Should I use medications to treat my OCD?
A very common question my clients ask about OCD treatment is, “Should I use medications?” That’s what we’ll review in this post. This is the first post in a series discussing this question. This post is focused on the use of medications for the treatment of adults with OCD. In a later post in this series, we’ll review the use of medications for the treatment of pediatric (child and adolescent) OCD.
Before getting started, a very important consideration:
As an OCD therapist, I can provide information about the research evaluating medication effectiveness and the possible role of medications in OCD treatment. However, I’m not a prescribing professional. Any decisions regarding beginning, stopping, or changing medications should be made in consultation with a qualified prescribing professional, such as a psychiatrist or primary care provider. So: Please be sure you consult with your prescribing professional before making any change to your medication use!
If you don’t want to read this entire post, preferring I cut to the chase, the answer to the question “Should I use medications” is something like: While we can’t predict the specific optimal response for any given individual, research indicates that combining ERP treatment with a medication is not significantly more effective than ERP treatment alone. In other words, participating in ERP treatment without also taking medication is usually about as effective as participating in ERP treatment while taking medication.
What this means is that the evidence suggests you’ll improve about as much participating in ERP alone as you would improve participating in ERP while also taking medication.
That’s the long-story short. But there are many, many details I want to make explicit. And that’s why this post is the first in a series.
Often, when I inform my clients that ERP alone is about as effective as ERP plus a medication, they are confused, upset, or both. They may have been told by a doctor or therapist that “combined treatment” (ERP + medication) is the “gold-standard” in OCD treatment. Or they may have heard that OCD is caused by a “chemical imbalance” or a “brain disorder” and, as a result, they need to take medications in the same way that someone with diabetes needs insulin.
Unfortunately, in cases such as these, my clients have received information that is misleading at best and straight-up inaccurate at worst. Below, we’ll take a deep dive into the research that illuminates and substantiates what I mean.
The Research
When clients ask me about the possible use of medication in the treatment of OCD, they’ve usually heard from a friend or peer that medications were very helpful in managing OCD. Or their doctor or therapist might have suggested their use.
Whether they’re aware of it or not, when clients ask about medication use, they’re almost always asking about the use of antidepressants, including selective serotonin reuptake inhibitors (SSRIs) like Prozac or Tricyclics (TCAs) like Anafranil. In severe, treatment resistant OCD, they might even be considering adding an antipsychotic medication, like Abilify (which we won’t be focused on in this post).
Before turning to what the specific research shows, let’s first examine the prominent treatment guidelines.
In 2007, the American Psychiatric Association (APA; the flagship Psychiatric association in the United States) published treatment guidelines for the treatment of OCD in adults.¹ Like other treatment guidelines (for instance, the National Institute for Health Care and Excellence of England²), the APA guidelines recommend a stepped care approach to OCD treatment.
A stepped care approach emphasizes treatment which targets symptom reduction while minimizing adverse effects, such as medication side-effects, etc. The APA guidelines suggest that both ERP and SSRI medications can be considered “frontline” interventions, which can be confidently recommended from the beginning of OCD treatment. The APA guidelines point in the direction of considering psychotherapy (such as ERP) as a front-line intervention for OCD before SSRI treatment. However, the guidelines suggest that if there are complicating factors, such as co-occurring depression, it may make sense to consider combining ERP with a SSRI. They point out, however, “The available data suggest that combining an SRI and CBT is more effective than monotherapy in some patients, but is not necessary for all” (p. 27).
This phrase should catch our attention: Combined treatment (SSRI + ERP) is more effective than monotherapy (e.g., ERP alone) in some but not all patients. It was this sort of phrasing that really caught my attention when I was engaged in my research all the way back in 2017.
I wondered: “What do they mean when they wrote ‘may’? What’s the difference in treatment effectiveness between ERP, SSRI, and ERP + SSRI? Have things changed since then? Are there new studies showing that combined treatment is better than ERP alone?”
These questions motivated me to look further.
ERP compared to ERP plus SSRI
The APA hasn’t produced another treatment guideline for OCD since 2007. However, in 2013, Koran and Simpson, two of the authors of the original APA OCD treatment guidelines, published an update.³ Long story short: The update by Koran and Simpson doesn’t make any significant changes to treatment recommendations. So the guidelines have remained stable.
Curious, I did a deep dive into the studies exploring the treatment outcomes of ERP compared to ERP plus SSRI.
My research culminated in the publication of my article Biogenetic Etiologies of OCD: Review and recommendations for clinicians, published in the Journal of Obsessive-Compulsive and Related Disorders. This research article was later used by the The International OCD Accreditation Task Force in creating knowledge and competency standards for the treatment of adult OCD.
In other words, my research was relied on in the creation of comprehensive guidelines for clinicians treating OCD. What did I discover in my research?
Interestingly, despite the popularity of suggesting combined treatment (ERP + SSRI) to those with OCD, the research studies consistently found that ERP alone (including ERP + placebo) was, on average, as effective in treating OCD as ERP + SSRI. The studies I identified in my research can be seen in the reference list.⁴
“That’s so weird” I thought. It caught my attention that the research clearly indicated that ERP alone was as effective as ERP + medication, especially since I’d had so many discussions with clients, therapists, and doctors in which the accepted wisdom was that combined treatment (ERP + SSRI) was better than monotherapy alone (ERP alone or SSRI alone).
“What’s causing this disconnection between what the research evidence shows and the “common wisdom” and related recommendations I’m hearing from mental health professionals?
One possible explanation for this misunderstanding is described in Mao et al. (2022).⁵ Mao et al. was a systematic review designed to comprehensively integrate studies evaluating treatment outcomes for OCD when participants in the studies were participating in ERP treatment alone, SSRI treatment alone (when only one type of treatment is being used, it’s often referred to as monotherapy), or combined treatment.
In this systematic review, Mao et al. pointed out that it’s correct that adding ERP to medication typically yields improved treatment outcomes. So monotherapy with medication is not as effective as combined therapy where ERP is added to medication.
Crucially, improved treatment outcomes are not usually seen when adding medication to ERP.
In other words, adding ERP to a medication improves the treatment outcome. But adding medication to ERP does not improve treatment outcomes.
The Conclusions
So, what we can see is that the idea that combined treatment works better than monotherapy is half true. Combined treatment is more effective than medication monotherapy. But combined treatment doesn’t appear to be more effective than ERP monotherapy.
Mao et al. isn’t the only peer-reviewed, systematic review to identify this finding.
In fact, this was the conclusion of the comprehensive meta-analysis conducted by Öst, Havnen, Hansen, & Kvale,⁶ in which they reported: “Adding Cognitive behavior therapy to antidepressant medication leads to a better effect than that of antidepressant medication alone. Adding antidepressant medication to cognitive behavior therapy does not yield a better effect than that of cognitive behavior therapy alone” (p. 167).
Just like Mao et al., it’s possible that mental health professionals read, or were told, that combination treatment works better than medication alone (which is supported by the evidence) and assumed that this means combination treatment works better than ERP alone (which is not supported by the evidence).
The reviews completed by Mao et al., and Öst et al. are congruent with both older and the most recent clinical trials comparing ERP and SSRI monotherapy to combined therapy that, once again, find that ERP + SSRI does not yield superior treatment outcomes compared to ERP alone.⁷
So, that’s one way that the “combined treatment is better” idea may have spread. But I suspect there are multiple other contributors to the “combined treatment is better” idea that are more common and, perhaps, more impactful. We’ll turn to this subject in part 2 of “Should I use medications?”
References:
Koran, L. M., Hanna, G. L., Hollander, E., Nestadt, G., Simpson, H. B., & American Psychiatric Association. (2007). Practice guideline for the treatment of patients with obsessive-compulsive disorder. The American Journal of Psychiatry, 164(7 Suppl), 5-53.
National Institute for Health and Care Excellence. (2005). Obsessive-compulsive disorder and body dysmorphic disorder: Treatment (Clinical guideline). NICE. https://www.nice.org.uk/guidance/cg31
Koran, L. M., & Simpson, H. B. (2013). Guideline Watch (March 2013): Practice guideline for the treatment of patients with obsessive-compulsive disorder. American Psychiatric Association. Retrieved from https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/ocd-watch.pdf
Guzick, A. G., Cooke, D. L., Gage, N., & McNamara, J. P. (2018). CBT-Plus: A meta-analysis of cognitive behavioral therapy augmentation strategies for obsessive-compulsive disorder. Journal of Obsessive-Compulsive and Related Disorders, 19, 6-14.
Romanelli, R. J., Wu, F. M., Gamba, R., Mojtabai, R., & Segal, J. B. (2014). Behavioral therapy and serotonin reuptake inhibitor pharmacotherapy in the treatment of obsessive–compulsive disorder: A systematic review and meta‐analysis of head‐to‐head randomized controlled trials. Depression and Anxiety, 31(8), 641-652.
Mao, L., Hu, M., Luo, L., Wu, Y., Lu, Z., & Zou, J. (2022). The effectiveness of exposure and response prevention combined with pharmacotherapy for obsessive-compulsive disorder: A systematic review and meta-analysis. Frontiers in Psychiatry, 13, 973838.
Öst, L. G., Havnen, A., Hansen, B., & Kvale, G. (2015). Cognitive behavioral treatments of obsessive–compulsive disorder. A systematic review and meta-analysis of studies published 1993–2014. Clinical Psychology Review, 40, 156-169.
Abramowitz, J. S., Taylor, S., & McKay, D. (2009). Obsessive-compulsive disorder. The Lancet, 374(9688), 491-499.
Albert, U., & Brunatto, C. (2009). Obsessive-compulsive disorder in adults: Efficacy of combined and sequential treatments. Clinical Neuropsychiatry, 6(2), 83-93.
Foa, E. B., Liebowitz, M. R., Kozak, M. J., Davies, S., Campeas, R., Franklin, M. E., ... & Tu, X. (2005). Randomized, placebo-controlled trial of exposure and ritual prevention, clomipramine, and their combination in the treatment of obsessive-compulsive disorder. American Journal of Psychiatry, 162(1), 151-161.
Mao, L., Hu, M., Luo, L., Wu, Y., Lu, Z., & Zou, J. (2022). The effectiveness of exposure and response prevention combined with pharmacotherapy for obsessive-compulsive disorder: A systematic review and meta-analysis. Frontiers in Psychiatry, 13, 973838.
Marazziti, D., Pozza, A., Avella, M. T., & Mucci, F. (2020). What is the impact of pharmacotherapy on psychotherapy for obsessive-compulsive disorder?. Expert Opinion on Pharmacotherapy, 21(14), 1651-1654.
Panah, M. E., Farhadian, M., Ghaleiha, A., Renner, F., & Moradveisi, L. (2025). The Effectiveness of Cognitive-Behavioral Therapy With and Without Sertraline in Patients with Obsessive–Compulsive Disorder: A Pilot Randomized Trial. International Journal of Cognitive Behavioral Therapy, 1-16.
Wheaton, M. G., Rosenfield, B., Rosenfield, D., Marsh, R., Foa, E. B., & Simpson, H. B. (2023). Predictors of EX/RP alone versus EX/RP with medication for adults with OCD: Does medication status moderate outcomes?. Journal of Obsessive-Compulsive and Related Disorders, 39, 100850.
Wheaton, M.G., DeSantis, S.M & Simpson, H.B. (2016). Network meta-analyses and treatment recommendations for obsessive-compulsive disorder. The Lancet Psychiatry, 3, 921-922.