Presented by Steven Poskar, MD
Medication Treatment of OCD:
Separating Fact from Fiction
OCDNJ President Allen H Weg, EdD and Steven Poskar, MD of OCD NYC
On Monday June 12, 2017, Steven Poskar, M.D. presented at the quarterly meeting of OCD New Jersey (OCDNJ). Dr. Poskar is the director of OCD NYC, a treatment center specializing in OCD and Related Disorders. He completed his psychiatric training at Montefiore Medical Center, where he went on to complete a research fellowship at the Compulsive, Impulsive, and Autism Spectrum Disorder Program. Dr. Poskar is currently a member of the International OCD Foundation Scientific and Clinical Advisory Board. He is also a member of the International OCD Foundation's Body Dysmorphic Disorder, Hoarding, and Autism Spectrum Disorder Special Interest Groups. He is a co-founder and current Vice President of OCD New York, the NY affiliate of The International OCD Foundation.
Dr. Poskar’s presentation focused on the treatment of OCD using medication. He began by discussing how therapy, specifically Exposure and Response Prevention (ERP), is the most important treatment for OCD. He went on to describe how medication can be a helpful addition to therapy given that it can alleviate OCD symptoms by making them more manageable, and can make it easier to engage in ERP. Dr. Poskar made the point that medication is not a cure for OCD and will not completely eliminate symptoms.
Dr. Poskar described the history of medication use for anxiety disorders and OCD. He discussed a large period of time in which there were useful medications for anxiety disorders and depression, but not OCD specifically. He identified 1975 as the year that the first OCD medication, Clomipramine, was identified as leading to significant decreases in symptoms. However, he discussed a number of side effects associated with Clomipramine, and explained that the reason for this is that it hits many receptors of the brain. Given that Clomipramine targeted serotonin receptors primarily, the hypothesis emerged that serotonin is linked to OCD. He described a trend in the field that led to the use of selective serotonin reuptake inhibitors (SSRIs) for OCD given that they are associated with fewer side effects. Dr. Poskar debunked the myth that too little serotonin is the cause of symptoms, and SSRIs reduce symptoms by increasing serotonin levels. He also clearly stated that there is no link between low serotonin and depression, anxiety, or OCD.
Dr. Poskar continued his presentation by discussing the general progression of medication trials. He explained that psychiatrists typically start by prescribing an SSRI, which has been found to be effective in 40 to 60% of patients with OCD, with a 20 to 40% decrease in symptoms. If it is ineffective, Dr. Poskar suggested trying another SSRI, and then Clomipramine if needed. He explained that although a meta-analysis suggests greater efficacy for Clomipramine than SSRIs, there are more side effects associated with Clomipramine, so it makes sense to try it last.
Dr. Poskar went on to talk about the side effects of SSRIs in detail, which include weight gain, sexual dysfunction, gastrointestinal distress, agitation, insomnia, and increased sweating. He explained that there is no “best” SSRI for OCD, however, individual patients may respond well to some and not others. Dr. Poskar described a couple of ways to determine which SSRI to try, including adverse side effects and potential drug interactions, past response to medication, family history of medication response, and the presence of co-occurring medical or psychiatric conditions.
He provided the audience with valuable information on the typical response to medication for individuals with OCD. He explained that OCD typically requires higher doses of SSRIs, and the SSRIs typically take a longer time for patients to respond. If the medication treatment is unsatisfactory, he discussed how it is important to consider poor adherence, for example, if the patient is only taking the medication when symptoms are present, as well as the diagnosis and co-occurring conditions, especially autism spectrum disorder, bipolar disorder, and attention-deficit hyperactivity disorder. He discussed the possibility of needing to augment the SSRI with other types of medication. Dr. Poskar closed by discussing the suggested way of stopping medication, by tapering off after demonstrating a noticeable improvement through therapy that has lasted a couple of years.
DVDs of this presentation are available for purchase by emailing firstname.lastname@example.org. All DVD titles from previous meetings are available on our website, www.ocdnj.org.
Dr. Rachel Pess is a post-doctoral fellow at Stress and Anxiety Services of New Jersey. She can be reached at 732-390-6694.
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