What medication changes are appropriate for a patient with poorly controlled OCD, ADHD, and a history of seizures, currently on clomipramine, lamictal, adderall, and NP thyroid?

Medication Management for Treatment-Resistant OCD with Comorbid ADHD and Seizure History

Primary Recommendation

Augment the current clomipramine 175mg with an atypical antipsychotic (aripiprazole 5-10mg or low-dose risperidone 0.5-2mg) as the next step for inadequately controlled OCD, while maintaining seizure precautions and continuing lamotrigine for mood stabilization and seizure prophylaxis. 1

Clinical Reasoning and Treatment Algorithm

Current Situation Assessment

This patient has treatment-resistant OCD (Y-BOCS 24 indicates moderate-severe symptoms) despite being on clomipramine 175mg, which is already a high dose of the most potent serotonergic agent available 1, 2. The patient has failed multiple SSRI trials and is now on clomipramine, representing second-line therapy 1. The comorbid depression (BDI 19), anxiety (GAD-7 19), and suicidal ideation with plan require urgent attention 1.

Specific Medication Changes

1. Antipsychotic Augmentation (First Priority)

Add aripiprazole starting at 5mg daily, titrating to 5-10mg as tolerated 1, 3:

• Aripiprazole is preferred because it has lower seizure risk compared to other antipsychotics and causes fewer extrapyramidal symptoms 1
• Recent evidence shows successful early aripiprazole augmentation with clomipramine in severe OCD 3
• The combination of lamotrigine (already on board at 75mg) plus aripiprazole augmentation of clomipramine has demonstrated marked improvement in severe treatment-resistant OCD 3

Alternative: Low-dose risperidone 0.5-1mg daily if aripiprazole is not tolerated 1:

• Start at 0.25-0.5mg and titrate slowly given seizure history 1
• Risk of extrapyramidal symptoms increases above 2mg daily 1

2. Optimize Lamotrigine Dose (Second Priority)

Increase lamotrigine from 75mg to 100-200mg daily 4, 3, 5:

• Lamotrigine augmentation of clomipramine has shown >50% Y-BOCS reduction in treatment-resistant OCD cases 4, 5
• The current dose of 75mg is subtherapeutic for OCD augmentation; effective doses range from 100-200mg daily 4, 3, 5
• This increase provides dual benefit: enhanced OCD treatment through glutamatergic modulation and continued seizure prophylaxis 4, 5
• Titrate slowly (increase by 25mg every 1-2 weeks) to minimize rash risk 4

3. Clomipramine Dosing Consideration

Maintain clomipramine at 175mg rather than increasing further 2, 6:

• Doses above 250mg/day significantly increase seizure risk (2.1% vs 0.48% at ≤250mg/day) 6
• Given this patient's seizure history, pushing clomipramine higher is contraindicated 2, 6
• The current dose is adequate; focus should be on augmentation strategies 1

4. Continue Current Medications

Maintain Adderall 20mg for ADHD 1:

• ADHD treatment should continue as this represents appropriate management of a separate comorbid condition 1
• Stimulants do not significantly worsen OCD symptoms in most patients 1

Continue NP Thyroid 60mg as thyroid optimization supports overall psychiatric treatment response 1

Critical Safety Considerations

Seizure Risk Management

• Do NOT increase clomipramine above 175mg due to dose-dependent seizure risk with history of seizures 2, 6
• Lamotrigine provides seizure protection while augmenting OCD treatment 4, 5
• Avoid medications that lower seizure threshold further (e.g., bupropion, high-dose antipsychotics) 1

Medication Combination Rationale

The combination of clomipramine + lamotrigine + atypical antipsychotic is supported by guideline principles for treatment-resistant OCD 1:

• This represents augmentation for inadequate response to first-line SRI treatment 1
• Each medication targets different mechanisms: serotonergic (clomipramine), glutamatergic (lamotrigine), and dopaminergic (antipsychotic) 1, 3
• The combination has specific evidence in severe, treatment-resistant cases 3, 5

Monitoring Plan

• Y-BOCS reassessment at 8-12 weeks after antipsychotic addition and lamotrigine optimization 1
• Weekly assessment of suicidal ideation given current plan without intent 1
• Monitor for extrapyramidal symptoms if using antipsychotic augmentation 1
• Seizure monitoring given history and polypharmacy 2, 6

If Inadequate Response After 12 Weeks

Consider intensive outpatient or residential OCD treatment programs, as this patient has now failed clomipramine plus adequate augmentation trials 1. Neurosurgery (including deep brain stimulation) is reserved only after three SRI trials (including clomipramine), adequate CBT trial, and disease incapacitation 1.

What NOT to Do

• Do not add another SSRI to clomipramine, as there is limited evidence for combining two serotonergic agents and increased risk of serotonin syndrome 1
• Do not discontinue medications prematurely given the severity of symptoms and suicidal ideation 1
• Avoid benzodiazepines for long-term anxiety management due to tolerance, addiction risk, and potential cognitive impairment 1