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While current guidelines support the use of cognitive-behavioral therapy and SSRIs as first-line treatments for OCD, the findings suggest clinicians may not need to wait eight to 12 weeks (as is currently recommended) before adjusting pharmacotherapy if a child shows no improvement on the medication.
Anjali Varigonda, M.D., a PGY-2 in psychiatry at the University of Vermont Medical Center, Burlington, and colleagues identified nine randomized, controlled trials comparing SSRIs (fluoxetine, fluvoxamine, paroxetine, and sertraline) or clomipramine to placebo for the treatment of pediatric OCD. The researchers extracted weekly symptom data from trials in order to characterize the trajectory of pharmacological response to SSRIs.
They found a significant benefit of SSRI compared with placebo as early as two weeks after the initiation of treatment in pediatric OCD. Over 85% of the improvement observed on SSRI compared with placebo in pediatric OCD trials was observed by week 2.
The meta-analysis also found the tricyclic antidepressant clomipramine to be more effective than SSRIs when both agents were compared with placebo in children with OCD; however, the authors cautioned much of clomipramine’s apparent increased efficacy may be due to the fact clomipramine trials were performed earlier on likely less refractory pediatric patients with OCD (When meta-analysis was restricted to examining SSRI agents, there was a significant relationship between measured efficacy of SSRIs and publication year). The researchers also noted that clomipramine has significant side effects, including weight gain, anticholinergic side effects, and arrhythmias, making it a less-desirable first-line drug.
The findings “may possibly suggest that pharmacotherapy trials of 8-12 weeks may not be necessary and that if a child shows no improvement with SRI treatment, trial durations could potentially be shorter,” the authors wrote. “However, before a change in guidelines is considered, there needs to be more OCD pharmacological research that focuses on the prognostic utility of early SSRI response data on individual patient outcomes. Additionally, more effective, evidence-based treatments for SRI-refractory pediatric patients with OCD are needed, as there is limited guidance for further treatments once SRIs and CBT prove unhelpful.”
For related information, see the Psychiatric News article “How Effective Are Antidepressants in Youth?”
(Image: iStock/Christopher Futcher)