A 22-year-old medical student has intrusive thoughts of contamination and performs elaborate washing rituals for 3–4 hours daily. He recognises the thoughts are irrational but cannot resist. For pharmacotherapy, which regimen is MOST appropriate if he fails to respond to adequate first-line monotherapy?
- A Add an atypical antipsychotic (risperidone or aripiprazole) to the current SSRI — augmentation strategy ✓
- B Add lithium augmentation
- C Switch to a different SSRI at maximum tolerated dose for 12 weeks before declaring failure
- D Switch to a benzodiazepine and CBT alone
Explanation
OCD treatment follows a stepped approach. First-line is SSRI (at maximum tolerated dose, for at least 10–12 weeks) combined with CBT (ERP). If adequate SSRI monotherapy (two trials) fails, the evidence-based augmentation strategy is adding a low-dose atypical antipsychotic — risperidone and aripiprazole have the strongest RCT evidence for OCD augmentation (haloperidol also works but has more side effects). Lithium augmentation is not evidence-based for OCD. Benzodiazepines are not effective for OCD. Augmentation is preferred over switching once adequate trials have been completed.
Reference: Kaplan & Sadock's Synopsis of Psychiatry, 11th ed.
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Written and medically reviewed by the StethoPrep medical team.