Learning Objectives

After reading this article, you should be able to:

1. Identify the primary medications used for treating obsessive-compulsive disorder (OCD).

2. Understand the importance of monitoring medication progress and communicating with prescribing professionals.

3. Demonstrate an understanding of evidence-based techniques for managing symptoms and improving functioning in clients with OCD.

As a psychotherapist treating a client with obsessive-compulsive disorder (OCD), you need to know which medications are typically prescribed along with common side effects. Cognitive behavioral therapy (CBT), including exposure and response prevention, is often the first choice for treating mild OCD (National Institute for Health Care Excellence (NICE), 2005 https://www.nice.org.uk/guidance/cg31); however, medication are usually necessary, either alone or in combination with CBT.

Selective serotonin reuptake inhibitors (SSRIs) are the primary medications for OCD. Currently, the following SSRIs are approved for treating OCD in the US (Soomro, G. M., Altman, D., Rajagopal, S., & Oakley-Browne, M. (2008). Selective serotonin re-uptake inhibitors (SSRIs) versus placebo for obsessive compulsive disorder (OCD). The Cochrane database of systematic reviews, 2008(1), CD001765. https://doi.org/10.1002/14651858.CD001765.pub3):

• Fluoxetine (Prozac)
• Fluvoxamine (Luvox)
• Paroxetine (Paxil, Pexeva)
• Sertraline (Zoloft)

Another option is clomipramine (Anafranil), a tricyclic antidepressant (TCA) with significant serotonin reuptake inhibition properties. However, due to its side effect profile, it is usually reserved for patients who have failed SSRI treatment.

It's crucial to remember that while medications can help, they rarely lead to complete remission of OCD symptoms. Most patients will not experience substantial improvement until at least four to six weeks after starting medication, and some may take up to 10 to 12 weeks (Koran LM and Simpson HB, Practice guideline for the treatment of patients with obsessive-compulsive disorder Guideline Watch March 2013).

If a patient doesn't respond to their first medication, you should ensure comorbid psychiatric illnesses are treated and consider adding CBT, switching to a different SSRI, or using clomipramine (Koran & Simpson, 2013).

For patients who have failed multiple treatments, augmentation strategies may be beneficial. These include pro-serotonergic agents (eg, buspirone, lithium); antipsychotics; and benzodiazepines. There's strong evidence for second-generation antipsychotics like aripiprazole (Abilify) or risperidone (Risperdal) as augmentation (Brakoulias, V., & Stockings, E. (2019). A systematic review of the use of risperidone, paliperidone and aripiprazole as augmenting agents for obsessive-compulsive disorder. Expert opinion on pharmacotherapy, 20(1), 47–53. https://doi.org/10.1080/14656566.2018.1540590 ).

Although not used often, several other medications can be used for augmentation, including ondansetron (Zofran); memantine (Namenda); riluzole (Rilutek); low-dose clomipramine; lamotrigine; and mirtazapine (Remeron). For a list of medications discussed, see the table, “FDA-Approved Medications for OCD,” (below).

Nonpharmacologic treatments showing promise for OCD include neurosurgery; deep brain stimulation (DBS); electroconvulsive therapy (ECT); and transcranial magnetic stimulation (Koran, L. M., Hanna, G. L., Hollander, E., Nestadt, G., Simpson, H. B., & American Psychiatric Association (2007). Practice guideline for the treatment of patients with obsessive-compulsive disorder. The American journal of psychiatry, 164(7 Suppl), 5–53). However, these treatments are typically reserved for patients with severe, treatment-resistant OCD or those with comorbid depression. 

As a psychotherapist, it's also important to be aware of potential side effects of the medications your clients may be taking. They may be sharing more with you about these side effects than they share with their prescribers, who often schedule relatively brief “med-check” visits. SSRIs can cause mild gastrointestinal effects, anxiety, agitation, insomnia, sexual dysfunction, weight gain, and QTc prolongation. Clomipramine, on the other hand, can cause anticholinergic side effects (which include dry mouth, dry eyes, constipation, and difficulty with urination), as well as cardiac toxicity.

Supporting medication treatment as a therapist

In addition to providing therapy to target your clients’ OCD symptoms, there are various ways you can help to enhance their response to medications. 

1. Incorporate exposure and response prevention (ERP) techniques: Since medications alone may not lead to full remission of OCD symptoms, ensure that you're incorporating ERP techniques into your therapy sessions. This can help clients build the skills necessary to manage symptoms effectively, regardless of medication status.
2. Discuss the role of medication in treatment goals: During the goal-setting process, discuss with your clients how medication can help them achieve their therapy goals. Explain that medication can act as a tool to reduce symptoms, making it easier for them to engage in therapeutic activities and work towards their goals.
3. Monitor progress and ask about side effects: Regularly assess your client's response to medication, including any side effects they may be experiencing. Keep track of their progress in therapy and how the medication may be impacting their ability to engage in therapeutic activities. Share this information with the prescribing professional to ensure appropriate adjustments are made to the medication regimen (Janardhan Reddy, Y. C., Sundar, A. S., Narayanaswamy, J. C., & Math, S. B. (2017). Clinical practice guidelines for Obsessive-Compulsive Disorder. Indian journal of psychiatry, 59(Suppl 1), S74–S90. https://doi.org/10.4103/0019-5545.196976).
4. Develop a medication tracking system: Help clients create a personalized system to track their medication usage, side effects, and progress. This can include a medication log or a smartphone app, which can improve adherence and facilitate discussions about medication-related concerns during therapy sessions.
5. Prepare for medication discontinuation: When appropriate, discuss with your clients and the prescribing professional the possibility of tapering off medication. Help clients understand the process and potential challenges, such as the risk of relapse or withdrawal symptoms, and plan for additional therapeutic support during this transition period.
6. Promote self-care and healthy lifestyle choices: Encourage your clients to engage in self-care activities and adopt healthy habits that can support their recovery process. This may include regular exercise, maintaining a balanced diet, practicing relaxation techniques, and getting sufficient sleep.

*Notes on use during pregnancy: The strongest warnings are for paroxetine, which has been linked to congenital malformations (primarily cardiovascular) associated with exposure during the first trimester.