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Memantine as an Augmenting Agent for Severe Pediatric OCD

To the Editor: The present case study is a follow-up to a previous case report (1), published in the Journal, on effective augmentation of the glutamatergic agent memantine to treat severe adult obsessive compulsive disorder (OCD). The previous report contributed to converging evidence for a pathogenic glutamatergic role in OCD (2–4). The efficacy and safety of pediatric memantine use warrants investigation, since OCD has childhood onset in at least one-third of patients (5). As an indicated Alzheimer’s disease medication, there have been few case reports on pediatric use of memantine and, to our knowledge, none for the use of memantine to treat pediatric OCD. We describe the effective, safe use of memantine for an adolescent with treatment-resistant OCD.

A 15-year-old girl presented with severe OCD characterized by prominent mental rituals in addition to aggressive, contamination, and somatic obsessions as well as repeating, superstitious, and checking rituals. The patient experienced onset of OCD symptoms between the ages of 4 and 5 years. Her symptoms became impairing, and she met OCD diagnostic criteria between the ages of 10 and 11 years. Her OCD treatment history included years of cognitive behavioral therapy (CBT) with an experienced psychologist and pharmacological trials with sertraline and fluvoxamine treatment, both of which were discontinued as a result of an agitation side effect. Initiating treatment with citalopram and increasing the dose to 80 mg/day for 10 weeks did not result in symptom improvement. The patient was hesitant to initiate a clomipramine or antipsychotic treatment trial, given potential cardiac and weight gain side effects, respectively. As a result of her extremely severe symptoms (Children’s Yale-Brown Obsessive Compulsive Scale score=36/40), the off-label use of memantine augmentation as well as the drug’s risks and benefits were discussed with the patient, and she and her mother provided informed consent. Memantine, 5 mg/day, was initiated, while her citalopram dose and CBT parameters remained unchanged. Subsequently, the patient’s mother and psychologist reported her increasingly debilitating OCD symptoms. At day 10, this decline dramatically shifted, and she successfully resisted obsessions and controlled rituals for the first time since her OCD onset. Memantine was increased to a final dose, 5 mg b.i.d., without reported side effects. One month after memantine initiation, the patient revealed only mild to subclinical symptoms (Children’s Yale-Brown Obsessive Compulsive Scale score=6). No subsequent medication or treatment changes were made.

The patient is presently in month 9 of memantine augmentation, with no evidence of OCD relapse or medication intolerance. Her reported obsessions last less than 1 hour daily, with low intensity and distress and increased ability to resist and control them. Her last reported compulsion occurred on day 10 of the memantine trial. Of interest, the patient attributes success to her emergent ability to resist obsessions and engage in CBT response prevention strategies.

Although anecdotal, the present case indicates dramatic improvement in treatment-resistant pediatric OCD using memantine augmentation. Moreover, since there were no reported side effects, memantine may represent a safer alternative augmenting agent relative to clomipramine or antipsychotics. Of note, riluzole (6), another glutamatergic medication, was reportedly effective in open trials in child (7) and adult (8) OCD samples. Our case supports the need for future research on the mechanisms and effectiveness of memantine for OCD across age groups.

Footnotes

Dr. Stewart currently receives support from the Anxiety Disorder Association of America (ADAA) and the Obsessive-Compulsive Foundation. She has not received funding from industry sources and has no conflict of interest to disclose. Dianne Hezel and Katherine Beattie report no competing interests.

This letter (doi: 10.1176/appi.ajp.2008.08091427) was accepted for publication in November 2008.

Reprints are not available; however, Letters to the Editor can be downloaded at http://ajp.psychiatryonline.org.

References

1. Poyurovsky M, Weizman R, Weizman A, Koran L: Memantine for treatment-resistant OCD. Am J Psychiatry 2005; 162:2191–2192[Free Full Text]
2. Welch JM, Lu J, Rodriguiz RM, Trotta NC, Peca J, Ding JD, Feliciano C, Chen M, Adams JP, Luo J, Dudek SM, Weinberg RJ, Calakos N, Wetsel WC, Feng G: Cortico-striatal synaptic defects and OCD-like behaviours in Sapap3-mutant mice. Nature 2007; 448:894–900[CrossRef][Medline]
3. Pittenger C, Krystal JH, Coric V: Glutamate-modulating drugs as novel pharmacotherapeutic agents in the treatment of obsessive-compulsive disorder. NeuroRx 2006; 3:69–81[CrossRef][Medline]
4. Pasquini M, Biondi M: Memantine augmentation for refractory obsessive-compulsive disorder. Progr Neuropsychopharmacol Biol Psychiatry 2006; 30:1173–1175[Medline]
5. Rasmussen SA, Eisen JL: Epidemiology of obsessive compulsive disorder. J Clin Psychiatry 1990; 51:10–13
6. Egashira N, Okuno R, Harada S, Matsushita M, Mishima K, Iwasaki K, Nishimura R, Oishi R, Fujiwara M: Effects of glutamate-related drugs on marble-burying behavior in mice: implications for obsessive-compulsive disorder. Eur J Pharmacol 2008; 586:164–170[Medline]
7. Grant P, Lougee L, Hirschtritt M, Swedo SE: An open-label trial of riluzole, a glutamate antagonist, in children with treatment-resistant obsessive-compulsive disorder. J Child Adolesc Psychopharmacol 2007; 17:761–767[Medline]
8. Coric V, Taskiran S, Pittenger C, Wasylink S, Mathalon DH, Valentine G, Saksa J, Wu YT, Gueorguieva R, Sanacora G, Malison RT, Krystal JH: Riluzole augmentation in treatment-resistant obsessive-compulsive disorder: an open-label trial. Biol Psychiatry 2005; 58:424–428[Medline]

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