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Obsessive-compulsive disorder (OCD) is characterized by recurrent…

- - - - Self-harm.
      - Self-neglect.
      - A significant comorbidity such as substance misuse, severe depression, anorexia nervosa, or schizophrenia.
      - Suicide — refer urgently (same day) to the crisis resolution and home treatment team if the person is at high risk of suicide.
      - https://cks.nice.org.uk/topics/obsessive-compulsive-disorder/management/management/
- - - - If there has not been an adequate response to a standard dose of an SSRI, and there are no significant side effects after 4–6 weeks, a gradual increase in dose should be considered. For more information, see the relevant sections on dosage and titration in Prescribing information. Monitor the person around the time of dose changes for any new symptoms or worsening of their condition.
      - For adults with an inadequate response to initial treatment (a full 12 weeks of treatment with an SSRI, or more than 10 therapist hours of CBT [including ERP]), other treatment options include combined treatment with CBT (including ERP) and an SSRI, and/or switch to a different SSRI, or a switch to clomipramine. If there has been no response to a full trial of at least one SSRI alone, a full trial of combined treatment with CBT (including ERP) and an SSRI, and a full trial of clomipramine alone, the person should be referred to a multidisciplinary team with specific expertise in the treatment of OCD for assessment and further treatment planning.
      - Note: It is advisable to monitor cardiac function with ECG during long-term therapy with clomipramine, at intervals determined by clinical judgement and depending on factors including length of treatment, the persons age, and cardiac risk factors. Advise the person to report cardiac symptoms such as palpitations, vertigo, syncope, or seizures and if these develop during treatment, arrange for the person to have an ECG.
    - - Consider the severity and duration of the initial illness, the number of previous episodes, the presence of residual symptoms, and concurrent psychosocial difficulties.
      - If treatment is continued for an extended period beyond 12 months after remission, the need for continuation should be reviewed at regular intervals and written in the notes.
      - When reducing or stopping SSRIs or clomipramine, the dose should be tapered gradually over at least several weeks, according to the person's need. The rate of reduction should take into account the starting dose, the drug half-life and particular profiles of adverse effects. Advise the person to seek advice if they experience significant discontinuation/withdrawal symptoms.