(Focus - Singapore)
According to the World Health Organization, OCD affects approximately 1% of the global population. This may seem small, but it equates to around 70 million individuals worldwide. Despite the prevalence of OCD, there is still a significant amount of stigma surrounding the condition. As one of the best healthcare systems in the world, how is Singapore fighting this stigma?
To learn more about it, we had a short discussion with Dr. Abishek Abraham, a renowned Psychiatrist from Singapore, who mentioned the challenges of OCD treatment and management and suggestions to improve the awareness of OCD among people in Singapore.
Dr. Abishek Abraham is a Medical Director & Senior Consultant Psychiatrist at Better Life Psychological Medicine Clinic, in Singapore.
I use SSRIs as my first line. I maximize the dosage if they can tolerate it—and for augmentation, harder-to-treat, or treatment-resistant OCD, I tend to use low doses of antipsychotics. So Abilify, maybe Risperidone, but usually Abilify is my go-to medication for augmentation.
Although obsessive-compulsive disorder (OCD) majorly starts in late adolescence or early twenties, there are some cases where the onset of OCD occurs before the age of 14 and is unrecognized or underreported.[1] What are the warning signs that would alarm the parents to present their children to a physician?
Dr. Abishek - When they start doing behaviors that don't seem to have any basis in logical, rational thinking, such as repeated handwashing or repeated checking, showering for long periods, and regularly using soap, and common manifestations of OCD in children will be checking of locks, curtains, and windows because of some irrational fear.And if you ask them, there's no logical reason for this.
Doctor, how often is OCD detected in children? Is it often reported, or is it underdiagnosed?
Dr. Abishek - I would say most mental health conditions are underdiagnosed, and it takes years after symptoms develop for someone to seek help.
According to the study conducted at Yale OCD Research Clinic, United States, OCD was observed to be common among males in childhood but is common among females in adolescence and adulthood.[2] What are your thoughts on this? Do you observe the similar trends in Singapore?
Dr. Abishek - Well, to be honest, I don't see any distinction between the genders. I find it equally common between males and females in childhood and early adulthood.
We understand that selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCA) are the first-line treatment for OCD. However, OCD being refractory to available therapy is the current challenge in treating severe OCD patients. How do you treat your severe OCD patients?
Dr. Abishek - I use SSRIs as my first line. I maximize the dosage if they can tolerate it—and for augmentation, harder-to-treat, or treatment-resistant OCD, I tend to use low doses of antipsychotics. So Abilify, maybe Risperidone, but usually Abilify is my go-to medication for augmentation. I'm not trying many others. Perhaps sometimes, if I'm running out of options, I might also try a mood stabilizer, and maybe dual antidepressants will be something else I have tried.
Talking about neuromodulation techniques, previously, a transcranial magnetic stimulation system (TMS) was used for major depressive disorder. However, now we have FDA approval for TMS to treat OCD. What is your experience with treating OCD patients via the TMS technique?
Dr. Abishek - I've not had too many patients whom I've sent for OCD. But I have sent people for rTMS for depression before, and even the results were limited for depression, and patients didn't respond fantastically.
There's always a big stigma to getting mental health treatment support in the first place. So, there's a gap of seven, eight years minimum average for people to come and seek help. Another challenge is that, in some ways, Singapore is a high-pressure society; there's a lot more pressure and stress that tend to trigger OCD, and there is a higher chance of relapse.
Pilot research done at Queen Mary University of London and the University of Roehampton, London, have discovered that patients suffering from OCD have increased levels of a protein called Immuno-moodulin (Imood) in their lymphocytes, a type of immune cell.[3] What are your thoughts on the relationship between OCD and immune processes?
Dr. Abishek - I think they found that Immuno-moodulin or lymphocytes are elevated in those with OCD. So, these OCD tend to be bit more comorbid, wondering whether antibodies can be used to treat it.
Is there any clinical trial going on regarding immunotherapies to treat OCD?
Dr. Abishek - It's not something that has been openly done in Singapore, not that I know personally.
One of the most common features of OCD patients is fear of contamination.[4] How were contamination-related OCD patients managed during COVID 19 pandemic?
Dr. Abishek - A lot of them ended up staying at home for longer periods. They stocked up sanitizers and things that would keep themselves supposedly clean and germ-free. So they sat at home a lot more, or their movements outside were restricted and limited in what they could and couldn't do. So they were more greatly impaired.
Are there any challenges or unmet needs related to treating and managing OCD patients?
Dr. Abishek - There's always a big stigma to getting mental health treatment support in the first place. So, there's a gap of seven, eight years minimum average for people to come and seek help. Another challenge is that, in some ways, Singapore is a high-pressure society; there's a lot more pressure and stress that tend to trigger OCD, and there is a higher chance of relapse. Even the academic stress of being perfect or getting very good results is there. So, it's a kind of demand for perfection or excellence. And it's also related to OCD because OCD is also about trying to do something perfectly, like behaviors that try to have certainty or some kind of reassurance.
So, is enough awareness given in Singapore related to OCD?
Dr. Abishek - No, I would say it is better than ten years ago but definitely not enough.
What are your thoughts and suggestions on improving the awareness of OCD among people in Singapore?
Dr. Abishek - Increasing the use of mass media to raise awareness of mental health issues, including OCD, will help. We can publicize articles on social media, in newspapers, and post videos of people coming forward to share their experiences. This will help in reaching and connecting to more people about such conditions. We can also have campaigns targeted at specific populations, such as schools.
We understand that management of OCD symptoms is possible. However, it may reappear in the same or a different form. So, what do you suggest to OCD patients to decrease the chance of OCD relapse?
Dr. Abishek - Psychological intervention is very important for me, and changing your mindset on how you see the symptoms is crucial to overcoming OCD. OCD is often about trying to get certainty about something; “I need to be certain that my hands are clean” and repetitive behaviors are an attempt to get assurance. So, one of the challenges I issue to my patients is learning to live with uncertainty - so what if my hands are a little bit dirty? If they are not going to eat something right now, it may be beneficial for them to be a bit dirty because I'm building up my immunity. So, it is okay to live with uncertainty and drop the focus of having to do the compulsion in the first place. And that may help to prevent other new, obsessive symptoms from forming in the future.
Thank you for your time and valuable insights!
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