On another page, we noted that it is SSRIs, not clomipramine, that are the first-line treatment for OCD. See HERE. How should we choose which SSRI to start with? Here are some facts to consider:
1. There is no evidence that one of the SSRIs is more effective than the other. For example, there is no reason to believe that fluvoxamine is better for OCD than the other SSRIs. That is a myth that is commonly held.
2. Four of the SSRIs are approved by the FDA for OCD (fluoxetine, fluvoxamine, paroxetine, and sertraline), while two of them are not (citalopram, escitalopram).
3. A disadvantage of citalopram and escitalopram is that their use in higher than the FDA-approved dose range is problematic due to risk of QTc prolongation. This does not mean that they cannot be used, but while choosing the SSRI, we should keep in mind that persons with OCD frequently require high doses. The warning not to use higher than FDA-approve doses also applies to fluoxetine though it has a wider FDA-approved dose range (up to 80 mg/day).
4. Based on these factors, adverse effect profiles, and because there is a randomized, controlled clinical trial supporting use of sertraline at higher than FDA-approved doses, I usually choose sertraline as the first medication to prescribe for OCD, unless there is a special reason to choose differently.
5. We should make sure the trial of the SSRI was adequate, i.e, full dose and at least 8 to 12 weeks. We should remember that compared to their use in depression, SSRIs require longer to show benefit in OCD and higher doses may be needed.
6. If there is minimal or only partial benefit with the full dose of that SSRI, we should consider using a dose of the SSRI higher than the FDA-recommended dose range. For a discussion of the potential use of higher than usual doses of SSRIs, HERE.
American Psychiatric Association. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Arlington, VA: American Psychiatric Association, 2007. Available online at http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/ocd.pdf. Guideline Watch (2013) available at http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/ocd-watch.pdf
Erzegovesi S, Cavallini MC, Cavedini P, Diaferia G, Locatelli M, Bellodi L. Clinical predictors of drug response in obsessive-compulsive disorder. J Clin Psychopharmacol. 2001 Oct;21(5):488-92. PubMed PMID: 11593074.
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