A 25-year-old man with OCD has failed two adequate SSRI trials (fluoxetine 60 mg for 12 weeks and sertraline 200 mg for 12 weeks). What is the most evidence-based next step?
- A Augment with low-dose risperidone (0.5–2 mg/day) ✓
- B Augment with lithium
- C Switch to venlafaxine
- D Switch to mirtazapine
Correct answer: A. Augment with low-dose risperidone (0.5–2 mg/day)
Explanation
For treatment-resistant OCD (failure of ≥2 adequate SSRI trials), augmentation with a low-dose antipsychotic — specifically risperidone or aripiprazole — has the strongest evidence base (multiple RCTs; included in NICE and APA guidelines). Haloperidol augmentation has also been studied, particularly in OCD with tic disorder. Venlafaxine (SNRI) has limited evidence in OCD and is not a guideline-recommended switch. Lithium augmentation has minimal evidence in OCD. Mirtazapine augmentation has some data but is not first-line augmentation strategy.
Reference: Kaplan & Sadock's Synopsis of Psychiatry, 11th ed.
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