Cognitive Behavior Therapy Augmentation of Pharmacotherapy in Pediatric Obsessive-Compulsive Disorder

Abstract

Context The extant literature on the treatment of pediatric OCD indicates that partial response to serotonin reuptake inhibitors (SRIs) is the norm, and that augmentation with short-term OCD-specific cognitive behavior therapy (CBT) may provide additional benefit. Objective To examine the effects of augmenting SRIs with CBT or a brief form of CBT, instructions in CBT (I-CBT) delivered in the context of medication management (MM). Design A 12-week, 3 (site: Penn, Duke, Brown) × 3 (treatment conditions: MM, MM+I-CBT, & MM+CBT) × 4 (repeated measures: weeks 0, 4, 8, & 12) randomized controlled trial. Setting The outpatient clinics of three academic medical centers between 2004 and 2009. Participants Outpatients (N = 124) between the ages of 7–17 with primary OCD and a Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) score ≥ 16 despite an adequate SRI trial. Interventions Participants were randomized to receive 12 weeks of: 1) MM (7 sessions), 2) MM+I-CBT (7 sessions) or 3) MM+CBT (7 sessions of MM plus 14 concurrent CBT sessions). Main Outcome Measures Responder status as defined as a post-treatment CY-BOCS reduction of 30% or greater compared to baseline; change in continuous CY-BOCS total score over 12 weeks. Results MM+CBT was superior to MM and to MM+I-CBT on all outcome measures. In the primary ITT analysis, 68.6% in MM+CBT (95% confidence interval [CI], 53.9%–83.3%) were considered responders, which was significantly better than the 34.0% in MM+I-CBT (95% CI, 18.0% to 50.0%), and 30.0% in MM (95% CI, 14.9% to 45.1%). Planned pairwise comparisons show that MM+CBT was superior to both MM and MM+I-CBT (p < 0.01 for both). MM+I-CBT was not statistically significant from MM (p = 0.72). The number needed to treat (NNT) with MM+CBT versus MM to see one additional RESPONSE at Week 12, on average, was estimated as 3; for MM+CBT versus MM+I-CBT the NNT was also estimated as 3 ;for MM+I-CBT versus MM the NNT was estimated as 25. Conclusion Among patients age 7–17 with OCD and partial response to SRI use, the addition of CBT by a psychologist to medication management compared with medication management alone resulted in a significantly greater response rate, whereas, augmentation of medication management with the addition of instructions in CBT by the psychiatrist did not. Dissemination of full CBT augmentation for pediatric OCD partial responders of SRI should be an important public health objective.

Quality of life in children with OCD before and after treatment

“…In the NordLOTS study, responders were defined by a CY-BOCS score of <16. This definition was based on the experience in the Pediatric OCD Treatment Study, in which the same value was used to define clinically relevant OCD symptoms [67]. Another reason for the comparably high cut-off score was the fact that nonresponders were later randomized to receive either CBT or a selective serotonin reuptake inhibitor (SSRI).…”

Evidence-Based Treatments in Treatment-Naïve and Treatment-Resistant Pediatric Obsessive-Compulsive Disorder

“…Second, when CBT expertise is absent, treatment-naïve patients can confidently be treated with an SSRI. However, if they do not respond, previous studies indicate that the addition of full CBT may be necessary to obtain a response [59].…”

“…Despite that combining CBT and SSRIs may be necessary and in fact much more effective than continuing with an SSRI alone, even for those that do not respond to SSRIs [59].…”

Optimal management of pediatric obsessive-compulsive disorder

“…Between 40% and 70% of OCD patients treated with a serotonin reuptake inhibitor alone do not respond adequately to treatment, 49,52,[58][59][60] and full symptom remission from serotonin reuptake inhibitor monotherapy is infrequent. 36,49,50 An adequate dose of serotonin reuptake inhibitor therapy is defined as a minimum of 10 weeks of serotonin reuptake inhibitor therapy at maximum recommended or maximum tolerated doses, with no change in dose for the preceding three weeks.…”