What is the best medication for a 19-year-old male with obsessive-compulsive disorder (OCD) symptoms, including intrusive thoughts, obsession with his girlfriend, compulsions, intermittent aggression towards his parents, lack of focus on studies, and absence of clear personal goals?

Best Medication for OCD in a 19-Year-Old Male

Start with an SSRI—specifically sertraline 50 mg daily—as first-line pharmacotherapy for this 19-year-old with moderate-to-severe OCD symptoms including intrusive thoughts, obsessive preoccupation with his girlfriend, and compulsive behaviors. 1, 2

Why SSRIs Are First-Line

• SSRIs are the backbone of OCD pharmacotherapy due to superior safety, tolerability, and equivalent efficacy compared to older agents like clomipramine 3, 4
• The FDA specifically approves fluoxetine for OCD in both adults and pediatric patients, with established efficacy in reducing obsessions and compulsions 5
• Sertraline 50 mg daily is recommended as the first-line SSRI for moderate-to-severe OCD symptoms in this age group 2
• Treatment duration should be 10-12 weeks at adequate doses before assessing response 3, 4

Addressing the Complete Clinical Picture

Core OCD Features Present

• Intrusive thoughts and girlfriend obsession fit the classic OCD pattern of ego-dystonic, unwanted thoughts that cause marked distress 1
• These obsessions are likely driving anxiety and the compulsive behaviors described 1
• The lack of focus on studies and absence of goals may represent functional impairment secondary to OCD, which affects 65.3% of cases severely 1

Aggression Requires Careful Assessment

• Intermittent aggression toward parents warrants evaluation for comorbidity, as 90% of OCD patients meet criteria for another lifetime disorder 1
• The aggression could represent:
  • Frustration related to OCD symptoms and family accommodation
  • Comorbid impulse-control disorder (common in OCD) 1
  • Irritability from untreated anxiety/depression 1

Treatment Algorithm

Step 1: Initiate SSRI Monotherapy

• Start sertraline 50 mg daily and titrate as needed 2
• Alternative first-line SSRIs include fluoxetine 20-80 mg daily 5, 3
• Higher doses are often required for OCD compared to depression—don't stop at standard antidepressant doses 4, 6

Step 2: Combine with Cognitive-Behavioral Therapy

• SSRI combined with Exposure and Response Prevention (ERP) produces optimal outcomes compared to either treatment alone 1, 4, 7
• ERP should specifically target the reassurance-seeking and girlfriend-related compulsions 2
• This combination approach is first-line treatment per multiple guidelines 2, 4

Step 3: If Inadequate Response After 10-12 Weeks

• Switch to a different SSRI (e.g., fluoxetine, fluvoxamine) 3, 4
• Consider clomipramine, which is FDA-approved for OCD and showed 35-42% improvement on Yale-Brown OCD Scale in clinical trials 8
• Clomipramine dosing: up to 250 mg/day for adults, with mean baseline YBOCS scores of 26-28 showing 10-point reductions 8

Step 4: Augmentation for Treatment-Resistant Cases

• Add an atypical antipsychotic to the SSRI—this is the only augmentation strategy with substantial empirical support 4, 6
• Other augmentation strategies lack consistent evidence 4

Critical Pitfalls to Avoid

Don't Underdose or Stop Too Early

• OCD requires higher SSRI doses and longer trials (10-12 weeks minimum) than depression 3, 4
• Many patients are undertreated despite growing awareness of OCD 1

Don't Miss Comorbidities

• Assess for anxiety disorders, mood disorders, impulse-control disorders, and substance use given 90% comorbidity rate 1
• The aggression and lack of motivation may indicate comorbid depression or impulse-control issues requiring additional intervention 1

Don't Ignore the Relationship Obsession Pattern

• Obsessional jealousy is a recognized OCD presentation that requires specific ERP targeting 1
• This is ego-dystonic (unwanted, distressing) rather than normal relationship concerns 2

Monitoring and Long-Term Management

• Use the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) to quantify severity, with scores ≥14 indicating clinically significant OCD 2
• Periodically reevaluate long-term medication need beyond the acute phase 8, 5
• Address family dynamics and reduce accommodation behaviors that may reinforce compulsions 2