Serotonin reuptake inhibitor-cognitive behavioural therapy-second generation antipsychotic combination for severe treatment-resistant obsessive-compulsive disorder. A prospective observational study

Introduction: Six in ten patients with obsessive-compulsive disorder (OCD) do not respond to the first-line treatments with serotonin reuptake inhibitor (SRI) or cognitive behavioural therapy including exposure and response prevention (CBT/ERP), and several do not respond to second-line treatments, i.e., SRI-second generation antipsychotic (SGA) or SRI-CBT/ERP augmentation. Evidence on third-line treatments is inconsistent. Objective: We investigated the 1-year response to SRI-CBT/ERP-SGA combination in patients with severe treatment-resistant OCD, who failed to respond to SRI and to SRI-SGA or SRI-CBT/ERP augmentation. Methods: Twenty-eight patients were consecutively recruited and treated with SRI (drug(s) and doses previously administered), SGA (risperidone median dosage 1 mg/day in 14 cases, aripiprazole median dosage 3 mg/day in 14 cases) and CBT/ERP (median hours 32.5). Exclusion criteria: mental retardation and organic brain syndrome. Results: The mean Y-BOCS total score reduction at 12 months was 28.2%, 60.7% of patients improved, 46.4% partially responded, 32.1% responded, and 28.6% remitted. Patients previously resistant to SRI-SGA and SRI-CBT/ERP did not significantly differ in the rates of improvement, partial response, response and remission. Conclusions: This study suggests that SRI-SGA-CBT/ERP combination could be useful for severe treatment-resistant OCD. Small sample size is a limitation.Key points Up to 6 in 10 patients with OCD do not respond to first line treatments (CBT/ERP or SRIs) and several to second-line treatments (SRI-SGA or SRI CBT/ERP augmentation). In our study, patients with OCD resistant to the first and the second line treatment improved (61%), partially responded (46%), responded (32%), or remitted (29%) combining SRI, SGA and CBT/ERP. In our patients the SRI-SGA-CBT/ERP augmentation improved working/school, social and family impairment. SRI-SGA-CBT/ERP augmentation is easier to use than other treatments for severe treatment-resistant OCD.