
Antipsychotics and New-Onset Obsessive-Compulsive Disorder in Schizophrenia
Comorbidity or medication adverse effect? Researchers performed a nested case-control study of new-onset obsessive-compulsive disorder following antipsychotic use in schizophrenia.
RESEARCH UPDATE
CASE VIGNETTE
“Mr Harris” is a 30-year-old male with a 5-year history of schizophrenia. His primary psychotic symptoms included auditory hallucinations and persecutory delusions. In the first year after the onset of his illness, he developed an obsessive fear of contamination and compulsive hand washing and bathing. He failed trial (adequate dose and duration) of 2 different second-generation and 1 first-generation antipsychotic. During a psychiatric hospitalization, he was subsequently started on clozapine, which was titrated to 300 mg/day. His auditory hallucinations remitted, and his persecutory delusions were significantly reduced. However, his compulsive hand washing and bathing worsened within 3 months of clozapine treatment. He was aware that his fears of contamination were excessive, but he was unable to resist acting on them. Adjunctive treatment with clomipramine 50 mg/day significantly decreased his obsessive thoughts and compulsive behaviors.
Many patients with schizophrenia have comorbid obsessive-compulsive symptoms (OCS) or
The Current Study
Accordingly, Park and colleagues3 investigated the association between antipsychotic use and the risk of new-onset OCD in patients with schizophrenia using a nationwide cohort in Korea.
The authors used a nationwide medical claims database that covers about 98% of the Korean population. Patients aged 15 to 60 with a first diagnosis of
The authors used a nested case-control design to avoid potential biases (eg length bias due to antipsychotic exposure).
Among approximately 50,000 patients newly diagnosed with schizophrenia during the study period, 775 cases of new-onset OCD and 3100 matched controls were identified. The mean subject age was 31, and the sample was 54% male. Compared to haloperidol,
Study Conclusions
The authors concluded that clozapine was associated with almost threefold increased odds (versus haloperidol) of new-onset OCD inpatients with schizophrenia, with no significant difference in risk for other antipsychotics. Strengths of the study include the population-based representative sample. Study limitations include the inability to assess the frequency of subthreshold OCS, which are more common than OCD and may require clinical attention. Data on other potential risk factors, such as genetics/family history of OCD and severity of psychotic symptoms, were not available.
The Bottom Line
There is reliable evidence for the risk of OCD associated with commonly prescribed antipsychotics, particularly clozapine (and within the first 2 years of treatment).
Dr Miller is professor in the Department of Psychiatry and Health Behavior, Augusta University, Augusta, Georgia. He is on the Editorial Board and serves as the schizophrenia section chief for Psychiatric TimesTM. The author reports that he receives research support from Augusta University, the National Institute of Mental Health, and the Stanley Medical Research Institute.
References
1. Swets M, Dekker J, van Emmerik-van Oortmerssen K, et al.
2. Schirmbeck F, Swets M, de Haan L. Epidemiology: prevalence and clinical characteristics of obsessive-compulsive disorder and obsessive-compulsive symptoms in patients with psychotic disorders. In: de Haan L, Schiirmbeck F, Zink M, eds. Obsessive-Compulsive Symptoms in Schizophrenia. Springer; 2015:47-61.
3. Park CI, Han M, Jung I, et al.
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