What should an OCD follow-up note include?

Current dose and how long they have been on it, Y-BOCS or an equivalent if you use one, function (time spent ritualizing, work, relationships), side effects that limit further titration, and the next step: increase, wait, augment, or add CBT/ERP.

Does a PHQ-9 count as an OCD outcome measure?

No. Depression scores can move while rituals do not. If you only record a PHQ-9, you have not documented OCD response.

When is an OCD medication trial actually a failed trial?

Q: When is an OCD medication trial actually a failed trial?

Under the 2026 CANMAT-ICOCS guidance, an SSRI trial for OCD is not a failed trial until it has run at least 12 weeks at the maximally tolerated dose. Treatment-resistant OCD requires two such trials. A six-week trial at a timid dose is an incomplete trial, not a failure.

CANMAT-ICOCS now wants 12 weeks at a tolerated high dose before you call an SSRI a failure. Most notes I review call it at week six.

An SSRI trial for OCD is not a failed trial until it has run at least 12 weeks at a dose they can actually take. That is the 2026 CANMAT-ICOCS line, published in the Journal of Psychiatric Research. Most charts I inherit call it a failure at week six, at 50 mg, because everyone got bored.

I have done this. The patient is still washing, I am still late, and “failed sertraline” is a faster sentence than “still titrating.” Then they show up as “treatment-resistant” on a Spravato form and nobody has ever given them 200 mg of sertraline for three months.

What “failed” has to mean in the note

Name the drug, the highest dose reached, the date they hit that dose, and how many weeks they stayed there. “Sertraline 200 mg since 3 June, week 11, rituals 4 hours/day, down from 7” is a trial. “Failed SSRIs” is a rumor.

If they never got above 50 mg because of nausea, that is a tolerability limit, not a failed OCD trial. Write the limit. The next clinician needs to know whether to try a slower titration or a different agent.

Two adequate trials before you use the word treatment-resistant. The guideline is blunt about this. I was sloppy about it for years.

Outcome, not vibes

I like a Y-BOCS when they will sit still for it. I will accept a time-spent number they give me in the room: hours ritualizing, late to work, one shower. Pick something you can compare in four weeks.

A PHQ-9 is not an OCD scale. I still record it when depression is in the room. I do not let it stand in for the rituals.

If they started ERP with someone, name that someone and whether they are actually doing exposures. “In therapy” is how CBT/ERP disappears. The same guideline puts aripiprazole, risperidone, or CBT/ERP on top of the SSRI after two failed trials, and wants eight weeks before you judge the augmentation. Write which one you picked and the start date.

Titration is the visit

OCD doses are often higher than depression doses. The note has to show you knew that. “Continue sertraline 50 mg for OCD” on visit four is either a plan with a reason (they cannot go up, ERP just started) or it is inertia.

If I hold a dose, I write why. GI. Activation. They have a wedding. I am not increasing into a hypomanic window. “Stable” is not a reason when they still cannot leave the house.

What I search for when I take over a chart

The last dose that was actually swallowed, not the last dose someone intended. Pharmacy history beats the med list.

Any mention of clomipramine, which people skip because it is old and annoying, and then call the patient resistant anyway.

Whether anyone ever named the obsession. Contamination versus harm versus “just anxiety” changes what a response looks like. If the prior notes never said, I ask today and I put it in this note.

Questions I get

Can I call it failed if they stopped at week four? You can call it an incomplete trial. You cannot use it as one of the two required failures unless they truly could not continue.

Do I need Y-BOCS every visit? No. You need a repeatable marker. Time spent, avoidance, or a scale. Same marker next time.

What if they refuse a high dose? Document the discussion, the highest dose they will take, and the backup (second SSRI, clomipramine, ERP referral). Refusal is data. It is not a secret.