Commonly asked questions in the treatment of obsessive-compulsive disorder

Abstract

Obsessive-compulsive disorder (OCD) is a common and often a highly disabling condition that was considered untreatable before the 1960s. The advent of serotonin reuptake inhibitors and exposure and response prevention revolutionized the treatment of OCD. Although they are still the first line treatments for OCD, new treatments like augmentation strategies, brain stimulation techniques, psychosurgery, newer forms of psychotherapy (like cognitive therapy, acceptance and commitment therapy) have been added to the armamentarium. With the available treatment strategies, many patients can achieve at least partial remission of symptoms. Nevertheless, the plethora of information gives rise to many questions on their application for practicing clinicians. We provide evidence-based responses to these questions and suggest a broad guideline for treatment of OCD.

Keywords::

• augmentation
• behavior therapy
• cognitive-behavior therapy
• obsessive-compulsive disorder
• psychosurgery
• repetitive transcranial magnetic stimulation
• selective serotonin reuptake inhibitor
• treatment

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• The first-line treatment of obsessive-compulsive disorder (OCD) is either selective serotonin reuptake inhibitors (SSRI) or behavior therapy/cognitive behavior therapy (CBT).

• Combination of SSRI and CBT is recommended for severely ill and SSRI non-responsive patients.

• Both behavioral and cognitive interventions are effective and can complement each other.

• A second SSRI can be tried in those who do not show response to first trial. Clomipramine can be tried in patients not responding to ≥2 SSRIs.

• Augmentation with CBT or atypical antipsychotics has the best evidence base and therefore is recommended in partial responders and non-responders to SSRIs.

• Other potential augmentation strategies include N-methyl-d-aspartate antagonists, 5HT-3 antagonists, clomipramine, lamotrigine and topiramate.

• Ablative neurosurgery or deep brain stimulation may be tried in carefully selected treatment refractory patients.