Version July 2025
CBT: cognitive-behavioral therapy; CBT/ERP: CBT using exposure and response prevention; DBS: deep brain stimulation; OCD: obsessive-compulsive disorder; SGA: second-generation antipsychotic; SSRI: selective serotonin reuptake inhibitor; TMS: transcranial magnetic stimulation; Y-BOCS: Yale-Brown Obsessive Compulsive Scale.
* Initial treatment of OCD may consist of a serotonin reuptake inhibitor, CBT/ERP, or a combination. We consider many factors in determining the choice of initial treatment. For example, we consider the severity of symptoms, presence of suicidality, presence of comorbid psychiatric or other medical disorders, treatment history, ability, and willingness to participate in CBT/ERP, availability of CBT/ERP, and patient preference. This algorithm assumes that medication management is needed (either with or without CBT/ERP).
¶ Our choice among serotonin reuptake inhibitors is based on the properties of individual medication, past treatment, and patient preference. This is typically an SSRI. However, clomipramine is a reasonable alternate choice. Refer to UpToDate content for further discussion of the choice of agent in the treatment of OCD in adults.
Δ We consider an adequate trial of an SSRI to include at least 12 weeks of treatment, with at least 6 of these weeks at the target dose (if this high a dose is needed). Refer to UpToDate content for further discussion of dosing and length of medication trials in the treatment of adults with OCD.
◊ We monitor using the Y-BOCS at each visit. Refer to UpToDate content for further discussion of monitoring and defining responses.
§ We continue the most effective medication for at least 2 to 3 years. However, when using antipsychotics, we consider attempting to taper off after 1 to 2 years to minimize potential adverse effects such as weight gain, metabolic dysregulation, extrapyramidal symptoms, or tardive dyskinesia. Refer to UpToDate content for further discussion of the length of treatment with antipsychotic medications used as augmentation for refractory OCD in adults.
¥ We continue at the maximum dose reached in the supratherapeutic range for 4 to 8 weeks prior to determining response. Refer to UpToDate content for further discussion of supratherapeutic dosing in adults with refractory OCD.
‡ Subsequent pharmacotherapy for individuals who have not responded to treatment to this point (initial management, addressing potential causes, SSRI to supratherapeutic dose range) is informed in part by the level of response to treatment. However, as minimal data support switching versus augmentation of ineffective medication in adults with OCD, clinical judgment, history, and patient preference are the deciding factors in this decision. Our preference is the augmentation of the SSRI for individuals with a clinically meaningful response to an SSRI that is not an adequate response. For those with minimal to no response, we often prefer changing to a different SSRI.
† Our choice of augmentation agent is based on several factors including side effects of medication, past history, patient preference, and the quality of the evidence. Refer to UpToDate content for further discussion of augmenting agents in the treatment of adults with OCD.
** We titrate the augmenting antipsychotic agent over several months. Refer to UpToDate content for the augmentation using antipsychotics in the treatment of adults with OCD, including choosing the agent, side effects, and length of treatment.
¶¶ Refer to UpToDate content for further discussion of dose, titration, and monitoring during clomipramine treatment. We are particularly vigilant to adverse effects when using clomipramine with SSRI agents. Refer to UpToDate content for further discussion of adverse effects including serotonin syndrome.
ΔΔ We augment with buspirone or a glutamate modulator for at least 6 to 8 weeks prior to determining the effect. Refer to UpToDate content for further discussion of the use of glutamate modulators and buspirone in the treatment of refractory OCD.
◊◊ When changing to a different SSRI agent, our preferred method is to cross-titrate from the initial SSRI to the new medication. This can usually be accomplished over 1 to 2 weeks and may avoid side effects or discontinuation symptoms.
§§ Refer to UpToDate content for further discussion of venlafaxine in the treatment of refractory adult OCD.
¥¥ Refer to UpToDate content for further discussion of neuromodulatory treatments including TMS and DBS for refractory OCD in adults.