Adapted from the Obsessive-Compulsive Foundation website
Research clearly shows that the serotonin reuptake inhibitors (SRIs) are uniquely effective treatments for OCD. These medications increase and regulate the concentration of serotonin, a chemical messenger in the brain. Seven SRIs are currently available by prescription in the United States:
- Clomipramine (Anafranil)
- Fluoxetine (Prozac, Sarafem)
- Fluvoxamine (Luvox)
- Paroxetine (Paxil)
- Sertraline (Zoloft)
- Citalopram (Celexa)
- Escitalopram (Lexapro)
Fluoxetine, fluvoxamine, paroxetine, sertraline, citalopram, and escitalopram are called selective serotonin reuptake inhibitors (SSRIs) because they primarily affect only serotonin. Clomipramine is a nonselective SRI, which means that it affects many other neurotransmitters besides serotonin. For this reason, clomipramine has a more complicated set of side effects than the SSRIs. In general, SSRIs are usually tried first because they are easier for people to tolerate. Although the SSRIs are not used in combination with each other, an SSRI plus clomipramine can sometimes be used together to combat severe symptoms. The usual effective doses of these medications are higher for OCD than they are for other disorders, like depression, which also respond to SRIs.
How well do medications work? When patients are asked about how well they are doing compared to before starting treatment, they report marked to moderate improvement after 8-12 weeks on an SRI. Usually, the maximum benefit is only seen after about 12 weeks, and it can take as long as 6 months. At least 60% of people will have some improvement with medications on their first try. Most people have some improvement, although fewer than 20% of those treated with medication alone will have a complete remission of symptoms. This is why medication is often combined with cognitive behavior therapy (CBT) to get more complete and lasting results. About 20% of people don’t experience much improvement at all with the first SRI and need to try another one.
Which medication should I choose? Overall, studies show that all the SRIs are about equally effective. If you or someone in your family did well or poorly with a medication in the past, this may influence the choice. If you have medical problems (for example, an irritable stomach or trouble sleeping) or are taking another medication, these factors may cause your doctor to recommend one or another medication to minimize side effects or to avoid possible drug interactions.
What are the side effects of these medications? In general, the SRIs are well tolerated by most people with OCD. The six SSRIs (fluoxetine, fluvoxamine, paroxetine, sertraline, citalopram, and escitalopram) have similar side effects, although there are some individual differences. These include nervousness, insomnia, restlessness, nausea and diarrhea. Most of these side effects will go away as your body gets used to taking the medication. Headaches can also occur infrequently with the SSRIs. The most common side effects of clomipramine are dry mouth, sedation, dizziness, and weight gain. All of the SRIs can cause sexual problems. Clomipramine can also cause problems with blood pressure and irregular heartbeats, so that children and adolescents and patients with preexisting heart disease who are treated with clomipramine must have electrocardiograms (EKGs) before beginning treatment and at regular intervals during treatment.
Remember that most side effects depend on the dose of medication and on how long you have been taking it. If side effects are a big issue, it is important to start with a low dose and increase the dose slowly. More severe side effects are associated with a rapid increase in the dose, and to a lesser extent, to larger doses. Although these medications are not addictive, all SRIs (except maybe fluoxetine) should be tapered and stopped slowly because of the possibility of the return of symptoms and withdrawal reactions.
Tell your doctor about any side effects you have: Some people have different side effects than others and one person’s side effect (for example, unpleasant sleepiness) may actually help another person (someone with insomnia), or may not occur in another person. The side effects you may get from medication depend on:
- The type and amount of medicine you take
- Your body chemistry
- Your age
- Other medicines you are taking
- Other medical conditions you have
If side effects are a problem for you, your doctor can try a number of things to help:
- Reducing the amount of medicine: The doctor may gradually lower the dose to try to achieve a dose low enough to reduce side effects but not low enough to cause a relapse.
- Adding another medication may be helpful for some side effects, such as trouble sleeping or sexual problems.
- Trying a different medicine to see if there are fewer or less bothersome side effects: Even when a medication is clearly helping, side effects sometimes make it intolerable. In such a case, trying another medication is a reasonable strategy.
What if I can’t afford the medications? Some medications are now available in generic forms, which in general are much less expensive than brand name drugs, and are just as effective. Ask your doctor if your medication is available in a generic form. The companies who manufacture the five SRI medications listed above each have a special program to provide free medications for patients who cannot afford them. Each company has its own rules about who is eligible for their programs, usually based on income and insurance status. Ask your doctor about these programs if you feel that you cannot afford the medications.
Maintenance treatment: Once OCD symptoms are eliminated or much reduced maintenance of treatment gains becomes the goal. When patients have completed a successful course of treatment for OCD, most experts recommend monthly follow-up visits for at least 6 months and continued treatment for at least 1 year before trying to stop medications or CBT. For most people, OCD is a chronic disorder. Relapse is very common when medication is withdrawn, particularly if the person has not had the benefit of CBT. Therefore, experts recommend that most patients continue medication, particularly if they do not have access to CBT. Individuals who have repeated episodes of OCD may need to receive long-term or even lifelong medication. The experts recommend such long-term treatment after 2 to 4 severe relapses or 3 to 4 milder relapses.
Discontinuing treatment: When someone has done well with maintenance treatment and does not need long-term medication, most experts suggest discontinuing medication only very gradually, while giving CBT booster sessions to prevent relapse. Discontinuing treatment should be done with care, and only after discussion with your doctor. Some people find that if they need to re-start medication, they don’t respond as well to it the second time. Gradual medication withdrawal usually involves lowering the dose by 25% and then waiting 2 months before lowering it again, depending on how the person responds. Because OCD is a lifetime waxing and waning condition, you should always feel comfortable returning to your clinician if your OCD symptoms come back.
What if the first medication doesn’t work? First, it is important to remember that these medications don’t work right away. Most patients notice some benefit after 3-4 weeks, while maximum benefit should occur between 12 weeks and 6 months of treatment at an adequate dose of medication. When it is clear that a medication is not working well enough, most experts recommend switching to another SRI. While most patients do equally well on any of the SRIs, some will do better on one than another, so it is important to keep trying until you find the medication and dose that is right for you.
Does it help to add CBT to an SRI? When medication has produced only a little benefit after 6-12 weeks, adding CBT or another medication to the SRI is also sometimes useful. Many experts believe that CBT is the most helpful treatment to add when someone with OCD is not responding well to medication alone. Medication works well in combination with CBT because it helps to reduce the anxiety associated with doing or not doing the compulsions, and allows CBT to be more effective in helping people to learn how to prevent or eliminate compulsions.
Do I have to choose between CBT and medication? No single approach works best for everyone with OCD, although most people probably do best with CBT plus an SRI. The treatment choice will of course depend on the patient’s preference. Some people prefer to start with medication to avoid the time and trouble associated with CBT; others prefer to begin with CBT to avoid medication side effects.
The need for medication depends on the severity of the OCD and the age of the person. In milder OCD, CBT alone is often the initial choice, but medication may also be needed if CBT is not effective enough. Individuals with severe OCD or complicating conditions that may interfere with CBT (e.g., severe anxiety, panic disorder, depression) often need to start with medication, adding CBT once the medicine has provided some relief. In younger patients or patients who are pregnant, clinicians are more likely to use CBT alone. However, trained cognitive-behavioral psychotherapists are in short supply. Thus, when CBT is not available, medication may become the treatment of choice. Consequently, it is likely that many more people with OCD receive medication than CBT.
Before deciding on a treatment approach, you and your clinician will need to assess your OCD symptoms, other disorders you have, the availability of CBT, and your wishes and desires about what treatment you want. Try to find a clinician who will talk to you about these possibilities so that you can make your own best choice among the options available.
Adding another medication: Another option is to add another medication as an adjunct to the first. This is usually done if the patient has gotten some improvement from the first medication, but continues to have significant symptoms. There are many choices for adjunct medications, including:
- Adding clomipramine to an SSRI
- An anxiety-reducing medication, such as clonazepam, alprazolam or buspirone, in patients with high levels of anxiety
- A neuroleptic, such as haloperidol or risperidone, especially for people with pathological doubting (a symptom where you do not trust your own senses or need reassurance that you have or haven’t done a particular thing), or where tics or thought disorder symptoms are present.
- Lithium, particularly if big changes in mood are a problem
What if nothing seems to work? Before deciding that a treatment has failed, your therapist needs to be sure that the treatment has been given in a large enough dose for a sufficient period of time. There is little consensus among the OCD experts on what to do next when someone with OCD fails to respond to expert CBT plus well-delivered, sequential SRI trials. Switching from an SSRI to clomipramine may improve the chances that a previously non-responsive patient may have a good response. Most experts recommend considering a trial of clomipramine after 2 or 3 failed SSRI trials. Occasionally, a doctor may wish to combine an SSRI with clomipramine either to reduce side effects or to increase the potential benefits of medication.
Is hospitalization an option? People with OCD can almost always be treated as outpatients. In very rare cases in which the OCD involves severe depression or aggressive impulses, hospitalization may be necessary for safety. When a person has very severe OCD or the OCD is complicated by a medical or neuropsychiatric illness, hospitalization can sometimes be a useful way to give intensive CBT.
For patients who have severe OCD plus depressions electroconvulsive therapy (ECT) may sometimes be of benefit. Some doctors believe that for adults with extremely severe and unremitting OCD, neurosurgical treatment to interrupt specific brain circuits that are malfunctioning can be helpful.
Answers to other questions about medications
- If you think you might be pregnant or are planning to become pregnant, most experts prefer to treat OCD with CBT alone. However, if medications are necessary (and they may be since OCD commonly gets worse during pregnancy), it is better to use them sparingly and to select an SSRI rather than clomipramine.
- The SSRIs are preferred in patients with renal failure or coexisting heart disease who require medication.
- When another psychiatric disorder is present, your doctor will likely mix and match treatment for the other conditions with treatment for OCD. Sometimes, the same medication can be used for two disorders (e.g., an SRI for OCD and panic disorder). In other cases, such as concurrent mania and OCD, more than one medication will be necessary (e.g., a mood stabilizer and an SRI).
- Laboratory tests are necessary before and during treatment with clomipramine but not with the SSRIs.
- The SRIs are not addictive, but it is a good idea to stop them gradually.