title: Treating OCD: what to do when first-line therapies fail.
abstract: OBJECTIVE
  To provide a clinically-focused review of the biological treatment of treatment-resistant obsessive compulsive disorder (OCD).
  
  
  CONCLUSIONS
  There is a paucity of research on how to manage OCD patients who fail to respond adequately to first line therapies. High-dose selective serotonin reuptake inhibitors (SSRIs) and clomipramine have good evidence-based data. Combinations of SSRIs have little support in clinical trials, but the combination of SSRIs and clomipramine can be helpful: careful clinical and cardiac monitoring is required. Certain adjunctive antipsychotics have a reasonable evidence base in OCD, but their use also needs to be weighed against the potential side effect burden. In patients with substantial generalised anxiety symptoms, clonazepam is worth considering. Of the other augmenting strategies, memantine and ondansetron appear useful in some cases, and are well tolerated. Topiramate might ameliorate compulsions to some degree, but it is less well tolerated. If all these strategies, along with expert psychological therapy, fail, careful consideration should be given to deep brain stimulation (DBS), which has an emerging evidence base and which can result in dramatic benefits for some individuals. For some patients, gamma radiosurgery might also still have a place.
authors.affiliation: Professor and Chair of Psychiatry, St. Vincent's Hospital Melbourne, University of Melbourne, Melbourne, VIC, and; Adjunct Professor, Faculty of Health Sciences, Australian Catholic University, Fitzroy, VIC, Australia david.castle@svha.org.au.
authors.forename: David
authors.initials: D
authors.lastname: Castle
authors.affiliation: Director of Clinical Services, St Vincent's Mental Health, Fitzroy, VIC, and; Associate Professor, Department of Psychiatry, University of Melbourne, Fitzroy, VIC, Australia.
authors.forename: Peter
authors.initials: P
authors.lastname: Bosanac
authors.affiliation: Professor, Swinburne University, Melbourne, VIC, Australia.
authors.forename: Susan
authors.initials: S
authors.lastname: Rossell
mesh_terms: D006801:Humans; D009771:Obsessive-Compulsive Disorder / Q000188:drug therapy / Q000628:therapy*
keywords: adults; clinical guidance; deep brain stimulation; disability measures; drug therapy; obsessive compulsive disorder; options; review; second-line therapies; serotonin reuptake inhibitor; transcranial magnetic stimulation; treatment resistance