Hoarding: Drug Treatment

This is the fourth post examining the problem of hoarding. In the first post, I reviewed some of the characteristics of people with animal hoarding behavior.  The second post examined some of the common co-occuring mental disorders in those with hoarding.   The third post looked at some evidence that the BDNF gene status may contribute to hoarding and also be linked in increased risk of obesity.


In this post, I will comment on the use of  pharmacotherapy as a part of a treatment program for hoarding.  Saxena recently published a review of the research literature of drug treatment of hoarding and also outlined results from a small open label study of the drug venlafaxine.  


Saxena reports that his group performed the only study specifically designed to assess the response of compulsive hoarding behaviors to a selective serotonin reuptake inhibitor (paroxetine) compared to a control group of individuals with OCD but no hoarding compulsions.


SSRI drugs have been the most promising group of agents for the treatment of OCD.  However, only about one third of those with OCD report a response approaching remission criteria when treated with an SSRI.  An additional third report partial improvement in symptoms while the remaining third appear to have no response to SSRIs.


There is some anecdotal reports claiming that hoarding symptoms in OCD predict a poorer response of OCD to SSRI therapy.  However, in the Saxena et al study of paroxetine for hoarding the following outcome was noted:

• The OCD response rates were similar in the hoarding (28%) and the non-hoarding (32%) OCD groups
• Hoarding symptoms were reduced by 24% with paroxetine (similar to response size in other OCD symptom clusters)
• There was no finding of a correlation between the severity of hoarding symptoms and treatment response
• A significant number of hoarders (and non-hoarders) were unable to tolerate the higher doses often needed in OCD populations

The Saxena review then summarizes an open-label trial of venlafaxine (Trade name Effexor in the U.S.) in thirteen hoarders.  Venlafaxine is a serotonin reuptake inhibitor as well as a norepinephrine reuptake inhibitor at higher doses.  Preliminary results in this sample suggest good response of hoarding behaviors in some individuals with a trend for greater reduction in hoarding symptoms compared to the paroxetine.

These manuscripts support consideration of use of an SSRI or venlafaxine type antidepressants in those with significant hoarding behaviors.  A comprehensive program that includes drug therapy, individual behavior therapy, family education and assistance with clutter clean up may be needed for the most severe cases of hoarding.


Molecular model of the antidepressant drug venlafaxine is in the public domain from Wikimedia Commons authored by Benjah-bmm27.


Saxena, S. (2011). Pharmacotherapy of compulsive hoarding Journal of Clinical Psychology, 67 (5), 477-484 DOI: 10.1002/jclp.20792

Escitalopram for Hot Flashes

Hot flashes commonly occur in the course of menopause in healthy women.  Some women find their hot flashes to be very uncomfortable and distressing.  Hormone replacement can reduce the symptom severity of hot flashes, but recent research has underscored the potential risks associated with hormone replacement.  Therefore, there is increased interest in finding safer alternatives.

Freeman and colleagues recently published a randomized controlled trial of the selective serotonin reuptake inhibitor escitalopram (Lexapro) for hot flashes in healthy menopausal women.  The key research design features of this study were:

• Patient selection: women between 40 and 62 with reduced or absent menses
• Symptom severity: 28 or more hot flashes or night flashes rated bothersome or severe on at least 4 days per week
• Exclusion: recent use of prescription or over the counter drugs for hot flashes, current hormone replacement therapy, current severe medical illness or mental disorder (major depression, bipolar disorder, suicide attempt, alcohol or drug abuse)
• Drug regimen: escitalopram 10 mg per day versus placebo, if hot flashes not reduced by 50% at week 4 escitalopram was increased to 20 mg per day for 4 additional rates
• Primary outcome measure: weekly hot flash frequency and severity (rated 1 to 3, mild, moderate, severe) 

Escitalopram proved superior to placebo in this study with hot flash frequency reduced from 9.9 per day on average to 4.3 at week 8 of the study.  Placebo treated women also had a decrease in hot flash frequency (reduced by 3.2 on average per day).   Hot flashes severity ratings were decreased from 2.17 (moderate to severe) to 1.63 at week 8 (mild to moderate).  After 8 weeks of treatment when escitalopram was discontinued, hot flash frequency and severity increased.  Interestingly the escitalopram group had no increased rate of side effect endorsement compared to placebo including no report of sexual side effects.

The majority of responders needed only the 10 mg dose of escitalopram.  About 20% of responders required going to the 20 mg dose.

This study confirms previous randomized control trials that suggest that antidepressant drugs may improve hot flashes for a significant number of women.  Other psychotropic drugs that have significant data for hot flashes include venlafaxine (Effexor XR) 75 mg, gabapentin 600 mg, and pregabalin 75 mg twice daily.  Although herbal remedies are promoted for hot flashes, a recent randomized controlled trial of black cohosh and red clover were no more effective than placebo.  For some women with severe hot flashes a period of hormonal treatment remains a common clinically used option.  

Photo of white pelicans courtesy of Yates Photography.

Freeman EW, Guthrie KA, Caan B, Sternfeld B, Cohen LS, Joffe H, Carpenter JS, Anderson GL, Larson JC, Ensrud KE, Reed SD, Newton KM, Sherman S, Sammel MD, & LaCroix AZ (2011). Efficacy of escitalopram for hot flashes in healthy menopausal women: a randomized controlled trial. JAMA : the journal of the American Medical Association, 305 (3), 267-74 PMID: 21245182

Geller SE, Shulman LP, van Breemen RB, Banuvar S, Zhou Y, Epstein G, Hedayat S, Nikolic D, Krause EC, Piersen CE, Bolton JL, Pauli GF, & Farnsworth NR (2009). Safety and efficacy of black cohosh and red clover for the management of vasomotor symptoms: a randomized controlled trial. Menopause (New York, N.Y.), 16 (6), 1156-66 PMID: 19609225