Medicine for OCD
The following information refers to OCD medicines in adults. For information on medicine in children, click here. This page will focus on medicines, but that is not meant to lessen the importance of CBT/ERP, which in fact may be our most effective treatment for OCD.
- Medicine is an effective treatment for OCD.
- About 7 out of 10 people with OCD will benefit from either medicine or cognitive behavior therapy (CBT). For the people who benefit from medicine, they usually see their OCD symptoms reduced by 40-60%.
- The treatment, for most OCD patients should involve the combination of CBT/ERP with medicine.
- For medicines to work, they must be taken regularly and as directed by their doctor. About half of OCD patients stop taking their medicine due to side effects or for other reasons.
What kinds of medications may help OCD?
Most drugs that help OCD are known as antidepressants. Depression often results from OCD. Doctors can treat both the OCD and depression with the same medicine.
Do all antidepressants help OCD symptoms?
No! Some commonly used antidepressants have almost no effect whatsoever on OCD symptoms. Drugs, such as imipramine (Tofranil®) or amitriptyline (Elavil®), that are good antidepressants, rarely improve OCD symptoms.
Which Medicines Help OCD?
Most drugs that help OCD are known as antidepressants. Eight of these drugs worked well in studies:
- clomipramine (Anafranil®)
Have These Drugs Been Tested?
Anafranil has been around the longest and is the best studied OCD medicine. There is growing evidence that the other drugs are as effective. In addition to these carefully studied drugs, there are hundreds of case reports of other drugs being helpful. For example, duloxetine (Cymbalta®) has been reported to help OCD patients who have not responded to these other medicines.
What Are the Usual Doses for These Drugs?
High doses are often needed for these drugs to work in most people. Studies suggest that the following doses may be needed:
- fluvoxamine (Luvox®) - up to 300 mg/day
- fluoxetine (Prozac®) - 40-80 mg/day
- sertraline (Zoloft®) - up to 200 mg/day
- paroxetine (Paxil®) - 40-60 mg/day
- citalopram (Celexa®) - up to 40 mg/day*
- clomipramine (Anafranil®) - up to 250 mg/day
- escitalopram (Lexapro®) - up to 40 mg/day
- venlafaxine (Effexor®) - up to 375 mg/day
Which Drug Should Someone Try First?
Whenever any of the above drugs have been studied head to head, there seems to be no significant difference in how well they work. However, for any given patient, one drug may be very effective, and the others may not. The only way to tell which drug will be the most helpful with the least side effects is to try each drug for about 3 months.
Remember! It is important not to give up after failing one or two drugs.
How Do These Medicines Work?
It remains unclear as to why these particular drugs help OCD. The good news is that after decades of research, we know how to treat patients, even though we do not know exactly why our treatments work.
We do know that each of these medicines affect a chemical in the brain called serotonin. Serotonin is used by the brain as a messenger. If your brain does not have enough serotonin, then your the nerves in your brain might not be communicating right. Adding these medicines to your body can help boost your serotonin and get your brain back on track.
Are There Side Effects?
- Yes. Most patients will experience one or more side effects from all of the medicines listed above.
- The patient and doctor must weigh the benefits of the drug against the side effects.
- It is important for the patient to be open about problems that may be caused by the medicine. Sometimes an adjustment in dose or a switch in the time of day it is taken is all that is needed.
Who Should Not Take These Medicines?
Women who are pregnant or are breastfeeding. If severe OCD cannot be controlled any other way, these medicine seem to be safe. Many pregnant women have taken them without difficulty. Some OCD patients use exposure and response prevention to minimize medicine use during the first or last trimester of pregnancy.
Very elderly patients should avoid Anafranil as the first drug tried,since it has side effects that can interfere with thinking and can cause or worsen confusion.
Patients with heart problems should use special caution if taking Anafranil.
What if I cannot take even the smallest pill size of the medication?
Some patients are sensitive to these medicines and can't stand the effects that come with even the lowest dose. However,patients can start at very low doses (for example, 1-2 mg per day) and very slowly increase the dose. For most people,they will eventually be able to handle the medicine at its normal dose. This method has proven successful for so many people, that there is now a "fan club" of those helped by this approach.
There are two main ways to try this either by breaking pills in half to allow for lower doses or using a liquid form to slowly increases their doses.
Be sure to talk to your doctor before making any changes to the way you take your medicines!
The following is one example as told by Dr. Michael Jenike:
"One woman, who was started on Prozac 20 mg/day, complained of bothersome side effects such as increased anxiety, shakiness, and terrible insomnia. She felt it made her OCD worse. She had horrible side effects from even 12.5 mg of Anafranil, and later with low dosages of Paxil and Zoloft. She started 1-2 mg/day of liquid Prozac, because she heard it was good from other patients that she met from a computer bulletin board. She felt no side effects, and over a period of a few weeks, she got up to 20 mg/day without the previous side effects that she had felt on this dose in the past. She continued to increase the Prozac to 60 mg/day over a couple more months. Her OCD gradually improved quite dramatically."
Should I Take These Medicines Only When I Am Feeling Stressed?
No. This is a common mistake. These medicines are meant to be taken every day to keep a constant level. They are not taken like typical anti-anxiety meds, when you feel upset or anxious. It is best not to miss doses if possible. However, if you do miss a dose here or there, it is unlikely that any bad effect on OCD will occur. In fact,sometimes your doctor might tell you to skip doses to help manage troublesome side effects,like sexual problems.
What Kind of Doctor Should I Look For to Prescribe These Medicines?
Although any licensed physician can legally prescribe these drugs, it is probably best to deal directly with a board-certified psychiatrist who understands OCD. It is important to find a psychiatrist who has special knowledge about the use of drugs to treat mental health disorders. Click here to find a psychiatrist in your area.(Look for therapists with an MD or DO after their name.)
What If I am Afraid to Take My Medicine Because I Have an Obsessional Fear About Drugs?
Usually with help from a doctor that you trust, your fears can be overcome. If you have fears about taking medicine,CBT can be started first and part of the therapy can focus on these fears.
How Long Does it Take for These Medicines to Work?
It is important not to give up on a medicine until you have been taking it as prescribed for 10 to 12 weeks. Many patients feel no positive effects for the first few weeks of treatment but then improve greatly.
Will I Have to Take Medicines Forever?
No one knows how long patients should take these medicines once they have been effective. Some patients are able to stop their medicines after a 6 to 12-month treatment period. It does appear that over half of OCD patients (and maybe many more) will need to be on at least a low dose of medicine for years, perhaps even for life. It seems likely that the risk of relapse is lower if patients learn to use behavior therapy techniques while they are doing well on medicines. And if medication is tapered slowly (even over several months), the CBT/ERP treatment may enable patients to control any symptoms that return when they stop taking the medicine.
After medicines are stopped, symptoms do not return immediately; they may start to return within a few weeks to a few months. If OCD symptoms return after a medicine is stopped,most patients will have a good response if the medicine is restarted. However, some patients may not respond event after they start taking the medicine again.
Can I Drink Alcohol While on These Medicines?
Many patients drink alcohol while on these medicine sand handle it well, but be sure to ask your doctor or pharmacist if it is safe. It is important to keep in mind that alcohol may have a greater effect on individuals who are taking these medicines;one drink could affect an individual as if it were two drinks. Also, alcohol may limit some of the medicines' benefits, so it may be wise to try not to drink alcohol during the first couple of months after starting any new medicine.
Do I Need Other Treatments Too?
Most psychiatrists and therapists believe that combining Cognitive Behavior Therapy (CBT), specifically Exposure and Response Prevention (ERP), and medicine is the most effective approach.
What if I Can't Afford My Medicine?
Drug companies give doctors free samples of some medicines. Doctors give these samples to patients who cannot afford the cost of the medicines.
Most drug companies also have programs that help patients get these and other medicines free or at a reduced cost. For more information, visit: www.pparx.org or call 1-888-477-2669.
By Michael Jenike, MD
Chair, International OCD Foundation's Scientific Advisory Board
Harvard Medical School
* The FDA has issued some warnings on the use of this medication in higher doses. Please check with your physician.
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