OCD and Medication
The following information regarding OCD is sourced from an article written by : Michael A. Jenike, M.D. Chairman, OC Foundation Scientific Advisory Board.
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 commonly results from the disability produced by OCD, and that 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. There is some evidence that the medications and behavior therapies discussed in this pamphlet will help some of these patients also, but more research is needed in this area to give firm recommendations”.
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 & how do we know these drugs are effective?
“There are six drugs that have been shown to be useful in very good double-blind (both physician and patient unaware of whether patient is receiving drug or placebo [inert sugar pill]) placebo-controlled (about half of the patients receive drug and the other half placebo or inactive pill) studies. This is a very good way to evaluate drugs since improvements can be evaluated in an unbiased manner and drug effectiveness can be accurately determined.
The six drugs that have been shown to be effective in such studies include: fluvoxamine (Faverin), fluoxetine (Prozac), sertraline (Lustral), paroxetine (Seroxat), citalopram(Cipramil), and clomipramine (Anafranil). Anafranil has been around the longest and is the best studied throughout the world, but 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 occasionally being helpful.”
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 in communicating with one another. Unlike some other neurotransmitters, its receptors are not localized in a few specific areas of the brain; hence, 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 by which the chemicals are taken back up (Re-uptake) into the transmitting cell. The anti-obsessional drugs are called serotonin reuptake inhibitors or SRIs; they work by slowing the reuptake of serotonin, thus making it more available to the receiving cell and prolonging its effect on the brain. We think that this 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. OCF also believe that these receptors may be abnormal in patients with OCD, and 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. In fact, when activity in the brain’s serotonergic system is altered, this changes the activity of other brain systems.
Experiments have been done with drugs that directly stimulate components of the serotonin system in the brain, and it was found that such so-called serotonergic agonists actually make OCD symptoms worse. However, after patients are successfully treated for OCD, these agonists do not worsen OCD symptoms, thus suggesting that there may be some changes in the brain’s serotonergic system with effective drug treatment that somehow result in improvement in symptoms.
Don’t worry if this does not make sense to you. Researchers do not know how the drugs work, and that is why this is all so confusing. The good news is that we do know, after decades of research, how to treat patients, even though OCF do not know exactly why our treatments work.
At what dosages are these drugs used?
OCD Ireland has found the following information the most comprehensive and up-to-date.
As a general rule, it appears that for most people high dosages of these drugs are required to obtain anti-obsessional effects. The studies done to date suggest that the following dosages may be necessary:
Faverin (up to 300 mg/day)
Prozac (40-80 mg/day)
Lustral (up to 200 mg/day)
Seroxat (40-60 mg/day)
Cipramil (up to 60 mg/day)*
Anafranil (up to 250 mg/day)
Where a lower dosage was listed, at least some of the studies have suggested that a dose lower than the minimum was not significantly better than placebo. I have also seen a very small number of patients who have not responded to large dosages of these medications, but who improved on extremely low doses, such as 5-10 mg/day of Prozac or 25 mg/day of Anafranil. These patients have not been carefully studied and, to my knowledge, these low-dosage responders are not reported in the psychiatric literature. If patients fail to improve with high dosages of the above medications, it is probably worth a trial of a very low dose.
Effexor (venflaxine), though not licensed for OCD, is being used by some European practitioners as a treatment on its own or in conjunction with another of the above listed medications. Dosages between 150mg- 300mg are needed. Effexor is selective serotonin norepenepherine re uptake inhibiter (SNRI) and bicyclic anti-depressant because it acts on both the norepinepherine & serotonin systems.
Sevincok L, Uygur B.
Aust N Z J Psychiatry. 2002 Dec;36(6):817.
Yentreve (duloxetine) is a new SNRI, similar to Effexor, which has been licensed for Generalised Anxiety Disorder(GAD) and Depression by the Food and Drug Administration (FDA) in the US, but has yet to undergoe clinical trials for OCD.
*Information regarding Cipramil
(The following information has been obtained from: Forest Laboratories/Lundbeck 2003)
Forest Laboratories/Lundbeck does not make any claims to the effectiveness or safety of using Cirpamil to treat OCD as this medication is not indicated by the FDA to treat any OCD condition.
Furthermore Forest Laboratories/Lundbeck have released a newer drug Lexapro (escitalopram), a selective serotonin reuptake inhibitor (SSRI) used for the treatment of depression and other related problems. It is the active isomer of the antidepressant drug Cipramil (citalopram). It is regarded as faster acting and having fewer side effects.
“Cipramil consists of molecules with mirrored halves. Only the left-hand side is believed to enhance brain serotonin levels; the right side is thought to be inactive or perhaps linked to some side effects. Lexapro is Cipramil cut in half to get the presumed good side”.
Forest vice president, Dr. Lawrence Olanoff.
“In a 491-patient study, 10 milligrams of Lexapro once a day worked as well as 40 mg of Cipramil. A few patients felt better about a week sooner than Cipramil users.”
Lauran Neergaard of Boston.com
Are there side effects?
“Each of these drugs has side effects, and it is quite unusual for an individual patient not to have one or more side effects. As with all drugs, the patient and physician must weigh the benefits of the drug against the side effects. It is important for the patient to be open and forceful about problems that may be caused by the medication. Sometimes just an adjustment in dosage or switch in the time of day that one takes the medication is all that is required.
Faverin, Prozac, Seroxat, Cipramil, and Lustral 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 that may range from lowering of sexual drive to delayed ability to have an orgasm to complete inability to have an erection or orgasm. Interestingly, there is an uncommon side effect that has been reported where patients have spontaneous orgasms while yawning. This must be quite uncommon since no patient has ever told me of such a symptom, and when patients yawn in my office, they always look bored, not excited. Occasionally patients report increased interest in sexual activity.
Although it may seem embarrassing, you should tell your physician about sexual difficulties so that he or she can help you figure out how best to deal with them. These side effects are so common that your psychiatrist will not be surprised.
There is some evidence that Cipramil does not cause as many sexual side effects or weight gain, but it is new to the United States market so the final word on this remains to be determined.
The SSRIs also 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. There are many other less common side effects with these drugs that your physician may discuss with you. As a general rule, these drugs are very safe, even with long term use, and all of the side effects completely reverse when the drugs are stopped; thus there is no evidence that they do permanent damage to the body. ”
What if I can’t tolerate even the smallest pill size of the medication?
Occasionally patients are very sensitive to medications and cannot tolerate even the lowest dosage that comes in pills.
Many of the pills can be broken in half to allow for lower dosages. There is also a liquid form of Prozac that has allowed many patients to gradually increase the dosage to therapeutic levels. Often, if patients can start at very low dosages (e.g., 1-2 mg/day) and very slowly increase the dose, they will eventually be able to tolerate the medication. This technique has proven so successful for many people that there is now a “fan club” of those helped by this approach. Many patients have been able to use liquid Prozac. For example, one woman who was started on Prozac at 20 mg/day complained of very bothersome side effects such as increased anxiety, shakiness, and terrible insomnia. She also felt it had made her OCD worse.
In addition, she had horrible side effects from even 12.5 mg of Anafranil, and later with low dosages of Seroxat and Lustral. She then started 1-2 mg/day of liquid Prozac that she had heard was good from other patients whom she met over a computer bulletin board. She felt no side effects, and over a period of a few weeks, she again 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 of months, and her OCD gradually improved quite dramatically. Thus, careful and gradual increases in dosage with liquid medication may allow some medication-sensitive patients to reach therapeutic levels.
Do anti-obsessional meds cause long-term, irreversible side effects?
As far as we know, there are no irreversible side effects caused by the standard anti-obsessional drugs. Many patients have used them for years without difficulties. Some of the drugs that are occasionally used such as the older antipsychotic (or sometimes called neuroleptic) drugs like haloperidol (Haldol,Serenace), chlorpromazine (Thorazine,Largactil), thioridazine (Mellaril), and trifluoperazine (Stelazine) can produce irreversible neurological problems, such as persistent tremor 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.
For example, in OCD patients who 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 SRI medication helps OCD symptoms. In OCD patient s without tics, there is no evidence that neuroleptics are helpful, and they are best avoided. There are newer neuroleptic agents, like clozapine (Clozaril) and risperidone(Risperdal), that may have fewer of these types of neurological problems, and that may be helpful when added to SRI treatment. These new drugs should not be used alone since they have been associated with worsening of OCD symptoms when not taken in combination with a SRI.
Who should not take anti-obsessional medications?
In general, we try not to give anti-obsessional medications to women who are pregnant or who are breast-feeding. 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, however, 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 three months of pregnancy when the baby’s brain is developing. Some OCD patients are able to use the behavioral techniques of exposure and response prevention to avoid medications at least during the initial three months of pregnancy.
If your OCD is very 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 cause or worsen confusion in the elderly. Some of the other anti-obsessional drugs like Prozac, Faverin, Lustral, and Seroxat can be used in the elderly, but greatly reduced dosages are usual ly 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.
Should I take anti-obsessional meds only when I am feeling stressed?
No. This is a common mistake. These medications are meant to be taken on a regular daily basis to maintain a constant level in your blood stream. They are not taken like the typical anti-anxiety agents, when you feel upset or anxious. It is best not to miss dosages if possible. Having said this, 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 (see earlier section).
What kind of doctor should I look for to prescribe these meds?
Although any licensed physician can legally prescribe these drugs, it is probably best to deal directly with a board-certified psychiatrist who understands OCD. A list of psychiatrists with special interest in OCD can be obtained from the OC Foundation.
Keep in mind, however, that these are physicians who have expressed an interest in OCD and whom the Foundation has not evaluated in any way. (Legally, OCF is obligated to list any psychiatrist who expresses an interest in the disorder; a Treatment Providers List is available upon request.) It is also important to find a psychiatrist who is a psychopharmacologist; that is, one who has special knowledge about the use of drugs to treat psychiatric disorders.
What if I feel as if I’ve failed because I need a drug to help me?
A useful way of thinking 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, in fact, a neurologic or medical illness and not simply a result of some problem in the environment or of improper upbringing. As with the diabetic who needs insulin to live a normal life, some OCD patients need anti-compulsive medication to function normally (diabetics, like Obsessive-Compulsives, often feel angry and up set about having to take medication). There is no evidence that OCD is a result of anything that the patient has done, and it is best to consider it a chemical or neurologic disorder affecting a part of the brain.
What if I’m afraid to take meds because of obsessional drug fears?
Usually, with reassurance from a doctor that you trust, your fears can be overcome. If you still refuse to take medication, behaviour therapy can be started first, and part of the therapy can focus on your reluctance to take medication. Our experience indicates that the combination of medication and behaviour therapy will maximize your chances for improvement.
How long does it take anti-obsessional 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, but then they may improve greatly. Unfortunately during the early part of treatment, patients may only have side effects and no positive results, and 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. Keep in mind that even many psychiatrists give up on the medications after four to six weeks, since this is the time it takes for depressed patients to improve. Thus, you may have to remind your psychiatrist to keep you on the medication longer.
How helpful can I expect these medications to be?
In the large studies that have been done, each medication helps about 75% to 85% of the patients at least a little. About 50% to 60% of patients in each trial had at least a moderate response to medication. We know that 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. I have seen patients who have had no response to three of the above medications, then have a wonderful response to the next one.
There are also techniques of combining medications that may increase the response magnitude and rate (see next section). One patient wrote this to me: “Seeking an effective medication for OCD is a lot like dating to find a mate; don’t be afraid to shop around and try different meds till you find one that works for you!”
What about augmenting one drug with another?
The best augmenting technique is to add behaviour therapy to ongoing drug treatment. However, to boost a drug’s effect, we sometimes combine two or more medications together. For example, some people respond to combining Faverin or Prozac 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, so it is important to keep Anafranil’s dose low, at least during the initial stages of treatment. Some times, blood levels are helpful, but most of the time, a good clinician can just 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 the following: buspirone (Buspar), lithium carbonate, clonazepam(Rivotril), methylphenidate (Ritalin), fenfluramine (Pondamin), and other antidepressants (e.g., trazodone, bupropion, desipramine, etc.). The controlled trials that have been done with these augmenting agents have been largely disappointing, but since occasional patients respond to the addition of a second drug, clinicians frequently try this technique.
Are there other medications that can be used to treat OCD?
Yes, there are drugs that are occasionally helpful in individual patients besides the ones already mentioned. For example, some patients may be helped by drugs called monoamine oxidise inhibitors (e.g., Nardil [phenelzine] and Parnate [tranylcypromine]) that work in a different way than the previously mentioned drugs.
These drugs inhibit one of the enzymes that degrades the chemical messengers in the nerve gaps, thereby lengthening the time that the messenger can be active. There is some anecdotal evidence that OCD patients who also have panic attacks or prominent concerns with symmetry may be more likely to improve with monoamine oxidise inhibitors. With these drugs, certain foods and medications cannot be taken or potentially fatal reactions can occur. They are particularly dangerous in combination with the SRI medications, so these must be stopped for at least two weeks (five weeks for Prozac, which is longer lasting) prior to starting monoamine oxidise inhibitors.
The other antidepressants occasionally help, but chances of this are quite small.
Will I have to take anti-obsessional medications forever?
No one knows how long patients should take these medications once they have been effective. Some patients areable to discontinue medications after a six- to twelve-month treatment period. However, it does appear that more than 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 will be lower if patients learn to use behavior-therapy techniques while they are doing well on medication that is tapered very slowly (even over several months).
The behavioral techniques may enable patients to control any symptoms that return when they stop taking medication. Typically, after medications are stopped, symptoms do not return immediately, but 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 these 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; that is, one drink could affect an individual as if it were two drinks, etc.
Also, it is not known if alcohol can counteract some of the therapeutic effects of the medication, so it may be worth trying not to drink alcohol during the first couple of months after starting medication.
What if my OCD gets better, but I remain depressed?
It sometimes happens that OCD improves and depression persists. Occasionally, a second drug is added to combat the depression.
Sometimes, your doctor can assist you in finding other reasons why depression persists.
What are some signs of depression?
- Loss of appetite
- Weight loss
- Early morning awakenings
- Lack of energy
- Too much sleeping
- Crying, especially without knowing why
- Suicidal thoughts
- Feelings of hopelessness
- Feelings of helplessness
- Lack of interest in things that were of interest to the person
- Lack of enjoyment of life
The presence of one or more of these symptoms does not necessarily indicate depression, but if several are present, you may be depressed. For further information regarding depression, please feel free to contact Aware.
Medication can be quite effective in reducing the urge to pull to a more manageable and less stressful level although in some cases people have reported that medication stopped the urge to pull altogether. It is important to work with a professional, such as a GP or a psychiatrist, who understands what Trich is and the appropriate treatment of it. Don’t be afraid of asking the treater questions about his/her knowledge of this disorder since not everyone will have the same level of knowledge or experience with this.
What can I take to make me stop pulling?
Questions about pharmacological treatment of Trichotillomania are among the most frequently asked of TLC. Understandably, many want to know, “What can I take to make me stop pulling?”
As of yet, there is no magic pill for the treatment of Trichotillomania. In fact, people respond very individually to medications, so there probably will never be a single drug that helps everyone. There is also a strong possibility that there is more than one form of Trichotillomania, and that different forms will respond to different treatments.
That said, some people do benefit from drug therapies for Trichotillomania, either alone or in conjunction with cognitive-behaviour therapy. Many experience a reduction of the urge to pull, and some have experienced total cessation. The effect, however, is often (though not always) temporary. It can be useful to use a period of relief to explore additional treatment or support resources that may help you in the long term.
Because reaction to medications is so individual, it is often necessary for you and your doctor to try more than one drug or combination of drugs before finding one that helps. Medications in the SRI or SSRI category have shown to be the most useful to date, but results are mixed. Please see our “Clinicians’ Guides” for more detailed information.
The use of medication for the treatment of Trichotillomania in children or adolescents brings additional concerns. Very few drug trials involve children and to date there have been no studies of the use of medication for treatment of TTM in children. Due to the limited evidence supporting its effectiveness, as well as concerns about the long-term effects of medications on the developing brain, TLC’s Scientific Advisory Board advises that for most children and adolescents with Trichotillomania, medications should not be used as a treatment of first choice.
It is important for you and your doctor to be aware that many people with Trichotillomania suffer with additional problems, such as depression and anxiety, which should be screened for and treated. In addition to being serious or even life threatening in their own right, the existence of additional disorders can hinder ones ability to benefit from treatment of Trichotillomania.
Body Dysmorphic Disorder and Medication
Low levels or insufficient use of cartooning in the brain has been implicated with the disorder and so SSRI drugs are commonly and with some success used in the treatment of Body Dysmorphic Disorder. SSRI stands for Selective Serotonin Reuptake Inhibitor; these anti-depressant medications work on re-aligning serotonin levels in the brain, which serves to normalize mood. An example is the well-known brand name Prozac. SSRI’s are sometimes regarded as anti-obsessional medications, and in the case of body dysmorphic disorder have been successful in inhibiting such self-defeating behaviors as compulsive mirror checking. Drug treatment may include the use of an anxyolitic, or anti-anxiety drug, which may serve to alleviate compulsive behaviors as well.
As with all drugs these must be prescribed by and used under the supervision of a GP or psychiatrist, following professional assessment for suitability. It is important that a client feels comfortable with their doctor, especially in a situation where one requires help in tackling issues of mental health. Should it be felt that one’s needs and concerns are not being fully addressed, it is recommended to simply ‘shop around’ for a GP that is familiar with and supportive of one’s concerns.
It is becoming increasingly apparent, however, that CBT (Cognitive Behavioral Therapy) coupled with Exposure Therapy, may be the most effective method of treating BDD. For further information please consult the National Institute of Health Clinical Excellence