Some brief notes on medications for OCD

Before listing a few notes on medications for OCD, let me post a disclaimer: this is NOT meant to be medical advice for your specific OCD. ALWAYS consult your own doctor, since he or she knows you best. NEVER take a medication that has not been prescribed to you.

So now you might be asking, which one is better treatment for my OCD, medications or behavior therapy? The exact answer to that will vary a lot from person to person. However, a couple of things are certain. Even if you have a good response to medications, once you go off the medications your symptoms will probably return. On the other hand, people who learn E & RP techniques seem to maintain their improvements for years. Certain physicians say that medication is management for OCD, while behavior therapy is a treatment for OCD, even though responses to behavior therapy vary a lot. But there are lots of reasons that one might consider using both approaches together, especially at first. For instance, if someone’s anxiety is too high to allow them to sit and listen to this type of presentation, or to do the homework assignments that behavior therapy requires, then they might benefit from medication that would reduce their anxiety. If someone’s obsessions or compulsions were so consuming that they couldn’t get to therapy or do their assignments, then again they might want to start anti-obsessional medication first, just to make it possible for them to do the behavior therapy. Finally, if other factors are keeping them from being able to do behavior therapy (for instance, a concurrent depression), medications designed to treat the other problem might be a good starting place as well. Fortunately, most of the medications that we use for OCD are good for treating anxiety and depression as well, so often it’s possible to treat several problems with one medication.

Let’s introduce some of the names of these medications now. I’ve mentioned the SSRIs already. In this group are fluoxetine, also called Prozac; sertroline, also called Zoloft; paroxetine, also called Paxil; fluvoxamine, also called Luvox; citalopram, also called Celexa; and escitalopram, also called Lexapro. These are the medications that we refer to as the SSRIs, and the list is growing by about one every year. There are two other medications that are hybrids of these drugs, in that they are not completely serotonin-specific. Effexor (venlafaxine) and Cymbalta (duloxetine) also work on the norepinephrine system, and are referred to as SNRIs; at least Effexor is turning out to be effective for certain types of OCD-related symptoms. Remeron, an anti-depressant in a class by itself, is also turning out to be useful for treating anxiety, but probably not OCD. But before I go on with these medications, let me mention the oldest, and for some people still the best, of the anti-OCD medications. This is clomipramine, also called Anafranil. This one is sort of an SRI, since it acts on other systems in addition to serotonin and therefore isn’t as specific. It is a member of class of medications related to the anti-depressant imipramine. These are called tricyclics because their chemical structure includes three rings of carbon atoms. The side effects of these tricyclics are similar to each other, and there are generally more side effects for most people than for the SSRIs. Side effects are often the reasons people don’t like taking them, even though they work very well. But for many people, these side effects can be managed with not too much difficulty. The side effects most often complained about include sedation or tiredness, dry mouth, constipation, dizziness and blurry vision. Rarely these side effects include increased likelihood of seizures, changes in heart function, sexual side effects, urinary hesitancy and weight gain.

Sounds like a pretty impressive list, huh? Some of you may be thinking after hearing this, “Boy, none of that for me, thank you!” But it really isn’t as bad as it may sound at first. No one gets all these side effects, and some people don’t get any of them. Many of these side effects go away over the first few days to weeks of treatment. Most important is that the majority of them can be easily managed. For instance, if your medication makes you sleepy, your doctor may instruct you to take it at night. You’re going to be asleep anyway, so why not have your drowsiness occur then? If you get dry mouth, you might carry around hard candy (sugarless, of course) in your pocket, or always have a water bottle handy. If you are constipated, add more fruits and green leafy vegetables to your diet. These do your body good in lots of ways that other laxatives can’t. Dizziness is usually experienced when getting up from a prone position. This is due to the tendency of these medications to slow down the body’s natural mechanism that raises your blood pressure slightly when you get up after lying down. Normally, this mechanism allows you to continue to get enough blood to your brain, even though the system has to work harder to pump the blood uphill when you are standing than it did when you were lying down. So if you get up quickly, the system lags a bit before catching up. You end up with a few moments of insufficient blood to your brain, and you feel lightheaded or dizzy. What can you do about it? You can get up more slowly, especially at night when your blood pressure is normally at it’s lowest of the day.

Blurry vision is related to most of the other potential side effects we’ve covered, since it results from action of the medication on the same non-serotonin system (called the cholinergic system because it uses the neurotransmitter acetylcholine). It’s slightly more complicated to manage as a side effect, and you should talk to your doctor about your specific case (as you should if you experience any of these effects). Seizures, if they occur, are primarily found in people with a personal or family seizure history, so it’s important that your doctor take a thorough history from you before starting you on these medications. Heart complications primarily occur in older men or men with a history of cardiovascular illness; in higher risk cases, or just to be sure, your doctor may recommend a heart scan (or EKG) before you start. Even weight gain can often be managed by some simply dietary adjustments. So you can see that most of the potential side effects of medications like Anafranil can be managed by adjusting a few of your habits.

Let’s talk briefly about the potential side effects of the SSRIs in particular (in a future post, I’ll discuss the sexual side effects of these medications and offer some thoughts on how to handle them). Of these medications, Zoloft and Luvox are the weakest and probably the least specific, followed by Prozac and Celexa, with Lexapro and Paxil being the strongest and most specific. By this I mean that 50 milligrams (mg) of Zoloft has about the same effect as 12 mg of Prozac or 10 mg of Paxil. Now it’s important to remember that the number of milligrams is not an indicator of how well a medication may work for you. For example, a single aspirin is 325 mg. And your physiology is unique, meaning that everyone will have different responses to each medication. In terms of side effects, these medications are pretty similar, with the primary complaints being headaches, stomach upset and restlessness. Again, most of these go away after a few days to two weeks. Some people that take Prozac find that they feel activated, and may have some mild insomnia. One of the best ways to deal with this is to take the medication in the morning. Some people complain of weight loss with Prozac, but some people experience just the opposite problem. Neither weight loss nor insomnia appears to be a frequent problem with Zoloft or Celexa, although Paxil and Luvox may be more likely to cause drowsiness. One other difference between these SSRIs is the half-life of the medication, or the time it takes your body to reduce the effective amount of medication in your system to about half. The longer the half life, the longer the medication remains active; if the half life for a medication is 24 hours, then in one day the effectiveness of the medication is reduced by half, in two days it is reduced by three fourths, etc. The half-lives of Zoloft and Paxil are each about 24 hours; the half-life of Luvox is about 12-15 hours, and the half-life of Prozac is about 7-10 days. This concept is important if you are waiting for the drug to be washed out of your system before switching medications, and also in managing some side effects. Also, the longer half-life of Prozac means that it might be a better medication for you if you tend to skip or forget doses occasionally.

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