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American Psychiatric Association Guidelines for
Obsessive-Compulsive Disorder

Posted: October 2007  
American Journal of Psychiatry   2007;164:1-56

The APA has issued an updated practice guideline for the treatment of obsessive-compulsive disorder (OCD). The guideline appears in 3 distinct sections: treatment recommendations; background information and review of available evidence; and future research needs. A summary of the treatment recommendations is presented below. The other sections are available in the July 2007 supplement to the American Journal of Psychiatry and on the APA website.

Pharmacotherapy and cognitive behavioral therapy (CBT) are both acceptable first-line treatments for OCD. The choice between the two should be based on the nature and severity of symptoms, treatment history, patient preference, and the availability of a CBT practitioner. CBT focused on exposure and response prevention should be the first choice for patients whose symptom severity does not prevent them from participating in the treatment and for patients who prefer not to use medication. Antidepressant pharmacotherapy is recommended for those who cannot participate in a CBT program, have a history of treatment response with antidepressants, or who request medication. Combining CBT and pharmacotherapy can be considered when patients have comorbid conditions that are expected to respond to an antidepressant and when they want to limit medication exposure.

Clomipramine, fluoxetine, fluvoxaine, paroxetine, and sertraline are all FDA approved for OCD. Head-to-head comparisons show no difference in efficacy between clomipramine and the SSRIs, but the SSRIs have a more benign adverse effect profile. If pharmacoptherapy is selected, properties of each SSRI should be considered when choosing among the drugs. For example, paroxetine has the greatest potential for weight gain and would not be the best choice for patients with obesity or diabetes. Drug interactions and previous response should also be considered. No patient-specific factors have been identified that predict response to any 1 of the agents.

Antidepressants should be initiated at the manufacturer’s recommended dose and then titrated based on response in weekly increments over 4 weeks. Substantial improvement is not expected before 4-6 weeks and some patients require 10-12 weeks of treatment before experiencing treatment gains. The maximum tolerated dosage should be continued for =6 weeks before medication is considered ineffective and a change in treatment is considered. Patients treated with high-dose SSRIs should be carefully monitored for adverse effects including serotonin syndrome. After pharmacotherapy is started, follow-up visits should be frequent, varying based on patient-specific factors (e.g., severity, comorbid conditions) from every few days to 2 weeks.

First-line CBT can be delivered in individual, group, or family sessions at a frequency of at least 1 session/week for 13-20 weeks. Patients who require more intensive initial treatment can be treated with daily sessions for 3 weeks. Booster sessions are recommended for patients with more severe illness and for those likely to relapse. To prevent relapse, successful pharmacotherapy should be continued for 1-2 years before being gradually tapered and monthly CBT booster sessions should be completed for at least 3-6 months.

Treatment changes should be considered if acceptable response is not obtained after 13-20 weeks of weekly CBT, 3 weeks of daily CBT, or 8-12 weeks of SSRI therapy. Augmentation is preferred in patients with partial response. Partial SSRI responders should receive augmentation with either an antipsychotic or with CBT. Patients not responding completely to CBT should have the intensity increased (e.g., from weekly to daily) or begin concomitant treatment with one of the SSRIs. Patients who do not respond at all to their first SSRI should be switched to another SSRI or to mirtazapine. There is little evidence supporting further treatment options but some research has suggested augmenting SSRIs with clomipramine, buspirone, pindolol, riluzole, or morphine sulfate. Monotherapy with D-amphetamine, tramadol, an MAOI, ondansetron, transcranial magnetic stimulation or deep brain stimulation have also been tried, but little evidence supports their use.