Augmentation Strategies for People taking SRIs
OCD is a Serious Illness
Obsessive-compulsive disorder (OCD) can be a severe and disabling illness. According to a World Health Organization study, OCD is the tenth leading cause of disability worldwide, with a total cost in the US estimated at more than $8 billion annually. People with OCD usually spend years suffering before beginning effective treatment. The situation is complicated by the fact that many health professionals are not educated about the best treatments available to OCD patients.
Common Medications for OCD
The first-line treatment for obsessive-compulsive disorder is typically a course of anti-depressant medications, specifically serotonin reuptake inhibitors (SRIs). This term encompasses the well-known "selective" serotonin reuptake inhibitors (SSRIs), which include fluoxetine (Prozac), fluvoxamine (Luvox), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa) and escitalopram (Lexapro), as well as the older tricyclic medication clomipramine (Anafranil). Dosages for the anti-obsessional qualities are often higher than typically needed for anti-depressant effects. The table below illustrates what is generally considered an adequate dose for OCD based on the current literature. However, some individuals respond with lower doses and others require even higher doses. SSRIs are very safe medications for most people, which is one reason physicians are quick to prescribe these to patients with OCD symptoms. However, there have been recent concerns with using SSRIs among children and teenagers, as there may be increased incidence of suicidal thoughts among depressed youths.
Common SRI Medications for OCD
|Medication (Brand Name)|| Adequate Dose for OCD|
|Fluoxetine (Prozac)|| 60 mg|
|Setraline (Zoloft)|| 200 mg|
|Paroxetine (Paxil)|| 60 mg|
|Paroxetine (Paxil CR)*|| 75 mg|
|Fluvoxamine (Luvox)|| 250 mg|
|Citalopram (Celexa)*|| 60 mg|
|Escitalopram (Lexipro)*|| 30 mg|
|Clomipramine (Anafranil)|| 225 mg|
* Has not been approved by the FDA for use as an anti-obsessional drug in OCD, though frequently prescribed "off-label" for this purpose.
Though most people who try SRIs will be "treatment responders," research has shown that actual symptom reduction tends to be modest at best. Having a response to medication is not a complete cure, merely an indication that the treatment has reduced OCD symptoms by some measurable degree. Although there are reports of dramatic improvements from SRIs alone, on average people with OCD will experience only about a 30% reduction in symptoms.
Historically, people who tried one medication without success would then be switched to a different SRI until an effective one could be found. However, the use of this strategy is not well-supported by the current research. Considering the long period SRIs may take to be effective, often 4-8 weeks, the waiting and switching process can be frustrating to patients, and partial responders to one SRI are vulnerable to similar problems with other SRIs. For this reason it is increasingly common to augment SRI medication, either with a type of psychotherapy specifically for OCD or an "add-on" medication.
Augmenting Your SRI with Cognitive-Behavioral Therapy
Augmenting medication with cognitive-behavioral therapy (CBT) may be an especially good choice, as 80-90% of patients treated with drugs alone will relapse after they stop medication. CBT is a term used to describe evidence-based treatments that focus on reducing a patient's current symptoms through the application of learning theories to psychotherapy. This is not the same as therapies that focus on childhood issues, relationships, or unconscious conflicts; such "insight-oriented" strategies are not effective treatments for OCD. CBT treatments have a proven track-record of helping people with a variety of mental disorders, particularly anxiety disorders like OCD. The most effective CBT techniques include exposure and response prevention (EX/RP, also called exposure and ritual prevention or ERP) and cognitive therapy (CT). EX/RP involves direct confrontation (exposure) to anxiety-provoking material while intentionally refraining from compulsions and is extremely effective, with CT as a recommended secondary option.
Among psychotherapeutic techniques, only EX/RP has been tested as an augmentation treatment for people taking SRIs. In one recent study, EX/RP was tested against stress management training (SMT), a treatment involving the use of relaxation techniques and problem-solving strategies, but without direct confrontation of the OCD symptoms. In this study, all patients stayed on their SRI medicine and were randomly assigned to receive one of the add-on therapies. Three-quarters of EX/RP patients responded to treatment and one-third were left with minimal OCD symptoms at the end of the 8-week treatment period. In contrast, the SMT group did not improve much. EX/RP appears to be a very effective augmentation strategy for those with SRI-resistant OCD.
Augmenting Your SRI with Another Medication
Although EX/RP is very effective and offers lasting gains, it is not the solution for everyone. Because EX/RP requires that patients confront their fears, many people with OCD feel unable to undertake CBT, or they may begin CBT and find the treatment too distressing to complete. In addition, rural and underserved areas may not have a qualified professional available to offer CBT for OCD, or the sufferer may not have the resources to afford treatment even when available. Finally, a minority of OCD patients who have completed a course of EX/RP will remain highly symptomatic. For these reasons, other pharmacological strategies are important options.
Many medications have been used to augment SRIs in people with OCD. These include benzodiazepines (i.e. muscle relaxants such as Clonazepam), mood stabilizers (e.g., lithium), tryptophan (an amino acid), inositol (vitamin B8), and others. However, the only strategy with proven efficacy in reducing OCD symptoms under the most strict research conditions makes use of a class of medications called neuroleptics, also called antipsychotics or major tranquilizers. These medications have been successful in helping people with a wide range of problems, including schizophrenia, bipolar disorder, delirium, nausea and vomiting, autism, Tourette's syndrome, and Huntington's disease, as well as OCD.
One of the first neuroleptics to be studied as an augmenter was haloperidol, but it was effective only for people with OCD who also had tics. Small doses of newer, safer medications have since been added to SRI regimens with good results. These second-generation "atypical" neuroleptics include risperidone (Risperdal), olanzapine (Zyprexa), and quetiapine (Seroquel). All of these medications are FDA approved for certain uses, but are currently used off-label in the treatment of OCD. In research studies both olanzapine and quetiapine showed some positive results when compared to placebo, but risperidone demonstrated the most consistent performance across studies. Augmentation with atypical neuroleptics is now considered one of the better ways of approaching poor response to SRI treatment.
Despite the benefits and safety of augmentation, many people with OCD are reluctant to attempt this strategy for a variety of reasons. OCD patients are prone to worry, and even minor or temporary side-effects can cause premature discontinuation of potentially beneficial medication. People with contamination concerns are often uncomfortable taking any medication at all, and the idea of two drugs can be especially troubling. The older generation of antipsychotic medications, administered in higher doses, was connected to many serious side-effects, such as movement disorders, weight gain, and excessive sedation. Fortunately, second-generation medications like risperidone, taken under the careful supervision of a qualified psychiatrist, rarely result in any long-term serious problems, and often lead to major improvements in functioning.
Maximizing Treatment Outcome
At one time OCD was regarded as an intractable disorder and no effective treatments existed. Patients lived in shame, unable to function, feeling frightened and hopeless. Today's treatments represent considerable advances beyond those early times, though many continue to suffer needlessly. SRIs bring most people with OCD some measure of relief. Augmentation with EX/RP and risperidone are good options for those who still have significant symptoms. Lack of access, lack of knowledge, and fear of new treatments keep many from experiencing the improved quality of life that may be possible for people with OCD.
There is still much research to be done, as it has not yet been determined which augmentation strategy is most effective (i.e., EX/RP or risperidone). Furthermore it is not known how to best tailor treatment based on an individual's unique symptom profile, comorbid conditions, and personal characteristics. Nevertheless, every person suffering with OCD owes it to themselves and their loved ones to persist with the existing validated strategies until they have achieved the best quality of life possible. There is no cure for the disorder, but with proper treatment and persistence many can and will beat OCD.
About the Author: Monnica Williams, Ph.D., is an Assistant Professor of Psychology in Psychiatry at the Center for the Treatment and Study of Anxiety (CTSA) at the University of Pennsylvania School of Medicine, where she conducts OCD research. She also administrates the BrainPhysics OCD Mental Health website. Anyone interested in learning more about treatment for OCD, including no cost treatment as part of research studies, is encouraged to contact Dr. Williams.
This article originally appeared in the G.O.A.L. Post Newsletter for the Philadelphia OC Foundation, 2008. Sources:
A Bystritsky, Current Pharmacological Treatments for Obsessive-Compulsive Disorder, Essent Psychopharmacol, 5:4, 2004. C Blanco, M Olfson, DJ Stein, HB Simpson, MJ Gameroff, WH Narrow, Treatment of obsessive-compulsive disorder by U.S. Psychiatrists, Journal of Clinical Psychiatry, 67(6), 946-951, Jun 2006. EB Foa, MR Liebowitz, MJ Kozak, et al, Randomized Placebo-Controlled Trial of ERP, Clomipramine, and Their Combination in the Treatment of OCD, Am J Psychiatry, 162: 151-161, 2005. AD Lopez, CCJL Murray, The global burden of disease, 1990-2020, Nature Medicine, 4, 1241-1243, 1998. HB Simpson, EB Foa, MR Liebowitz, et al, A Randomized Controlled Trial of CBT for Augmenting Pharmacotherapy in OCD, Am J Psychiatry in Advance, 1-10, March 2008.