Behavior Therapy Best for Kids With OCD

Combo Therapy Helps Kids With Obsessive Compulsive Disorder, No Evidence of Suicidal Thoughts, Study Shows

From the WebMD Archives

Oct. 27, 2004 -- 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, 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 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," 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% 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%, 21%, and nearly 4% 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.

Too Reliant on Drugs

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 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."

Show Sources

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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