What is the treatment for Obsessive-Compulsive Disorder (OCD)?

Treatment of Obsessive-Compulsive Disorder (OCD)

Cognitive-behavioral therapy (CBT) with exposure and response prevention (ERP) is the first-line treatment for OCD, with selective serotonin reuptake inhibitors (SSRIs) recommended as first-line pharmacotherapy either alone or in combination with CBT for more severe cases. 1

First-Line Treatment Options

Psychotherapy

• CBT with ERP has larger effect sizes than pharmacotherapy, with a number needed to treat of 3 for CBT versus 5 for SSRIs 1
• Individual and group CBT delivered in-person or via internet-based protocols are effective treatment modalities 1
• Patient adherence to between-session homework (ERP exercises) is the strongest predictor of good outcomes with CBT 1
• Treatment should begin with psychoeducation and building a therapeutic alliance with the patient and family members 1

Pharmacotherapy

• SSRIs (fluoxetine, fluvoxamine, paroxetine, sertraline, citalopram) are the first-line pharmacological treatment based on efficacy, tolerability, safety, and absence of abuse potential 1, 2, 3
• Higher doses of SSRIs are typically required for OCD than for other anxiety disorders or depression 1, 4
• Clomipramine, a tricyclic antidepressant, is effective but less preferred than SSRIs due to its less favorable side effect profile 5, 6

Treatment Algorithm

1. Mild to Moderate OCD:

   • Start with CBT incorporating ERP as first-line treatment 1, 7
   • If CBT is unavailable or patient prefers medication, initiate SSRI treatment 7

2. Severe OCD:

   • Consider combined treatment with CBT+ERP and SSRI medication 1
   • Combined treatment is particularly beneficial for patients with severe symptoms, those with partial response to monotherapy, and cases with significant comorbidities 1

3. Treatment-Resistant OCD:

   • For patients with partial response to SSRIs, consider augmentation with antipsychotics (recommended: risperidone or aripiprazole) 8
   • Intensive CBT protocols (multiple sessions over a few days, sometimes in inpatient settings) may be beneficial 1
   • For extremely treatment-resistant cases, neuromodulation approaches such as deep brain stimulation or transcranial magnetic stimulation may be considered 1, 7

Duration of Treatment

• Long-term treatment is typically necessary as OCD is often a chronic condition 1
• For CBT, monthly booster sessions for 3-6 months after initial treatment help maintain gains 1
• Pharmacotherapy should be continued for a minimum of 1-2 years before very gradual withdrawal may be considered 6

Special Considerations

• Family involvement is crucial, especially for children and adolescents with OCD 1
• Address any comorbid conditions, which may require additional interventions beyond standard OCD treatment 1
• Patient preferences should be considered - research shows many patients prefer combination treatment (43%) or ERP alone (42%) over medication alone (16%) 9
• Computer-assisted self-help CBT interventions that include ERP components and last more than 4 weeks can be effective alternatives when in-person therapy is not available 1

Common Pitfalls to Avoid

• Failing to address stigma and family accommodation behaviors that may maintain OCD symptoms 1
• Insufficient dosing of SSRIs (higher doses are typically needed for OCD than for depression) 1, 4
• Premature discontinuation of treatment (OCD is often chronic and requires long-term management) 1, 6
• Lack of recognition of common OCD symptom types leads to an average delay in diagnosis by almost 10 years and a delay in effective treatment of nearly 2 years 7