OCD medication works on average but modestly, and the main drugs are SSRIs and clomipramine. A 2016 network meta-analysis of 54 trials found that SSRIs as a class and clomipramine both reduced symptoms more than drug placebo, while behavioural and cognitive therapies had larger effects. [skapinakis-2016] This guide covers what that analysis and a dose-response review found, how medication compares with therapy, what the research could not show and what to ask a prescriber. Our overview of OCD covers the condition itself.
Which medications work for OCD?
SSRIs and clomipramine both do, and neither is clearly better. The 2016 analysis compared drugs and therapies with placebo using scores on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), where a larger drop means fewer symptoms. It included 54 trials with 6,652 participants. Clomipramine (13 trials, 831 patients) reduced scores by 4.72 points versus drug placebo (95% credible interval 2.60 to 6.85), and SSRIs as a class (37 trials, 3,158 patients) by 3.49 points (1.81 to 5.12). [skapinakis-2016]
Clomipramine was not better than SSRIs: the difference was 1.23 points, with a credible interval from 3.41 points better to 0.94 points worse, which includes no difference at all. [skapinakis-2016] The Y-BOCS runs from 0 to 40, so a 3 to 5 point average drop is a real change but a limited one, which is worth knowing before starting a drug.
Does a higher dose help OCD?
Higher doses of SSRIs did better, though with more side-effects. A meta-analysis pooled 9 randomised, double-blind, placebo-controlled trials with 2,268 adults that compared several fixed doses of SSRIs with each other and with placebo. Compared with low or medium doses, higher doses were associated with improved efficacy, measured either by Y-BOCS score or by the proportion of responders. [bloch-2010]
Dose was not associated with the number of all-cause dropouts, but higher doses were associated with a significantly higher proportion of dropouts due to side-effects. The authors noted that this pattern stands in contrast to other conditions such as major depression, and that there are insufficient data to apply the findings to children or adolescents. [bloch-2010]
How does OCD medication compare with therapy?
In one analysis the therapies did better, with an important caveat. The 2016 network meta-analysis found behavioural therapy reduced Y-BOCS scores by 14.48 points (11 trials, 287 patients), cognitive therapy by 13.36 (6 trials, 172 patients) and cognitive behavioural therapy by 5.37 (9 trials, 231 patients), all compared with placebo. [skapinakis-2016]
Mean reductions in Yale-Brown Obsessive Compulsive Scale scores compared with placebo, from the network meta-analysis by Skapinakis and colleagues (2016) of 54 trials and 6,652 adults. All values are mean differences compared with placebo as reported in the abstract, which does not describe what the therapy trials used as a control, and most therapy trials allowed stable antidepressant doses, so the bars are not a like-for-like contest.
The caveat is the one the authors state: a serious limitation was that most psychotherapy trials included patients who were taking stable doses of antidepressants (12 of the 15 explicitly allowed them). So the therapy results may partly reflect therapy added to medication. Their overall interpretation was that a range of interventions is effective, with considerable uncertainty about relative efficacy, and that combining therapy and medication is likely to be more effective than therapy alone, at least in severe OCD. [skapinakis-2016]
| Question | What the research found | Caveat |
|---|---|---|
| Do SSRIs work? | 3.49-point drop on the Y-BOCS versus drug placebo (37 trials) | Modest on a 40-point scale |
| Is clomipramine better? | Not shown (1.23-point difference, interval includes zero) | Neither ranked above the other |
| Do higher doses help? | Better efficacy than low or medium doses (9 trials) | More dropouts due to side-effects |
| Therapy or drugs? | Therapy effects larger, combination likely better in severe OCD | Most therapy trials allowed stable antidepressants |
What can this research not show?
It cannot show which drug suits you, what to do when the first drug fails or how quickly any of them work. Five limits matter most:
- Treatment-resistant OCD is outside it. The network meta-analysis excluded studies that focused only on treatment-resistant populations, so it says little about what works after a first drug fails. [skapinakis-2016]
- The therapy and drug comparison is not like for like. Therapy trials mostly allowed stable antidepressants, which the authors call a serious limitation. [skapinakis-2016]
- Relative efficacy is uncertain. The authors describe considerable uncertainty and limitations in comparing treatments with each other. [skapinakis-2016]
- The dose findings are for adults. The dose-response analysis says there are insufficient data to generalise to children or adolescents. [bloch-2010]
- Speed, side-effects and stopping are not covered. We could not verify evidence on timelines, individual side-effect profiles or discontinuation, so those are questions for a prescriber.
What should you ask a prescriber?
Ask which drug is being proposed and why, what dose range is planned and what the plan is if it does not help. This section is our suggestion and is not something the reviews tested.
Useful questions are how long to give a drug before judging it, what side-effects to expect at higher doses given that dropouts for side-effects rise with dose, [bloch-2010] and whether therapy with exposure and response prevention should run alongside it. Our guide to exposure and response prevention covers that therapy, and CBT for intrusive thoughts covers the cognitive side. Do not stop a prescribed drug suddenly without speaking to the prescriber.
No screener on this site covers OCD. The self-assessment hub lists the seven we do have, and none is built for this question.
When to seek help
Speak to a doctor if obsessions or compulsions take up much of your day, cause distress or get in the way of work, relationships or sleep, or if you are already on medication that is not helping or is causing side-effects. If you feel unable to stay safe, contact your local emergency services or a crisis helpline.
How MyFreud can help
A record shows a prescriber what has changed. Daily mood tracking in MyFreud shows how your days run over weeks, and the notepad is somewhere to note how much time OCD took, side-effects and what you tried. It does not replace a doctor or a prescriber.
Download MyFreud and start today: App Store or Google Play.