The Ontario Obsessive Compulsive Disorder Network

Medication

Research has shown that drugs that affect levels of the neurotransmitter serotonin in the brain benefit people with OCD. The principal class of medications that do this are a type of antidepressants known as serotonin reuptake inhibitors. This group of medications includes clomipramine (Anafranil), and the newer 'selective' serotonin reuptake inhibitors (SSRI's). The SSRIs consist of fluoxetine (Prozac), fluvoxamine (Luvox), sertraline (Zoloft), and paroxetine (Paxil). A new medication in this family, citalopram (Celexa) may possibly prove helpful as well, but has not yet been demonstrated effective in research studies.

Overall, these medications help about 70% of the time. All of these OCD medications seem to be about equally effective overall, however a given individual may have a good response to one drug, and none at all to another. It is therefore not uncommon for someone to try two or three of these drugs, before finding one that works best for them. When they work, people notice a slow reduction in the intensity of the obsessions and compulsions. However, it is important to realize that although helpful, it is rare for any of these medications to eliminate symptoms completely. There is usually a lag of several weeks before any change in symptoms is noticed, followed by gradual improvement. As a result, it is generally accepted that these drugs should be taken for approximately three months before one can be sure about how much they will benefit you. All of them should be taken regularly, generally once each day, for best response. Although these medications are all effective antidepressants as well, studies have shown that OCD symptoms may require a somewhat higher dosage than is used in depression. However, although safe, all of these medications can cause side effects. For this reason, most doctors recommend starting at a low dose, and then increasing gradually to a more optimal dose, if the medication is well tolerated.

If left untreated, OCD can be a fairly chronic disease. For this reason, accepted practice is to take the medication for a period of at least six to twelve months. Most doctors then recommend tapering the medication slowly. However, in some cases, it may be best to take the medication for even longer periods of time. It is always best to make any decision to taper or discontinue medication in conjunction with your doctor.

A common misconception is that these medications may be "addictive"; this is not the case. Even if taken long-term, these medications are safe, however it is fairly common for individuals to stay on them long term, as there is a significant risk of relapse with discontinuation. The most effective strategies to reduce the risk of relapse if discontinuing medication, are the following: gradual reduction in dosage, regular follow-up with a health-care professional to help monitor symptom severity, and concomitant cognitive behavioural therapy, for people who have not already received it.

Clomipramine is the oldest and best studied of these medications, and belongs to a class of antidepressants known as the tricyclics. It helps about 80% of people who take it. It can cause a variety of side effects, including constipation, sedation, dry mouth, dizziness with sudden changes in posture, blurred vision, tremor, increased sweating, weight gain, difficulty urinating, and sexual side effects (such as difficulty maintaining erections, or inability to achieve orgasm). On rare occasions, it can induce a manic episode or a seizure. Clomipramine also affects conduction of electrical impulses through the heart. This is not generally a problem in healthy adults, but necessitates that it be used with caution in individuals with a history of certain heart problems. In general, however, most of these side effects fade with time, so that most people can tolerate this medication quite well over the long term. The usual effective dosage range for clomipramine is between 150 - 250 mg daily.

The SSRIs all have a similar side-effect profile, with only slight differences between them. Common side effects include constipation or diarrhea, nausea, insomnia or sedation, headaches, increased sweating, tremor, and sexual side effects. Weight gain can also be a problem with long-term use. Generally, this class of drugs is extremely safe to use. However, one potential problem with many of the drugs in this class is that they can impact on the ability of the liver to metabolize many other commonly prescribed medications, such as certain antihypertensives, anxiolytic medications, tricyclic antidepressants (like clomipramine), anticonvulsants, and anticoagulants. There is a potentially dangerous interaction with the antihistamines terfenadine (Seldane) and astemizole (Hismanal), so these should be avoided completely, although other antihistamines are completely safe. However, in general, as with most medications, it is best to check with a physician before taking any other drugs. The typical daily dose range for the medications in this class is as follows: 20 - 80 mg fluoxetine (Prozac), 150 - 300 mg fluvoxamine (Luvox), 20 - 60 mg paroxetine (Paxil), and 100 - 200 mg sertraline (Zoloft). Although the efficacy of citalopram in OCD is not well established, the usual dose range for this medication is 20 - 60 mg daily.

Other medications for OCD

Most doctors recommend that people with OCD try one of the SSRIs first. Generally individuals start with one of these because of their effectiveness and their milder side-effect profile, as compared to clomipramine. However, there is still some dispute as to whether clomipramine may be slightly more effective, thus if an individual fails to get benefit from the first medication they try, it may be a good second choice. It is usually suggested that people try at least three drugs in the SRI class before going on to consider other drug alternatives. It is also important to keep in mind that the most common reasons for limited response to these drugs is the failure to take them at adequate dosage, or for the 3 months required for a good trial. However, if an individual has had optimal trials without benefit, there are a number of alternatives. These consist principally of other non-SRI antidepressants, or combining an SRI with a secondary agent. Adding a second drug to the primary one in this way is often referred to as augmentation.

Other Antidepressants

Generally, these alternatives all impact on serotonergic neurotransmission, although in different ways than the SRIs. Among newer drugs, venlafaxine (Effexor) has been observed to be helpful in a small number of individuals. However, the likelihood of benefiting from this drug is hard to assess, as systematic studies of the impact of this medication in large numbers of people with OCD under carefully controlled conditions have not yet been published. Similarly, nefazadone (Serzone) may also potentially benefit some people, but has not been well studied yet. The older class of antidepressants known as the monoamine oxidase inhibitors have been shown to have some limited benefits in OCD, in addition to being very effective antidepressants. However the two available drugs in this class, phenelzine (Nardil) and tranylcipramine (Parnate), are less effective antiobsessional agents than the SRIs , and more difficult to tolerate. As a result, they are generally only used in individuals who have failed to respond to the SRI drugs. Moclobemide (Manerix) is a newer drug that works in somewhat the same way as the monoamine oxidase inhibitors, although it is safer and easier to tolerate. Unfortunately, it has not been shown to benefit people with OCD.

Augmentation

Other non-antidepressant medications may be very helpful in OCD when they are added to an SRI. One of the most commonly added class of medication is the benzodiazepines or tranquilizer drugs. These medications tend to alleviate anxiety, although it is not clear if they directly affect the intensity of obsessions or compulsions. One of the best alternatives in this class of medications is clonazepam (Rivotril), which may specifically effect serotonin balance. Other alternatives that are commonly prescribed include lorazepam (Ativan), alprazolam (Xanax), diazepam (Valium), oxazepam (Serax), and temazepam (Restoril). However it should be kept in mind that drugs in this class can impact on short-term memory and learning. For this reason, it is usually better to avoid these drugs if you are also trying to get any form of cognitive-behavioural therapy. It may also be wise to avoid driving or operating hazardous equipment when first starting one of these drugs, until you are accustomed to the effect.

In the last few years there has been increasing recognition that certain antipsychotic drugs can also benefit people with OCD. The ones that have been best shown to be helpful include haloperidol (Haldol) and pimozide (Orap). When added to an SRI, these drugs may reduce the intensity of symptoms by a modest amount, particularly in people who suffer from a tic disorder or Tourette's syndrome. Unfortunately, these drugs are also not without risk, as they can induce tardive dyskinesia, a potentially irreversible involuntary movement disorder. For this reason, they should only be used with caution. The newer "atypical" antipsychotic drugs appear to carry less risk for this severe side effect. There have been case reports of these medications making OCD worse, but risperidone (Risperidol) has also been tested in OCD, with some limited benefit.

A number of mood stabilizing drugs have also been tried as augmenting agents in OCD. Lithium is the best studied of this class of drugs. Although it seems to have very little impact on the OCD symptoms directly, it can be very helpful for symptoms of depression, which is so often associated with OCD.

Tryptophan is a naturally occurring amino acid found in certain foods, and is also a precursor of serotonin. It has been tried in conjunction with SRI medications, with very limited benefits in a minority of people who tried it. Although very safe, it can cause considerable sedation, and so is usually best taken at night. There has also been some research suggesting that tryptophan might help if combined with lithium, or the antihypertensive drug pindolol, in addition to an SRI.

Buspirone (Buspar) is an anxiolytic drug that has complex effects on serotonin neurotransmission. Results of studies in OCD have been mixed, with some observing benefit, and others not. Overall, it appears that it may help a small minority of people with OCD.










				Medication Research has shown that drugs that affect levels of the neurotransmitter serotonin in the brain benefit people with OCD. The principal class of medications that do this are a type of antidepressants known as serotonin reuptake inhibitors. This group of medications includes clomipramine (Anafranil), and the newer 'selective' serotonin reuptake inhibitors (SSRI's). The SSRIs consist of fluoxetine (Prozac), fluvoxamine (Luvox), sertraline (Zoloft), and paroxetine (Paxil). A new medication in this family, citalopram (Celexa) may possibly prove helpful as well, but has not yet been demonstrated effective in research studies. Overall, these medications help about 70% of the time. All of these OCD medications seem to be about equally effective overall, however a given individual may have a good response to one drug, and none at all to another. It is therefore not uncommon for someone to try two or three of these drugs, before finding one that works best for them. When they work, people notice a slow reduction in the intensity of the obsessions and compulsions. However, it is important to realize that although helpful, it is rare for any of these medications to eliminate symptoms completely. There is usually a lag of several weeks before any change in symptoms is noticed, followed by gradual improvement. As a result, it is generally accepted that these drugs should be taken for approximately three months before one can be sure about how much they will benefit you. All of them should be taken regularly, generally once each day, for best response. Although these medications are all effective antidepressants as well, studies have shown that OCD symptoms may require a somewhat higher dosage than is used in depression. However, although safe, all of these medications can cause side effects. For this reason, most doctors recommend starting at a low dose, and then increasing gradually to a more optimal dose, if the medication is well tolerated. If left untreated, OCD can be a fairly chronic disease. For this reason, accepted practice is to take the medication for a period of at least six to twelve months. Most doctors then recommend tapering the medication slowly. However, in some cases, it may be best to take the medication for even longer periods of time. It is always best to make any decision to taper or discontinue medication in conjunction with your doctor. A common misconception is that these medications may be "addictive"; this is not the case. Even if taken long-term, these medications are safe, however it is fairly common for individuals to stay on them long term, as there is a significant risk of relapse with discontinuation. The most effective strategies to reduce the risk of relapse if discontinuing medication, are the following: gradual reduction in dosage, regular follow-up with a health-care professional to help monitor symptom severity, and concomitant cognitive behavioural therapy, for people who have not already received it. Clomipramine is the oldest and best studied of these medications, and belongs to a class of antidepressants known as the tricyclics. It helps about 80% of people who take it. It can cause a variety of side effects, including constipation, sedation, dry mouth, dizziness with sudden changes in posture, blurred vision, tremor, increased sweating, weight gain, difficulty urinating, and sexual side effects (such as difficulty maintaining erections, or inability to achieve orgasm). On rare occasions, it can induce a manic episode or a seizure. Clomipramine also affects conduction of electrical impulses through the heart. This is not generally a problem in healthy adults, but necessitates that it be used with caution in individuals with a history of certain heart problems. In general, however, most of these side effects fade with time, so that most people can tolerate this medication quite well over the long term. The usual effective dosage range for clomipramine is between 150 - 250 mg daily. The SSRIs all have a similar side-effect profile, with only slight differences between them. Common side effects include constipation or diarrhea, nausea, insomnia or sedation, headaches, increased sweating, tremor, and sexual side effects. Weight gain can also be a problem with long-term use. Generally, this class of drugs is extremely safe to use. However, one potential problem with many of the drugs in this class is that they can impact on the ability of the liver to metabolize many other commonly prescribed medications, such as certain antihypertensives, anxiolytic medications, tricyclic antidepressants (like clomipramine), anticonvulsants, and anticoagulants. There is a potentially dangerous interaction with the antihistamines terfenadine (Seldane) and astemizole (Hismanal), so these should be avoided completely, although other antihistamines are completely safe. However, in general, as with most medications, it is best to check with a physician before taking any other drugs. The typical daily dose range for the medications in this class is as follows: 20 - 80 mg fluoxetine (Prozac), 150 - 300 mg fluvoxamine (Luvox), 20 - 60 mg paroxetine (Paxil), and 100 - 200 mg sertraline (Zoloft). Although the efficacy of citalopram in OCD is not well established, the usual dose range for this medication is 20 - 60 mg daily. Other medications for OCD Most doctors recommend that people with OCD try one of the SSRIs first. Generally individuals start with one of these because of their effectiveness and their milder side-effect profile, as compared to clomipramine. However, there is still some dispute as to whether clomipramine may be slightly more effective, thus if an individual fails to get benefit from the first medication they try, it may be a good second choice. It is usually suggested that people try at least three drugs in the SRI class before going on to consider other drug alternatives. It is also important to keep in mind that the most common reasons for limited response to these drugs is the failure to take them at adequate dosage, or for the 3 months required for a good trial. However, if an individual has had optimal trials without benefit, there are a number of alternatives. These consist principally of other non-SRI antidepressants, or combining an SRI with a secondary agent. Adding a second drug to the primary one in this way is often referred to as augmentation. Other Antidepressants Generally, these alternatives all impact on serotonergic neurotransmission, although in different ways than the SRIs. Among newer drugs, venlafaxine (Effexor) has been observed to be helpful in a small number of individuals. However, the likelihood of benefiting from this drug is hard to assess, as systematic studies of the impact of this medication in large numbers of people with OCD under carefully controlled conditions have not yet been published. Similarly, nefazadone (Serzone) may also potentially benefit some people, but has not been well studied yet. The older class of antidepressants known as the monoamine oxidase inhibitors have been shown to have some limited benefits in OCD, in addition to being very effective antidepressants. However the two available drugs in this class, phenelzine (Nardil) and tranylcipramine (Parnate), are less effective antiobsessional agents than the SRIs , and more difficult to tolerate. As a result, they are generally only used in individuals who have failed to respond to the SRI drugs. Moclobemide (Manerix) is a newer drug that works in somewhat the same way as the monoamine oxidase inhibitors, although it is safer and easier to tolerate. Unfortunately, it has not been shown to benefit people with OCD. Augmentation Other non-antidepressant medications may be very helpful in OCD when they are added to an SRI. One of the most commonly added class of medication is the benzodiazepines or tranquilizer drugs. These medications tend to alleviate anxiety, although it is not clear if they directly affect the intensity of obsessions or compulsions. One of the best alternatives in this class of medications is clonazepam (Rivotril), which may specifically effect serotonin balance. Other alternatives that are commonly prescribed include lorazepam (Ativan), alprazolam (Xanax), diazepam (Valium), oxazepam (Serax), and temazepam (Restoril). However it should be kept in mind that drugs in this class can impact on short-term memory and learning. For this reason, it is usually better to avoid these drugs if you are also trying to get any form of cognitive-behavioural therapy. It may also be wise to avoid driving or operating hazardous equipment when first starting one of these drugs, until you are accustomed to the effect. In the last few years there has been increasing recognition that certain antipsychotic drugs can also benefit people with OCD. The ones that have been best shown to be helpful include haloperidol (Haldol) and pimozide (Orap). When added to an SRI, these drugs may reduce the intensity of symptoms by a modest amount, particularly in people who suffer from a tic disorder or Tourette's syndrome. Unfortunately, these drugs are also not without risk, as they can induce tardive dyskinesia, a potentially irreversible involuntary movement disorder. For this reason, they should only be used with caution. The newer "atypical" antipsychotic drugs appear to carry less risk for this severe side effect. There have been case reports of these medications making OCD worse, but risperidone (Risperidol) has also been tested in OCD, with some limited benefit. A number of mood stabilizing drugs have also been tried as augmenting agents in OCD. Lithium is the best studied of this class of drugs. Although it seems to have very little impact on the OCD symptoms directly, it can be very helpful for symptoms of depression, which is so often associated with OCD. Tryptophan is a naturally occurring amino acid found in certain foods, and is also a precursor of serotonin. It has been tried in conjunction with SRI medications, with very limited benefits in a minority of people who tried it. Although very safe, it can cause considerable sedation, and so is usually best taken at night. There has also been some research suggesting that tryptophan might help if combined with lithium, or the antihypertensive drug pindolol, in addition to an SRI. Buspirone (Buspar) is an anxiolytic drug that has complex effects on serotonin neurotransmission. Results of studies in OCD have been mixed, with some observing benefit, and others not. Overall, it appears that it may help a small minority of people with OCD.

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