Obsessive Compulsive Disorder (OCD) part 11

None!  These are safe in overdose, they don't require any special monitoring. No EKGs, no blood pressure, no blood levels.  In very rare cases, they can produce unusual movements, but these go away once the drug is stopped.  However, this may take a few months.  No one knows exactly how frequent this is.  Probably around one in 10,000.

Since these drugs have similar side effects, there is no certain reason to start with one rather than another.  These drugs need to be taken with food.  The following examples show how they are used.

Slowness can be very hard to treat with behavior treatment, which is why we started Randy on medications right away.  We started Randy on Sertraline (Zoloft) because it worked well in his mother for depression.  Randy started with 25 mg and worked up to 150 mg a day, which is about a 3 mg/kg.  He went up by 25 mg every few days.  He always took it on a full stomach except once.  That episode of stomach ache convinced him he should never take it on an empty stomach again.  Well, two months went by and the dose was increased to a maximum of 300 mg a day and he kept tolerating it well, but it did nothing.  So, we stopped that and switched to Paxil (paroxetine).  We started with 10 mg a day and slowly increased to 50 mg a day.  Well, it worked real well.  Randy was able to do more in a day than he had done in a week before.  Unfortunately, he didn't sleep.  He started getting crabby as his sleep went down to four hours a night.  So, since he was doing well , we adding a medication called Trazadone, which is used for sleep disorders in children.  It worked and he has done well.

So after trying some cognitive behavioral treatments, Erika gave up.  She was getting quite hopeless, so we started her on Luvox, partly because the family didn't have a lot of money and I had a lot of samples of this.  Well, she only took it once.  Even though she took it on a full stomach at only 25 mg size, She had diarrhea all night and nausea the whole next day.  She missed two days of school.  It was another month before she was ready to try another of "Dr. Chandler's poisons".  This time we tried Prozac, as it is the cheapest of the group.  We got her up to 40 mg a day and she had no side effects and enough improvement in her OCD and depression to get by through the school year.  She is thinking about doing the behavior modification treatment again, next year!

We first tried behavior treatment alone on Justin, because it was easy to engage him in trying things like purposefully making messy letters for a few minutes and then not erasing.  Unfortunately, One day after he and his resource teacher were working on their OCD assignments and his mom had a car accident in the snow.  She wasn't hurt.  Justin started obsessing that this was his fault and it came out that he thought bad things would happen if he didn't do things just right, and now this accident had "proved it".  He would not consider behavior treatment. So we started him on Zoloft.  We slowly increased the dose from 50 to 250 mg a day over a month.  He had no side effects except an occasional headache.  There was also no benefit.  After two months more, he was just as ill.  So we tried Luvox.  It made no difference either after a two month trial.  Justin kept saying, "I told you these pills aren't going to help".  So we started him on Anafranil instead.  He had severe blurred vision, constipation, and trouble urinating on only 20 mg a day.  So, we decided to try Paxil.  With in three months he was 100% better. But then the question was, was it the Paxil or did the OCD go away on its own?  He will find out in another 6 months when we discontinue the drug.

Mary was placed on Prozac to start with and the dose was increased by 10 mg every week until she was taking 40 mg a day.  She gradually improved.  She stopped picking up junk, and with only a little bit of protest, would throw things away.  One day she came up to her mom and said, "how do you think I am doing?  "fine", her mother answered.  Well, that just proved to Mary she didn't need to take any medication.  She had been spitting out her medication for three days.  I tired to explain to Mary that this did not mean the drug wasn't working, as it takes longer than that to see a change.  She refused to believe me.  She stopped taking the medication and did fine for four months, and then started to relapse back into her old ways.  She still would not take her medicine.  All the progress she had made was lost.  Almost a year later she finally decided to take it, but still said she didn't need it for OCD, which she still denied she had.  She admitted she was depressed, and said that was the only reason she would take it.  She did, and improved.  No one ever says that her medicine is for OCD, too!

Judy started doing behavior treatment and taking medications.  She started with Prozac.  She showed minimal improvement with the behavior treatment.  Over a year, she had a 12 week course of Prozac, Luvox, and a combination of Prozac and Anafranil.  She tolerated all of these, but never improved.  She was getting pretty hopeless about anything ever working.  Her doctor, Judy, and her family decided they would try one more medication treatment and at the same time set up a second opinion.  Judy started on Anafranil as the only drug.  She had bad constipation which required laxatives.  She had blurred vision and she sweated very easily if she did anything.  For most people, these side effects would have been too much to bear.  The EKG, heart rate, and blood pressure were all okay.  She got up to 250 mg a day and was about 50% better.  Again, that isn't great, but it was the best she had ever felt in her life.  She is still going to get the second opinion.

For balance, I should give an example of someone who never improved on medications, even after consulting other physicians and trying everything.  I actually have not seen that.  It occurs, but it is very rare.

Medications can be very effective in OCD.  They also can cause problems.  As long as the patient, family and doctor understand what they are doing, they are quite safe.

When children have OCD it is very unfortunate.  However, I rarely see those children.  Usually by the time I end up seeing someone they have at least one or two other co-morbid conditions.  It is not uncommon for me to see a child with ADHD, depression, OCD, and social phobia.  Here is how I approach the treatment of those cases:

Sometimes OCD is present, but since the person is suicidal from depression, it is hardly the main focus.  Sometimes it isn't any one thing but everything together.  Then we go to the next step.

Some things in pediatric psychiatry are easy to treat.  Others are not.  Sometimes one treatment will work for a couple of problems (the same drugs that are used for OCD are also used for depression and social phobia).  I am always looking for the simplest treatments that will affect the most symptoms.

Usually I find that one type of treatment or another will be just ridiculous given the family and the child, even though it is clinically indicated.  If you are a 100 km away from the nearest person who can help your child do behavior treatment and you don't have a car, that type of treatment is probably out.  If one parent is dead set against medications, that is obviously out.

Every study of the long term out come of psychiatric disorders has found that the more diagnoses that a person has, the worse the outcome.  That is why if people have OCD only, I will quite willingly try to just do behavior treatment for a while.  However, if they have other diagnoses, too, then I highly recommend doing everything, including medications.  This is similar to the treatment of cancer.  The best results are with surgery, chemotherapy, and radiation (for example), not just one type of treatment.

OCD can be a very disabling illness.  It is often accompanied by other psychiatric disorders, too.  The good news is it is usually quite treatable, but not always easily treated.  The first step is to understand a little about what OCD is and how it is treated.  The next step is to talk to others who have had this or still do for information and support.  The final step is to do something about it!