Obsessive-Compulsive Disorder: Clinical Guidelines

List of Abbreviations

SGA — second-generation antipsychotics (#amisulpride, #aripiprazole, #quetiapine**, #clozapine, #olanzapine**, #paliperidone**, #risperidone**, etc.)

AD — antidepressants

FGA — first-generation antipsychotics (#haloperidol**, #sulpiride**, etc.)

DBS — deep brain stimulation

State Register of Medicines

MAOI-A — monoamine oxidase type A inhibitors

SRI — serotonin reuptake inhibitors (clomipramine** and SSRIs)

CBT — cognitive behavioral therapy

CSTC — cortico-striato-thalamo-cortical circuit

OCD — obsessive-compulsive disorder

CVA — cerebrovascular accident

OFC — orbitofrontal cortex

ACC — anterior cingulate cortex

PFT — psychopharmacotherapy

PET — positron emission tomography (positron emission tomography combined with brain computed tomography)

RCT — randomized controlled trial

SSRI — selective serotonin reuptake inhibitors (escitalopram, fluvoxamine, paroxetine**, fluoxetine**, sertraline**, citalopram)

SNRI — serotonin-norepinephrine reuptake inhibitors (according to ATC - other antidepressants): #venlafaxine, #duloxetine,

ADDS — antidepressant discontinuation syndrome

TCA — tricyclic antidepressants (according to ATC - non-selective monoamine reuptake inhibitors, clomipramine**, etc.)

LoE — level of evidence

LeR — level of recommendation validity

MRI — magnetic resonance imaging (brain magnetic resonance imaging)

fMRI — functional magnetic resonance imaging (functional brain magnetic resonance imaging)

rTMS — repetitive (pulsed) transcranial magnetic stimulation

TBI — traumatic brain injury

ECG — electrocardiography (electrocardiogram recording)

EPS — extrapyramidal symptoms

ECT — electroconvulsive therapy

EEG — electroencephalography

EMDR — eye movement desensitization and reprocessing

ERP — exposure and response prevention

Y-BOCS — Yale-Brown Obsessive-Compulsive Scale

NMDA receptor — ionotropic glutamate receptor that selectively binds N-methyl-D-aspartate (NMDA)

PANDAS — Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections

Terms and Definitions

Cognitive behavioral therapy is a psychosocial intervention (a form of psychotherapy) aimed at correcting cognitive distortions (negative, anxious, intrusive, and other thoughts) through their awareness and processing, followed by changing pathological behavioral patterns.

Compulsions (rituals) are repetitive behaviors or mental acts that a person performs driven by a sense of necessity related to obsessions, or according to rules that require strict execution to achieve a feeling of "completeness" or "perfection" of performance.

Obsessions (intrusions) are repetitive or persistent thoughts, images, or impulses that are not pleasurable and are not experienced as voluntary.

Psychopharmacotherapy is the use of pharmacological agents in the treatment of mental disorders.

Psychotherapy is a system of non-pharmacological, predominantly communicative (verbal) therapeutic intervention on the human psyche aimed at treating various disorders.

Exposure therapy is a behavioral therapy method for treating various mental disorders (anxiety disorders, OCD, PTSD). Exposure therapy involves acquainting the patient with the source of anxiety, fear, or its context without the intention of causing any danger (desensitization).

EMDR (eye movement desensitization and reprocessing) is a form of psychotherapy originally designed to alleviate distress associated with traumatic memories, such as post-traumatic stress disorder (PTSD); it involves focusing on traumatic memories in a manner similar to exposure therapy while simultaneously performing side-to-side eye movements or other forms of bilateral stimulation.

ERP (exposure and response prevention) is a variant of exposure-based behavioral therapy grounded in the idea that therapeutic effect is achieved when subjects confront their fears and refrain from engaging in escape behavior or rituals. ERP involves purposefully inducing fear, anxiety, and/or distress in an individual by exposing them to a feared stimulus. Response prevention thus involves compelling the individual to refrain from ritualistic or other compulsive behavior.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Obsessive-compulsive disorder (OCD) is characterized by recurrent, intrusive thoughts, images, impulses, or ideas (obsessions) that typically cause anxiety or distress, as well as repetitive mental or behavioral phenomena (compulsions) accompanied by a feeling of necessity to perform them either in accordance with obsessions or according to specific rules that must be followed to achieve a sense of "action completeness" [1 - 3].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Both genetic and environmental factors influence the development of OCD. Numerous studies confirm the involvement of the cortico-striato-thalamo-cortical (CSTC) circuit in the pathophysiology of the disorder [4]. Other brain regions are also involved in the pathogenesis of OCD [4, 5].

Twin studies and family studies of OCD have confirmed a substantial hereditary component in the etiopathogenesis of OCD. Furthermore, a greater weight of genetic factors was noted when OCD manifested in childhood rather than adulthood [6]. Specific genes and gene groups influencing the likelihood of developing OCD are unknown, although research in this area is ongoing [7 - 10].

Several environmental factors appear to influence the likelihood of developing OCD, although causal relationships have not yet been reliably verified [11]. These factors include the following. The onset or exacerbation of OCD in some children has been linked to an autoimmune process known as "PANDAS" (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections) [12] associated with group A streptococcal infection. It is hypothesized that in PANDAS, OCD symptoms are triggered by an autoimmune reaction to group A beta-hemolytic streptococci, leading to basal ganglia damage. Importantly, other infectious agents can also cause a similar condition—"pediatric acute neuropsychiatric syndrome" [13].

The premenstrual and postpartum periods can lead to the onset or exacerbation of OCD, suggesting that hormonal fluctuations may play an etiological role in the development of OCD [14].

The development of OCD following traumatic events has been described in adult patients, suggesting that an acute stress reaction may act as a "trigger" for this disorder [15]. There are numerous case reports of OCD developing after neurological injuries (stroke, TBI) affecting the CSTC circuit [16, 17]. Furthermore, neurosurgical interventions in CSTC regions have been shown to reduce the intensity and frequency of OCD symptoms in adults [17, 18]. Animal experiments have demonstrated that disruption of this system leads to OCD-like behavior [19, 20].

Neuroimaging studies have revealed anatomical abnormalities in the CSTC circuit in patients with OCD [1]. Despite contradictory results across meta-analyses, most studies generally report abnormalities in the orbitofrontal cortex (OFC), anterior cingulate cortex (ACC), and striatum. A meta-analysis of several neuroimaging studies also found abnormalities in the dorsomedial prefrontal cortex, inferior frontal gyrus, and cerebellum [21]. A meta-analysis of neuroanatomical data from several international studies revealed distinct patterns of subcortical abnormalities in adult patients and children with OCD—specifically, abnormalities in the globus pallidus and hippocampus in adults, and abnormalities in the thalamus in children [22]. Positron emission tomography (PET) and functional magnetic resonance imaging (fMRI) have identified abnormal activity in OCD within CSTC regions, including the OFC, ACC, and striatum [4]. Abnormal activity has been found to increase during symptom provocation and normalize following successful treatment. fMRI studies utilizing cognitive tasks have demonstrated CSTC dysfunction in patients with OCD [1]. For instance, several studies found that during procedural learning tasks, patients with OCD exhibited activity in the hippocampus, whereas healthy controls showed activity in the striatum [263].

There are assumptions regarding the role of the serotonin and/or dopamine systems in the pathogenesis of OCD [23, 24]. The results of pharmacological and neuroimaging studies aimed at testing these hypotheses have been contradictory. In addition, some modern models suggest that OCD symptoms are directly or indirectly related to abnormalities in glutamatergic neurotransmission within cortico-striatal pathways [25, 26].

1.3 Epidemiology of the Disease or Condition

According to various estimates, the prevalence of OCD is about 1–3% of the population [24, 25, 28]. The prevalence among women is slightly higher in adulthood, whereas in childhood, by contrast, males are affected more frequently [25, 26]. The average age of onset for OCD is 19–20 years. By the age of 14, the disorder develops in 25% of patients, and manifestation of the disease after 35 years of age is rare [27]. In male patients, the onset of the disease tends to be earlier, with 25% of them experiencing the first manifestations by the age of 10, whereas in women this percentage is significantly lower [25]. Among patients with OCD, 76% have a history of anxiety spectrum disorders (panic disorder, social phobia, generalized anxiety disorder, specific phobias), 63% have affective disorders (most commonly recurrent depressive disorder (41%) [28, 29, 31]), and 23–32% have a comorbid personality disorder, predominantly with anankastic traits [33].

In addition, up to 29% of individuals with OCD seek help for various tics [28, 29, 31]. Such a combination is more characteristic of males whose OCD began in childhood. Furthermore, body dysmorphic disorder [30], trichotillomania, and neurotic excoriation (compulsive skin picking and other forms of skin and mucosal damage) occur more frequently in OCD than in the general population [34].

At the same time, obsessive-compulsive syndrome occurs more frequently than in the general population in schizophrenia and schizoaffective disorder (12% of patients) [36, 37, 197], bipolar disorder [35], anorexia nervosa and bulimia nervosa [38], and Tourette syndrome [34].

1.4 Features of Coding the Disease or Condition

F42.0 Predominantly obsessions or ruminations

F42.1 Predominantly compulsive acts (obsessive rituals)

F42.2 Mixed obsessions and compulsions

F42.8 Other obsessive-compulsive disorders

F42.9 Obsessive-compulsive disorder, unspecified

1.5 Classification of the disease or condition

In the International Classification of Diseases, 10th Revision [35], adapted for clinical practice in the Russian Federation (1995, 1999), OCD is assigned to a separate category F42 and included in the general cluster of neurotic, stress-related, and somatoform disorders (F40–F48) [39].

Comment: In DSM-5, OCD is placed in a category separate from anxiety disorders, designated as "Obsessive-Compulsive and Related Disorders" [40].

Obsessive-compulsive disorder (F42)

An essential feature of the condition is the presence of recurrent obsessions or compulsions. Obsessions are ideas, images, or impulses that enter the patient's mind again and again in a stereotyped form. They are almost always distressing, and the patient often attempts to resist them unsuccessfully. Nevertheless, the patient recognizes these thoughts as their own, even though they are involuntary and repulsive. Compulsions, or rituals, are stereotyped behaviors that the patient repeats over and over again. They are neither pleasurable nor do they lead to the completion of inherently useful tasks. Rather, their function is to prevent some objectively unlikely event, often perceived as harm that the patient might otherwise cause or suffer. Typically, this behavior is recognized by the patient as pointless or ineffective, and repeated efforts are made to resist it. Anxiety is almost invariably present. If compulsive acts are suppressed, the anxiety becomes more pronounced.

Included:

• anankastic neurosis;

• obsessive-compulsive neurosis.

Excluded: obsessive-compulsive personality (disorder) (F60.5).

F42.0 Predominantly obsessions or ruminations

They may take the form of ideas, mental images, or urges to act, which almost always cause distress to the patient. Sometimes the ideas are unfinished, endlessly weighed alternatives associated with the inability to make a routine but necessary decision concerning daily life. The link between obsessive ruminations and depression is particularly close, so the diagnosis of obsessive-compulsive disorder should be preferred only if the obsessions arise or persist in the absence of a depressive episode.

F42.1 Predominantly compulsive acts (obsessive rituals)

Most compulsive actions are related to contamination cleaning (mainly hand washing), repeated checking to ensure that a potentially dangerous situation cannot arise, or maintaining neatness and tidiness. Underlying this overt behavior is usually the fear of danger to which the patient or someone else might be exposed, and the ritualistic actions are an ineffective or symbolic attempt to prevent the danger.

Other categories

F42.2 Mixed obsessions and compulsions

F42.8 Other obsessive-compulsive disorders

F42.9 Obsessive-compulsive disorder, unspecified

Definitions of certain symptoms and syndromes

Various content options for obsessions and rituals have been described. Nevertheless, the following categories («symptom dimensions») can be distinguished among them [42 - 44].

«Cleaning» — fears related to contamination/infection and cleaning rituals.

«Symmetry» — obsessions regarding symmetry and rituals of repeated, «correct» performance of actions, arranging items in a specific order, and counting.

«Taboo thoughts» — examples include aggressive, sexual, blasphemous obsessions and related compulsions.

«Harm» — for example, thoughts or mental images about causing harm to oneself or someone else («contrasting obsessions») and reassessment («re-checking») rituals regarding this.

«Hoarding» — obsessions and compulsions regarding collecting and accumulating various items.

1.6 Clinical presentation of the disease or condition

OCD in patients manifests as obsessions, compulsions, or both simultaneously. Furthermore, studies show that the combination of obsessions and compulsions in the clinical picture is more common than either syndrome occurring separately [42, 43].

Obsessions are recurrent and persistent thoughts, urges, or images. Obsessions are neither pleasurable nor experienced as voluntary. They are intrusive and unwanted, and most people suffer or experience anxiety from their appearance. Patients with OCD try to ignore, avoid, suppress obsessions, or neutralize them with other thoughts or actions (e.g., by performing rituals).

Compulsions (rituals) are repetitive behaviors or mental acts that a person performs driven by a sense of necessity in relation to the content of obsessions or according to rules that require strict precision or achieving a sense of «completeness» or «wholeness» of execution. The goal is to reduce the distress caused by obsessions or to prevent undesirable events. At the same time, compulsions are not realistically connected to these «dangerous» events or are clearly excessive compared to normal actions. Compulsions may also be performed to get rid of the feeling of « incompleteness » — for example, the need to repeat an action multiple times until it is done «absolutely right». Performing rituals does not bring pleasure, although some patients experience relief from anxiety and discomfort.

Obsessions and compulsions can vary in frequency and intensity — from 1–2 hours a day with mild intensity to constantly present distressing symptoms that significantly impair work capacity and/or quality of life.

At the moment when obsessive thoughts or compulsive actions appear, the patient may experience a variety of emotions. Thus, some patients feel pronounced anxiety, at the peak of which panic attacks (psychovegetative paroxysms) can develop and recur. Other patients report a pronounced feeling of disgust. When performing a ritual, many patients experience an unpleasant feeling of «incompleteness» or awkwardness that does not stop until the actions are completed (e.g., certain items are arranged in the «correct» way).

Many patients with OCD exhibit erroneous beliefs and attitudes [44, 45], including the following:

• an exaggerated sense of personal responsibility for future events and a tendency to overestimate the negative consequences of failures;

• perfectionism and the inability to tolerate uncertainty («low tolerance for uncertainty»);

• overestimation of the role and importance of mental phenomena (thoughts) — for example, the belief that having «bad, forbidden» thoughts is just as bad as real actions;

• the belief in the possibility of overcoming obsessive thinking.

There is a link between OCD and suicidal behavior; the lifetime prevalence of suicidal ideation in OCD patients is 63.5%, and suicide attempts are 46% [46]. Patients with comorbid psychiatric conditions, symptoms of depression and anxiety, and a history of suicide attempts are at a higher risk. Some patients experience an obsessive fear of harming others, but there is no evidence that they are more likely to commit an aggressive act than individuals from the general population.

OCD patients vary in how they assess the senselessness and excessiveness of their obsessions and rituals. The degree of insight into symptoms depends on individual characteristics and may change as the disorder progresses. In a small percentage of cases (less than 4%), when insight is absent, obsessions may transform into delusions—for instance, when a patient is convinced that their thoughts can cause real harm to another person [41].

The onset of OCD symptoms is usually gradual; an acute onset has been described, for instance, following an infectious illness [47]. Without treatment, OCD typically follows a chronic course with stabilization and even alleviation of symptoms [48, 49, 53]. In some patients, the course is episodic, and in rarer cases, it is unfavorable, marked by worsening and increasingly complex symptoms.

Avoidant behavior is frequently formed in OCD, whereby patients avoid people, objects, and places whose presence amplifies obsessions and compulsions. For example, in the case of contamination fear, such behavior may extend to public places—restaurants, restrooms—to reduce the risk of contamination or infection. Patients with aggressive obsessions may restrict social interactions. Avoidant behavior can encompass various spheres of life and significantly impair daily functioning, occupational capacity, and/or quality of life [50–52].

In the absence of appropriate therapy, remission rates for OCD in adults are quite low—around 20% [49]. Even with active therapy, only a small proportion of patients fully recover over time [48, 49, 53, 221].

The development of OCD leads to a diminished quality of life and significantly impairs social and occupational adaptation [50, 51]. Impairments affect many aspects of lifestyle and depend on the severity of symptoms. They are typically caused by the following consequences of obsessions or compulsions:

• time spent dwelling on obsessive thoughts and performing rituals;

• avoidant behavior towards situations that provoke an exacerbation of OCD symptoms;

• specific limitations associated with the theme (content) of the symptoms.

2. Diagnostics, medical indications and contraindications for diagnostic methods

Criteria for establishing the diagnosis/condition (ICD-10 research diagnostic criteria):

A. Either obsessions or compulsions (or both) are present on most days for at least a two-week period.

B. Obsessions (thoughts, ideas, or images) and compulsions (acts) share features, all of which must be present:

1. They are recognized as the patient's own thoughts and impulses and are not imposed by external influences or persons.

2. They are repetitive and unpleasant; at least one obsession or compulsion must be recognized by the patient as excessive or senseless.

3. The subject attempts to resist them, but if they have been present for a long time, resistance to some obsessions or compulsions may be minimal. There must be at least one obsession or compulsion against which resistance has proved unsuccessful.

4. The carrying out of compulsive acts and obsessive thoughts is not inherently pleasurable. (This characteristic must be distinguished from the temporary relief of anxiety or tension).

5. The obsessions or compulsions cause distress or interfere with the patient's social or individual functioning, usually by wasting time.

C. Most commonly used exclusion criteria. The obsessions or compulsions are not the result of other mental disorders, such as schizophrenia and related disorders (F20–F29) or mood (affective) disorders (F30–F39).

When OCD is suspected, a differential diagnosis must be performed to rule out various forms of anxiety-phobic and stress-related disorders, depressive episodes, tics, anankastic (obsessive-compulsive) personality disorder, eating disorders, impulse control disorders, body dysmorphic disorder [30], as well as obsessive symptoms within the schizophrenia spectrum [36, 37].

2.1 Complaints and Anamnesis

Consultation with a psychiatrist by OCD patients is driven by the distress of overcoming the obsessions and rituals that determine the severity of this disorder. Patients complain of thinking difficulties associated with the involuntary appearance and intrusive presence of both isolated stereotyped thoughts and affectively charged memories, reflections, and fears (e.g., blasphemous thoughts or the fear of harming another person); the need to spend increasingly more time performing rituals and checks (e.g., the need to repeatedly check whether the door is properly locked, the gas is turned off, etc.); anxiety and a feeling of 'incompleteness' when actions—their own or even someone else's—are performed in a 'wrong' order (e.g., the need to set the table 'correctly'); and limitations on social activities due to such behavioral traits (e.g., the inability to spend time away from home due to fears of contamination in public restrooms). In most cases, these patients demonstrate an understanding of the unnatural and illogical nature of their obsessions and states, yet feel powerless in their attempts to overcome them. They frequently express a fear of 'losing their mind' or acting on aggressive or self-directed aggressive impulses. In the case of contrast obsessions, their emergence can lead to an intense internal struggle accompanied by pronounced anxiety.

A detailed analysis of the subjective history aims to identify the onset time and course of the disease, as well as to assess the dynamics of avoidant behavior. Obtaining objective anamnestic data (information from the patient's close relatives) is essential to evaluate the scope and severity of compulsive symptoms that patients may conceal [1–3, 41].

• For all patients undergoing initial diagnosis, targeted questioning and screening to identify OCD symptoms in the patient's mental status and history are recommended, performed as part of the initial psychiatric interview and psychopathological examination (examination, consultation) by a psychiatrist [1, 3, 61].

Level of Evidence — 3, Strength of Recommendation — C.

Comment: When taking a psychiatric history, one should keep in mind the risk groups for developing OCD, which include patients with a history of depression, anxiety, alcohol and substance abuse, body dysmorphic disorder [30], or eating disorders [38].

To more effectively identify obsessive and compulsive symptoms in these patients, the following direct questions can be used [1, 3, 61]:

• Do you wash your hands/whole body frequently?

• Do you frequently monitor/recheck the performance of your own actions?

• Do you experience thoughts that continue to bother you even when you try to get rid of them—and cannot?

• Does it happen that completing daily routines takes a very long time?

• Do you keep your belongings in strict order, and do you have specific rules the violation of which can greatly upset you?

• How much do these problems distress you?

The Yale-Brown Obsessive-Compulsive Scale [54, 55] (Appendix G1) can also be used for screening OCD symptoms and assessing their severity.

• Symptom screening for the diagnosis of OCD is recommended in dermatology clinic patients, in whom skin lesions may accompany or be secondary to a psychiatric disorder [2, 157].

Level of Evidence — 5, Strength of Recommendation — C.

• For all patients diagnosed with OCD, in order to timely detect suicidal tendencies and prevent death by suicide, it is recommended to assess the risk of self-harming and suicidal behavior, especially if symptoms of depression are present [6, 46].

Level of Evidence — 2, Strength of Recommendation — A.

Comment: When assessing suicide risk using the Columbia-Suicide Severity Rating Scale (Appendix G2), as well as the risk of self-harm and aggression, it is necessary to consider the impact of compulsions on the behavior of the patient and their environment, alongside comorbid disorders and psychosocial factors [37, 50–52, 249, 250]. Concurrently, co-occurring somatic and mental pathologies and other risk factors must be ruled out [2, 3, 6].

2.2 Physical Examination

• To rule out somatic diseases, detect signs of self-harming behavior, including self-cutting (taking into account its duration), and assess somatic status, a physical examination is recommended for all patients with suspected OCD [1,2,3].

Level of Evidence — 3, Strength of Recommendation — C.

Comment: A detailed physical examination of patients with OCD (external examination, including visual dermatological examination (A01.01.002), measurement of height, body weight, physical development level, etc.) is aimed primarily at identifying skin and mucosal lesions, as well as other potential health risks that may be associated with compulsive actions and rituals [1 - 3, 34, 37].

2.3 Laboratory Diagnostics

Currently, there are no laboratory diagnostic methods for OCD. Laboratory tests are used to rule out other clinically similar conditions and to assess the risks of adverse effects during psychopharmacological therapy [2, 3, 7, 61].

Level of Evidence — 5, Strength of Recommendation — C.

Level of Evidence — 5, Strength of Recommendation — C.

• It is recommended that all patients with OCD undergo testing for hepatitis B virus surface antigen (HBsAg) in the blood, antibodies to hepatitis C virus (HCV) in the blood, antibodies to Treponema pallidum in the blood, and human immunodeficiency virus HIV-1/HIV-2 antibodies (IgM, IgG) in the blood upon hospital admission to rule out association with HIV infection, hepatitis, or syphilis [2, 252].

Level of Evidence — 5, Strength of Recommendation — C.

2.4 Instrumental Diagnostics

Currently, there are no instrumental diagnostic methods for OCD.

• It is recommended that patients with OCD undergo electroencephalography (EEG) to assess brain bioelectric potentials in order to rule out paroxysmal states as part of the initial assessment and upon hospital admission [218].

Level of Evidence - 3, Strength of Recommendation - C.

• It is recommended that patients with OCD undergo electrocardiography (ECG) to rule out comorbid cardiovascular pathology as part of the initial assessment and upon hospital admission [219].

Level of Evidence - 4, Strength of Recommendation - C.

• It is recommended that patients with OCD undergo brain magnetic resonance imaging (MRI) to rule out organic brain lesions as part of the initial assessment and when organic disorder is suspected [16, 17, 22].

Level of Evidence - 3, Strength of Recommendation - C.

2.5 Other Procedures

• It is recommended that all patients with OCD undergo a baseline Yale-Brown assessment to evaluate symptom severity and objectively track symptom dynamics during therapy [1-3].

Level of Evidence - 3, Strength of Recommendation - C.

Comment: The Yale-Brown Obsessive-Compulsive Scale is the gold standard for psychometric assessment of OCD severity [54, 55]. The scale consists of a checklist of obsessions and compulsions, as well as a severity rating scale. There are self-rated and clinician-rated versions of this scale, making it applicable in various clinical situations [56]. See Appendix G1.

• To determine the patient's psychological and personality traits as well as targets for psychotherapeutic intervention, it is recommended that all patients with OCD undergo a clinical and psychological psychodiagnostic assessment (individual clinical and psychological counseling) (A13.29.003.001) and/or pathopsychological/experimental-psychological (psychodiagnostic) testing (B03.035.004) as part of the initial evaluation [2, 92].

Level of Evidence - 5, Strength of Recommendation - C.

Comment: OCD is a disorder in which psychological factors play a major role in pathogenesis and clinical manifestations, and psychotherapy is one of the effective treatments. Based on the biopsychosocial model of mental disorders, involving clinical (medical) psychologists in multidisciplinary teams is essential to conduct specialized psychological assessment and determine targets for psychotherapeutic intervention [2, 92-97].

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 Psychopharmacotherapy

• For patients with a confirmed diagnosis of OCD who lack motivation for psychotherapy, have severe comorbid psychiatric pathology, abuse psychoactive substances, or have marked cognitive impairment that hinders psychotherapeutic correction, psychopharmacotherapy (PPT) is recommended to correct obsessive and compulsive symptoms [60, 94, 95].

Level of Evidence - 2, Strength of Recommendation - B.

Comment: Most patients respond favorably to PPT, but 40–60% of patients retain residual symptoms even after adequate courses of treatment in terms of duration and intensity (dosage) [60–63].

• SSRI antidepressants are recommended as first-line medications for all patients with OCD [64, 67, 68].

Level of Evidence - 1, Strength of Recommendation - A.

Comment: In repeatedly replicated RCTs, SSRIs have demonstrated good efficacy against OCD symptoms [64–66]. A Cochrane systematic review showed efficacy in both acute (short-term) and maintenance (prophylactic) stages of treatment [67]. Currently, there is no convincing evidence of the superiority of any single SSRI over other drugs in this class (escitalopram, fluvoxamine, paroxetine**, fluoxetine**, sertraline**) [67].

The onset of the therapeutic effect of SSRIs in OCD generally takes longer than in depression. However, a recent meta-analysis showed that the superiority of SSRIs over placebo appears as early as 2 weeks after treatment initiation [68].

Long-term prophylactic studies (24–52 weeks) have shown that the prophylactic efficacy of SSRIs significantly exceeds that of placebo. The maintenance treatment phase following the initial SSRI prescription should continue for at least 12 months at the maximum effective dose [104]. SSRI doses (escitalopram, fluvoxamine, paroxetine**, fluoxetine**, sertraline**) that produce an effect in OCD generally exceed those used in the treatment of depression (Appendix A3 [66, 67, 70, 98, 99, 136, 137, 156, 187]).

The starting dose of fluoxetine** is 20 mg/day, the therapeutic and maintenance dose is 20–60 mg/day, and the maximum dose of #fluoxetine is 120 mg/day [156]. If necessary, the dose can be split into morning and evening doses. The effect generally appears no earlier than 6–8 weeks of therapy [158].

The starting dose of escitalopram is 10 mg/day, and the maximum dose of #escitalopram is 60 mg/day [156, 159]. The use of doses exceeding 20–30 mg/day has been poorly studied [110, 111]. The course of maintenance therapy should be at least 6 months [66, 70, 98].

The starting dose of fluvoxamine is 50 mg/day at bedtime, with a therapeutic dose range of 100-300 mg/day. The dose is titrated gradually by 50 mg/day every 4-7 days depending on tolerability. The maximum dose of #fluvoxamine can reach up to 450 mg/day [156]. The dose is divided into morning and evening intakes, with the larger dose administered at bedtime [102,160].

The starting dose of paroxetine** is 20 mg/day, with a therapeutic and maintenance dose range of 20-60 mg/day; the use of higher doses has been poorly studied, but the maximum dose of #paroxetine** can reach up to 100 mg/day [156]. The dose is taken once daily and increased at intervals of 10 mg per week until a clinical effect is achieved [161]. The therapeutic effect is maintained for 6 months of therapy; longer-term use in OCD has not been sufficiently studied [81].

The starting dose of sertraline** is 50 mg once daily, with a therapeutic dose range of 50-200 mg once daily [162]. The use of higher doses has been poorly studied; the maximum dose of #sertraline** is 400 mg/day [109,156]. The dose is titrated by 50 mg weekly. Effective therapy may continue for several months [112].

A small RCT demonstrated the superiority of citalopram over placebo in the treatment of OCD [230]. The drug may be inferior in efficacy and tolerability to other SSRIs, so its use is better considered as a second-line therapy. The starting dose of citalopram is 20 mg once daily, with a therapeutic dose range of 20-60 mg daily. Caution should be exercised when prescribing citalopram doses exceeding 40 mg/day due to the risk of dose-dependent QT interval prolongation [231].

A positive family history of OCD, obsessions with aggressive, sexual, and religious content, decreased glucose metabolism in the orbitofrontal cortex, as well as increased glucose metabolism in the right striate body (caudate nucleus) may serve as predictors of a good response to SSRIs [71, 72].

The presence of hoarding symptoms, comorbid depression, and a significant decline in occupational and social functioning can serve as predictors of a poor response to SSRIs [73-75]. Fluvoxamine in doses of 50-300 mg/day may be considered as the drug of choice in OCD patients with body dysmorphic disorder and pathological gambling [246-248].

Recommended doses of SSRIs are provided in the section "Appendix A3. Tab. 1. Recommended dosage range of drugs for the treatment of OCD".

Disadvantages of SSRIs include delayed onset of effect, possible increase in anxiety during the first week of therapy, negative impact on sexual function, development of nausea, and certain other side effects [136,170]. QT interval prolongation is more common with citalopram and escitalopram [183]. It is necessary to warn patients with GAD about the potential development of side effects at the onset of antidepressant therapy to ensure compliance. During the first weeks of administration, it is advisable to monitor the patient, assessing suicide risks and possible intensification of anxiety symptoms [46, 212].

• Clomipramine** is a non-selective monoamine reuptake inhibitor, a TCA with a pronounced serotonin-positive effect, recommended as a second-line drug for the treatment of OCD in patients with insufficient response to SSRIs [77-80].

Level of Evidence - 2, Strength of Recommendation - B.

Comment: The efficacy of clomipramine** regarding obsessions and compulsions has been confirmed in repeatedly replicated RCTs, including large multicenter trials, and in meta-analyses [77-80]. Clomipramine** is comparable in efficacy to SSRIs in OCD and was previously considered a slightly more effective treatment method; however, a meta-analysis did not confirm its superiority [60]. In addition, clomipramine** has a less favorable safety and tolerability profile compared to SSRIs [77,81,188,189]. Among the most frequent side effects of the drug that significantly reduce patient compliance are anticholinergic effects (xerostomia, constipation, urinary retention, accommodation disorders, etc.), antihistamine effects (sedation, weight gain), anti-alpha-adrenergic effects (hypotension), arrhythmogenic effects (ECG monitoring required), and lowering of the seizure threshold [136].

Treatment is initiated with 1 tablet containing 25 mg of clomipramine** at bedtime (the dose can be divided into two intakes). Then, during the first week of treatment, the dose of the drug is gradually increased by 25 mg every few days (depending on tolerability) until reaching a daily dose of 100-150 mg (usually within 2 weeks) [163]. During the dose titration period, it is best to take the drug with food to prevent gastrointestinal irritation. In severe cases, the daily dose may be increased to a maximum of 250 mg/day. Maintenance therapy with the drug can continue for several months, and to prevent the sedative effect, the entire dose can be administered once a day [163,164]. It is advisable to maintain the minimum effective dose of clomipramine** [104]. Hypokalemia should be corrected before starting therapy [164]. Rare but dangerous adverse events associated with clomipramine** include seizures and hyperfermentemia. More frequent and relatively safe adverse effects are peripheral effects characteristic of all TCAs, manifesting as tachyarrhythmias, dry mucous membranes, difficulty urinating, accommodation disorders, and slowed bowel motility. The vast majority of patients tolerate clomipramine** satisfactorily; however, the tolerability of this drug is generally worse than that of SSRIs [81, 98, 99, 136].

• As a second-line therapy for patients with insufficient efficacy of SSRIs for the relief of OCD symptoms, the use of the serotonin and norepinephrine reuptake inhibitor (SNRI) #venlafaxine is recommended [82-87, 251].

Level of Evidence — 3, Strength of Recommendation — C.

Comment: It has been shown that a short course (12 weeks) of #venlafaxine treatment is comparable in efficacy to a course of treatment with clomipramine**, while #venlafaxine is characterized by better tolerability [82]. Several open-label studies have demonstrated the efficacy of #venlafaxine in both pharmacologically naive and treatment-resistant OCD patients, with a satisfactory response rate (30-60%) [83-87]. A comparative study with paroxetine** showed a comparable effect in both groups; however, a high dose of paroxetine** (60 mg/day) may be more effective in treatment-resistant cases than #venlafaxine [88]. Despite the existence of several double-blind randomized comparative studies, #venlafaxine does not have a registered indication for OCD. The starting dose is usually 75 mg/day, although in sensitive patients treatment can be started at 37.5 mg/day; the therapeutic and maintenance dose range is 75-225 mg/day [82], and the maximum dose in severe cases can be 375 mg/day [85]. Immediate-release formulations are prescribed 2-3 times a day, and extended-release formulations once a day. The dose is increased at intervals of 4-7 days by 75 mg until clinical effect is achieved [165]. Doses above 225 mg/day are rarely used and their efficacy has been poorly studied [85]. The therapeutic effect is maintained for 6 months of therapy; longer-term use in OCD has not been sufficiently studied [76].

• As an alternative second-line therapeutic option in patients with OCD for the correction of psychopathological symptoms, the use of the SNRI #duloxetine is recommended [89, 90, 253].

Level of evidence - 3, Strength of recommendation - B.

Comment: #Duloxetine demonstrates efficacy regarding OCD symptoms; however, these data were obtained from studies with small sample sizes and case series [89, 90]. The starting dose of #duloxetine is 30 mg/day, with a therapeutic dose of 60 mg/day [166,220,253]. Although dose titration can be performed daily by 30 mg, some patients require a more gradual dose increase (30 mg once a week). The maximum dose is 120 mg/day, although there is no convincing evidence of the efficacy of higher doses [90]. Treatment to maintain the clinical effect can last for several months, requiring careful monitoring of the patient's condition [76].

• For the treatment of OCD in patients with an insufficient therapeutic effect of SSRIs or the presence of pharmacokinetic conflicts, #mirtazapine in doses of 30-60 mg/day is recommended as a second-line therapy [138, 229].

Level of evidence - 2, Strength of recommendation - B.

Comment: The initial dose of #mirtazapine is 15 mg once at bedtime, the therapeutic dose is 30–45 mg/day, and the dose is increased by 15–30 mg gradually over 1–2 weeks of therapy [229]. The drug has a pronounced sedative effect, so the entire daily dose is usually prescribed as a single dose before sleep. The maximum studied dose is 60 mg/day [138, 182, 231].

3.2 Pharmacological therapy strategies for treatment-resistant cases

3.2.1 Combination thymoleptic therapy

About 40–60% of patients receiving monotherapy with SSRIs (clomipramine**, SSRIs, or SNRIs) do not respond to an adequate course of treatment in terms of dosage and duration (at least 4–6 weeks) [101, 185]. Lack of response is defined as an insufficient therapeutic response, i.e., a symptom reduction of less than 25–35% on the Y-BOCS scale [206]. In such cases, some guidelines consider the possibility of adding other agents to SSRIs and clomipramine**, specifically first-generation antipsychotics (FGAs) or second-generation antipsychotics (SGAs), after 8–12 weeks of SSRI monotherapy [99]. Strategies for cases where two courses of adequate therapy with first- and second-line drugs are ineffective may include adding another antidepressant to the already prescribed SSRI (adding clomipramine** to an SSRI, or adding an SSRI or SNRI to clomipramine**), using doses exceeding average therapeutic doses for OCD, using parenteral forms of antidepressants, as well as adding drugs from other groups to SSRIs and using non-pharmacological therapies [98, 99, 137, 186, 189, 190]. Any therapy with additional agents (adjuvant to clomipramine**) requires careful (preferably weekly) monitoring of tolerability and safety [62, 190].

• If monotherapy is insufficiently effective in the treatment of patients with OCD in treatment-resistant cases, a combination of clomipramine** with an SSRI is recommended to increase treatment efficacy [103, 104].

Level of Evidence - 4, Strength of Recommendation - C

Comment: Open-label studies have provided data on the efficacy and safety of long-term (up to 12 weeks) combination therapy with clomipramine** and an SSRI [103, 104]. Although the doses in combination therapy of clomipramine** with an SSRI remain within the therapeutic range, the use of maximum dosages should be approached with extreme caution due to the increased risk of serotonin syndrome [98, 99, 105, 244].

• In treatment-resistant cases of OCD, parenteral administration of clomipramine** is recommended to increase efficacy [107, 108].

Level of Evidence - 2, Strength of Recommendation - B.

Comment: Parenteral administration of antidepressants (clomipramine**)

makes it possible to accelerate the onset of the therapeutic effect; however, after 4–6 weeks, differences in efficacy compared to a comparable oral dose of the same antidepressant may diminish [106]. Intravenous administration of clomipramine** in treatment-refractory cases proved to be more effective than oral clomipramine** in two RCTs [107, 108]. The dosage regimen and route of administration for parenteral clomipramine** are determined individually. Intramuscular injections are started with 25–50 mg, then the dose is increased daily by 25 mg (1 ampoule) until a daily dose of 100–150 mg is reached [168]. Once improvement is noted, the number of injections is gradually reduced, replacing them with maintenance therapy using oral forms of the drug. For intravenous infusions, treatment is initiated with an intravenous drip of 50–75 mg (the contents of 2–3 ampoules) once daily. The maximum therapeutic dose of the drug is 150 mg per day [168]. To prepare the infusion solution, 250–500 ml of isotonic sodium chloride solution or glucose solution is used; the duration of the infusion is 1.5–3 hours. During the infusion, careful monitoring of the patient is necessary to timely detect potential adverse reactions. Particular attention should be paid to blood pressure monitoring, as orthostatic hypotension may develop [136]. Upon achieving improvement, clomipramine** is administered intravenously for another 3–5 days. Then, to maintain the achieved effect, patients are switched to oral administration; 2 tablets of 25 mg are usually equivalent to 1 ampoule of clomipramine** containing 25 mg. To gradually transition from infusion therapy to maintenance oral administration, the patient may initially be switched to intramuscular administration [168].

• In treatment-resistant cases of OCD, increasing SSRI doses to the maximum (see Appendix 4) is recommended to increase efficacy [99].

Level of Evidence — 5, Strength of Recommendation — C.

Comment: In treatment-resistant cases, SSRI doses are increased to the maximum (see Appendix A3) with careful monitoring of adverse events and limiting the treatment course to 4–12 weeks [99, 188]. If this strategy is ineffective, cautious use of SSRI doses exceeding those recommended in the package leaflet is possible in some cases of OCD [99, 187]. In refractory OCD patients, in exceptional cases, it is possible to increase the doses of #escitalopram to 60 mg/day, #fluvoxamine to 450 mg/day, #fluoxetine** to 120 mg/day, #paroxetine** to 100 mg/day, and #sertraline** to 400 mg/day [99, 156]. Thus, one RCT demonstrated the superiority of #sertraline** at a dose of 250–400 mg/day over standard therapeutic doses of the drug [109]. Similar data were obtained in an open-label study and an RCT using high doses (30–50 mg/day) of #escitalopram [110, 111]. When using high doses of SSRIs, gastrointestinal and sexual adverse effects of these drugs, as well as serotonin syndrome, are more likely to occur [136, 187].

3.2.1 Antipsychotics

One of the most studied methods for overcoming treatment resistance in OCD is the addition of antipsychotics to ongoing SSRI therapy [113–118]. Approximately one-third of patients experience significant clinical improvement within 4–8 weeks of such combination therapy [185, 191, 208]. Currently, no antipsychotic is approved for this indication either domestically or abroad [116, 118, 170]. When using a combination of SGAs (other antipsychotics) and SSRIs, one must keep in mind the high probability of drug-drug interactions due to cross-hepatic metabolism of most drugs in these groups [235, 236].

• For the treatment of OCD in treatment-resistant cases, the addition of #haloperidol**, #risperidone**, and #aripiprazole to ongoing SSRI therapy is recommended [114, 117–121, 126, 208].

Level of Evidence - 1, Strength of Recommendation - A.

Comment: For #haloperidol**, #risperidone**, and #aripiprazole, there are replicated positive results in large RCTs, systematic reviews, and meta-analyses [114, 117–121, 126, 208], which is why these drugs are primarily

used in refractory cases of OCD.

The initial dose of #haloperidol** is 2 mg/day for the first 3 days, then, depending on the patient's response to treatment, the dose is gradually increased by 2 mg/day every three days up to 10 mg/day and divided into 2–3 doses [169, 254]. High doses of #haloperidol** in OCD have been little studied and are used in rare cases; the maximum dose is 10 mg/day [118, 223]. If extrapyramidal symptoms (EPS) occur, agents with central anticholinergic action (anticholinergics) are added [171].

#Risperidone**, despite a slight advantage of #haloperidol** in reducing the total Y-BOCS score in individual RCTs, has better tolerability than #haloperidol** (it provokes EPS less frequently) and is more likely to lead to an improvement in anxiety and depression symptoms [123]. The initial dose of #risperidone** is 0.5–1 mg/day, then, depending on tolerability, the dose is gradually increased by 0.5–1 mg per day, in most cases up to 2–4 mg/day, and divided into 2 doses [119, 172, 231]. High doses of #risperidone** in OCD have been insufficiently studied and are used in rare cases; the maximum dose is 6 mg/day [118, 126].

The initial dose of #aripiprazole** is 5 mg/day every day, and the dose is gradually (once every 2 weeks) increased by 5 mg until reaching the maximum of 20 mg/day [173, 227, 231]. The therapeutic and maintenance dose is 10–15 mg/day once daily [121]. The use of higher doses of #aripiprazole** in OCD has been insufficiently studied; the maximum dose used was 20 mg/day [227]. Unlike other SGAs, #aripiprazole** does not cause somnolence or weight gain [173, 209].

• For the treatment of OCD in treatment-resistant cases, patients are recommended to be prescribed #quetiapine**, #olanzapine**, and #paliperidone as a second line of SSRI-augmenting therapy [113–118, 122, 207, 208].

Level of Evidence - 2, Strength of Recommendation - A.

Comment: Data on the efficacy of #quetiapine**, #olanzapine** and

#paliperidone** in treatment-refractory OCD are less convincing (unreplicated positive RCTs, presence of negative RCTs, lack of a significant effect size in meta-analyses) [113-118, 122, 207, 208]; therefore, these agents are recommended as second-line augmentation therapy to SSRIs.

The starting dose of #quetiapine** is 25 mg/day [175]. If well tolerated, the dose is increased weekly by 25 mg/day to a therapeutic dose of 200 mg/day [175, 207, 228]. The dose can be divided into 2-3 intakes per day. Depending on the clinical effect and individual tolerability, the dose may be increased up to a maximum of 600 mg/day [118]. #Quetiapine** has antidepressant and anxiolytic effects, which can be useful in patients with corresponding comorbid symptoms.

The starting dose of #olanzapine** is 5 mg/day; depending on the effect, the dose is increased weekly by 5 mg to 10-15 mg once daily (similar to patients with schizophrenia) [114, 115, 176, 231, 261]. High doses of #olanzapine** in OCD have been insufficiently studied and are used in rare cases; the maximum dose is 20 mg/day [118].

The starting dose of #paliperidone** is 3 mg/day, then, depending on tolerability, the dose is gradually increased by 3 mg per day at 5-day intervals. The therapeutic dose in most cases is 6 mg/day once daily [122, 231]. Higher doses of #paliperidone** in OCD have been insufficiently studied; the maximum studied dose is 9 mg/day [118, 122].

• If the above antipsychotic agents added to SSRIs are ineffective or poorly tolerated, the appointment of #amisulpride is recommended as an adjuvant agent to enhance treatment efficacy in patients with OCD [124].

Level of evidence - 2, Strength of recommendation - B.

Comment: Although data on the efficacy of #amisulpride as an adjuvant to SSRIs in treatment-refractory OCD come from only a single open-label study [124], the drug can be used in case of inefficacy or intolerance to the aforementioned antipsychotics.

The starting dose of #amisulpride is 200 mg/day once daily, and the therapeutic dose is 200-600 mg/day. Doses exceeding 400 mg/day are divided into two intakes [124, 178]. High doses of #amisulpride in OCD have been insufficiently studied and are used in rare cases; the maximum studied dose is 600 mg/day [124].

• #Clozapine is not recommended for use in patients with treatment-resistant OCD due to the lack of convincing efficacy data and the potential for exacerbation of OCD symptoms [91, 125-127].

Level of Evidence - 4, Grade of Recommendation - C.

Comment: #Clozapine can provoke the onset of obsessive-compulsive symptoms or lead to the exacerbation of pre-existing obsessions and compulsions in patients with schizophrenia (this risk is dose-dependent and amounts to 20-25% upon initial administration of #clozapine to a patient with schizophrenia) [91, 125-127, 167].

3.2.3 Anticonvulsants

• For the treatment of obsessions and compulsions in patients with treatment-resistant OCD, the administration of #topiramate** at a daily dose of 50-400 mg (mean dose 178 mg/day) is recommended as an alternative adjuvant therapy to SSRIs [128, 129].

Level of Evidence - 2, Strength of Recommendation - B.

Comment: One small RCT demonstrated the efficacy of adjuvant #topiramate** therapy at a daily dose of 50-400 mg (mean dose 178 mg/day) regarding compulsions (but not obsessions) in SSRI-refractory OCD [128]. Another small-sample RCT demonstrated the efficacy of adjuvant #topiramate** therapy (100-200 mg/day) to SSRIs regarding both obsessions and compulsions [129]. A third RCT with a similar design failed to confirm the efficacy of #topiramate** in refractory OCD [130]. The drug may be used as add-on therapy in treatment-resistant OCD.

The starting dose of #topiramate** is 25 mg/day once daily, and the therapeutic dose is 100-200 mg/day. Dose titration is carried out weekly by 50 mg increments. The dose is divided into morning and evening intakes [128, 129, 179]. The use of higher doses of #topiramate** in OCD has been insufficiently studied; the maximum dose is 400 mg/day [128, 179]. The minimum duration of therapy is 12 weeks [128, 129].

• To increase treatment efficacy in resistant cases, the use of #lamotrigine as an adjuvant drug to SSRIs at a daily dose of 100-200 mg is recommended for patients with OCD [131-134].

Level of Evidence - 4, Grade of Recommendation - C.

Comment: The efficacy of #lamotrigine as an adjuvant therapy method to SSRIs for refractory OCD (at a daily dose of 100-200 mg) was demonstrated in several case reports and subsequently confirmed in two RCTs [131-134, 231].

Due to the risk of skin rash, dose titration should be carried out very gradually, especially in patients with allergic reactions to other antiepileptic drugs. The initial dose of #lamotrigine is 25 mg/day once daily for 2 weeks; during the 3rd and 4th weeks, the dose is 50 mg/day; at the 5th week, 100 mg once daily; starting from the 6th week, the dose may be increased to 200 mg/day. The therapeutic dose is 100–200 mg/day once daily [132,134,231]. The use of higher doses of #lamotrigine in OCD has been insufficiently studied; the maximum dose is 400 mg/day. When co-administered with inhibitors or inducers of hepatic glucuronidation enzymes, the dose of #lamotrigine requires appropriate adjustment [180].

• In patients with refractory OCD, to accelerate the onset of fluoxetine** effect when its efficacy is insufficient, the addition of #gabapentin at a dose of 600 mg/day is recommended [135].

Level of evidence - 2, Strength of recommendation - B.

Comment: An open-label randomized comparative study demonstrated the potential ability of #gabapentin to accelerate the therapeutic effect of fluoxetine** in patients with refractory OCD. However, the study did not show a greater specific efficacy of combination therapy and noted a higher incidence of adverse effects in the combination treatment group [135]. The drug can be used to accelerate the onset of fluoxetine** effect when its efficacy is insufficient in patients with OCD.

The drug was used at 150 mg 4 times a day [135, 231]. The use of higher doses of #gabapentin in OCD has not been studied; the maximum studied dose is 900 mg/day [135].

3.2.4 Other agents

• In treatment-resistant cases, for patients with OCD who for various reasons cannot or do not wish to take FGA or SGA, #ondansetron** at a daily dose of 1-8 mg is recommended in addition to SSRIs to increase their efficacy [143].

Level of Evidence — 5, Strength of Recommendation — C.

Comment: #Ondansetron**, a serotonin 5-HT3 receptor antagonist, is currently used primarily as an antiemetic drug. The efficacy and good tolerability of #ondansetron** as an add-on to SSRIs in OCD have been demonstrated in several RCTs [139-142]. #Ondansetron** can be used as an alternative method of adjuvant therapy to SSRIs (at a daily dose of 1-8 mg) in refractory OCD patients who for various reasons cannot or do not wish to take FGAs or SGAs [143]. The starting dose of #ondansetron** is 1 mg/day, and the therapeutic dose is 2-8 mg/day once daily [139, 142, 143, 183]. The use of higher doses of #ondansetron** in OCD has not been studied.

• In treatment-resistant cases, for patients with OCD who for various reasons cannot or do not wish to take FGAs or SGAs, #granisetron at a daily dose of 2 mg is recommended in addition to SSRIs to increase their efficacy [211, 231].

Level of evidence - 2, Strength of recommendation - B.

Comment: #Granisetron, a drug close in mechanism of action to #ondansetron**, showed a promising effect in a small RCT when combined with fluvoxamine in SSRI-resistant OCD patients [211] and can be used as an alternative to #ondansetron** augmentation therapy in case of its inefficacy or intolerance. The therapeutic dose of #granisetron is 2 mg/day (1 mg every 12 hours) [211, 212, 231]. The use of higher doses of #granisetron in OCD has not been studied; the maximum dose is 2 mg/day [212].

• For patients with treatment-resistant OCD, #acetylcysteine** at a daily dose of 600-3000 mg is recommended as an SSRI-augmenting therapy to enhance their efficacy [186, 192-196].

Level of Evidence - 2, Strength of Recommendation - B.

Comment: #Acetylcysteine**, a drug with glutamatergic action, has proven its efficacy when added to SSRIs in treatment-resistant OCD patients in 3 out of 5 placebo-controlled RCTs, as well as in a series of clinical cases and a systematic review, and can be used in such patients [186,192-196].

The therapeutic dose of #acetylcysteine** ranges from 600 to 3000 mg/day, divided into multiple doses [192, 196, 231]. The course of therapy is 8-16 weeks; if an effect is achieved,

maintenance therapy may continue for more than a year [196]. The maximum dose is 3000 mg/day [196].

• For SSRI-treatment-resistant OCD patients, to increase treatment efficacy as an augmenting therapy, it is recommended to use #memantine** at a daily dose of 20 mg [146-148, 198].

Level of Evidence - 2, Strength of Recommendation - B.

Comment: #Memantine**, a non-competitive NMDA receptor antagonist,

which is currently widely used for the treatment of Alzheimer's type dementia, has shown its efficacy as an adjuvant agent in refractory OCD in three RCTs with small comparison groups [146-148], as well as in a meta-analysis [198], and can be used in patients with therapeutic resistance to SSRIs. The starting dose of #memantine** is 5 mg/day; if well tolerated, the dose is gradually increased by 5 mg weekly, with a therapeutic dose of 10-20 mg/day [146,147,231]. The use of higher doses of #memantine** in OCD has not been sufficiently studied; the maximum dose is 20 mg/day [148].

3.3 Non-pharmacological methods of biological therapy

Deep brain stimulation (DBS) is a neurosurgical treatment method that involves the stereotactic implantation of intracerebral electrodes that stimulate nerve tissue with electrical impulses. A distinctive characteristic of the method is its reversibility (i.e., the possibility of removing the electrodes) and flexibility, meaning the ability to adjust individual stimulation parameters (frequency, intensity, current strength, etc.) during treatment. This method is most widely used in advanced stages of Parkinson's disease to correct persistent disabling motor symptoms. In OCD, the use of this method is possible only in cases of complete resistance to other types of therapy and is considered, along with other neurosurgical methods, as a "last-resort treatment." There is literature data on at least 8 open-label studies and 6 RCTs with a small number of participants, in which the efficacy of DBS was 30-40% [216]. Out of 63 patients with refractory OCD who participated in controlled and uncontrolled DBS clinical trials, 34 showed a reduction in symptom severity of 34% or more [149-151,216]. CBT enhanced the efficacy of DBS in OCD [217].

• For the treatment of OCD symptoms, the use of DBS is recommended for patients only in cases of complete resistance to other types of therapy as a "last-resort treatment" [149-151, 216].

Level of Evidence - 2, Strength of Recommendation - A.

Comment: In accordance with the nomenclature of medical services, DBS includes several procedures: neurostimulator implantation, intracerebral electrode implantation, stereotactic intracerebral electrode implantation, and brain electrical neurostimulation. The anatomical targets for stereotactic electrode insertion and stimulation are diverse - the anterior limb of the internal capsule, the medial part of the globus pallidus, the ventral capsule/ventral striatum, the nucleus accumbens, the subthalamic nuclei, and the inferior thalamic peduncle [216]. Various stimulation parameters (current strength and voltage, polarity, pulse characteristics and frequency, etc.) vary widely and are selected individually. Psychological support, family counseling, and psychotherapy are of great importance for success [217].

• For the purpose of additional symptom correction and achieving remission in patients with pharmacoresistant forms of OCD, transcranial magnetic stimulation (TMS) is recommended [155,199, 200, 237].

Level of Evidence - 2, Strength of Recommendation - B.

Comment: Transcranial magnetic stimulation, primarily so-called

rhythmic (pulsed) or cyclic (cTMS), as well as deep TMS in several open-label and randomized studies (18 RCTs) on small patient samples (from 12 to 60 patients) with OCD refractory to pharmacotherapy, has demonstrated moderate and rapid efficacy [155,199,200], which was also confirmed in several meta-analyses [201,202,204]. At the same time, motor compulsions and comorbid depressive symptoms were reduced to a greater extent. Given the short two-week course and good tolerability, TMS can be used in pharmacoresistant forms of OCD [237]. Although the determination of the most effective TMS protocol and stimulation site needs clarification, currently preference is given to high-frequency (20 Hz) deep TMS over the medial prefrontal cortex area (the technique was approved by the FDA in 2019 for resistant OCD) and the anterior cingulate cortex with preliminary symptom "provocation" to achieve the highest treatment efficacy, as well as right-sided prefrontal cTMS over the supplementary motor area [203,204].

Non-pharmacological experimental methods for which convincing evidence of efficacy in refractory OCD has not yet been obtained include electroconvulsive therapy (ECT) and a number of neurosurgical techniques, including conformal external beam radiotherapy, including IMRT, IGRT, ViMAT, stereotactic (A07.30.009.001) ("gamma knife") (laser capsulotomy, tractotomy, etc.) [152,156,185,189,213,214,239]. Therefore, all these therapeutic methods cannot yet be widely used in clinical practice. An exception is the use of ECT for severe comorbid depression and high suicidal risk [214,215].

3.4 Psychotherapy

Psychotherapy is an effective method for treating OCD. The most optimal approach is a combination of psychopharmacotherapy and psychotherapy. The addition of psychotherapy is possible at all therapeutic stages. Specific psychotherapy methods directed directly at OCD symptoms (CBT, ERP) are distinguished from non-specific psychotherapy methods aimed at accompanying factors related to lifestyle, adaptation level, and stress coping (existential-humanistic therapy, family clinical-psychological counseling, short-term clinical-psychological counseling, clinical-psychological milieu therapy, etc.) [1, 2, 98,99].

Psychotherapeutic intervention is difficult and is not used in the following categories of patients [224,225]:

1. patients with a fear of self-disclosure and a predominance of denial within their complex of psychological defense mechanisms;

2. patients with insufficient motivation for change and obvious secondary gain from the illness;

3. patients with low interpersonal sensitivity;

4. patients who are unable to regularly attend psychotherapy sessions;

5. patients who will not participate in the process of active verbalization and listening in individual and group psychotherapy;

6. patients whose characterological features do not allow them to work constructively in individual and group psychotherapy and benefit from this work.

• CBT and its variant ERP as first-line monotherapy are recommended for the correction of OCD symptoms in pharmacologically naive patients with mild to moderate levels of distress or maladaptation, in patients without severe comorbid psychiatric pathology, and in patients who for various reasons prefer to postpone pharmacotherapy or refuse it [2, 92-95, 97,100, 232].

Level of Evidence - 1, Strength of Recommendation - A.

Comment: Conducting psychotherapy as monotherapy or together with pharmacotherapy is possible immediately after establishing the diagnosis of OCD. A large meta-analysis of 29 RCTs showed that CBT (cognitive behavioral therapy) and its variant ERP (exposure and response prevention therapy) for OCD are significantly superior in efficacy to placebo (waiting list) and unstructured psychological counseling methods. The average reduction in symptom severity (assessed in most studies using the Y-BOCS scale) was 50-70% [94,95]. The sufficient efficacy of various Internet-based CBT (i-CBT) techniques has also been demonstrated [232,233]. A meta-analysis of active-control studies showed a large significant difference between i-CBT and active control [232]. Another meta-analysis showed that i-CBT was more effective than inactive control, but the result did not differ from active control [233].

• For OCD patients with insufficient response to CBT, to reduce overall anxiety and tension levels and to teach self-regulation skills, the use of biofeedback therapy is recommended [226, 232, 262].

Level of evidence - 2, Grade of recommendation - C.

Comment: The method is more effective in combination with psychopharmacotherapy [262].

• For OCD patients with insufficient response to CBT, in order to reduce overall anxiety and tension levels and to teach self-regulation skills, it is recommended to use the EMDR technique [233].

Level of evidence - 2, Strength of recommendation - B.

Comment: The EMDR method showed results comparable to CBT in one study, but the data are not sufficiently convincing [233].

• For OCD patients with a moderate to severe level of distress or maladaptation, or with severe comorbid psychiatric pathology, it is recommended to use various types of psychotherapy in combination with psychopharmacotherapy for a more effective and sustained reduction in anxiety and tension levels, coping with stress, teaching self-regulation skills, learning relaxation, correction of irrational beliefs, etc. [2,96-99,224,232].

Level of evidence - 1, Strength of recommendation - B.

Comment: Combination therapy (psychopharmacotherapy + psychotherapy) demonstrates better efficacy rates than psychopharmacotherapy alone [96-97]. CBT and exposure therapy as standalone interventions are less effective in patients with substance abuse, as well as in patients with marked cognitive decline, lack of motivation for psychological treatment, and severe comorbid psychiatric pathology.

3.5 Criteria for evaluating treatment efficacy

• All patients with OCD receiving pharmacotherapy and/or psychotherapy are recommended to undergo an evaluation of the efficacy of each treatment stage during a follow-up psychiatrist appointment (examination, consultation) in order to monitor clinical dynamics and justify clinical decision-making [1 - 3, 37, 61].

Level of Evidence — 3, Strength of Recommendation — C.

Comment: Clinical guidelines of the World Federation of Societies

of Biological Psychiatry (WFSBP) [232], the American Psychiatric Association (APA) [99], and the Canadian Psychiatric Association [137, 189] indicate the necessity to evaluate the efficacy of ongoing pharmacotherapy (including the use of standardized psychometric instruments such as the Y-BOCS scale) and review the treatment regimen every 4–6 weeks. At the same time, in half of the patients, the effect of SSRIs develops more slowly, requiring at least 8–12 weeks of therapy at doses close to the maximum [185].

For psychotherapy, an appropriate course duration is 8 or 16 weeks with sessions lasting 90–120 minutes 2 or 1 time per week, respectively. Treatment efficacy should be evaluated at the end of the psychotherapy course [100, 223, 224, 231].

To evaluate the efficacy of pharmacotherapy and/or psychotherapy, a clinical interview (clinical and psychopathological examination) and psychometric instruments/scales (Y-BOCS, etc.) are used [54-59]. Furthermore, the effect (response to therapeutic intervention) is defined as a reduction in the total Y-BOCS score by at least 25-35% [98, 102, 189]. However, the concept of a clinical response to therapy may not always serve as an adequate measure of clinical efficacy, since the degree of symptom reduction depends on the initial severity, and in severe cases, significant residual symptoms may persist, continuing to impair social functioning and maladaptating the patient. Therefore, it is important to achieve a state of remission with minimal residual symptoms. An acceptable symptom severity level for OCD remission on the Y-BOCS scale is a total score of less than 14, and for recovery, less than 10-12 points [206].

3.6 Long-term relapse-prevention therapy

• Upon achieving a clinical effect after the first stage of treatment (i.e., SSRI monotherapy for 8–12 weeks) or subsequent stages (switching to clomipramine** or using adjuvant agents and treatment methods alongside SSRIs for 8–12 weeks), all patients with OCD are recommended to continue therapy for 1–2 years to prevent disease relapse [61, 112, 137, 144-145, 152-154, 156].

Level of Evidence — 3, Strength of Recommendation — C.

Comment: Achievement of a clinical effect is defined as a reduction in the intensity (severity) of OCD symptoms, their frequency and duration, as well as the level of distress and impairment of adaptation in the patient. Symptom reduction during therapy is typically assessed using the Yale-Brown Obsessive Compulsive Scale (YBOCS, see Appendix G). In cases of high symptom severity and refractoriness, pharmacotherapy may be administered indefinitely to prevent disease relapse in patients with OCD [61, 137, 144-145, 152-154, 156].

• For all patients with OCD upon the planned completion of long-term antidepressant therapy or forced premature discontinuation (due to poor compliance or tolerability), a gradual dose reduction is recommended to prevent withdrawal symptoms [255, 257].

GCR BLEL 3Grade of Recommendation — B (Level of Evidence — 3).

Comment: The dose tapering period may take several days, weeks, or even months, depending on the dose, duration of treatment, pharmacological properties of the drug, and the patient's condition. The need for a gradual dose reduction is due to the potential development of antidepressant discontinuation syndrome (ADS) [258,259]. These symptoms are usually transient and quickly resolve upon re-initiation of the antidepressant. The risk of their development is higher when the anticholinergic properties of the drug are more pronounced, the dose used is higher, and the duration of use is longer. Among newer-generation antidepressants, ADS is most characteristic of #venlafaxine [260] and SSRIs with a short half-life (e.g., paroxetine**), and less characteristic of fluoxetine**. Abrupt discontinuation of TCAs can trigger a cholinergic rebound phenomenon (flu-like state, myalgia, cramping abdominal pain). To avoid ADS or manage its manifestations if discontinuation of the antidepressant is decided, the following algorithm for the prevention and management of patients with antidepressant discontinuation syndrome is proposed (see Appendix B).

4. Medical Rehabilitation and Sanatorium-Resort Treatment

• All patients with OCD are recommended to undergo social and rehabilitation interventions in order to shorten the duration of temporary disability, facilitate early socialization in society, and improve quality of life [1–3, 98, 99].

Level of evidence – 3, Grade of recommendation – B.

• All patients with OCD are recommended psychotherapy for rehabilitation purposes [1, 2, 92–97].

Level of Evidence — 5, Strength of Recommendation — C.

Comment: First, this refers to specific psychotherapeutic methods directed immediately at OCD symptoms (CBT, ERP), which directly contribute to the patient's rehabilitation and the improvement of their social, occupational, and medical prognosis. Second, non-specific psychotherapeutic methods can be used, aimed at concomitant factors related to lifestyle, level of adaptation, and stress coping (existential-humanistic therapy, family clinical-psychological counseling, short-term clinical-psychological counseling, clinical-psychological milieu therapy, etc.).

5. Prevention and Dispensary Observation

Primary prevention of OCD does not exist. Secondary prevention should promote the prevention of relapses, reduction of the risk of symptom exacerbation, substance use, and suicidal behavior, and includes regular follow-up (dispensary observation) by specialized professionals, psychoeducation, and timely psychotherapeutic correction.

• For all patients with OCD, in order to reduce the risk of symptom exacerbation, it is recommended to initiate treatment as early as possible, adhere to the proper regimen of pharmacotherapy and psychotherapy sessions, and correct comorbid health- and lifestyle-related risk factors [1–3, 96, 243].

Level of Evidence — 5, Strength of Recommendation — C.

• For all patients with OCD, in order to reduce the risk of symptom exacerbation, prevent disease relapse, and foster treatment adherence, it is recommended to conduct psychoeducational sessions [3, 93, 231, 243].

Level of Evidence — 5, Strength of Recommendation — C.

Comment: Further research is needed regarding methods of secondary prevention for OCD. The effectiveness of psychoeducation in patients with OCD and their families as a prevention strategy requires additional scientific evaluation.

• Depending on the severity of OCD, for the purpose of dynamic status assessment, determination of indications for treatment adjustment, and timely hospitalization, patients are recommended regular outpatient (dispensary) monitoring by a multidisciplinary team, including a psychiatrist, psychotherapist, and social worker [1–3].

Level of Evidence — 5, Strength of Recommendation — C.

Comment: The minimum frequency of dispensary follow-up visits (examination, consultation) by a psychiatrist and psychotherapist in cases where the disease course has not required patient hospitalization for 3 years is once every 3 months; in case of hospitalization within 2 years, at least once every 2 months (during the first year, once a month). The objectives of dispensary follow-up include: clinical monitoring of the dynamics of psychopathological disorders (including the quality of remission) and prescribing additional examinations (if necessary), determining the characteristics of the social status, social functioning, and quality of life of patients, implementing maintenance and relapse-prevention treatment and adjusting it if necessary, arresting outpatient-level exacerbations, ensuring continuity of care after discharge from a psychiatric hospital and day hospital, identifying and managing side effects and complications of psychopharmacotherapy, assessing treatment adherence, conducting psychosocial rehabilitation, and preventing socially dangerous actions and suicidal behavior in patients. The frequency of dispensary visits (examinations, consultations), the scope of preventive, diagnostic, and therapeutic measures, and the necessity and scope of psychosocial rehabilitation are determined by the psychiatrist based on the clinical and social status of the patient in accordance with the features of the OCD course and the patient's current clinical status, pursuant to Order of the Russian Ministry of Health No. 453n dated June 30, 2022, "On Approval of the Procedure for Dispensary Follow-up of a Person Suffering from a Chronic and Prolonged Mental Disorder with Severe Persistent or Frequently Exacerbating Disease Manifestations," based on clinical guideline data. Dispensary follow-up is terminated upon recovery or significant and persistent improvement in the mental state of a person suffering from OCD.

6. Organization of Medical Care

Psychiatric care for patients with OCD is provided by medical and other organizations of the state, municipal, and private healthcare systems holding a corresponding license to carry out medical activities in mental disorders and behavioral disorders. Psychiatric care to a patient suffering from OCD is provided on a voluntary basis (subject to informed voluntary consent) except for cases stipulated by the legislation of the Russian Federation. Establishing an OCD diagnosis, making a decision to provide psychiatric care on an involuntary basis, or obtaining an opinion for the consideration of this issue is the exclusive right of a psychiatrist or a commission of psychiatrists. Psychiatric care may be provided outside a medical organization (at the call location of an ambulance, including specialized emergency medical care team); on an outpatient basis (in conditions not providing for round-the-clock medical observation and treatment), including at home upon calling a medical worker; in a day hospital (in conditions providing for medical observation and treatment during the day, but not requiring round-the-clock observation and treatment); or inpatiently (in conditions ensuring round-the-clock medical observation and treatment).

The provision of psychiatric care to patients with OCD is preferred in the least restrictive conditions—outpatiently or in a day hospital setting. Indications for inpatient treatment (hospitalization) may include comorbid depression, severe distress, suicidal and parasuicidal thoughts and suicide risk, treatment-refractoriness requiring more intensive therapeutic interventions in an inpatient setting, as well as pronounced social and occupational maladjustment (for example, due to restrictive behavior or severe disabling compulsions). Following inpatient treatment, the grounds for discharge from the hospital are clinical improvement, satisfactory tolerance of the new treatment regimen, and the absence of suicide risk [241,242].

Pharmacotherapy for OCD is divided into three stages: acute (resolving), continuation (stabilizing), and maintenance (prophylactic/relapse-prevention) [1]. Psychotherapy (CBT, ERP) is also used for rehabilitation and contributes to improving social and occupational adaptation (rehabilitation), reducing disease-related distress, and is applicable at any stage of treatment [1-3, 92].

When organizing and providing psychiatric care, telemedicine technologies may be used for remote interaction between medical workers, as well as between medical workers and patients and/or their legal representatives.

7. Additional Information

Factors contributing to unfavorable disease course and treatment resistance in OCD:

• Comorbid mental disorders (personality disorder, depression, schizophrenia spectrum disorder, etc.).

• Unfavorable social and family conditions (lack of a supportive environment, loneliness).

• Unfavorable lifestyle factors (stressful situations, physical inactivity, lack of a healthy work-rest schedule, and proper sleep-wake schedule).

• Low compliance (poor adherence to treatment).

• Concomitant alcohol and psychoactive substance abuse (in particular, psychostimulants [psychostimulants, agents used for attention deficit hyperactivity disorder, and nootropic drugs] and benzodiazepine derivatives).

• Use of antipsychotics, with the exception of low doses of #haloperidol**. Extrapyramidal disorders arising from the administration of antipsychotics with pronounced dopamine receptor antagonism may exacerbate compulsions (motor obsessions).

• Unjustified use of multiple medications enhancing serotonergic activity (MAO-A inhibitors combined with clomipramine**, SSRIs, or SNRIs) may increase the risk of serotonin syndrome.

• Unjustified shortening of relapse-prevention treatment terms may lead to symptom exacerbation.

Criteria for Evaluating the Quality of Medical Care

Quality assessment criteria for primary health care provided to adults with obsessive-compulsive disorder (ICD-10 codes: F42 [F42.0, F42.1, F42.2, F42.8, F42.9])

Quality assessment criteria for specialized medical care provided to adults with obsessive-compulsive disorder (ICD-10 codes: F42 [F42.0, F42.1, F42.2, F42.8, F42.9])

References

Appendix A1. Working Group Composition

1. Grigorova Oksana Valeryevna - PhD in Medical Sciences, Senior Researcher, Department of Borderline Psychiatry, V.P. Serbsky National Medical Research Centre for Psychiatry and Narcology of the Russian Ministry of Health, Member of the Russian Society of Psychiatrists

2. Kolyutskaya Elena Vladimirovna - MD, Professor, Leading Researcher, Department for the Study of Borderline Mental Pathology and Psychosomatic Disorders, Mental Health Research Center, Member of the Russian Society of Psychiatrists

3. Mosolov Sergey Nikolaevich - MD, Professor, Honored Scientist of the Russian Federation, Head of the Department of Therapy for Mental Disorders at the Moscow Research Institute of Psychiatry — branch of the V.P. Serbsky National Medical Research Centre for Psychiatry and Narcology of the Russian Ministry of Health, Head of the Department of Psychiatry at the Russian Medical Academy of Continuing Professional Education of the Russian Ministry of Health, Member of the Executive Board of the Russian Society of Psychiatrists

4. Khasanova Ayperi Kylychbekovna – Assistant, Department of Psychiatry, Russian Medical Academy of Continuing Professional Education of the Russian Ministry of Health, Member of the Russian Society of Psychiatrists

There is no conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience of these clinical guidelines: Psychiatrists

1. Psychiatrists

2. Psychotherapists

3. Medical (clinical) psychologists

4. General practitioners (family physicians)

5. Clinical pharmacologists

1. Level of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

2. Level of Evidence (LoE) grading scale for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

3. Grade of Recommendation (GoR) scale for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data regarding the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

A3.1 Legal documents (orders and instructions)

1. Federal Law No. 323-FZ of November 21, 2011 "On the Fundamentals of Protecting the Health of Citizens in the Russian Federation";

2. Law of the Russian Federation No. 3185-1 of July 2, 1992 "On Psychiatric Care and Guarantees of Citizens' Rights in Its Provision"

3. Order of the Russian Ministry of Health No. 468n dated 05.07.2022 «On approval of the standard of medical care for adults with obsessive-compulsive disorder (diagnosis, treatment and follow-up)» www.pravo.gov.ru, 12.08.2022, N0001202208120007.

4. Order of the Russian Ministry of Health No. 668n dated October 14, 2022 "On Approval of the Procedure for Providing Medical Care for Mental Disorders and Behavioral Disorders" (Registered with the Ministry of Justice of Russia on November 14, 2022, No. 70940)

5. Order of the Russian Ministry of Health No. 453n dated June 30, 2022 "On Approval of the Procedure for Dispensary Observation of a Person Suffering from a Chronic and Prolonged Mental Disorder with Severe Persistent or Frequently Relapsing Disease Manifestations" (Registered with the Ministry of Justice of Russia on July 28, 2022, No. 69429)

6. Order of the Russian Ministry of Health No. 451n dated June 30, 2022 "On Approval of the Procedure for Conducting Medical Psychiatric Examinations" (Registered with the Ministry of Justice of Russia on July 28, 2022, No. 69435)

7. Order of the Russian Ministry of Health No. 342n dated May 20, 2022 "On Approval of the Procedure for Mandatory Psychiatric Examination of Employees Performing Certain Types of Activities, Its Frequency, as Well as the Types of Activities for Which Psychiatric Examination Is Performed" (Registered with the Ministry of Justice of Russia on May 30, 2022, No. 68626)

8. Order of the Ministry of Health of the Russian Federation No. 1104n of November 26, 2021 “On Approval of the Procedure for Conducting Medical Examinations for the Presence of Medical Contraindications to Weapon Ownership, Including Extraordinary Examinations, and the Procedure for Issuing Medical Reports Based on Their Results, Forms of the Medical Certificate on the Absence of Medical Contraindications to Weapon Ownership and the Medical Certificate on the Absence of Narcotic Drugs, Psychotropic Substances, and Their Metabolites in the Body”

A3.2 Reference materials and dosage tables for the medications mentioned in the text

Table 1. Recommended dosage range of drugs for the treatment of OCD

Appendix B. Physician Action Algorithms

Management algorithm for patients with OCD

age of onset, typology, target symptoms, comorbid disorders, and assessing the efficacy and tolerability of previous therapy, one should proceed to Stage I of the algorithm — monotherapy with one of the first-line SSRIs for 8–12 weeks.

SSRI dosages exceeding those used in other anxiety disorders are employed (see Appendix A3). Depending on the treatment method, the efficacy of treatment should be assessed on days 14–28 of therapy. In the absence of an effect, diagnostics should be refined and iatrogenic causes of non-response ruled out, the main ones being insufficient dosage and/or inadequate duration of therapy.

In case of true inefficacy or intolerance to the first course of SSRIs, one should proceed to Stage II — monotherapy with clomipramine** or another SSRI (also for 8–12 weeks). The efficacy of the two methods of the second stage (switching to another SSRI or to clomipramine**) is comparable — in both cases, a therapeutic effect occurs in 30–40% of patients. The efficacy of switching to other antidepressants requires further clarification. In the case of clomipramine**, intravenous administration for 10–14 days (in an inpatient setting with cardiovascular monitoring) followed by a transition to oral administration is permissible to enhance the therapeutic effect. Upon achieving an effect, patients transition to a long-term (preferably 1–2 years) period of monotherapy with the same antidepressant at previous or slightly lower doses (for clomipramine**, the maintenance dose can be significantly lower than the therapeutic dose).

If the described methods are ineffective, patients proceed to adjuvant therapy for 8–12 weeks (Stages III–V). Currently, the combination of an SSRI with antipsychotics is recognized as the most effective. When using such combinations, careful monitoring of the patient's somatic and mental status is required (preferably weekly). Preferred agents are #aripiprazole, #risperidone**, and, to a lesser extent, #quetiapine**, #amisulpride, #olanzapine**, and #paliperidone** at moderate therapeutic doses (see diagram). #Haloperidol** may be added in small doses (up to 5 mg/day).

Alternative methods of adjuvant therapy used in Stage IV may include anticonvulsants (#gabapentin, #lamotrigine, #topiramate**), as well as #memantine**, #acetylcysteine**, #mirtazapine, and #ondansetron**.

Experimental methods of adjuvant therapy used in Stage V may include previously unused options.

If a therapeutic effect is achieved, patients transition to long-term (1–2 years) therapy with the previous SRI with gradual discontinuation of the adjuvant agent or long-term combination therapy of an SSRI with antipsychotics.

If interventions are ineffective at any stage, one must re-evaluate diagnostic accuracy, check compliance, and rule out comorbid mental disorders and concurrent diseases that may hinder the therapeutic effect (e.g., substance abuse, personality disorder, etc.).

In the absence of a positive response, the next stages are initiated, which include non-invasive non-pharmacological therapies (rTMS, deep TMS), as well as psychosurgery (PSG). Among all rTMS options, right-sided prefrontal rTMS over the supplementary motor area has the highest efficacy. The disadvantage of PSG is its invasiveness and the side effects characteristic of neurosurgical interventions. Currently, other non-pharmacological and neurosurgical methods are experimental and indicated only in cases of refractory illness with severe distress and disability. ECT may also be used in the presence of suicidal ideation and severe comorbid depression. If a non-pharmacological method proves effective, one should transition to long-term SSRI monotherapy.

Psychotherapy should be considered as first-line monotherapy in pharmacologically naive patients with mild to moderate levels of distress or maladaptation, in patients without severe comorbid psychiatric pathology, and in patients who for various reasons prefer to delay pharmacotherapy or refuse it. Psychotherapy can be considered as an adjunctive (to pharmacotherapy) method at any stage of treatment regardless of OCD symptom severity.

Prevention and management algorithm for antidepressant discontinuation syndrome (ADS)

Note: AD – antidepressant, SSRI – selective serotonin reuptake inhibitor, SNRI – serotonin-norepinephrine reuptake inhibitor (other antidepressants), ADWD – antidepressant withdrawal syndrome

If a decision is made to discontinue long-term antidepressant therapy, a gradual dose reduction of the antidepressant is preferred. If there is a high risk of antidepressant withdrawal syndrome (ADWD), the slowest possible dose reduction is desirable, although there are no universal guidelines regarding the duration of the tapering period and the minimum dose to which the antidepressant should be reduced prior to cessation. If ADWD cannot be avoided and is mild in severity, pharmacotherapy is not indicated, and it is sufficient to inform the patient about the temporary nature of the symptoms. For moderate ADWD, symptomatic treatment is necessary. In cases of severe symptoms upon antidepressant discontinuation or a significant dose reduction, the following equivalent options can be utilized (i.e., there is no specific order of application): 1) resume the antidepressant at the minimum effective dose or at the dose where withdrawal symptoms were absent, followed by a more fractional and gradual titration; 2) when discontinuing an SSRI or SNRI, one can switch to fluoxetine** with discontinuation of the original AD after several weeks of fluoxetine** therapy, followed by a gradual taper of the latter; when discontinuing an antidepressant from other groups, one can switch to a pharmacologically similar antidepressant with a longer half-life and subsequently taper both antidepressants gradually as in the switch to fluoxetine**.

Appendix C. Patient Information

What is obsessive-compulsive disorder?

Obsessive-compulsive disorder is a nervous system disorder,

whose main manifestation is recurrent intrusive thoughts, images, or impulses (obsessions) that are recognized as one's own, often absurd or even meaningless, and cause distress or suffering (anxiety), along with an urge to resist them in various ways, including through protective behaviors (compulsions).

What are the main symptoms of obsessive-compulsive disorder?

The most common obsessions involve contamination, infection, aggressive acts, desires for symmetry and precision of objects, and unpleasant bodily sensations, among others. Among compulsions, checking behaviors, washing and cleaning, and counting are most frequently observed. Many patients develop avoidance behavior in situations related to their obsessions. For example, patients with a fear of contamination avoid using public restrooms or shaking hands with strangers.

Diagnosis of obsessive-compulsive disorder

The diagnosis of obsessive-compulsive disorder is typically established based on the presence of intrusive thoughts and protective behaviors after ruling out all other conditions that may present with similar symptoms. Diagnosis and treatment of obsessive-compulsive disorder are performed by a psychotherapist or psychiatrist.

A preliminary diagnosis may be made by a general practitioner (family doctor) or neurologist.

Treatment of obsessive-compulsive disorder

Treatment of obsessive-compulsive disorder includes psychotherapy and the prescription of medications that reduce the severity of obsessions and lower anxiety, predominantly antidepressants that increase serotonin levels in the central nervous system. In severe cases or when psychotherapy combined with well-established medications is ineffective, other pharmacological agents, including antipsychotics, and non-pharmacological therapies, such as transcranial magnetic stimulation and deep brain stimulation, may be used. Pharmacological treatment is usually long-term. Prescription, adjustment, and discontinuation of medications are carried out exclusively by a specialist physician.

Psychotherapy can be conducted individually or in small groups. Behavioral psychotherapy is the most effective approach, including gradual adaptation and learning to control triggering situations. Compulsions generally respond better to psychotherapy than obsessions. Behavioral training in various situations and psychological exercises help build self-confidence, reduce stress, anxiety, and the severity of obsessions.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1.

Russian title: Florida Yale-Brown Obsessive-Compulsive Scale for Assessing Obsessive-Compulsive Symptoms

Original title: FLORIDA YALE-BROWN OBSESSIVE COMPULSIVE SCALE (FLY-BOCS)

Source: original version [54, 55], Russian-language version [1].

Type (underline):

- rating scale

- index

- questionnaire

- other (specify):

Purpose: assessment of symptoms and their severity in obsessive-compulsive disorder, including reassessment for dynamic monitoring during treatment.

Content (template): The scale consists of 10 items, 5 of which assess the severity of obsessive symptoms and 5 assess the severity of compulsions. Each item is scored on a 5-point scale from 0 to 4 points. For each item, the average symptom severity over the past week is determined. The severity of obsessive and compulsive symptoms is determined by the following criteria: duration of symptoms per day, degree of functional impairment, level of psychological discomfort, resistance to symptoms, and control over them.

Below are the instructions for use, the scale, the symptom recording form, and a structured interview with questions.

Key (interpretation): The total score on the FLY-BOCS scale is the sum of items 1-10 (excluding items 1b and 6b); in addition, the obsession subscale score (items 1-5, excluding 1b) and the compulsion subscale score (items 6-10, excluding 6b) are calculated. The severity of OCD is categorized as subclinical (0-7 points), mild (8-15 points), moderate (16-23 points), severe (24-31 points), and extreme (32-40 points).

Notes: Assessment is carried out based on a structured interview.

1.1 General guidelines

This scale is designed to assess symptom specificity and severity in obsessive-compulsive disorder (OCD). Most items are rated based on the patient's reports, but the overall score is based on the expert's clinical judgment. Each item assesses the patient's condition over the past week, including the day of the interview. For each item, the scores reflect the state most characteristic of that week.

Assessment is conducted via a structured interview. The expert should evaluate symptoms in the proposed order and adhere to the standard questioning format. At the same time, the expert may ask additional questions at their discretion to clarify information. Information provided by the patient on their own initiative should also be taken into account. The assessment must be based on information obtained during the conversation and observations made.

If the expert's clinical judgment differs from the information obtained during the conversation, the expert has the right to question the patient's reports, which should be duly noted in item 19.

Additional information obtained from the patient's relatives or observers is used in the assessment only under the following conditions:

1. The additional information is primary in assessing the patient's condition

2. The additional information is consistently available during each conversation with the patient, and the source of information is the same person.

Before asking the patient questions, the terms obsessions and compulsions should be explained to them.

Obsessions are unwanted and distressing ideas, thoughts, images, or experiences that arise and recur against your will. They may seem meaningless or unpleasant, and may contradict your personal views.

Compulsions (ritualistic behaviors) are unwanted urges to perform an inappropriate action or behave in a strange manner. If the action is not performed, anxiety typically develops. Therefore, resisting such actions is often difficult.

Here are some examples of obsessions and compulsions.

Example of an obsession: constantly recurring thoughts of inflicting physical harm on your own children, even though you fully understand that you will never and under no circumstances do so.

Example of a compulsion: the need to return several times to check whether the TV or iron is turned off, the water is shut off, or the doors are locked; you cannot leave the house without checking all of this repeatedly. Most often, compulsions manifest in behavior, but mental compulsions are also possible—for example, every time an unpleasant thought occurs to you, you feel that you must mentally repeat special words that are unrelated to what is happening and may even be completely meaningless, but you feel the necessity of thinking them through.

Do you happen to have any questions about compulsions or obsessions?

During follow-up interviews with patients, there is no need to re-explain the meaning of the terms obsession and compulsion (provided you have confirmed that the patient understands these words). It is only important to remind the patient from time to time that obsessions are thoughts and experiences, while compulsions are urges to perform actions, even if those actions are mental operations.

The patient is asked to list the obsessions and compulsions that trouble them so that the expert can compile a symptom checklist for further tracking. The FLY-BOCS symptom checklist is designed for accurate and most comprehensive recording of symptoms. It is also important to identify and account for obsessions and compulsions that were observed previously, as former symptoms may recur during the current rating process. Having identified the existing obsessions and compulsions, the expert compiles a list of target symptoms; when compiling the list, one should adhere to the clinical classification (for example, separating compulsive checking from compulsive washing). The main features of the target symptoms should be described to facilitate their subsequent tracking. For example, when specifying the symptom of compulsive checking, one should clarify what exactly and in what manner the patient checks.

It is important to indicate the most prominent symptoms that will subsequently have the greatest impact on the current ratings. At the same time, it must be remembered that the total scale score reflects the severity of all obsessions and compulsions present in the patient.

The expert is required to assess to what extent the identified symptoms are manifestations of OCD and to differentiate the diagnosis (in particular, from simple phobias and impulse control disorders). The differential diagnosis between certain motor tics and some compulsions (e.g., involuntary touching) may be difficult or impossible altogether. In such cases, it is especially important to compile an exhaustive description of the target symptom and carefully track changes in this symptom over time. When using the FLY-BOCS scale to assess the severity of non-OCD symptoms in patients who meet OCD criteria, it is recommended to use the FLY-BOCS twice: first to assess OCD, and then to assess symptoms not directly related to OCD.

In such cases, scoring is performed separately to determine the severity of OCD and to assess other symptoms whose relationship to OCD is not definitively established. During follow-up interviews, the list of target symptoms may be revised. In such cases, item 1 accounts for a different obsession, and item 6 accounts for a different compulsion.

The total FLY-BOCS score is the sum of items 1–10 (excluding items 1b and 6b); in addition, the obsession subscale score (items 1–5, excluding 1b) and the compulsion subscale score (items 6–10, excluding 6b) are calculated.

The severity of OCD is categorized as subclinical (0–7 points), mild (8–15 points), moderate (16–23 points), severe (24–31 points), and extreme (32–40 points).

1.2 FLY-BOCS Symptom Checklist

Full Name ______________________________________________________________________

Date _____ /_____________ /__________

The list above should be used to note all symptoms reported by the patient. The main symptoms should be highlighted.

(The expert should determine whether the identified symptoms are a manifestation of OCD rather than another disorder, such as a phobia or hypochondriasis. Symptoms marked with an asterisk «*» may pertain to both OCD and other disorders

1.3 Target Symptom Checklist

Full Name ______________________________________________________________________

Date _____ /_____________ /___________

Obsessions

1.       ___________

2.     ___________

3.     ___________

Compulsions

1.       ___________

2.     ___________

3.     ___________

Avoidance

1.       ___________

2.     ___________

3.     ___________

1.4 Structured Interview "Now I would like to ask you in more detail about your obsessive thoughts" (The question should precisely name the patient's obsession)

1. Duration of obsessive thoughts

Question: How much time do obsessive thoughts take up? (If the obsessions are in the nature of momentary, transient flashes, the patient may experience difficulty determining their duration in hours and minutes. In these cases, to help the patient, it should be clarified how often the obsessions appear. Subsequently, the frequency of short-term obsessions and their duration are taken into account). Additional question: How many times a day do obsessive thoughts appear? (Obsessive thoughts should be strictly distinguished from situationally or affectively driven ruminations, which, while absorbing the patient's attention and taking up most of their time, are nevertheless rational and ego-syntonic to the patient's personality)

0 = no obsessive thoughts

1 = less than 1 hour per day, or isolated short-term episodes

2 = from 1 to 3 hours per day, or frequent short-term episodes

3 = from 3 to 8 hours per day, or numerous short-term episodes

4 = more than 8 hours per day, or constant short-term episodes

1b. Lucid intervals (time free of obsessions) — not added to the total score

Question: How many hours a day does the usual break between obsessive thoughts last? (Clarify if necessary). Additional question: How many hours can the longest break between obsessions last?

0 = no obsessions occur

1 = long breaks, more than 8 hours a day without obsessions

2 = fairly long breaks, from 3 to 8 hours a day without obsessions

3 = short breaks, from 1 to 3 hours a day without obsessions

4 = very short breaks, less than 1 hour a day without obsessions

2. Impact of obsessions on social activity

Question: How much do obsessions interfere with your lifestyle and work? Perhaps because of obsessive thoughts you cannot perform some of your duties or give up something in your personal life? (if the patient is not working at the time of the interview, when asking the question, it should be clarified how much the obsessions would interfere with professional activity)

0 = no impact

1 = mild impact on social or occupational activity; the patient's general behavior and lifestyle do not change

2 = moderate impact on social or occupational activity; the patient manages to cope with the obsessions

3 = severe impact, which significantly impairs the patient's social and occupational activity

4 = extreme severity; obsessions prevent leading a normal lifestyle and coping with professional duties

3. Distress due to intrusive thoughts (subjective burden of obsessions)

Question: Do you find it difficult to cope with your obsessions? (It should typically be determined to what extent the obsessions or the struggle against them are associated with anxiety. At the same time, the patient may report the burdensome nature of obsessions while denying anxiety. Anxiety should not be scored under this item if it is caused by reasons other than obsessions).

0 = patient is not burdened by obsessions

1 = mildly distressing subjectively, no outward manifestations

2 = moderately distressing subjectively, patient manages to cope with it

3 = severely distressing subjectively, obsessions are traumatic for the patient

4 = extreme severity, patient is almost completely overwhelmed by obsessions

4. Resistance to obsessions

Question: Do you have to make an effort to cope with obsessive thoughts? Do you often have to intentionally switch your attention to avoid yielding to obsessive thoughts or to distract yourself from them when they arise? (This item evaluates only the efforts and attempts to resist, while the success of obsession suppression is not considered. The effort spent on resisting obsessions does not always correspond to successfully getting rid of them. It should also be noted that the score for this item should not be influenced by the severity of obsessions: it evaluates the patient's insight and attitude—the energy with which the patient confronts the obsessions. Avoidance is not considered resistance to obsessions. Enacting obsessive thoughts or compulsions (to find relief) is not considered resistance. The more attempts at resistance the patient makes, the lower the score on this item. There are "active" and "passive" forms of resisting obsessions. For example, during psychotherapy, a patient may be taught not to fight obsessive thoughts, to simply let them pass, or the patient may consciously invoke opposing obsessions to displace the original ones. When scoring this item, any psychotherapeutic defense methods should be considered as resistance to obsessions.)

If the severity of obsessions is minimal, the patient may feel no need to resist them. In such cases, a score of zero is given.

0 = always resists obsessions, or the severity of obsessions is minimal and there is no need to resist

1 = attempts to resist almost always when obsessions occur

2 = usually tries to resist

3 = yields to all obsessions without resistance, but is unhappy about it

4 = completely yields to obsessions

5. Ability to control obsessions

Question: To what extent can you control your obsessive thoughts? Are you able to stop obsessive thoughts? Can you distract yourself from obsessive thoughts? Can you get rid of obsessive thoughts at will? (In contrast to the previous item, the patient's success in resisting obsessions is evaluated higher the more severe the manifestations of obsessions are)

0 = complete control over obsessions

1 = almost complete control; with some effort, the patient is almost always able to cope with obsessive thoughts or get rid of them

2 = moderate control; from time to time manages to cope with obsessions

3 = poor control; the patient rarely manages to distract themselves from obsessions or get rid of them

4 = no control over obsessions, completely yields to them; even brief attempts to distract oneself are difficult for the patient

"And now I will ask you in more detail about compulsions" (The question should specifically state the patient's compulsion)

6. Duration of compulsions

Question: How much time do your compulsions take up? If compulsions manifest as the ritualization of daily chores, you should ask: how much more time do your daily responsibilities take up due to rituals? (If compulsions manifest as brief, transient urges to act, the patient may have difficulty determining their duration in hours and minutes. In such cases, to help the patient, one should clarify how often the compulsions occur. Subsequently, both the frequency of short-term compulsions and their duration are taken into account. Frequency in this case refers to the number of newly emerging compulsions, not the number of repeated actions performed. For example, if a patient goes to the bathroom 20 times a day to wash their hands 5 times in a row, the frequency is 20 times a day). Question: How many times a day do you perform compulsive actions? (Most of the time, compulsions are obvious, such as hand washing, but sometimes they are imperceptible, such as the patient silently checking the order of something).

0 = no compulsions

1 = less than 1 hour a day or isolated compulsions

2 = from 1 to 3 hours a day, or frequent compulsions

3 = from 3 to 8 hours a day or numerous compulsions

4 = more than 8 hours a day or constant compulsions that cannot be counted

6b. Lucid intervals (time free of compulsions) - not included in the total score

Question: How many hours a day does the usual break between compulsions last? (Clarify if necessary). Additional question: How many hours can the longest break between compulsions last?

0 = no compulsions

1 = long intervals, more than 8 hours per day without compulsions

2 = fairly long intervals, from 3 to 8 hours per day without compulsions

3 = short intervals, from 1 to 3 hours per day without compulsions

4 = very short intervals, less than 1 hour per day without compulsions

7. Impact of compulsions on social activity

Question: How much do compulsions interfere with your lifestyle and work? Perhaps because of compulsions you cannot fulfill some of your duties or give up something in your personal life? (if the patient is not working at the time of the interview, the question should be framed to determine how much compulsions would interfere with professional activity)

0 = no impact

1 = mild impact on social or professional activity, the patient's general behavior and lifestyle do not change

2 = moderate impact on social or professional activity, the patient manages to cope with compulsions

3 = severe impact, which significantly impairs the patient's social and professional activity

4 = extreme severity, compulsions prevent leading a usual lifestyle and coping with professional duties

8. Distress associated with compulsions (subjective burden of compulsions)

Question: If you fail to perform the actions you feel urged to do, what do you feel? (Pause) Do you experience anxiety? (Assess how distressed the patient would be if suddenly deprived of the opportunity to carry out compulsions. Most often, the opportunity to perform compulsive urges reduces anxiety. If, in the patient's opinion, anxiety decreases only in case of successful struggle with compulsions, this should be clarified). Additional question: Do you feel anxious while performing compulsive actions? How severe is it?

0 = patient is not distressed

1 = mild anxiety if it is impossible to carry out compulsions, or slight anxiety during the performance of compulsive actions

2 = moderately severe, manageable anxiety if it is impossible to carry out compulsions, or the patient manages to cope with anxiety by performing compulsive actions

3 = severe, overwhelming, and distressing anxiety when unable to perform

compulsions or during the performance of compulsive actions

4 = extreme anxiety upon any attempt to interfere with the performance of compulsions, or the development of completely overwhelming anxiety during the execution of compulsions

9. Resistance to compulsions

Question: Do you make an effort to fight compulsions? (Only attempts to resist compulsions should be assessed; the success of the struggle is not taken into account. The efforts made by the patient to fight compulsions do not always correspond to the ability to control them. It should also be noted that the severity of compulsions should not influence the score in this item: the patient's critical attitude and mindset are assessed - the energy with which the patient opposes compulsions. The more attempts the patient makes to fight them, the lower the score on this item. If the severity of compulsions is minimal, the patient may not feel the need to fight them. In such cases, a score of zero is given.)

0 = always fights compulsions, or the severity of compulsions is minimal and

there is no need to fight.

1 = attempts to fight almost always when compulsions appear

2 = usually tries to resist

3 = yields to all compulsions without a fight, but is unhappy about it

4 = completely subservient to compulsions

10. Ability to control compulsions

Question: How strong are the urges to perform compulsive actions that you experience? Do you manage to stop compulsions? Do you manage to distract yourself from compulsions? Can you get rid of compulsions at will? (In contrast to the previous item, the patient's success in fighting compulsions is rated higher the more severe the manifestations of compulsions are)

0 = complete control over compulsions

1 = almost complete control, with some effort the patient is almost always able to cope with compulsions or get rid of them

2 = moderate control, occasionally manages to cope with compulsions

3 = weak control, the patient rarely manages to distract themselves from compulsions or get rid of them

4 = absolute lack of control over compulsions, completely subdued by them, even attempts to briefly stop compulsive actions are difficult for the patient

1.5 Florida Yale-Brown Obsessive-Compulsive Scale (FLY-BOCS) Symptom Checklist

Full Name ______________________________________________________________________

Date _____ /_____________ /___________

Patient ID code ______________________________________________________________________

Rater ______________________________________________________________________

Obsession subscale score (1-5) ___

Compulsion subscale score (6-10) ___

Total score for items 1-10 ___

Appendix G 2. Assessment of Suicide Risk and Suicidal Behavior

Russian title: Columbia-Suicide Severity Rating Scale

Original title: Columbia-Suicide Severity Rating Scale (C-SSRS)

Source: Posner K, Brown GK, Stanley B, Brent DA, Yershova KV, Oquendo MA, Currier GW, Melvin GA, Greenhill L, Shen S, Mann JJ. The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry. 2011 Dec;168(12):1266-77.

Type (underline):

- rating scale

- index

- questionnaire

- other (specify):

Purpose: assessment of suicide severity and suicide risk.

Content (template):

Columbia-Suicide Severity Rating Scale (C-SSRS)

Total score:

Key (Interpretation): A score of "3" or higher on the severity of suicidal ideation indicates a serious risk of suicide. A score of "5", as well as any identified suicidal behavior, indicates an extremely high risk and an absolute necessity for urgent therapeutic interventions and hospitalization. The "suicidal intent" section allows for a more accurate assessment of the severity of the condition and prediction of its dynamics.