To the Editor: Trichotillomania has historically been difficult to treat pharmacologically (1, 2). Antipsychotic augmentation has been proposed to assist in managing symptoms in this difficult-to-treat population (3, 4). We know of one report of olanzapine augmentation of fluoxetine in the treatment of trichotillomania (5). I report on four patients who were consecutively treated with olanzapine augmentation of citalopram for refractory trichotillomania.
Ms. A was a 47-year-old Caucasian woman with a psychiatric history significant for trichotillomania, dysthymia, and past alcohol abuse whose trichotillomania had failed to respond to treatment with fluoxetine, 60 mg/day, and citalopram, 60 mg/day. She found that olanzapine, 7.5 mg b.i.d., in addition to citalopram helped reduce her hair pulling dramatically, over citalopram alone, to a point at which she was finally able to have her first haircut in over 10 years. She has had a good response to this treatment for almost a year.
Ms. B was a 33-year-old Caucasian woman with a psychiatric history significant for major depression, obsessive-compulsive disorder (OCD), and 19 years of trichotillomania whose hair pulling failed to respond to treatment with paroxetine, 60 mg/day; she obtained partial response when taking citalopram, 80 mg/day. She described ongoing and continual dramatic improvement when taking 5 mg/day of olanzapine to augment treatment with citalopram. She was still seeing benefit from this therapy after 6 months.
Ms. C was a 45-year-old Caucasian woman with a psychiatric history that was significant for bipolar II disorder, alcohol dependence (in remission), and trichotillomania whose mood disorder had responded to treatment with carbamazepine but whose trichotillomania had failed to respond to a regimen of 40 mg b.i.d. of fluoxetine, 50 mg of fluvoxamine at 6 p.m. and 150 mg at bedtime, 40 mg/day of paroxetine, 100 mg b.i.d. of sertraline, and 80 mg of citalopram at bedtime. Olanzapine augmentation, 1.25 mg/day, provided an enhanced mood benefit but had no impact on Ms. C’s trichotillomania. She could not tolerate higher doses of olanzapine.
Ms. D was a 49-year-old Caucasian woman with a psychiatric history significant for dysthymia, OCD, and trichotillomania who had medication intolerance or insufficient response to the trichotillomania portion of her illness when taking 75 mg b.i.d. of venlafaxine, 50 mg/day of paroxetine, 50 mg b.i.d. of sertraline, 40 mg b.i.d. of fluoxetine, 100 mg b.i.d. of fluvoxamine, and 60 mg/day of citalopram; clonazepam was prescribed at a dose of 0.5 mg every 6 hours on an as-needed basis. Ms. D claimed profound enhanced control of her hair pulling with olanzapine augmentation at a dose of 2.5 mg at bedtime along with citalopram, 50 mg at bedtime. She stated that this was the greatest control she had felt "in 10 years."
These consecutively treated patients described enhanced clinical benefit from olanzapine augmentation of citalopram; three of four patients had a clear improvement in their trichotillomania symptoms. They described enduring benefit over several months, which suggests that it was not a placebo effect, although a definitive placebo-controlled trial would be necessary to reach this conclusion with certainty. None of these patients has lost the benefit of the drug as of yet. The limitations of this report include its small group size and the lack of a standardized assessment tool to evaluate response, along with a possible sampling bias. Nevertheless, these patients’ self-reports described clear clinical benefit from this strategy, even though their mood symptoms were essentially stable before we began these trials. Further studies would help delineate the degree of response, optimal dose, and recommendations for duration of treatment.