MANAGEMENT OF TREATMENT-REFRACTORY OBSESSIVE-COMPULSIVE DISORDER PATIENTS

Often obsessive compulsive disorder (OCD) patients are labeled as trea tment refractory when some first-line options have not been fully expl ored. Most patients should be encouraged to participate in behavior th erapy, even when pharmacotherapy alone has been partially successful. Antiobsessional agents such as clomipramine, fluoxetine, and fluvoxami ne should be considered first-line drugs. Their prescription for a suf ficient time and at therapeutic doses is imperative. Enhancement strat egies for a selected group of OCD patients include low-dose high-poten cy neurleptics. In addition, clonazepam can be helpful in augmenting t he response to a first-line drug. Results from controlled studies with lithium and buspirone have been disappointing. If most of these pharm acologic alternatives fail, MAOIs appear to be the next best choice. S ince in the future most referrals for treatment-refractory OCD patient s will emanate from nonpsychiatrists, following a systematic strategy in their evaluation and pharmacologic management is most important.