Text Size :
A A A

Treating Obsessive-Compulsive Disorder (OCD)

The following treatment guidelines are meant as a reference tool only, and are not intended as treatment advice or to replace the clinical decision-making process of psychiatrists or other health professionals who administer these treatments. In clinical practice there are often good reasons why treatment approaches differ from what is described here.

 

Children and adolescents, or adults with severe forms of OCD or with co-occuring Major Depression, should begin with Steps 1 and 2 simultaneously. For all other individuals, start at Step 1.

Step 1:  Start a course of psychotherapy (either CBT, ERP, or a therapy that combines these two methods)

    • If the OCD symptoms resolve fully, treatment can be stopped once the course of therapy is complete, though clinical follow-up should continue
    • If after 8 weeks of once-weekly therapy sessions there is no improvement in the OCD symptoms, or if after 20 sessions there is not a complete recovery, go to Step 2 while continuing the therapy.

Step 2:  Start an SSRI medication

    • If the OCD symptoms resolve completely, go to Step 8.
    • If after 4-6 weeks at a therapeutic dose there is no improvement in the OCD symptoms, stop this medication and go to Step 3.
    • If after 4-6 weeks at a therapeutic dose the OCD symptoms have improved but not resolved, increase the dose every 2 weeks until the symptoms resolve or the maximum dose has been reached, keeping in mind that very high doses are often required (see individual medication information for dosage ranges). 
      • If with this approach the OCD symptoms resolve completely, go to Step 7. 
      • If after 4 weeks at the maximum tolerated dose the OCD symptoms have not resolved, go to Step 4.

Step 3:  Switch the medication to one of the following options:

    • If the OCD symptoms resolve completely, go to Step 8.
    • If after 4-6 weeks at a therapeutic dose there is no improvement in the OCD symptoms, repeat Step 3.
    • If after 4 weeks at a therapeutic dose the OCD symptoms have improved but not resolved, increase the dose every 2 weeks until the symptoms resolve or the maximum dose has been reached, keeping in mind that very high doses of SSRIs are often required (see individual medication information for dosage ranges). 
      • If with this approach the OCD symptoms resolve completely, go to Step 7. 
      • If after 4 weeks at the maximum tolerated dose the OCD symptoms have not resolved, go to Step 4.

Step 4:  Add one of the following medications:

Step 5:  Add one of the following medications:

    • If the OCD symptoms resolve completely, go to Step 8.
    • If after 2 weeks at a therapeutic dose there is no improvement in the OCD symptoms, stop the new medication and then repeat Step 5 or go to Step 6.
    • If after 4 weeks at an optimal dose the episode has improved but not resolved, continue the new medication at its current dose and repeat Step 5 or go to Step 6.

Step 6:  Try a course of ECT  

    • If the OCD symptoms resolve completely, go to Step 8.
    • If the symptoms do not resolve completely after a full course of ECT, go to Step 7.

Step 7:  Try one of the following treatments (for carefully selected patients only):

    • If the OCD symptoms resolve completely, go to Step 8.
    • If the symptoms do not resolve completely repeat Step 7.

Step 8:  Maintenance treatment

    • There is insufficient research to make any definitive recommendations on how long to continue treatment following recovery.
    • Medications should probably be continued for at least 6 months after full recovery. However, in cases where the symptoms were severe or difficult to treat, it would make sense to continue all effective medications for longer, and in some cases indefinitely.
    • Whenever it is decided to stop medications, this should be done one medication at a time, and gradually, not quicker than 4 weeks per medication.
    • There is no evidence to support the use of booster sessions of CBT / ERP after recovery, but these can be considered on a case by case basis.

 

prev

Overview of Treatments