Aripiprazole as Adjunct Treatment for OCD
Aripiprazole is an effective augmentation strategy for treatment-resistant OCD when added to SSRIs, with evidence supporting doses of 5-15 mg/day, though it should be reserved for patients who have failed adequate trials of SSRI monotherapy and cognitive-behavioral therapy. 1
When to Consider Aripiprazole Augmentation
Before initiating aripiprazole, ensure the patient has:
- Failed at least 8-12 weeks of maximum tolerated SSRI doses (higher than depression dosing) 1
- Attempted or been offered cognitive-behavioral therapy with exposure and response prevention (ERP), which has superior efficacy to pharmacotherapy alone 2
- Tried switching to a different SSRI or considering clomipramine if not already attempted 1
Approximately 50% of OCD patients fail to fully respond to first-line treatments, making augmentation strategies necessary. 1
Evidence for Aripiprazole Efficacy
The research evidence consistently demonstrates benefit:
- Multiple case series show significant Y-BOCS score reductions with aripiprazole augmentation at doses of 3-20 mg/day (mean ~10-12 mg/day) 3, 4, 5
- Seven of 10 treatment-resistant patients achieved >35% Y-BOCS reduction when aripiprazole was added to ongoing SSRIs 5
- Even low doses (10-15 mg/day) achieved significant remission in obsessive-compulsive symptoms 6
- Pediatric data shows striking improvement with mean doses as low as 4.75 mg/day in children resistant to at least two SSRIs and CBT 7
Practical Dosing Algorithm
Start aripiprazole at 5 mg/day and titrate gradually:
- Begin with 5 mg/day added to the existing SSRI regimen 4
- Titrate upward by 2.5-5 mg increments every 1-2 weeks based on response and tolerability 4, 5
- Target dose range: 10-15 mg/day for most patients 6, 5
- Maximum studied dose: 20 mg/day, though most patients respond to lower doses 4
- Continue treatment for at least 12 weeks to assess full efficacy 4, 5
Critical Safety Considerations and Common Pitfalls
Extrapyramidal symptoms are the most significant tolerability concern:
- Many patients require antiparkinsonian medications to control extrapyramidal symptoms 3
- Most common side effects include akathisia, tremors, hyperkinesia, tension/inner unrest, and nausea 4
- Monitor carefully for metabolic effects, though aripiprazole has advantages over risperidone and olanzapine regarding weight gain and metabolic changes 5
The major pitfall is initiating aripiprazole before optimizing first-line treatments:
- Ensure SSRIs are dosed at OCD-specific levels (higher than depression dosing) for adequate duration 1
- Verify that CBT with ERP has been offered, as it has larger effect sizes than pharmacotherapy (number needed to treat of 3 for CBT vs 5 for SSRIs) 2
- Consider clomipramine, which may be more efficacious than SSRIs, before adding antipsychotics 2
Monitoring and Long-Term Management
- Assess response using Y-BOCS scores at baseline and week 12 4
- Monitor vital signs and screen for extrapyramidal symptoms at each visit 4
- If effective, continue maintenance treatment for at least 12-24 months after achieving remission due to high relapse risk 1
- Carefully weigh the risk-benefit ratio of antipsychotic augmentation, particularly regarding metabolic effects 1