Obsessive compulsive disorder (OCD)

Lothian: Antidepressants - Swapping and Stopping

First line treatment is non-pharmacological measures. Treatment options for anxiety disorders include psychological, and guided self-help approaches as first line. Choice of treatment in individual cases will usually be determined by patient preference, and the severity of the condition.

Initially 50mg daily, dose can be increased in 50mg increments at intervals of at least 1 week to 200mg daily maximum.

Initially 20mg daily, dose increase should be considered if no response after twelve weeks but may increase potential for side-effects; max 60mg daily.

Initially 25mg daily, then increased to 100-150mg daily, dose to be increased gradually over 2 weeks; maximum 250mg per day.

Prescribing Notes:

There is evidence that SSRIs are effective for anxiety and related disorders, however the licensed indications are different for each.
There may be an increase in impulsive thoughts when an SSRI is started especially during the first week of treatment. Special caution should be exercised in those patients under 25 years of age.
Improvement of OCD may not be apparent for 12 weeks. Treatment should be continued for at least 12 months. Long-term maintenance is often necessary.
Clomipramine and SSRIs have proven efficacy in OCD but clomipramine is associated with more adverse effects.
Clomipramine is a sedating TCA which has a high incidence of side-effects and can be lethal in overdose. However, it is well established in general practice and may still be useful for those who have responded to it previously.
Co-prescribing of a benzodiazepine may be useful for 2-4 weeks during the initiation of an SSRI.
Due to the risk of withdrawal reactions, cessation of treatment should involve a very gradual downward titration. If intolerable symptoms develop it may be necessary to reinstate the previously prescribed dose and withdraw more gradually. See local protocols for advice.
Discontinuation of drug treatment may result in recurrence of symptoms. The patient outcome may be improved by use of concurrent psychological therapies.
SSRIs are associated with an increased risk of bleeding, especially in older people or in people taking other drugs that have the potential to damage the gastrointestinal mucosa or interfere with clotting. Consider prescribing a gastroprotective drug in older people who are taking non-steroidal anti-inflammatory drugs (NSAIDs) or aspirin.
SSRIs should be used with caution in patients over 80 years due to the risk of gastro-intestinal bleeding.
Speed of response to treatment can be slow – it may be 12 weeks before patients obtain maximal benefit from treatment.
A minimum of 12 months treatment is recommended and long-term maintenance treatment may be indicated.
General notes on prescribing in pregnancy are available in the Pregnancy section of the formulary.

History Notes

09/04/2024

Addition of link to general notes on prescribing in pregnancy, ERWG May 24.

27/10/2022

East Region Formulary content agreed.

Dose as per specialist and BNFc.

Prescribing Notes:

Please refer to NICE clinical guideline 31: Obsessive compulsive disorder and body dysmorphic disorder: treatment, for detailed information.
Some patients manage without drug treatment. For many, optimal treatment will be a combination of psychological therapy and drug treatment.
In children and adolescents, SSRIs should only be prescribed as part of a package including psychological therapy. Specific arrangements must be made for careful monitoring of adverse drug reactions (including impulsivity, acts of self harm and suicidal ideation), as well as for reviewing mental state and general progress; for example, weekly contact with the child or young person and their parent(s) or carer(s) for the first 4 weeks of treatment and as appropriate thereafter. The precise frequency will need to be decided on an individual basis and recorded in the notes.
Sertraline is unlicensed for OCD in children under 6 years.
Improvement of OCD may not be apparent for 12 weeks. Treatment should be continued for at least 6 months after therapeutic response. Long-term maintenance is often necessary.
Sertraline or fluoxetine may also be prescribed for repetitive or compulsive behaviour occurring in children with autism.
OCD needs to be considered separately from other anxiety disorders. It tends to have different aetiology and a longer chronic relapsing course.
In children and young people with OCD, an attempt should be made to withdraw medication if remission has been achieved and maintained for at least 6 months, and if that is their wish. They should be advised to contact their medical practitioner should symptoms of discontinuation/withdrawal arise. Seek specialist advice if required.
Medicines for Children information leaflets for parents and carers are available for fluoxetine and sertraline.
There is evidence that SSRIs are effective for anxiety and related disorders, however the licensed indications are different for each.
There may be an increase in impulsive thoughts when an SSRI is started especially during the first week of treatment. Special caution should be exercised in those patients under 25 years of age.
Due to the risk of withdrawal reactions, cessation of treatment should involve a very gradual downward titration. If intolerable symptoms develop it may be necessary to reinstate the previously prescribed dose and withdraw more gradually. See local protocols for advice.
Discontinuation of drug treatment may result in recurrence of symptoms. The patient outcome may be improved by use of concurrent psychological therapies.
SSRIs are associated with an increased risk of bleeding, especially in people taking other drugs that have the potential to damage the gastrointestinal mucosa or interfere with clotting.
Suicidal behaviour has been linked with the use of antidepressants, particularly in children and young people. Children and young people should be monitored for suicidal behaviour and risk of self-harm, particularly at the beginning of treatment or if the dose is changed

History Notes

05/03/2025

Sertraline formulation update, ERFC Feb 25.

15/01/2024

East Region Formulary content agreed.