Medication for OCD

Medication can be an important part of OCD treatment. For some people, it takes the edge off enough that therapy becomes possible. For others, it is a long-term support that helps keep symptoms manageable. And many people do well with therapy alone. There is no single right path, and choosing medication is not a sign that you have failed at therapy or are taking a shortcut.

SSRIs: the first-line option

Selective serotonin reuptake inhibitors (SSRIs) are the most commonly prescribed medications for OCD. They include fluoxetine, fluvoxamine, sertraline, paroxetine, citalopram, and escitalopram. Their exact way of helping OCD isn't fully understood, but they affect the brain's serotonin system, which is involved in the circuits linked to OCD.

Two things often surprise people who have taken SSRIs for depression before:

• Doses are often higher. Effective doses for OCD are frequently toward the upper end of the usual range, higher than what is typically needed for depression.
• Effects take longer. Improvement in OCD symptoms tends to be gradual, and it can take several weeks to begin and longer to reach full effect.

What a fair trial looks like

Because effects are slow, prescribers generally recommend giving a medication around 8 to 12 weeks, with at least several of those weeks at an adequate dose, before deciding whether it is working. Stopping too early is a common reason people conclude a medication "didn't work" when it simply hadn't had time.

1. 1

   Assessment

   Your prescriber reviews your symptoms, medical history, other medications, and any previous treatment.

2. 2

   Start low

   Medication is usually started at a lower dose to reduce side effects, then gradually increased.

3. 3

   Increase to an effective dose

   Over several weeks, the dose may be raised toward the level often needed for OCD, as tolerated.

4. 4

   Wait and track

   You keep noting symptoms and side effects. Some people find it useful to track time spent on obsessions and compulsions each day.

5. 5

   Review

   After a fair trial, you and your prescriber decide whether to continue, adjust the dose, switch, or add something.

How much do SSRIs help?

Research suggests that somewhere around 40 to 60 percent of people respond meaningfully to an SSRI, though improvement is often partial rather than complete. A typical response might mean OCD takes up noticeably less time and feels less intense, not that it disappears. If the first SSRI doesn't help enough, a different one sometimes does.

Clomipramine

Clomipramine is an older medication from the tricyclic family and was one of the first shown to help OCD. It is effective, and some studies suggest it may be at least as effective as SSRIs. However, it tends to cause more side effects, such as dry mouth, constipation, drowsiness, and dizziness, and it requires more careful monitoring, sometimes including heart checks. For these reasons, it is usually considered after one or more SSRIs have been tried.

When first steps aren't enough: augmentation

If someone has had partial benefit from an SSRI at a good dose, a prescriber may suggest augmentation, adding a second medication to boost the effect. The best-studied approach is adding a low dose of certain antipsychotic medications. Other options are being researched, and evidence for them is still developing. A specialist can walk you through what may be appropriate for your situation.

Medication and therapy together

Medication and ERP are not competitors. Many people take medication while doing ERP, and some find that medication lowers their distress enough to engage more fully with exposures. Therapy, in turn, teaches skills that last. Some research suggests that people who learn ERP skills may be better protected against relapse if they later reduce medication, though that decision should always be made with a prescriber.

Stopping medication

Many prescribers suggest continuing medication for at least a year or more after symptoms improve before considering a taper, but this is an individual decision. Planning a taper alongside a relapse prevention plan can make the process smoother.

Questions to bring to your prescriber

• What dose range is usually effective for OCD with this medication?
• How long should I wait before we judge whether it's working?
• Which side effects should I watch for, and which ones should I report right away?
• How does this interact with my other medications or health conditions?
• If this doesn't help enough, what would we try next?

Our practice provides therapy rather than prescribing, but we are happy to work alongside your prescriber. If you have questions about combining treatment, see our FAQ or contact us.