A Qualitative Analysis of Nonresponse: Management of Treatment-Refractory Obsessive-Compulsive Disorder

Serotonin reuptake inhibitors (SRIs), especially potent ones given at high doses over long periodsof time, are often effective in the treatment of obsessive-compulsive disorder (OCD). However, alarge percentage of patients do not respond to treatment with SRIs, and those who do respond often donot fully remit, which should be the standard goal of treatment in OCD. If a patient has been treatedfor several months and has not yet responded to treatment with several SRIs, the physician shouldperform a careful assessment of resistant and/or residual clinical symptoms and any comorbid conditionsto determine which next-step treatment would be the most appropriate. One strategy for patientswho have not responded to treatment with an SRI is to switch them to a serotonin-norepinephrinereuptake 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 trialshave shown that intravenous (IV) clomipramine and IV citalopram may be effective in the treatmentof resistant OCD. Novel pharmacotherapeutic treatments and electroconvulsive therapy have beenattempted, with mixed success. Recently, researchers have been studying repetitive transcranial magneticstimulation, vagal nerve stimulation, and neurosurgical approaches such as gamma knife capsulotomyand deep brain stimulation to learn if these procedures are effective in treating treatment-resistantOCD. Repetitive transcranial magnetic stimulation has possibilities not only as a therapybut 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 bedetermined.