한국형 강박장애 치료 알고리듬 2007(Ⅱ) : 초기 치료와 치료 저항성 강박장애

Abstract

Objective：Treating obsessive-compulsive disorder (OCD) has always been a challenge requiring a mix of science and art. Although selective serotonin reuptake inhibitors (SSRIs) provide clinically significant relief to a large group of patients, a large number of patients do not respond to adequate trials of SSRIs. For these treatment-resistant patients, other treatment options such as augmentation, switching, combination strategies, and neurosurgical or devicebased approaches have been suggested. Because several sequential treatment steps are often needed to achieve an adequate treatment benefit, we have developed a Korean treatment algorithm for OCD. Method：A questionnaire to survey the expert opinion of medications for OCD was completed by the review committee, which consisted of 24 experienced Korean psychiatrists. The questionnaire was composed of 47 questions, and each question included various subitems. We classified the expert opinions into three categories (1st line, 2nd line, and 3rd line). Results： For initial treatment of OCD, SSRIs (fluoxetine, sertraline, paroxetine, citalopram) were recommended as 1st line therapy. If treatment by a SSRI fails, changing to another SSRI is preferred over augmentation strategy. When the response is not sufficient after changing SSRIs, augmentation strategies including atypical antipsychotics or changing to clomipramine are recommended. Among atypical antipsychotics, risperidone is the drug of choice for augmentation. Neuromodulation such as deep brain stimulation, neurosurgery, ECT, or repetitive transcranial magnetic stimulation are recommended after four or five failures of SSRIs including clomipramine. Conclusion：These re-sults, which reflect recent studies and clinical experiences, suggest that the treatment strategies for OCD are changing. The development of a more comprehensive treatment algorithm for OCD, that includes cognitive-behavioral therapy, is needed.