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Obsessive-compulsive disorder (OCD) can be a severe and disabling illness. According to the World Health Organization, OCD is a major cause of disability worldwide, with a total cost in the US estimated at more than $8 billion annually. People with OCD usually spend years suffering before beginning effective treatment. The situation is complicated by the fact that many health professionals are not educated about the best OCD treatments available to patients.
Common Medications for OCD
* Has not been approved by the FDA for use as an anti-obsessional drug in OCD, though frequently prescribed "off-label" for this purpose.
The first-line treatment for obsessive-compulsive disorder is typically a course of anti-depressant medications, specifically serotonin reuptake inhibitors (SRIs). This term encompasses the well-known "selective" serotonin reuptake inhibitors (SSRIs), which include fluoxetine (Prozac), fluvoxamine (Luvox), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa) and escitalopram (Lexapro), as well as the older tricyclic medication clomipramine (Anafranil). Dosages for the anti-obsessional qualities are often higher than typically needed for anti-depressant effects. The table below illustrates the maximum dose for OCD based on the current literature. Patients with OCD should take the highest dose they can tolerate up to the maximum amount; however, some individuals respond adequately with lower doses. SSRIs are generally safe medications for most people, which is one reason physicians are quick to prescribe these to patients with OCD symptoms. However, there have been recent concerns with using SSRIs among children and teenagers, as there may be increased incidence of suicidal thoughts among depressed youths.
Other problems include sexual side effects, which are a common reason for early discontinuation. SSRIs prevent or delay orgasm in 35% of patients, decrease libido in 20%, and cause problems with erectile function in 10% of men; the SRI clomipramine causes anorgasmia in 90% of patients. These difficulties may be more common in patients with OCD since they require larger doses of SSRIs compared to patients with depression in whom these problems have been studied. Sometimes sexual dysfunction improves on its own, but other direct means of addressing these side effects are often necessary.
Though most people who try SRIs will be "treatment responders," research has shown that actual symptom reduction tends to be modest at best. Having a response to medication is not a complete cure, merely an indication that the treatment has reduced OCD symptoms by some measurable degree. Although there are reports of dramatic improvements from SRIs alone, on average people with OCD will experience only about a 20-30% reduction in symptoms. Thus, many patients are unsatisfied with the result.
Historically, people who tried one medication without success would then be switched to a different SRI until an effective one could be found. However, the use of this strategy is not well-supported by the current research. Considering the long period SRIs may take to be effective, often 4-8 weeks, the waiting and switching process can be frustrating to patients, and partial responders to one SRI are vulnerable to similar problems with other SRIs. For this reason it is increasingly common to augment SRI medication, either with a type of psychotherapy specifically for OCD or an "add-on" medication.
80-90% of patients treated with drugs alone will relapse after they stop.
Augmenting medication with cognitive-behavioral therapy (CBT) may be an especially good choice, as 80-90% of patients treated with drugs alone will relapse after they stop medication. CBT is a term used to describe evidence-based treatments that focus on reducing a patient's current symptoms through the application of learning theories to psychotherapy. This is not the same as therapies that focus on childhood issues, relationships, or unconscious conflicts; such "insight-oriented" strategies are not effective treatments for OCD. CBT treatments have a proven track-record of helping people with a variety of mental disorders, particularly anxiety-related disorders like OCD. The most effective CBT techniques include exposure and ritual prevention (EX/RP, also called exposure and response prevention or ERP) and cognitive therapy (CT). EX/RP involves direct confrontation (exposure) to anxiety-provoking material while intentionally refraining from compulsions and is extremely effective, with CT as a recommended secondary option.
Among psychotherapeutic techniques, only EX/RP has been tested as an augmentation treatment for people taking SRIs. In one recent study, EX/RP was tested against stress management training (SMT), a treatment involving the use of relaxation techniques and problem-solving strategies, but without direct confrontation of the OCD symptoms. In this study, all patients stayed on their SRI medicine and were randomly assigned to receive one of the add-on therapies. Three-quarters of EX/RP patients responded to treatment and one-third were left with minimal OCD symptoms at the end of the 8-week treatment period. In contrast, the SMT group did not improve much. EX/RP appears to be a very effective augmentation strategy for those with medication-resistant OCD.
Although EX/RP is very effective and offers lasting gains, it is not the solution for everyone. Because EX/RP requires that patients confront their fears, many people with OCD feel unable to undertake CBT, or they may begin CBT and find the treatment too distressing to complete. In addition, rural and underserved areas may not have a qualified professional available to offer this treatment for OCD, or the sufferer may not have the resources to afford treatment even when available. Finally, a minority of OCD patients who have completed a course of EX/RP will remain highly symptomatic. For these reasons, other medication strategies are important options.
Many medications have been used to augment SRIs in people with OCD. These include benzodiazepines (i.e. muscle relaxants such as Clonazepam), mood stabilizers (e.g., lithium), tryptophan (an amino acid), inositol (vitamin B8), and others. Neuroleptics, also called antipsychotics or major tranquilizers, have been successful in helping people with a wide range of problems, including schizophrenia, bipolar disorder, delirium, nausea and vomiting, autism, Tourette's syndrome, and Huntington's disease, as well as OCD. One of the first neuroleptics to be studied as an augmenter was haloperidol, but it was effective only for people with OCD who also had tics. Small doses of newer, safer medications have since been added to SRI regimens. These second-generation "atypical" neuroleptics include risperidone (Risperdal), olanzapine (Zyprexa), and quetiapine (Seroquel). All of these medications are FDA approved for certain uses, but are currently used off-label in the treatment of OCD. In early research studies both olanzapine, quetiapine, and risperidone showed promise. However, the most current research indicates that such strategies are no more effective than placebo.
At one time OCD was regarded as an intractable disorder and no effective treatments existed. Patients lived in shame, unable to function, feeling frightened and hopeless. Today's treatments represent considerable advances beyond those early times, though many continue to suffer needlessly. SRIs bring most people with OCD some measure of relief. Augmentation with EX/RP is a good option for those who still have significant symptoms. Lack of access, lack of knowledge, and fear of new treatments keep many from experiencing the improved quality of life that may be possible for people with OCD.
Every person suffering with OCD owes it to themselves and their loved ones to persist with the existing effective strategies until they have achieved the best quality of life possible. There is no cure for the disorder, but with proper treatment and persistence many can and will beat OCD. Anyone interested in learning more about treatment for OCD, is encouraged to contact our treatment center for more information.
Source: Williams, M. T., Davis, D. M., Powers, M., & Weissflog, L. O. (2014). Current Trends in Prescribing Medications for Obsessive-Compulsive Disorder: Best Practices and New Research. Directions in Psychiatry, 34 (4), 247-261.