Medications for OCD

The following information refers to OCD medications in adults. For information on medication in children, click here.

Overview

  • Medication is an effective treatment for OCD.
  • About 7 out of 10 people with OCD will benefit from either medication or Exposure and Response Prevention (ERP). For the people who benefit from medication, they usually see their OCD symptoms reduced by 40-60%.
  • For medications to work, they must be taken regularly and as directed by their doctor. About half of OCD patients stop taking their medication due to side effects or for other reasons. If you experience side effects, you should bring this up with your doctor so they can help you address them. They may be able to change your dose or find a different type of SRI that your system better tolerates.

What kinds of medications may help OCD?

The types of medication that research has shown to be most effective for OCD are a type of drug called a Serotonin Reuptake Inhibitor (SRI), which are traditionally used as an antidepressants, but also help to address OCD symptoms. (Note: Depression can sometimes result from OCD, and doctors can treat both the OCD and depression with the same medication.)

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 Medications Help OCD?

The following antidepressants have been found to work well for OCD in  research studies:

  • fluvoxamine (Luvox®)
  • fluoxetine (Prozac®)
  • sertraline (Zoloft®)
  • paroxetine (Paxil®)
  • citalopram (Celexa®)*
  • clomipramine (Anafranil®)
  • escitalopram (Lexapro®)
  • venlafaxine (Effexor®)

 

Have These Drugs Been Tested?

Anafranil has been around the longest and is the best-studied OCD medication. 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 medications.

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. Drugs work very differently for each person.

How Do These Medications Work?

It remains unclear as to how 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 medications 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 medications 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 medications 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 medication. 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 Medications?

  • Women who are pregnant or are breastfeeding should weigh the decision to take these drugs with their doctor. If severe OCD cannot be controlled any other way, research has indicated that these medications seem to be safe. Many pregnant women have taken them without difficulty. Some OCD patients choose to use exposure and response prevention (ERP) to minimize medication use during the first or last trimester of pregnancy. Click here to read more about the benefits and risks of using SRIs during pregancy and/or while breastfeeding.
  • 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 medications 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 medication at its normal dose.

Ask your doctor if you can try a lower dose by breaking pills in half or using a liquid form of medication to slowly increase your doses.

ALWAYS be sure to talk to your doctor before making any changes to the way you take your medications!

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 requested to start 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. Under the supervision of her doctor, 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 Medications Only When I Am Feeling Stressed?

No. This is a common mistake. These medications are meant to be taken every day to keep your serotonin at 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 Medications?

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 Medication 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 medication, ERP can be started first and part of the therapy can focus on these fears of medications.

How Long Does it Take for These Medications to Work?

It is important not to give up on a medication 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 Medications Forever?

No one knows how long patients should take these medications once they have been effective. Some patients are able to stop their 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 dose 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. And if medication is tapered slowly (even over several months), the ERP treatment may enable patients to control any symptoms that return when they stop taking the medication.

After medications 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 medication is stopped, most patients will have a good response if the medication is restarted.

Can I Drink Alcohol While on These Medications?

Many patients drink alcohol while on these medications and 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 medications; one drink could affect an individual as if it were two drinks. Also, alcohol may limit some of the medications’ benefits, so it may be wise to try not to drink alcohol during the first couple of months after starting any new medication.

Do I Need Other Treatments Too?

Most psychiatrists and therapists believe that combining a type of Cognitive Behavior Therapy (CBT), specifically Exposure and Response Prevention (ERP), and medication is the most effective approach.

What if I Can’t Afford My Medication?

Drug companies give doctors free samples of some medications. Doctors give these samples to patients who cannot afford the cost of the medications.

Most drug companies also have programs that help patients get these and other medications 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.