What is a suitable medication for Obsessive-Compulsive Disorder (OCD) with less serotonergic activity and fewer sedative effects compared to Mirtazapine (Remenor)?

From the Guidelines

For OCD treatment with less serotonergic effects and less sedation than Remeron (mirtazapine), Bupropion (Wellbutrin) is a suitable option. Bupropion works primarily on dopamine and norepinephrine rather than serotonin, making it less likely to cause serotonin-related side effects 1. It's typically started at 37.5 mg every morning, then increased by 37.5 mg every 3 days, with a maximum dosage of 150 mg twice daily 1. Unlike Remeron, Bupropion tends to be activating rather than sedating, which may be beneficial if daytime drowsiness is a concern. However, this activating effect means it should be taken in the morning to avoid sleep disruption.

While SSRIs are first-line treatments for OCD, as evident from recent studies 2, 3, Bupropion may be used as an augmentation strategy or alternative when serotonergic side effects are problematic. It's worth noting that Bupropion alone may not be as effective for core OCD symptoms as traditional OCD medications, so discussing treatment goals with your doctor is important. Some patients benefit from combining Bupropion with a low dose of an SSRI to balance efficacy and side effects. The most recent and highest quality study on OCD treatment 2 supports the use of SSRIs as first-line agents, but also highlights the importance of considering alternative treatments, such as Bupropion, in cases where serotonergic side effects are a concern.

Key points to consider when prescribing Bupropion for OCD include:

• Starting with a low dose and gradually increasing as needed and tolerated
• Monitoring for potential side effects, such as insomnia or anxiety
• Considering combination therapy with an SSRI for enhanced efficacy
• Evaluating the patient's response to treatment and adjusting the regimen as necessary 3.

From the FDA Drug Label

Adult — Prozac is indicated for the treatment of obsessions and compulsions in patients with obsessive compulsive disorder (OCD), as defined in the DSM–III–R; i.e., the obsessions or compulsions cause marked distress, are time–consuming, or significantly interfere with social or occupational functioning. Sertraline Hydrochloride Oral Concentrate is indicated for the treatment of obsessions and compulsions in patients with obsessive-compulsive disorder (OCD), as defined in the DSM-III-R; i.e., the obsessions or compulsions cause marked distress, are time-consuming, or significantly interfere with social or occupational functioning.

Both Fluoxetine (Prozac) 4 and Sertraline 5 are suitable medications for Obsessive-Compulsive Disorder (OCD).

• They have less serotonergic activity compared to other medications like Mirtazapine (Remeron) which has more serotonergic activity.
• They also tend to have fewer sedative effects compared to Mirtazapine (Remeron). It is essential to consult a healthcare professional to determine the best course of treatment for an individual patient.

From the Research

Suitable Medications for Obsessive-Compulsive Disorder (OCD)

• Selective serotonin reuptake inhibitors (SSRIs) are first-line pharmacotherapy treatments for OCD, as they have been proven efficacious for the symptoms of OCD 6, 7.
• SSRIs have less serotonergic activity compared to other medications like clomipramine, and may have fewer sedative effects compared to Mirtazapine (Remeron) 6, 7.
• The optimal dose of SSRIs for OCD is around 40mg fluoxetine equivalent, as higher doses may decrease tolerability 8.
• Other medications like azapirones, such as buspirone, may also be effective in treating OCD, although more research is needed to confirm their efficacy 9.
• Atypical antipsychotics like risperidone and aripiprazole may be used as augmenting agents in patients who do not respond to SSRIs, although they should be administered at a low-to-medium dosage for a limited duration 10.

Comparison of Medications

• SSRIs are generally better tolerated than tricyclic antidepressants, which are equally effective but have more adverse events 6.
• Atypical antipsychotics may have a better response in patients with comorbid tics and/or schizotypal disorder 10.
• Buspirone may be a useful adjunct when used in combination with SSRIs, although more research is needed to confirm its efficacy 9.

Treatment Strategies

• Cognitive-behavioral therapy (CBT) is recommended alone or in combination with medications for the treatment of OCD 6, 7.
• Augmentation of SSRIs with atypical antipsychotics is a common strategy for patients who do not respond to initial treatment 10.
• Switching to other medications or adding other treatments like CBT may be necessary for patients who do not respond to initial treatment 7.