A 35-year-old man with OCD fails to respond after 12 weeks of fluoxetine 60 mg/day combined with adequate CBT/ERP therapy. The MOST appropriate pharmacological augmentation strategy is:

• A Add a low-dose antipsychotic (risperidone or aripiprazole) ✓
• B Add lithium
• C Switch to a TCA (clomipramine) alone
• D Add valproate

Explanation

For OCD refractory to adequate SSRI trials (at least 8–12 weeks at maximum tolerated dose), augmentation with a low-dose atypical antipsychotic is the FIRST-LINE augmentation strategy. Risperidone and aripiprazole have the strongest evidence base for SSRI augmentation in OCD. Their mechanism involves 5-HT2A/D2 receptor modulation complementing SSRI action on the cortico-striato-thalamo-cortical circuit. Clomipramine (a TCA with serotonin reuptake inhibition) is an option if switching is considered, but adding antipsychotic augmentation to the existing SSRI is the preferred step. Lithium augmentation is primarily used in treatment-resistant depression.

Reference: Kaplan & Sadock's Synopsis of Psychiatry, 11th ed.

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Written and medically reviewed by the StethoPrep medical team.