Treatment of obsessive-compulsive disorder

Summary of treatment options
Treatment of OCD involves two major components - psychological therapy and medication. Alone, each form of treatment is effective for 70 per cent of people who have OCD. Used in combination, they will help 80-90 per cent of people with OCD. Behavioural therapy is somewhat better for compulsions and medication for obsessions, but either can be useful.

Psychosocial treatments

Psychological therapy is the main component of this group of therapies for OCD. Behavioural therapy is the form of psychological therapy which has been found helpful in the treatment of OCD. Any therapy should be provided to people and their families and whanau in a manner which is respectful of them and with which they feel comfortable and free to ask questions. It should be consistent with and incorporate their cultural beliefs and practices.

Medication

The most important medications for OCD are some of the antidepressant group. Those that increase the activity of the brain chemical messenger serotonin are most effective. Even if the person is not depressed these are useful in OCD.

Tranquillisers may be used briefly to reduce high anxiety early in the course of treatment. They are rarely used for any length of time because they have no long- term effect on the symptoms of OCD and because they often cause addiction problems.

If you are prescribed medication you are entitled to know the names of the medicines; what symptoms they are supposed to treat; how long it will be before they take effect; how long you will have to take them for and what their side effects (short and long-term) are. If you are pregnant or breast-feeding no medication is entirely safe. Before making any decisions about taking medication in pregnancy you should talk with your doctor about the potential benefits and problems associated with each particular type of medication.

Complementary therapies

Complementary therapies which enhance people's lives may be used in addition to therapy and prescription medicines.

Psychosocial treatments

Behavioural therapy
OCD is a terrible trap. Although people with the disorder realise the senselessness of their repetitive compulsive behaviours, they are powerless to resist performing them as this is their only relief from the anxiety caused by their recurring obsessions. People with OCD come to believe that they, and other people, are kept safe because of the repetition of these behaviours. This belief keeps OCD going.

Behavioural therapy works by encouraging the person with OCD to challenge this belief. If you can allow yourself to repeatedly experience your obsessions without following them by compulsive behaviours, you soon come to learn that the disaster you fear so much is most unlikely to occur. As a result, the protective power of the compulsions dwindles, and they occur less often. Obsessions become less frequent and the anxiety they cause starts to fade.

The behavioural therapeutic technique used to help people with OCD is called exposure and response prevention. Because the idea of stopping the compulsions is alarming and distressing to people with OCD, the technique is carried out in a slow, systematic, step-by-step way. Therapists, family or whanau members and friends often work together to give the person with OCD all the support and encouragement they need in order to start saying 'no' to their compulsions.

Over some weeks, with hard work and frequent repetitions of the therapy tasks, significant progress is often seen.

Behaviour therapy is very effective for around 70 to 80 per cent of people with OCD. They will have very good results which may last for some years. Unfortunately, most general practitioners do not have the time or training to do behavioural therapy. This is most often done on a one-to-one basis with the help of a psychologist or other trained health professional.

Most specialist community mental health services attached to hospitals deal only with the most severe cases. Those people who meet their criteria for acceptance will receive treatment free of charge. At a number of community service agencies, charges are based on your ability to pay. Private therapists' fees may range from around $60 to $200 per session but many also have a sliding scale of fees.

Medication

Antidepressants
Antidepressants are also effective for treating OCD and work even if you are not depressed. As mentioned above, they are often used along with psychological therapy. They have no immediate effect and all need to be taken regularly, once or twice a day. They take up to two weeks to work and there are a number of side effects. You may need to try different medications to see which one suits you. One drug would be tried for eight to 12 weeks to see if it was helpful.

For people with OCD, antidepressants are often used at a slightly higher dose than for depression. Almost all are in tablet or capsule form. They are not addictive, but there may be a small rebound effect of anxiety and insomnia if you suddenly stop taking them. The side effects (see below) vary from person to person.
 
Antidepressant medications do not completely cure OCD. They are likely to remove a number of symptoms, which is important, as this change almost always causes a significant improvement in the quality of your life. However, you may still be at some risk of OCD recurring if you stop taking them. It is hard to know exactly how long to stay on medication. They are usually given for six months or more. If you have had OCD more than once and it has been very damaging to your life, you may be advised to stay on them longer, perhaps for many years.

Antidepressants effective in OCD increase the activity of the brain chemical, serotonin. There are two groups of antidepressants used in its treatment - the older, tricyclic drugs (TCAs) and the newer Selective Serotonin Re-uptake Inhibitors (SSRIs).

Selective serotonin re-uptake inhibitors (SSRIs)
Over the past decade the Selective Serotonin Re-uptake Inhibitors (SSRI) antidepressants have become available. SSRIs have their effect specifically on serotonin. This type of antidepressant is usually first choice for treatment of OCD because they are effective and usually have fewer side effects than the tricyclics.

Compared to tricyclics, SSRIs rarely cause drowsiness, although nausea, headaches and sexual problems may be more common. With SSRIs there are fewer problems with other medications, alcohol, and other illnesses, except if you have severe liver or heart disease. They can affect some medicines, especially those taken for epilepsy.

Unfortunately it is hard to predict who will respond to which medication and who will have side effects. For people who do not have much benefit from the antidepressants alone, other medications may be added. Combinations of medicines should usually only be prescribed by a specialist.

Tricyclic antidepressants (tricyclics/TCAs)
The only medication within the tricyclic group of antidepressants which is a specifically effective treatment for OCD is clomipramine. In the early stages of treatment this may cause dry mouth, constipation, tremor, and blurred vision. These problems often go away after you have taken the medication for two to three weeks. Less common side effects are nausea, dizziness, low blood pressure, weight gain and sexual problems.

Clomipramine is often sedating which can be useful to help you sleep at night but may also cause drowsiness during the day. Alcohol should be avoided as its effects are magnified with tricyclics. While this may seem quite an alarming list of side effects, many people have only minor problems and tolerate this medication well. It is usual to start at a lower dose and build up over several weeks to see how much you need, and to check for side effects.

Tricyclics can affect the heart and an ECG (heart recording) is often done if you are over 50. Precaution is also needed if you have epilepsy, glaucoma, liver disease or problems with urination. They are very dangerous in overdose.

SSRI-like medications
The newest generations of antidepressants target serotonin and noradrenaline neurotransmitter systems. Overseas studies suggest these medications may also be effective for treating OCD, however, no conclusive results are yet available. Those available may not be subsidised and, depending on dose, may cost up to $400 per month.

Benzodiazepines (tranquillisers)
The common tranquillisers are called benzodiazepines (the Valium type of medications). They are used to treat anxiety symptoms. They have no effect on the presence of obsessions or the performance of compulsions. They increase the activity of a chemical in the brain called GABA (gamma amino butyric acid) which regulates alertness. This lessens anxiety, induces sleepiness, and makes the muscles relax.

Benzodiazepines work almost immediately and have few side effects. The main side effect of drowsiness or fatigue may be useful during the acute phase. This usually wears off.

There are two ways of taking benzodiazepines. One is for very short periods to relieve great distress or allow you to cope with some important event you cannot avoid. The other, less common way, is to take them regularly for weeks or months to reduce anxiety. Because they are known to be addictive they are usually only prescribed for short periods (up to two weeks at a time).

Stopping them needs to be done gradually. Sudden stopping may produce withdrawal symptoms such as anxiety, insomnia, headaches, nausea and dizziness, and occasionally, may induce epileptic seizures.

People with epilepsy must be careful as withdrawal can also make seizures more likely. If you have trouble with addictions they are best avoided.

Benzodiazepines are not advised in pregnancy especially near birth, as they can affect the baby and some of them get into breast milk.

Benzodiazepines are safe with almost all other medicines. They magnify the effects of alcohol, so this should be avoided.

Common side effects of benzodiazepines

• Drowsiness is particularly dangerous for people who operate machinery or while driving vehicles.
• Muscle relaxation can be a risk for older people whose muscles may be weak and thereby increase their risk of falling.
• Confusion, particularly with older people .
• Breathing difficulties. Benzodiazepines can reduce breathing a little. Those people with severe breathing problems need to be careful.
• Dependency and withdrawal problems - see discussion above.

Medicine interactions

Most psychiatric medicines tend to react with each other when taken in combination. Your doctor will, where possible, limit the number of medications prescribed.

The effects of alcohol and many illegal drugs will also be heightened, so they should be avoided. It is important the doctor knows all the medications (including any herbal medicines such as St John's Wort) you are taking, as some taken together can be dangerous. You should not mix different types of antidepressants unless instructed by your doctor, as this could be very dangerous.

Complementary therapies

The term complementary therapy is generally used to indicate therapies and treatments which differ from conventional Western medicine and which may be used to complement, support or sometimes replace it.  There is an ever-growing awareness that it is vital to treat the whole person and assist them to find ways to address the causes of mental health problems rather than merely alleviating the symptoms. This is often referred to as an holistic approach. 

Complementary therapies often support an holistic approach and are seen as a way to address physical, nutritional, environmental, emotional, social, spiritual and lifestyle needs.
 
Many cultures have their own treatment and care practices which many people find helpful and which can often provide additional benefits to health and wellbeing.  Rongoa Maori is the indigenous health and healing practice of New Zealand. Tohunga Puna Ora is a traditional healing practitioner. Traditional healing for many Pacific Islands' people involves massage, herbal remedies and spiritual healers.

In general, meditation, hypnotherapy, yoga, exercise, relaxation, massage, mirimiri and aromatherapy have all been shown to have some effect in alleviating mental distress.

Complementary therapies can include using a number of herbal and other medicinal preparations to treat particular conditions. It is recommended that care is taken as prescription medicines, herbal and medicinal preparations can interact with each other. 

When considering taking any supplement, herbal or medicinal preparation it is advisable to consult a doctor to make sure it is safe and will not harm your health.

Women who may be pregnant or breastfeeding are advised to take extra care and to consult a doctor about any supplements, herbal or medicinal preparations they are considering using, to make sure they are safe and will not harm their own or their baby's health.

See also: OCD; OCD - living with

Original material provided by the Mental Health Foundation of New Zealand, 2002. Edited by everybody, June 2005.