OCD and Atypical Antipsychotics

English: Risperdal (United Kingdom packaging)

English: Risperdal (United Kingdom packaging) (Photo credit: Wikipedia)

Medication had a significant impact on my son Dan’s journey through severe OCD. While certain drugs appear to be helpful for some OCD sufferers, they only seemed to make things worse for Dan. Part of the problem stemmed from his being overmedicated, as well as the fact that he was prescribed drugs that we now know can exacerbate obsessive-compulsive disorder.

Atypical antipsychotics (also known as second generation antipsychotics) are sometimes given to OCD sufferers to “enhance” the effects of an SSRI. This was the explanation given to us twice, once when Dan was prescribed Abilify (aripiprazole), and the other when he was given Risperdal (risperidone). I’ve written previously about some of the side effects he experienced so I won’t go into that here, but suffice it to say no good (and quite a lot of bad) came out of his taking these drugs.

In a recent blog post, Dr. Seth Gillihan discusses a study conducted by researchers at Columbia University and The University of Pennsylvania. Participants already taking an SSRI to treat their OCD were separated into three groups. One group was given seventeen sessions of Exposure and Response Prevention (ERP) therapy, one group was given Risperdal, and the final group was given a placebo.

From Dr; Gillihan’s post:

The results after 8 weeks were striking. Individuals in the ERP condition on average had a 52% reduction in their OCD severity scores, whereas those in the risperidone (13% reduction) and placebo (11% reduction) conditions were virtually indistinguishable.

It’s clear. Exposure and Response Prevention (ERP) therapy is effective. Risperdal, however, did not provide any statistically significant benefit over that of a placebo. Given this information, I would think long and hard before taking such a heavy-duty medication for the treatment of OCD. Certainly I hope doctors will think long and hard before prescribing it.

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25 Responses to OCD and Atypical Antipsychotics

  1. 71 & Sunny says:

    Thought provoking article, Janet. I too am wary about atypical antipsychotics. I read an interesting article about them in Sept 2012 (and blogged about it). One big concern is that it is thought that these newer antipsychotics (atypical) are an improvement over the older antipsychotics, but apparently it is actually not so. Also, according to the article that I read (and I freely admit, it was just this one article) the quoted doctor said that these drugs don’t really seem to be helpful in the case of anxiety disorders. Obviously, if I was currently on an antipsychotic, I would not stop taking it without my psychiatrist’s approval and help first, but I’ll tell you, these recent articles would certainly give me something to talk about with my psychiatrist!

    • Thanks for sharing, Sunny. I will have to go back and reread your post. I agree with everything you say and can definitely attest to the fact that these “new and improved” drugs come with a slew of serious side effects that,in Dan’s case, were downplayed by all of his doctors (except for the one who finally got him off them). We absolutely need to be our own advocates.

  2. Good post, Janet. I’ve been on two of those atypicals, and I didn’t do well. At all. Part of what confused things was that I was also being treated for depression, and what might have been good if I had “just” been depressed didn’t work well with the OCD and anxiety. It’s a challenge to find something that works–if medication is used. I understand not everyone needs/wants it.

    • Hi Tina, Thanks for commenting. I know things get more complicated when you are dealing with comorbid conditions. I think the main thing is to be as educated as possible about these drugs and have a doctor who listens to you and takes you seriously when you have concerns.

  3. I take .5 mg of Risperdal every night! It’s been a blessing to me. Though I know every person reacts differently to various meds. Even 1 mg was too much, but the .5 is just right. I can’t sleep at night without it!

    • Hi Jackie, I am glad you have medication that works for you. You are certainly knowledgeable about OCD and what you need. My concern is more for those who are still floundering through OCD treatment, and are given these drugs with high hopes, and little to no mention of the potential side effects. The important thing is for us all to become educated about the pros and cons and then make an informed decision with the help of a trusted healthcare provider. Continued monitoring is also very important.Thanks for sharing!

  4. Well written. I agree far too many people are being put on meds with no mention of therapy or erp.

  5. time2cher says:

    Hi Janet, my daughter has not been placed on antispychotics for her OCD and depression to date. We actually just switched her to the name brand of Lexapro as I have realized that she has been on the generic form of all of the SSRI’s, four to be exact, that have started out well but just leveled off after time and had no effect even after increases. I have to say that ERP therapy has made a huge difference and recommend that to all. It helped her significantly! I hope she doesn’t need to start with antisphycotics at 16 but we will see what the future may hold. Right now I hope the namebrand over the generic is the key. I would love feedback on the difference for anyone. Wish us luck:)

    • Thanks for sharing, time2cher. I’m glad that ERP has helped your daughter and hope she is continuing with that therapy. Of course I am not a doctor but if her psychiatrist wants to put her on antipsychotics I would strongly advise carefully weighing the pros and cons of her particular situation. If you feel it’s not the way to go, you can decline the meds.

    • debbie nelson says:

      My son is 13 and does take abilify and lexapro. He has gained weight which is awful, but seems to be coping better. I would like to find him an online support group for his age-any ideas.?

      • Hi Debbie, I know there are quite a few forums out there, but I don’t participate in them, so I wouldn’t know what to recommend for a teen. I’d suggest checking out the IOCDF web site as they have lots of resources for young people, and could also steer you in the right direction. I don’t know where you live, but if there are any “live” support groups in your area (check with your son’s therapist, or local hospitals or health centers) that might be a good idea also. Good Luck!

  6. sethgillihan says:

    Great post, Janet, on an important topic. I remember about 10 years ago learning from Dr. Steven Siegel at Penn about atypical antipsychotic medications and their limitations. Apparently even then it was known that these meds were linked to potentially serious adverse events. We always have to balance a drug’s efficacy against its potential for harm, and when the drug doesn’t work that well it can make it even harder to accept the risk of serious side effects.

    • Thanks for your insight, Seth (and for the original blog post :)). I think that’s the bottom line: are the potential risks worth the expected benefits of this drug. For those with OCD, it seems the answer would more likely be no than yes.

  7. eventer79 says:

    Very good and so true. I have a lovely mix of OCD (very internal and obsessional based for me), ADHD, and depression (I take lexapro and wellbutrin already for the latter). We’re still working on finding the right med mix for the ADHD, not sure I’ll ever have much luck w/ the OCD aside from some Xanax when I get mega-anxious, but I did have the distinct (dis)pleasure of trying Abilify. OMG.

    I do love my pdoc and I realize it is very difficult for them because everyone reacts to drugs so differently. But I developed extreme akasthesia within a week and literally COULD NOT SIT STILL without feeling like I wanted to peel off my skin. I wanted to sit down, I was exhausted, but all I could do was pace and twitch and I hated it, it was one of the most horrible feelings I have ever experienced, so we quit that very quickly and thankfully, that went away in a few days. m My doctor did warn be beforehand that this could happen and if it did, I should notify him IMMEDIATELY, but that there could be positives too, so he does try very hard to make sure I am fully informed.

    On the other hand, Abilify has been wonderful for a good friend who is very bipolar, so once again, there is just no gold standard and no way to know without trying. I think the key is (1) a doctor who is really on the ball and ready to take quick action and listen to the patient and (2) a patient or advocate who can recognize and report if and when things aren’t working.

    • Thank you so much for sharing your experience, eventer79, and I agree wholeheartedly with your last sentence. Good communication and respect are so important in the doctor/patient relationship. I’m glad Abilify has helped your friend who has bipolar disorder. If I understand correctly (and I might not), these atypical antipsychotics have been more successful in treating bipolar disorder and schizophrenia than OCD.

      • sethgillihan says:

        I’d agree with that statement, Janet, about the use of atypicals for bipolar disorder and schizophrenia. For example, the American Psychiatric Association in its practice guidelines for bipolar disorder (DOI: 10.1176/appi.books.9780890423363.50051) recommends antipsychotic medication (often in combination with other meds like lithium) as a first-line treatment.

      • eventer79 says:

        That has been my understanding. I can’t remember exactly, but he suggested trying it because it was a cousin of something else and we’d really been struggling with anxiety and focus. We’d also tried Adderall (which is, naturally, completely different and we were coming from the ADHD angle) and that GAVE me psychotic (dissociative) experiences that were truly truly bizarre (out of body type things) so my brain does not have good reactions to these types of powerful medications. Pdoc did say he’d had some very good results with them in others, but it certainly wouldn’t be my go to for anyone with an anxiety type disorder!!

      • My son also took Adderall at one point…..a bad choice for him as well. So much trial and error. At least you have a doctor who listens to you, which of course is so important.

  8. Mike says:

    I have been on a mix of clomipramine and lustral for three and a half years now. I started on just clomipramine and found it very effective at reducing my OCD the only side effect was lethargy, which has attenuated with time.

    The lustral was for depression which unfortunately goes hand in hand with my OCD. This combination has been very effective for me but I would still like to come off them if I can. So I will be looking into any Exposure and Response Prevention providers in my area.

    Thanks for the article,

    Mike

  9. You’re welcome, Mike, and thanks for sharing. Both drugs you mention have been helpful for many people with OCD, and, as I’m sure you know, are not atypical antipsychotics. I’m glad you found the right meds to help you and hope you are able to find a good ERP therapist. Good luck as you move forward with treatment!

  10. Azari says:

    The metabolic disturbances from most anti-physicotics do not outweigh the risks in my opinion. I am of the stance that their use should be discontinued due to the facts. Usually doctors favor the second generation for their lesser effects, but even those still pose risks to physiology.

    When I was young I was prescribed various drug argumentation following recommendation from the ADA with accordance of their guidelines for treatment of OCD. Many argumentation were antidepressants and various antiphysichotics.

    I became obese as a result of heavy use of these drugs.

    It shouldn’t be surprising when you step outside your normal physiology and it’s normal energy homeostasis that it can have dire effects on metabolism.

    For example many antiphysicotics have effects on glucose metabolism. So influencing uptake such that it’s is not facilitated in myocytes and leading to chronic hyperglycemia is just asking for trouble with insulin. Alter triglyceride levels is asking for trouble with fatty livers and obesity.

    The neural pathways involved the various energy homeostatic mechanisms such as feeding, energy equilibrium and dynamics are all influenced by these drugs and can theoretically set one’s biology up for a various pathogenic conditions (in chronic use). Biology adapts to environment and the endocrine system maintains this equilibrium. I sometimes feel that the medicine paradigm needs to go back to it’s roots in biology.

    Recently the NIH has found a correlation with T2D and antipyschotic use among children. It’s not surprising given the above facts. It’s also interesting to note that the obesity problem in mental health patients around the world.

    Of course a psychiatrists will usually default to phrase such as “not everyone develops these conditions” as justification for their continued use. I would suggest that he/she would not neglect genetics and phenotype. I would further note that many “lean” individuals can still develop T2D in the abstinence of obesity via chronic hypoglycemic environment.

    Obesity is caused by many underlining factors. So rather you blame it on neuroendocinre factors such as NPY, PPY, Gerhlin, GIP, Leptin, Insulin or specific factors in neural reward circuitry, feeding circuitry, genes or larger factors such as environment, and/or social psychology the fact is the pathology is too complex and should be taken seriously. Most of the damage on these systems is permanent and irreversible so avoiding such a pathological environment is best.

    Diet and exercise don’t step outside energy homeostasis and both influence the dynamics thus can offset later anyways. You don’t get to beat your biology when you are influencing it with drugs.

    Luckily the medical community is catching up with the obesity researchers, but it’s slow and taking time.

    Good news is progress in neuroscience(s) is always getting better for alternatives in anxiety and/or other fear related conditions. So perhaps better drugs will be available

    I follow a lot of PTSD research because I believe a lot of the same pathways involved in PTSD will overlap in OCD and can provide clues and perhaps better pharmacological intervention. Especially since the DoD invests heavily in research on PTSD it tends to get more alternative funding and advance research.

    Plus genetics always holds promise. Each sequencing gives clues to new targets.

    Anyways, my little rant should probably end since it’s becoming too long, but make no mistake these drugs are not candy and should be used with caution.

    In closing, I should mention remission of my OCD came after a self-help book introduced me to “real” CBT/ERP. I was able to achieve remission despite not actively on medication for months. The only thing I regret is the medication. Did I mention one should use caution with these drugs?

    Anyways, I’m a strong proponent of properly administrated ERP. It is the most effective treatment. Keyword is “properly”

  11. Thank you so much for your comprehensive, in-depth comment, and you just confirm how I feel. These drugs have powerful side-effects that cannot be ignored. I am so glad ERP helped you and your last sentences sum it up. Proper ERP works! Thanks again for sharing.

  12. susan says:

    My daughter has OCD, Tourettes and ADHD and was just prescribed an atypical antipsychotic because the tourettes is so bad right now and these meds are indicated to help tics. Has anyone used it for that? (My daughter can’t tolerate ssris.

    • My son seemed to develop some involuntary movements from the atypical antipsychotics, Susan, but he doesn’t have Tourettes. Maybe some of my readers will chime in? Wishing you and your daughter better days ahead.

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