COMORBID RECURRENT DEPRESSION IN OBSESSIVE-COMPULSIVE DISORDER A CASE REPORT

CLINICAL CASE COMORBID RECURRENT DEPRESSION IN OBSESSIVE-COMPULSIVE DISORDER A CASE REPORT 1 2 3 4 Anamaria Vasilache, Alina Beldie, Elena Cãlinescu, Iuliana Cozac Abstract: We reported a case study of a 57-year-old man who presented at Prof. Dr. Alexandru Obregia Clinical Hospital of Psychiatry with symptoms associated with obsessive-compulsive and depressive disorder: obsessive ideas, compulsions, depressive ruminations, depressive mood, anxiety related to the obsessive thoughts, anhedonia, ideas of incurability, feelings of worthlessness, social withdrawal, multiple somatic complains, fatigue, insomnia. We discuss therapeutic and prognostic implications of the association between the two disorders. The occurring of depressive simptomatology may complicate treatment adherence and response therefore it is crucial to evaluate the affective patterns in obsessivecompulsive patients presenting for treatment. Key words: obsessive ideas, depressive simptomatology, SSRIs, antipsychotic drugs. Rezumat: Prezentãm cazul unui bãrbat în vârstã de 57 ani care s-a prezentat la Spitalul Clinic de Psihiatrie Prof. Dr. Alexandru Obregia pentru simptome asociate cu Tulburarea obsesivo-compulsivã ºi cu Tulburare depresivã recurentã: idei obsesive, compulsii, ruminaþii depresive, dispoziþie depresivã, anxietate legate de ideile obsesive, anhedonie, idei de incurabilitate, sentimente de inutilitate, retragere socialã, multiple simptome, obosealã, insomnie. Am discutat implicaþiile terapeutice ºi prognostice ale asocierii dintre cele douã tulburãri. Apariþia simptomatologiei depresive poate complica complianþa ºi rãspunsul la tratament, prin urmare, este crucial sã se evalueze simptomele afective la pacienþii care se prezintã pentru tratamentul Tulburãrii obsesivocompulsive. Cuvinte cheie: idei obsesive, simptome depresive, ISRS, antipsihotice. People with obsessive-compulsive disorder (OCD) frequently experience, throughout their life, additional psychiatric disorders such as: affective, OCD spectrum, anxiety, tic, personality disorders and drug addiction (1, 2). Depression is the most frequent comorbid condition in OCD in adult and children with a prevalence that range from 30% to 80% in clinical and general population. The comorbidity of major depressive disorder (MDD) in OCD has been related to unfavorable prognosis and poor treatment response (1, 4). Several factors are positively correlated with the association of depressive disorders in obsessivecompulsive patients. Among them, the early onset and diagnosis and severity of OCD are significantly associated with development of recurrent major depressive disorder. The early age at onset has been a hallmark for genetic predisposition to many diseases that aggregate in families, therefore it was assumed that OCD with comorbid depression may identify a more homogenous group with a genetic predisposition. Alternatively, the patients with early onset and more severely impairing symptoms may become more discouraged, stigmatized, and ultimately liable to depression because of the impact of the illness on their emotional and social life (1, 4). It was found that aggressive, philosophical, existential, odd or superstitious obsession are more common in patients with both OCD and MDD and that sexual and religious obsessions are more frequent in patients with comorbid of recurrent major depressive disorder (1, 5). We report the case of a 57-year-old man, hospitalized the following reasons: obsessive ideas with aggressive content ( I've lost a screwdriver and I'm thinking that someone might find and use it to harm someone with it. ; Someone died and I'm thinking that maybe he was murdered with the screwdriver I've lost ; I was walking by a car and I smashed it's mirror, now I'm obsessed with the idea that the owner of that car had an accident because of me ), sexual obsessions and ruminations ( As a child, I tried to have intimate relations with my sisters and my mother. Now I'm obsessed with what I have done to my mother and my sisters...i know I haven't done anything but what if I did? ), compulsions ( Every evening I check the gas tank and the door lock several times ; I tie my shoelaces several times to be sure they are properly done ; If I don't step correctly, I turn back and redo the steps again ; I don't touch anyone, and if I do I wash my hands immediately. ), depressive ruminations ( I believe that I killed a woman I was working with, even though I'm sure I didn't. I'm thinking I killed that woman but I don't know when that happened. ), depressive mood ( I feel sad, maybe it's the weather, my thoughts won't leave me alone. ; Today I feel sad because of my thoughts. ); anxiety related to the obsessive thoughts, anhedonia ( I feel like doing nothing. ; I can't work anymore, I have no pleasures. ), ideas of incurability ( I don't believe that I will ever get better. ), suicidal ideation ( I'm thinking to take my life. ), feelings of worthlessness ( It feels like my life has no meaning. ), social withdrawal, multiple somatic complains: cervical and occipital paresthesia ( I feel numbness in the back of my head and down my neck, the feeling gets stronger when my thoughts appea. ), 1, 2, 3, 4 Resident in Psychiatry, Clinical Hospital of Psychiatry Prof. Dr. Alexandru Obregia, Bucharest, Romania. Contact e-mail: ana_vslch@yahoo.com 118

Romanian Journal of Psychiatry, vol. XII, No.3, 2010 dizziness, pain in the right upper abdomen, fatigue, insomnia ( I haven't slept all night. ). Symptoms appeared insidiously and then progressively developed over financial difficulties that the patient had for about 12 months History According to patient, the onset of the obsessive symptoms held around age of 15 when he was first hospitalized. Depressive symptoms first appeared around the age of 27 when he divorced his first wife. He later had several hospitalisations until the age of 40 when he received electroconvulsivant therapy. After that, he had neither hospitalisations nor treatment until the age of 57. The only symptoms present in this period were compulsions, but their frequency and intensity haven't had a significant influence on patient's life. From the patient's heredocolateral history we found that his mother suffered from a psychiatric disorder and had an infection with hepatitis B virus, and his father was a chronic alcohol user. From the social history we found that the patient divorced at age 27 an remarried 3 years later. He has 4 children (1 daughter from the first marriage, 2 sons from the second and 1 adopted daughter). He's living with his wife and one son. After graduating a vocational school, he worked as a mechanic and a master aid (12 years in a toxic environment at an Aluminium Plant ) until 2002 when he reached the retirement age. The paraclinical examinations (laboratory, cerebral CT, EEG) didn't show any relevant abnormalities. The patient met the DSM-IV-TR criteria for OCD and recurrent, major depressive disorder. Severe, prolonged episode. Management We started the treatment with citalopram (increased until the maximum dosage of 60mg/day), lorazepam (3mg/day) and zolpidem 10mg/day. After 6 weeks the obsessive symptoms didn't improved, depresive symptoms were persisting and general improvement was minimal (CGI=3). We added quetiapine (300mg/zi) which we had to interrupt because of it's side effects: drowsiness, dizziness, headache and postural hypotension. Consequently we chose another atypical antipsychotic, risperdone (2mg/day). After 2 weeks obsessive symptoms improved and depressive symptoms remitted. Lorazepam was gradually stopped and afterwards, zolpidem was removed too. Citalopram dosage was reduced to 40 mg/day. The general improvement was significant (CGI=2) and the patient was released with the prescription of citalopram 40 mg/day, risperidone 2 mg/day and zolpidem 10 mg/day if needed. He returnead after 3 months with recurrent depressive and obsessive symptoms which emerged because the patient stopped the treatment. The previous drug prescription was restarted and the symptoms remited after 8 weeks alowing the patient's release. After aproximately 2 months the patient's condition got worse, despite the treatment, with predominant somatic symptoms (anhedonia, depressive mood, ideas of incurability, feelings of worthlessness). Citalopram (40 mg/day) was gradually replaced with escitalopram. Rispolept (2 mg/day) and zolpidem (10mg/day) were maintained and there was added sodium valproate (500 mg/day). After 6 weeks of treatment symptoms remited and the patient was released once again. DISCUSSION Coexistence of major depression with OCD was found to be related to chronicity and severity of obsessivecompulsive symptoms, poor response to treatment, a higher number of suicide attempts and hospitalizations and bad prognosis, conclusions wich are confirmed by other international researches (6). A recent study that compared depressive symptoms of pure MDD with those from OCD complicated with depressive symptoms of equal severity showed that patients suffering from both OCD and MDD scored significantly and substantially higher on MADRS items for anxiety and pessimistic thoughts and significantly and substantially lower on the items reflecting vegetative symptoms (7). In uncomplicated OCD, both SSRIs and Cognitive behavioral therapy (CBT) in the form of exposure and response prevention (ERP) are evidence based first-line treatments (8). Co-occurring MDD has been associated with a less satisfactory outcome in many ERP monotherapy trials of patients with OCD, and limited evidence from controlled trials supports the use of ERP in combination with fluvoxamine or imipramine in such cases. Evidence suggests that for some patients with uncomplicated OCD, combining an SSRI and CBT is more effective than either treatment as monotherapy (9,10). No useful predictive factors exist to orient the choice of SSRI. and limited information is currently available comparing SSRIs among each other. There does not seem to be any clear therapeutic advantage associated with any particular SSRI. Therefore, the choice should be based on their particular side effect profiles and on their potential for drug drug interactions (11). Patients with concomitant major depression and OCD may have a poorer response to treatment than non depressed patients (12), but there are studies showing that the presence of MDD does not necessarilly predict a low response of OCD to SSRI treatment (13), although occasionally SSRI treatment may relieve the OCD but increase the patient's depression (14). A recent study suggests that this may indicate differences in the neurobiological substrates for OCD and MDD response in patients with both disorders (15). Results from a case series suggest that when an SSRI relieves OCD and simultaneously worsens MDD, the depression may respond to the addition of an antidepressant that inhibits norepinephrine reuptake (14). However, the addition of the noradrenergic antidepressant desipramine to SSRIs in a double-blind, placebo-controlled trial in treatmentresistant OCD did not improve OCD response (16). Although SSRIs are first-line pharmacological agents in the treatment of OCD, approximately 40 60% of patients with the disorder do not respond to this treatment (17, 18). This suggests a role in OCD for other neurotransmitters such as the dopaminergic system, which has recently been a particular focus of interest (19). Augmentation of SSRIs by traditional and atypical antipsychotics in treatment-resistant OCD can lead to symptom improvement (20). The duration of the adjunct therapy has been reported to be significantly associated 119

Anamaria Vasilache, Alina Beldie, Elena Cãlinescu, Iuliana Cozac: Comorbid Recurrent Depression In Obsessivecompulsive Disorder A Case Report with a better outcome; at least 8 weeks of therapy appears to be required to determine anti psychotic-related effectiveness in the treatment of OCD. In a systematic review, Skapinakis et al (21) have summarized the results of previous studies of use of various antipsychotic drugs as adjunct therapy in refractory OCD. In this review, haloperidol, olanzapine, quetiapine and risperidone were found to be effective in refractory OCD. In a retrospective, comparative study that compared the efficacy of quetiapine and ziprasidone as adjuncts for treatment-resistant OCD, clinical improvement was established in 80% of the quetiapine group and in 44.4% of the ziprasidone group (22). There is evidence indicating that a hyperglutamatergic activity is involved in OCD. Therefore, a drug that could directly decrease GLU neurotransmission would in theory induce a rapid onset of action, in contrast to SSRIs, which take several weeks to enhance inhibitory 5-HT transmission (23, 24). Such a net effect could be obtained by pre- or postsynaptic action in the GLU system. A first possibility would be to decrease GLU release. Recently, riluzole, a medication thought to act in amyotrophic lateral sclerosis by exerting this very effect, has been reported to be effective in treating SSRI-resistant OCD patients (25). Another possibility would be to activate inhibitory autoreceptors on GLU terminals to turn down excessive GLU release. These neurons are endowed with just such a subtype of autoreceptor, the mglur type 2, which exerts an inhibiting effect only when GLU release is increased (26). Such an agent has already been tested in humans, with positive results in an experimental model of anxiety (27). 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