Current and up-and-coming pharmacotherapy for obsessive-compulsive disorder in adults

ABSTRACT

Introduction: Only 40–60% of obsessive-compulsive patients respond to first line treatments, such as selective serotonin reuptake inhibitors (SSRIs) and cognitive-behavioral therapy. Several second-line treatments have been investigated in the last two decades, and most of them seem to work, at least in a subset of patients. However, since there is still a lack of treatment predictors, the treatment of obsessive-compulsive disorder (OCD) is still empirical and non-evidence based.

Areas covered: In this paper, we review current and up-and-coming pharmacotherapy for OCD in adults, focusing on two emerging fields of research, inflammation and glutamate systems, since they have attracted the greatest attention in recent years in OCD pharmacological research.

Expert opinion: Most of the investigated second-line agents seem to work at least in a subset of patients with OCD. These results raise an open question: what works for who? In our opinion, this question should be answered in a precision medicine perspective or, in other words, individualizing diagnostic processes and treatment approaches. In a precision medicine approach, OCD treatment should be sub-type specific, phase specific, multimodal and sequential, and, more importantly, dimensional.

KEYWORDS:

• Obsessive-compulsive disorder
• precision-medicine
• RDoC
• inflammation
• glutamate
• neuromodulation
• recovery
• microbioma
• microbiota
• treatment resistance

Article highlights

• Most second-line treatments for OCD seem to work at least in a subset of patients. However, since there is still a lack of treatment predictors, the treatment of OCD is still empirical and non-evidence based.

• Several studies have suggested a glutamate system dysfunction in adults with OCD and several glutamatergic agents have been investigated in the last years, supporting their potential benefit in the treatment of OCD.

• Several evidences suggest that inflammation plays a role in adults with OCD and some controlled trials support the use of anti-inflammatory agents as augmentation strategies

• A precision-medicine approach should be adopted to improve OCD treatment and to reach the final goal of recovery.

• In a precision-medicine approach, OCD treatment should be sub-type specific (both in terms of symptom dimensions and comorbidity patterns), phase specific (in a clinical staging perspective), multimodal and sequential and, more importantly, dimensional (in a Research Domain Criteria perspective).

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose

Additional information

Funding

This manuscript was not funded.