What is the recommended treatment for obsessive compulsive disorder (OCD)?

Treatment of Obsessive-Compulsive Disorder

First-line treatment for OCD is either cognitive-behavioral therapy with exposure and response prevention (ERP) or an SSRI, with the choice determined by patient preference, symptom severity, comorbidities, and CBT availability. 1

Initial Treatment Selection

Choose between CBT or SSRI based on the following criteria:

Start with CBT (10-20 sessions of ERP) if: 1

• Patient prefers psychotherapy over medication 1
• OCD exists without comorbid disorders requiring medication 1
• SSRIs are contraindicated (e.g., comorbid bipolar disorder, pregnancy, intolerance to adverse effects) 1
• CBT with a trained clinician is available 1
• Patient has previously responded to CBT 1

Start with an SSRI if: 1

• Patient prefers medication to CBT 1
• Severe OCD prevents engagement with CBT 1
• Comorbid disorders exist for which SSRIs are recommended (such as major depression) 1
• CBT is unavailable 1

SSRI Pharmacotherapy

First-line SSRI options (all have similar efficacy): 1, 2

• Sertraline (FDA-approved for OCD): Start 50 mg/day, target 150-200 mg/day 3, 4
• Fluoxetine (FDA-approved for OCD): Start 20 mg/day, increase to 40-80 mg/day (maximum 80 mg/day) 2, 5
• Paroxetine (FDA-approved for OCD): Titrate to therapeutic dose 2, 6
• Fluvoxamine or citalopram are acceptable alternatives 7

Critical dosing principles: 3, 2

• OCD requires higher doses than depression or other anxiety disorders—this is the most common cause of apparent treatment resistance 3, 2
• Maintain maximum recommended or tolerated dose for at least 8-12 weeks before determining efficacy 1, 3, 2
• Early response by 2-4 weeks predicts ultimate treatment success, but full therapeutic effect may be delayed 4-5 weeks or longer 2, 5

Avoid clomipramine as first-line due to less favorable adverse-event profile, though it remains an option for treatment-resistant cases 7, 8

Cognitive-Behavioral Therapy Implementation

CBT with ERP is the gold-standard psychological intervention with a number needed to treat of 3 (compared to 5 for SSRIs) 3, 2

ERP protocol: 1, 2

• 10-20 sessions (individual or group format) 1
• Can be delivered in-person or via internet-based protocols 1
• Involves gradual exposure to feared stimuli while preventing compulsive responses 2
• Patient adherence to between-session homework is the strongest predictor of treatment success 3, 2
• Include family psychoeducation to address accommodation behaviors 2

Combined Treatment Strategy

For moderate-to-severe OCD, combine CBT with SSRI from the outset as this yields larger effect sizes than either monotherapy alone 3, 2

Combined treatment is particularly indicated when: 2

• Symptoms are severe 2
• Partial response to monotherapy occurs 2
• Significant comorbidities exist 2

Maintenance Treatment

Continue pharmacotherapy for 12-24 months after achieving remission to prevent relapse 1, 3, 2, 7

Maintenance strategies: 1, 2

• Monthly booster CBT sessions for 3-6 months after initial treatment 1, 2
• Many patients require longer-term or indefinite treatment 2
• Periodically reassess need for continued treatment 2

Treatment-Resistant OCD

Approximately 50% of patients fail to respond adequately to initial treatment 9

Sequential strategies for inadequate response after 8-12 weeks at maximum tolerated SSRI dose: 1, 8

1. Add CBT if not already implemented (2 positive RCTs support this strategy) 8

2. Augment with atypical antipsychotics (most evidence-based augmentation strategy): 1, 8, 9

   • Risperidone or aripiprazole have the strongest evidence 3, 8, 9
   • Also supported: quetiapine, haloperidol 8, 9
   • 16 RCTs examined antipsychotic augmentation, with 10 showing positive results 8

3. Switch to a different SSRI or trial clomipramine 1, 8

4. Switch to venlafaxine (SNRI) if SSRI trials fail 1, 8

5. Consider intravenous clomipramine (2 positive RCTs) 8

6. Intensive outpatient or residential treatment with multiple CBT sessions over condensed timeframes (days to weeks) for severely treatment-resistant cases 1, 3, 2

7. Neurosurgery (including deep brain stimulation) only after failure of three SRIs (including clomipramine), adequate CBT trial, and disease incapacitation 1, 9

Critical Pitfalls to Avoid

• Never use inadequate SSRI doses or insufficient trial duration (less than 8-12 weeks at maximum tolerated dose)—this is the most common cause of apparent treatment resistance 3, 2
• Avoid premature medication discontinuation before 12-24 months of remission, as relapse risk is substantial 3, 2
• Do not neglect family involvement and psychoeducation regarding accommodation behaviors that maintain symptoms 2
• Monitor for SSRI adverse effects including gastrointestinal symptoms, sexual dysfunction, and behavioral activation in initial weeks 3, 2

Monitoring

• Assess treatment response using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) to track symptom severity objectively 3, 2
• Provide psychoeducation explaining that OCD is a common, biologically-based disorder with effective treatments that can substantially reduce symptoms and improve quality of life 3, 2