Table 1 Therapeutic alternatives for treatment-resistant obsessive-compulsive disorder [9, 10, 121,122,123]

From: Evolution of gamma knife capsulotomy for intractable obsessive-compulsive disorder

Treatment status

Possible strategies

1. Non-response to monotherapy with an SSRIa or clomipramine or to BT aloneb

Combine pharmacological and psychological treatmentsc

2. Non-response to SSRI + BT

Change SSRIa,d

Change to clomipraminea,e

Augmentation with atypical antipsychotic drugs or haloperidolc

Intensive BTc

3. Non-response to second trial with SSRI

Augmentation with clomipraminee

Augmentation with risperidone or haloperidolc

Augmentation with other atypical antipsychotic drugse

4. Non-response to clomipramine and to augmentation with atypical antipsychotic drugs or haloperidol

High-dose SSRI (off-label, informed consent required)e

SSRI + clomipraminee

Augmentation of SSRI with glutamatergic drugs (e.g., memantinee, topiramatee, lamotriginee, and N-acetylcysteine), ondansetrone, nonsteroidal anti-inflammatory drugse (e.g., celecoxib), or mirtazapine monotherapyd

5. Non-response to the available treatments

Neuromodulatory treatments: rTMSe, GKCe, RF capsulotomye, and DBSd

  1. aUsually up to the maximum dose (fluoxetine, 80 mg; fluvoxamine, 300 mg; sertraline, 200 mg; paroxetine, 60 mg; citalopram, 40 mg; escitalopram, 40 mg; clomipramine, 250 mg) and for a period of at least 3 months
  2. bFor at least 20 h
  3. cGrade A recommendation
  4. dGrade C recommendation
  5. eGrade B recommendation
  6. For information on levels of evidence and grades of recommendation, please refer to the Oxford Centre of Evidence-Based Medicine at http://www.cebm.net/ocebm-levels-of-evidence [124].
  7. SSRI selective serotonin reuptake inhibitor, BT behavior therapy, rTMS repetitive transcranial magnetic stimulation, GKC gamma knife capsulotomy, RF radiofrequency, DBS deep brain stimulation.
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