What is the next best step for a patient with Major Depressive Disorder (MDD) and Obsessive-Compulsive Disorder (OCD) who has shown a good response to sertraline (Selective Serotonin Reuptake Inhibitor - SSRI) 200mg, but still suffers from significant Generalized Anxiety Disorder (GAD) and residual depression?

Next Step: Add Cognitive Behavioral Therapy to Sertraline

The optimal next step is to augment the current sertraline 200mg with cognitive behavioral therapy (CBT) consisting of exposure and response prevention (ERP), 10-20 sessions, while maintaining the current medication regimen. 1, 2

Rationale for CBT Augmentation Over Medication Changes

The patient has achieved good response for MDD and OCD but continues to experience significant GAD and residual depression—this represents a partial response scenario where augmentation is preferred over switching. 2

Key advantages of CBT augmentation include:

• Lower discontinuation rates due to adverse effects compared to pharmacological augmentation 2
• Sustained long-term benefits beyond the treatment period 2
• Similar efficacy to pharmacological augmentation for residual symptoms 2
• Addresses all three conditions (MDD, OCD, and GAD) simultaneously 1, 3

Treatment Algorithm

First-Line Approach: CBT Augmentation

• Add CBT with ERP protocol: 10-20 sessions (can be delivered in-person, remotely via internet, or in group format) 1
• Continue sertraline 200mg (already at maximum recommended dose for OCD) 1
• Monitor response over 8-12 weeks while CBT is ongoing 1

Second-Line Approach: If CBT Unavailable or Patient Declines

• Add bupropion 150mg/day as pharmacological augmentation 2
• Bupropion shows decreased depression severity with lower adverse effect discontinuation compared to buspirone 2
• Monitor for serotonin syndrome during the first 24-48 hours after initiation 3

Third-Line Approach: If Inadequate Response to Augmentation

• Consider atypical antipsychotic augmentation (risperidone 2mg/day, aripiprazole, or olanzapine 5-10mg/day) 1, 4
• This is particularly supported for OCD with comorbid conditions 4
• Double-blind studies demonstrate efficacy specifically for OCD augmentation 5, 4

Critical Clinical Considerations

Why augmentation is preferred over switching:

• The patient has achieved "good response" for MDD and OCD—switching risks losing this partial benefit 6
• Augmentation strategies obtain faster response than switching compounds 5
• Sertraline is already at maximum dose (200mg), making dose escalation not an option 1

Common pitfalls to avoid:

• Do not switch to another SSRI—this offers no mechanistic advantage and similar side effect profiles with risk of losing current gains 3
• Do not add another SSRI to sertraline—combination of two SSRIs increases serotonin syndrome risk without evidence of benefit 5
• Avoid tricyclic antidepressants as they are not recommended for anxiety disorders due to high anticholinergic burden 3

Monitoring requirements:

• All antidepressants carry black box warnings for increased suicidal thinking, requiring close monitoring especially during treatment transitions 3
• If adding pharmacological augmentation, monitor for serotonin syndrome particularly in first 24-48 hours 3
• Assess response at 8-12 weeks before declaring treatment failure 1

If All Strategies Fail

After adequate trials of CBT augmentation and pharmacological augmentation strategies, consider:

• Switching to clomipramine (if not previously tried) 1
• Intensive outpatient or residential treatment programs 1
• Neurostimulation approaches (repetitive transcranial magnetic stimulation over supplementary motor area) 1, 4