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Cognitive Behavior Therapy, Sertraline, and Their Combination for Children and Adolescents with OCD 

Cognitive Behavior Therapy, Sertraline, and Their Combination for Children and Adolescents with OCD
Chapter:
Cognitive Behavior Therapy, Sertraline, and Their Combination for Children and Adolescents with OCD
Author(s):

Falisha Gilman

, and Zheala Qayyum

DOI:
10.1093/med/9780190625085.003.0012
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Children and adolescents with OCD should begin treatment with the combination of CBT plus a selective serotonin reuptake inhibitor or CBT alone.

POTS Investigators1

Research Question:

To assess and compare the efficacy of sertraline, cognitive behavioral treatment (CBT), and their combination, in the initial treatment of children and adolescents with clinically significant obsessive-compulsive disorder (OCD).

Funding:

National Institute for Mental Health (NIMH)

Year Study Began:

1997

Year Study Published:

2002

Study Location:

Duke University, University of Pennsylvania, and Brown University

Who Was Studied:

Outpatients 7 to 17 years old with a DSM-IV diagnosis of OCD, Children’s Yale–Brown Obsessive Compulsive Scale (CY-BOCS) total score ≥16, NIMH Global Severity Score >7, IQ >80, and who have been off of anti-OCD medications prior to initiation of the study. Patients with attention-deficit/hyperactivity disorder (ADHD) who had been stably medicated with psychostimulants for 3 consecutive months were included.

Who Was Excluded:

Patients with major depression or bipolar illness, a primary diagnosis of Tourette disorder, pervasive developmental disorders, psychosis, simultaneous treatment with psychotropic medication or psychotherapy outside the study, a history of two or more unsuccessful trials of a selective serotonin reuptake inhibitor (SSRI) or CBT for OCD, intolerance of sertraline, pregnancy, and children previously treated who had complete or near complete remission of symptoms.

How Many Participants:

112

Study Overview:

See Figure 12.1 for a summary of the study design.

Figure 12.1 Summary of Study Design

Figure 12.1 Summary of Study Design

notes: OCD = obsessive-compulsive disorder. CBT = cognitive behavioral therapy.

Study Intervention:

Patients assigned to treatment with sertraline or placebo were clinically monitored by one child and adolescent psychiatrist (CAP) who oversaw medication titration and provided general support to cope with OCD symptoms. The CAP saw patients weekly for the first 6 weeks during titration of sertraline from 25 mg to 200 mg. After reaching maximum dose, adjustments were only made if there was an adverse drug event. For the remaining 6 weeks, patients met every other week with the CAP, totaling nine visits over 12 weeks. Psychotherapy specific for OCD was not allowed in groups receiving sertraline or placebo alone.

CBT consisted of two visits during the first two weeks of the intervention, followed by 10 one-hour long sessions every week. Therapeutic interventions included psychoeducation, self and parental monitoring of OCD symptoms, exposure and response prevention, and developing cognitive based strategies to resist OCD symptoms.

Patients with combination of CBT and sertraline medication management (placebo or sertraline) started interventions simultaneously. To decrease inconvenience and increase compliance, medication and therapy appointments were scheduled to be around the same time. Protocols were conducted independently, so changes in one protocol did not alter the other protocol.

Patients were assessed by the same independent masked evaluator.

Follow-Up:

12 weeks

Endpoints:

Change in CY-BOCS score over 12 weeks; “rate of clinical remission,” defined as a CY-BOCS score ≤10

Results

  • Combined sertraline and CBT treatment was statistically superior to all of the other groups for the CY-BOCS outcome measure, though was not statistically superior to the CBT group for the remission rate measure.

  • The sertraline and CBT monotherapy groups were not significantly different from each other on either measure.

  • On the remission rate measure, sertraline alone did not differ from placebo; however, CBT alone was superior to placebo.

  • All three active treatments were well tolerated (Table 12.1).

Table 12.1 Summary of the POTS Key Findings at 12 Weeks

Outcome

CBT

P value

Sertraline

P value

CBT + Sertraline

P value

Placebo

Mean CY-BOCS

14.0

0.003

16.5

0.007

11.2

0.001

21.5

Rate of clinical remission (95% CI)

39.3% [24%, 58%]

21.4% [10%, 40%]

53.6% [36%, 70%]

3.6% [0%, 19%]

notes: POTS = Pediatric OCD Treatment Study. CBT = cognitive behavioural therapy. CY-BOCS = Children’s Yale–Brown Obsessive Compulsive Scale. P values are as compared to placebo.

Criticisms and Limitations:

The impact of CBT without medication was statistically greater at the University of Pennsylvania than Duke, but there was no site effect for combined treatment. The presence of site differences raises concern about the generalizability of the CBT intervention. In particular, this study did not grade the patient’s symptoms (mild, moderate, severe), which may have led to a differences in the patient populations having different responses to the CBT intervention. The site could also be explained by system factors (e.g., location of sessions, payment source, culture of clinical practice), as well as differences in therapist characteristics (i.e., specialized training, supervision, compensation). This questions the transportability of these evidenced-based treatments when implemented in community practices where expertise in CBT for OCD is limited.2

OCD in children commonly co-occurs with other psychiatric illnesses including Tourette disorder, bipolar illness, major depressive disorder, and persistent depressive disorder.3 Although patients with ADHD on stimulant medication were included in this study, patients with comorbid psychiatric disorders and those prescribed other psychotropic medications were excluded. Therefore, results of this study may not apply to children and adolescents with OCD and additional comorbidities.

Other Relevant Studies and Information:

  • A follow-up Pediatric OCD Treatment Study (POTS) investigated CBT +/– sertraline in patients with comorbid diagnoses. The analysis showed that for patients who had a partial response to a SSRI alone, there is additional benefit to adding full CBT to improve patients’ quality of life, anxiety not attributed to OCD, hyperactivity, and inattention, but not depression.4

  • Based on the results of this and other studies, the American Academy of Child and Adolescent Psychiatry recommends OCD-focused CBT for the treatment of mild to moderate cases of OCD. For moderate to severe cases, medications (including SSRIs) are warranted in addition to CBT.5

Summary and Implications:

The Pediatric OCD Treatment Study found that in children and adolescents with OCD, CBT alone or CBT plus an SSRI should be first line treatment. Sertraline is not as efficacious as CBT alone or in combination. Existing CBT protocols are efficacious; however, few children are provided this evidence-based treatment in practice.

Clinical Case: Treatment of OCD in a Child or Adolescent

Case History

A 10-year-old boy in fifth grade is referred to a child psychiatrist by his teacher. The patient describes checking that doors are locked in his family’s home every night and obsessing about things being clean, such as his food and hands. He also experiences ruminating thoughts about his parents dying to the point of not being able to go to school. The psychiatrist makes the diagnosis of OCD. No comorbid psychiatric illnesses were diagnosed.

Based on the results of the POTS, how should this patient be treated?

Suggested Answer

The POTS found that for children or adolescents diagnosed with OCD, OCD-specific CBT or the combination of sertraline and CBT were both effective first-line treatment options. This and other studies support recent American Academy of Child and Adolescent Psychiatry guidelines to consider therapy for mild to moderate cases of pediatric OCD and the combination of an SSRI and CBT for moderate to severe cases.

The boy in this case is typical of a patient included in the POTS. Therefore, the psychiatrist should consider treatment with CBT or CBT plus an SSRI such as sertraline. The psychiatrist should provide psychoeducation to the parents and child about OCD and have a detailed conversation about the risks and benefits of the various types of psychotherapy and medication interventions before initiating treatment.

References

1. Pediatric OCD Treatment Study (POTS) Team. (2004). Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: The Pediatric OCD Treatment Study (POTS) randomized controlled trial. JAMA, 292(16), 1969–1976.Find this resource:

2. Schoenwald, S. K., & Hoagwood, K. (2001). Effectiveness, transportability, and dissemination of interventions: What matters when? Psychiatric Services, 52(9), 1190–1197.Find this resource:

3. Boileau, B. (2011). A review of obsessive-compulsive disorder in children and adolescents. Dialogues in Clinical Neuroscience, 13(4), 401–411.Find this resource:

    4. Conelea, C. A., Selles, R. R., Benito, K. G., Walther, M. M., Machan, J. T., Garcia, A. M., . . . Freeman, J. B. (2017). Secondary outcomes from the pediatric obsessive compulsive disorder treatment study II. Journal of Psychiatric Research, 92, 94–100.Find this resource:

    5. Mancuso, E., Faro, A., Joshi, G., & Geller, D. A. (2010). Treatment of pediatric obsessive-compulsive disorder: A review. Journal of Child and Adolescent Psychopharmacology, 20(4), 299–308.Find this resource: