Treatment Criteria for OCD

Physical Treatment Methods

As a guiding principle, all of the physical treatments that have been shown to be effective in OCD (preferably in randomised, controlled trials) must have been tried in adequate dosage for an adequate period of time. In general terms, this will reflect the prescription of antidepressant drugs within, or sometimes above, the dose range recommended by the BNF for a period of 12-16 weeks.

Treatment gains can accrue slowly and premature termination of treatment trials should be avoided. Most patients referred for assessment will have been exposed to many different treatment trials. The following represent those deemed ‘essential’ before proceeding to surgery.

The minimum inclusion criteria are:

  1. At least one course of treatment with the tricyclic antidepressant drug clomipramine for 12-16 weeks in a dose in excess of 150 mg/day. Except in exceptional circumstances, the dose should be titrated upwards towards a target of 250 mg/day (or above) depending on tolerability. Compliance may be determined by plasma level estimation where deemed necessary.
  2. At least two courses of treatment with different selective serotonin re-uptake inhibitors (SSRI's) (fluoxetine, fluvoxamine, paroxetine, citalopram, sertraline or escitalopram) at a maximally tolerated dose for a period of 12-16 weeks. This may involve the prescription of these drugs at a dose in excess of the BNF maximum recommended dosage. Other than in exceptional circumstances, ALL of the drugs from the SSRI class ought to be tried, sequentially, in full dosage (or maximum tolerated dosage), for an adequate period of time. (the target dose for fluoxetine would be at least 60 mg/day, fluvoxamine at least 300 mg/day, sertraline at least 200mg/day, citalopram at least 60 mg/day and paroxetine 60-80 mg/day).
  3. A single trial of a maximally tolerated dose of the serotonin and noradrenaline reuptake inhibitor venlafaxine.
  4. At least one trial of clomipramine or an SSRI plus antipsychotic drug augmentation for a period of 12 weeks. Please note – antipsychotic drugs are not effective as monotherapy for OCD and should be avoided other than as augmenting agents. The drugs which have been demonstrated to exert some benefit in resistant OCD are risperidone (up to 3mg daily) and quetiapine (up to 200-300mg daily).
  5. The value of olanzapine, amisulpride and clozapine is uncertain. Clozapine has been reported to provoke OCD symptoms, in the absence of co-morbid schizophrenia, should generally be avoided. (NB: older antipsychotic drugs such as pimozide and haloperidol may be tried particularly where OCD is co-morbid with Tic disorders or psychotic symptoms).
  6. It is also anticipated that additional strategies may have been tried (e.g. combination of two SSRI’s or SSRI with clomipramine, intravenous administration of clomipramine) but these are not absolute requirements. There is insufficient evidence upon which to base a recommendation for a trial of either ECT or transcranial magnetic stimulation (rTMS) for refractory OCD. However, for patients with severe co-morbid depression, ECT may be considered.

Psychological treatment methods.

  1. At least one sustained trial (>26 weeks) of exposure and response prevention under the supervision of a BABCP-accredited therapist (minimum therapist contact time 90min per week). Whenever possible, we would expect a period (12 weeks) of in-patient behavioural therapy, conducted in a specialist unit. However, many sufferers are unwilling, for a variety of reasons, to consent to this. Cognitive therapy can also be an effective adjunct to exposure treatment if intrusive thoughts and ruminations are prominent. Again, trials of cognitive therapy ought to be conducted under the supervision of a BABCP-accredited therapist.