Lamotrigine Augmentation in Treatment-Resistant Pediatric Obsessive-Compulsive Disorder with a 16 Month Follow-up.

Abstract

[Author Affiliation]Ahmed Naguy. 1 Child and Adolescent Psychiatry, Kuwait Center for Mental Health, Alamanara Unit, Kuwait City, Kuwait.Bibi Alamiri. 1 Child and Adolescent Psychiatry, Kuwait Center for Mental Health, Alamanara Unit, Kuwait City, Kuwait. 2 Department of Psychiatry, Tufts University School of Medicine, Boston, Massachusetts.Souleiman Al-Khadhari. 1 Child and Adolescent Psychiatry, Kuwait Center for Mental Health, Alamanara Unit, Kuwait City, Kuwait. 3 Department of Psychiatry, Kuwait University, Kuwait City, Kuwait.Konstantinos Francis. 1 Child and Adolescent Psychiatry, Kuwait Center for Mental Health, Alamanara Unit, Kuwait City, Kuwait. 4 Department of Child Psychiatry, Athens University, Chalandri, Greece.Address correspondence to: Konstantinos Francis, MD, PhD, PB 1443, Agios Spyridon Pikermiou, 19009, Rafina, Greece, E-mail: cfrancis@otenet.grTo The Editor:Obsessive compulsive disorder (OCD) is a neuropsychiatric disorder characterized by the presence of persistent, recurrent, and intrusive thoughts, images, or impulses (obsessions) and/or repetitive, purposeful behaviors (compulsions) that are time consuming and cause distress or interference in the patient's life (American Psychiatric Association DSM-5 Task Force 2013). OCD is one of the most prevalent neuropsychiatric disorders, with lifetime prevalence of 1-3%, and with symptom onset before puberty in up to one half of sufferers (Kessler et al. 2005).Selective serotonin reuptake inhibitors (SSRIs) are the first-line medications for OCD in children, adolescents, and adults, either alone or in combination with cognitive behavioral therapy (CBT) (Stein et al. 2012). Albeit their proven effectiveness, both these options often have inadequate results, with almost half of the patients not responding or having residual symptoms (Catapano et al. 2006; Abramowitz et al. 2009). In these cases, clinicians can chose either to switch to an alternative SSRI, bearing in mind that the possibility of response is less likely than expected in naive patients (Ackerman et al. 1998), or follow an augmentation strategy by adding another agent (National Institute for Health and Clinical Excellence 2005; Stein et al. 2012). Agents that are commonly employed are clomipramine (CMI) (Stein et al. 2012) and the atypical antipsychotics (Bloch et al. 2006; Stein et al. 2012), but a multitude of other drugs have also been tried, such as stimulants, gabapentin, sumatriptan, pindolol, inositol, opiates, St. John's wort, N-acetyl cysteine, memantine, and riluzole, without conclusive evidence (Pittenger 2011, 2012).Albeit the predominant role of the monoaminergic systems (mainly that of serotonin and, to a lesser extent, dopamine) in neurobiology, and hence in the treatment of OCD, preclinical and clinical data do implicate other neurotransmitters also. Recent evidence suggests that the excitatory neurotransmitter glutamate is dysregulated in OCD, and that this dysregulation may contribute to the pathophysiology of the disorder (Ting and Feng 2008; Pittenger et al. 2011; Wu et al. 2012). Lamotrigine is an antiepileptic drug and mood stabilizer that was proven to reduce excessive glutamate release (Burstein 1995; Reid et al. 2013). Therefore, it is a good candidate agent for augmentation in refractory cases of OCD. Apart from an initial negative case series study (Kumar and Khanna 2000), research data are quite encouraging for its use, with two positive case reports (Uzun 2010; Arrojo-Romero et al. 2013) of successful use in special populations (Bisol and Lara 2009; Poyurovsky et al. 2010), and one recent double-blind, randomized, placebo-controlled trial, also with positive results (Bruno et al. 2012).Here, we report a case of pediatric OCD who showed a marked response to lamotrigine augmentation. The patient was treatment resistant and received multiple psychotropic trials over a course of >2 years, militating against the possibility of placebo response. …