Obsessive-Compulsive Disorder, Treatment Resistant Disorders
Conditions
Keywords
Immunopsychiatry, pediatric acute-onset neuropsychiatric syndrome
Brief summary
This study evaluates the addition of rituximab to 12 patients diagnosed with treatment resistant obsessive-compulsive disorder in an open trial.
Detailed description
Immunological factors may be determinants for some psychiatric disorders, thus immunomodulation may be helpful. Rituximab (antibodies against CD20, cluster of differentiation), a standard treatment for multiple sclerosis, is an anti-inflammatory drug, hitherto not tested for psychiatric disorders. The aim of this study is to investigate whether the psychiatric symptoms of treatment-resistant adult psychiatric patients, diagnosed with obsessive-compulsive disorder (OCD), are significantly improved after treatment with rituximab. The investigator's purpose is to implement recent insights from Immunopsychiatry to find efficacious, but still tolerable treatment for these patients. This is a single-site, 20-week, open pilot, add-on treatment as usual, trial, where the patients will be followed for 1 year. Rituximab will be administered with one single dose of 1000 mg. Investigators will analyse inflammatory and metabolic biomarkers in relation to the primary outcome, treatment response (defined as clinically relevant reduction in the validated measure Y-BOCS). Other outcomes are much or very much improved on Clinical Global Impression - Improvement scale (CGI-I) and change in Personal and Social Performance Scale measuring overall disability.
Interventions
DRUGRituximab
Infusion
Sponsors
Örebro University, Sweden
Region Örebro County
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
TREATMENT
Masking
SINGLE (Outcomes Assessor)
Masking description
Each patient will be video recorded at base line, week 12, 20 and 40 in order to enable blinded assessment by an independent rater, and for the patient's own evaluation.
Eligibility
Sex/Gender
ALL
Age
18 Years to 40 Years
Healthy volunteers
No
Inclusion criteria
(Swedish citizens): 1. patient ages 18 to 40 years. 2. a duration of illness exceeding 2 years. 3. correspond to Markedly ill, Severely ill or Among the most extremely ill patients on the Clinical Global Impression - Severity scale (CGI-S). 4. Global Assessment of Functioning (GAF) below 50. 5. obsessive-compulsive disorder according to The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). 6. treatment resistance, i.e. failing to remit despite adequate treatments. 7. if female and with any risk for pregnancy, willing to use contraceptives. 8. if psychotropic treatment is prescribed the plasma concentrations of the drug must be tested and shown to be within therapeutic interval. 9. subjects should be judged by the investigator to be lucid and oriented to person, place, time, and situation when giving the informed consent. 10. immunoglobulin levels within the normal range.
Exclusion criteria
1. on-going immunomodulatory treatment. 2. pregnancy or breast-feeding. 3. weight below 40 kg. 4. clinically relevant on-going infection. 5. chronic infections . 6. positive screening test for hepatitis B, C, HIV or tuberculosis 7. any change of psychotropic medication within the previous 4 weeks 8. much or very much improved already at baseline according to CGI-I. 9. severe heart failure (NYHA grade IV) or other severe heart disease or history of cardiac arrhythmia or myocardial infarction. 10. unable to make an informed decision to consent to the trial. 11. in compulsory treatment. 12. treatment with clozapine within the last 2 months. 13. previous treatments with immunosuppressive agents. 14. malignancy currently or within 2 years prior to inclusion.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Yale-Brown obsessive- compulsive scale (Y-BOCS) | week 20 | Y-BOCS maps symptoms and measures severity of obsessive-compulsive symptoms by a clinician. Y-BOCS has a range between 0 and 40 points, higher scores denotes worse symptoms. Outcome is measured as change in Y-BOCS score from baseline. At least 35% reduction in the score since baseline is defined as a response. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Clinical Global Impression-severity (CGI-S) scale | week 20 | CGI-S is a clinician rated measure of overall clinical severity that is rated on a scale between 1 and 7. A person with no clinical complaints or problems will get a score of 1. The score 7 indicates the highest level of severity is phrased as Among the most extremely ill patients. |
| Clinical Global Impression-Improvement (CGI-I) in relation to inflammatory markers | week 20 | Clinical Global Impression-Improvement scale (CGI-I) measures change of symptoms on a 7 point Likert scale. A CGI-I score of 1 or 2 corresponds to be much or very much improved. Change in inflammatory markers in blood (gene expression and proteins) towards normality, in relation to clinical response (assessed by the clinician) will be measured. |
| Personal and Social Performance Scale (PSP) | week 20 | Personal and Social Performance Scale (PSP) gives a score for disability. The PSP is a 100-point single-item rating scale (range 1-100), subdivided into 10 equal intervals. Lower scores denote lower functioning. The ratings are based mainly on the assessment of patient's functioning in four main areas: 1) socially useful activities; 2) personal and social relationships; 3) self-care; and 4) disturbing and aggressive behaviours. Change in score between enrolment and week 20 will be measured. |
| Clinical Global Impression-Improvement (CGI-I). | week 20 | Clinical Global Impression-Improvement scale (CGI-I) measures change of symptoms on a 7 point Likert scale. A CGI-I score of 1 or 2 corresponds to be much or very much improved. Three different informants base their CGI-I evaluations on independent assessments: a) The treating clinician, b) The patient's self-assessment and c) A next of kin. Range 3-21. A lower score depicts larger improvement. |
| Adverse event: Any Adverse Reactions (AAR). Safety and tolerability of Rituximab | week 20 | Any Adverse reactions (AAR) is a rating scale developed for this study and is not a validated questionnaire. It consists of a list of 26 symptoms. AAR maps adverse events related to rituximab treatment. These items are assessed for severity on a Likert scale (4 levels: none; mild; moderate; severe) and frequency (3 levels: occasionally; daily; several times daily). AAR is assessed by the clinician. An adverse event scale was required as an outcome measure by the Swedish Medical Products Agency. |
| Clinical Global Impression-Improvement (CGI-I). Proportion of responders. | week 20 | Clinical Global Impression-Improvement scale (CGI-I) measures change of symptoms on a 7 point Likert scale. A CGI-I score of 1 or 2 corresponds to be much or very much improved. Three different informants base their CGI-I evaluations on independent assessments: a) The treating clinician, b) The patient's self-assessment and c) A next of kin. If the mean value of these three is below 2.5 then the patient will be regarded as a responder (representing much or very much improved since baseline). |
Other
| Measure | Time frame | Description |
|---|---|---|
| Life quality measured with Brunnsviken Brief Quality of Life Scale (BBQ) | week 40 | BBQ is a 12-item self-rated measurement of life satisfaction, it is a likert scale, range 0-48. Higher scores denote higher life satisfaction. |
| Yale-Brown obsessive- compulsive scale (Y-BOCS) | week 40 | Y-BOCS maps symptoms and measures severity of obsessive-compulsive symptoms by a clinician. Y-BOCS has a range between 0 and 40 points, higher scores denotes worse symptoms. Outcome is measured as change in Y-BOCS score from baseline. At least 35% reduction in the score since baseline is defined as a response. |
| Clinical Global Impression-Improvement (CGI-I). Proportion of responders. | week 40 | Clinical Global Impression-Improvement scale (CGI-I) measures change of symptoms on a 7 point Likert scale. A CGI-I score of 1 or 2 corresponds to be much or very much improved. Three different informants base their CGI-I evaluations on independent assessments: a) The treating clinician, b) The patient's self-assessment and c) A next of kin. If the mean value of these three is below 2.5 then the patient will be regarded as a responder (representing much or very much improved since baseline). |
| Personal and Social Performance Scale (PSP) | week 40 | Personal and Social Performance Scale (PSP) gives a score for disability. The PSP is a 100-point single-item rating scale (range 1-100), subdivided into 10 equal intervals. Lower scores denote lower functioning. The ratings are based mainly on the assessment of patient's functioning in four main areas: 1) socially useful activities; 2) personal and social relationships; 3) self-care; and 4) disturbing and aggressive behaviours. Change in score between enrolment and week 40 will be measured. |
| Clinical Global Impression-severity (CGI-S) scale | week 40 | CGI-S is a clinician rated measure of overall clinical severity that is rated on a scale between 1 and 7. A person with no clinical complaints or problems will get a score of 1. The score 7 indicates the highest level of severity is phrased as Among the most extremely ill patients. |
| Clinical Global Impression-Improvement (CGI-I) in relation to inflammatory markers | week 40 | Clinical Global Impression-Improvement scale (CGI-I) measures change of symptoms on a 7 point Likert scale. A CGI-I score of 1 or 2 corresponds to be much or very much improved. Change in inflammatory markers in blood (gene expression and proteins) towards normality, in relation to clinical response (assessed by the clinician) will be measured. |
| Changes in cognitive functioning | week 20 | Improvement in cognitive tests using a subset of tests included in Wechsler Adult Intelligence Scale (WAIS) (i.e. Block design, digit span, letter number sequencing and digit symbol coding, visuospatial test). |
| CGI-I in relation to treatment and evaluated by the treating clinician, the patient's self-assessment and a next of kin | week 40 | Clinical Global Impression-Improvement scale (CGI-I) measures change of symptoms on a 7 point Likert scale. A CGI-I score of 1 or 2 corresponds to be much or very much improved. Three different informants base their CGI-I evaluations on independent assessments: a) The treating clinician, b) The patient's self-assessment and c) A next of kin. Range 3-21. A lower score depicts larger improvement. |
| B cell subpopulations in relation to clinical response | week 20 | B-cell depletion at week 5, and B-cell subpopulations at week 20 in relation to clinical response (CGI-I) (assessed by the clinician) and baseline levels of B-cells. |
Countries
Sweden
Outcome results
None listed