OCD SSRI Dose

[zenman]

How much higher a dose do you go with SSRI's for OCD?

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[billypilgrim37]

How much higher a dose do you go with SSRI's for OCD?

I have seen 400mg Zoloft or 120mg Prozac. Can't use Celexa/Lexapro at those super high doses anymore.

 

[F0nzie]

I have seen 400mg Zoloft or 120mg Prozac. Can't use Celexa/Lexapro at those super high doses anymore.

You can if you think out of the box. Just have them carry around a heart monitor.

 

[billypilgrim37]

You can if you think out of the box. Just have them carry around a heart monitor.

And a magnesium salt block!

 

[MacDonaldTriad]

Not that the APA guidelines are the absolute last on the subject, but here is a link to a summary (in case you don't have an APA account). The table can be useful.

http://www.aafp.org/afp/2008/0701/p131.html

 

[vistaril]

How much higher a dose do you go with SSRI's for OCD?

i've seen 60 of lexapro once

 

[birchswing]

Do psychiatrists ever use Anafranil for OCD? I've read a couple of patients describe it as a "cure" for their OCD. I know that no one here would use that word, but it made me curious about the drug.

 

[OldPsychDoc]

Do psychiatrists ever use Anafranil for OCD? I've read a couple of patients describe it as a "cure" for their OCD. I know that no one here would use that word, but it made me curious about the drug.

I inherited an outpatient on clomipramine, stable for well over 15 years, and understandably uninterested in any suggestion of a switch.

 

[billypilgrim37]

Do psychiatrists ever use Anafranil for OCD? I've read a couple of patients describe it as a "cure" for their OCD. I know that no one here would use that word, but it made me curious about the drug.

It's also a cure for pooping and saliva. But, yes, it's a very good option for folks that haven't responded to a few trials of sustained high dose SSRIs.

 

[MacDonaldTriad]

Do psychiatrists ever use Anafranil for OCD? I've read a couple of patients describe it as a "cure" for their OCD. I know that no one here would use that word, but it made me curious about the drug.

I know of three studies looking at the Clomipramine vs SSRIs:

Freeman CPL, Trimble MR, Deakin JFW et al.
Fluvoxamine versus clomipramine in the treatment of OCD: A multicenter, randomized double-blind, parallel group comparison. J Clin Psychiatry. 1994;55:301-305

Koran LM, McElroy SL, Davidon JRT, et al
Fluvoxamine versus clomipramine for OCD: a double-blind comparison, J of Clin Psychopharmacol. 1996;16:121-129.

Pigott TA, Pato MT, Bernstein SE, et al. Controlled comparisons of clomipramine and fluoxetine in the treatment of OCD. Arch Gen Psychiatry. 1990;47:926-932.

I’ll save you the read. There were no differences, but the drop outs were so much higher for the clomipramine arms, the “last observation carried forward” design probably disadvantaged clomipramine (drop outs were included as failures for clomipramine).

Most experts believe there is some efficacy advantage to clomipramine, but it is so much harder to manage. They suggest two SSRI trials, but then start thinking clomipramine.

My personal two cents is that this depends a lot on what you see from the SSRIs. Almost no OCD cases get completely better and it becomes a decision about how much to chase perfection in most cases.

 

[xlithiumx]

Do psychiatrists ever use Anafranil for OCD? I've read a couple of patients describe it as a "cure" for their OCD. I know that no one here would use that word, but it made me curious about the drug.

I have a handful of patients with OCD that I started on clompiramine and it has been a lifesaver for them. Most had been on sertraline up to 300 mg daily or fluoxetine up to 80 mg daily before trying the clomipramine.

 

[splik]

I’ll save you the read. There were no differences, but the drop outs were so much higher for the clomipramine arms, the “last observation carried forward” design probably disadvantaged clomipramine (drop outs were included as failures for clomipramine).

a moot point but somewhat important - drop outs included as failures for clomipramine = intention to treat. last observation carried forward means exactly that, however the patient was doing before they dropped out was included as the final result. these are different things, though in RCTs you can't have LOCF without intention to treat but you can have ITT without LOCF. In fact today, no respectable journal would (or at least should) publish any study using LOCF because it is so flawed and is now discredited.

 

[MacDonaldTriad]

You are absolutely right. I did miss represent the criticisms of these studies with my oversimplification. The literature is full of studies using LOCF designs. I'm sure the proponents of LOCF felt superior to their parents in that at least they were not just dropping the drop outs from the analysis. I'm sure our children will look at our designs and point out a whole new set of "what ifs" in what we are doing now. I think we can be sure that there will never be a design that is impervious to criticism.

Until we can make subjects complete protocols despite side effects or lack of efficacy, this will always be a problem. It is safe to say that a lot more of the subjects in the Anafranil arm probably dropped due to side effects and not due to lack of efficacy when compared to the SSRI arms.

Getting back to the question this thread asks, Anafranil works when it works, and although it has less tolerability, most people do tolerate it. At least it is different and worth a try in a lot of cases.

I vote that we push training to include more MAOIs, TCAs, ECT, injectable long acting agents, if not, we might as well let our primary care providers do our work. I would like to see less consternation about NPs and psychology prescribers and more emphasis on what we can bring to the table that others cannot do as well as we can.

Sorry about the rant, I'm just tired of the APA calling my land line on Sundays asking me to help fund more lobbyists.