Behavior Therapy Best for Kids With OCD
Tuesday, October 26, 2004
By Salynn Boyles


Children and teens with obsessive-compulsive disorder respond better
to talk therapy than to antidepressants alone, but a combination of
the two approaches to treat OCD may work wonders, a government-
funded study group finds.

The findings are being reported less than two weeks after federal
health officials ordered makers of the most widely used
antidepressants to include warnings on their packaging about an
increased risk of suicidal thoughts and behaviors in children and
adolescents who take the drugs.

Medications that were originally approved for treatment of
depression are effective for anxiety disorders. Some of the newer
types of selective serotonin uptake inhibitors (search), such as
Fluoxetine, sertraline, fluvoxamine, paroxetine, and citalopram, are
among the SSRIs commonly prescribed for OCD.

Just more than half of the children and adolescents in the 12-week
study treated with a combination of behavioral therapy (talk
therapy) and the drug Zoloft (search) for three months had no
evidence of OCD four months later. Nearly two in five children
responded to talk therapy. While one in five participants taking
Zoloft alone had similar responses as did just under one in 20
treated with placebo.

The response rate for cognitive-behavior therapy alone was slightly
lower than for behavior therapy with the antidepressant, but
researchers concluded that either approach is an appropriate initial
treatment. The findings are reported in the Oct. 27 issue of the
Journal of the American Medical Association.


"The message is that we now have a clearly effective treatment for
obsessive-compulsive disorder in children and it is cognitive
behavior therapy (search)," researcher John March, MD, tells
WebMD. "In a relatively short period of time we have gone from
having no effective treatment to being able to bring half of the
kids with this disorder into the normal range within three months."

No Evidence of Suicidal Thoughts in OCD Patients

It is estimated that as many as one in 200 children have OCD,
characterized by intrusive thoughts, images, or impulses that lead
to repetitive or compulsive behaviors, such as frequent hand washing
or checking. Between a third and half of adults with OCD develop the
disorder during childhood.

In this study, 97 kids and teens with OCD completed 12 weeks of
treatment with either behavior therapy alone, treatment with Zoloft
alone, a combination of the two, or placebo. Four months later, just
nearly 54 percent of the kids treated with behavior and drug therapy
were considered to be in remission, meaning they were not engaging
in frequent repetitive behaviors. Remission rates, defined as an
obsessive-compulsive behavioral score of less than 10, were 39
percent, 21 percent, and nearly 4 percent for those treated with
behavior therapy alone, Zoloft alone, and placebo, respectively.

There was no evidence of an increase in suicidal thoughts among the
children taking the antidepressant drug Zoloft.

"It is reassuring in this study, as in others, that [antidepressant]
treatment was well tolerated, with no evidence of treatment-emergent
harm to self or others," the researchers wrote.

Drugs Relied on Too Much With OCD

The clear superiority of behavior therapy over drugs alone in this
study, along with the FDA warning, should have a major impact on how
OCD in children is treated in the U.S., child and adolescent
psychiatrist Rachel Ritvo, MD, tells WebMD.

"The sad fact is that economic considerations drive child mental
health care today, and treating a child with drugs is much, much
cheaper than psychotherapy," she says. "We have learned that kids
are very responsive to psychotherapy and psychosocial interventions,
probably even more so than adults."

Ritvo says a parent seeking treatment for a child with OCD should
push for psychotherapy, but she acknowledged that finding a
qualified therapist could be a challenge.

"There are fewer than 100 behavioral pediatricians in this country
and only about 7,000 child psychiatrists. That's it," she says. "I
turn away four or five people a week from my practice."

March counters that the behavioral therapy techniques used in the
treatment of children with OCD are easily learned and can be
administered by any good psychiatrist, psychologist, or mental
health social worker.

"Cognitive behavior therapy is a lot like physical therapy, but
instead of, say, rehabing a damaged knee you are retraining the
brain," he says. "This is a neurobehavioral illness (search) and
there are skillful and unskillful ways to treat it. The wrong
approach is relying on drugs alone or traditional psychotherapy. The
best treatment is clearly evidence-based cognitive behavior therapy."

By Salynn Boyles, reviewed by Brunilda Nazario, MD

SOURCES: Pediatric OCD Treatment Study, Journal of the American
Medical Association, Oct. 27, 2004, vol 292: pp 1969-1976. John S.
March, MD, MPH, department of psychiatry, Duke University Medical
Center, Durham, N.C. Rachel Ritvo, MD, general child and adolescent
psychiatrist; clinical associate professor of medicine, George
Washington University, Washington; and spokeswoman, American Academy
of Child and Adolescent Psychiatry




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