REVIEW OF: Melin K et al, J Am Acad Child Adolesc Psychiatry 2020;59(2):244–253

OCD affects 1%–4% of children and adolescents and can be chronically debilitating in 40%–60% of cases.

The well-known Pediatric OCD Treatment Study (POTS) published in 2004 showed that CBT and sertraline had comparable benefits over 12 weeks of treatment; however, it left us with questions about whether we should continue CBT or recommend pharmacotherapy for youth who do not respond to CBT in 12–16 sessions. Also, given the chronic course of OCD in many patients, questions persist about how treatment options compare in the long run. The current study tried to find answers to the latter.

The Nordic Long-term OCD Treatment Study (NordLOTS) enrolled 269 children and adolescents (ages 7–17 years) with OCD from clinics across Sweden, Norway, and Denmark. Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) scores were used as inclusion criteria (> 15) and to deem subjects as responders (0–15), non-responders (16–40), or in remission (0–10).

All participants were treated with 14 weeks of manualized exposure-based CBT. Non-responders to weekly CBT (n = 64) were randomized to continued CBT (n = 28) for 10 more sessions or switched to sertraline (n = 26) titrated at 25–200 mg over 16 weeks. Subjects were followed periodically for 3 years.

After 3 years, 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). Those who responded well to initial CBT (65%, n = 177) continued to do well with minimal additional intervention.

Non-responders to initial CBT had significantly more severe OCD 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.

Only 27% of the participants had a chronic course in this study (17% mild and 10% moderate to severe), perhaps due to early initiation of quality treatment (average 1.2 years after onset of symptoms).

CCPR’s Take
Quality manualized exposure-based CBT remains an excellent approach for pediatric OCD, but some kids need continued treatment for adequate response. In contrast to adult studies showing that CBT benefits may endure better than medication treatment once treatment ends (Ponniah K et al, J Obsessive Compuls Relat Disord 2013;2(2):207–218), 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.