MARA GOVERMAN: Parents often come into treatment hoping an SSRI will make their child's OCD disappear. But how much relief do these medications actually provide? Today, we look at a large meta-analysis that gives us a more realistic picture of what SSRIs can and can't do for pediatric OCD.

JOSH FEDER: I'm Dr. Josh Feder, the editor-in-chief of the Carlat Child Psychiatry Report and co-author of The Child Medication Fact Book for Psychiatric Practice, 2nd Edition 2023, and our other book, Prescribing Psychotropics.

MARA GOVERMAN: And I'm Mara Goverman, a licensed clinical social worker in Southern California with a private practice and an avid reader of the Carlat Psychiatry Reports. SSRIs are one of the most common medications we use for pediatric OCD, but families often ask a tough question, "How much do these medications actually help?"

JOSH FEDER: Okay. Well, we've been working with OCD for decades, you and me, Mara, and we're big proponents of starting with cognitive behavioral therapy for OCD because we'd rather not use medicines if we don't have to. But previously it looked like the research showed that if you prefer medication, medication often worked, especially SSRIs, and particularly in relatively high doses compared to what you might use for anxiety or depression. And then if that didn't work, then maybe clomipramine, which is a little bit more tricky medication, right? It's a tricyclic medication. We like to get EKGs with that one; you have to lock it up because it could be toxic in overdose… But it would be more effective if the SSRIs didn't do the job. So, our previous sense was that these medicines could work really well, but if you can get away with doing it without medicine and doing CBT response prevention, that sort of thing, that would be great, and the combination would be better than either of the two alone, at least the research we had back then. But now we have some additional information. A 2025 study by Cohen and colleagues pooled data from four randomized controlled trials involving more than 600 children and adolescents ages 6 to 18 with OCD.

MARA GOVERMAN: And everyone in the trials receives either an SSRI or placebo for about 10 to 13 weeks, and researchers track symptoms using the Children's Yale-Brown Obsessive Compulsive Scale, or CY-BOCS.

JOSH FEDER: CY-BOCS. Sounds very high-tech. But what's the bottom line? SSRIs outperformed placebo, but the effect actually was modest. On average, SSRIs reduced CY-BOCS scores by about three points more than placebo. Not very much. And we have a great piece that accompanies in this issue on how we read research that we did with Glenn Spielmans that talks about the idea of doing research with scales, right? So, we're not looking at all the different quality of life and stuff like that for people, but it's like a single scale. Now, it's an important scale. The CY-BOCS is excellent in terms of tracking symptoms, but it may be limited. So, this is really disappointing in some ways, but it might not tell the whole story.

MARA GOVERMAN: And so, what you're saying is that these medications can help, but they're not producing dramatic overnight recoveries.

JOSH FEDER: Not here, although we've seen it sometimes in clinical practice, and the more clinically meaningful finding might be response rates. So, kids taking SSRIs turned out to be nearly twice as likely to achieve a treatment response, which they define as at least a 35% reduction in symptoms. So that's another way of kind of looking at the data and trying to figure out, do the medicines work? So, you define what a meaningful response is: 35% reduction. That sounds pretty meaningful just on the face of it. Yeah, if you have SSRIs, twice as likely to respond. So that's something.

MARA GOVERMAN: I guess what you're saying is family and clinicians need to weigh the 35% reduction in symptoms and side effects in determining whether to continue.

JOSH FEDER: Yeah, and again, they're using the side box to determine that 35%, and to your point, what does that really mean in everyday life?

MARA GOVERMAN: So, one finding that stands out is the role of baseline severity. Children with milder OCD improve more, while those with more severe symptoms are less likely to respond.

JOSH FEDER: In fact, every one-point increase in baseline severity lowered the odds of response by about 8%.

MARA GOVERMAN: But severity does not seem to affect partial response rates with a 25% symptom reduction.

JOSH FEDER: So, it gets a little confusing, right? This suggests that SSRIs still kind of take the edge off-even the more severe cases, though they don't often produce full remission on their own. And again, that's a good commercial for combined care, right? Doing medication plus psychotherapy, presumably cognitive behavioral therapy for OCD, which is like this exposure and response prevention usually, and we've covered that in some other articles, and it's worth knowing what that is and talking with families about the combination.

MARA GOVERMAN: Yeah. What you said of the psychoeducation of supporting and educating families during this treatment process is critical to continuity and success. So, I appreciate that. In the trial, the researchers also looked at age, sex, weight, and illness duration, and none of those variables meaningfully changed the outcomes.

JOSH FEDER: So, in addition to using a single scale for the main responses, the study has other limitations. It only lasted for a few months, and we really want to see longer-term kinds of studies to really see year out, whatever, how people are doing. The other thing is that, like in depression, placebo response rates in OCD trials are notoriously high. So, it could be hard to know whether, maybe the medication's doing something, but because there's such a strong placebo impact, which has its own medical kind of thing going on, it may be lost in the placebo response. And then on top of that, they didn't really specify which SSRIs they were looking at and for how many people. So it might be that one or another SSRI may perform a lot better than the others, but we don't know that. And then finally, most of the participants came from North America, which is its own place, its own cultural entity. We have certain conditions like bipolar illness is a great example, where the diagnosis rates are much higher than the rest of the world, and there might be something different about how we diagnose, identify OCD in North America as well.

MARA GOVERMAN: The bottom line is the clinical message feels practical and helpful: SSRIs work for pediatric OCD, but they don't work wonders.

JOSH FEDER: Yeah, that's a key takeaway. Families sometimes hope medication alone will eliminate symptoms, especially in moderate to severe OCD, because that's when they come to us really hurting, right? But this study reminds us that medication is just usually one part of the treatment.

MARA GOVERMAN: For mild OCD, cognitive behavioral therapy with exposure and response prevention remains the first-line treatment, although medication alone can sometimes be reasonable.

JOSH FEDER: Right. When you have a family that isn't able to access a good cognitive behavioral therapy for OCD, which is a common problem; it's hard to find good therapists, then using medication first isn't the worst thing. Or if it's a family history of people responding to a particular SSRI, whether it's for OCD, anxiety, or depression, then maybe that SSRI could be helpful. Or just families who prefer to try medication first. It's definitely okay to think about. But for more severe OCD, SSRIs are often playing more of a supporting role alongside of exposure and response prevention, cognitive behavioral therapy, rather than serving as a standalone.

MARA GOVERMAN: So, it's really important to stress that when we set expectations with families and give them education, and support patients, honesty matters.

JOSH FEDER: Absolutely. SSRIs can reduce symptom intensity and improve functioning, but meaningful recovery usually requires the other treatment too. The government recently came out with a concern about overuse of antidepressants, and SSRIs are officially antidepressants, but we use them for OCD, anxiety, depression. They actually work best in kids for anxiety, and then depression; we have some decent data, especially fluoxetine. Then here we are today talking about OCD, and as a reminder, in higher than, quote-unquote, "usual doses.” But all that said, this statement by the government is, I think, an important one. At the Carlat Child Psychiatry Report, we've been talking for years and publishing in our books and our algorithms the importance of trying to do non-pharmacological things first when we can. Sometimes you really need to be thinking about combination kinds of treatments with medicine and therapies immediately from the outset. But, you know, for instance, there are times when somebody has a sensory problem, and you can go after that, and then they don't have whatever symptom it was, even if it seems like a repetitive compulsive symptom, say, in an autistic kid. The American Psychiatric Association, in response to the government, talked about how medications can be overprescribed, but they're often underprescribed, and I kind of like to underline that balance. I mean, we don't want people overusing medication, but we also don't want people underusing them or stopping medications that are clearly helping them without a significant side effect burden. So, to me, the important thing here is to consider the use of medication, to think about using non-pharmacological approaches when you can, and if you're going to use medication, to make sure you've got good follow-up and you're watching for side effects. I guess there's another thing that we should talk about whenever we're talking about SSRIs, and in our algorithms, we talk about the side effects of SSRIs. Well, what are the side effects of SSRIs? Some people get behavioral activation, meaning they're more impulsive. They look like they have ADHD-type symptoms. If they already have ADHD, it might look a little bit worse. It doesn't happen to everyone, but certainly kids can have this occur. You can also get some people who are more hypomanic or manic, maybe have trouble sleeping, things like that. Pretty rare, but it can happen, and in about 1% of people, you get new suicidal thinking, and that's why we need close follow-up. So even though these medicines tend to reduce suicidal thinking most of the time, rarely, it might create it, and so that's why you need good follow-up. It's not a reason to avoid the medications altogether. It is a reason to have good follow-up and to use them carefully. And finally, the things that are probably most common problems with SSRIs and are going to be more what any clinician's gonna run into when prescribing them are carbohydrate craving, which is not as bad as other psychotropic medications like many of the antipsychotics, but also sexual side effects. So, teenagers who, unless you ask them, aren't going to tell you that, for instance, having trouble with erections or having trouble coming to orgasm, those kinds of things. So, it all kind of comes to the same point, which is we have to do good assessments and evaluations. CYBOCS is a great thing to use with OCD but get the rest of the picture as well about how people are functioning. Think about all your choices for care, including psychotherapies like cognitive behavioral therapy for OCD as well as medications. Give good, informed consent. Have people make choices based on their culture and values as a family, and then provide good, solid follow-up so you can track for how well treatment is going and for side effects.

MARA GOVERMAN: Today's podcast is inspired by a review in our April/May/June 2026 newsletter. We'll link it in the show notes. And if you found this episode valuable, which we sure hope you did, please share it with others who need to hear this message.

JOSH FEDER: Everything from Carlat Publishing is independently researched and produced. There's no funding from the pharmaceutical industry.

MARA GOVERMAN: The newsletters and books that we produce depend entirely on reader support. There are no ads, and our authors don't receive industry funding, which helps us to bring you unbiased information that you can trust.