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February 28, 2008 — Selective serotonin-reuptake inhibitor (SSRI) antidepressants were almost twice as likely as placebo to confer modest improvement in symptoms of obsessive-compulsive disorder (OCD) among patients who responded to treatment in 17 short-term studies published from 1989 to 2004. The 5 SSRIs that were examined — citalopram (Celexa, Forest Pharmaceuticals), fluoxetine (Prozac, Eli Lilly), fluvoxamine (Luvox, Solvay Pharmaceuticals), paroxetine (Paxil, GlaxoSmithKline), and sertraline (Zoloft, Pfizer) — appeared to be equally effective, although individual drugs had different adverse effects, most commonly nausea, headache, and insomnia.These findings are from a review article, with lead author Ghulam Mustafa Soomro, PhD, from St. George's Hospital Medical School, in London, United Kingdom, published January 23 in the Cochrane Database of Systematic Reviews.
"This systematic review provides evidence that SSRIs are moderately effective, at least in the short term, in adults with OCD of varying duration," the group concludes. However, treatment decisions need to take into account the potential adverse effects with SSRIs, and in some patients, alternative treatments such as cognitive behavioral therapy may need to be considered, they note.
The necessary duration of SSRI treatment in OCD and the long-term outcomes remain to be determined, they add.
SSRIs vs Placebo for OCD
OCD, which is characterized by ritualistic behavior, is one of the most disabling anxiety disorders, the group writes. Behavioral therapy is a widely used and effective treatment strategy, but unfortunately, about 25% of patients who are offered this treatment refuse it, and of those who accept, 10% to 20% make minimal gains.
Randomized controlled trial evidence has shown that SSRIs are effective in OCD, but many published reviews or meta-analyses were flawed, the researchers write.
They aimed to perform a comprehensive, updated summary of the effectiveness and adverse effects of SSRIs for OCD.
The team performed a systematic search to identify all published and unpublished randomized controlled trials of SSRIs vs placebo in OCD.
They identified 17 studies:
1 trial of citalopram vs placebo.
3 trials of fluoxetine vs placebo.
5 trials of fluvoxamine vs placebo.
3 trials of paroxetine vs placebo.
5 trials of sertraline vs placebo.
The trials, involving a total of 3097 adult patients, lasted from 6 to 13 weeks.
The primary efficacy outcomes included:
A reduction in Yale-Brown Obsessive Compulsive Scale (YBOCS) scores.
A treatment response (a 25% or 35% reduction in YBOCS score).
In the overall group (17 studies, 3097 patients), with a short course of treatment, the reduction in obsessive-compulsive symptom scores was greater with SSRI treatment than with placebo (weighted mean difference, -3.21; 95%CI, -3.84 to -2.57).
Among treatment responders (13 studies, 2697 patients), those who received an SSRI were almost twice as likely to obtain a treatment response compared with patients receiving placebo (relative risk, 1.84; 95% CI, 1.56 – 2.17).
The individual drugs appeared equally effective.
The investigators determined that if 10% of OCD patients might be expected to recover without treatment (a very conservative estimate), then 12 patients would need to be treated with SSRIs to achieve improvement for 1 additional patient. Assuming that 20% of patients might recover without treatment (a conservative estimate), then 6 patients would need to be treated for 1 to improve.
Adverseeffects — most commonly nausea, headache, and insomnia — were significantly worse with an SSRI than with placebo. Other commonly reported adverse effects included dyspepsia, diarrhea, constipation, anxiety, fatigue, sedation, somnolence, asthenia, and forgetfulness.
"The effect of SSRIs in achieving improvement of OCD symptoms is modest, and the clinical utility of these interventions should be weighed against the adverse effects, particularly those that impact on quality of life, such as sexual adverse effects," the group summarizes.
The authors state that they have no potential conflict of interest.
Cochrane Database Syst Rev. 2008;1:CD001765. Abstract
