This is the third version of the guideline of the World Federation of Societies of Biological Psychiatry (WFSBP) Task Force for the Pharmacological Treatment of Anxiety, Obsessive–Compulsive and Po...

Obsessive–compulsive disorder (OCD) is a neuropsychiatric disorder affecting approximately 1–3% of the population. OCD is probably an etiologically heterogeneous condition. Individuals with OCD frequently have additional psychiatric disorders concomitantly or at some time during their lifetime. Recently, some authors proposed an OCD sub-classification based on comorbidity. An important issue in assessing comorbidity is the fact that the non-response to treatment often involves the presence of comorbid conditions. Non-responsive patients are more likely to meet criteria for comorbid axis I or axis II disorders and the presence of a specific comorbid condition could be a distinguishing feature in OCD, with influence on the treatment adequacy and outcome.

Aim: This is the third version of the guideline of the World Federation of Societies of Biological Psychiatry (WFSBP) Task Force for the Pharmacological Treatment of Anxiety, Obsessive–Compulsive and Posttraumatic Stress Disorders which was published in 2002 and revised in 2008. Method: A consensus panel of 34 international experts representing 22 countries developed recommendations based on efficacy and acceptability of the treatments. In this version, not only medications but also psychotherapies and other non-pharmacological interventions were evaluated, applying the same rigorous methods that are standard for the assessment of medication treatments. Result: The present paper (Part II) contains recommendations based on published randomised controlled trials (RCTs) for the treatment of OCD (n = 291) and PTSD (n = 234) in children, adolescents, and adults. The accompanying paper (Part I) contains the recommendations for the treatment of anxiety disorders. For OCD, first-line treatments are selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioural therapy (CBT). Internet-CBT was also superior to active controls. Several second-line medications are available, including clomipramine. For treatment-resistant cases, several options are available, including augmentation of SSRI treatment with antipsychotics and other drugs. Other non-pharmacological treatments, including repetitive transcranial magnetic stimulation (rTMS), deep brain stimulation (DBS) and others were also evaluated. For PTSD, SSRIs and the SNRI venlafaxine are first-line treatments. CBT is the psychotherapy modality with the best body of evidence. For treatment-unresponsive patients, augmentation of SSRI treatment with antipsychotics may be an option. Conclusion: OCD and PTSD can be effectively treated with CBT and medications.

Background: In old age, depressive syndromes often affect people with chronic medical illnesses, cognitive impairment, and disability, which can worsen the outcomes of other medical disorders and promote disability. Repetitive magnetic transcranial stimulation (rTMS) is a simple and effective treatment in patients with treatment-resistant depression. Therefore the use of rTMS could be of particular potential benefit in treatment-resistant elderly patients, who often cannot tolerate the higher doses of drugs needed or show phenomena of intolerance and interaction. However, several studies assessing the efficacy of rTMS found smaller response rates in elderly patients when compared to younger samples. Nevertheless, the correlation between age and response is still a controversial issue, and there is no strong evidence to date. The aim of our study was to retest the effectiveness and safety of low-frequency rTMS in a 3 weeks active treatment in a group of resistant-depressed patients, and to investigate the role of age in the response to stimulation treatment.Methods: Enrolled in this study were 102 treatment-resistant depressed patients. The patients were treated with low-frequency rTMS over the right dorso-lateral prefrontal cortex (DLPFC) for 3 weeks with a simple protocol (420 pulses per session for 15 sessions). At baseline, at the end of the second week, and at the end of the third week of treatment, the Hamilton Depression Rating Scale (HAM-D) and the Hamilton Anxiety Rating Scale (HAM-A) were administered.Results: Low-frequency rTMS on the prefrontal dorsolateral right area resulted in a statistically significant reduction of mean HAM-D scores in the entire group of patients at the end of treatment. The responder's rate in the whole group at the end of the third week was 56.86%. A significant inverse relationship between HAM-D reduction and age was found in the “older” (>60 years old) group, not in the “younger” (<60 years old) group.Conclusion: Results from this study show that low-frequency rTMS over the right DLPFC, with a relatively low number of pulses (420 pulses per session) and a relatively short period of treatment, is effective in the treatment of resistant patients (in a sample also including elderly patients) in a 3-weeks treatment protocol with a low reduction with the progress of age. Furthermore, we found a greater response in younger patients and an inverse correlation between age and treatment response. Adaptations of the protocol according to age are reviewed.

Objectives: ‘Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections’ (PANDAS) identified a unique subgroup of patients with abrupt onset of obsessive compulsive disorder (OCD) symptoms clinically related to Streptococcus infection and accompanied by neuropsychological and motor symptoms. After almost 20 years, PANDAS has not been accepted as distinct disorder and new criteria for paediatric acute-onset neuropsychiatric syndrome (PANS) have been replaced it, highlighting the fact that several agents rather than only Streptococcus might be involved. Methods: Extensive review of the PANDAS/PANS literature was performed on PubMed. Results: Although antibiotics have been reported to be effective for acute and prophylactic phases in several uncontrolled studies and non-steroidal anti-inflammatory drugs (NSAID) are used during exacerbations, clinical multicenter trials are still missing. Selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioural therapy (CBT) are still the first line of recommendation for acute onset OCD spectrum. Immunological therapies should be restricted to a few cases. Conclusions: While PANDAS has found no confirmation as a distinct syndrome, and it is not presented in DSM-5, patients with acute onset OCD spectrum, neurocognitive and motor symptoms should be evaluated for inflammatory, infective, immunological and metabolic abnormalities with a comprehensive diagnostic algorithm.

COVID-19 is associated with neuropsychiatric complications, the most frequent one being anxiety. Multiple biological and psychosocial factors contribute to anxiety in COVID-19. Among the biological factors, stress, genetics, gender, immune system, resilience, anosmia, hypogeusia, and central nervous system infection with SARS-CoV-2 are key. Anxiety is a complication of COVID-19 that may exacerbate the infection course, and the infection may exacerbate anxiety. We present the mechanisms of anxiety in symptomatic or asymptomatic COVID-19. We discuss the presentation of anxiety in patients without or with prior psychiatric illness, and with co-morbidities. Timely diagnosis and management of anxiety in COVID-19 patients is important. Given the frequent complication of COVID-19 with Acute Respiratory Distress Syndrome and Intensive Care Unit stay, anxiety may be a long-term complication. We review the diagnostic tools for anxiety in COVID-19, and summarise pharmacologic and non-pharmacologic treatments. We provide recommendations for diagnosis, treatment, prevention and follow up of anxiety in COVID-19.