Maintenance Escitalopram May Reduce Risk of Relapse for BDD

Long-term use of the antidepressant escitalopram delayed relapse in patients with body dysmorphic disorder (BDD) compared with placebo, according to a study in AJP in Advance. Many of the participants taking escitalopram continued to show improvements in their BDD symptoms while on the medication.

Between 1.7 and 2.4 percent of people are believed to have BDD—a severe and understudied disorder characterized by distressing preoccupations and behaviors related to perceived defects in appearance. Some evidence suggests short-term treatment with selective serotonin reuptake inhibitors (SSRIs) can decrease symptoms of the disorder, but less is known of the long-term effectiveness of the medications.

Rhode Island Hospital

“[Patients] commonly ask, ‘If I take this medication and it works, what will happen if I stay on it? Or, if I stop, what is the risk of relapse?’” said Katharine Phillips, M.D., a professor of psychiatry and human behavior at the Warren Alpert Medical School of Brown University and senior research scientist and director of the Body Dysmorphic Disorder Program at Rhode Island Hospital.

Phillips and colleagues at Massachusetts General Hospital set out to answer these questions with a trial that included over 100 adults with BDD—the largest BDD trial ever conducted, she said.

The study involved two phases: first, all of the patients with BDD received open-label escitalopram (up to 30 mg daily depending on tolerability) for 14 weeks; in the second phase, 58 people who responded to escitalopram were randomly assigned to continue treatment with escitalopram at their previous dose or receive placebo for six months.

At the conclusion of the second phase, the prevalence of relapse was significantly reduced in the escitalopram group (18 percent versus 40 percent). In addition, about 35 percent of the escitalopram-treated participants continued to show further improvements.

As positive as these long-term findings were, Phillips told Psychiatric News that the results from the first phase of the trial should not be discounted.

“Over 80 percent of patients who completed all 14 weeks [on escitalopram] showed a meaningful improvement in their symptoms, while 25 percent achieved a clinical remission,” she said. “We also saw improvements in their depressive symptoms and quality of life.”

The escitalopram treatment was well tolerated, with only four patients in phase one and one patient in phase two dropping out due to adverse effects from the medication.

Phillips noted that one of the reasons the team of researchers chose escitalopram is because the doses prescribed to treat compulsive disorders are typically higher than those prescribed for depression, and it has been shown to be one of the more well-tolerated SSRIs. (By comparison, the equivalent dose of the closely related medication citalopram is 60 mg daily. This is too high a dose under the current FDA-recommended dosing limit of 40 mg daily.)

“I think what we need next are SSRI-augmentation studies,” she said. “While many of the patients in our study showed big improvements in symptoms, most of them did not reach remission. It would be valuable to know what to give a patient who doesn’t fully respond to escitalopram alone.”

Phillips also noted that she would like to see a head-to-head study comparing the efficacy of SSRI medication with cognitive-behavioral therapy (CBT), as CBT is also commonly used to treat BDD.

This study was supported by grants from the National Institute of Mental Health. The escitalopram and matching placebo were provided by Forest Laboratories. ■