In treating OCD with medication, at least two trials of an SSRI or clomipramine in full or high dose should be done first. Then combination treatment with an SSRI or clomipramine along with exposure and response prevention should be tried. Only then should antipsychotic augmentation of the SSRI be considered.
Who? Are particular patients more likely to benefit?
Adding an antipsychotic may be particularly useful when:
1. There has been no more than a minimal response to an adequate trial of the SSRI, as opposed to a partial response. Note that this goes against the rule of thumb that we generally follow–that if there is no response, we should switch the medication and if there is partial response, we should add an augmenting agent. Here, we are recommending adding an augmenting agent even in the face of no response to the SSRI.
2. Tics are also present along with OCD (Bloch et al., 2006). Even a past history of tics may be a predictor of good response to augmentation with an antipsychotic.
What? Should particular antipsychotics be preferred?
Aripiprazole, haloperidol, olanzapine, quetiapine, and risperidone (listed here alphabetically) have been shown in a randomized controlled trial to be efficacious as augmenting agents in OCD.
However, meta-analyses combining data from multiple studies have shown that not all antipsychotics are equally effective for OCD.
– A 2013 meta-analysis (Dold et al., 2013) found that significant efficacy was found only for risperidone and not for quetiapine or olanzapine. The data for aripiprazole and haloperidol were inconsistent.
– A 2014 meta-analysis (Veale et al., 2014) found that aripiprazole and risperidone are efficacious as adjunctive medications with an SSRI for the treatment of OCD while quetiapine and olanzapine are not.
– An update (“Guideline Watch”) of the American Psychiatric Association’s Practice Guideline for the Treatment of Patients with Obsessive-Compulsive Disorder (2013) notes that “Recent studies of augmentation of SRI treatment with a second-generation antipsychotic raise serious doubt about the efficacy of quetiapine…”.
Therefore, I recommend using risperidone (or aripiprazole) as the antipsychotics of choice for augmenting SSRIs in OCD.
How much? What dose of the antipsychotic should be used?
1. Studies comparing different doses of antipsychotics in order to systematically determine which doses are more effective have not been done.
2. Studies have used very wide ranges of doses of antipsychotics for augmentation of an SSRI in OCD.
For example, risperidone has also been used in a wide range of doses from 0.5 mg/day to 3 mg/day. Doses of 1 to 2 mg/day have been recommended (Fineberg et al., 2015).
Similarly, aripiprazole has been used in a wide range of doses from 6 mg/day to 30 mg/day. A dose range of 15 to 30 mg/day has been recommended (Fineberg et al., 2015).
How long should the trial last?
Antipsychotic augmentation of SSRIs for OCD tends to work quickly, within about 4 weeks. Thus, a long trial is usually not needed. This is helpful because the risks of longer-term antipsychotic treatment can be avoided in persons who do not respond to antipsychotic augmentation within approximately 4 to 6 weeks.
What are the chances of responding?
Overall, about one-thirds of patients respond to antipsychotic augmentation of an SSRI (Bloch et al., 2006).
How long should the antipsychotic be continued?
There is little systematic data to answer this question, but one small study (Maina et al., 2003) found that the majority of patients who had responded to antipsychotic augmentation of an SRI relapsed when the antipsychotic was discontinued.
Therefore, it has been recommended that if the antipsychotic works, we should continue it for at least one year (Fineberg et al., 2015).
American Psychiatric Association. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Arlington, VA: American Psychiatric Association, 2007. Available online at http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/ocd.pdf. Guideline Watch (2013) available at http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/ocd-watch.pdf
Bloch MH, Landeros-Weisenberger A, Kelmendi B, Coric V, Bracken MB, Leckman JF. A systematic review: antipsychotic augmentation with treatment refractory obsessive-compulsive disorder. Mol Psychiatry. 2006 Jul;11(7):622-32. PubMed PMID: 16585942.
Castle D, Bosanac P, Rossell S. Treating OCD: what to do when first-line therapies fail. Australas Psychiatry. 2015 Aug;23(4):350-3. doi: 10.1177/1039856215590027. Review. PubMed PMID: 26104775.
Dold M, Aigner M, Lanzenberger R, Kasper S. Antipsychotic augmentation of serotonin reuptake inhibitors in treatment-resistant obsessive-compulsive disorder: a meta-analysis of double-blind, randomized, placebo-controlled trials. Int J Neuropsychopharmacol. 2013 Apr;16(3):557-74. PubMed PMID: 22932229.
Erzegovesi S, Guglielmo E, Siliprandi F, Bellodi L. Low-dose risperidone augmentation of fluvoxamine treatment in obsessive-compulsive disorder: a double-blind, placebo-controlled study. Eur Neuropsychopharmacol. 2005 Jan;15(1):69-74. PubMed PMID: 15572275.
Fineberg NA, Reghunandanan S, Simpson HB, Phillips KA, Richter MA, Matthews K, Stein DJ, Sareen J, Brown A, Sookman D; Accreditation Task Force of The Canadian Institute for Obsessive Compulsive Disorders. Obsessive-compulsive disorder (OCD): Practical strategies for pharmacological and somatic treatment in adults. Psychiatry Res. 2015 May 30;227(1):114-25. PubMed PMID: 25681005.
Maina G, Albert U, Ziero S, Bogetto F. Antipsychotic augmentation for treatment resistant obsessive-compulsive disorder: what if antipsychotic is discontinued? Int Clin Psychopharmacol. 2003 Jan;18(1):23-8. PubMed PMID: 12490771.
Skapinakis P, Caldwell D, Hollingworth W, Bryden P, Fineberg N, Salkovskis P, Welton N, Baxter H, Kessler D, Churchill R, Lewis G. A systematic review of the clinical effectiveness and cost-effectiveness of pharmacological and psychological interventions for the management of obsessive-compulsive disorder in children/adolescents and adults. Health Technol Assess. 2016 Jun;20(43):1-392. doi: 10.3310/hta20430. PubMed PMID: 27306503; PubMed Central PMCID: PMC4921795.
Veale D, Miles S, Smallcombe N, Ghezai H, Goldacre B, Hodsoll J. Atypical antipsychotic augmentation in SSRI treatment refractory obsessive-compulsive disorder: a systematic review and meta-analysis. BMC Psychiatry. 2014 Nov 29;14:317. PubMed PMID: 25432131; PubMed Central PMCID: PMC4262998.
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