Case outcome: interim follow-up visits through nine months

Fluoxetine (Prozac) and quetiapine-XR (Seroquel-XR) were both escalated to 80 mg/d and 700 mg/d, respectively

Patient returns depression free with only minor bouts of agitation

No longer stays in her car, but spends more time in her house

• – Still cleans a lot and assumes things are contaminated, but is more tolerant of these feelings

• – OCD symptoms are 50% better

Currently has no medication side effects

Collaboration with PCP shows

• – No metabolic worsening

• – Eye examinations are negative for cataracts

Patient declines further medication alterations as she feels better and also sees gradual improvement

Question

What would you do next?

Leave all medications as they are because the patient is in MDD remission and has a solid OCD response

Strongly encourage patient to escalate her medications further to attempt gaining OCD remission

Encourage patient to augment her current regimen with a third medication to attempt gaining OCD remission

Refer for a new course of CBT/ERP to attempt to gain OCD remission

Attending physician’s mental notes: interim follow-up visits through nine months

The goal is always to achieve remission where safe and possible

The patient is tolerating her medications very well with almost no adverse effects

It makes clinical sense to escalate her medication doses further

She has also been somewhat avoidant to going through a new course of psychotherapy as she has avoidant traits on top of her OCD symptoms

Another option would be to motivate her to attempt a new course of CBT/ERP to alleviate her remaining OCD symptoms

• – The short-term, time-limited approach might be more acceptable to her

Case outcome: interim follow-up visits through 15 months

Declines other medication options, feeling comfortable with her improvement thus far and relative absence of side effects

Agrees to undergo a 20-week CBT/ERP response prevention protocol to help her better address and cope with her contamination fears to specific areas of her house

She created a hierarchy of challenges to her OCD and currently attends CBT sessions regularly

Case debrief

Patients with OCD often develop depression as OCD frequently interferes immensely with psychosocial functioning

OCD patients often avoid treatment as they are aware that the OCD symptoms are abnormal and are embarrassed or ashamed to present their symptoms to clinicians as well

However, in this case, the patient was actually more comfortable with her OCD symptoms and less so with her depression and agitation

• – This poor insight into her contamination fear may have been poor insight-specified OCD or a depressive psychosis or delusion

• – This patient also began her MDD and OCD in a postpartum state

  • It is possible that she has had a smoldering psychosis since then that finally began to resolve when a higher-dose antipsychotic regimen was established

This patient is not currently depressed but still suffers mild to moderate fluctuating OCD

CBT/ERP was helpful to a certain degree in that she is more comfortable in certain areas of her house and seems to cope better when her OCD symptoms fluctuate higher

Take-home points

Patients with poor insight into their OCD might display more psychotic or delusional features

These symptoms may respond to atypical antipsychotics as long as the antipsychotic is also dosed therapeutically

Special attention should be given to each drug’s approval status and guidelines for effective dosing, based upon each clinical indication

Psychotherapy may be used as an augmentation strategy for residual symptoms