How do you deal with partial responders in OCD?

[Iparksiako]

I wonder what other Psychiatrists do in case of partial responders in these aspects of it:

1. Do you ever utilize higher than FDA approved doses of SSRIs?

2. Do you combine clomipramine with SSRIs? If yes, what's your approach?

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[calvnandhobbs68]

I wonder what other Psychiatrists do in case of partial responders in these aspects of it:

1. Do you ever utilize higher than FDA approved doses of SSRIs?

2. Do you combine clomipramine with SSRIs? If yes, what's your approach?

Yes, for sure. It's pretty clear you often actually have to go above FDA approved doses of SSRIs to get a good response in OCD. Like 200mg of Zoloft for example isn't even a real trial for OCD clinics.

 

[ObsequiousAplomb]

Yes, I go higher if necessary. Most importantly I make sure to wait long enough to ensure they've had enough time to respond. I know that historically people say you need to go really high on the doses, and at the same time there's a fair amount of data out there that it's time at a dose that is more important than the max dose. I believe the claim is that if you have someone taking an SSRI for 6 months you generally are at an above PDR max dose, but that the response rates aren't terribly different from 6 months at a lower dose.

Usually I do a monotherapy with clomipramine prior to using it as an augmenter. If I can't get them in with a good CBT therapist then I do it myself. I haven't had anyone yet who didn't respond to that, but I admit it's a numbers game. Despite all the adverse effects listed for clomipramine, the only one that has actually stopped my patients is the night sweats. First there's behavioral / comfort issues to address. Clonidine has worked fine when I've tried to address the sweats with medications.

 

[MacDonaldTriad]

Partial OCD response is the rule and not the exception. People try SGAs, but there is a lot of examples of people who get worse because of the 5HT-2 antagonism. This can go either way. You can try it but keep an eye on it and stop it unless they go in the right direction.

 

[Stagg737]

I've gone as high as 120mg of fluoxetine and 50mg of lexapro. I've rarely combined clomipramine with an SSRI (maybe 2-3 times) and it was no more effective than the clomipramine alone. I have used Abilify and mirtazapine as augmenting agents a couple times with mixed results. I also agree with MD3, I've never seen someone have complete "remission" of true OCD symptoms with medications alone and I don't go much over recommended dosing if the patient isn't also in therapy unless they've done it extensively in the past and can show they don't need a refresher with their coping skills. @clausewitz2 can probably give much better responses.

 

[Jules A]

Even what could be considered well controlled OCD still seems to wax and wane at times without a clear precipitant.

 

[birchswing]

Partial OCD response is the rule and not the exception. People try SGAs, but there is a lot of examples of people who get worse because of the 5HT-2 antagonism. This can go either way. You can try it but keep an eye on it and stop it unless they go in the right direction.

<Not a doctor or medical student>

I had read about the new DSM diagnosis of drug-induced OCD and it included SGAs that are sometimes used to treat OCD as second or third-line therapies.

Is the 5HT-2 antagonism also why some people with OCD get better on them? I assumed that was the part that would assist in treating OCD. I had looked at one point to see if there was some drug that was just a 5HT2 antagonist without other targets, but if I recall correctly, there were only research molecules that were like that.

 

[clausewitz2]

1. I routinely go over FDA recommended max for SSRIs and in fact treat the recommended max as more or less the first dose to try barring very compelling reasons to not ramp up quickly (or doubt about the diagnosis). So sertraline, for instance, I go rapidly to 200 (up by 50 per week), then hang out for 6-8 weeks. If we get zero response (I supplement interview by OCI-R) then on we go to 400 mg. If partial response we wait until at least 10-12 weeks after initiation before making changes.

2. If partial but unsatisfactory response to SSRIs, you could try a different SSRI at maximum dose. i cross-titrate over five days from, say, sertraline 400 to fluoxetine 100/120. I've literally never had anyone who tolerated high dose SRIs in the first place have any issues with this. More often we add 50 mg clomipramine to the 400 sertraline. This is most often a way station on the road to clomipramine alone but a) helps assess tolerability of clomipramine b) sometimes works out and c) despite being generic Anafranil has gotten super expensive in the last five years or so. If we transition to clomipramine mono we do it over about five days to come down on SSRI while increasing to 250 clomipramine. Again, this switch rarely causes problems.

3. SE from clomipramine I hear about most is probably sedation, followed by tremors that are dose-dependent and can sometimes be pretty noticeable. Clomipramine is also uniquely likely among TCAs to lower seizure threshold so tricky to use for people with co-morbid epilepsy or TBIs, which are populations with elevated rates of OCD to begin with. Constipation and weight gain also pop up a lot. Most common is dry mouth but usually easy to treat with PRN sugar free lifesavers.

4. For alternatives if clomipramine is not doable for whatever reason, I will augment. Risperidone or abilify are first choices, although never to high doses. Haldol distant third. Literature suggests quetiapine is useless. Clozapine is well-known to provoke OCS in people without previous history of OCD, and olanzapine may have a similar effect. Both not helpful regardless. Past that you get into stuff like buspirone, lamotrigine, phenelzine, ondansetron.

5. I explain why PRNs are not a thing we are going to be doing. I beat the drum for E/RP early and often and point them to NOCD if I have to.

 

[clausewitz2]

Even what could be considered well controlled OCD still seems to wax and wane at times without a clear precipitant.

The goal of OCD treatment is never, ever, ever to make people stop having intrusive thoughts. I mean, it's great when that happens, nice side benefit, but the actual goal is to just make it so the person in question treats them as irrelevant to their life and decision-making. OCD should become a gnat buzzing around your head. Obnoxious, for sure, and not something anyone would ever choose to have happen to them, but also not going to make you change your plans in the slightest.

 

[Iparksiako]

1. I routinely go over FDA recommended max for SSRIs and in fact treat the recommended max as more or less the first dose to try barring very compelling reasons to not ramp up quickly (or doubt about the diagnosis). So sertraline, for instance, I go rapidly to 200 (up by 50 per week), then hang out for 6-8 weeks. If we get zero response (I supplement interview by OCI-R) then on we go to 400 mg. If partial response we wait until at least 10-12 weeks after initiation before making changes.

2. If partial but unsatisfactory response to SSRIs, you could try a different SSRI at maximum dose. i cross-titrate over five days from, say, sertraline 400 to fluoxetine 100/120. I've literally never had anyone who tolerated high dose SRIs in the first place have any issues with this. More often we add 50 mg clomipramine to the 400 sertraline. This is most often a way station on the road to clomipramine alone but a) helps assess tolerability of clomipramine b) sometimes works out and c) despite being generic Anafranil has gotten super expensive in the last five years or so. If we transition to clomipramine mono we do it over about five days to come down on SSRI while increasing to 250 clomipramine. Again, this switch rarely causes problems.

3. SE from clomipramine I hear about most is probably sedation, followed by tremors that are dose-dependent and can sometimes be pretty noticeable. Clomipramine is also uniquely likely among TCAs to lower seizure threshold so tricky to use for people with co-morbid epilepsy or TBIs, which are populations with elevated rates of OCD to begin with. Constipation and weight gain also pop up a lot. Most common is dry mouth but usually easy to treat with PRN sugar free lifesavers.

4. For alternatives if clomipramine is not doable for whatever reason, I will augment. Risperidone or abilify are first choices, although never to high doses. Haldol distant third. Literature suggests quetiapine is useless. Clozapine is well-known to provoke OCS in people without previous history of OCD, and olanzapine may have a similar effect. Both not helpful regardless. Past that you get into stuff like buspirone, lamotrigine, phenelzine, ondansetron.

5. I explain why PRNs are not a thing we are going to be doing. I beat the drum for E/RP early and often and point them to NOCD if I have to.

Excellent! I've seen other colleagues combining fluvoxamine with clomipramine, but I wouldn't dare do that easily, at least not at high doses.

Do you always combine Clomipramine with Sertraline, or do you do it with Fluvoxamine, Fluoxetine too? (due to 2d6 inhibition).

Do you ask for cardiologic evaluation too for QTc or other noxious effects of clo?

Have you ever had any substantial serotonin toxicity when you do the 400mg sertraline + 50mg clomipramine?

 

[romanticscience]

Any tips for treating people with co-morbid ADHD? I know of no literature but do stimulants make the OC-process better or worse?

I have a few people who likely have some just right obsession, especially when it comes to their thinking, who subjectively think it's a focus issue and want higher stimulants. I think I read somewhere that the cognitive complaints in OCD are really more epiphenomena of the obsessive process and are not demonstrated on testing.

 

[ObsequiousAplomb]

Any tips for treating people with co-morbid ADHD? I know of no literature but do stimulants make the OC-process better or worse?

I have a few people who likely have some just right obsession, especially when it comes to their thinking, who subjectively think it's a focus issue and want higher stimulants. I think I read somewhere that the cognitive complaints in OCD are really more epiphenomena of the obsessive process and are not demonstrated on testing.

Anecdotally stimulants have helped my patients with OCD. There's some literature recommending stimulants as a 4th line option. Just like other treatments there's the risk of exacerbating symptoms.

 

[whopper]

Biological psychiatry had a great algorithm they printed a few years ago. I'll post it if I find it.

The newer atypical antipsychotics strongly bind 5HT1A much more strongly than the prior atypicals. I've found them to be much more effective in treating depression and OCD, even more so than SSRIs in several cases.
Lamotrigine, Buspirone, newer atypicals, but only after several antidepressants have been tried.

 

[Marasmus1]

To me, if there is not exposure/response prevention or some type of CBT in the treatment plan, improvement in OCD is modest at best. I have seen some cases rarely improve more than 50 % with only pharmacotherapy. Never seen any OCD patient in remission with only pharmacotherapy.

 

[Psychresy]

Biological psychiatry had a great algorithm they printed a few years ago. I'll post it if I find it.

The newer atypical antipsychotics strongly bind 5HT1A much more strongly than the prior atypicals. I've found them to be much more effective in treating depression and OCD, even more so than SSRIs in several cases.
Lamotrigine, Buspirone, newer atypicals, but only after several antidepressants have been tried.

Any in particular you like?

 

[MacDonaldTriad]

Like is always the case, clausewitz2 is right, but he/she makes me wonder if there is a clausewitz1.

Pressing SSRIs above the FDA limits is common, but we do risk serotonin syndrome. I would elevate the use of FGAs more than many suggest because there isn't a literature of them causing OCD or worsening OCD and they might help as you reach the end of antidepressant efficacy and risk serotonin syndrome. If you strive for perfection, you will seldom get there. Like panic disorder (an other anxiety disorders if you believe DSM-IV and not DSM-5 which took OCD out of the anxiety disorders chapter) using PRN directions is a bad idea for obsessional patients. It just drives them crazy wondering if they need a PRN.

 

[Liquid8]

The goal of OCD treatment is never, ever, ever to make people stop having intrusive thoughts. I mean, it's great when that happens, nice side benefit, but the actual goal is to just make it so the person in question treats them as irrelevant to their life and decision-making. OCD should become a gnat buzzing around your head. Obnoxious, for sure, and not something anyone would ever choose to have happen to them, but also not going to make you change your plans in the slightest.

Have one patient where this is the direction we’re heading. Was on high doses of Pristiq, Zeldox, plenty of other SSRIs – now clomipramine 250-300mg with no improvement. In this case the presentation is complicated by long standing grief and dependency issues which are frankly unsolvable.

For more straightforward OCD cases, have had good results on Lexapro 50-60mg, Fluoxetine 60-80mg, Zoloft 300mg etc.

 

[whopper]

Best one I've found today but the one I remember was even better. The better one, however, was released before TMS was integrated.

Integrating Deep Transcranial Magnetic Stimulation Into the OCD Treatment Algorithm

As our understanding of the neurobiology of OCD grows, additional treatment options become available and should be thoughtfully integrated into the treatment algorithm. One such option is dTMS.

www.psychiatrictimes.com

 

[whopper]

The one I'm remembering had Buspirone, atypicals, and Lamotrigine integrated into it. while the one above is great the one I remembered was better but this was before TMS.

If my memory serves it was published in Biological Psychiatry.

 

[JKinSC]

1. Do you ever utilize higher than FDA approved doses of SSRIs?

You're not even trying until you go higher than FDA-approved levels

 

[Psychferlyfe3000]

NMDA antagonists have some data behind them. As does TMS and ondansetron (5-HT3 antagonism).

 

[whopper]

Something not mentioned is evidenced-based data states you need to give the antidepressants not just the maximum dosage but up to a 3 month trial for OCD instead of the typical 4-6 week trial for antidepressants for depression.

No one ever told me this in training. I later picked this up reading journal articles later on.

 

[hamstergang]

Something not mentioned is evidenced-based data states you need to give the antidepressants not just the maximum dosage but up to a 3 month trial for OCD

It has been mentioned in this thread more than once, including in the image you posted. But worth noting nonetheless.

 

[Psychferlyfe3000]

What percentage of patients do you guys think have significant sexual dysfunction at these high SSRI doses recommended for OCD? I feel as though the numbers in the literature are not reflecting my clinical experiences in general with sexual dysfunction and SSRIs.

 

[ObsequiousAplomb]

What percentage of patients do you guys think have significant sexual dysfunction at these high SSRI doses recommended for OCD? I feel as though the numbers in the literature are not reflecting my clinical experiences in general with sexual dysfunction and SSRIs.

Do you mean the literature is too high or too low?

For mood and anxiety disorders I see a lot more discontinuation due to sexual dysfunction than I do in OCD. Most of my OCD patients have a substantial enough relief from their OCD symptoms that they choose to continue despite any sexual dysfunction.

 

[whopper]

Quite a lot. When prescribing SSRIs to men go off on a speech where if someone can't get it up they're not a real man then prescribe the medication. Then when the patient's back for a follow up start talking about General Patton and how he was a real man cause he was hard as steel and only real men are hard, then ask the patient, "so how have you been?"

 

[futureapppsy2]

The goal of OCD treatment is never, ever, ever to make people stop having intrusive thoughts. I mean, it's great when that happens, nice side benefit, but the actual goal is to just make it so the person in question treats them as irrelevant to their life and decision-making. OCD should become a gnat buzzing around your head. Obnoxious, for sure, and not something anyone would ever choose to have happen to them, but also not going to make you change your plans in the slightest.

Isn't the baseline occurence of some degree of intrusive thoughts in the general population pretty close to 100%? But I'm not sure if I would agree that treatment shouldn't significantly reduce obsessive thoughts. I mean, that's why EXRP works so well for OCD--The RP part distrupts the obsessive-compulsive feedback loop, so repeated RP also leads to the sharp decrease (and sometimes cessation) of the associated instrusive thoughts.

 

[clausewitz2]

Isn't the baseline occurence of some degree of intrusive thoughts in the general population pretty close to 100%? But I'm not sure if I would agree that treatment shouldn't significantly reduce obsessive thoughts. I mean, that's why EXRP works so well for OCD--The RP part distrupts the obsessive-compulsive feedback loop, so repeated RP also leads to the sharp decrease (and sometimes cessation) of the associated instrusive thoughts.

I mean as a practical matter EX/RP when successful usually does lead to a significant reduction in obsessive thoughts, but it can't be the focus of the treatment, or it can very easily turn into attempts at thought suppression or thought control, i.e. the opposite of what is helpful. The RP part is the way you formalize making the thoughts irrelevant to your action and I agree with you that it is critical. But the client cannot go into this trying not to have the thought if they want to not have the thought. I think it would be extremely challenging to not get sucked into mental compulsions without something like an attitude of acceptance towards the thoughts, though. 'We're doing this to try and make you not have these thoughts" is a hard line for most people to square with "learn to accept the fact you have no ability to stop these thoughts from happening and shouldn't try".

I also have worked with a number of people who tell me that the thoughts absolutely never go away and happen just as often but feels E/RP changed their life because they turn into obnoxious background chatter that doesn't seem super important or compelling.

 

[Desired Member]

Not directly related to OP's question, but the OCD patients I've cared for only have the bothersome obsessive thoughts (almost always ego dystonic, highly bothersome intrusive thoughts about killing others) and no compulsions so there really isn't any ERP to be done. Often times these patients also have bipolar disorder and treating with SSRI or clomipramine causes irritability or other negative mood changes, even when the patient is taking mood stabilizing medication. If anyone has any thoughts or experiences with dealing with these situations, I would be interested to hear them.

 

[clausewitz2]

Not directly related to OP's question, but the OCD patients I've cared for only have the bothersome obsessive thoughts (almost always ego dystonic, highly bothersome intrusive thoughts about killing others) and no compulsions so there really isn't any ERP to be done. Often times these patients also have bipolar disorder and treating with SSRI or clomipramine causes irritability or other negative mood changes, even when the patient is taking mood stabilizing medication. If anyone has any thoughts or experiences with dealing with these situations, I would be interested to hear them.

There is 100% E/RP to be done for these people. Mental rituals can be tricky to identify but are very much a part of the compulsions of OCD, as is rumination generally. I bet if you look closely you're going to find a lot of avoidance as well. You can't have them actually kill people, obviously, but between imaginal exposures and deliberately subjecting themselves to feared situations and triggers of intrusive thoughts you can do a lot of good work. Another critical bit is identifying the core fear explaining why these particular thoughts bother them so much; until you have a solid handle on that it is hard to design effective exposures.

I am always a little skeptical of bipolar/OCD comorbidity, although if they do seem to stop having intrusive thoughts when they are hypo or fully manic, I buy it a lot more readily.

If they genuinely cannot tolerate SRIs then I direct you to my post up thread.

 

[tr]

Quite a lot. When prescribing SSRIs to men go off on a speech where if someone can't get it up they're not a real man then prescribe the medication. Then when the patient's back for a follow up start talking about General Patton and how he was a real man cause he was hard as steel and only real men are hard, then ask the patient, "so how have you been?"

Huh? Are you seeing a lot of ED with SSRIs? I don't treat too many men anymore but I recall more issues with delayed ejaculation and anorgasmia. Doesn't primary care sometimes use SSRIs to treat premature ejaculation?

 

[Desired Member]

There is 100% E/RP to be done for these people. Mental rituals can be tricky to identify but are very much a part of the compulsions of OCD, as is rumination generally. I bet if you look closely you're going to find a lot of avoidance as well. You can't have them actually kill people, obviously, but between imaginal exposures and deliberately subjecting themselves to feared situations and triggers of intrusive thoughts you can do a lot of good work. Another critical bit is identifying the core fear explaining why these particular thoughts bother them so much; until you have a solid handle on that it is hard to design effective exposures.

I am always a little skeptical of bipolar/OCD comorbidity, although if they do seem to stop having intrusive thoughts when they are hypo or fully manic, I buy it a lot more readily.

If they genuinely cannot tolerate SRIs then I direct you to my post up thread.

Thanks for the response! I did see your post mentioning risperidone, abilify, haldol, buspar, lamictal, zofran etc. I was wondering if anyone on SDN has actually seen success treating OCD w/any of these meds. The patients I've cared for have been already taking relatively high doses of antipsychotics to control their mood episodes and/or psychosis. One patient I recently inherited, the previous psych has maintained patient on abilify 10 , Invega 234 LAI , and zyprexa. Presumably the abilify was to tx the OCD. The patient was still paranoid when taking invega and abilify and so zyprexa was added which seemed to help. OCD sx proceeded AP tx. Patient still having OCD obsessive thoughts. Pt has bipolar type schizoaffective illness.
That is really interesting what you said about "mental rituals" and "rumination", I'm assuming you may be referring to the patient feeling the need to think about the thought excessively as a way to somehow understand it and make it go away. If I recall correctly, patients have claimed that they try to brush the thought away, but they can't and it keeps recurring. I am curious about why you are skeptical of the bipolar/OCD link, if you have time to elucidate.

 

[annoyedpsychiatrist]

My approach is a little different than the above, once i get towards the max dose of zoloft, i add clomipramine before going further. I personally really like it for OCD and it seems to work well with my patients that ive had in the past on it. I will use it in addition to an SSRI. I have had some coverage issues for it though, I think there was an issue at one point where the pharmacies in the area didnt have it or insurance was being weird, I forget what happened.

 

[Stagg737]

Thanks for the response! I did see your post mentioning risperidone, abilify, haldol, buspar, lamictal, zofran etc. I was wondering if anyone on SDN has actually seen success treating OCD w/any of these meds. The patients I've cared for have been already taking relatively high doses of antipsychotics to control their mood episodes and/or psychosis. One patient I recently inherited, the previous psych has maintained patient on abilify 10 , Invega 234 LAI , and zyprexa. Presumably the abilify was to tx the OCD. The patient was still paranoid when taking invega and abilify and so zyprexa was added which seemed to help. OCD sx proceeded AP tx. Patient still having OCD obsessive thoughts. Pt has bipolar type schizoaffective illness.
That is really interesting what you said about "mental rituals" and "rumination", I'm assuming you may be referring to the patient feeling the need to think about the thought excessively as a way to somehow understand it and make it go away. If I recall correctly, patients have claimed that they try to brush the thought away, but they can't and it keeps recurring. I am curious about why you are skeptical of the bipolar/OCD link, if you have time to elucidate.

My N=1: In residency I inherited a couple of OCD patients on Abilify for augmentation of their SSRI/clomipramine who felt it worked. I've tried starting it once or twice, but wasn't successful there. I haven't seen other antipsychotics, lamotrigine, buspar, or zofran help with augmentation. I have seen mirtazapine help a couple times, but not sure if that's because of it's usefulness as an augmenting agent or just because they were sleeping better. Even if there's a concern for mania, you can still use high doses of SSRIs or clomipramine for OCD as long as their mood stabilizer is effective.

 

[clausewitz2]

Thanks for the response! I did see your post mentioning risperidone, abilify, haldol, buspar, lamictal, zofran etc. I was wondering if anyone on SDN has actually seen success treating OCD w/any of these meds. The patients I've cared for have been already taking relatively high doses of antipsychotics to control their mood episodes and/or psychosis. One patient I recently inherited, the previous psych has maintained patient on abilify 10 , Invega 234 LAI , and zyprexa. Presumably the abilify was to tx the OCD. The patient was still paranoid when taking invega and abilify and so zyprexa was added which seemed to help. OCD sx proceeded AP tx. Patient still having OCD obsessive thoughts. Pt has bipolar type schizoaffective illness.

Abilify and risperidone are not infrequently helpful, though generally smaller doses. Not sure I'd ever go over 5 if OCD was the main problem, but the schizo-obsessive folks obviously need more much of the time. At the end of the day medications rarely make it better by themselves, they are useful because they lower the threshold to behavioral changes from the patient and increased willingness to tolerate the distress of uncertainty.

That is really interesting what you said about "mental rituals" and "rumination", I'm assuming you may be referring to the patient feeling the need to think about the thought excessively as a way to somehow understand it and make it go away.

This is really what all rumination is, an attempt to "solve" an unsolvable problem, or at least "resolve" an uncertainty that can't be resolved. Michael Greenberg has written some interesting things about this relevant to OCD and a way of conceptualizing it not quite identical with traditional EX/RP.

If I recall correctly, patients have claimed that they try to brush the thought away, but they can't and it keeps recurring.

Yup, turns out trying not to think a thought is a great method for making sure you think about it all the time forever. This is the opposite of helpful.

I am curious about why you are skeptical of the bipolar/OCD link, if you have time to elucidate.

I am skeptical about co-morbidity as a general concept in mental health in most cases. Undoubtedly more or less true sometimes but our fairly arbitrary disorders not perfectly capturing someone does not mean that their difficulties are not essentially unitary, just that we have a poor means of describing the full picture. I suppose I just think that it's rare for these things to be totally orthogonal in practice.