KISEP Overview 16 3 2005 강박장애의약물치료전략 김세주 1 권준수 2 김찬형 1 ABSTRACT Pharmacotherapeutic Strategy for Obsessive-Compulsive Disorder Se Joo Kim, MD, 1 Jun Soo Kwon, MD 2 and Chan-Hyung Kim, MD 1 1 Department of Psychiatry, Yonsei University College of Medicine, Seoul, 2 Department of Psychiatry, Seoul National University College of Medicine, Seoul, Korea Obsessive-compulsive disorder OCD has a lifetime prevalence of approximately 23%. Until relatively recently, effective treatments for OCD were lacking. Fortunately, over the past decades, the availability of serotonin reuptake inhibitors SRIs and behavioral treatments using exposure-response prevention techniques has altered the outlook for patients suffering from OCD. But, treating OCD with medication still requires a blend of science and art. SRIs provide clinically significant relief to most patients, but they are not effective in all patients. Because significant number of patient with OCD do not respond to adequate trials of SRIs, other treatment options such as augmentation, switching, combination, or neurosurgical and device-based approaches may be needed. In this paper, the first-line treatment options and several alternative treatment options for OCD were reviewed. Finally, we reviewed several treatment guidelines and algorithm for OCD introduced previously by other researchers. We have a plan to develop Korean treatment algorithm for OCD based on expert s opinions. Also, we hope to use this algorithm for OCD in the clinical setting in near future. (Korean J Psychopharmacol 2005;16(3):197-207) KEY WORDSObsessive-compulsive disorder Treatment guideline Algorithm. 서 교신저자 론 197
본 론 1. 강박장애치료에있어서일반적인고려사항들 1) 일차약제로어떤약물을선택할것인가? - - - - - - 2) 어떤용량을어느기간동안사용하면효과가나타날것인가? 198 Korean J Psychopharmacol 2005;163:197-207
- 3) 유지치료는얼마동안어떻게해야하는가? 2. 1차선택약물이외에다른치료적접근 1) 병용요법전략 (Combination drug treatment strategies) - 199
- - 200 - - Korean J Psychopharmacol 2005;163:197-207
- 2) Clomipramine 또는 citalopram 정주투여 (Intravenous clomipramine or citalopram administration) 3) 인지행동치료 (Cognitive-behavioral therapy) 4) 신경외과적수술및기구를이용한치료법들 (neurosurgical and device-based approaches) - - - 201
- - 3. 치료-저항성강박장애 (Treatment-resistant OCD) 4. 강박장애치료지침및알고리듬 (Treatment guideline and algorithm of OCD) - 202 Korean J Psychopharmacol 2005;163:197-207
- DSM-IV diagnosis of OCD CMI SSRI #1 No Partial Alternate OCD drug If comorbid tics spectrum disorder add SSRI #1 CMI NL Clonazpm Buspirone CMI or SSRI Lithium No Partial No OCD drug OCD drug SSRI #2 No Partial No OCD drug SSRI #3 No Partial No OCD drug OCD drug MAOI Clonazepam Figure 1. Algorithm for the treatment of obsessive-compulsive disorder. 70) CMIclomipramine, NLneuroleptic, OCD obsessive-compulsive disorder, SSRIselective serotoinin reuptake inhibitor, enter augmentation section at nonredundant level, enter alternate OCD drug at non-redundant level. 203
- - - - Table 1. Flow sheet of treatment option for obsessive-compulsive disorder 23) 01. Selective serotonin reuptake inhibitor trials for 12 weeks at full dosage or highest tolerated Fluoxetine trial-40 to 80 mg daily Clomipramine trial-to 250 mg daily Sertraline trial-to 200 mg daily Paroxetine trial-40 to 60 mg daily Fluvoxamine trial-to 300 mg daily 02. Try augmenting fluoxetine or clomipramine or sertraline or paroxetine or fluvoxamine 03. Try the other selective serotonin reuptake inhibitors each drug for at least 12 weeks with augmentation of each drug 04. Try venlafaxine to 375 mg for 3 months 05. Stop fluoxetine for 5 weeks or sertraline, fluvoxamine, clomipramine, venlafaxine, or paroxetine for 2 weeks 06. Monoamine oxidase inhibitor trial 07. Try augmenting monoamine oxidase inhibitors for 1 month not buspirone 08. Trials of experimental agents when available 09. Other medication trials e.g., trazodone, imipramine, etc 10. If severe personality disorder present, consider halfway house or day treatment program 11. If patient is severely disabled, despite adequate treatment, consider psychosurgery 12. If poor compliance is a persistent problem, or patient prefers symptoms to being rid of them, or if patient also has obsessive-compulsive personality disorder or had early-onset OCD, consider concomitant psychodynamic psychotherapy As soon as patient has at least a partial response to medicationif patient has rituals, begin behavior therapy of exposure and response prevention. Drug trials should be continued for at least 12 weeks before they are considered failures 204 Korean J Psychopharmacol 2005;163:197-207
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