Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

mild to moderate symptoms: without comorbid personality disorders or dissociative symptoms

1st line – cognitive behavioural therapy (CBT)

Back
ACUTE
|
mild to moderate symptoms: without comorbid personality disorders or dissociative symptoms
1st line – 

cognitive behavioural therapy (CBT)

Patients with mild to moderate symptoms include those with Yale-Brown Obsessive-Compulsive Scale scores of 8 to 23.

For these patients, cognitive behavioural therapy is a first-line treatment option and involves exposure and response prevention (ERP).[53][55][56][104]

A graded hierarchy of symptom triggers is created with each patient. The therapist then encourages the patient to expose him or herself to the trigger (e.g., dirt). The patient is then encouraged to refrain from engaging in compulsive rituals (e.g., hand washing).

As symptoms begin to improve, more intense triggers are targeted. In addition, homework assignments focus on exposure to stimuli in naturalistic settings such as the home.

Consider – pharmacotherapy

Back
ACUTE
|
mild to moderate symptoms: without comorbid personality disorders or dissociative symptoms
Consider – 

pharmacotherapy

Additional treatment recommended for SOME patients in selected patient group

Combined treatment with cognitive behavioural therapy (CBT) and pharmacotherapy may be considered in people who do not have a satisfactory response to monotherapy.

Pharmacotherapy with either a selective serotonin-reuptake inhibitor (SSRI) or a tricyclic antidepressant (e.g., clomipramine) may be combined with CBT. Numerous studies have assessed the efficacy of SSRIs for this indication.[61][62][63][64] SSRIs have also been studied for anxiety disorders in children and adolescents.[67]

Clomipramine, the tricyclic antidepressant that most specifically inhibits the reuptake of serotonin, has been shown to be effective in the treatment of OCD in uncontrolled trials since the 1960s.[105]

Because of their more benign side-effect profile, SSRIs are considered the first-line pharmacological treatment for OCD with or without concurrent CBT,[53][55][70] although clomipramine is also widely used as a first-line treatment.

Higher SSRI doses are often required to achieve symptom reduction in OCD than are used in depression, and improvement is usually slower and requires more time than is typically required in depressive conditions (10 to 12 weeks).[25][106]​

Primary options

fluoxetine: children >7 years of age: 10 mg/day orally (immediate-release) initially, increase by 10 mg/day increments every 2-3 weeks according to response, maximum 60 mg/day; adults: 20mg/day orally (immediate-release) initially, increase by 10-20 mg/day increments every 2-3 weeks according to response, maximum 60 mg/day

OR

fluvoxamine: children >8 years of age: 25 mg/day orally (immediate-release) initially, increase by 25 mg/day increments every 4-7 days according to response, maximum 200 mg/day (children <12 years of age) or 300 mg/day (children >12 years of age); adults: 50 mg/day orally (immediate-release or extended-release) initially, increase by 50 mg/day increments every 4-7 days according to response, maximum 300 mg/day

OR

paroxetine: adults: 20 mg/day orally (immediate-release) initially, increase by 10 mg/day increments every 7 days according to response, maximum 60 mg/day

OR

sertraline: children >6 years of age: 25 mg/day orally initially, increase by 25-50 mg/day increments every 7 days according to response, maximum 200 mg/day; adults: 50 mg/day orally initially, increase by 25-50 mg/day increments every 7 days according to response, maximum 200 mg/day

OR

clomipramine: adults: 25 mg/day orally initially, increase by 25 mg/day increments every 4-7 days up to 100 mg/day in first 2 weeks, then continue increasing dose gradually according to response, maximum 250 mg/day

1st line – pharmacotherapy

Back
ACUTE
|
mild to moderate symptoms: without comorbid personality disorders or dissociative symptoms
1st line – 

pharmacotherapy

Patients with mild to moderate symptoms include those with Yale-Brown Obsessive-Compulsive Scale scores of 8 to 23. Pharmacotherapy alone is recommended when CBT is unavailable, when the patient prefers drug treatment alone, or when the patient has a history of responding well to a particular agent.[53][55]

For these patients, pharmacotherapy with either a selective serotonin-reuptake inhibitor (SSRI) or a tricyclic antidepressant (e.g., clomipramine) is another first-line treatment option. Numerous studies have assessed the efficacy of SSRIs for this indication.[61][62][63][64] SSRIs have also been studied for anxiety disorders in children and adolescents.[67]

Clomipramine, the tricyclic antidepressant that most specifically inhibits the reuptake of serotonin, has been shown to be effective in the treatment of OCD in uncontrolled trials since the 1960s.[105]

Because of their more benign side-effect profile, SSRIs are considered the first-line pharmacological treatment for OCD with or without concurrent CBT,[53][55][70] although clomipramine is also widely used as a first-line treatment.

Higher SSRI doses are often required to achieve symptom reduction in OCD than are used in depression, and improvement is usually slower and requires more time than is typically required in depressive conditions (10 to 12 weeks).[25][106]​​

Primary options

fluoxetine: children >7 years of age: 10 mg/day orally (immediate-release) initially, increase by 10 mg/day increments every 2-3 weeks according to response, maximum 60 mg/day; adults: 20mg/day orally (immediate-release) initially, increase by 10-20 mg/day increments every 2-3 weeks according to response, maximum 60 mg/day

OR

fluvoxamine: children >8 years of age: 25 mg/day orally (immediate-release) initially, increase by 25 mg/day increments every 4-7 days according to response, maximum 200 mg/day (children <12 years of age) or 300 mg/day (children >12 years of age); adults: 50 mg/day orally (immediate-release or extended-release) initially, increase by 50 mg/day increments every 4-7 days according to response, maximum 300 mg/day

OR

paroxetine: adults: 20 mg/day orally (immediate-release) initially, increase by 10 mg/day increments every 7 days according to response, maximum 60 mg/day

OR

sertraline: children >6 years of age: 25 mg/day orally initially, increase by 25-50 mg/day increments every 7 days according to response, maximum 200 mg/day; adults: 50 mg/day orally initially, increase by 25-50 mg/day increments every 7 days according to response, maximum 200 mg/day

OR

clomipramine: adults: 25 mg/day orally initially, increase by 25 mg/day increments every 4-7 days up to 100 mg/day in first 2 weeks, then continue increasing dose gradually according to response, maximum 250 mg/day

Consider – cognitive behavioural therapy

Back
ACUTE
|
mild to moderate symptoms: without comorbid personality disorders or dissociative symptoms
Consider – 

cognitive behavioural therapy

Additional treatment recommended for SOME patients in selected patient group

Cognitive behavioural therapy (CBT) involves exposure and response prevention (ERP).[53][55][56][104] Combined treatment with pharmacotherapy and CBT may be considered in people who do not have a satisfactory response to monotherapy.

A graded hierarchy of symptom triggers is created with each patient. The therapist then encourages the patient to expose him- or herself to the trigger (e.g., dirt). The patient is then encouraged to refrain from engaging in compulsive rituals (e.g., hand washing).

As symptoms begin to improve, more intense triggers are targeted. In addition, homework assignments focus on exposure to stimuli in naturalistic settings such as the home.

2nd line – increase in dose of current medication or consideration of combination drug therapy

Back
ACUTE
|
mild to moderate symptoms: without comorbid personality disorders or dissociative symptoms
2nd line – 

increase in dose of current medication or consideration of combination drug therapy

The first step in the case of a partial responder (25% to 35% reduction in Yale-Brown Obsessive-Compulsive Scale [Y-BOCS] score) at the sixth to eighth week of treatment should be to increase the dose of the current medication.

At 12 weeks, if a patient has exhibited a partial response to an agent, one might prefer to utilise augmentation strategies instead of switching to a different drug. Augmentation strategies include: increasing the current medication to the highest tolerable dose; using intravenous citalopram or clomipramine (however, these formulations are not available in general clinical settings in the US); or combining regimens (e.g., selective serotonin-reuptake inhibitor [SSRI] plus clomipramine, or SSRI plus an antipsychotic medication).[80]​

Caution is advised when using citalopram, due to association with QT interval prolongation. Special caution is advised in those over 60 years of age or in those who have pre-existing potential for QTc prolongation/arrhythmias either due to inherent disease or due to other concomitant medications.[55][69][78]

If the patient does not respond to the highest tolerated dose of SSRI for 12 weeks, augmentation with an antipsychotic medication may be considered. It should also be noted that some antidepressants may inhibit antipsychotic metabolism; cytochrome P450 2D6 inhibition by fluoxetine and paroxetine may be particularly important. Several studies have suggested that risperidone is effective as an augmentation agent in OCD.[81][82][83][84][86]​ Evidence also exists for haloperidol, quetiapine, and olanzapine.[85][86][89][107][108][109][110][111]​ Due to an association with metabolic syndrome, use should be accompanied by screening of lipids, fasting glucose, and other metabolic syndrome indicators.

Prior to starting combination therapy with an SSRI plus clomipramine, a screening EKG should be performed, heart rate and BP should be monitored as the dose is titrated, and plasma levels of clomipramine and desmethylclomipramine should be assayed 2 to 3 weeks after reaching a dose of 50 mg/day.[53] The total plasma level of clomipramine and desmethylclomipramine should be kept below 500 nanograms/mL in order to avoid CNS and/or cardiac toxicity.[53][112]

Consider – cognitive behavioural therapy

Back
ACUTE
|
mild to moderate symptoms: without comorbid personality disorders or dissociative symptoms
Consider – 

cognitive behavioural therapy

Additional treatment recommended for SOME patients in selected patient group

If the patient has not had an adequate trial of cognitive behavioural therapy (CBT), in the form of exposure and response prevention, it should be added to the treatment regimen.

A graded hierarchy of symptom triggers is created with each patient. The therapist then encourages the patient to expose him- or herself to the trigger (e.g., dirt). The patient is then encouraged to refrain from engaging in compulsive rituals (e.g., hand washing).

As symptoms begin to improve, more intense triggers are targeted. In addition, homework assignments focus on exposure to stimuli in naturalistic settings such as the home.

3rd line – consideration of switching to a different antidepressant

Back
ACUTE
|
mild to moderate symptoms: without comorbid personality disorders or dissociative symptoms
3rd line – 

consideration of switching to a different antidepressant

If patients have not achieved at least a 25% reduction in Y-BOCS score or a 4 on the clinical global impression (CGI) scale after 12 weeks at full dose of a single drug, switching to a different drug is recommended, as patients may respond to one drug better than another.[53][55] However, one should keep in mind that there is also evidence suggesting that patients who failed to respond to the initial drug may be less likely than treatment-naive patients to respond to further trials of other drugs.[103]

The label 'treatment-resistant' is generally used to describe patients who have failed to respond to at least two adequate trials of clomipramine or selective serotonin-reuptake inhibitor (SSRI) (at least 12 weeks). After trials with clomipramine and at least two SSRIs, with augmentation using CBT, a patient may be classified as a non-responder.

Primary options

fluoxetine: children >7 years of age: 10 mg/day orally (immediate-release) initially, increase by 10 mg/day increments every 2-3 weeks according to response, maximum 60 mg/day; adults: 20mg/day orally (immediate-release) initially, increase by 10-20 mg/day increments every 2-3 weeks according to response, maximum 60 mg/day

OR

fluvoxamine: children >8 years of age: 25 mg/day orally (immediate-release) initially, increase by 25 mg/day increments every 4-7 days according to response, maximum 200 mg/day (children <12 years of age) or 300 mg/day (children >12 years of age); adults: 50 mg/day orally (immediate-release or extended-release) initially, increase by 50 mg/day increments every 4-7 days according to response, maximum 300 mg/day

OR

paroxetine: adults: 20 mg/day orally (immediate-release) initially, increase by 10 mg/day increments every 7 days according to response, maximum 60 mg/day

OR

sertraline: children >6 years of age: 25 mg/day orally initially, increase by 25-50 mg/day increments every 7 days according to response, maximum 200 mg/day; adults: 50 mg/day orally initially, increase by 25-50 mg/day increments every 7 days according to response, maximum 200 mg/day

OR

clomipramine: adults: 25 mg/day orally initially, increase by 25 mg/day increments every 4-7 days up to 100 mg/day in first 2 weeks, then continue increasing dose gradually according to response, maximum 250 mg/day

Consider – cognitive behavioural therapy

Back
ACUTE
|
mild to moderate symptoms: without comorbid personality disorders or dissociative symptoms
Consider – 

cognitive behavioural therapy

Additional treatment recommended for SOME patients in selected patient group

If the patient has not had an adequate trial of cognitive behavioural therapy (CBT), in the form of exposure and response prevention, it should be added to the treatment regimen.

A graded hierarchy of symptom triggers is created with each patient. The therapist then encourages the patient to expose him- or herself to the trigger (e.g., dirt). The patient is then encouraged to refrain from engaging in compulsive rituals (e.g., hand washing).

As symptoms begin to improve, more intense triggers are targeted. In addition, homework assignments focus on exposure to stimuli in naturalistic settings such as the home.

4th line – further specialist evaluation

Back
ACUTE
|
mild to moderate symptoms: without comorbid personality disorders or dissociative symptoms
4th line – 

further specialist evaluation

After trials with clomipramine and at least two selective serotonin-reuptake inhibitors (SSRIs), with augmentation using cognitive behavioural therapy, a patient may be classified as a non-responder.

Rarely, cases may be related to an organic cause (e.g., neurodegenerative processes, post-stroke OCD phenomena, hypothyroidism, or other so-called 'acquired' forms of OCD that can occur as a result of Huntington's disease, Sydenham's chorea, rheumatic fever, bacterial or viral infection, or encephalitis). The characteristics of the residual clinical features should guide the choice of further treatment.

At this point, further consultant evaluation is suggested, as other augmentation regimens may be warranted, depending on comorbidities or prevalent features in the individual patient's OCD symptomatology.

severe symptoms or with comorbid personality disorders or dissociative symptoms

1st line – cognitive behavioural therapy plus pharmacotherapy

Back
ACUTE
|
severe symptoms or with comorbid personality disorders or dissociative symptoms
1st line – 

cognitive behavioural therapy plus pharmacotherapy

Patients with severe symptoms include those with Yale-Brown Obsessive-Compulsive Scale scores of 24 to 40.

Drug therapy may alleviate severe symptoms enough to allow participation in cognitive behavioural therapy (CBT).[53][55]

Those who do not respond to monotherapy with either CBT or pharmacotherapy, especially those who have comorbid personality disorders or dissociative symptoms, may benefit from combined therapy.[74][75][76]

Combining CBT with pharmacotherapy is indicated as first-line treatment for comorbid OCD with depression.

Primary options

cognitive behavioural therapy

-- AND --

fluoxetine: children >7 years of age: 10 mg/day orally (immediate-release) initially, increase by 10 mg/day increments every 2-3 weeks according to response, maximum 60 mg/day; adults: 20 mg/day orally (immediate-release) initially, increase by 10-20 mg/day increments every 2-3 weeks according to response, maximum 60 mg/day

or

fluvoxamine: children >8 years of age: 25 mg/day orally (immediate-release) initially, increase by 25 mg/day increments every 4-7 days according to response, maximum 200 mg/day (children <12 years of age) or 300 mg/day (children >12 years of age); adults: 50 mg/day orally (immediate-release or extended-release) initially, increase by 50 mg/day increments every 4-7 days according to response, maximum 300 mg/day

or

paroxetine: adults: 20 mg/day orally (immediate-release) initially, increase by 10 mg/day increments every 7 days according to response, maximum 60 mg/day

or

sertraline: children >6 years of age: 25 mg/day orally initially, increase by 25-50 mg/day increments every 7 days according to response, maximum 200 mg/day; adults: 50 mg/day orally initially, increase by 25-50 mg/day increments every 7 days according to response, maximum 200 mg/day

or

clomipramine: adults: 25 mg/day orally initially, increase by 25 mg/day increments every 4-7 days up to 100 mg/day in first 2 weeks, then continue increasing dose gradually according to response, maximum 250 mg/day

2nd line – increase in dose of current medication or consideration of combination drug therapy

Back
ACUTE
|
severe symptoms or with comorbid personality disorders or dissociative symptoms
2nd line – 

increase in dose of current medication or consideration of combination drug therapy

The first step in the case of a partial responder at the sixth to eighth week of treatment should be to increase the dose of the current medication. This may involve increasing the dose to the highest tolerable dose beyond what is approved for this indication.

At 12 weeks, if a patient has exhibited a partial response to an agent, one might prefer to utilise augmentation strategies instead of switching to a different drug. Augmentation strategies include: increasing the current medication to the highest tolerable dose; using intravenous citalopram or clomipramine (however, these formulations are not available in general clinical settings in the US); or combining regimens (e.g., selective serotonin-reuptake inhibitor (SSRI) plus clomipramine, or SSRI plus an antipsychotic medication).[80]​

Caution is advised when using citalopram, due to association with QT interval prolongation. Special caution is advised in those over 60 years of age or in those who have pre-existing potential for QTc prolongation/arrhythmias either due to inherent disease or due to other concomitant medications.[55][69][78]

If the patient does not respond to the highest tolerated dose of SSRI for 12 weeks, augmentation with an antipsychotic medication may be considered. It should also be noted that some antidepressants may inhibit antipsychotic metabolism; cytochrome P450 2D6 inhibition by fluoxetine and paroxetine may be particularly important. Several studies have suggested that risperidone is effective as an augmentation agent in OCD.[81][82][83][84][86]​ Evidence also exists for haloperidol, quetiapine, and olanzapine.[85][86][89][107][108][109][110][111]​ Due to an association with metabolic syndrome, use should be accompanied by screening of lipids, fasting glucose, and other metabolic syndrome indicators.

Prior to starting combination therapy with an SSRI plus clomipramine, a screening ECG should be performed, heart rate and BP should be monitored as the dose is titrated, and plasma levels of clomipramine and desmethylclomipramine should be assayed 2 to 3 weeks after reaching a dose of 50 mg/day.[53] The total plasma level of clomipramine and desmethylclomipramine should be kept below 500 nanograms/mL in order to avoid CNS and/or cardiac toxicity.[53][112]

Consider – cognitive behavioural therapy

Back
ACUTE
|
severe symptoms or with comorbid personality disorders or dissociative symptoms
Consider – 

cognitive behavioural therapy

Additional treatment recommended for SOME patients in selected patient group

If the patient has not had an adequate trial of cognitive behavioural therapy (CBT), in the form of exposure and response prevention (ERP), it should be added to the treatment regimen.

A graded hierarchy of symptom triggers is created with each patient. The therapist then encourages the patient to expose him- or herself to the trigger (e.g., dirt). The patient is then encouraged to refrain from engaging in compulsive rituals (e.g., hand washing).

As symptoms begin to improve, more intense triggers are targeted. In addition, homework assignments focus on exposure to stimuli in naturalistic settings such as the home.

3rd line – consideration of switching to a different antidepressant

Back
ACUTE
|
severe symptoms or with comorbid personality disorders or dissociative symptoms
3rd line – 

consideration of switching to a different antidepressant

If patients have not achieved at least a 25% reduction in Y-BOCS score or a 4 on the clinical global impression (CGI) scale after 12 weeks at full dose of a single drug, switching to a different drug is recommended, as patients may respond to one drug better than another.[53][55] However, one should keep in mind that there is also evidence suggesting that patients who failed to respond to the initial drug may be less likely than treatment-naive patients to respond to further trials of other drugs.[103]

The label 'treatment-resistant' is generally used to describe patients who have failed to respond to at least two adequate trials of clomipramine or selective serotonin-reuptake inhibitor (SSRI) (at least 12 weeks). After trials with clomipramine and at least two SSRIs, with augmentation using cognitive behavioural therapy, a patient may be classified as a non-responder.

Primary options

fluoxetine: children >7 years of age: 10 mg/day orally (immediate-release) initially, increase by 10 mg/day increments every 2-3 weeks according to response, maximum 60 mg/day; adults: 20mg/day orally (immediate-release) initially, increase by 10-20 mg/day increments every 2-3 weeks according to response, maximum 60 mg/day

OR

fluvoxamine: children >8 years of age: 25 mg/day orally (immediate-release) initially, increase by 25 mg/day increments every 4-7 days according to response, maximum 200 mg/day (children <12 years of age) or 300 mg/day (children >12 years of age); adults: 50 mg/day orally (immediate-release or extended-release) initially, increase by 50 mg/day increments every 4-7 days according to response, maximum 300 mg/day

OR

paroxetine: adults: 20 mg/day orally (immediate-release) initially, increase by 10 mg/day increments every 7 days according to response, maximum 60 mg/day

OR

sertraline: children >6 years of age: 25 mg/day orally initially, increase by 25-50 mg/day increments every 7 days according to response, maximum 200 mg/day; adults: 50 mg/day orally initially, increase by 25-50 mg/day increments every 7 days according to response, maximum 200 mg/day

OR

clomipramine: adults: 25 mg/day orally initially, increase by 25 mg/day increments every 4-7 days up to 100 mg/day in first 2 weeks, then continue increasing dose gradually according to response, maximum 250 mg/day

Consider – cognitive behavioural therapy

Back
ACUTE
|
severe symptoms or with comorbid personality disorders or dissociative symptoms
Consider – 

cognitive behavioural therapy

Additional treatment recommended for SOME patients in selected patient group

If the patient has not had an adequate trial of cognitive behavioural therapy (CBT), in the form of exposure and response prevention, it should be added to the treatment regimen.

A graded hierarchy of symptom triggers is created with each patient. The therapist then encourages the patient to expose him- or herself to the trigger (e.g., dirt). The patient is then encouraged to refrain from engaging in compulsive rituals (e.g., hand washing).

As symptoms begin to improve, more intense triggers are targeted. In addition, homework assignments focus on exposure to stimuli in naturalistic settings such as the home.

4th line – further specialist evaluation

Back
ACUTE
|
severe symptoms or with comorbid personality disorders or dissociative symptoms
4th line – 

further specialist evaluation

After trials with clomipramine and at least two selective serotonin-reuptake inhibitors (SSRIs), with augmentation using cognitive behavioural therapy, a patient may be classified as a non-responder.

Rarely, cases may be related to an organic cause (e.g., neurodegenerative processes, post-stroke OCD phenomena, hypothyroidism, or other so-called 'acquired' forms of OCD that can occur as a result of Huntington's disease, Sydenham's chorea, rheumatic fever, bacterial or viral infection, or encephalitis). The characteristics of the residual clinical features should guide the choice of further treatment.

At this point, further consultant evaluation is suggested, as other augmentation regimens may be warranted, depending on comorbidities or prevalent features in the individual patient's OCD symptomatology.

back arrow

Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer