When do you consider adding an antipsychotic for SSRI-refractory OCD, and which agent do you typically choose first?

There are so many factors that play into my decision-making; it truly is a case-by-case basis.

In my opinion, the most common mistake is not adequately titrating the dose of the SSRI. You also need to make sure they are getting high-quality CBT/ERP at least 1x/week, ideally 2x/week for the first month or two. You also want to set clear expectations for treatment (goal of symptoms being manageable rather than eliminated).

My general approach:

1. Start with prozac (80% of the time) or zoloft (20% of the time) and titrate to an appropriate dose as quickly as tolerated, and be willing to go above FDA-approved maximums.

There are studies showing improved efficacy and safety for prozac up to 80 mg for kids (120 mg for adults) and zoloft 300 mg f...

Thank you, Drs. @Dr. First Last and @Dr. First Last for sharing your thoughtful expertise.

The addition of "treatment resistant" to a question in this series routinely triggers at least one comment reminding us to ask, “What did I miss?"

For treatment-resistant OCD, the question must recognize the possibility of an autoimmune neurologic process. It is a disturbing reality that too many children with treatable autoimmune neuropsychiatric disorders are trapped in the chasm between neurology and psychiatry. OCD, Tourette’s, autistic spectrum disorder, schizophrenia, etc.… are some of the syndromes where autoimmune processes may play a significant, causal role. Identification and treatment of the process is vital and potentially life-altering.