for important intellectual content and counseled on the interpretation of the data.

All authors have contributed to and approved the final manuscript.

Acknowledgment

The authors are grateful to all participating hospitals and drug monitors for their voluntary and careful collection of data.

The authors would like to thank Dr. Pietro Ballinari (University Berne, Switzerland) for designing and performing the statistical analyses.

We also thank Ms. Christel Apfelbaum for assisting with the literature searches and for proof reading as well as Judy Benson for copyediting the manuscript.

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