The most effective therapies and medications for treating OCD

• OCD treatment usually involves a combination of medication and therapy.
• The most effective type of therapy for OCD is exposure and response prevention therapy, which involves invoking discomfort and then fighting through it.
• The two types of medications that are effective for OCD are selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs).
• This article was medically reviewed by Mayra Mendez, Ph.D., LMFT, a licensed psychotherapist and program coordinator for intellectual and developmental disabilities and mental health services at Providence Saint John's Child and Family Development Center in Santa Monica, California.

Obsessive-compulsive disorder (OCD) is a mental health condition that affects two to three million adults in the US and is characterized by having distressing obsessions and compulsions.

There are two ways that OCD can be treated: medication and therapy. However, it's most common to manage OCD with a combination of both meds and therapy. With proper treatment, OCD symptoms can be reduced and the person can have better control over their thoughts and behaviors. Here's how:

Exposure and Response Prevention (ERP) therapy

Therapy is the first line of defense in treating OCD. The most effective form of therapy for OCD is Exposure and Response Prevention (ERP), which is a specialized form of cognitive-behavioral therapy (CBT), says Christopher Pittenger, MD, PhD, a Yale School of Medicine psychiatrist and Director of the Yale OCD Research Clinic.

The premise of ERP is to evoke discomfort and fight through it under the supervision of a licensed therapist or other mental health professional. Pittenger says ERP involves triggering unpleasant symptoms on purpose and then refraining from engaging in the compulsions that someone would usually engage in.

To understand ERP, we can look at an example of somebody whose main obsession is contamination, which involves an intense fear of germs and a compulsion to clean excessively.

Someone with a contamination obsession in ERP would be told to deliberately trigger contamination anxiety by touching the floor or the bottoms of their shoes, and then sit with the anxiety and unpleasant feelings instead of acting on the compulsion to wash their hands immediately.

Over time, the person can learn that they are able to get through the anxiety on their own, and the horrible thing that they would imagine happening (like getting very sick from touching the floor) is extremely unlikely to happen, even if the compulsion isn't performed.

When this therapy is successful, Pittenger says the anxiety may improve, and the unwanted intrusive thoughts that trigger the anxiety become easier to manage over time.

ERP therapy is often conducted in an outpatient setting in a therapist's office one or more times a week, depending on the severity of the OCD. In more severe cases, it may be conducted in an intensive outpatient program where the person may attend therapy multiple times a week in both individual and group settings.

Medications for OCD

Although ERP may be effective for some, people with severe cases of OCD should rely on a treatment plan that combines medication and therapy, says David A. Merrill, MD, PhD, a psychiatrist at Providence Saint John's Health Center in Santa Monica, California.

Here are some medications that have been proven to be helpful for OCD.

Selective serotonin reuptake inhibitors (SSRIs)

Selective serotonin reuptake inhibitors (SSRIs) are technically antidepressants, but they are also used to treat other mental illnesses besides depression, and are the most commonly prescribed medications for OCD.

SSRIs block a protein that transports serotonin from neurons in the brain, which increases the amount of serotonin available. Serotonin is a neurotransmitter that helps regulate mood and psychological function — and having more of it can lead to a symptom reduction in OCD.

There are four SSRIs approved by the FDA for treating OCD. They are:

• Sertraline (Zoloft): Approved for adults and children who are at least 6 years old
• Fluoxetine (Prozac): Approved for adults and children who are at least 7 years old
• Fluvoxamine (Luvox): Approved for adults and children who are at least 8 years old
• Paroxetine (Paxil): Approved for adults only

Two other SSRIS –– citalopram (Celexa) and escitalopram (Lexapro) –– are not FDA approved for OCD, but they are still prescribed for OCD since the mechanism by which they affect the brain is the same.

"The reality is, antidepressants as a class have about the same degree of efficacy for OCD altogether. So, really, you could use pretty much any of the six SSRIs [to treat OCD]," says Merrill.

Keep in mind that it can take weeks to feel any symptom improvement when taking SSRIs. Additionally, Pittenger says that people with OCD typically need higher doses of these meds than people who take them for anxiety or depression.

However, SSRIs come with side effects. Some of these common side effects are:

• Increased anxiety or nervousness (especially when starting the medication or increasing dose)
• Drowsiness
• Nausea and vomiting
• Diarrhea
• Reduced libido
• Difficulty orgasming
• Weight changes

Tricyclic antidepressants (TCAs)

Tricyclic antidepressants (TCAs) are another class of medication that is used to treat OCD. These medications are older than SSRIs and typically have more side effects. The main TCA that is FDA approved to treat OCD is called clomipramine, which has the brand name Anafranil.

Merrill says that clomipramine is usually prescribed as a second line of treatment after somebody tries one or more SSRIs and doesn't experience relief from them, even at high doses.

While SSRIs target serotonin, tricyclic antidepressants like clomipramine also affect other neurotransmitter systems including norepinephrine and dopamine on top of serotonin, Pittenger says. Doctors are not completely sure how exactly clomipramine treats OCD, but it is believed that it works similarly to SSRIs by modifying serotonin neurotransmission.

Clomipramine and TCAs in general tend to have more side effects than SSRIs, Pittenger says, and that's typically why SSRIs are tried first. Common side effects of clomipramine include:

• Sedation or drowsiness
• Weight gain
• Constipation
• Nausea and vomiting
• Dry eyes and mouth
• Nervousness
• Changes to sex drive and ability to orgasm

Blood levels of clomipramine must be measured with periodic blood tests, which can be inconvenient. Merrill adds that even more medical monitoring may be necessary, such as EKGs (tests that measure the electrical activity of the heart) before starting the medication and after starting it.

Additionally, Pittenger says that clomipramine is even more dangerous in overdose than SSRIs, and that it can cause seizures or heart arrhythmias in susceptible people, particularly if the medication is taken at a very high dose.

The bottom line

Between therapy and the variety of medications available, OCD can become a manageable condition. Make sure to stick with your treatment plan and communicate with your mental health professional if you feel like it isn't working. It may take some trial and error and a decent amount of time, but relief from OCD is possible.

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