Ziprasidone for obsessive compulsive disorder in schizophrenia

Introduction

Obsessive and compulsive symptoms (OCSs) are a common [Cunill et al. 2009] and hardly treatable feature in schizophrenia. No pharmacological add-on strategy has gained convincing evidence for successful treatment so far. Therefore, we here report on five patients suffering from chronic schizophrenia according to DSM-IV criteria, on admission with OCSs in the spotlight, showing diminished symptoms after add-on therapy with ziprasidone.

One female (aged 44) and four male patients (aged 27–33) suffering from chronic paranoid schizophrenia with a mean duration of illness of 10 years were administered to our hospital due to severe OCSs.

In all of their psychiatric histories OCSs had begun concurrently with the onset of schizophrenia and prior to initiation of any medical treatment (including prior clozapine treatment, as this drug seems to be associated with an onset of OCSs [Schirmbeck and Zink, 2012]). The content of OCSs was about shameful thoughts such as sexual deviations and contamination; observable compulsions were washing, cleaning and controlling. All patients were aware of the fact that they were suffering from OCSs with no delusional aspect. OCSs had been unresponsive to therapy including diverse typical and atypical antipsychotics as well as selective serotonin reuptake inhibitors (SSRIs) in adequate doses (for obsessive–compulsive disorder).

On admission, patients had been treated with monotherapy, which was stable for at least 6 months (quetiapine up to 800 mg, clozapine up to 425 mg, or flupenthixol 15 mg). No acute psychotic symptoms were detectable.

Add-on treatment with ziprasidone with a mean dosage of 240 mg/day was started given ziprasidone’s pharmacological profile inhibiting serotonin reuptake concurrently blocking dopamine receptors. Up-titrating within 2–3 weeks, all patients showed relevant serum levels of ziprasidone (61–158 ng/ml, reference range 50–120 ng/ml).

All five patients responded with an improvement with regard to obsessions as well as to compulsive behavior with a significant decrease in the Yale–Brown Obsessive Compulsive Scale. No side effects of the combination treatment were observed. The QTc of all patients was within normal range at any time point. In the total observation period of 12 months there was no relapse in any of the five patients of OCSs whilst on the stable outpatient therapy regime.

Similar to the first-line treatment recommendations in patients suffering from obsessive– compulsive disorder, SSRIs have formerly been found to be effective in patients with schizophrenia and OCSs [Reznik and Sirota, 2000]. However, in terms of being more effective, add-on treatment with atypical antipsychotics seems to be a more favorable solution for OCSs in schizophrenia. This efficacy might be due to the relatively high doses of ziprasidone used. In a review on OCSs in schizophrenia, Poyurovsky and colleagues proposed ziprasidone as a potentially reasonable drug [Poyurovsky et al. 2004], based on its unique serotonin/norepinephrine reuptake inhibition property and therefore accessory SSRI similarity. Noteworthy, there is no report on ziprasidone’s adoption in the literature so far. Given the treatment success of our five patients, ziprasidone might be a valuable treatment option with larger and controlled studies warranted to replicate the present findings.