A 30-year-old male patient with a history of OCD after a suicide attempt was admitted to the Emergency Room and then transferred to our psychiatric unit. The patient appeared anxious with thoughts of contamination, order, and symmetry; affectivity was characterized by feelings of worthlessness, fatigue, loss of energy, and diminished ability to concentrate. No other medical health problems were known or present. According to the patient, the onset of the disease was in 2006, at the age of 24 years, when he started having obsessive thoughts for cleanliness and order (daily hand washing up to 25-30 times), tendency to perfectionism, marked anxiety, insomnia, feelings of worthlessness, and social withdrawal. In the previous years, several psychiatrists who confirmed the diagnosis of OCD according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV TR) criteria visited him. Over the years, the patient was treated with both antidepressant (SSRI) and benzodiazepine and refused psychotherapy. First, he assumed fluvoxamine 50 mg/day, gradually titrated to 200 mg/day in 6 weeks. Due to non-satisfactory clinical improvement, the fluvoxamine dose was increased up to 300 mg/day. After 6 months, the patient obtained a partial improvement of his symptomatology with a marked reduction in anxiety and washing compulsions. The fluvoxamine dosage was then kept at 200 mg/day. Under this treatment regimen, the patient was able to resume his studies and had an active social life. He then decided to stop the treatment against medical advice.
In 2010, he showed relapse of symptoms with obsessive ideation regarding his academic career cleanliness and order. Typically, he was reading the same textbook's page many times, and sometimes he was spending hours looking at the book cover page. In addition, he had a remarkable social withdrawal and was often worried about forgetting something of importance. The patient then consulted a psychiatrist who prescribed him a therapy with fluoxetine (up to 60 mg/daily). He was compliant with the medication regimen and had a partial remission. In 2011, after he failed several courses, he was dismissed by his university. After few months, there was a dramatic worsening of the OCD symptoms with suicidal thought and ideation. He attempted suicide ingesting 25 tablets of fluoxetine, and he was hospitalized in our psychiatric unit.
During the hospitalization, the patient had few social interactions with other patients; he often stayed alone in his room that personally arranged at least 10 times a day (remaking the bed and the bedside continually). OCD diagnosis was confirmed according to DSM IV-TR SCID I interview that excluded comorbid disorders like a major depressive episode and other anxiety disorders. The Yale-Brown Obsessive-Compulsive Scale (YBOCS) score was 31, and Columbia-Suicide Severity Rating Scale (C-SSRS) showed moderate-to-severe suicidal ideation. The patient was initially treated with venlafaxine 75 mg/day and lorazepam 2.5 mg/day at bedtime for insomnia. During the first week of hospitalization, venlafaxine was titrated to 225 mg/day. At this dosage, the patient had a minimal improvement of the OCD symptoms (YBOCS = 28): the insomnia persisted. We then increased the venlafaxine dose to 300 mg/day. After 3 weeks of treatment, the patient did not show any further improvement. For this reason, agomelatine 25 mg/day was added. After few days, the patient showed improvement of insomnia, and after 2 weeks, the OCD symptoms improved (YBOCS = 22) and there were no evidence of suicidal thoughts or ideation. The patient was discharged after 4 weeks of hospitalization with the prescription of venlafaxine 300 mg/daily and agomelatine 25 mg/day. At follow-up (8 weeks), he showed a significant improvement of symptomatology, as indexed by a reduction of more than 50% on the YBOCS (score = 15). He also planned to resume his studies.