OCD That Has Not Responded to Treatment
Treatment-resistant OCD is a solvable problem, but only if it is properly defined first
If you have had treatment for OCD and are still unwell, the first thing I want to establish is whether the treatment you had was adequate, because very often it was not. A course of cognitive behavioural therapy that never involved sustained exposure, a serotonergic antidepressant given at the dose used for depression rather than the higher dose OCD needs, a medication stopped at six weeks when OCD takes ten to twelve to judge: these are the commonest reasons people believe they have "treatment-resistant OCD" when in fact they have never had the treatment that works. Genuine resistance exists: about one person in ten does not respond after fully adequate treatment. For them there is a clear, evidence-based next step. Either way, the answer begins with an honest audit of what has been tried.
- What “adequate” means
- For medication: a serotonin reuptake inhibitor at the maximum tolerated dose for at least ten to twelve weeks (for fluoxetine that means 60–80 mg, not 20) and, if that fails, a second, and then clomipramine, the most effective of the class. For psychological therapy: exposure and response prevention delivered with fidelity, usually twelve to twenty sessions, with exposure actually done, in session and between sessions, rather than talked about. Combining the two is more effective than either alone: in the classic comparison, exposure therapy or medication alone helped roughly 55–60% of patients, while the combination helped 85%.
- Response, resistance and refractoriness
- I use the standard definitions so that we both know where we stand. A full response is a 35% or greater fall on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS); a partial response is 25–35%; non-response is less than 25%. Remission is a Y-BOCS below 16, and recovery below 8. “Refractory” is reserved for illness that has not changed, or has worsened, despite all available therapies. Measured this way, the picture is usually clearer, and more hopeful, than it feels.
- What I do
- I take a full history of the illness and of every treatment: what, how much, for how long, delivered by whom, and with what result. I look for the things that quietly defeat treatment: an undiagnosed tic disorder, autism, ADHD or depression; mental compulsions and reassurance-seeking that were never targeted; family accommodation; a neurological cause. Then we build the next course: an adequate trial where there has not been one; augmentation of medication with a low-dose antipsychotic, which is the best-supported strategy for partial response; intensified, home-based or residential exposure work; and, where illness has been adequately treated and remains severe, assessment for neuromodulation.
- Beyond step six
- NICE's stepped-care model for OCD ends at step six: intensive treatment programmes and inpatient care. In my view there is a step seven, neuromodulatory and neurosurgical treatment: transcranial magnetic stimulation, deep brain stimulation, and the focused lesion procedures that Queen Square alone provides in the UK. These are for the small refractory minority, but for them they are transformative, and part of my role is to make sure that no one who needs them is left waiting on a step that has already failed.
- Why it is worth persisting
- Untreated chronic OCD costs the person, on one estimate, around £75,000 in lost earnings, and over a forty-year illness the cost to the individual, their family and the state exceeds a million pounds. After successful treatment the residual impairment attributable to OCD is small; the expectation is a return to the life you had before. Treatment-refractory OCD is, as I put it to colleagues, a solution-refractory problem: the solutions exist, and the task is to reach them.
Individual outcomes vary. I will discuss any treatment I recommend with you in full, including its benefits, risks and alternatives.
To arrange an assessment
Private Secretary
020 8123 0234 ·
secretary@drhimanshutyagi.com