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In 2004, the well-known pediatric OCD treatment study also known as POTS study revealed that CBT and sertraline had comparable benefits over 12 weeks of treatment for children with OCD. Yet this study left us with a few unanswered questions.  For instance, for those who don’t respond to initial CBT therapy, should we continue CBT or switch to an SSRI like sertraline.

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Published On: 12/2/2021

Duration: 6 minutes, 32 seconds

Referenced Article: “Long-Term Treatment Response in Pediatric OCD,” The Carlat Child Psychiatry Report, March 2021

Joshua Feder, MD, has disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.

Transcript:

Dr. Feder: Hi I’m doctor Josh fader the editor in chief of the Carlat Child Psychiatry Report and in today’s episode of 60 seconds psych I’ll be talking about a recent study that explored the long-term treatment outcomes for children with obsessive compulsive disorder. 

In 2004, the well-known pediatric OCD treatment study also known as POTS study revealed that CBT and sertraline had comparable benefits over 12 weeks of treatment for children with OCD. Yet this study left us with a few unanswered questions.  For instance, for those who don’t respond to initial CBT therapy, should we continue CBT or switch to an SSRI like sertraline. Since the 2004 POTS study, many studies have tried to uncover these questions, but between these studies there has been substantial heterogeneity in study types, differing lengths of treatment, and large disparities between their follow-up period durations, as well as small sample sizes, making it very difficult to compare results between these follow-up studies. But the 2020 Nordic Long-term OCD Treatment Study, called NORDLOTS, addressed many of the unknowns surrounding the long-term treatment outcomes for pediatric OCD.

This 2020 study by Dr. Karin Melin and colleagues set out to determine whether non-responders to initial CBT had poorer long term outcomes, and whether non-responders had better long-term outcomes with continued CBT vs switching to sertraline. Additionally, they wanted to see if response to initial CBT was an indicator for long-term improvement.

The NORDLOTS study enrolled 269 children and adolescents, ages 7-17 (mean age 12.8 years old), with a DSM-IV diagnosis of OCD and a total OCD symptom severity score of greater than or equal to 16 on the Children’s Yale-Brown Obsessive-Compulsive Scale, or CY-BOCS. Participants were recruited from clinics across Sweden, Norway, and Denmark. All patients were given weekly manual-based exposure-based CBT, with family interventions, for 14 weeks. Treatment response was designated at a CY-BOCS score of 15 or less, and remission was set at a score of 10 or less. Those who did not respond to initial CBT were randomized to 16 weeks of either continued CBT or a switch to sertraline. Continued CBT consisted of 10 additional sessions focused on identifying any obstacles that may have negatively affected progress in step 1 CBT. And the sertraline group had 6 sessions guided by a pharmacotherapy manual based off of the manual used in the POTS study. Sertraline was slowly titrated up from a starting dose of 25 mg/day to 100 mg/day over the course of 4 weeks, and the dose was increased to a maximum of 200 mg/day if needed. Follow-up assessments were conducted at 6-months, 1-year, 2-years, and 3-years after completion of initial CBT. Boosters and additional CBT or sertraline were offered to participants over the follow-up period to mimic clinical practice. 

About 65% of all participants responded to initial CBT, and these responders maintained their treatment effect with a significant decrease in their CY-BOCS total scores at 1-year follow-up. 

After 3 years, 90% of the total sample were responders, and 73% (n = 196) of kids were in remission with 24% scoring 0 on the CY-BOCS. Another 17% (n = 46) had mild symptoms (CY-BOCS 11–15), and only 10% had moderate to severe symptoms and did not meet criteria for treatment response. 

Non-responders to initial CBT had significantly more severe OCD symptoms at baseline (CY-BOCS 26.4 vs 23.8, p < 0.001) but showed comparable improvement at 2-year follow-up (CY-BOCS 9.6 vs 5.6, p < 0.001) and caught up with responders at 3-year follow-up (CY-BOCS 5.0 for both). Surprisingly, non-responders to initial CBT did equally well with continued CBT vs a switch to sertraline. 

On the secondary outcome measure of Children’s Global Assessment Scale, the total sample of participants showed significant improvement in functioning at 3-year follow-up. 

During the follow-up period, approximately 20% of all participants had further OCD-specific treatment, most of which had one specific form of additional treatment. 

As a bottom-line message, long-term prognosis of pediatric OCD did not differ between those who respond to initial CBT and those who require additional treatment. If a child doesn’t respond to initial CBT, then you can consider extending CBT treatment or a switch to an SSRI. And it’s important to regularly assess patients for at least 2 years after an effective response to treatment has been achieved. Also, offer booster sessions or additional treatment to patients who may need it during your reevaluations. 

This study shows that in kids, SSRIs are just as effective for those who don’t benefit from or cannot access CBT. Either treatment works better when started earlier and coupled with ongoing monitoring. With good treatment, long-term prognosis for pediatric OCD is excellent.

Thanks for listening and have a great day!

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