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letter
. 2007;9(6):466–467. doi: 10.4088/pcc.v09n0611c

Escitalopram in Obsessive-Compulsive Disorder: A Case Series

Amit Zutshi 1, Suresh Bada Math 1, Y C Janardhan Reddy 1
PMCID: PMC2139927  PMID: 18185830

Sir: Obsessive-compulsive disorder (OCD) is a chronic and debilitating psychiatric disorder. The lifetime prevalence of OCD is estimated to be 1.94% to 3.29% according to population-based surveys.1–3 Serotonin reuptake inhibitors (SRIs) are known to be effective in OCD.4–6 However, 50% to 60% of OCD patients may not respond to the first SRI but will respond to another SRI. Hence, sequential trials of SRIs are considered.7 Escitalopram is the pure S-enantiomer (single isomer) of the racemic, bicyclic, phthalane derivative citalopram. Escitalopram has been approved by the U.S. Food and Drug Administration for use in major depressive disorder and has also been used in various anxiety disorders such as generalized anxiety disorder, social anxiety disorder, and panic disorder.8 There are studies reporting the efficacy of citalopram in OCD.9,10 The available data suggest that escitalopram possesses advantages over citalopram in terms of both efficacy and safety.11 A search of MEDLINE and PubMed using the keywords obsessive-compulsive disorder and escitalopram retrieved no published reports or articles. Herein, we describe cases of 3 patients with OCD who had never been treated with selective SRIs, with illness duration ranging from 3 to 30 years, and who responded to treatment with escitalopram. Informed consent was given by the patients before starting treatment with escitalopram.

Case 1

Ms. A, a 60-year-old housewife of middle-class socioeconomic status and urban background, presented to our hospital in June 2006 with an insidious onset and continuous course of 30 years' duration that was characterized by obsessive and compulsive symptoms. She had a well-adjusted premorbid personality and a family history of nonaffective psychosis in a younger brother.

Structured assessment using the Mini-International Neuropsychiatric Interview (MINI-Plus)12 revealed that she had had 2 episodes of depression in the past, characterized by sadness of mood, increased fatigability, anhedonia, ideas of guilt, reduced concentration, and impaired biological and social functioning. She had received treatment with dothiepin 75 mg/day with much improvement in depression but not in obsessive-compulsive symptoms. During the current assessment, she had no depressive symptoms but fulfilled the diagnostic criteria for OCD. The Yale-Brown Obsessive Compulsive Scale (YBOCS)13,14 checklist showed obsessions of contamination, aggression, and religion and compulsions of cleaning and checking. Baseline assessment revealed a YBOCS severity rating total score of 26 (obsession 12, compulsion 14), a Clinical Global Impressions-Severity of Illness (CGI-S)15 score of 4 (severely ill), and a YBOCS-11 (item 11) insight score of 1 (good insight).

Ms. A was started on treatment with escitalopram 10 mg/day, which was increased to 25 mg/day. At 3-month follow-up, the patient's YBOCS severity total score was 10 (obsession 5, compulsion 5), her CGI-S score was 2 (borderline mentally ill), and her CGI-Improvement (CGI-I)15 score was 2 (showing much improvement).

Case 2

Mr. B, a 26-year-old unemployed, unmarried man of middle-class socioeconomic status and rural background, presented to our hospital for the first time in August 2006 with an illness of 3 years' duration, with insidious onset and continuous course and characterized by obsessions of contamination, doubts, and sexual content, followed by compulsions of washing, checking, and mental rituals. His personal history and family history were noncontributory. His premorbid personality revealed that he was shy and reserved, avoiding social situations, and had few friends.

Structured assessment with the MINI-Plus revealed comorbid diagnoses of dysthymia and social phobia along with mixed obsessive-compulsive disorder. Baseline assessment revealed a YBOCS severity rating total score of 24 (obsession 14, compulsion 10), a CGI-S score of 4 (severely ill), and a YBOCS-11 insight score of 2 (fair insight).

Mr. B was started on treatment with escitalopram 10 mg/day, which was increased to 20 mg/day. At 3-month follow-up, the patient's YBOCS severity total score was 11 (obsession 6, compulsion 5), his CGI-S score was 2 (borderline mentally ill), and his CGI-I score was 2 (much improvement). It is interesting to note that during follow-up he did not meet the criteria for social phobia on the MINI-Plus.

Case 3

Mr. C, a 34-year-old unemployed, married man of middle-class socioeconomic status and urban background, presented for the first time in August 2006 with an illness of 7 years' duration, with insidious onset and continuous course and characterized by complaints suggestive of obsessive doubts, sexual obsessions, and obsessions regarding need for symmetry. He also had checking compulsions, repeating rituals, and ordering compulsions. His premorbid personality was well adjusted, and he reported noncontributory personal and family histories.

After structured assessment with the MINI-Plus, he was diagnosed with OCD, mixed subtype. His baseline YBOCS severity rating total score was 29 (obsession 15, compulsion 14), his CGI-S score was 5 (markedly ill), and his YBOCS-11 insight score was 2 (indicating that he had fair insight into his problems).

Mr. C was started on treatment with 10 mg/day of escitalo-pram, which was increased to 20 mg/day. During his 3-month follow-up assessment, his YBOCS severity total score was 14 (obsession 9, compulsion 5), his CGI-S score was 2 (borderline mentally ill), and his CGI-I score was 2 (much improvement).

The 3 cases of OCD presented above had a duration of illness ranging from 3 to 30 years and were assessed with a structured instrument, indicating a stable diagnosis. During intake and follow-up of the patients, at least 1 qualified psychiatrist, who is a consultant in an OCD clinic, did the ratings of YBOCS severity and the CGI scales. All 3 patients responded to treatment with escitalopram: YBOCS scores dropped by more than 50%, CGI-S scores showed all patients to be “borderline mentally ill,” and there was “much improvement” on the CGI-I scale.

Currently, clomipramine, fluoxetine, sertraline, fluvox-amine, paroxetine, and citalopram have been clearly documented to be effective in OCD.4–6 Choice of SRI in treatment of OCD is largely based on side effect profile and comorbid medical/psychiatric conditions.16 Available data on escitalopram reveal that it has minimal drug interaction and is well tolerated in depressed patients in primary care.17 Hence, it can be used safely in OCD patients with comorbid medical/psychiatric conditions. It is interesting to note that 1 patient reported improvement even in social phobia. The other 2 patients had no current comorbid conditions during intake. Thus, improvement in OCD was not related to improvement in comorbid conditions, and use of the YBOCS severity scale clearly documented the improvement in OCD symptoms. This case series assumes importance in light of the relative paucity of escitalopram studies in OCD. Escitalopram is known to be well tolerated and to have few interactions with other drugs, and these benefits provide a boon for our OCD patients. Double-blind, placebo-controlled studies examining the efficacy of escitalopram in OCD are needed.

Acknowledgments

The authors report no financial or other affiliations that can be considered a conflict of interest relevant to the subject of this letter.

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