What is the next step in managing a patient with persistent Obsessive-Compulsive Disorder (OCD) symptoms, who has been on sertraline (Selective Serotonin Reuptake Inhibitor (SSRI)) 100mg for 2 weeks, after a recent dose increase from 75mg?

Continue Current Sertraline Dose and Reassess at 8-12 Weeks

Two weeks is insufficient time to determine SSRI efficacy for OCD—you should continue sertraline 100mg and reassess response at 8-12 weeks before making any treatment changes. 1, 2

Why It's Too Early to Change Treatment

• OCD treatment guidelines specify 8-12 weeks as the optimal duration to determine SSRI efficacy, not 2 weeks 1, 2
• While some improvement may be observed within 2-4 weeks, this early response is a predictor of eventual response at 12 weeks, not a reason to abandon treatment 1
• The patient recently increased from 75mg to 100mg only 2 weeks ago—this is far too soon to judge the new dose 1

Current Management Strategy

Continue sertraline 100mg for at least 6-10 more weeks (total 8-12 weeks at this dose) before considering any changes 1, 2

During this waiting period:

• Monitor for early signs of improvement in OCD symptoms, which can predict eventual response 1
• Assess tolerability and side effects systematically 3
• Consider adding CBT with exposure and response prevention (ERP) now rather than waiting, as combination therapy shows superior outcomes 1, 4, 5

If Still No Response After 8-12 Weeks at 100mg

First-Line Options (in order of preference):

1. Add CBT with ERP to the current SSRI - This has the strongest evidence, with 80% response rates compared to 23% for antipsychotic augmentation 5, 4

2. Increase sertraline dose to 150-200mg daily - Higher doses are typically required for OCD than depression, and doses up to 200mg are FDA-approved 3, 6, 7

   • One study showed significantly greater improvement with 250-400mg daily in non-responders, though this exceeds standard dosing 6
   • Titrate by 50mg increments every 2 weeks as tolerated 7

3. Switch to a different SSRI (such as fluoxetine or fluvoxamine) - Head-to-head trials show equivalent efficacy between SSRIs 1, 8

Second-Line Options (only after adequate SSRI trial):

1. Augment with risperidone or aripiprazole - These have the strongest evidence among antipsychotics, but only achieve clinically meaningful response in one-third of patients 1, 4

   • Monitor carefully for metabolic side effects including weight gain, glucose, and lipids 4, 2

2. Consider clomipramine - Reserved for patients who have failed multiple SSRIs, as it has equivalent efficacy but worse tolerability 1, 4, 8

   • Risk of seizures, cardiac arrhythmias, and serotonin syndrome limits its use 1, 2

Critical Pitfalls to Avoid

• Do not prematurely switch or augment treatment before 8-12 weeks - This is the most common error in OCD management 1, 2
• Do not use subtherapeutic SSRI doses - OCD requires higher doses than depression or other anxiety disorders 1, 2
• Do not add antipsychotics before trying CBT or dose optimization - CBT augmentation has superior efficacy and safety profile 5, 4
• Do not abruptly discontinue sertraline - This can cause withdrawal symptoms including anxiety, irritability, and electric shock-like sensations 3

Long-Term Considerations

• Once remission is achieved, maintain treatment for minimum 12-24 months due to high relapse risk after discontinuation 1, 4, 2
• Approximately 50% of OCD patients fail to fully respond to first-line treatments, so treatment resistance is common and expected in many cases 1, 4