Management of treatment-refractory obsessive compulsive disorder patients.

Often obsessive compulsive disorder (OCD) patients are labeled as treatment refractory when some first-line options have not been fully explored. Most patients should be encouraged to participate in behavior therapy, even when pharmacotherapy alone has been partially successful. Antiobsessional agents such as clomipramine, fluoxetine, and fluvoxamine should be considered first-line drugs. Their prescription for a sufficient time and at therapeutic doses is imperative. Enhancement strategies for a selected group of OCD patients include low-dose high-potency neuroleptics. In addition, clonazepam can be helpful in augmenting the response to a first-line drug. Results from controlled studies with lithium and buspirone have been disappointing. If most of these pharmacologic alternatives fail, MAOIs appear to be the next best choice. Since in the future most referrals for treatment-refractory OCD patients will emanate from nonpsychiatrists, following a systemic strategy in their evaluation and pharmacologic management is most important.