OCD is a devastating illness that can result in considerable social and economic disability for both afflicted patients and their family members. OCD is usually treated with a combination of specific behavioral therapies, called exposure and response prevention, and medications. It is important to note that many psychoactive medications are not likely to help OCD symptoms. That a number of partially-effective drugs have now been carefully evaluated.

way to think about the use of medication for OCD is to compare your illness with a common medical disorder such as diabetes. There is growing evidence that OCD is a neurologic or medical illness not simply a result of some problem in the environment or of improper upbringing. As the diabetic needs insulin to live a normal life, some OCD patients need anticompulsive medication to function normally. Diabetics often feel angry and upset about having to take insulin. There is no evidence that OCD is a result of anything that the patient or their parents have done. It is best to consider it a chemical or neurologic disorder affecting a part of the brain.

What kinds of medications may help OCD?

The majority of the drugs that help OCD are classified as antidepressants. It is important to note that depression results from the disability produced by OCD. Doctors can treat both the OCD and depression with the same medication.

There are also a number of disorders that are possibly related to OCD, such as compulsive gambling and sexual behaviors, trichotillomania, body dysmorphic disorder, compulsive eating, nail biting and compulsive spending.

Do all antidepressants help OCD symptoms?

No! Some commonly used antidepressants have no effect whatsoever on OCD symptoms. Drugs, such as imipramine or amitriptyline, that are good antidepressants, only rarely improve OCD symptoms.

Which drugs help OCD and how do we know these drugs are effective?

The six drugs shown to be effective in  good double-blind placebo controlled studies include: fluvoxamine (Luvox), fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and clomipramine (Anafranil). Anafranil has been around the longest and is the best studied throughout the world. There is growing evidence that the other drugs are as effective. There are reports of small number of patients that suggest that venlafaxine (Effexor) may be effective.

Why do these drugs help ?

It remains unclear as to why these particular drugs help OCD while similar drugs do not. Each has potent effects on a particular neurotransmitter, or chemical messenger, in the brain called serotonin. It appears that potent effects on brain serotonin are necessary (but not sufficient) to produce improvement in OCD. Serotonin is one of several neurotransmitter chemicals that nerve cells in the brain use to communicate with one another. Unlike some other neurotransmitters, its receptors are not localized in a few specific areas of the brain. Its uptake and release affects much of our mental life, including OCD and depression.
Neurotransmitters such as serotonin are active when they are present in the "gap" (referring to the synaptic cleft) between nerve cells. Transmission is ended by a process where the chemicals are taken back up into the transmitting cell. The anti-obsessional drugs are called "serotonin reuptakeinhibitors" or SRIs. They work by slowing the reuptake of serotonin, making it more available to the receiving cell and prolonging its effect in the synapse. We believe that the increased serotonin produces changes, over a period of a few weeks, in receptors (areas where serotonin attaches) in some of the membranes of the nerves.

These receptors may be abnormal in patients with OCD. That the  changes that occur in them due to these medications at least partly reverse the OCD symptoms. This is only part of how drugs work. It is very likely that other brain chemicals in addition to serotonin are involved. When activity in the brain's serotonergic system is altered, this changes the activity of other brain systems.

At what dosages are these drugs used?


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.

There are newer neuroleptic agents, like clozapine (Clozaril), olanzapine (Zyprexa), quietapine (Seroquel), and risperidone (Risperdol) that may have fewer neurologic problems, that may be helpful when added to SSRI treatment. These new drugs should not be used alone since they have been associated with  causing the onset of OCD symptoms when not taken in combination with a SSRI.
    Who should not take antiobsessional medications?

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.

In very elderly patients, it is best to avoid Anafranil as the initial drug since it has side effects that can interfere with thinking and can cause or worsen confusion in the elderly. Some of the other antiobsessional drugs like Prozac, Zoloft, Luvox, Celexa and Paxil can be used in the elderly, but greatly reduced dosages are often needed. Although these drugs can be taken by patients with heart disorders, special caution is required, and close monitoring with frequent cardiograms (ECGs) may be necessary.

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 long does it take antiobsessional medications to work?
    It is important not to give up on a medication until you have been taking it at a therapeutic dose for 10 to 12 weeks. Many patients feel no positive effects for the first few weeks of treatment. Then they may improve greatly. During the early part of treatment, patients may have side effects and no positive results. Sometimes physicians forget to tell patients about this lag in response. We do not know why the medications take so long to work for OCD.

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.

Other drugs are sometimes combined with ongoing SRI medications. Some that have commonly been used include: buspirone (Buspar), lithium carbonate (Eskalith), clonazepam (Klonopin), methylphenidate (Ritalin), gabapentin (Neurontin), and other antidepressants (eg, trazodone, bupropion, desipramine, etc). The controlled trials that have been done with these augmenting agents have been disappointing. But since some patients respond to the addition of a second drug, clinicians often try this technique.

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


There are drugs that are occasionally helpful in individual patients besides the ones already mentioned. Some patients may be helped by drugs called monoamine oxidase inhibitors (e.g., Nardil [phenelzine], Parnate [tranylcypromine]) that work in a different way than the other mentioned drugs. These drugs inhibit one of the enzymes that degrades the chemical messengers in the nerve gaps,  lengthening the time that the messenger is active.

There is some anecdotal evidence that OCD patients who have panic attacks or prominent concerns with symmetry may improve with monoamine oxidase inhibitors.
Certain foods and medications cannot be taken with these drugs or potentially fatal reactions can occur. They are particularly dangerous in combination with the SRI medications so these must be stopped for at least 2 weeks (5 weeks for Prozac which is longer lasting) prior to starting monoamine oxidase inhibitors.

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?

    Many patients drink alcohol while on medications and tolerate it well. It is important to keep in mind that alcohol may have a greater effect on individuals who are taking medication. One drink could affect an individual as if it were two drinks. Also, alcohol may counteract some of the therapeutic effects of the medication, so it may be wise to try not to drink alcohol during the first couple of months after starting medication.
    What is Behavior Therapy?

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.

With a combination of drug and behavioral therapy, the majority of OCD patients will be able to function well in both their work and social lives. The ongoing search for causes, along with research on treatment modalities , promises to yield even more options  for people with OCD and their families.
    How are OCD and depression related?

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.

    What are some signs of depression?
A.   Loss of appetite
B.   Weight loss
C.   Early morning awakenings
D.   Lack of energy
E.   Too much sleeping
F.   Sadness
G.   Crying, especially without knowing why
H.   Suicidal thoughts
I.   Feelings of hopelessness
J.   Feelings of helplessness
K.   Lack of interest in things which were formerly interesting
L.   Lack of enjoyment of life

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.

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