It appears that for most people high dosages of these drugs are required to obtain antiobsessional effects. The studies done to date suggest that the following dosages may be necessary: Luvox (up to 300 mg/day), Prozac (40-80 mg/day), Zoloft (up to 200 mg/day), Paxil (40-60 mg/day), Celexa (up to 80 mg/day), Anafranil (up to 250 mg/day). I have also seen a small number of patients who have not responded to large dosages of each of these medications. Some improved on extremely low doses, such as 5-10 mg/day of Prozac or 25 mg/day of Anafranil.  If patients fail to improve with high dosages of the above medications, it is probably worth a trial of a very low dose.

Are there side effects?

Each of these drugs has side effects. It is quite unusual for an individual patient not to have one or more side effects. The patient and physician 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 medication. Sometimes an adjustment in dosage or switch in the time of day that one takes the medication is all that is required.

Luvox, Prozac, Paxil, Celexa, and Zoloft are called SSRIs or selective serotonin reuptake inhibitors, while Anafranil is an older tricyclic antidepressant or SRI (serotonin reuptake inhibitor) that has effects on other chemical messengers besides serotonin and is thus not selective for serotonin. All of these drugs commonly produce sexual side effects in both sexes. These side effects may range from lowering of sexual drive to delayed ability to have an orgasm to complete inability to have an erection or orgasm.

The SSRIs commonly cause nausea, inability to sit still, sleepiness in some individuals, insomnia in others, and a heightened sense of energy. The tricyclic Anafranil may cause pronounced effects like drowsiness, dry mouth, racing heart, memory problems, concentration difficulties, and problems with urination (mostly in men). Sometimes weight gain is a problem and a strict diet may be needed if appetite is increased.  These drugs are very safe, even with long-term use; and all of the side effects completely reverse when the drugs are stopped. There is no evidence that they do permanent damage to the body.

Do antiobsessional medications cause long-term, irreversible side effects?

There are no irreversible side effects caused by the standard antiobsessional drugs. Many patients have used them for years without difficulties. Some of the drugs that are occasionally used - such as the antipsychotic (or sometimes called neuroleptic) drugs like haloperidol (Haldol), chlorpromazine (Thorazine), thioridazine (Mellaril), and trifluoperazine (Stelazine) - can produce irreversible neurologic problems, such as, persistent tremor, mouth movements or tongue thrusting. These drugs are best avoided in patients with the usual forms of OCD; if they are used, it should generally be for only a few weeks.
Occasionally patients need to remain on these potentially troublesome drugs for longer periods of time. In OCD patients that also have tics (brief muscle jerks, such as, repetitive eye blinks, nervous cough, or shoulder shrugs), there is now evidence that very low doses of these neuroleptic drugs added to ongoing SSRI medication helps OCD symptoms. In OCD patients without tics, there is no evidence that neuroleptics are helpful and are best avoided.

Try not to give antiobsessional medications to women who are pregnant or are breastfeeding. Since we do not clearly understand the long-term effects of these drugs on a fetus or infant, this is the most prudent course of action. If severe OCD cannot be controlled any other way, these medications seem to be safe and many pregnant women have taken them without difficulty. If there were risk to the fetus, it is likely that most of the risk would be during the first 3 months of pregnancy when the brain is developing. Some OCD patients use the behavioral techniques of exposure and response prevention to avoid medications at least during the initial 3 months of pregnancy. If your OCD is severe, you may need to take a medication throughout the course of pregnancy.

These medications are meant to be taken on a daily basis to maintain a constant level. They are not taken like the typical antianxiety agents; when you feel upset or anxious. It is best not to miss dosages if possible. It is unlikely that any adverse effect on OCD will occur if a daily dose is missed occasionally and sometimes missed dosages are prescribed by your doctor to help manage troublesome side effects, such as, sexual dysfunction.

How helpful can I expect these medications to be?

Each medication helps about 75% to 80% of the patients. About 50% to 60% of patients have a moderate response to medication. Some patients have no response at all. If you do not respond to the first medication, then it is important to go on to the next.  There are techniques of combining medications that may increase the response magnitude and rate.
 
However, to boost a drug's effect, we sometimes combine two or more medications together. Some people respond to combining an SSRI with Anafranil. It is important for the physician to keep in mind that Anafranil's blood level can be dramatically increased by adding one of the other drugs. It is important to keep Anafranil's dose low during the initial stages of treatment. Sometimes blood levels are helpful, but most often a good clinician can follow side effects and symptom reduction to find the correct dosage.

Are there other medications that can be used to treat OCD?

Will I have to take antiobsessional medications forever?

No one knows how long patients should take these medications once they have been effective. Some patients are able to discontinue medications 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 dosage of medication 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 medications.  The behavioral techniques may enable patients to control any symptoms that return when they stop taking medication.  After medications are stopped, symptoms do not return immediately. They may start to return within a few weeks to a few months.
When one of these drugs is working and then discontinued and symptoms return. The vast majority of patients have a good response upon reinstitution of the medication. However, I have now seen a few patients who did not respond when the discontinued drug was restarted.

Can I drink alcohol while on medication?

Traditional psychotherapy, aimed at helping the patient develop insight into their problem, is generally not helpful specifically for OCD symptoms. Traditional psychotherapy may be of benefit as part of a treatment package for patients who have been ill and isolated for many years or for those whose illness started at an early age.
Behavior therapy consisting of techniques called "exposure and response prevention" is effective for many people with OCD. In this approach, the patient is deliberately and voluntarily exposed to feared objects or ideas, either directly or by imagination (the exposure component). Then he is discouraged or prevented (with the patient's permission) from carrying out the usual compulsive response (the response prevention component). A compulsive hand washer may be urged to touch an object believed to be contaminated, and then may be denied the opportunity to wash for several hours. When the treatment works well, the patient gradually experiences less anxiety from the obsessive thoughts they become able to do without the compulsive actions for extended periods of time. To achieve the best results, a combination of factors are necessary. The therapist should be well trained; the patient must be highly motivated; and the patient's family must be cooperative. In addition to visits to the therapist, the patient must be faithful in fulfilling "homework assignments." Those patients who complete the course of treatment, the improvements can be significant.

Approximately 2/3 of OCD patients have suffered at least one major depression during their life. About 1/3 are depressed when they come to us for treatment. Some schools of thought believe the OCD causes the depression while others believe the OCD and depression simply tend to co-exist. Most patients tell me that their OCD symptoms came first, and then the depression began when they were unable to handle the OCD.

The presence of one or more of these symptoms does not necessarily indicate the presence of depression; but if several are present, you may be depressed.