Selective Serotonin Reuptake Inhibitors (SSRI)

SSRIs are typically used to treat depression and other mental illnesses, such as anxiety and OCD. They are usually the first type of medication your doctor will prescribe. They come in tablet form which you take every day. The dosage varies depending on what’s agreed by you and your doctor. Typically you will be started off on a smaller dose, which will then be increased if you’re not getting the results you need. In general, dosages of SSRIs are higher when treating OCD than when treating depression.

How do SSRIs work?

To understand how SSRIs work, first we need to look at serotonin itself. Different areas of the brain communicate by using neurotransmitters. Neurotransmitters are like little messengers made of chemicals which transfer signals between different parts of your brain. Serotonin is one of these neurotransmitters. This process of sending messages and maintaining good communication helps your brain to function, which in turn keeps your body and mind working in harmony.

When a part of the brain has a message to send, it sends out some of the appropriate neurotransmitter. Once the message is sent, that part of the brain needs to retrieve the neurotransmitter it sent out and reabsorb it. This is called ‘reuptake’ of the neurotransmitter.

Serotonin is used to help the parts of the brain which regulate your emotions and mental wellbeing communicate. When you struggle with mental illness, like OCD, often the balance of serotonin and how it functions can be disturbed. While this imbalance isn’t the sole cause of mental illness, it can contribute to mental health issues.

SSRIs block (or ‘inhibit’) the reuptake of serotonin, making more serotonin available so that that balance can be regained. This can enable the brain to regulate emotions more effectively.

Another positive to taking SSRIs is that not only do they treat OCD symptoms, they also help with depression (which often accompanies OCD).

What types of SSRIs are available?

There are a few types of SSRI you may be prescribed. You may hear them referred to under different names, which are included in brackets (this isn’t necessarily all of the names they will come under, only the most common). This can seem confusing, but the names in brackets are still the same medication.

• Citalopram (Cipramil, Celexa)
• Sertraline (Lustral, Zoloft)
• Fluoxetine (Prozac, Oxactin)
• Escitalopram (Cipralex)
• Dapoxetine (Priligy)
• Vortioxetine (Brintellix)
• Paroxetine (Seroxat, Paxil, Pexeva)
• Fluvoxamine (Faverin)

What are the side effects of SSRIs?

While SSRIs are FDA approved to treat OCD and are generally safe to take, there is the potential for side effects. Usually side effects are at their most severe within the first 2 weeks of taking the medication and tend to ease in the period after that.

Each individual medication may have specific side effects. Not everybody will experience all of the possible side effects. Some people may experience very few, if any, side effects at all. We’re all individuals, and even when experiencing the same side effect, it may impact us differently. Your doctor should arrange to see you regularly to monitor your side effects and guide you through any problems you’re having.

Some of the side effects can sound scary, but remember that not everyone will experience all of them. As well as the risk of side effects, there’s also the likelihood that when you find the right medication for you, it can really help to reduce your symptoms and bring you some relief. The International OCD Foundation states that people who find medication effective, “usually see their OCD symptoms reduced by 40-60%.” It’s important to make an informed decision in your own best interests (with the guidance of your doctor of course).

Some of the more common side effects experienced with SSRIs are included below. This is by no means an exhaustive list (a complete list can be found in the information leaflet you receive with a medication or sought online for each specific SSRI).

• Nausea
• Vomiting
• Feeling agitated, shaking or irritable
• Feeling dizzy
• Headaches
• Problems sleeping (insomnia and strange dreams when sleeping)
• Problems going to the toilet (either diarrhea or constipation)
• Dry mouth
• Excess sweating
• Problems concentrating
• Blurred vision
• Lowered sex drive (in women it can be difficult to achieve an orgasm and in men it can lead to erectile dysfunction)
• Sometimes SSRIs can increase mental illness symptoms at first, including increasing the risk of self harm and suicidal thoughts and actions.

Tricyclic Antidepressants (TCA)

TCAs are usually only prescribed if SSRIs haven’t worked or aren’t suitable for the individual. This is because they are an older antidepressant and tend to have more side effects than SSRIs. As with SSRIs, TCAs are taken in tablet form every day.

How do TCAs work?

TCAs work in a similar way to SSRIs: they block the reuptake of serotonin, and another neurotransmitter called norepinephrine. Both of these neurotransmitters play an important role in regulating our emotions and stress levels, and ultimately our mental wellbeing. Giving the brain a better balance of these chemicals can help to ease symptoms of OCD.

What types of TCAs are available?

The TCA recommended for OCD is Clomipramine (Anafranil).

What are the side effects of clomipramine?

There are a wide range of side effects which can be experienced with clomipramine, some of which are similar to that of SSRIs. Side effects are more commonly experienced with TCAs than SSRIs. Some of the possible side effects are listed below.

• Dry mouth
• Blurred vision
• Dizziness, lightheadedness and feeling faint (especially when getting up from sitting or lying down)
• Fatigue and drowsiness
• Nausea and sickness
• Problems going to the toilet (diarrhea and constipation)
• Headaches
• Sweating and hot flashes
• Changes within tests results (for example changes to blood test results and heart rhythm)
• Confusion and inability to focus
• Skin rashes and irritations
• Weight changes
• Changes in sexual function

Antipsychotics

Antipsychotics are typically used to treat mental illnesses with psychosis based symptoms, such as schizophrenia and bipolar disorder. However some antipsychotics may be used to treat other mental illnesses, such as OCD. Like antidepressants, they work with the neurotransmitters in the brain to increase emotional regulation and decrease symptoms of mental illness.

Antipsychotics also affect a neurotransmitter called dopamine. In many of the conditions antipsychotics are prescribed for, dompanie is overactive. Antipsychotics block some of the dompanie receptors in the brain to try to correct this imbalance.

Antipsychotics are not prescribed on their own to treat OCD, but may be prescribed alongside antidepressants. They are used to help the antidepressants work more effectively. You might hear this referred to as ‘augmentation’ or even ‘augmentation therapy’.

This article from Owen Kelly, PhD, a specialist in anxiety disorders, explains that, “Usually, augmentation therapy is implemented when clomipramine or SSRIs fail to improve OCD symptoms after at least three months.”

Augmentation therapy can have positive outcomes for patients. This article from Harvard Medical School explains that studies have shown, “40% to 55% of patients with OCD, after failing to respond to a first treatment, do improve when an antipsychotic is added to an SSRI”.

What types of antipsychotics are available?

You may be prescribed the following antipsychotics:

• Risperdal (risperidone)
• Haloperidol (haldol)
• Zyprexa (olanzapine)
• Seroquel (quetiapine)
• Aripiprazole (abilify)

What are the side effects of antipsychotics?

Depending on the type of antipsychotic you take and the dose prescribed, side effects can vary greatly. Just like with antidepressants, side effects can be different for every individual.

Some of the possible side effects you could experience include:

• Weight gain
• Dry mouth
• Blurred vision
• Constipation
• Hormonal changes (this can result in sexual problems)
• Drowsiness, fatigue and ‘slow’ reactions
• Akathisia (this means you feel restless and may find it hard to keep still)
• Tardive dyskinesia (this causes movements you may not be able to control, usually in the face and mouth area)
• Increased risk of other health conditions (like diabetes and some heart conditions)

Benzodiazepines

Benzodiazepines are sedatives which slow down some of your bodily processes to produce a feeling of calm. They are sometimes prescribed for severe anxiety and insomnia. Unlike the other medications we’ve discussed, they’re not designed to be taken every day, or to be taken in the long term. They’re a short-term solution, designed to be taken as a ‘one-off’ when they’re needed. If they’re taken continuously in the long term, not only can they be addictive but they stop being effective because your body ‘gets used’ to their effect and adjusts accordingly.

Due to their nature combined with withdrawal symptoms and side effects (which are more likely and pronounced than the other medications) benzodiazepines are only prescribed for OCD patients when all other medications have failed. They may be prescribed alongside antidepressants or antipsychotics. They are only prescribed for adult patients.

Benzodiazepines may also be prescribed in the short-term if an OCD patient is facing an unavoidable situation within which they are very fearful and their OCD is triggered, for example going for an operation or staying in hospital. Alternatively they may be used as a short term solution when OCD symptoms are very severe, while other treatment is being sought.

How do benzodiazepines work?

The charity Mind explains that benzodiazepines, “work by increasing the effect of a brain chemical called GABA (gamma amino butyric acid).” An increase in this chemical reduces function in specific areas of the brain to provide a short term sedative effect.

What type of benzodiazepines are available?

You may be prescribed the following benzodiazepines:

• Clonazepam (klonopin)
• Lorazepam (ativan)
• Diazepam (valium)
• Chlordiazepoxide (librium)
• Oxazepam (serax)
• Xanax (alprazolam)

What are the side effects of benzodiazepines?

Just like with the other medications, side effects can vary for each individual. Some of the possible side effects that may be experienced are included below.

• Dizziness, lightheadedness and increased risk of falling
• Blurred vision
• Confusion and memory problems
• Dry mouth
• Nausea and sickness
• Problems going to the toilet (constipation and diarrhea)
• Paradoxical effects (this means that in some people, the opposite of sedation may happen, causing agitation, irritation and increased anxiety, for example)

Always take your medication as instructed

It’s vital you take your medication exactly as instructed. This includes taking the prescribed dosage, as well as taking your medication at the right time of day. Most of these medications will need to be taken at the same time each day. It can help to set an alarm on your phone to remind you, especially when you’re first getting into a medication routine.

Some medications may need to be taken before or after food specifically. It’s really important these instructions are followed, as they’re designed to keep you safe, to help the medications work as effectively as possible, and to minimize any side effects.

Keep notes

Until you find a medication that works for you, it’s a great idea to keep notes of how you feel each day and what side effects you experience. This can help both you and your doctor to get a clearer view of whether the medication you’re currently taking is working for you, and aid you in weighing up the benefits against side effects.

Speak to your doctor about side effects

If you’re experiencing side effects, bring them up with your doctor at your next visit. If they’re distressing you, you can always call your doctor or mental health professional, or make an appointment to discuss your experiences. If you’re really concerned you’re having severe side effects, either mentally or physically, seek immediate professional help.

Know that you can change medications

Remember that if one medication doesn’t work for you, you can change medications with the guidance of your doctor. It doesn’t mean you won’t be able to find a medication that helps you. Even though it can be disheartening, try not to lose hope.

Never stop your medication without the guidance of your doctor

You have the right to choose to stop your medication when you decide it’s right for you of course, but don’t do so without the guidance of your doctor. If you stop psychiatric medications suddenly, it can cause withdrawals which can be really unpleasant and in some cases dangerous.

If you tell your doctor you want to stop or change your medication, they will be able to guide you through tapering off your medication gradually (meaning reducing the dose a little bit at a time over a few weeks) to reduce withdrawal symptoms.

Advocate for yourself if you feel you aren’t being listened to

If you feel as though your concerns and opinion are not being heard, ensure you advocate for yourself. This may involve being persistent in the point you are trying to make. It may be that you take someone with you for moral support if you feel you are too anxious to be firm.

Remember you have the right to ask for another opinion or a different doctor if you are really unhappy with the treatment you’re getting. It’s important you feel safe and heard with any medical professional: that is your right.

How to combat side effects

If you find a medication that works for you, the benefits may outweigh the risks. That’s certainly been the case for me in finding a medication combination for my bipolar disorder and anxiety. While some of the side effects I experience can be distressing, the stability and happiness I’ve gained since finding the right medication is well worth it.

Once you’ve found the right medication, there are ways that you can combat and cope with the side effects you experience. Your doctor may be able to guide you through coping with specific side effects. Some ways to combat common side effects are included below.

• Side effects in general
  It’s often a good idea (provided your doctor agrees) to take your medication at night if you’re experiencing a lot of side effects, so that the highest dose of your medication is while you’re sleeping: this can make things a little easier on you during the day.
• Nausea
  Taking your medication after eating (if the instructions allow) can help to reduce nausea. You could speak to your doctor about anti-sickness medication if you are vomiting regularly.
• Headaches
  Ensuring you are hydrated and are eating properly can help. Take rests when you need them. Try to avoid caffeine and alcohol which can worsen headaches.
• Dry mouth

  Taking regular sips of water or another hydrating drink can be useful. I find sucking lollipops helpful. Some people find sugar free sweets or chewing gum help.

  
• Problems getting to sleep
  If you’re struggling to get to sleep because of your medication, you could try taking it earlier in the day (if your doctor agrees).
• Problems with drowsiness and fatigue
  If, like me, your medication makes you sleepy, you could try taking it before bed (if agreed upon by your doctor). This can help you to make the most of the side effect by using it to aid sleep, and can reduce tiredness during the day.
• Diarrhoea
  It’s important to take regular small sips of water to keep yourself dehydrated. You could ask your doctor about over the counter remedies to reduce diarrhea, but ensure you check that they’re safe to take alongside your medication first.
• Constipation
  High fibre foods (like fresh fruit and vegetables) can help. Keeping hydrated and increasing exercise levels can help to combat constipation. If the problem persists, as with diarrhea, you could check with your doctor about over the counter treatments.
• Sweating and hot flashes
  As distressing as these can be (this is something I struggle with daily), remembering that they will pass can help. Cool compresses, a handy fan, and a nice facial mist can provide some relief.
• Weight gain

  Gaining weight through medication can be really difficult to deal with. Personally I’ve found that the weight gain is worth the mental stability the medication has given me, but this needs to be a personal decision for you.

  Ways to deal weight gain as a side effect can include extra exercise and a healthy diet to combat the gain as much as possible. It’s also vital to focus on building confidence, self-love and body positivity.

  
• Dizziness
  Focus on getting up from sitting and standing positions slowly and carefully to reduce the risk of falls. Take your time to do activities if you are feeling dizzy and don’t be afraid to ask for help or reassurance from a loved one.
• Increased self harm and suicide risk
  Although this sounds scary it’s important to remember that this is temporary, that your doctor will monitor you, and that in the long term the medication is likely to reduce these symptoms rather than increase them. If you’re struggling, reach out for help immediately.

Fear of medication

If your OCD makes you fearful of taking medication or you have an obsession around medication, you can still take medication. It’s important to talk this through with your mental health professional or doctor and explain the situation: they may be able to help guide you through the experience at a pace that makes you feel comfortable.

In this situation it’s vital you have a professional you can really trust and build a relationship with. If you don’t feel you can open up to one doctor, don’t be afraid to seek further help or find a different doctor. You have a right to get the care you need.

It may be possible to get started with CBT before you begin your medication, so that you can deal with the fear of the medication as part of your therapy.

Taking medication forever

It’s very much down the individual and how their OCD treatment goes in regards to how long you need to take medication. For some, medication may be long term or indeed forever, and there’s nothing wrong with that. Just as many other mental and physical illnesses require long term medication, it’s valid to continue taking medication for OCD. The International OCD Foundation states that, “over half of OCD patients (and maybe many more) will need to be on at least a low dose of medication for years, perhaps even for life.”

For others, medication may be a shorter term solution to allow them to fully engage in psychological therapy, and then they may be able to taper off the medication. However even ‘short term’ typically means a decent number of months. OCD UK discuss the The National Institute for Health and Care Excellence recommendations: “if the medication has helped a person, they should continue taking the medication for at least 12 months to ensure their symptoms continue to improve and prevent relapses.”

Typically once patients start to reduce their medication, they may see symptoms return but by this point they should have the tools in place through therapy to deal with their symptoms more effectively. If patients find that they are not coping when they stop medication, they can always restart it. It doesn’t mean you have to make a permanent decision that you can’t reverse.