Practice Guidelines

APA Releases Guidelines on Treating ObsessiveCompulsive Disorder

MARA LAMBERT

Guideline source: American Psychiatric Association

Literature search described? Yes
Evidence rating system used? Yes
Published source: American Psychiatric Association Web site
Available at: http://www.psych.org/psych_pract/treatg/pg/
prac_guide.cfm

In 2007, the American Psychiatric Association (APA)

published treatment recommendations for obsessivecompulsive disorder (OCD). Patients with OCD usually
experience symptoms that wax and wane over time.
Treatment should be considered when the symptoms
interfere with patients functioning or cause them significant distress. Management of OCD can involve many
therapeutic actions depending on the needs, capacities, and desires of the patient. Coordinating care with
other physicians and social agencies (e.g., schools, vocational rehabilitation programs) with which the patient is
involved is important. Physicians should advise patients
with OCD of the genetic risk of passing the disorder to
their children. Genetic counseling may be recommended
to patients who want more information.

ed., text revision (DSM-IV-TR), it is important to distinguish the obsessions, compulsions, and rituals of OCD
from similar symptoms found in other disorders.
USING RATING SCALES

The 10-item Yale-Brown Obsessive Compulsive Scale can

measure the baseline severity of the patients symptoms,
which provides a way to assess the patients response
to therapy. If a rating scale is not used, it is advisable
to record the patients estimate of how much time is
spent obsessing and performing compulsive behaviors
throughout the day, and how much effort is spent trying
to resist the behaviors.
ENHANCING THE SAFETY OF THE PATIENT AND OTHERS

The physician should evaluate the patients potential for

self-injury or suicide. Patients with OCD alone or with
OCD and a concomitant disorder are at higher risk of suicide than the general population. Although most patients
with OCD do not respond violently when others interfere
with their rituals, it is important to discuss previous aggressive behavior. If the patient is a parent, the physician should
work with the unaffected parent or social agencies to diminish the effects of the disorder on the patients children.

Psychiatric Management

COMPLETING THE PSYCHIATRIC ASSESSMENT

ESTABLISHING A THERAPEUTIC ALLIANCE

During the psychiatric assessment, the physician should

document the patients history of concomitant conditions such as depression, bipolar disorder, anorexia
nervosa, bulimia nervosa, alcohol abuse, and attentiondeficit/hyperactivity disorder. All symptoms and the
treatment history, including psychiatric hospitalizations
and medication trials, are relevant.
The patients developmental, psychosocial, and sociocultural history should be documented, as well as how the
OCD has affected the patients familial, social, and sexual
relationships. It is advisable to review the patients current
medications, including hormonal therapies and herbal
remedies, for allergies and potential interactions with psychotropic drugs. Additionally, the physician should perform a mental status examination during the assessment
to record the patients signs and symptoms of illness.

To effectively plan and implement treatment for OCD, the

physician should establish a strong therapeutic alliance
with the patient. This can involve tailoring a communication style to the patients needs, explaining symptoms in
understandable terms, and encouraging and comforting
the patient. Because patients with OCD may experience
excessive doubting, it may be helpful to repeat explanations and give the patient extra time to make decisions
regarding treatment. The physician should also take into
account how the patient feels about him or her and what
the patient expects from treatment.
ASSESSING THE PATIENTS SYMPTOMS

When establishing a diagnosis using criteria from the

Diagnostic and Statistical Manual of Mental Disorders, 4th

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Practice Guidelines
ESTABLISHING GOALS FOR TREATMENT

Because clinical recovery and full remission can take

time, if they occur at all, the physician and patient should
set goals to improve the patients quality of life. This
includes decreasing symptom frequency and severity, and
improving functioning. Other goals can include enhancing the patients cooperation with care, minimizing
adverse effects of treatment (e.g., medication side effects),
developing coping strategies for stressors, and educating
the patient and family regarding OCD and its treatment.
ESTABLISHING THE APPROPRIATE SETTING FOR TREATMENT

Treatment should take place in a safe, effective environment, which may be a hospital, residential treatment
program, or outpatient care.
ENHANCING TREATMENT ADHERENCE

Treatment adherence may be enhanced through education about the disorder and its treatments. The Obsessive Compulsive Foundation (http://www.ocfoundation.
org) provides educational materials that benefit many
patients. Explaining to patients about potential side
effects of medications and responding quickly to their
concerns can also enhance adherence. It may be helpful to advise patients on what is involved in cognitive
behavior therapy (CBT), such as confronting feared
thoughts and situations. It is also appropriate to discuss
practical concerns, such as treatment costs and insurance coverage.

Choosing a Specific Pharmacologic Treatment

The U.S. Food and Drug Administration (FDA) has
approved the following pharmacologic agents for treatment of OCD: clomipramine (Anafranil), fluoxetine
(Prozac), fluvoxamine (Luvox; brand only available in
extended-release tablets), paroxetine (Paxil), and sertraline (Zoloft; Table 1). Because clomipramine has more
troublesome side effects than SSRIs, an SSRI is preferred
for a first medication trial. When choosing which SSRI
to prescribe, physicians should consider the possible
side effects, applicable FDA warnings, past treatment
response, the potential for drug interactions, and the
presence of other medical conditions.
Choosing a Specific Form of Psychotherapy
The evidence supports using CBT that focuses on techniques such as exposure and response prevention. Some
data support using cognitive techniques. Dynamic psychotherapy or psychoanalysis has not been shown to be
effective in addressing the core symptoms of OCD. Psychodynamic psychotherapy may help patients overcome
their resistance to accepting a treatment, and it may also
help address the interpersonal consequences of OCD
symptoms. Motivational interviewing may help patients
overcome resistance to treatment. Family therapy can be
used to reduce interfamily tensions that are worsening
the patients symptoms.
Implementing a Treatment Plan
PHARMACOTHERAPY

Choosing an Initial Treatment Modality

When beginning a treatment for OCD, the physician
should consider the patients motivation and ability to
comply with pharmacotherapy and psychotherapy. Selective serotonin reuptake inhibitors (SSRIs) and CBT are
recommended as safe and effective first-line treatments
(Figure 1). The physician should choose whether to use
one or both of these treatments based on several conditions, including the nature and severity of the patients
symptoms, current medications, treatment history, and
the availability of CBT. An SSRI alone is recommended
for patients who have previously responded well to a given
drug or who are unable to cooperate with CBT. Patients
who dislike medications and who are not too depressed
or anxious may benefit from CBT (i.e., exposure and
response prevention) alone. Combined treatment is
recommended for patients who have not responded to
monotherapy, those with concomitant psychiatric conditions that respond to SSRIs, and those who want to limit
the duration of the SSRI treatment. There may be risks
associated with taking a psychotropic medication during
pregnancy or while breastfeeding. The physician should
discuss the risks and benefits with the patient.
132 American Family Physician

Most patients begin pharmacotherapy at the manufacturers recommended dosages. If the patient is concerned
about side effects, a lower dosage may be given because
many SSRIs are available in liquid form or as pills that can
be split. For many patients, substantial improvement will
not be apparent until four to six weeks after beginning the
medication. Some patients will not show signs of improvement for 10 to 12 weeks. The medication dosages may be
titrated upward each week in increments recommended
by the manufacturer during the first month of therapy. If
there is no improvement after four weeks of pharmacotherapy, the physician may increase the dosage weekly or
biweekly to what is comfortably tolerated and indicated.
Occasionally this can exceed the manufacturers recommended maximal dosage. The treatment trial should be
continued at this dosage for a minimum of six weeks.
If the patients response to the treatment is inadequate,
trial data suggest that higher SSRI dosages produce a
somewhat higher response rate and greater relief of symptoms. Higher dosages may be appropriate for those who
tolerate the medication well and have had little response
to the treatment. For patients who take a higher dosage,
it is important to monitor for side effects, including the

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Treatment of Obsessive-Compulsive Disorder

First-line treatments

CBT (ERP)

Is the response adequate after 13 to

20 weekly sessions of CBT?

No

A SSRI plus CBT (ERP)

SSRI

Is the response adequate after eight to 12 total

weeks of SSRI (four to six weeks at maximal
tolerable dosage) or 13 to 20 weekly sessions
of CBT or weekday daily CBT for three weeks?

Yes

Go to A
Yes

No
Strategies for moderate response*
Augment with a second-generation antipsychotic or
with CBT (ERP) if not already provided
Add cognitive therapy to ERP

For medication: continue for one to two years, then

consider gradual taper over several months or more
For CBT: provide periodic booster sessions for three to
six months after acute treatment

Strategies for little or no response

Switch to a different SSRI (may try more than one trial)
Switch to clomipramine (Anafranil)
Augment with a second-generation antipsychotic
Switch to venlafaxine (Effexor)
Switch to mirtazapine (Remeron)
Yes

Adequate response?
No

*Moderate response means clinically significant but inadequate response.

Treatment with little supporting evidence (e.g., one or few
small trials or case reports or uncontrolled case series).
Venlafaxine is not indicated by the U.S. Food and Drug
Administration for obsessive-compulsive disorder and is less
likely to produce an adequate response.

Strategies for moderate* and for little or no response

Switch to a different augmenting second-generation antipsychotic
Switch to a different SSRI
Augment with clomipramine
Augment with buspirone (Buspar), pindolol (Visken), morphine
sulfate, inositol, or a glutamate antagonist (e.g., riluzole
[Rilutek], topiramate [Topamax])
Strategies only for little or no response
Switch to dextroamphetamine (Dextrostat) monotherapy
Switch to tramadol (Ultram) monotherapy
Switch to ondansetron (Zofran) monotherapy
Switch to an MAOI
After first- and second-line strategies have been exhausted, other
options that may be considered include transcranial magnetic
stimulation, deep brain stimulation, and ablative neurosurgery

Figure 1. Algorithm for the treatment of obsessive-compulsive disorder. (CBT = cognitive behavior therapy; ERP = exposure and response prevention; MAOI = monoamine oxidase inhibitor; SSRI = selective serotonin reuptake inhibitor.)

serotonin syndrome. Older patients should use a lower

starting dosage, and any increase should be gradual and
monitored for side effects. Managing medication side
effects involves several strategies, including gradually
titrating the initial dosage to reduce the possibility of
gastrointestinal distress, prescribing a sleep-promoting
medication to minimize insomnia, prescribing a modest dosage of modafinil (Provigil) to minimize fatigue,
and prescribing a low-dose anticholinergic to minimize
sweating. To minimize sexual side effects, the physician
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should reduce the dosage of the SSRI, wait for symptoms

to abate, encourage a weekly one-day break from the
medication before sexual activity, prescribe an alternative SSRI, or add a pharmacologic agent such as bupropion (Wellbutrin).
After beginning a new pharmacotherapy, follow-up
visit frequency can vary between a few days to two weeks,
depending on the severity of the symptoms, the presence
of troubling side effects, the presence of suicidal thoughts,
and any complexity caused by concomitant conditions.

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American Family Physician 133

Practice Guidelines
Table 1. Dosing of SSRIs/SNRIs in Obsessive-Compulsive Disorder

Drug

Starting and
incremental dosages
(mg per day)*

Usual
target dosage
(mg per day)

Usual
maximal dosage
(mg per day)

Occasionally prescribed
maximal dosage
(mg per day)

Citalopram (Celexa)
Clomipramine (Anafranil)

20
25

40 to 60
100 to 250

80
250

120

Escitalopram (Lexapro)
Fluoxetine (Prozac)
Fluvoxamine (Luvox; brand
only available in extendedrelease tablets)
Paroxetine (Paxil)
Sertraline (Zoloft)

10
20
50

20
40 to 60
200

40
80
300

60
120
450

20
50

40 to 60
200

60
200

100
400

SNRI = serotonin norepinephrine reuptake inhibitor; SSRI = selective serotonin reuptake inhibitor.
*Some patients may need to start at one half of this dosage or less to minimize undesired side effects such as nausea or to accommodate anxiety
about taking medication.
These dosages are sometimes used for rapid metabolizers or for patients with no or mild side effects and inadequate therapeutic response after
eight weeks or more at the usual maximal dosage.
Combined plasma levels of clomipramine plus desmethylclomipramine 12 hours after dosing should be kept below 500 ng per mL to minimize risk
of seizures and cardiac conduction delay.
Sertraline is better absorbed with food.

COGNITIVE BEHAVIOR THERAPY

CBT can occur in individual, group, or family therapy

sessions. One session can last anywhere from less than
one hour to two hours. Patients should attend a therapy
session at least once a week. Five exposure and response
prevention sessions per week may be more effective
than once-weekly sessions, but not more so than twiceweekly sessions. Most patients should attend 13 to
20 weekly sessions; however, the number and length of
sessions and the duration of an adequate trial have not
been established. Booster sessions are recommended for
patients who are severely ill, who have relapsed, or who
show signs of an early relapse. If CBT is not available,
the physician can recommend self-help treatment guides
and support groups such as those available through the
Obsessive Compulsive Foundation.
CHANGING TREATMENTS AND PURSUING SEQUENTIAL
TREATMENT TRIALS

Patients are unlikely to see a full recovery from all symptoms after the first treatments. If a good response is not
achieved after 13 to 20 weeks of weekly CBT, three weeks
of daily CBT, or eight to 12 weeks of SSRI treatment, the
physician should consider altering the treatment. The physician and patient should base this decision on the patients
tolerance and acceptance of the symptoms. If the patient
lacks motivation to pursue further treatment despite limited improvement, the physician should address issues of
depression and secondary gains of the illness.
When the initial treatment is unsatisfactory, several
factors may be contributing to the lack of improvement:
134 American Family Physician

interference by concomitant conditions, inadequate

patient adherence to the treatment plan, the presence
of psychosocial stressors, the familys degree of accommodation for the patients symptoms, and the patients
inability to tolerate psychotherapy or medication.
If an interfering factor cannot be identified for
patients who have only a partial response, the physician
should consider augmenting current strategies rather
than switching strategies. SSRIs should be augmented
with trials of other antipsychotic medications or with
CBT. Similarly, CBT should be augmented with an
SSRI. Combining pharmacotherapy and psychotherapy
should be considered when the patient has a partial
response to monotherapy or when the patient has a
concomitant condition that is responsive to SSRIs.
Combined treatment can also help prevent a relapse
once medication is stopped. Increasing the intensity
of the exposure and response prevention therapy may
help if the patient is having only a partial response to
the behavior therapy. Adding cognitive therapy to the
exposure and response prevention therapy may enhance
the results.
For patients who do not respond to the initial SSRI,
a different SSRI should be considered. Other options
include switching to venlafaxine (Effexor), although it is
less likely to produce an adequate response, or switching
to mirtazapine (Remeron). Available evidence cannot
predict the chance of response to a medication switch.
Those unresponsive or partially responsive to SSRIs
have responded to augmentation with antipsychotic
medications or CBT.

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Practice Guidelines
If first- and second-line treatments are unsuccessful, other strategies may be tried, although they are less
well-supported. These strategies include augmenting
SSRIs with clomipramine, buspirone (Buspar), pindolol
(Visken), riluzole (Rilutek), or once-weekly oral morphine sulfate. Morphine sulfate is not recommended
for patients with contraindications to opiate administration. If the SSRI is augmented with clomipramine,
the physician should use precautions to prevent cardiac
and central nervous system side effects. Other less wellsupported monotherapies include dextroamphetamine
(Dextrostat), tramadol (Ultram), monoamine oxidase
inhibitors, ondansetron (Zofran), transcranial magnetic
stimulation, and deep brain stimulation. Patients who
are severely resistant to treatment may benefit from
intensive residential treatment or partial hospitalization. Patients with severe and treatment-refractory OCD
may consider ablative neurosurgery, although it is rarely
indicated. Along with deep brain stimulation, ablative
neurosurgery should only be performed at sites with
expertise in treating OCD with this approach.
Discontinuing Active Treatment
Patients whose symptoms are successfully treated with
medication should continue treatment for one to two
years. After this time, patients may taper the dosage by
10 to 25 percent every one to two months while watching for the return or exacerbation of symptoms. Monthly
booster sessions for three to six months are recommended for patients who were treated successfully with
exposure and response prevention. For patients who
discontinue pharmacotherapy, the rates of relapse vary
widely because of study methodology differences. For
this reason, discontinuing pharmacotherapy should be
carefully considered. The effects of CBT with exposure
and response prevention may be more lasting than SSRIs
after discontinuation, but the difference in relapse rates
could be caused by other factors.

CDC Reports on AntimicrobialResistant S. Pneumoniae

is complicated by antimicrobial resistance. Although rates

of antimicrobial-nonsusceptible invasive pneumococcal
disease decreased in the United States after the introduction of heptavalent pneumococcal conjugate vaccine
(PCV7; Prevnar) in 2000, there is growing concern about
antimicrobial resistance in serotypes not covered by this
vaccine.
The Centers for Disease Control and Prevention
(CDC) analyzed surveillance data of invasive pneumococcal disease in Massachusetts residents younger
than 18 years from 2001 to 2006, and it examined the
clinical characteristics of patients with antimicrobialnonsusceptible, nonPCV7-type disease. Susceptibility
to five commonly used antimicrobials (i.e., amoxicillin, penicillin, ceftriaxone [Rocephin], azithromycin [Zithromax], and trimethoprim/sulfamethoxazole
[Bactrim, Septra]) was determined. The findings show
an increased number of cases of invasive pneumococcal
disease caused by serotypes not covered by PCV7 (particularly 19A), and a related increase in antimicrobial
resistance among these isolates.
There were 467 cases of invasive pneumococcal disease
in children between October 2001 and September 2006.
Of 353 isolates (76 percent) available for serotyping,
94 (27 percent) were serotype 19A. This serotype was
responsible for 33 cases (41 percent) of invasive pneumococcal disease between 2005 and 2006, compared with
six cases (10 percent) between 2001 and 2002 (P < .01).
There were no significant changes in the proportions of
disease caused by other PCV7 or PCV7-related serotypes
or by non-PCV7 serogroups. Overall rates of invasive
pneumococcal disease remained stable (15.9 to 18.6
per 100,000 children younger than five years), despite
the increased incidence of antimicrobial-nonsusceptible
disease. The clinical outcomes for disease caused by
nonsusceptible and susceptible S. pneumoniae serotypes
were comparable.
The results confirm that although PCV7 is effective
in preventing invasive pneumococcal disease, antimicrobial resistance among serotypes not covered by the
vaccine is a concern.
LIZ SMITH

Source: Centers for Disease Control and Prevention

Published source: Morbidity and Mortality Weekly Report,
October 19, 2007
Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/
mm5641a2.htm

Treatment of invasive pneumococcal disease caused by

infection with Streptococcus pneumoniae (pneumococcus)

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Answers to This Issues CME Quiz

Q1. C
Q2. A
Q3. B
Q4. D
Q5. C

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Q6. C
Q7. A
Q8. D
Q9. C
Q10. A, B, C

11. B, C, D
Q
Q12. A, B, C
Q13. A, D

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