A Qualitative Analysis of Nonresponse: Management of Treatment-Refractory Obsessive-Compulsive Disorder
J Clin Psychiatry 2004;65(suppl 14):6-10
© Copyright 2014 Physicians Postgraduate Press, Inc.
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Serotonin reuptake inhibitors (SRIs), especially potent ones given at high doses over long periods
of time, are often effective in the treatment of obsessive-compulsive disorder (OCD). However, a
large percentage of patients do not respond to treatment with SRIs, and those who do respond often do
not fully remit, which should be the standard goal of treatment in OCD. If a patient has been treated
for several months and has not yet responded to treatment with several SRIs, the physician should
perform a careful assessment of resistant and/or residual clinical symptoms and any comorbid conditions
to determine which next-step treatment would be the most appropriate. One strategy for patients
who have not responded to treatment with an SRI is to switch them to a serotonin-norepinephrine
reuptake inhibitor, because some patients may respond better to agents that target multiple systems.
Another promising approach is the augmentation of SRIs with neuroleptics. In addition, open trials
have shown that intravenous (IV) clomipramine and IV citalopram may be effective in the treatment
of resistant OCD. Novel pharmacotherapeutic treatments and electroconvulsive therapy have been
attempted, with mixed success. Recently, researchers have been studying repetitive transcranial magnetic
stimulation, vagal nerve stimulation, and neurosurgical approaches such as gamma knife capsulotomy
and deep brain stimulation to learn if these procedures are effective in treating treatment-resistant
OCD. Repetitive transcranial magnetic stimulation has possibilities not only as a therapy
but also as an instrument that can help researchers describe the neurocircuitries involved in OCD.
More results are needed before the effectiveness of the nonpharmacologic treatments for OCD can be