Research on medications for hoarding disorder (HD) has focused on serotonin reuptake inhibitors (SRI) because they have proven useful for obsessive compulsive disorder (OCD) which is considered to be a related disorder per the DSM-5. There is some disagreement about whether hoarding behavior improves with serotonergic drugs. Recent studies [1] have suggested that SRIs may be as effective for HD symptoms as they are for non-hoarding OCD. But, other reviews of the literature have reached different conclusions. It is clear that more research is needed to determine what medications may be effective for HD and its specific symptoms of difficulty discarding, acquiring, and clutter.
What We Know, and What We Don’t Know about Treatment
A recent meta-analysis included 21 studies involving over 300 patients with OCD who also had HD symptoms. This study examined the response to pharmacotherapy, behavior therapy, and the combination [2]. Seven of the studies showed that people with HD consistently responded poorly to serotonergic medication treatments compared with patients with OCD but no HD. Similarly, when medications were combined with behavior therapy, patients with HD did not respond well, although two studies did show a better response. Overall, the degree of benefit of pharmacotherapy, behavior therapy, or the combination for patients with HD symptoms was about half the benefit to patients with OCD without HD.
Only two studies have examined medications for people diagnosed with HD who did not have OCD. One open trial of paroxetine (a selective serotonergic reuptake inhibitor or SSRI, a common name brand of which is Paxil®) showed that both HD and non-HD patients had similar outcomes [3]. That is, 28% of those with HD and 32% of those with OCD but not HD responded fully to paroxetine treatment. About half of each group showed at least a partial benefit. A number of patients had difficulty tolerating paroxetine, however.
A second open trial examined the effects of extended-release venlafaxine (a common name brand is Effexor®) which is a serotonin-norepinephrine reuptake inhibitor (SNRI) for 24 patients with HD [4]. This study showed that HD symptoms decreased by 32%, and 70% of those who completed the trial were considered “responders” – a very good response rate. These studies indicate that serotonergic medications may be useful for patients with HD, but unfortunately the controlled trials needed to establish the true efficacy of these medications for HD have not yet been done.
Another question is whether adding medications to cognitive-behavioral treatments for HD is beneficial. According to a meta-analysis of research on HD treatments, medications might improve the specific symptom of difficulty discarding, but not other types of HD symptoms such as excessive acquiring or clutter [5]. However, because the types of medications tested varied in these studies, it was not possible to determine whether certain medications were beneficial during cognitive behavior therapy.
Current Practice and Potential Approaches
Because there is very limited research on medications for HD and no general consensus about which medications may be the most effective, the typical approach to treating HD with medications is to start with selective serotonin reuptake inhibitors (SSRIs) that are commonly used to treat OCD (click here for list of medications used in OCD treatment). If the person with HD does not show an improvement even after the physician has tried using an SSRI at both its highest dose and/or for at least 12 weeks, they may choose to add a second medication such as risperidone (Risperdal®), olanzapine (Zyprexa®), quetiapine (Seroquel®), haloperidol (Haldol®), or fluphenazine (Prolixin®).
Almost no information is available about the use of non-serotonergic medications for HD. A few case reports indicate that HD symptoms might benefit from glutamate modulators [6], [7]. Information-processing problems are often seen among people with HD, and therefore medicines that target problems with decision-making, organization, categorization, attention, and memory might be useful. For example, medications that are considered cognitive enhancers and are used to treat Alzheimer’s disease may potentially be useful for HD. These include donepezil (Aricept®) and galantamine (Reminyl®). These medicines might make it easier for patients to discard items, and organize their time and living space.
Finally, stimulants that are often used to treat attention deficit hyperactivity disorder (ADHD) may also be helpful since they improve attention, alertness, and how fast information is processed.
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Sources:
- [1] Saxena, S (2014). Pharmacotherapy of compulsive hoarding. In R.O. Frost & G. Steketee (Eds.), The Oxford Handbook of Hoarding and Acquiring (p. 391-302). New York: Oxford. ↩
- [2] Bloch MH, Bartley CA, Zipperer L, Jakubovski E, Landeros-Weisenberger A, Pittenger C, Leckman JF. Meta-analysis: hoarding symptoms associated with poor treatment outcome in obsessive-compulsive disorder. Molecular Psychiatry.2014, 19, 1025-1030. ↩
- [3] Saxena, S., Brody, A.L., Maidment, K.M., & Baxter, L.R. (2007). Paroxetine treatment of compulsive hoarding. Journal of Psychiatric Research 41(6), 481-487. ↩
- [4] Saxena S, & Sumner J. (2014). Venlafaxine extended-release treatment of hoarding disorder. International Clinical Psychopharmacology, 29: 266-273. ↩
- [5] Tolin, D.F., Frost, R.O., Steketee, G., & Muroff, J. (2015). Cognitive behavioral therapy for hoarding disorder: A meta-analysis. Depression and Anxiety, 32, 158-166. ↩
- [6] Pittenger, C., Kelmendi, B., Wasylink, S., Bloch, M.H., & Coric, V. (2008). Riluzole augmentation in treatment-refractory obsessive-compulsive disorder: A series of 13 cases, with long term follow-up. Journal of Clincial Psychopharmacology, 28(3), 363-367. ↩
- [7] Rodriguez, C.I., Bender, J., Marcus, S.M., Snape, M., Rynn, M., Simpson, H.B. (2010). Minocycline augmentation of pharmacotherapy in obsessive-compulsive disorder: an open-label trial. Journal of Clinical Psychiatry, 71(9), 1247-9. ↩