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If your medication doesn't work. One question we've heard is, "Who is a good candidate for medication?" Well, just about anyone with OCD who isn't opposed to medications, who believes that they will help them, who doesn't have obsessions that involve medications per se, and who doesn't have some physical or biochemical reason not to take them (for instance, pregnant or nursing women may choose not take these medications, although profound anxiety probably makes for a worse environment for a developing fetus than does the presence of an SSRI). Almost anyone else with OCD will probably benefit from meds. However nothing is certain, and to be honest, a small percentage of OCD sufferers don't benefit from meds. People often come to the conclusion that their medication isn't working for them, and end up in their doctor's office wanting to adjust the treatment. Let's talk about that for a minute. It's important to note a couple of things in general about medications in this area. Improvement on medications is measured over a much longer term for OCD than for depression. People often need to be on the SSRI medications for 8-12 weeks just to know if it will be effective, and if it is, they may continue to improve for up to a year to get the maximal benefit. Depression often responds completely in a few weeks to months. Also, it's important that your medication trial be not only long enough, but at a high enough dose. The useful dose of most of the SSRIs for treating OCD is 3-5 times the useful dose for treating depression with the same medication. That may seem like a lot, but patients often state (when they're on too low a dose of these medications), "Well, doc, I feel better because my depression is better, but I still have my obsessions and compulsions." Finally, 7 out of 10 people improve on medications, but not always on the first medication tried. That's in part because everyone's physiology is slightly different, and we don't always know which medication will be the best one for any given person. We have a lot of things to consider when we make the first recommendation (like family history of medications, your previous history, other current conditions and potential side effects - we'll talk more about this in a minute), but sometimes it turns out that the second medication we try works much better than the first. So it's important to be on the right med for you, at the right dose for long enough.

Now sometimes the first med that we try doesn't do the job, as we mentioned before. After a fair trial (remember, that means long enough at the correct dose), if the medication isn't doing its job or if the side effects have been intolerable and unmanageable, then we might consider switching medications. In some cases we may try adding medications. For instance, some people have a mild insomnia with Prozac. One of the unfortunate problems of using the Valium-class of meds as sleeping medications is that they change the quality of sleep, so you may not feel as refreshed as you would otherwise. On the otd¸¿¾fps always preA!-ble to getting no sleep at all! However, another medication called Trazodone (or Desyrel) acts like a weak SSRI, but as a side effect it is very sedating. Taking Prozac in the morning and Trazodone in the evening is an effective way to deal with the sleep problem and enhance the anti-OCD quality of the Prozac at the same time. Trazodone also doesn't have the negative side-effects of other sleeping pills, in that it doesn't change the quality of the sleep you get (the so-called sleep architecture), and it is non-addictive. Other additions that are have been found to be effective for some people is to combine a low dose of Anafranil with a moderate dose of Prozac. This turns out to be very good anti-OCD treatment for some people, and for them the stimulation of the Prozac may be balanced out by the sedating effect of the Anafranil. In addition, the dose of Anafranil may be low enough that the other potential side effects are not noticeable.

As we mentioned before, a few people don't benefit from meds. Some of these people can do behavior therapy with success. And let me make sure to mention that being on medications will not, in any way, keep you from getting benefit from behavior therapy. You will still be able to do the assignments and learn the skills. In fact, if we can briefly treat your OCD medically so that you can learn the behavior therapy and start inducing serotonin changes in your brain on your own, then you can wean yourself off meds. That is our target, so don't be concerned about combining the two approaches.

Three last comments about medications. First, all of the medications that we have for treating OCD are the products of years of research. However, our research is moving so fast that some of this information you've read here may be out of date in a year or so. It's a good idea to keep asking your doctor for medication updates. Second, most of this research would not be possible if not for volunteers with OCD. So if you can make the time and are not opposed to taking part in research protocols, we urge you to call the various research programs and find out what they are doing. You can always decide not to take part after you find out what's involved. Many of them don't involve taking medications that you're not taking now, while some will provide free meds while you're in the program. Most don't involve any kind of invasive procedures, and some will even pay you for your time and effort. Please check into it; it's the best way that we have to develop new and more effective treatments for OCD. And third, we need to remind you once again to make sure that you direct all of your medication questions or potential changes to your own medications doctor. He or she knows you the best, and should ALWAYS be consulted about changes in medications.

Chapter 5
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