In a 38-year-old male with severe anxiety, insomnia treated with zolpidem (Ambien) and trazodone, and refractory obsessive‑compulsive disorder despite fluvoxamine (Luvox) 100 mg twice daily and a benzodiazepine for anxiety attacks, what additional evidence‑based treatments should be added?

Augment with Antipsychotic and Optimize Fluvoxamine Dosing

Your patient requires immediate addition of aripiprazole or risperidone to the current fluvoxamine regimen, as approximately one-third of SSRI-resistant OCD patients achieve clinically meaningful response with antipsychotic augmentation. 1

Critical Issue: Inadequate Fluvoxamine Dosing

Your current regimen of fluvoxamine 100 mg twice daily (200 mg/day total) is within therapeutic range, but you should verify this has been maintained for a full 8-12 weeks before concluding treatment resistance. 2 Higher doses of SSRIs are typically required for OCD compared to other anxiety disorders, and fluvoxamine can be dosed up to 300 mg/day. 2, 3

First-Line Augmentation Strategy

Add aripiprazole 5 mg daily or risperidone, as these have the strongest evidence for SSRI-resistant OCD according to the American College of Psychiatry. 1, 4

• Start aripiprazole at 5 mg daily and titrate cautiously based on response and tolerability 1
• Risperidone is equally effective but carries slightly higher risk of extrapyramidal symptoms 4
• Continue fluvoxamine at current dose while adding augmentation 1

Monitoring Requirements for Antipsychotic Augmentation

• Monitor weight, blood glucose, and lipid profiles at baseline and regularly during treatment 1, 4
• Assess for extrapyramidal symptoms, particularly akathisia which can worsen anxiety 4
• Watch for metabolic side effects including weight gain 1

Add Cognitive Behavioral Therapy Immediately

CBT with Exposure and Response Prevention (ERP) produces larger effect sizes than antipsychotic augmentation alone and should be implemented now if not already in place. 1, 4

• Patient adherence to between-session ERP homework is the strongest predictor of good outcomes 2, 1
• Consider intensive CBT (multiple sessions over days) if standard weekly sessions are insufficient 2
• CBT can be delivered individually, in groups, or via internet-based protocols 2

Alternative Augmentation Options if Antipsychotics Fail or Are Not Tolerated

N-acetylcysteine (NAC) has the strongest evidence among glutamatergic agents, with three out of five randomized controlled trials showing superiority to placebo. 1

• NAC is generally well-tolerated with minimal drug interactions 1
• Memantine has also demonstrated efficacy in several trials 1
• These agents work through different mechanisms than SSRIs and antipsychotics 1

Consider Switching to Clomipramine if Current Strategy Fails

Clomipramine is reserved for treatment-resistant OCD after SSRI failure and may be more efficacious than SSRIs, though head-to-head trials show equivalent efficacy. 2, 1

• Clomipramine requires cardiac monitoring and has higher side effect burden than SSRIs 2, 1
• This should only be considered after adequate trials of SSRI plus augmentation strategies 1
• Monitor carefully for serotonin syndrome during transition from fluvoxamine 1

Address the Benzodiazepine Use

The "looping" (likely lorazepam or similar benzodiazepine) for anxiety attacks is concerning for several reasons:

• Benzodiazepines can interfere with ERP by providing short-term anxiety relief that prevents habituation 2
• They do not treat the underlying OCD and may perpetuate avoidance behaviors 2
• Consider tapering the benzodiazepine once antipsychotic augmentation and CBT are established 1

Treatment Duration and Relapse Prevention

Maintain treatment for 12-24 months after achieving remission due to high relapse rates after discontinuation. 1, 4

• Do not discontinue medications prematurely even if symptoms improve 1
• Approximately 40-60% of OCD patients continue to experience symptoms despite adequate medical management 2

Advanced Options for Highly Refractory Cases

If the above strategies fail after adequate trials:

• Deep repetitive transcranial magnetic stimulation (rTMS) is FDA-approved for treatment-resistant OCD with moderate effect size (0.65) and 3-fold increased likelihood of response versus sham. 1
• Deep brain stimulation has Level I evidence for bilateral subthalamic nucleus stimulation in medically refractory OCD 2
• Consider intensive outpatient or residential OCD treatment programs 1

Critical Pitfall to Avoid

Never conclude treatment resistance without documenting at least one adequate trial: proper dose for 8-12 weeks with confirmed adherence. 1 Verify your patient has been compliant with the full 200 mg/day fluvoxamine dose for the full duration before adding augmentation.