OCD SSRI Dose Escalation

J.B. is a 41-year-old female patient who is being managed for obsessive compulsive disorder. She has been in exposure response therapy (ERT) for several months with marginal improvement, but she has never approached true remission. At one time she was on fluvoxamine with notable improvement, but after a few months it ceased to produce any notable impact and after conferring with her therapist she was converted to fluoxetine 20 mg qd. After two months she was still struggling with symptoms, so two months ago her dose was increased to 40 mg qd. Today she presents for follow-up, reporting no notable improvement with pharmacotherapy. She continues to engage in psychotherapy but at this point is becoming very frustrated.

The appropriate approach at this point would be to:

A. Continue fluoxetine 40 mg daily for one more month and reassess

B. Convert the patient to therapy with a tricyclic antidepressant

C. Continue fluoxetine at 40 mg daily and consider a change in therapy.

D. Increase the fluoxetine to 60 mg daily and reassess in four to eight weeks

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