From the Guidelines
The most recent and evidence-based treatment for resistant obsessive-compulsive disorder (OCD) is a combination approach that includes augmenting first-line selective serotonin reuptake inhibitors (SSRIs) with antipsychotics, particularly risperidone (0.5-2mg daily) or aripiprazole (2.5-10mg daily), along with intensive cognitive-behavioral therapy with exposure and response prevention (CBT-ERP) 1.
Treatment Approach
The treatment approach for resistant OCD involves several steps, including:
- Augmenting SSRIs with antipsychotics, such as risperidone or aripiprazole, to enhance treatment response 1
- Using higher-than-typical doses of SSRIs, such as fluoxetine up to 80-120mg daily, sertraline up to 400mg daily, or escitalopram up to 40mg daily, maintained for at least 12 weeks to evaluate efficacy 1
- Adding clomipramine (150-250mg daily) when multiple SSRIs have failed 1
- Considering glutamate-modulating agents like memantine (10-20mg daily) or N-acetylcysteine (2400-3000mg daily) as adjunctive treatments 1
Treatment Algorithm
The treatment algorithm for OCD involves:
- First-line treatment with SSRIs or CBT
- Augmentation with other treatment modalities for unresponsive patients
- Consideration of neurosurgery, including deep brain stimulation, after three SRIs (including clomipramine), adequate CBT trial, and disease incapacitation 1
Key Considerations
- The presence of specific comorbidities may change the treatment algorithm 1
- Effect sizes are similar for different SSRIs 1
- Monthly booster sessions for 3 to 6 months may be necessary to maintain treatment response 1
- The treatment approach should be individualized based on patient needs and response to treatment 1
From the Research
Treatment Options for Resistant Obsessive Compulsive Disorder
The following treatment options have been identified as effective for resistant obsessive compulsive disorder:
- Antipsychotic addition to SRIs, with aripiprazole and risperidone being the most effective options 2
- Cognitive-behavioral psychotherapy (CBT) addition to medication, which has been shown to be effective in two positive RCTs 2
- Switch to intravenous clomipramine (SRI) administration, which has been shown to be effective in two positive RCTs 2
- Switch to paroxetine (SSRI) or venlafaxine (SNRI) when the first trial was negative, which has been shown to be effective in one positive RCT 2
- Brain stimulation techniques, such as deep brain stimulation (DBS) and transcranial magnetic stimulation (TMS), which have been shown to be effective in treating severely ill OCD patients unresponsive to drugs and/or behavioral therapy 3
- Repetitive transcranial magnetic stimulation (rTMS), which has been shown to be moderately effective for reducing OCD symptom severity and has a 3-fold increased likelihood of treatment response compared with sham conditions 4
Comparison of Treatment Options
A comparison of cognitive-behavioral therapy (CBT) and transcranial direct current stimulation (tDCS) as adjuncts to pharmacotherapy for OCD patients found no significant difference between the two groups in terms of OCD symptoms and depression, but CBT was found to be more effective in improving quality of life 5 Aripiprazole augmentation has been shown to be effective and well-tolerated in patients with treatment-resistant OCD, with significant improvement in Y-BOCS total score and CGI-S scale 6
Brain Stimulation Techniques
Different brain stimulation techniques have been investigated for the treatment of resistant OCD, including:
- Deep brain stimulation (DBS), which has been shown to be effective in treating severely ill OCD patients unresponsive to drugs and/or behavioral therapy 3
- Transcranial magnetic stimulation (TMS), which has been shown to be moderately effective for reducing OCD symptom severity and has a 3-fold increased likelihood of treatment response compared with sham conditions 4
- Transcranial direct current stimulation (tDCS), which has been shown to be effective in improving quality of life in OCD patients, but not in reducing OCD symptoms or depression 5