Ever heard the phrase” first-line treatment”? It refers to the go-to treatment option that doctors recommend when someone is diagnosed with a particular medical condition. Obsessive Compulsive Disorder (OCD) has two.
One is called exposure and response prevention therapy, or ERP. It works by a specially-trained therapist gradually exposing people with OCD to their fears or triggers while refraining from engaging in their usual compulsive behaviors. Through this process, people desensitize to the emotions associated with the triggers, often learn that their fears are unfounded, and that they can tolerate their doubts. For most people, ERP successfully reduces their OCD symptoms over time—often in a matter of weeks.
The other first-line treatment is any one of a number of medications that have been demonstrated to reduce the severity of OCD symptoms. One of the most frequently used for this purpose is escitalopram, most commonly known by the brand name Lexapro.
This article aims to impart an understanding of what Lexapro is and when it might be used to treat OCD symptoms. We’ll also discuss Lexapro’s limitations and the possible side effects associated with the drug, so you can make informed decisions on the journey to regaining control of your life.
Understanding Obsessive-Compulsive Disorder (OCD)
Before delving into how Lexapro and other drugs can be a game-changer for many with OCD, let’s take a moment to get to grips with what this disorder is all about. Affecting at least 4 million people in the US alone (almost 8 million in their lifetime), OCD is characterized by a cycle of obsessions and compulsions that can significantly impact a person’s daily life.
When we talk about obsessions in the context of OCD, we’re talking about intrusive thoughts, images, or urges that cause anxiety and distress. Just about everybody has these random, intrusive thoughts, but for people with OCD, those thoughts aren’t easily dismissed—they’re “sticky.” This causes people with the disorder to engage urgently with these mental glitches, mistakenly assigning meaning to them and unwittingly turning them into obsessions. In almost all cases, these obsessions are ego-dystonic, meaning they directly oppose the sufferer’s values, intentions, and beliefs.
To reduce the distress they feel when obsessions strike, people with OCD engage in a range of behaviors called compulsions. Compulsions can be repetitive physical actions, repeated phrases, the avoidance of certain situations, the need for constant reassurance from friends or family, or excessive research to prove or refute the validity of their obsession. Whatever form their compulsions take, they’re all intended to alleviate the feelings of anxiety or dread their obsessions are causing them. However, the relief these compulsions offer is only temporary, and actually reinforces and perpetuates the vicious cycle of OCD.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) provides specific criteria for diagnosing OCD, including obsessions or compulsions that cause significant distress, take up more than an hour per day, and interfere with daily functioning. There is a wide spectrum of severity in people with OCD; in some cases, its symptoms can be debilitating, even putting people at a higher risk of developing other mental disorders as well as suicide.
Overview of Lexapro (escitalopram)
Lexapro belongs to a class of medications known as selective serotonin reuptake inhibitors (SSRIs) along with Celexa (citalopram), Prozac (fluoxetine), Zoloft (sertraline), Luvox (fluvoxamine), and Paxil (paroxetine). Though serotonin and norepinephrine reuptake inhibitors (SNRIs) and a tricyclic antidepressant (TCA) called clomipramine are sometimes used to treat OCD symptoms, SSRIs are more frequently prescribed for this purpose.
The immediate effect of SSRIs is to increase the amount of serotonin between nerve cells in certain parts of the brain. However, there is no conclusive evidence of a serotonin deficiency in people with OCD, so the benefits of SSRIs in OCD treatment aren’t thought to be a result of this immediate effect. Rather, they most likely work as a tool to alleviate OCD symptoms through gradual changes that occur over time in response to these increased serotonin levels. SSRIs are also used to treat depression, generalized anxiety disorder (GAD), and post-traumatic stress disorder (PTSD)—conditions that frequently co-occur with OCD—although the main mechanisms of action believed to alleviate symptoms of these disorders differ.
Lexapro’s use in the treatment of OCD
Numerous research studies have demonstrated the efficacy of Lexapro in reducing OCD symptoms. It can help alleviate obsessions, compulsions, and related anxiety, allowing people to regain control over their thoughts and behaviors. It’s estimated that anywhere between 40 and 60% of people with OCD may experience a positive response to SSRI treatment, including Lexapro. While Lexapro does not specifically have an FDA indication for treating OCD, research studies and clinical experience show that it is effective.
You may be wondering why people would undergo several, often uncomfortable, ERP sessions when taking an inexpensive, generic pill is often successful in getting OCD symptoms under control. Well, the first thing to take into consideration is the length of time it takes medications like Lexapro to work.
“When you take Lexapro for anxiety or depression, it tends to work for most people within two to four weeks,” says Jamie Feusner, MD, Professor of Psychiatry at the University of Toronto and Chief Medical Officer at NOCD. “With OCD, it usually takes anywhere from about six weeks to about 12 weeks to start working, and, in some cases, things continue to improve for many weeks or even months after that. Needless to say, this requires a lot of patience. There’s also a chance that Lexapro might not work sufficiently, or at all for an individual, but we really have to wait for at least 12 weeks to make that assessment. At that point, a provider might prescribe another type of SSRI or something else entirely.”
It’s worth noting that ERP usually results in a significant reduction of OCD symptoms within 12 to 20 weeks of beginning treatment for most people. Another thing differentiating Lexapro’s use in treating OCD as opposed to other mental disorders is the dose.
“Usually, higher doses of Lexapro are used for OCD compared to GAD or depression,” explains Dr. Feusner. “In fact, at higher doses, it really becomes a different drug because it works on an entirely different area of the brain.”
Exactly how much bigger are those doses? Feusner says that a daily 40mg dose of Lexapro is typical among OCD patients, whereas 20 mg is a typical dose for people with depression. He adds that doses of 50 or even 60 mg may be necessary to see an optimal reduction in symptoms in some OCD patients. Although outside the FDA-recommended range, there is a lot of clinical experience that doses this high can be safe, tolerated, and effective for some people.
Another thing people need to consider when taking Lexapro is the side effects it’s associated with—side effects that people may experience whether the drug reduces their OCD symptoms or not. Many of these are mild to moderate and tend to disappear within a few weeks. That said, other side effects can persist longer. Some of Lexapro’s more common side effects include:
- dry mouth
- insomnia
- reduced sex drive
- nausea
- dizziness
- fatigue
- diarrhea
- constipation
- decreased appetite
As is the case with all psychiatric medications, they should be carefully chosen for each individual and monitored by the prescriber, particularly in the first few weeks, to ensure that more serious side effects do not occur.
Dr. Feusner adds that just because a person with OCD is taking two or three times the dose of someone using Lexapro for depression or anxiety, the side effects aren’t typically two or three times more severe. Something else to consider is any pre-existing medical conditions. People with liver or kidney problems may require dose adjustments or careful monitoring.
The relationship between OCD medication and therapy
The biggest difference medications have with the other first-line OCD treatment is that drugs treat the symptoms of the condition while ERP can result in more long lasting benefits that continue beyond the episode of treatment. What that means is that stopping taking medication used to treat OCD symptoms will result in those symptoms showing up once again. If Lexapro’s side effects are non-noticeable or easily managed, this treatment may end up being a long-term option to keep OCD symptoms at bay, as it has been for many.
Often, however, medication like Lexapro is used as a means of making ERP more tolerable—or even possible—for some people, especially those with more severe and debilitating OCD symptoms.
These medications can help reduce anxiety and other distress associated with OCD, as well as the severity of obsessions and urges to do compulsions. This could provide an additive effect with ERP of reducing OCD symptoms. Secondly, some (but not all) with more severe symptoms might find it helpful to have at least a slight reduction in severity of obsessions, urges to do compulsions, and distress, in order to start difficult exposure exercises and resist certain compulsions. Importantly, when someone is taking an SSRI for OCD but there is not a sufficient response, research demonstrates that adding ERP is very effective in further reducing OCD symptoms.
While not always necessary for a full recovery, medications like Lexapro can be an effective treatment option for individuals living with OCD. They’ve been shown to reduce obsessions, compulsions, and related anxiety, allowing people to regain control over their lives. For some, the most effective treatment plans could involve a combination of ERP and medication to reduce symptoms. NOCD therapists are specially trained in delivering ERP and regularly refer members to qualified prescribers who can identify medication that may reduce their OCD symptoms and/or the symptoms of other commonly co-occurring disorders such as depressive disorders and anxiety disorders.