How do you manage obsessive-compulsive disorder refractory to high-dose SSRI and cognitive behavioral therapy?

In general, I follow a decision tree based on refractoriness and comorbid conditions.

Let us first assume that we have already provided an adequate dose of an SSRI for an adequate duration of 12 weeks. I use the following doses as general targets for SSRI treatment:

• Fluoxetine 80 mg/d
• Escitalopram ...

1. First, I would ask what "high dose" is being used. High doses for some are regular doses for others. This would be, of course, after verifying that the patient has been taking the medication regularly and as prescribed.
2. Second, I would ask what the duration of the current regimen of medications has...

Assure SSRI is in fact maximal as tolerated, and that CBT and lifestyle medicine approaches are being addressed...(OCD is not who you are, etc.)

Add Anafranil first regarding medications...and at the same time, triple look at family dynamics.

Look at TMS augmentation.

Some 1/3 or so of OCD patients ...

Agree with Dr. @Dr. First Last. As a reference, SSRI at double FDA-approved dose, anafranil no more than 50 mg added, then the MDMA antagonists memantine or riluzole (too expensive), then risperidone or aripiprazole, TMS, and finally surgery. Patients should at all times have ERP.

I agree with Dr. @Dr. First Last, though in my clinic we use slightly higher doses of sertraline -400 mg and always the 40 mg of escitalopram. We do not use citalopram due to the QT issues, and escitalopram is a better choice -40 mg. Fluoxetine 120 mg is what we use. The other issue is time. PLEASE ...