What medications treat severe Obsessive-Compulsive Disorder (OCD) and anxiety?

Medications for Severe OCD and Anxiety

For severe Obsessive-Compulsive Disorder (OCD) and anxiety, Selective Serotonin Reuptake Inhibitors (SSRIs) at higher doses than those used for depression are the first-line pharmacological treatment due to their established efficacy, tolerability, safety profile, and absence of abuse potential. 1

First-Line Pharmacological Treatments

SSRIs

• SSRIs are the primary medication choice for both OCD and anxiety disorders 1
• Higher doses of SSRIs are typically required for OCD compared to those used for anxiety disorders or depression 1
• Treatment should be maintained at the maximum recommended or tolerated dose for at least 8 weeks to determine efficacy 1
• Common SSRIs used for OCD include:
  • Sertraline (FDA-approved for OCD) 2
  • Paroxetine (FDA-approved for OCD and anxiety disorders) 3, 4
  • Fluoxetine (effective at doses of 40-60mg daily for OCD) 5
• When choosing an SSRI, consider:
  • Adverse effect profiles (which differ between medications)
  • Potential drug interactions
  • Presence of comorbid conditions
  • Past treatment response
  • Cost and availability 1

Clomipramine

• A non-selective serotonin reuptake inhibitor that was the first agent to show efficacy in OCD 1
• Can be considered as an alternative to SSRIs 1, 6
• Has similar efficacy to SSRIs in head-to-head trials 1
• Has more side effects than SSRIs (anticholinergic effects, cardiotoxicity) 5

Treatment Duration and Maintenance

• OCD treatment guidelines recommend 8-12 weeks as the optimal duration to determine SSRI efficacy 1
• Significant improvement may be observed within the first 2-4 weeks of treatment 1
• Maintenance treatment should continue for a minimum of 12-24 months after achieving remission 1, 7
• Longer treatment may be necessary due to high risk of relapse after discontinuation 1

Treatment-Resistant OCD and Anxiety

Approximately 50% of patients with OCD fail to fully respond to first-line treatments 1. For inadequate response:

Augmentation Strategies

• Augment SSRIs with cognitive-behavioral therapy (CBT) with exposure and response prevention (ERP) 1
• Switch to a different SSRI 1
• Try higher doses of an SSRI than the maximum recommended dose 1
• Consider a serotonin-norepinephrine reuptake inhibitor (SNRI) like venlafaxine 1, 6

Pharmacological Augmentation

• Add antipsychotics to SSRIs (particularly risperidone or aripiprazole) 1
• Consider clomipramine augmentation to an SSRI 1
• Try glutamatergic agents such as N-acetylcysteine or memantine 1
• For anxiety disorders specifically, benzodiazepines may be used in treatment-resistant cases when there's no history of dependency 8, 6

Treatment Algorithm

1. Start with an SSRI at a higher dose than typically used for depression 1
2. Maintain treatment for 8-12 weeks to determine efficacy 1
3. If good response: Continue treatment for 12-24 months minimum 1
4. If inadequate response:
   • Add CBT with exposure and response prevention if available 1
   • OR switch to a different SSRI 1
   • OR try clomipramine 1
5. If still inadequate:
   • Consider augmentation with antipsychotics 1
   • OR glutamatergic agents 1
   • OR SNRIs 1

Important Considerations and Caveats

• Higher dropout rates: Higher doses of SSRIs are associated with greater efficacy but also higher rates of dropout due to adverse effects (gastrointestinal symptoms, sexual dysfunction) 1
• Careful monitoring: Ongoing assessment of SSRI adverse effects is crucial when establishing the optimal dose 1
• Antipsychotic augmentation: While effective, requires careful monitoring of risk-benefit ratio, particularly for weight gain and metabolic effects 1
• Clomipramine concerns: When combining clomipramine with SSRIs, monitor for potentially life-threatening events such as seizures, heart arrhythmia, and serotonergic syndrome 1
• Benzodiazepines: Should only be considered for anxiety when there's no history of dependency and other treatments have failed 8, 6