Aripiprazole Dosing for OCD Augmentation
For treatment-resistant OCD in adults, start aripiprazole at 5-10 mg/day and titrate to a target dose of 10-15 mg/day, with a maximum of 20 mg/day if needed for response. 1, 2, 3
Starting Dose and Titration
- Begin with 5-10 mg/day of aripiprazole added to ongoing SSRI or clomipramine therapy 4, 5
- Titrate gradually over 2-4 weeks to the target therapeutic dose based on tolerability 4
- Target dose is 10-15 mg/day, which has demonstrated efficacy in multiple controlled trials 2, 3, 4
- Maximum dose is 20 mg/day if lower doses prove insufficient after adequate trial 4
Treatment Duration and Response Assessment
- Continue augmentation for a minimum of 12 weeks before assessing full therapeutic response 2, 3, 4
- Approximately one-third of SSRI-resistant OCD patients show clinically meaningful response to aripiprazole augmentation 1
- Significant Y-BOCS reduction (>35%) can be expected in responders by week 12 5, 3
Evidence Base for Dosing
The American College of Psychiatry identifies aripiprazole and risperidone as having the strongest evidence for efficacy in SSRI-resistant OCD 1. Multiple double-blind, placebo-controlled trials support this dosing range:
- A 12-week RCT using 10 mg/day showed significant Y-BOCS reduction (P < 0.0001) compared to placebo 2
- A 16-week RCT using 15 mg/day demonstrated substantial improvement in both obsessions (P = 0.007) and compulsions (P = 0.001) 3
- Case series data with mean doses of 10.9-12.6 mg/day showed 70% of patients achieving >35% Y-BOCS reduction 5, 4
Critical Prerequisites Before Starting
Ensure the patient has had an adequate SSRI trial (maximum tolerated dose for 8-12 weeks with confirmed adherence) before adding aripiprazole 1. The American Academy of Child and Adolescent Psychiatry warns that inadequate medication trials increase the risk of unnecessary medication switches and polypharmacy 6.
Consider adding CBT with exposure and response prevention (ERP) first or concurrently, as meta-analyses show CBT produces larger effect sizes than antipsychotic augmentation alone 1.
Monitoring and Side Effects
- Monitor for extrapyramidal symptoms (EPS), particularly akathisia, which is the most common side effect 7, 4
- Many patients may require antiparkinsonian medications to control EPS 7
- Monitor metabolic parameters including weight, glucose, and lipid profiles, though aripiprazole has a more favorable metabolic profile than other antipsychotics 1, 5
- Assess for serotonin syndrome when combining with serotonergic medications, though risk is low 1, 6
Common Pitfalls to Avoid
- Do not start aripiprazole without documenting an adequate SSRI trial (proper dose for 8-12 weeks) 1, 6
- Do not discontinue prematurely before 12 weeks, as full response may take the entire trial period 2, 3, 4
- Do not exceed 20 mg/day, as higher doses increase side effects without additional benefit 4
- Do not use aripiprazole as monotherapy for OCD—it is only indicated as augmentation to ongoing SSRI/clomipramine therapy 2, 7, 5, 3, 4
Adolescent Considerations
For adolescents with treatment-resistant OCD, newer atypical antipsychotics like aripiprazole are generally preferred over first-generation antipsychotics due to lower risk of extrapyramidal symptoms 8. However, use the same cautious dosing approach starting at 5 mg/day 8.
Long-Term Management
If aripiprazole augmentation is successful, maintain treatment for 12-24 months after achieving remission due to high relapse rates after discontinuation 1, 6. Regular reassessment is essential to balance symptom control with side effect management 1, 6.