A 28-year-old woman with OCD has failed two adequate SSRI trials at maximum tolerated doses. Which pharmacological augmentation strategy has the strongest evidence base for treatment-resistant OCD?

• A Switch to a benzodiazepine
• B Add lithium carbonate
• C Add methylphenidate
• D Augmentation with low-dose haloperidol or risperidone ✓

Explanation

For OCD unresponsive to two adequate SSRI trials, augmentation with a low-dose antipsychotic (haloperidol, risperidone, quetiapine) has the strongest evidence and is the recommended next step per current guidelines. Antipsychotic augmentation is particularly effective in OCD patients with comorbid tic disorders (haloperidol and risperidone have the best RCT data). Lithium augmentation lacks evidence in OCD. Methylphenidate is not an evidence-based strategy for OCD. Benzodiazepines address comorbid anxiety but do not reduce obsessions/compulsions.

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

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