Dopaminergic augmentation with drugs such as risperidone (Risperdal) or haloperidol (Haldol), and olanzapine (Zyprexa) have been fairly extensively studied. This approach, which consists of adding a medication that affects the dopaminergic system to the ongoing SSRI, has been well-supported.18 However, it is unclear as to how long to continue treatment as many patients relapse upon discontinuation and the antipsychotics are linked to undesirable side effects such as sedation, weight gain, or (particularly with higher doses of risperidone) extrapyramidal effects.
Strategies for adding a second serotonergic medication include switching to a new agent or adding another. Indeed, many patients with an inadequate response to one SSRI may have a favorable response to another.10
Prognosis
Left untreated, the course of obsessive-compulsive disorder is chronic and unremitting, with symptoms generally fluctuating over time due to stress-induced exacerbations of symptoms.19 Children with this disorder remain at higher risk for other psychiatric problems into adulthood,20,21 and adults frequently display additional symptoms as well. Comorbidity with Major Depressive Disorder is particularly common in both children and adults, as are ADHD and other anxiety, mood, and tic disorders.22-24 Symptoms also disrupt family, social, academic, and occupational functioning.25-27
Accurate diagnosis of OCD and the identification of a qualified treatment provider remain the 2 major obstacles to treatment of OCD. In one study, the average delay between onset of symptoms and provision of appropriate treatment was 17 years.27 However, once appropriate treatment begins, prognosis for patients with OCD is positive. One meta-analysis demonstrated significant long-term improvement (range, 1–15 years) in pediatric patients receiving any treatment (ie, pharmacological, psychological, or combined) for OCD.28 Other studies have demonstrated that medication generally accounts for significant symptom reduction compared with baseline levels,14,15 and 57% to 64% of pediatric patients exhibit no symptoms or subclinical levels of symptoms at follow-up.29,30 Studies of adults have also demonstrated significant symptom reduction,12 with about 50% of patients responding to medication.31 In addition, numerous studies have demonstrated that CBT is as effective or more effective than pharmacotherapy alone for both children and adults.12,15,31
As noted previously, upwards of 85% of patients improve significantly with CBT.3,31 Thus, CBT alone or combined with medication has the best prognosis for children and adults.
CORRESPONDENCE
Eric A. Storch, PhD, Department of Psychiatry, University of Florida, Box 100234, Gainesville, FL 32610. E-mail: estorch@psychiatry.ufl.edu