When it comes to obsessive-compulsive disorder (OCD), medication is often a critical part of the treatment plan—but not because it “cures” the condition. Rather, medications play a supporting role: they make it easier for patients to engage in the kind of therapy that does the heavy lifting. 

Why Medications Matter

OCD is a chronic condition marked by intrusive thoughts (obsessions) and repetitive behaviors (compulsions) aimed at reducing anxiety. Many individuals struggle to fully engage in therapy due to the severity of their symptoms. This is where medications come in:

• Facilitate therapy: By reducing symptom severity, medications can make ERP more tolerable and effective.
• Modulate Anxiety: SSRIs and related medications can help lessen the intensity of anxiety and distress.
• Improve Daily Functioning: Even partial symptom relief can significantly improve quality of life.  For some people just turning down the volume or reducing intensity of their upsetting thoughts can be enough to help improve their overall function.

That said, medications do not:

• Cure OCD
• Eliminate the need for therapy
• Provide lasting freedom from the effects of OCD
• Enhance insight into the condition
• Often don’t provide immediate relief
  • *There are some medications such as benzodiazepines, which are sedative medications that have an immediate calming effect, but these are not generally recommended in OCD treatment as they are addictive or habit-forming, would not be a sustainable effective longterm treatment, and can interfere with the learning that is part of recovery from OCD 

How Choices Are Made

There are no medications specifically designed for OCD. However, several are FDA-approved, and others are used off-label based on clinical experience and research meta-analyses. Since there are no head-to-head trials comparing effectiveness, decisions are guided by:

• Side effect profiles
• Previous treatment responses
• Medication interactions
• Co-occurring disorders

Where to Seek Help

Should Patients with OCD See a Psychiatrist for Medication Management?

In general, my answer is yes. Seeing a psychiatrist with expertise in OCD can make a meaningful difference in treatment outcomes. OCD often requires medication at higher doses and for longer durations than other conditions, particularly when using SSRIs. A psychiatrist trained in OCD will be more comfortable adjusting dosages appropriately and monitoring for therapeutic effect and side effects.

Being Sensitive to Access Barriers

However, we must recognize the reality that not all patients have access to a psychiatrist—let alone one trained in OCD. Many people live in underserved areas, face insurance limitations, or cannot afford out-of-pocket psychiatric care. In these cases, the only accessible option may be a primary care provider, who may not be trained to recognize the full picture of OCD or know how to appropriately manage its pharmacotherapy.

What Patients Can Do

It’s often hard to access mental health care or specialist treatment. The healthcare system often presents significant barriers, but there are still steps individuals can take. If a patient is being treated by a primary care physician, they can inquire whether their current medication dose falls within the effective range for OCD. They may also ask if the provider would consider consulting with a psychiatrist—even through a virtual platform—to help guide treatment decisions. While self-advocacy can be challenging, it has the potential to improve the quality of care received.

First-Line Options

Most commonly, psychiatrists start with Selective Serotonin Reuptake Inhibitors (SSRIs) such as fluoxetine (Prozac), sertraline (Zoloft), or fluvoxamine (Luvox), which are first line treatments in many of the evidence-based protocols available. While not as well studied, another reasonable starting point is escitalopram (Lexapro). Clomipramine (Anafranil), a tricyclic antidepressant, is also highly effective but often reserved due to its side effect burden. Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) like venlafaxine (Effexor) may be considered in some cases.

If one SSRI doesn’t work, another is usually tried before moving on to other strategies.

Augmentation Strategies (Second-Line Options)

When first-line treatments provide only partial relief, clinicians may consider second-line strategies, such as augmentation or adding in with additional medications. These options are typically used when multiple trials of SSRIs or clomipramine have not helped enough with symptom improvement. Augmentation aims to enhance the therapeutic effect without discontinuing the primary medication. Common approaches include:

• Second-generation antipsychotics (e.g., aripiprazole (Abilify), risperidone (Risperdal)
• Lamotrigine (Lamictal), memantine (Namenda), or buspirone (Buspar)
• Other options include mirtazapine (Remeron), topiramate (Topamax), and N-acetylcysteine

What to Expect During Treatment

• Higher Doses Required: If a medication isn’t helping it may not that the medication is ineffective, it may be that the dose is inadequate.  OCD typically requires higher doses of SSRIs than depression or anxiety. This aspect of prescribing is not always covered in standard medication guidelines or drug labeling, largely because the FDA has not issued dosing guidance for many medications commonly used off-label in OCD treatment. As a result, many prescribers rely on clinical experience or consensus guidelines like the American Psychiatric Association’s practice guidelines, which outlines evidence-based examples of these higher dosing strategies. Also, the Canadian Clinical Practice Guidelines for the Management of Anxiety, Posttraumatic Stress, and Obsessive Compulsive Disorders is more recently published and provides excellent information. For instance, fluoxetine may be titrated up to 80 mg/day, and sertraline to 200 mg/day or higher, which are doses generally above those used for depression.
• Delayed Onset: Effects may take 8–12 weeks or even longer to become noticeable.
• Long-Term Commitment: Treatment often lasts a minimum of 1–2 years before tapering off is considered, and some individuals remain on medication long-term.

Addressing Medication Concerns

Many individuals have understandable hesitations when it comes to psychiatric medications. These concerns are not only common, they are valid and often grounded in personal experience, cultural beliefs, or the nature of OCD itself. For example, health- or contamination-related OCD themes can directly influence attitudes toward medication use. 

Some frequent concerns include:

• Worries about short- and long-term side effects
• A desire for “natural” or non-medication-based treatments
• Cultural or personal stigma around psychiatric medication
• Fears that needing medication signifies failure or inadequacy
• Preference for psychotherapy alone

By creating space to explore these thoughts collaboratively, therapists and prescribers can help individuals make informed decisions that align with both their values and treatment goals. Building trust and offering clear, compassionate education can significantly enhance comfort with the idea of incorporating medication into care.

What Not to Use

While sedatives like benzodiazepines might seem helpful for anxiety, they are not recommended for OCD. These medications can:

• Undermine the learning that occurs during therapy
• Promote avoidance or safety behaviors
• Lack evidence for long-term efficacy in OCD

Final Thoughts

Medications are not a magic bullet for OCD, but they are a powerful tool when used wisely and in conjunction with therapy. For patients and therapists alike, understanding the strengths and limitations of pharmacologic treatment can help demystify the process and foster more effective, compassionate care.

Medications do not need to be seen as a last resort, but as a component of evidence-based OCD treatment.

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