Podcast Summary: “Dr Steven Poskar: Medications for OCD” – The OCD Stories #510

Host: Stuart Ralph
Guest: Dr. Steven Poskar (Psychiatrist, Clinical Director of OCD nyc)
Release Date: November 2, 2025

Overview

In this episode, Stuart Ralph interviews Dr. Steven Poskar, an OCD-specialist psychiatrist, to explore medications used in treating OCD. The discussion centers on breaking down myths, comparing medication options, augmenting with other drugs, tapering off, and emerging areas like psychedelics and cannabis. Dr. Poskar provides nuanced insight and a strong message about integrating therapy and medication for optimal outcomes.

Dr. Poskar’s Journey & Philosophy

• Late Entry into Psychiatry
  • Dr. Poskar was inspired by a family member’s late-onset OCD and found parallels between OCD treatment, philosophy, and Buddhism.
  • He returned to school at 28, starting medical school at 30 (03:47).
  • Chose psychiatry specifically to treat OCD, valuing versatility:

    “To me, it was more, I'm going to be an OCD specialist. And therefore, whatever treatments are used to treat OCD, I want to know them and be able to access them all.” (05:14)

• Importance of Combined Approach
  • Emphasizes therapy as the cornerstone, with medication to “bring down the volume” so therapy can be accessed:

    “If I had to choose between using therapy or medicine, it's not even close. Right. It's always going to be therapy.” (06:34)

  • Describes a roughly "thirds" approach—some patients only need therapy, some only meds, some both (05:14).

Myths & Misconceptions About OCD Medication

• Personality Change Fear
  • “It's actually quite the opposite... the medicine can help the disease and allow your actual [self] to be who you really are.” (07:58)
  • Notes rare emotional blunting but says most patients, including artists, find their abilities improve.
• The “OCD Drug” Myth (Luvox/Fluvoxamine)
  • Luvox isn’t superior; it was just first approved for OCD due to regulatory strategy (08:44).
• Serotonin Imbalance Myth
  • No evidence for “low serotonin” theory in OCD.

    “You can't assume that, oh, if this helped me be more awake, then the reason I was sleepy was because I had low caffeine.” (10:30)

  • Disease viewed as circuitry issues rather than a neurotransmitter imbalance (12:00).
• Mechanisms Remain Unclear
  • While SSRIs work for OCD, exactly why is still a mystery (13:57).

SSRIs and Medications for OCD

• First Treatments (15:12)
  • Clomipramine (a tricyclic) was the earliest effective OCD med.
  • SSRIs followed due to efficacy and fewer side effects. Major SSRIs:
    • Sertraline (Zoloft)
    • Fluoxetine (Prozac)
    • Fluvoxamine (Luvox)
    • Citalopram (Celexa)
    • Escitalopram (Lexapro)
    • Paroxetine (Paxil)
  • All are comparably effective for OCD, choice guided by side effect profile.
• Side Effect Profiles (17:37)
  • Paroxetine (Paxil): more sedation, weight gain, sexual dysfunction.
  • Choice is individualized, sometimes guided by family history or metabolism.
  • “One man's adverse effect is another man's great effect.” (18:02)
• Dosing for OCD
  • Doses are significantly higher for OCD than for depression or anxiety (44:08).

Special Considerations

• Children/Teens
  • “The effectiveness of the drugs does not appear different” for children (19:25).
• Tapering Off Medication (19:57)
  • Always provide informed consent; about 5% may not regain their response if symptoms recur.
  • Taper “really, really slowly”—drop a dose, wait two months, repeat.
  • Prefer at least one year of solid wellness before considering taper.
  • The importance of therapist/psychiatrist collaboration:

    “If you're super busy and you can't talk to people or get...information from psychologists, then you maybe should be seeing less patients.” (23:16)

Augmentation & Emerging Medications

• Adding Antipsychotics (24:48)
  • If SSRIs don’t work, low-dose antipsychotics (especially Risperidone/Risperdal and Aripiprazole/Abilify) can help about a third of non-responders.
  • Side effects: metabolic syndrome, movement disorders.
  • Cautions against being too quick to prescribe:

    “People are a little bit too cavalier with them.” (26:59)

• Glutamate Modulators (27:42)
  • Riluzole, Memantine, Ketamine, Lamotrigine, and others explored; less data, generally safer than antipsychotics.
  • May help subgroups depending on individual brain chemistry.

    “OCD is a heterogeneous condition…maybe some people have OCD in those circuits because glutamate's the issue…” (32:20)

• On Dansetron: Some promise, but not robust (33:05).

Benzodiazepines and Anxiety (34:44)

• Not used for OCD as they don’t target obsessions/compulsions.
• Sparing use for anxiety only; PRN use discouraged (“can become another compulsion”).
• Prefer scheduled baseline dosing if used at all, short-term.
• Always screen for history of addiction.

Psychedelics and Cannabis

• Psychedelics (psilocybin, MDMA, LSD) (37:16)
  • Research is early; some promising results in depression, small studies underway for OCD.
  • Not ready for clinical use outside of controlled research settings.
  • Warns of risks and “bad trips” without supervision:

    “My biggest concern is...people are restless…and are going to go out and use these drugs on the street.” (39:34)

• Cannabis (41:58)
  • No evidence for efficacy in OCD; Dr. Poskar advises against regular use as it can insidiously impact functioning (42:10).

Reasons for Medication Failure

• Under-dosing (44:08)
  • Many people haven’t been on adequate doses long enough.
• Co-occurring Conditions (44:29)
  • Undiagnosed ADHD can prevent progress; treating it often helps both ADHD and OCD.
• Trial Duration (46:46)
  • Need 8-12 weeks minimum at target dose before ruling a medication out.

Supplements & Vitamins

• N-acetylcysteine (NAC): Ineffective for OCD, may help hair pulling/skin picking (51:03).
• Omega-3s, Inositol, Tryptophan: Not impressive for OCD; focus on overall healthy diet.

• “I don't recommend any to my patients, nor do I know anybody that does.” (52:13)

Notable Quotes & Moments

• On Therapy vs. Medication:

  “The job of medicine really is to decrease the volume of the symptoms so that they can access the therapy and do a better job.” (06:34)

• On Medical Collaboration:

  “That’s part of your job...to not get collateral information is...not doing your job.” (23:32)

• On OCD as ‘Slavery’:

  “There's no two ways about it. OCD is slavery. Right. You're just a slavery to this thing in your brain that makes. Tells you what you can do, what you have to do here...freedom is scary, but it’s not much of a life without it.” (49:48)

• On Learning:

  “Try to learn and don't make learning stressful...being okay, not knowing, which is what we teach all our OCD patients.” (48:46)

Key Segment Timestamps

• 02:45: Dr. Poskar’s therapy/medical journey
• 06:34: Therapy versus medicines for OCD
• 07:57: Myths about medication (personality, Luvox, serotonin)
• 13:57: How SSRIs work for OCD—uncertainty
• 15:12: Overview of SSRIs used in OCD
• 17:37: Choosing SSRIs based on side effects and individualization
• 19:57: Weaning off medication – risks and recommendations
• 24:48: Augmentation with antipsychotics
• 27:42: Glutamate-based medications and other augmentation strategies
• 34:44: Benzodiazepines – limited use in OCD
• 37:16: Psychedelics—current research and concerns
• 41:58: Cannabis—lack of evidence and clinical caution
• 44:05: Common reasons for medication failure
• 51:03: Supplements and vitamins—general stance

Conclusion

This episode delivers a thorough, practical, and accessible exploration of medications in OCD treatment. Dr. Poskar underlines the necessity of individualized care, close coordination with therapists, the primacy of well-dosed, well-timed SSRIs, and careful deliberation when considering augmentation or experimental treatments. He offers a compassionate, science-driven, and honest perspective—essential listening for anyone weighing medication decisions in their OCD journey.