What's the next step in managing a patient with major depressive disorder (MDD), obsessive-compulsive disorder (OCD), and attention-deficit/hyperactivity disorder (ADHD) who is currently taking sertraline (Selective Serotonin Reuptake Inhibitor - SSRI) 200mg, lamotrigine (Lamictal) 100mg, guanfacine (Guanfacine Extended Release - ER) 1mg, and clonazepam as needed, and has not responded adequately to the addition of lamotrigine for OCD augmentation?

Next Steps for Treatment-Resistant OCD with Comorbid MDD and ADHD

Since lamotrigine augmentation has failed after adequate trial, you should discontinue lamotrigine and optimize the sertraline dose to the full OCD range (up to 200mg, which the patient is already receiving), then add cognitive-behavioral therapy with exposure and response prevention (ERP) as the next evidence-based augmentation strategy. 1, 2

Why Lamotrigine Should Be Discontinued

• Lamotrigine lacks evidence for OCD augmentation in patients without bipolar disorder. The guidelines do not support lamotrigine as an augmentation strategy for OCD, and its use here appears to be off-label without strong supporting evidence 1, 2
• The patient has already demonstrated inadequate response to lamotrigine augmentation, confirming it is not effective in this case 2

Optimizing Current SSRI Therapy

• Sertraline 200mg is already at the maximum recommended dose for OCD, which is appropriate since OCD requires higher SSRI doses than depression (50-200mg daily range) 2, 3
• You must allow at least 8-12 weeks at maximum tolerated dose before declaring treatment failure, as OCD response is slower than depression response 1, 2
• If the patient has not been on sertraline 200mg for a full 8-12 weeks, continue current dose and reassess before making changes 2

Evidence-Based Next Steps in Order of Priority

First-Line Augmentation: Add CBT with ERP

• CBT with exposure and response prevention is the recommended first augmentation strategy for inadequate SSRI response in OCD, rather than immediately adding or switching medications 1
• This approach has demonstrated effectiveness specifically in treatment-resistant OCD cases 1

Second-Line: Switch to Different SSRI

• If CBT is unavailable or ineffective after adequate trial, switch from sertraline to fluoxetine (60-80mg daily) or another SSRI before considering other medication classes 1
• Different SSRIs show similar efficacy for OCD, but individual patients may respond better to one versus another 1, 2

Third-Line: Atypical Antipsychotic Augmentation

• If two adequate SSRI trials plus CBT have failed, consider augmentation with an atypical antipsychotic (not lamotrigine), as this is the evidence-based augmentation strategy for treatment-resistant OCD 4

Critical Considerations for This Complex Case

Regarding Clonazepam PRN

• Clonazepam is not effective as monotherapy or augmentation for OCD and should only be continued if specifically targeting comorbid anxiety symptoms separate from OCD 5
• The evidence shows no significant benefit of clonazepam over placebo for OCD symptoms 5

Regarding Guanfacine for ADHD

• Continue guanfacine 1mg ER as it addresses the ADHD component and has been shown effective in combination with sertraline for comorbid OCD/ADHD 6
• The combination of sertraline and guanfacine specifically has case evidence supporting efficacy in this exact clinical scenario 6

Common Pitfalls to Avoid

• Do not add multiple augmentation agents simultaneously - this makes it impossible to determine what is helping and increases side effect burden 7
• Do not switch medications before allowing adequate trial duration (8-12 weeks at maximum dose for OCD) 2
• Do not use depression dosing strategies for OCD - the higher SSRI doses required for OCD will simultaneously address depressive symptoms 1
• Do not continue ineffective augmentation agents like lamotrigine - this adds unnecessary medication burden without benefit 1, 2

Monitoring Requirements

• Reassess treatment response every 1-2 weeks initially, particularly monitoring for worsening depression or suicidal ideation with SSRI therapy 7
• Plan for long-term maintenance (12-24 months minimum after achieving remission) due to high OCD relapse risk 2