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

From the Guidelines

Treatment-resistant Obsessive Compulsive Disorder (OCD) should be managed with augmentation strategies, including the use of antipsychotics, clomipramine, or glutamatergic agents, in addition to optimizing SSRI therapy.

Augmentation Strategies

• Antipsychotic augmentation: Risperidone and aripiprazole have shown efficacy in treating SSRI-resistant OCD, although ongoing monitoring of the risk-benefit ratio is necessary due to potential adverse events such as weight gain and metabolic dysregulation 1.
• Clomipramine augmentation: Clomipramine has been shown to be effective in reducing OCD symptoms when combined with SSRIs, but caution is needed due to the increased risk of severe events such as seizures and serotonergic syndrome 1.
• Glutamatergic agent augmentation: N-acetylcysteine and memantine have demonstrated efficacy in reducing OCD symptoms and can be considered as augmentation agents in clinical practice 1.

Optimizing SSRI Therapy

• Switching to a different SSRI: Switching to a different SSRI or using a higher dose of an SSRI than the maximum recommended dose can be considered for patients with treatment-resistant OCD 1.
• Combination with CBT: Combining SSRIs with Cognitive Behavioral Therapy (CBT) can be an effective strategy for treating OCD, although it may not always be feasible due to availability or tolerability issues 1.

Key Considerations

• Monitoring and follow-up: Ongoing monitoring of the risk-benefit ratio is necessary when using augmentation strategies, particularly with antipsychotics, due to potential adverse events 1.
• Individualized treatment: Treatment should be individualized and based on the patient's specific needs and circumstances, taking into account the potential benefits and risks of each augmentation strategy 1.

From the Research

Evidence-Based Treatment for Resistant Obsessive Compulsive Disorder (OCD)

The treatment of resistant OCD involves several strategies, including pharmacological and psychological interventions.

• The most effective pharmacological intervention for SSRI-resistant OCD is the augmentation of SSRIs with antipsychotics, such as risperidone or aripiprazole 2, 3.
• Other pharmacological options for treatment-resistant OCD include the switch to another SSRI or serotonin-norepinephrine reuptake inhibitor (SNRI), or the addition of other medications to SSRIs 2, 3.
• Cognitive-behavioral therapy (CBT) is also an effective treatment for OCD, and can be used in conjunction with medication or as a standalone treatment 4, 5.
• For patients who have not responded to standard CBT, intensive CBT or other forms of psychotherapy may be effective 5.

Pharmacological Interventions

Pharmacological interventions for resistant OCD include:

• Augmentation of SSRIs with antipsychotics, such as risperidone or aripiprazole 2, 3.
• Switch to another SSRI or SNRI 2, 3.
• Addition of other medications to SSRIs, such as glutamate-modulating agents 2.
• Use of intravenous clomipramine for patients who have not responded to oral SSRIs 3.

Psychological Interventions

Psychological interventions for resistant OCD include:

• Cognitive-behavioral therapy (CBT), specifically exposure and response prevention (ERP) 4, 5.
• Intensive CBT for patients who have not responded to standard CBT 5.
• Other forms of psychotherapy, such as acceptance and commitment therapy (ACT) or mindfulness-based cognitive therapy (MBCT) 4.