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In the current Psychiatric Services, Alicia Kaplan, MD and Eric Hollander, MD of Mt Sinai, New York do a decade-long review of treatments for obsessive-compulsive disorder. They point out early in the article that the optimal treatment for OCD involves a combination of pharmacologic and cognitive-behavioral therapies, however they also describe that "advances in psychopharmacology have led to safe and effective treatments for obsessive-compulsive disorder that provide clinically significant improvement in symptoms."
For the purposes of review, they included double-blind, placebo-controlled studies as well as open-label studies and case reports from 1991 to 2002. The serotonin reuptake inhibitors are first-line agents and many have been approved by the U.S. Food and Drug Administration for the treatment of adults with obsessive-compulsive disorder (fluvoxamine, fluoxetine, sertraline, and paroxetine) and clomipramine as well('Clomipramine not only works as an SRI but also blocks the reuptake of norepinephrine and dopamine'). Three of these (clomipramine, fluvoxamine, and sertraline) have been approved for treatment of children and adolescents.
Even though SRIs are first line treatment and have a better-tolerated side-effect profile, according to the study, "40 to 60 percent of patients with obsessive-compulsive disorder do not respond to adequate treatment trials with SRIs , and agents that alter serotonin receptors and other neurotransmitter systems, such as dopamine and norepinephrine, as well as second-messenger systems may play a role in the treatment of obsessive-compulsive disorder." There are other treatment options for patients who do not respond to SRIs. These include switching, augmentation, and novel-agent strategies. Although patients who respond may experience clinically significant improvement in their obsessions and compulsions, they are not cured of the illness and may still have residual symptoms. It was noted that in head-to-head trials, no individual SRI has been shown to be superior to another. Treatment of OCD with SRIs differ from SRI treatment of depression in that higher dosages and longer treatment trials are needed.
The authors make the point that obsessive-compulsive disorder is highly comorbid with other psychiatric disorders, (up to two-thirds of patients) especially major depressive disorder.'Treatment should be ultimately aimed at targeting all core and associated symptoms among patients with obsessive-compulsive disorder.' Finally, nonpharmacologic invasive techniques (neurosurgery, deep-brain stimulation, electroconvulsive therapy, and repetitive transcranial magnetic stimulation) may play a role in refractory cases of OCD, but much more research is indicated.
Psychiatr Serv 54:1111-1118, August 2003
12:50:21 PM 
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