Initial pharmacotherapy for obsessive compulsive disorder in adults and young people
Follow the approach to managing obsessive compulsive disorder (OCD) in adults and young people. Psychosocial interventions are first-line treatment for OCD.
If an antidepressant is indicated for OCD in an adult or young person, initial choice should be informed by:
- the drug’s adverse effect profile, potential for drug interactions and safety in overdose
- the patient’s comorbidities
- the patient’s age:
- older people are more likely to have multiple comorbidities or be more sensitive to antidepressant adverse effects (eg hyponatraemia with selective serotonin reuptake inhibitors [SSRIs])
- young people are more susceptible to developing activation and suicidal thoughts when starting treatment with an antidepressant; this effect has been most often observed with SSRIs. Despite this, SSRIs remain a first-line option when antidepressant therapy is indicated; paroxetine, however, should be avoided because it has been associated with an increased risk of suicidal thoughts and behaviours, and other serious adverse events
- the patient’s response to previous treatments and family history of response to treatments
- tolerability when stopping treatment
- whether the patient is planning pregnancy, or is pregnant or breastfeeding (also see Considerations in managing anxiety disorders during the perinatal period).
SSRIs (citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline) are first-line drugs for OCD. There is limited evidence supporting the use of serotonin noradrenaline reuptake inhibitors (SNRIs) (desvenlafaxine, duloxetine, venlafaxine), but they are an option if the patient has a poor response to, or does not tolerate, SSRIs.
Often the doses of SSRIs and SNRIs required to effectively treat OCD are higher than the doses for other indications. If using a dose in the upper range of those recommended below, the patient must be monitored for adverse effects, including with an electrocardiogram (ECG). Because the risk of QT-interval prolongation appears to be higher with citalopram compared to other SSRIs, the maximum recommended dose of citalopram is comparatively lower than the maximum doses of other SSRIs.
Many patients relapse when antidepressants are withdrawn, so require long-term pharmacotherapy.
If an SSRI or SNRI is considered appropriate for obsessive compulsive disorder, individualise the choice of drug (see above). Lower doses may be needed in older people; consult a source of drug information. Use:
1 citalopram 20 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 10 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 40 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing obsessive compulsive disorder (adult) citalopram citalopram citalopram
OR
1 escitalopram 10 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 5 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 40 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing obsessive compulsive disorder (adult) escitalopram escitalopram escitalopram
OR
1 fluoxetine 20 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 10 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 80 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing obsessive compulsive disorder (adult) fluoxetine fluoxetine fluoxetine
OR
1 fluvoxamine 50 mg orally, at night. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 25 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 300 mg is reached. Doses above 150 mg daily may be given in 2 divided doses for better tolerability. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing obsessive compulsive disorder (adult) fluvoxamine fluvoxamine fluvoxamine
OR
1 paroxetine 20 mg orally, in the morning1. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 10 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 60 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing obsessive compulsive disorder paroxetine paroxetine paroxetine
OR
1 sertraline 50 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 25 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 300 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing obsessive compulsive disorder (adult) sertraline sertraline sertraline
OR
2 desvenlafaxine 50 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 50 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 200 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing obsessive compulsive disorder desvenlafaxine desvenlafaxine desvenlafaxine
OR
2 duloxetine 60 mg orally, daily. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 30 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 180 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing obsessive compulsive disorder duloxetine duloxetine duloxetine
OR
2 venlafaxine 75 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 37.5 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 300 mg is reached. If there is an acceptable response, continue at the same dose for 6 to 12 months, then consider deprescribing. obsessive compulsive disorder venlafaxine venlafaxine venlafaxine