Effective Choices for OCD Medication
Medication has been proven to be very effective in the treatment of Obsessive-Compulsive Disorder (OCD). For some, medication alone is enough, for others it offers little help. In general, for every individual, there is at least one medication that will help alleviate some of the symptoms of OCD.
Although very helpful, medicine is not a permanent cure for OCD — often a person feels better only when they are on the drug. This is manageable if one feels comfortable taking a drug long-term, but long-term effectiveness is not always consistent. Many others choose to discontinue medication, even though it had been effective, for a variety of reasons. They may feel they no longer need it, don't like the side effects, don't want to be thought of as a "pill popper," can't afford the medication, etc. The OCD symptoms then typically return.
For this reason, behavioral therapy is recommended in addition to medication. The most effective, proven treatment of OCD, and the best way to beat it for good, is cognitive-behavioral therapy (CBT), with or without medication.
OCD Medication Options: Antiobsessional Drugs
The two medications proven to be most effective in the treatment of OCD are tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs). Serotonin is a chemical in the brain called a neurotransmitter that may be imbalanced in people with OCD.
While both drugs are very effective, SSRIs have generally become the preferred medication for anxiety disorders, including OCD. SSRIs have less side effects than other forms of antidepressants, less withdrawal symptoms, less danger in the event of an overdose and overall are considered safer that other types of drugs (TCAs and SSRIs are both very safe drugs, however).
Common SSRIs include fluoxetine (Prozac), fluvoxamine (Luvox), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and escitalopram (Lexapro).
There are other drugs that can be used to treat OCD, or even to augment SSRIs and TCAs. These drugs include monoamine oxidase inhibitors (MAOIs) and atypical antidepressants. (MAOIs are not to be combined with SSRIs.)
For drugs such as MAOIs, not much research has been done in regards to their effectiveness in treating OCD, and the research that has been done often offers conflicting reports. Some clinical trials show similar effectiveness to TCAs, and others show none greater than a placebo effect. No MAOIs have been designated by the FDA as an OCD drug, but some have shown effectiveness in limited research, and should be explored if traditional OCD medication offer no success. Common MAOIs include phenelzine (Nardil) and tranylcypromine (Parnate).
Atypical antidepressants include drugs such as buproprion (Wellbutrin) and venlafaxine (Effexor), which are often used to augment medication. A drug such as buproprion is termed atypical because it has a different chemical structure than other antidepressant. Its primary effect is on a neurotransmitter called dopamine, whereas other SSRIs concentrate on serotonin. It does have some effect on serotonin and another neurotransmitter called norepinephrine, however. Because of this, side effects are often different, such as none to very rare cases of sexual dysfunction.
When paired with SSRIs, buproprion has actually been shown to minimize and sometimes even reverse sexual side effects. Drugs such as these should be explored if other medications do not work, or to augment a preferred treatment, and in some cases reverse the side effects.
In addition, the medical literature contains scattered reports of individual OCD patients benefitting from buspirone (Buspar), bromocriptine (Parlodel), clonazepam (Klonopin), alprazolam (Xanax), and trazodone (Desyrel).
Other medications occasionally been reported helpful as augmentors include clonidine (Catapres), risperidone (Risperdal) and, for OCD patients who also have tics or a certain personality style, haloperidol (Haldol) and pimozide (Orap). More about augmenting OCD drugs when your medications aren't doing enough...
OCD Medication: Mechanism of Action
SSRIs first appeared in the early 1980s, and are now the most prescribed drug for OCD. Earlier antidepressants were discovered by accident, but SSRIs were created in labs by pharmaceutical companies based on speculation of the role serotonin plays in the development of mood disorders. Since people suffering from OCD and other Anxiety Disorders are also thought to have less serotonin than they need, SSRIs were found to work in the treatment of anxiety, too.
How SSRIs work
SSRIs work by inhibiting reuptake of serotonin in the presynaptic nerve ending, which allows more serotonin to increase in the synaptic cleft, where it is needed. (More about how this works.) SSRIs are "selective" because they appear to have little effect on norepinephrine and dopamine (two other neurotransmitters) however they are not entirely selective because some of them block other neurotransmitters. The different types of SSRIs effect different parts of the brain and vary in potency, meaning one type of SSRI may work for one person but not another. Therefore, when taking SSRIs, one must not become discouraged if a particular drug does not work, because another may.
Of course, sometimes SSRIs will not work at all for a particular individual, but there are plenty of other medications and treatments to try, including, as mentioned, TCAs. It also appears that some SSRIs work better for certain disorders than others, e.g. Paxil for Social Phobia, Luvox for OCD.
TCAs have been in use since the 1950s, but have declined in popularity since the introduction of SSRIs. The reason for the decline is not because of ineffectiveness — rather because TCAs have more side effects. TCAs have been proven to be just as effective as SSRIs in the treatment of anxiety disorders. However, only one TCA is recommended for the treatment of Obsessive-Compulsive Disorder: clomipramine (Anafrinal). This drug is proven to be as effective as SSRIs in treating OCD and should be considered if SSRIs are not working.
OCD Medication Side Effects
Side effects are the most common reason for the discontinuation of medication. Interestingly, people suffering from OCD appear to be more tolerant of side effects than those suffering from other anxiety disorders. This could be due to the debilitating nature of severe OCD.
Common side effects for TCAs include: weight gain, dry mouth, overstimulation (feeling jittery, nervous lightheaded and difficulty sleeping — side effects that are upsetting to patients because of their similarities to anxiety), sexual side effects and orgasmic dysfunction.
Common side effects for SSRIs include: nausea, constipation, drowsiness, headaches, dry mouth, insomnia and sleep disturbance, which are generally minor and short term. The most bothersome side effect for SSRIs is of course sexual dysfunction. The number of people — both male and female — who suffer from decreased sexual desire and orgasmic dysfunction is thought to be close to 50 percent. However, erectile dysfunction medication, such as Viagra, Levitra, and Cialis are helping this problem greatly. Unfortunately, many insurance companies will not cover Viagra prescriptions.
Drugs can be mixed and matched and can often augment one another. Drugs within the same category can even be mixed and matched (e.g. one can take Prozac and Luvox at the same time).
OCD Medication Dosages
Is your dose right for you? If you're taking medication for OCD but it's not working, your dosage may be incorrect. Correct dosages vary from drug to drug, based on your weight and severity of symptoms. One other thing to keep in mind when taking medication is: the dosages for OCD are often much higher than dosages prescribed for other disorders (i.e. the depression dosage for Prozac is 20 mg, the OCD dosage is generally 60-80 mg). Make sure you talk to your doctor about the right dose for you, as it can often make all the difference.
Listed below is some general information regarding the recommended dosages for the most popular medications, and the typical amount of time needed for effective outcomes. Generally the time it takes to see whether an SSRI will be effective for you is 10 to 12 weeks, with at least 4 to 6 of those being at the maximum dosage. The SSRIs citalopram, sertraline and fluvoxetine usually have milder side effects than the SSRIs fluvoxamine and paroxetine.
- Clomipramine (Anafranil)
- Doses for treating OCD range from 75-300 mg. Generally 150 mg to 250 mg is the most effective dosage for OCD. A dosage such as 75-100 mg is usually only used on women weighing in the 100 pound range. The starting dosage of clomipramine is 25-50 mg, which can then be increased by 25-50 mg every 1 to 3 days. It takes 6-10 weeks for the full effect of clomipramine to kick in. So, a dosage close to 250 mg taken over ten weeks is on average what produces the best results.
- Fluoxetine (Prozac)
- 40-80 mg is the recommended OCD dosage, with 60-80 mg generally being the most effective range. It usually takes 4 to 12 weeks for significant decrease of symptoms. Prozac is becoming less popular for OCD as it takes a longer time to wash out of a person's system, which can cause delays in symptom relief if the medication needs to be switched.
- Fluvoxamine (Luvox)
- is a very effective drug in the treatment of OCD. It was the first non-TCA drug approved by the U.S. Food and Drug Administration (FDA) specifically for the treatment of OCD. A dose between 100-300 mg is recommended, with the target being 200 mg. Initial dosage should begin with 25-50 mg, increased by 50 mg every 3-4 days. An increase to 300 mg is recommended if there is no symptom relief. As with all SSRIs, 10-12 weeks is usually the time it takes for significant improvement. NOTE: Solvay Pharmaceuticals has withdrawn Luvox tablets from the US market, but the drug is still marketed in other countries and available in the US in generic form. Solvay does plan to reintroduce Luvox into the US at some point in the future.
- Sertraline (Zoloft)
- like other drugs works very well in the treatment of OCD, but may also offer other advantages. It is considered to be one of the safest SSRIs and mixes very well with other medications. Unlike other SSRIs, which have shown that fixed doses are most effective, and that the higher dose is the more effective it usually is, studies have shown that sertraline is equally effective at a 50 mg and 200 mg dose. Thus, the recommended dose is 50 mg, but a dosage as high as 200 mg can be tried if a lower one is still ineffective. Zoloft has also been shown to be very effective in the treatment of OC Spectrum Disorders. One other advantage to sertraline is its short half-life, which means the drug leaves your system faster than others.
- Paroxetine (Paxil)
- is the most potent SSRI. The recommended OCD dosage is 40-60 mg. Start with 10 mg a day, stepping up in weekly 10 mg doses. Should not exceed 60mg. Paroxetine has a very long half-life, meaning it stays in your system longer than other drugs. Sometimes the side effects related to Paroxetine are more powerful than that of other SSRIs.
- Citalopram (Celexa)
- doesn't have much history in the treatment of OCD, but in disorders such as depression it has proven to be as effective as other SSRIs. Based on the few studies that have been done, it appears to also be effective in the treatment of OCD. The recommended OCD dosage for Citalopram is 40-60 mg. It also has very good interaction with other drugs, making it a favorable SSRI.
- MT Pato and J Zohar, Current Treatments of Obsessive Compulsive Disorder, 2nd ed, 2001. A Bystritsky, Current Pharmacological Treatments for Obsessive-Compulsive Disorder, Essent Psychopharmacol 5:4, 2004. HB Simpson, EB Foa, et al, A Randomized Controlled Trial of CBT for Augmenting Pharmacotherapy in OCD, Am J Psychiatry, 2008, 1-10.