Increase meds or just keep trying to fight this with CBT?

[leif]

Just wondering about people that meds have worked for--have you had to keep increasing, or have you remained on the same dose for a number of years.

I'm on a relatively low dose of sertraline and am wondering if I should increase. I am doing CBT stuff as well but just struggling a lot.

I am afraid to increase the meds I case I need to keep increasing all the time and will be left eventually with nowhere to increase to once I've hit the maximum dose.

I keep hoping I can get through this with just CBT but I'm not sure I can.

[dksea]

With the usual caveats (I am not a pharmacist or a doctor, medication for OCD does not work the exact same for everyone, etc.) here goes:

I can understand the fear you are facing, the idea that the meds might stop working one day, or you will need to keep increasing and have nowhere to go.  Its a very relatable problem.  Keep in mind that the question itself has a bit of OCD attached to it, worrying about possible future scenarios that we can't know for sure.  

OCD medication does not work like, say illicit drugs, where you need to keep taking more and more to get the same result.  For the most part your body does not build up a tolerance to these kind of drugs.  There are some cases where a particular drug seems to lose its effectiveness (the term Prozac poop-out is one you may have come across for example).  In such cases there are a number of options the doctor and patient can pursue.  Increased dosage is one possibility, switching to a different medication is another, sometimes a second helper drug is added while the patient keeps taking the original drug.  However even these situations are not necessarily permanent either.  You might, after stabilizing and experiencing no problems for awhile be able to back down to a lower dose and be fine.  You might switch to a different drug for a period but later return to the original without issue.  The exact reasons for why the medication at a particular level seem to be less effective is not well understood and can vary from person to person.  It might be something temporary like increased stress, physiological changes due to environment, illness, aging, etc.  There is just really know way of knowing what the future will hold for you and your medication needs.  While I can understand that you want to try and "save" some room for higher dosages later, if you need them now to help you regain control (and quality) of life, then you and your doctor should do whats needed now.  Later, down the line you can consider your options if some other change becomes necessary.

I can't speak for all medication users, but I can share my own experience.  I have been taking SSRIs for OCD since I was 13, so about 25 years now.  In that time I have changed meds once about 15 years ago now (fluoxetine to citalopram/escitalopram) and while on both I've gone up and down on the dosage level depending on my general handling of the OCD over that time.  I've been at the same dosage level for quite some time now, when I tried to go below the current level I experienced some noticeable relapse symptoms, so for me this seems to be the just right level.  It can take time to find that level, and if you're current level is not sufficient then its reasonable to go up a dose if agreed to by your doctor.

 

27 minutes ago, leif said:

I keep hoping I can get through this with just CBT but I'm not sure I can.

CBT is definitely important, I wish I had had more of it when I was first starting to deal with OCD.  For some people CBT alone will meet there needs, but not everyone can take that path, some of us need the additional support medication can provide, and thats ok too.  The important part is to help you get things back under control.  Perhaps, in time you'll be able to use the CBT alone and you won't need the medication.  Or you'll be like some of us who use medicine long term.  None of us can know what your future holds, keep it in mind of course, but remember that the present is where the most important focus is. Good luck.

 

[leif]

Thank you so much for your thorough, thoughtful and knowledgeable reply dksea. I really appreciate that. It answers a lot of my questions...yes as you say the uncertain element around meds is another thing for the ocd to play with. That's very encouraging that you've been on the same meds for so long and seem to be doing well with that.

I'm sure I'll keep up my internal debate about increasing but I'm tending more toward it as time goes on. I am certainly glad that the meds do seem to help me, as I know they don't work for everyone.

I really appreciate your presence on this forum. I always find your advice to be really good.

[dksea]

@leif - Thanks for the compliments, thats very gratifying to hear!  The forums were here and helpful for me when I was going through a period of struggle so I'm glad to be able to return the favor and help others along the way with their own OCD struggles.  It adds a small bit of silver lining to the otherwise not so great aspects of this disorder!

Yes, its very frustrating that our knowledge of psychopharmacology is still so limited that we basically have to take a guess and try when it comes to things like SSRI's.  Perhaps someday they will be able to do a test that will tell them which drug and what level is best for each patient.  Of course a cure would be even better!  

I definitely recommend discussing your dosage levels with your doctor and see what they say, if they are supportive going up to the next dosage level might make a big difference.  I feel like, for me at least, that once its above the required level being on higher doses doesn't change anything, so its not as if more == better, its just that you need to get the right amount to fully trigger whatever switch it is that needs to be flipped to get closer to "normal".  I hope you are able to find the relief you need and maybe in time you'll be able to lower your dosage back again.  If not though, at least we have tools that work for us!

 

[taurean]

For some people, the right med does a lot more than just give them "water wings" to give them support and help them engage with therapy (I reckon my 20mg of Citalopram balances mood swings and aids my resilience). 

For these persons, there really does seem to be a chemical change in brain chemistry, and neurotransmission, that really makes a difference to their tackling their OCD. 

My sister takes fluoxetine. When she tried to reduce her dose the OCD came back with a vengeance, so it seems maybe she falls into this category. 

I remember PolarBear and Whitebeam reporting in with this meds need also. 

Like Dksea, I fervently hope that in the future it will be possible for medics to ascertain a truer picture of who might benefit from what meds - meanwhile it's, sadly, trial and error. 

 

Edited March 29, 2019 by taurean

[leif]

9 hours ago, dksea said:

I definitely recommend discussing your dosage levels with your doctor and see what they say, if they are supportive going up to the next dosage level might make a big difference.

Yes my doctor would like to see me increase. However, I find doctors tend to stress the meds too heavily so I hesitate to immediately take their advice. Where I live there is no free CBT therapy provided. So the doctors tend to stress meds over therapy whereas I tend to think it should be the other way around! That's why I actually value advice on here since people seem to be very aware that the CBT is just as or maybe even more important than meds.

9 hours ago, taurean said:

My sister takes fluoxetine. When she tried to reduce her dose the OCD came back with a vengeance, so it seems maybe she falls into this category. 

Yes that's what happened to me a few years back when I tried to come off even my low dose. My OCD was more severe than it had ever gotten to before I tried meds for it! So that may be an indication that for me I am one of those that really does respond to meds! But also why I hesitate to go up on meds in case I can never come back down without having a terrible relapse!

[taurean]

2 hours ago, leif said:

Yes my doctor would like to see me increase. However, I find doctors tend to stress the meds too heavily so I hesitate to immediately take their advice. Where I live there is no free CBT therapy provided. So the doctors tend to stress meds over therapy whereas I tend to think it should be the other way around! That's why I actually value advice on here since people seem to be very aware that the CBT is just as or maybe even more important than meds.

Yes that's what happened to me a few years back when I tried to come off even my low dose. My OCD was more severe than it had ever gotten to before I tried meds for it! So that may be an indication that for me I am one of those that really does respond to meds! But also why I hesitate to go up on meds in case I can never come back down without having a terrible relapse!

But maybe for some they do truly need the meds as well as CBT. 

I don't think that is how I am with the meds and, once I have our home all sorted with new draperies and blinds, and a re-landscaped back garden, I intend to work down from 20mg to 10mg of Citalopram and see how that goes. 

Ideally I am aiming to come off the meds altogether, if this proves possible. 

[leif]

On ‎29‎/‎03‎/‎2019 at 11:57, taurean said:

But maybe for some they do truly need the meds as well as CBT. 

yes definitely! I'm not against using meds at all and am super grateful that they do seem to help me...I just feel that sometimes there can be too much emphasis on the meds, partly because we don't have good coverage where I am for CBT.

 

On ‎29‎/‎03‎/‎2019 at 11:57, taurean said:

I don't think that is how I am with the meds and, once I have our home all sorted with new draperies and blinds, and a re-landscaped back garden, I intend to work down from 20mg to 10mg of Citalopram and see how that goes. 

I hope it goes well for you Taureen! At least you will have a good knowledge base to work from as you try to cut back.

[dksea]

On 31/03/2019 at 04:57, leif said:

.I just feel that sometimes there can be too much emphasis on the meds, partly because we don't have good coverage where I am for CBT.

I agree that sometimes a practitioner will focus more on the pharmaceutical side of treatment than the therapeutic side, my first OCD doctor was definitely in that camp and it wasn't until years later that I even learned about CBT.  While I am eternally grateful to her for diagnosing my OCD and prescribing the medication to me (meds for adolescents/teens was not super common for OCD at that point), in retrospect I wish I had been given CBT at the time as well.  So your concern IS valid. 
Having said that, I think your situation is also different.  It seems you are well aware of CBT and what it has to offer and are invested in continuing to pursue CBT treatment.  In the meantime you have the option of medication available to you, and if it can provide you with relief I think thats a pretty good reason to consider it, especially if you have tolerated the medication well up til this point.  Remember, taking medication doesn't rule out continuing CBT, they aren't exclusive of each other, and treatment with both has been found to be. more effective than treatment with either approach alone!

[leif]

 

@dksea I have begun my increase...thanks again for your support!

I wish I could get professional help with the cbt as I think I would do well with extra support with it, but so it goes...I'm glad to have at least a fairly good understanding of it through workbooks. And yes will continue with it best I can along with the increase of meds!

 

 

Edited April 4, 2019 by leif