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Evidence-Based Reviews
Treatment-resistant OCD: There’s more we can do
Current Psychiatry. 2018 November;17(11):10-12,14-18,51
Elana Harris, MD, PhD Assistant Professor Division of Child and Adolescent Psychiatry Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio
Sergio V. Delgado, MD Professor Medical Director of Outpatient Services Division of Child and Adolescent Psychiatry Cincinnati Children’s Hospital Medical Center Department of Psychiatry and Behavioral Neuroscience University of Cincinnati Cincinnati, Ohio
Acknowledgments The authors acknowledge support from the National Institute of Mental Health 5K23MH100640-04 and helpful editorial comments from Dr. Jessica McClure.
Disclosures The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
Augmentation strategies with neuroleptics,61 transcranial magnetic stimulation,62 and deep brain stimulation63 have recently been reviewed. Space limitations preclude a comprehensive review of these strategies, but in a cross-sectional study of augmentation strategies in OCD, no difference was found in terms of symptom severity between those prescribed SSRI monotherapy or augmentation with neuroleptics, benzodiazepines, or antidepressants.64
CASE CONTINUED Progress in CBT
Mr. S agrees to a trial of NAC as an augmentation strategy, but after 8 weeks of treatment with NAC, 600 mg twice daily, his Y-BOCS had declined by only 2 points. He also complains of nausea and does not want to increase the dose. You discontinue NAC and opt to further explore his reaction to CBT. Mr. S shares that he has been seeing his psychologist only once every 3 weeks because he does not want to miss work. You encourage him to increase to weekly CBT sessions, and you obtain his permission to contact his therapist and his family members. Fortunately, his therapist is highly qualified, but unfortunately, Mr. S’s father has been sending him multiple critical emails about not advancing at his job and for being “lazy” at work. You schedule a session with Mr. S and his father. Great progress is made after Mr. S and his father both share their frustrations and come to understand and appreciate each other’s struggles. Four weeks later, after weekly CBT appointments, Mr. S has a Y-BOCS of 18 and spends <2 hours/d checking emails for errors and apologizing.
Bottom Line
It is unrealistic to expect OCD symptoms to be cured. Many ‘treatment-resistant’ patients have not received properly delivered cognitive-behavioral therapy, and this first-line treatment modality should be considered in every eligible patient, and augmented with a selective serotonin reuptake inhibitor (SSRI) when needed. Glutamatergic agents, in turn, can augment SSRIs.
