Continued cognitive-behavior therapy versus sertraline for children and adolescents with obsessive–compulsive disorder that were non-responders to cognitive-behavior therapy: a randomized controlled trial

Abstract

Expert guidelines recommend cognitive-behavior therapy (CBT) as a first-line treatment in pediatric obsessive–compulsive disorder (OCD) and the addition of selective serotonin reuptake inhibitors when CBT is not effective. However, the recommendations for CBT non-responders are not supported by empirical data. Our objective was to investigate the effectiveness of sertraline (SRT) versus continued CBT in children and adolescents that did not respond to an initial course of CBT. Randomized controlled trial conducted in five sites in Denmark, Sweden and Norway, 54 children and adolescents, age 7–17 years, with DSM-IV primary OCD were randomized to SRT or continued CBT for 16 weeks. These participants had been classified as non-responders to CBT following 14 weekly sessions. Primary outcomes were the CY-BOCS total score and clinical response (CY-BOCS <16). The study was a part of the Nordic Long-Term OCD Treatment Study (NordLOTS). Intent-to-treat sample included 50 participants, mean age 14.0 (SD = 2.7) and 48 % (n = 24) males. Twenty-one of 28 participants (75 %) completed continued CBT and 15 of 22 participants (69.2 %) completed SRT. Planned pairwise comparison of the CY-BOCS total score did not reveal a significant difference between the treatments (p = .351), the response rate was 50.0 % in the CBT group and 45.4 % in the SRT group. The multivariate χ2 test suggested that there were no statistically significant differences between groups (p = .727). Within-group effect sizes were large and significant across both treatments. These large within-group effect sizes suggest that continued treatment for CBT non-responders is beneficial. However, there was no significant between-group differences in SRT or continued CBT at post-treatment.

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

“…When the results of CBT are attenuated for some reason, the addition of medication may be important [20]. However, continuing CBT beyond a standard trial of 14 sessions seems to be a viable option [50].…”

“…No significant differences between the groups were found for the primary outcomes. However, both groups seemed to benefit from the treatment [50]. Preliminarily, clinicians should thus evaluate whether switching to an SSRI could be a better choice for pediatric OCD CBT non-responders with comorbid tic disorder as shown in a post hoc analysis within the same study [51].…”

Defining cognitive-behavior therapy response and remission in pediatric OCD: a signal detection analysis of the Children’s Yale-Brown Obsessive Compulsive Scale

“…Established cutoffs can assist in decision-making for instance by informing whether to switch or augment treatment in the absence of response, continue treatment in the presence of response without remission or provide boosters sessions rather than regular treatment in the presence of remission. For example, if a patient does not obtain 35% symptom reduction after 14 weeks of CBT the clinician might consider adding or switching to SSRI [37]. However, if the patient has obtained at least 35% symptom reduction but still has a high CY-BOCS total score (above 11) he should receive further CBT sessions until he reaches the threshold of remission.…”

De dwangstoornis bij kinderen en jongeren, verklaringsmodellen en behandeling: een overzicht van nieuwe ontwikkelingen

“…Een Nederlandse studie (Wolters et al in voorbereiding) en een Scandinavische, de Nordlotstudie (Skarphedinsson et al 2014). In beide studies bleek het voortzetten van de CGT effectief.…”

“…Het aantal patiënten in remissie (CY-BOCS-score < 12) na voortzetting was 55 % (Skarphedinsson et al 2014) en 47 % (Wolters et al in voorbereiding). In het onderzoek van Skarphedinsson en anderen werd de voortgezette CGT vergeleken met een combinatie van CGT en medicatie (sertraline).…”