Obsessive-compulsive disorder (OCD) is a complex mental health condition that 1 in 40 people will develop over the course of their lifetime. The first-line, evidence-based treatments for reducing OCD symptoms are exposure and response prevention (ERP) therapy and medication.
Although ERP can be effective on its own, many people benefit from adding medication to their treatment plan to reduce the severity of their symptoms. Studies have shown that people with OCD who were prescribed selective serotonin reuptake inhibitors (SSRIs) had, on average, a partial reduction in their symptoms.
In this guide, we’ll discuss how medications can reduce OCD symptoms, the types of medications available, doses, and how you can seek a prescription.
How can medications help manage OCD?
Medications may be added to your OCD treatment for several reasons, including:
- The severity of your OCD symptoms
- Co-occurring mental health conditions, such as generalized anxiety disorder (GAD), major depressive disorder (MDD), or post-traumatic stress disorder (PTSD)
- Your unique psychology and neurology
- Your personal decision to try medication
It’s common for providers to suggest medication if you’re having difficulty getting through ERP therapy exercises, as part of it involves intentionally exposing yourself to your obsessions, which can bring about distress and anxiety. Or, if you have severe OCD, taking medication could reduce the intensity of your symptoms.
While some people can take medication on its own and see a reduction in their OCD symptoms, it is typically part of a broader treatment plan when combined with ERP. Research reveals that this treatment combination can lead to significant results.
A randomized, controlled trial compared patients who had received SSRIs combined with ERP to patients who received SSRIs alongside stress management training. After 17 sessions, over three times (74%) the number of patients doing ERP with medication experienced at least 25% reduction in OCD symptoms compared with the other group (22%).
It’s important to note that while medication can reduce OCD symptoms, it is unlikely to lead to long-term symptom reduction for OCD without the inclusion of ERP.
“Medication by itself typically doesn’t remove OCD symptoms 100%,” says Jamie Feusner, MD, Professor of Psychiatry at the University of Toronto and Chief Medical Officer at NOCD. “In fact, if [a person] gets a 35% reduction of symptoms, that’s considered a full response—just like it is for ERP. On average, people taking medications have around a 30-50% reduction in symptoms.”
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Types of OCD medications
There are three classes of drugs shown to be effective in reducing OCD symptoms. These include:
Selective serotonin reuptake inhibitors (SSRIs)
SSRIs are considered the first-line medication prescribed to treat OCD symptoms. SSRIs are designed to increase the availability of serotonin, a key neurotransmitter in the brain that plays a significant role in regulating mood, anxiety, and other emotional processes. These medications work by blocking serotonin from being recycled in the brain (a process known as reabsorption). Over time, this can increase communication between cells to improve mood, reduce anxiety, and relieve symptoms of mental health conditions like depression and OCD.
“The benefits for OCD, however, aren’t a result of their immediate effects of increasing serotonin between nerve cells, but rather the gradual changes that occur over many weeks in response to these increased levels,” explains Dr. Feusner. “This is why the benefits take a long time to emerge. SSRIs are not correcting a serotonin deficiency in OCD since there is no conclusive evidence of a deficiency of serotonin in OCD. Rather, they work as a ‘tool’ to alleviate OCD symptoms. This is similar to how acetaminophen (e.g., Tylenol) can help reduce pain, but does not correct a deficit of acetaminophen in your body.”
Dr. Feusner also notes that SSRIs are prescribed at higher doses when being used to treat OCD, compared with the doses for anxiety or depression. “People with OCD often need higher doses of SSRIs than you’d need for treating depression or other anxiety problems, although those are also treated by SSRIs effectively—but the dose for OCD often needs to be three, four, five, or even six times higher,” he explains.
The following SSRIs may be prescribed to treat OCD:
- Fluoxetine (Prozac)
- Fluvoxamine (Luvox)
- Paroxetine (Paxil)
- Sertraline (Zoloft)
- Escitalopram (Lexapro)
Citalopram and venlafaxine
There’s another SSRI, citalopram (Celexa), that may be prescribed for managing OCD, but Dr. Feusner says that most experts don’t recommend it as a first-line medication. This is because federal regulations regarding dosage limitations affect its impact on symptom relief. “Citalopram is not recommended by the U.S. Food and Drug Administration (FDA) to be used higher than 40 milligrams (mg) in adults because a dosage higher than that can potentially increase the risk of having a problematic heart rhythm,” he explains.
Venlafaxine (Effexor) is a serotonin and norepinephrine inhibitor (SNRI) that might be used when someone does not respond well enough to several trials of different SSRIs or clomipramine (see below). Venlafaxine increases the amounts of serotonin and norepinephrine in the brain by preventing these neurotransmitters from being reabsorbed. Norepinephrine is a neurotransmitter and hormone regulating arousal, attention, cognitive function, and stress reactions.
Side effects
Like any medication, SSRIs may cause some unwanted side effects, such as:
- Dry mouth
- Agitation
- Insomnia
- Reduced sex drive
- Nausea or vomiting
- Dizziness
- Fatigue
- Diarrhea
- Constipation
- Decreased appetite
- Withdrawal symptoms if stopped abruptly
However, most side effects are relatively mild and subside or go away after an initial period.
Another less common side effect that could occur, typically only when multiple medications that affect serotonin are combined, is a rare but serious condition known as serotonin syndrome. This is caused by excessive levels of serotonin in the brain, which can lead to high fever, severe tremor, rapid heart rate, and in some cases seizures. If you’re experiencing any of these symptoms after starting medication, seek emergency medical care immediately by calling 911 or going to the nearest emergency room.
How long do SSRIs take to work?
According to Dr. Feusner, it can take six to 12 weeks for SSRIs to take effect on OCD symptoms. “There’s also a chance that the drugs might not work sufficiently,” he says. “At that point, a provider might prescribe another SSRI or something else entirely.”
Tricyclic antidepressants (TCAs)
Tricyclic antidepressants, or TCAs, work primarily by influencing the levels of norepinephrine and serotonin in your brain. TCAs block the reuptake (reabsorption) of these neurotransmitters. Over several weeks, this can boost communication in these cells, which can improve mood, reduce symptoms of depression and anxiety, and minimize the intensity and frequency of obsessions and compulsions in people with OCD.
The most commonly prescribed TCA for OCD is clomipramine (Anafranil). The antidepressant was created in 1964 to treat depression, but researchers later found that it was also effective for treating OCD symptoms, and it has FDA approval for treating OCD in those aged 10 and older. What makes clomipramine, in particular, different from other TCAs is its receptor profile, which emulates that of an SSRI.
“[Clomipramine] has a lot of the same properties as SSRIs, so it is mostly a serotonin reuptake inhibitor (SRI),” says Dr. Feusner. “But it also has effects on other neurotransmitter systems other than serotonin. For example, it also has norepinephrine reuptake inhibition, and it also affects some other neurotransmitter systems that might be beneficial for OCD as well.”
Dr. Feusner says that clomipramine can be used as a second-line medication for treating OCD symptoms if SSRIs aren’t effective. “If someone doesn’t respond to one SSRI, they might try a second or even a third SSRI,” he says. “If they’re still not effective, then they might try clomipramine.” Clomipramine is sometimes also added to an SSRI when the SSRI alone is not sufficiently effective.
Side effects
The most common side effects of clomipramine include:
- Weight gain
- Dry mouth
- Constipation
- Sexual side effects
- Low blood pressure
How long does clomipramine take to work?
Like SSRIs, it can take between six to 12 weeks for clomipramine to reduce obsessions and compulsions, although it may alleviate anxiety and insomnia symptoms almost immediately.
Atypical antipsychotics
Atypical antipsychotics, or second-generation antipsychotics, are a class of drugs that treat psychosis, mania, depression, and, when combined with an SSRI, OCD.
Atypical antipsychotics are prescribed off-label for OCD as augmentation medications. Dr. Feusner says clinicians may recommend atypical antipsychotics as an add-on or augmentation agent for OCD symptom reduction.
Atypical antipsychotics have effects on the dopamine and serotonin systems. They have different mechanisms of action that allow them to enhance or inhibit the activity of these neurotransmitters, which can contribute to mood stabilization and symptom reduction in several mental health conditions.
Atypical psychotics that are the most effective for OCD include:
- Aripiprazole (Abilify)
- Risperidone (Risperdal)
In addition, haloperidol (Haldol), in a class of medications called typical antipsychotics, also has some evidence for efficacy in augmenting SSRIs but is considered a second-line choice.
Side effects
Possible side effects of atypical antipsychotics can include:
- Nausea
- Vomiting
- Headache
- Weight gain
- Insomnia
- Drowsiness
- Restlessness
- Tremors
Other, more serious side effects such as a movement disorder called tardive dyskinesia, while relatively rare, can also occur from long-term use of atypical and typical antipsychotics.
OCD medications for children
Medication is also a viable option for treating children and adolescents with OCD. “In children and adolescents, the American Academy of Child and Adolescent Psychiatry recommends that the first line treatment for mild to moderate OCD is cognitive-behavioral therapy—typically with exposure and response prevention (ERP) techniques. For moderate to severe OCD, it is cognitive-behavioral therapy and medication,” says Dr. Feusner.
Medications approved by the FDA to treat children with OCD include:
- Fluoxetine (Prozac) for ages 7 and up
- Fluvoxamine (Luvox) for ages 8 and up
- Sertraline (Zoloft) for ages 6 and up
- Clomipramine (Anafranil) for ages 10 and up
Parents and caregivers should consult their child’s psychiatrist or other prescriber to determine whether medication should be added to the treatment plan.
What are the doses for OCD medications?
Typically, people with OCD receive specific doses of medications that may be generally higher (e.g., for SSRIs, clomipramine, and SNRIs) or lower (e.g., for atypical or typical antipsychotics) than what’s prescribed for other mental health conditions.
Below is a table of doses for OCD medications:
| Medication | Drug class | Level of medication | Dose (mg) |
| Fluoxetine (Prozac) | SSRI | First-line | 40-80 mg |
| Fluvoxamine (Luvox) | SSRI | First-line | 200-300 mg |
| Paroxetine (Paxil) | SSRI | First-line | 40-60mg |
| Sertraline (Zoloft) | SSRI | First-line | 100-200 mg |
| Escitalopram (Lexapro) | SSRI | First-line | 20* mg |
| Clomipramine (Anafranil) | TCA | Second-line or as augmentation | 100-250 mg |
| Aripiprazole (Abilify) | Atypical antipsychotic | Augmentation | 2-20 mg |
| Haloperidol (Haldol) | Typical antipsychotic | Augmentation | 2-10 mg |
| Risperidone (Risperdal) | Atypical antipsychotic | Augmentation | 0.5-3 mg |
*Clinical trials have demonstrated effectiveness with doses as high as 30 and 50 mg/day. However, >20 mg/day increases the risk of QT prolongation, and caution is advised when using doses greater than 10 mg/day in patients older than 65. Additionally, for doses above 20 mg/day, regular electrocardiogram monitoring is recommended.
Your prescriber should provide further details on the specific doses necessary to reduce your OCD symptoms.
Who shouldn’t take medications for OCD?
Not every OCD medication will be safe for everyone to take. There are contraindications among the different categories of OCD medications that you should be aware of. Contraindications can include other medications, symptoms, or medical conditions that are a reason for you not to receive a particular treatment because it may harm your health.
For example, some of the potential contraindications of SSRIs include:
- Certain medications that increase serotonin levels, such as MAOIs
- Pimozide
Certain herbs, such as St. John’s Wort, and supplements such as SAMe and 5-HTP should be used only with caution in combination with SSRIs
Before being prescribed medications for OCD, be sure to notify your healthcare provider of any medications you’re currently taking, any existing medical conditions, and your family medical history. Doing so can lower your risk of adverse side effects.
How to get a prescription for OCD medications
In the United States, licensed physicians, physician assistants, and nurse practitioners can legally prescribe any of the above-mentioned medications for OCD. However, not all of them have the necessary training to prescribe these medications to reduce OCD symptoms, which is why it’s so important to see an OCD specialist.
“Specialists will be comfortable prescribing these medications at the doses that are most effective, but prescribers who are not as familiar with OCD might only go to a certain, lower dose, and this could be a problem, as OCD doses are typically higher than typical antidepressant doses,” explains Dr. Feusner.
To find a licensed provider who can prescribe OCD medications, check out the IOCDF’s provider directory or work with one of the 650+ specialty-trained ERP therapists in the NOCD Therapy directory who regularly refer therapy members for medication management with trained providers.
Bottom line
OCD is a chronic mental health condition that can impact almost every aspect of your life if left unmanaged. If your intrusive thoughts and compulsions are causing significant distress, consider getting evidence-based treatment.
While many benefit from ERP alone, a combination of the therapy with medication may be a more suitable treatment plan. If you’re ready to start your treatment journey, connect with a therapist specializing in OCD who can identify your triggers, obsessions, and compulsions, start ERP therapy, and refer you to a prescriber if needed.
