What is the best medication for Obsessive Compulsive Disorder (OCD)?
If you are one of the millions of people worldwide whose lives have been impacted by Obsessive Compulsive Disorder (OCD), you may be wondering about the best medication options for OCD. Dr. Holly Betterly MD, Board-Certified Psychiatrist in Weston, FL and member of the International OCD Foundation (IOCDF), sheds some light on the medications used to treat OCD, how effective they are in comparison to one another, and how psychiatrists go about selecting one that may be right for you.
This post is provided for educational purposes only, and does not constitute medical advice. If you have questions, reach out to your doctor for more information.
Struggling with your mental health? Reach out for professional support. Dr. Betterly is a board-certified psychiatrist in Weston, FL dedicated to helping you overcome depression, anxiety, and OCD. She offers appointments at her office in Weston, FL, conveniently located in Weston Town Center, as well as via telehealth. Request an appointment today to start your journey to better mental health.
Jump to Section:
Which medications are used to treat Obsessive Compulsive Disorder (OCD)?
What is the best medication for Obsessive Compulsive Disorder (OCD)?
How do psychiatrists select a medication to treat Obsessive Compulsive Disorder (OCD)?
How effective are the medications used to treat Obsessive Compulsive Disorder (OCD)?
Which medications are used to treat Obsessive Compulsive Disorder (OCD)?
In the United States, there are a number of different medications that have been approved by the Food and Drug Administration (FDA) for use in the treatment of Obsessive Compulsive Disorder (OCD) in adults.
Clomipramine
The first medication that was approved by the FDA for the treatment of OCD is Clomipramine. Clomipramine received FDA approval for OCD in 1989. Clomipramine is a type of Tricyclic Antidepressant (TCA). Tricyclic Antidepressants are an older category of antidepressants named for the three rings found in their chemical structure.
Clomipramine is usually taken by mouth. It is available by prescription only in the United States, meaning that it cannot be purchased over the counter, and should only be taken under the careful supervision of a physician.
Its mechanism of action, or how it produces an effect in the body, involves blocking the reabsorption of serotonin and norepinephrine, two neurotransmitters found in the brain. Clomipramine’s ability to block the reabsorption of serotonin is thought to be the reason behind its effectiveness in treating OCD.
Clomipramine is a medication that needs to be taken on a regular basis in order to be effective. Taking this medication only when you notice symptoms, or “as needed”, is not effective. It takes some time before you can expect to see an improvement in your symptoms when taking Clomipramine.
The list of side effects for Clomipramine is long, and includes sedation, fatigue, dizziness, headache, restlessness, anxiety, sweating, nausea, constipation, increased appetite and weight gain, urinary retention, blue-green urine, sexual dysfunction, and low blood pressure.
Some side effects of Clomipramine can be life threatening, including heart problems, such as abnormal heart rhythm or rapid heart rate, seizures, hyperthermia (elevated body temperature), liver failure, increased pressure in the eye, paralytic ileus, and Serotonin Syndrome. It can also trigger mania and thoughts of suicide.
The FDA package insert for Clomipramine provides additional information about potential side effects.
Because of the risks of potentially harmful side effects associated with Clomipramine, psychiatrists often prefer to start with other medication options that carry a lower risk of side effects.
Selective Serotonin Reuptake Inhibitors (SSRIs)
Selective Serotonin Reuptake Inhibitors (SSRIs) are a category of medications that are often used as a first-line medication option in the treatment of OCD. Psychiatrists often prefer to start with SSRIs rather than Clomipramine as SSRIs have a lower risk of potentially harmful side effects, and are generally better tolerated by patients.
SSRIs are usually taken by mouth, and are available in the United States by prescription only. They cannot be purchased over the counter, and should only be taken under the careful supervision of a physician.
SSRIs get their name from their mechanism of action, or how they produce an effect in the body. Similar to Clomipramine, SSRIs block the reabsorption of serotonin.
SSRIs needs to be taken on a regular basis in order to be effective. Taking these medications only when you notice symptoms, or “as needed”, is not effective. It takes some time before you can expect to see an improvement in your symptoms when taking an SSRI.
There are many different SSRIs available on the market, however only four have been FDA approved for use in the treatment of OCD. These include:
Sertraline
Fluoxetine
Paroxetine
Fluvoxamine
The SSRI category also includes other medications that are not listed above which may be used on an “off-label” basis for OCD. This means that they have not been approved by the FDA specifically for use in OCD.
Like all medications, SSRIs carry a risk of potential side effects, such as gastrointestinal upset (nausea, upset stomach, or diarrhea), jitteriness, agitation or anxiety, headache, dizziness, changes in sleep, changes in appetite and weight, sexual dysfunction, increased risk of bleeding/bruising, seizures, blurred vision, sweating, confusion and discontinuation syndrome (after the SSRI is stopped). SSRIs can cause Serotonin Syndrome, a life-threatening medical emergency. They can also trigger suicidal thoughts and behaviors.
Each individual SSRI is slightly different in terms of the specific side effects that it may cause, so it is important to review the FDA prescribing information specific to the individual medication.
In clinical practice, psychiatrists may also use medications on an “off label” basis when treating OCD. Off label medication use means that the medication has not specifically been approved by the FDA for the treatment of OCD, but has been approved for use in other conditions. Psychiatrists may consider adding off label medications when a patient has not responded to traditional OCD treatments, what we refer to as treatment refractory OCD.
What is the best medication for Obsessive Compulsive Disorder (OCD)?
When we think about the “best” medication for treating OCD, the answer is that it ultimately depends on the specific patient in question and their unique health circumstances. There is no one-size-fits all answer here. To give a more accurate answer, we need to break this question down into two different questions, answered in the next two sections.
For a closer look at how psychiatrists determine which options are safe and appropriate for a given patient, click here.
For information about how effective different OCD medications are in comparison to one another, click here.
How do psychiatrists select a medication to treat Obsessive Compulsive Disorder (OCD)?
Psychiatrists are medical doctors who specialize in the treatment of mental health disorders, such as OCD. They have extensive experience with prescribing mental health medications.
When selecting a medication for a patient with OCD, there are a number of factors that psychiatrists may consider in narrowing down the options to find the best fit. Some of these factors may include:
What mental health conditions has the patient been diagnosed with?
The specific diagnoses is important because we need to select a medication that has been shown in research studies to be effective for the condition that the patient is experiencing.
We also need to consider if the patient is experiencing multiple different mental health conditions, as certain medications may not be safe to use when certain mental health conditions are also present. For example, if a patient has bipolar disorder in addition to OCD, we may need to be more careful with medications that could potentially trigger a manic episode
What general medical conditions has the patient been diagnosed with?
Certain medications are not safe for use in patients with certain medical conditions. For example, if a patient has high blood pressure, we may try to avoid medications that could worsen this condition.
We also consider how well the patient’s internal organs, such as the heart, kidney, and liver are functioning. Certain medications may need to be dosed differently if certain organs aren’t functioning as well as they are supposed to, or may need to be avoided altogether.
How old is the patient?
Certain medications may need to be dosed differently depending on age, while others may not be safe for use in certain age groups.
What is the patient’s pregnancy and breastfeeding status?
Some medications can cause harmful effects to a baby if taken during pregnancy or breastfeeding, so doctors need to consider if the patient is currently pregnant, or may become pregnant, while taking the medication.
What other medications is the patient taking?
We need to consider everything else that the patient is taking, including over-the-counter medications and supplements. Medications can interact with one another, with potentially life threatening consequences. Always tell all of your doctors about everything that you are taking!
How has the patient responded to other medications? How about their family members?
If a patient has taken similar medications in the past, knowing how they responded can help to guide selection. Similarly, if a patient’s family member has taken similar medications, information about their response can be beneficial.
What are the patient’s preferences with respect to side effects?
You are in the driver’s seat when it comes to your mental health- let your doctor know if avoiding certain side effects is important to you so that they can help narrow down the list to those that align with your preferences. As an example, some patients may want to avoid medications that can impact their weight, while others may be more concerned about sexual dysfunction.
What are the patient’s preferences with respect to taking the medication?
Medications come in different formulations, such as tablets, capsules, and liquids, and some patients may have a preference for one over another
Some patients may prefer to take a medication only once daily, while others may be okay with a medication that needs to be taken multiple times per day
Some patients may want to take a medication in the morning, while others may prefer to take medications at bedtime
Is the patient likely to face barriers to accessing the medication?
Medications vary in terms of cost and insurance coverage. If the patient is not going to be able to afford a specific medication, other options may be worth considering.
How effective are the medications used to treat Obsessive Compulsive Disorder (OCD)?
Efficacy refers to how well a medication performs at reducing the symptoms of the condition for which it is prescribed.
In OCD, we may consider a medication to be effective if it does a good job of reducing obsessions, compulsions, and the distress associated with them. Research studies frequently use scores on instruments like the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) as an objective measure of efficacy.
Clomipramine:
The American Psychiatric Association Practice Guideline for the Treatment of Patients with Obsessive Compulsive Disorder provides an excellent overview of the research literature with respect to the efficacy of medications used in the treatment of OCD. Some highlights include:
Clomipramine is significantly superior to placebo in the treatment of OCD
Clomipramine Collaborative Study found that over a 10-week study period, participants taking Clomipramine experienced an average forty percent reduction in scores on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) versus an average four percent reduction in scores in participants taking placebo.
Clomipramine is similar in efficacy to SSRIs
SSRIs are generally better tolerated than Clomipramine
SSRIs:
A 2008 Cochrane Review comparing SSRIs to placebo in the treatment of OCD found that:
SSRIs, as a group of medications, were more effective than placebo in reducing symptoms of OCD as measured by an improvement in scores on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS).
Patients taking an SSRI were more than twice as likely to see a reduction in their OCD symptoms in comparison to patients taking placebo.
Individual SSRIs were similar to one another in terms of symptom reduction.
How do I know if OCD medications are right for me?
Obsessive Compulsive Disorder (OCD) can leave you feeling exhausted and overwhelmed. Fortunately, multiple effective treatments are available. While prescription medications may be one option, so are specialized therapies, like Exposure Response Prevention (ERP). To learn more about which treatment options may be available to you in consideration of your unique health circumstances, reach out to a board-certified psychiatrist.
Psychiatrists are medical doctors who specialize in the treatment of mental health disorders, such as OCD. They have extensive experience with prescribing mental health medications.
To locate a psychiatrist near you, visit the American Psychiatric Association (APA) Online Directory.
Dr. Holly Betterly is a board-certified psychiatrist in Weston, FL. She is a member of the International OCD Foundation (IOCDF), and is dedicated to helping her patients overcome OCD. She offers both in-person appointments in Weston, FL, as well as telehealth visits for patients across Florida. She is in-network for Aetna and Cigna. She is currently accepting new patients. To request an appointment with Dr. Betterly click here.
