David Baxter PhD
Late Founder
Can Mirtazepine be Used to Treat OCD Symptoms Associated With Asperger's Syndrome?
Bethany DiPaula, PharmD, BCPP
April 28, 2009
Question: Can Mirtazepine be used to treat OCD symtoms associated with Asperger's syndrome?
Response from Bethany A. DiPaula, PharmD, BCPP
PharmD, BCPP, Assistant Professor, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy Baltimore, Sykesville, Maryland; Director of Pharmacy, Springfield Hospital Center, Sykesville, Maryland.
The term "Autism Spectrum Disorders" refers to the group of neurodevelopmental disorders -- including autistic disorder, Asperger syndrome (AS), and pervasive developmental disorder -- that are characterized by social and communication impairments. Repetitive and stereotyped behaviors and interests are primary symptoms of all ASDs.[1] These atypical behaviors can manifest themselves in various manners including obsessions and compulsions. Obsessional and intrusive interests relating to topics and facts are considered hallmark symptoms of AS.[1,2] Patients with AS may also have difficulty transitioning between routines. While there is an overlap in AS and obsessive-compulsive disorder (OCD) symptoms, the latter is also diagnosed comorbidly with AS.[2-4]
Currently, there are no published trials that focus on the management of OCD in patients with comorbid AS. When OCD can be clearly diagnosed as comorbid, the symptoms should be managed using evidence-based medicine for this disorder.[5] The first-line treatment for OCD is selective serotonin reuptake inhibitors (SSRIs).[6] All SSRIs are considered equally efficacious, but there may be individual differences in response and/or tolerability. Some studies suggest mirtazapine may be beneficial as monotherapy in managing OCD.[7,8] Mirtazapine may improve response time and decrease side effects when used to augment SSRIs.[9] However, additional well-designed trials are necessary to establish mirtazapine's role in the management of OCD.[6]
If patients with AS do not meet the full criteria for comorbid OCD, psychotropic medications should be chosen for their specificity in targeting symptoms.[5] SSRIs may be effective in treating repetitive behaviors, behavioral rigidity, and obsessive-compulsive symptoms associated with ASD.[5,10,11] Compared to the OCD literature, there are less data to support the use of mirtazapine in managing obsessive-compulsive symptoms associated with AS. A small naturalistic, open-label trial of mirtazapine in patients with autism and other pervasive developmental disorders found it to be efficacious for the treatment of anxiety[12]; however, the authors noted no improvement in repetitive behaviors and did not specifically assess obsessive-compulsive symptoms.
It is difficult to provide a case-based answer to this question, because additional details are needed regarding psychiatric, medical, and medication history. SSRIs are regarded as first-line therapy in the treatment of OCD and are efficacious in treating obsessive-compulsive symptoms associated with AS. If side effects limit the use of a specific SSRI, switching to another SSRI may provide efficacy and better tolerability. While mirtazapine is an alternative treatment option, it probably should only be used after documented failure of at least 1 therapeutic SSRI trial.
References
Bethany DiPaula, PharmD, BCPP
April 28, 2009
Question: Can Mirtazepine be used to treat OCD symtoms associated with Asperger's syndrome?
Response from Bethany A. DiPaula, PharmD, BCPP
PharmD, BCPP, Assistant Professor, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy Baltimore, Sykesville, Maryland; Director of Pharmacy, Springfield Hospital Center, Sykesville, Maryland.
The term "Autism Spectrum Disorders" refers to the group of neurodevelopmental disorders -- including autistic disorder, Asperger syndrome (AS), and pervasive developmental disorder -- that are characterized by social and communication impairments. Repetitive and stereotyped behaviors and interests are primary symptoms of all ASDs.[1] These atypical behaviors can manifest themselves in various manners including obsessions and compulsions. Obsessional and intrusive interests relating to topics and facts are considered hallmark symptoms of AS.[1,2] Patients with AS may also have difficulty transitioning between routines. While there is an overlap in AS and obsessive-compulsive disorder (OCD) symptoms, the latter is also diagnosed comorbidly with AS.[2-4]
Currently, there are no published trials that focus on the management of OCD in patients with comorbid AS. When OCD can be clearly diagnosed as comorbid, the symptoms should be managed using evidence-based medicine for this disorder.[5] The first-line treatment for OCD is selective serotonin reuptake inhibitors (SSRIs).[6] All SSRIs are considered equally efficacious, but there may be individual differences in response and/or tolerability. Some studies suggest mirtazapine may be beneficial as monotherapy in managing OCD.[7,8] Mirtazapine may improve response time and decrease side effects when used to augment SSRIs.[9] However, additional well-designed trials are necessary to establish mirtazapine's role in the management of OCD.[6]
If patients with AS do not meet the full criteria for comorbid OCD, psychotropic medications should be chosen for their specificity in targeting symptoms.[5] SSRIs may be effective in treating repetitive behaviors, behavioral rigidity, and obsessive-compulsive symptoms associated with ASD.[5,10,11] Compared to the OCD literature, there are less data to support the use of mirtazapine in managing obsessive-compulsive symptoms associated with AS. A small naturalistic, open-label trial of mirtazapine in patients with autism and other pervasive developmental disorders found it to be efficacious for the treatment of anxiety[12]; however, the authors noted no improvement in repetitive behaviors and did not specifically assess obsessive-compulsive symptoms.
It is difficult to provide a case-based answer to this question, because additional details are needed regarding psychiatric, medical, and medication history. SSRIs are regarded as first-line therapy in the treatment of OCD and are efficacious in treating obsessive-compulsive symptoms associated with AS. If side effects limit the use of a specific SSRI, switching to another SSRI may provide efficacy and better tolerability. While mirtazapine is an alternative treatment option, it probably should only be used after documented failure of at least 1 therapeutic SSRI trial.
References
- Johnson CP, Meyers SM, American Academy of Pediatrics Council on Children With Disabilities. Identification and evaluation of children with autism spectrum diagnosis. Pediatrics. 2007;120:1183-1215.
- McPartland J, Klin A. Asperger's syndrome. Adolesc Med Clin. 2006;17:771-788.
- Volkmar F, Cook EH, Pomeroy J, Realmuto G, Tanquay P. Practice parameters for the assessment and treatment of children, adolescents, and adults with autism and other pervasive development disorders. J Am Acad Child Adolesc Psychiatry. 1999;38:32s-54s.
- Toth K, King BH. Asperger's syndrome: diagnosis and treatment. Am J Psychiatry. 2008;165:958-963.
- Scott MM, Johnson CP, American Academy of Pediatrics Council on Children With Disabilities. Management of children with autism spectrum disorders. Pediatrics. 2007;120:1162-1182.
- Koram LM, Hanna GL, Hollander E, Nestadt E, Simpson HB, American Psychiatric Association. Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder. Arlington, Va: American Psychiatric Association; 2007:5-53.
- Koran LM, Gamel NN, Choung HW, Smith EH, Aboujaoude EN. Mirtazapine for obsessive-compulsive disorder: an open trial followed by double-blind discontinuation. J Clin Psychiatry. 2005;66:515-520.
- Koran LM, Quirk T, Lorberbaum JP, Elliott M. Mirtazapine treatment of obsessive-compulsive disorder. J Clin Psychopharmacol. 2001;21:537-539.
- Pallanti S, Quercioli L, Bruscoli M. Response acceleration with mirtazapine augmentation of citalopram in obsessive-compulsive disorder patients without comorbid depression: a pilot study. J Clin Psychiatry. 2004;65:1394-1399.
- Aman MG, Arnold E, Armstrong SC. Review of serotonergic agents and perseverative behavior in patients with developmental disabilities. Ment Retard Dev Disabil Res Rev. 1999;5:279-289.
- Masi G. Pharmacotherapy of pervasive developmental disorders in children and adolescents. CNS Drugs. 2004;18:1031-1052.
- Posey DJ, Guenin KD, Kohn AE, Swiezy NB, McDougle CJ. A naturalistic open-label study of mirtazapine in autistic and other pervasive developmental disorders. J Child Adolesc Psychopharmacol. 2001;11:267-277.
