Antidepressant helps obsessive-compulsives.

Antidepressant Helps Obsessive-Compulsives

Preliminary results of a multicenter study of clomipramine, an antidepressant drug not approved for use in the United States, indicate it substantially improves the condition of many people with obsessive-compulsive disorder.

The Food and Drug Administration (FDA) is now considering making the drug available in "serious or life-threatening situations," says psychiatrist Joseph DeVeaugh-Geiss of Ciba-Geigy Pharmaceutical in Summit, N.Y., director of the 21-center clinical trial. He reported on the new study last week at the AMerican Psychiatric Association's annual meeting in Montreal.

Ciba-Geigy manufactures clomipramine under the brand name Anafranil and has sold it for 20 years in Europe, Canada and elsewhere. If the drug's promise holds up in the multicenter study, the company will ask for full FDA approval.

There is no standard treatment for obsessive-compulsive patients, but in recent years small studies in the United States have reported clomipramine's effectiveness with the disorder (SN: 4/20/85, p.245). Clomipramine blocks the action of serotonin, a chemical messenger in the brain. The mounting data prompted Ciga-Geigy to undertake more extensive trials required for an FDA approval. Previously, the company was no reason to gain approval for an antidepressant drug with no apparent superiority to others already available.

Obsessive-compulsive disorder is considered an "anxiety disorder" by psychiatrists, although depression often accompanies it. Obsessions are recurrent ideas and impulses experienced as senseless or repugnant; compulsions are bizarre rituals suggested by obsessive thoughts and aimed at preventing harm to oneself or others.

For example, a woman may spend six hours a day repeatedly washing herself, pursued by the fear that she might pass on a deadly disease to anyone she touches. Or a man might stop cooking and continually check electrical appliances for fear of causing a fire.

Nearly 5 million people in the United States suffer from this disorder, which often begins during childhood or adolescence. Many victims are ashamed of their behavior and attempt to keep it secret, rarely seeking treatment.

In the Ciba-Geigy trials, 578 adult obsessive-compulsives -- many of whom had gone seven years or more before seeking help -- received either clomipramine or a placebo for 10 weeks. The patients were divided into those with and without mild depression.

According to physician ratings, obsessive-compulsive symptoms were reduced by about 40 percent in both clomipramine groups, compared with a 5 percent reduction in the placebo groups. Clomipramine patients rated themselves as significantly more improved than placebo patients.

Clomipramine is not without side-effects, and DeVeaugh-Geiss notes that 10 percent of the patients dropped out of the clinical trial. Adverse reactions include nausea, dry mouth, dizziness, tremor and a reduction in sex drive. But most patients, he says, felt that alleviation of their obsessive-compulsive symptoms clearly outweighed any side-effects.

Effective clomipramine treatment often extends over a year or more, says psychiatrist Michele A.T. Pato of the National Institute of Mental Health in Bethesda, Md. She and her colleagues report that 16 of 18 obsessive-compulsive patients who responded well to clomipramine over an average of 11 months of treatment became significantly worse after receiving a placebo for seven weeks. A gradual decrease in the clomipramine dose might result in fewer symptoms returning, she notes.

But evidence suggests the first treatment for obsessive-compulsives should be behavior therapy, contends psychologist Edna Foa of the Medical College of Pennysylvania in Philadelhia. This approach includes supervised exposure to objects and situations that provoke anxiety, prevention of compulsive rituals and discussions with a therapist about irrational fears.

After three weeks of behavior therapy -- a total of 15 sessions, each about two hours long -- 16 of 21 obsessive-compulsive patients showed substantial improvement lasting at least three months, Foa reported at the psychiatric meeting. "Clomipramine may be helpful with those who do not respond to behavior therapy," she explains. It may also lessen the anxiety of many obsessive-compulsives who are afraid to undergo behavior therapy, thus allowing them to participate in the intensive psychological treatment.

Investigators, have not yet examined the effectiveness of combining behavior therapy with clomipramine.