Management of OCD in CAP

20/3/2010.Ramkumar G S

CAP,NIMHANS

Assessment

• current and past obsessive-compulsive (OC) symptoms and comorbid conditions

• identifying specific symptoms,

• assess their context, frequency, detailed phenomenology, and degree of associated distress and impairment,

• child's attitude and degree of insight into and resistance to the symptoms

Assessment

• development and psychosocial functioning (family, school, and social environment) ,

• medical, and family histories.• parental involvement with the child's

symptoms;  high “expressed emotion”; struggles and arguments with child; impairment in family life.

• Life events.

Children's Yale-Brown Obsessive Compulsive Scale can be used to rate and record symptom severity, and can be used to note the improvement.

Evidence Base for intervention in OCD Ref: CTP,9th Edition 2009

• Currently, there are two approaches supported in the research literature for pediatric OCD:

• Cognitive-behavioral therapy (CBT) with exposure and response prevention (E/RP) and pharmacotherapy with SRIs.

• According to the American Academy of Child and Adolescent Psychiatry CBT or CBT with concurrent pharmacotherapy using an SSRI is considered the first-line treatment for pediatric OCD.

• Overall, treatment methodology is improving for youth with OCD. The goals of treatment are now conceptualized as striving to achieve and maintain remission.

CBT for OCD Ref: CTP,9th Edition 2009

• Efficacious CBT protocols are based on therapy for adults with OCD. They consist of ERP ,Cognitive therapy (training the patient to identify and reframe anxiety-provoking cognitions).

• The first step of treatment is psychoeducation about OCD and E/RP. Next, a “fear hierarchy” is developed rank ordering symptoms. Following this, patients are systematically exposed to the feared situations (least feared first) while being instructed not to engage in their ritualistic behavior.

• Over repeated exposures, the associated anxiety dissipates through the process of autonomic habituation. In addition, when the feared consequences of not ritualizing fail to occur, the patient's heightened expectations of harm disappear, reducing anxiety even further.

Cognitive strategies Ref: CTP,9th Edition 2009

• In addition to E/RP, adjunctive cognitive strategies are utilized with pediatric patients. However, younger children and those with impaired cognitive functioning receive fewer and less sophisticated cognitive components to treatment due to developmental and cognitive limitations.

• A child's age, cognitive functioning, and insight into the nature of his or her OCD is paramount .

• Additionally, children's rituals frequently involve parental and family participation. Moreover, E/RP requires significant out-of-session practice for mastery and extinction of OCD symptoms. Many children are unwilling or unable to complete the necessary “homework” from therapy on their own (perhaps due to anxiety, lack of motivation, distraction).

• Thus, substantial parental involvement appears warranted, especially for younger children. psychoeducation about OCD as well as mechanisms of E/RP. observing techniques presented by a skilled therapist so they can assist their child with exercises in a supportive, noncoercive approach. Additionally, this can help parents to correctly extinguish ritualistic behavior and disengage from OCD rather than scold/react/blame.

POTS. CBT, sertaline and their combination for children

and adolescents with OCD.The pediatric OCD treatment study JAMA 2004

• 112 age 7-17yrs 12 weeks

• All interventions superior to placebo.

• Combined superior to CBT alone or sertaline alone

• CBT alone scored higher in efficacy in comparison to sertaline alone.

O'Kearney RT, Anstey K, von Sanden C, Hunt A. Behavioural and cognitive behavioural therapy for obsessive compulsive disorder in children and adolescents. Cochrane Database of Systematic Reviews 2006

• This review examines the overall efficacy of BT/CBT for

paediatric OCD, its relative efficacy against medication and whether there are benefits in using BT/CBT combined with medication.

• Although only based on a small number of studies which vary in quality, BT/CBT alone > none

• BT/CBT = medication alone • BT/CBT + medication > medication alone.• Additional higher quality trials are needed to confirm

these findings.

Which SSRI? A meta-analysis of pharmacotherapy trials in pediatric obsessive-compulsive disorder.  Gellar et al. Geller DA, BiedermanJ,Stewart

SE, Mullin B, Martin A: Am J Psychiatry. 2003;160:1919.• Identified clomipramine to be significantly superior over

SSRIs in reducing OCD symptoms. Nevertheless, the risk profile, adverse effects, and required electrocardiogram and blood-level monitoring associated with TCA (e.g., antiadrenergic, anticholinergic, and antihistaminergic adverse effects) are of concern with clomipramine.

• Thus, clomipramine is relegated to a second- or third-line treatment choice for children and adolescents and should not be used until sufficient trials of CBT with E/RP, two or more SSRIs, and combination CBT with SRRI therapy have been attempted.

Optimum Dose Ranges( mg/day)

• Fluoxetine• Sertaline• Fluvoxamine• Paroxetine• Citalopram• Escitalopram• Clomipramine

• Adult Pediatric• 40-80 20-60• 150-250 50-200• 200-300 50-200• 40-60 20-60• 40-60 20-60• 10-20 5-20• 150-225 50- 200

Summary of evidence Ref:OCD Current understanding and future directions: YCJR/SS

NIMHANS publication no.63, 2007

• Overall, clinically significant reductions in OCD symptomology have been documented in children and adolescents using SSRIs including fluoxetine, sertraline, fluvoxamine, and paroxetine with a relatively minimal side-effect profile (as compared to clomipramine). Based on these findings, SSRIs are the consensus first-line medication for pediatric OCD.

• Although there are no controlled comparisons between these medications in children, research suggests that the SSRIs are equally efficacious in children and the specific choice should be based on the patient's medical history, concomitant medications, and the adverse events.

• Poor clinical response to one SSRI is not necessarily predictive of failure with other SSRIs, suggesting adequate trials of multiple SSRIs may be indicated before augmentation. Additionally, significant clinical response is unlikely within the first few weeks of taking an SSRI; generally, 10 to 12 weeks at adequate dosage is necessary to fully evaluate the efficacy of the medication.

Summary of evidence Ref:OCD Current understanding and future directions: YCJR/SS NIMHANS

publication no.63, 2007

• In pediatric cases that are unresponsive to CBT and trials with multiple SSRIs, pharmacological augmentation may be considered. There is growing support for SSRI augmentation with atypical antipsychotics for refractory OCD in adult patients. Lithium carbonate (Eskalith) and buspirone (BuSpar) augmentation have generally not been efficacious augmentation strategies for treatment-refractory OCD in adults but may ameliorate depressive symptoms. Thus, augmentation may also be the case in children with comorbid conditions, for example, a tic disorder may require the addition of an α2-agnosit or neuroleptics.

• In sum, unlike the adult literature, there is a paucity of empirical data supporting augmentation strategies for pediatric OCD. Additionally, significant undesirable side effects should be considered prior to prescribing neuroleptics and benzodiazepines in children.

FDA approved drugs

• Current FDA approval has been granted for four medications for pediatric OCD use: Sertraline, fluoxetine, fluvoxamine, and clomipramine, although the minimum approved age varies by compound.

• The most frequent SSRI side effects include nausea, insomnia, headache, and asthenia. During clinical trials, the inability to tolerate treatment due to side effects was reported in 15 percent or less of cases.

Recent studies

• Soomro GM, Altman DG, Rajagopal S, Oakley Browne M. Selective serotonin re-uptake inhibitors (SSRIs) versus placebo for obsessive compulsive disorder (OCD). Cochrane Database of Systematic Reviews 2008

• SSRIs are more effective than placebo for OCD, at least in the short-term, although there are differences between the adverse effects of individual SSRI drugs. The longer term efficacy and tolerability of different SSRI drugs for OCD has yet to be established.

Pharmacotherapy in paediatric obsessive-compulsive disorder: a naturalistic, retrospective study. Masi G, Millepiedi S, Perugi G, Pfanner C, Berloffa S, Pari C, Mucci M: CNS Drugs. 2009;23(3):241-52..

• OBJECTIVE: To report the response to pharmacotherapy in children and adolescents with OCD naturalistically followed up and treated with SRIs.

• METHODS: From a consecutive series of 257 patients (174 males and 83 females; mean age 13.6+/-2.7 years) with OCD , 37 children improved significantly after psychotherapy and were excluded. The remaining 220 patients were included in the study.

• RESULTS: Eighty-nine patients (40.5%) were managed with SRI monotherapy and 131 with an SRI in combination with another medication. Compared with those who needed polypharmacy, patients managed with SRI monotherapy were younger at the time of the first consultation, had less severe symptoms at baseline, and more frequently presented with co-occurring anxiety and depressive disorders, while patients receiving polypharmacy presented with higher rates of bipolar disorder, tic disorder and disruptive behaviour disorders.

CNS Drugs. 2009;23(3):241-52..• 135 patients (61.4%) - responders.• responders had less severe disease at baseline, were

younger at the time of the first consultation, more frequently presented with the contamination/cleaning phenotype and less frequently presented with the hoarding phenotype.

• Treatment refractoriness was associated with higher rates of conduct disorder and bipolar disorder, and lower rates of generalized anxiety disorder and panic disorder.

• Forty-three children received therapy with an atypical antipsychotic as an augmenting strategy, and 25 of these children (58.1%) became responders. Responders to augmentation were less severely impaired at baseline, while different subtypes of OCD were similar between responders and nonresponders, as were patterns of co-morbidity.

• CONCLUSION: Our study suggests that putative variables associated with response to pharmacological treatment of paediatric OCD can be defined, and can help improve treatment strategies

Predictors of response to CBT

• Comorbid conditions- tic disorder may not hav any bearing on CBT outcome neither anxiety disorder.

• Lack of insight is common no data on bearing on CBT.

Curr Opin Pediatr. 2008 Oct;20(5):544-50.Pediatric obsessive-compulsive disorder: management priorities in primary care.Gilbert AR, Maalouf FT.

• The present study attempts to provide a parsimonious review of important studies of pediatric OCD with particular emphasis on studies over the last year.

• RECENT FINDINGS: It appears that OCD is a multidimensional disorder with substantial comorbidity with other neuropsychiatric disorders that may affect its course and treatment. Although its pathophysiology remains to be fully elucidated, evidence suggests that OCD likely results from a complex interaction between multiple genetic variants and nongenetic factors.

• SUMMARY: Results from the studies reviewed here reflect the heterogeneity of pediatric OCD. It is clear that clinicians need to consider specific symptoms, comorbid conditions, and the rapidly evolving clinical research when working with children and adolescents with OCD.

J Behav Ther Exp Psychiatry. 2008 Mar;39(1):11-22. Epub 2007 Jan 4.Evaluation of exposure with response-prevention for obsessive compulsive disorder in childhood and adolescence.

Bolton D, Perrin S.• 20 children and adolescents with OCD, not receiving

medication for this condition, were randomized to E/RP or a wait-list condition.

• Statistically and clinically significant symptomatic improvement was found in the E/RP group compared with controls, with improvement maintained at follow-up an average of 14 weeks later.

• Effect size in the main intention-to-treat analysis was 1.23 and in the secondary per protocol analysis was 1.64. This study lends further support to the view that E/RP is an effective treatment for childhood OCD.

Take Home message

• Pharmacotherapy- sertaline, fluoxetine

• ERP

• Combination.

• Other cognitive strategies.

• Attention for special needs of the child.

• Research implications- identification of subtypes of OCD in paediatric population.