Should anhedonia or obsessive-compulsive disorder (OCD) be treated first in a patient presenting with both conditions?

Treat OCD First, Then Address Anhedonia

In patients presenting with both OCD and anhedonia, prioritize treating the OCD first with cognitive-behavioral therapy (CBT) with exposure and response prevention (ERP), as OCD is a distinct disorder requiring specific treatment, while anhedonia may be secondary to the OCD itself or comorbid depression that can be addressed concurrently or subsequently. 1

Treatment Algorithm

Step 1: Establish Accurate Diagnosis

• Differentiate whether anhedonia is a symptom of comorbid major depressive disorder (MDD) or a feature of the OCD itself 2
• OCD patients exhibit deficits specifically in consummatory pleasure (not anticipatory pleasure), which differs from the pattern seen in MDD patients who show deficits in both 3
• Assess for comorbid conditions including depression, bipolar disorder, or schizoaffective disorder, as these fundamentally alter the treatment approach 1, 4

Step 2: Initiate OCD-Specific Treatment

• Begin with CBT incorporating ERP as the psychological treatment of choice, with 10-20 sessions typically recommended 1
• ERP involves gradual and prolonged exposure to fear-provoking stimuli combined with instructions to abstain from compulsive behaviors 2
• Patient adherence to between-session homework (ERP exercises in the home environment) is the strongest predictor of good outcomes 2, 1
• CBT has larger effect sizes than pharmacotherapy alone, with a number needed to treat of 3 for CBT versus 5 for SSRIs 4

Step 3: Consider Pharmacotherapy Based on Clinical Context

If OCD occurs without comorbid mood disorder:

• SSRIs are first-line pharmacological treatment for OCD based on efficacy, tolerability, safety, and absence of abuse potential 4
• Maintain SSRI treatment for a minimum of 8-12 weeks at maximum tolerated dose to assess efficacy 4

If comorbid depression with anhedonia is present:

• Address depressive symptoms aggressively, as depressive symptoms mediate the relationship between OCD and impaired quality of life 1
• Consider antidepressants with demonstrated efficacy for anhedonia: agomelatine, vortioxetine, ketamine, bupropion, or venlafaxine 5
• Traditional SSRIs showed limited benefit on anhedonia and may have pro-anhedonic effects in some subjects 6

If comorbid bipolar disorder or schizoaffective disorder:

• Establish mood stabilizers (lithium, valproate) and/or atypical antipsychotics first to control mood symptoms before aggressively targeting OCD 1, 4
• Aripiprazole augmentation shows particular promise for treating comorbid OCD-bipolar disorder 1
• Do not aggressively treat OCD symptoms before achieving mood stability, as this can destabilize the underlying mood disorder 4

Critical Pitfalls to Avoid

• Do not assume anhedonia requires separate treatment before addressing OCD - anhedonia in OCD patients may improve as OCD symptoms respond to treatment 3
• Do not use escitalopram/riluzole combination - this was ineffective in treating symptoms of anhedonia in MDD 5
• Do not delay OCD treatment to focus solely on anhedonia - anhedonia is associated with adverse outcomes including more severe depressive episodes and suicidality, but treating the primary disorder (OCD) takes precedence 7
• Do not overlook family accommodation - address family behaviors that may maintain OCD symptoms, as family involvement is crucial for treatment success 1, 4

Monitoring Treatment Response

• Evaluate quality of life regularly, as both OCD and anhedonia significantly reduce quality of life across multiple domains 1
• Monitor closely for behavioral activation, akathisia, or emergence of new suicidal ideation, particularly in the first weeks of SSRI treatment 4
• Anhedonia is a relevant risk factor for possible suicidal behaviors and may operate as an independent risk factor for suicidality apart from episode severity 6

Treatment-Resistant Cases

If OCD symptoms remain severe after 8-12 weeks of adequate treatment:

• Consider glutamatergic medications as augmentation agents, such as N-acetylcysteine (largest evidence base) or memantine 1, 4
• Neuromodulation approaches, including FDA-approved deep repetitive transcranial magnetic stimulation (rTMS) and deep brain stimulation (DBS), may be considered for severe, treatment-resistant OCD 1, 4
• Transcranial magnetic stimulation also shows benefit for anhedonia 6

Adjunctive Interventions for Anhedonia

• Behavioral activation therapy shows benefit for anhedonia and can be integrated with ERP 6
• Address specific reward functioning deficits including effort valuation, reward anticipation, and reward learning to improve treatment engagement 8
• Psychoeducation about both OCD and anhedonia should be provided to patients and family members 2, 4