Kaltenboeck Alexander, Foerster Elisa, Strafner Sabrina, Demal Ulrike, Mossaheb Nilufar, Friedrich Fabian
Clinical Division of Social Psychiatry, Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria.
Division of Clinical Psychology and Psychotherapy, Medical Head Office (Ärztliche Direktion), University Hospital Vienna, Vienna, Austria.
Front Psychiatry. 2023 Nov 28;14:1291077. doi: 10.3389/fpsyt.2023.1291077. eCollection 2023.
A 28-year-old man was admitted to our psychiatric ward with severe obsessive-compulsive disorder (OCD) and comorbid depression. At intake, obsessive-compulsive symptoms were present most time of the day and were related to an intense fear of causing interpersonal misunderstandings. Various treatment attempts, including cognitive-behavioural therapy (CBT) with exposure and response prevention (ERP), selective serotonin reuptake inhibitors, clomipramine, and add-on antipsychotics were either ineffective and/or were not tolerated, and the patient's condition worsened progressively. Following an in-depth multidisciplinary team discussion and a shared decision-making process, an off-label treatment trial with esketamine and concomitant psychotherapy was started. The patient received 10 esketamine + psychotherapy sessions over a period of about 2 months, followed by two maintenance sessions in about 3-week intervals. After this, he was discharged into regular outpatient care where he continued to receive maintenance esketamine treatment every 4-6 weeks and, independent of this, individual CBT. Following the establishment of esketamine with concurrent psychotherapy, the patient exhibited a remarkable clinical improvement. Obsessive-compulsive symptoms showed a clear and sustained response (Y-BOCS before treatment >35, Y-BOCS at week 8 = 23, Y-BOCS at week 26 = 14). Paralleling this, depressive symptoms also decreased (MADRS before treatment = 47, MADRS at week 9 = 12, MADRS at week 26 = 3). At a naturalistic follow-up at week 66, obsessive-compulsive symptoms were still mild (Y-BOCS = 13), and depression was still in remission (MADRS < 6). This clinical case suggests that (es)ketamine plus concomitant psychotherapy may hold promise as a therapeutic strategy for difficult-to-treat OCD and depression and its full clinical potential should be evaluated in more comprehensive future studies.
一名28岁男性因重度强迫症（OCD）合并抑郁症入住我们的精神科病房。入院时，强迫症状在一天中的大部分时间都存在，且与对引起人际误解的强烈恐惧有关。包括暴露与反应阻止疗法（ERP）的认知行为疗法（CBT）、选择性5-羟色胺再摄取抑制剂、氯米帕明以及联合使用抗精神病药物等多种治疗尝试均无效和/或患者无法耐受，患者病情逐渐恶化。经过深入的多学科团队讨论和共同决策过程，启动了艾氯胺酮联合心理治疗的超说明书治疗试验。患者在约2个月的时间内接受了10次艾氯胺酮+心理治疗，随后每隔约3周进行两次维持治疗。此后，他出院接受常规门诊治疗，在此期间他继续每4 - 6周接受一次艾氯胺酮维持治疗，与此无关的是，他还接受个体CBT治疗。在确立艾氯胺酮联合心理治疗后，患者临床症状有显著改善。强迫症状呈现明显且持续的缓解（治疗前耶鲁-布朗强迫症量表>35，第8周时耶鲁-布朗强迫症量表=23，第26周时耶鲁-布朗强迫症量表=14）。与此同时，抑郁症状也有所减轻（治疗前蒙哥马利-艾森伯格抑郁量表=47，第9周时蒙哥马利-艾森伯格抑郁量表=12，第26周时蒙哥马利-艾森伯格抑郁量表=3）。在第66周的自然随访中，强迫症状仍较轻（耶鲁-布朗强迫症量表=13），且抑郁症仍处于缓解状态（蒙哥马利-艾森伯格抑郁量表<6）。该临床病例表明，艾氯胺酮联合心理治疗可能有望成为治疗难治性强迫症和抑郁症的一种治疗策略，其全部临床潜力应在未来更全面的研究中进行评估。
