Disorders - Obsessive Compulsive Disorder
DiFrancesco, M. F., Halpern, C. H., Hurtig, H. H., Baltuch, G. H., Heuer, G. G.
Purpose Based on the success of deep brain stimulation (DBS) in the treatment of adult disorders, it is reasonable to assume that the application of DBS in the pediatric population is an emerging area worthy of study. The purpose of this paper is to outline the current movement disorder indications for DBS in the pediatric population, and to describe areas of investigation, including possible medically refractory psychiatric indications. Methods We performed a structured review of the English language literature from 1990 to 2011 related to studies of DBS in pediatrics using Medline and PubMed search results. Results Twenty-four reports of DBS in the pediatric population were found. Based on published data on the use of DBS for pediatric indications, there is a spectrum of clinical evidence for the use of DBS to treat different disorders. Dystonia, a disease associated with a low rate of remission and significant disability, is routinely treated with DBS and is currently the most promising pediatric application of DBS. We caution the application of DBS to conditions associated with a high remission rate later in adulthood, like obsessive-compulsive disorder and Tourette's syndrome. Moreover, epilepsy and obesity are currently being investigated as indications for DBS in the adult population; however, both are associated with significant morbidity in pediatrics. Conclusion While currently dystonia is the most promising application of DBS in the pediatric population, multiple conditions currently being investigated in adults also afflict children and adolescents, and thus warrant further research. (copyright)Springer-Verlag 2012.
Child's Nervous System, 28(10) : 1701-1714
- Year: 2012
- Problem: Obsessive Compulsive Disorder
- Type: Systematic reviews
-
Stage: Disorder established (diagnosed disorder)
-
Treatment and intervention: Biological Interventions (any)
, Deep brain stimulation (DBS)
Fineberg, Naomi A., Brown, Angus, Reghunandanan, Samar, Pampaloni, Ilenia
Pharmacological strategies for the treatment of obsessive-compulsive disorder (OCD) continue to develop apace but deficiencies remain. We present an updated literature review of the evidence supporting available strategies. We aim to answer key questions including: (1) What are the first-line treatments? (2) Does pharmacotherapy improve health-related quality of life? (3) How do we evaluate clinical response and relapse? (4) How long should treatment continue? (5) Can we predict treatment outcomes? (6) What is the management of treatment-refractory OCD? Selective serotonin reuptake inhibitors (SSRIs) remain the pharmacological treatment of choice for most patients and are associated with improved health-related quality of life. However, discontinuation is associated with relapse and loss of quality of life, implying treatment should continue long term. A substantial minority of patients fail to respond to SSRI. Such patients may respond to strategies such as dose elevation or adjunctive antipsychotic, although long-term trials validating the effectiveness and tolerability of these strategies are relatively lacking. Newer compounds targeting other neurotransmitter systems, such as glutamate, are undergoing evaluation.;
International Journal of Neuropsychopharmacology, 15(8) : 1173-1191
- Year: 2012
- Problem: Obsessive Compulsive Disorder
- Type: Systematic reviews
-
Stage: Disorder established (diagnosed disorder)
-
Treatment and intervention: Biological Interventions (any)
Bloch, M., Panza, K., Grant, J. E., Leckman, J., Pittenger, C.
Background: N-acetylcysteine (NAC) is an over-the-counter supplement that acts as an antioxidant and a glutamate modulatingagent. A randomized, placebo-controlled trial demonstrated theefficacy of NAC in the treatment of adults with trichotillomania(TTM). The goal of the current study was to examine the efficacy ofNAC for the treatment of pediatric TTM in a double-blind,placebo-controlled study.Methods: Thirty-nine children aged 8-17 years with pediatrictrichotillomania were randomly assigned to receive NAC or matchingplacebo for 12 weeks. Our primary outcome was change in severity ofhairpulling as measured by the Massachusetts General HospitalHairpulling Scale (MGH-HPS). Secondary measures assessed hairpullingseverity, automatic vs. focused pulling, clinician-rated improvementand comorbid anxiety and depression. Outcomes wereexamined using linear mixed models to test the treatment x timeinteraction in an intention-to-treat population.Results: No significant difference between N-acetylcysteine andplacebo was found on any of the primary or secondary outcomemeasures. On several measures of hairpulling, subjects significantlyimproved with time regardless of treatment assignment.Twenty-five percent of subjects in the NAC group were judged astreatment responders compared to 21% in the placebo group.Conclusions: We observed no benefit of NAC for the treatment ofchildren with trichotillomania. Our findings stand in contrast to aprevious, similarly designed trial in adults with TTM, which demonstrateda very large, statistically significant benefit of NAC. Based on thediffering results of NAC in pediatric and adult TTM populations, theassumption that pharmacological interventions demonstrated to beeffective in adults with TTM will be as effective in children, may beinaccurate. This trial highlights the importance of referring childrenwith TTM to appropriate behavioral therapy before initiatingpharmacological interventions, as behavioral therapy has demonstratedefficacy in both children and adults with trichotillomania.
Neuropsychopharmacology, 38 : S270
- Year: 2012
- Problem: Obsessive Compulsive Disorder
- Type: Randomised controlled trials
-
Stage: Disorder established (diagnosed disorder)
-
Treatment and intervention: Complementary & Alternative Interventions (CAM)
, Vitamins and supplements
Soomro, G. M.
INTRODUCTION: Obsessions or compulsions that cause personal distress or social dysfunction affect about 1% of adult men and 1.5% of adult women. About half of adults with obsessive compulsive disorder (OCD) have an episodic course, whereas the other half have continuous problems. Prevalence in children and adolescents is 2.7%. The disorder persists in about 40% of children and adolescents at mean follow-up of 5.7 years. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of initial treatments for obsessive compulsive disorder in adults? What are the effects of initial treatments for obsessive compulsive disorder in children and adolescents? What are the effects of maintenance treatment for obsessive compulsive disorder in adults? What are the effects of maintenance treatment for obsessive compulsive disorder in children and adolescents? What are the effects of treatments for obsessive compulsive disorder in adults who have not responded to initial treatment with serotonin reuptake inhibitors (SRIs)? We searched: Medline, Embase, The Cochrane Library, and other important databases up to April 2011 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 43 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: addition of antipsychotics to serotonin reuptake inhibitors, behavioural therapy alone or with serotonin reuptake inhibitors, cognitive therapy or cognitive behavioural therapy (CBT) (alone or with serotonin reuptake inhibitors), electroconvulsive therapy, optimum duration of maintenance treatment, psychosurgery, serotonin reuptake inhibitors (citalopram, clomipramine, fluoxetine, fluvoxamine, paroxetine, or sertraline), and transcranial magnetic stimulation.
BMJ clinical evidence, (pagination) :
- Year: 2012
- Problem: Obsessive Compulsive Disorder
- Type: Systematic reviews
-
Stage: Disorder established (diagnosed disorder)
-
Treatment and intervention: Biological Interventions (any)
, Selective serotonin reuptake inhibitors (SSRIs), Psychological Interventions (any)
, Cognitive & behavioural therapies (CBT)
Franklin, M. E., Edson, A. L., Ledley, D. A., Cahill, S. P.
Objective: To examine the efficacy and durability of a behavioral therapy (BT) protocol for pediatric TTM compared with a minimal attention control (MAC) condition. It was hypothesized that the BT condition would be superior to MAC at the end of acute treatment, and would also demonstrate durability of gains through the maintenance treatment phase. Method: A randomized controlled trial in which 24 youths were assigned to either a pilot-tested BT protocol, consisting of eight weekly sessions, or to MAC, consisting of three sessions and five telephone calls over 8 weeks. Independent evaluators assessed outcome at pretreatment (week 0) and post-treatment (week 8) for BT and MAC, and again at week 16 for BT patients only. The primary outcome measure was the National Institute of Mental Health Trichotillomania Severity Scale (NIMH-TSS). Results: For the BT condition, the week 8 mean NIMH-TSS score was significantly lower than that of the MAC condition. The BT condition's mean week 8 score was also significantly lower than their own mean week 0 score, whereas no such reductions were observed for the MAC condition. Upon completion of acute treatment at week 8, the BT group's gains were maintained through an 8-week maintenance treatment phase. Conclusions: BT produced a superior outcome compared with a condition that controlled for participation in a pediatric TTM research study, nonspecific therapist contact effects, repeated assessments, and the passage of time. Maintenance of gains after acute BT provides preliminary support for the durability of treatment gains.
Journal of the American Academy of Child &Adolescent Psychiatry, 50(8) : 763-771
- Year: 2011
- Problem: Obsessive Compulsive Disorder
- Type: Randomised controlled trials
-
Stage: Disorder established (diagnosed disorder)
-
Treatment and intervention: Psychological Interventions (any)
, Cognitive & behavioural therapies (CBT)
Franklin, Martin E., Sapyta, Jeffrey, Freeman, Jennifer B., Khanna, Muniya, Compton, Scott, Almirall, Daniel, Moore, Phoebe, Choate-Summers, Molly, Garcia, Abbe, Edson, Aubrey L., Foa, Edna B., March, John S.
Context: The extant literature on the treatment of pediatric obsessive-compulsive disorder (OCD) indicates that partial response to serotonin reuptake inhibitors (SRIs) is the norm and that augmentation with short-term OCD-specific cognitive behavior therapy (CBT) may provide additional benefit. Objective: To examine the effects of augmenting SRIs with CBT or a brief form of CBT, instructions in CBT delivered in the context of medication management. Design, Setting, and Participants: A 12-week randomized controlled trial conducted at 3 academic medical centers between 2004 and 2009, involving 124 pediatric outpatients between the ages of 7 and 17 years with OCD as a primary diagnosis and a Children's Yale-Brown Obsessive Compulsive Scale score of 16 or higher despite an adequate SRI trial. Interventions: Participants were randomly assigned to 1 of 3 treatment strategies that included 7 sessions over 12 weeks: 42 in the medication management only, 42 in the medication management plus instructions in CBT, and 42 in the medication management plus CBT; the last included 14 concurrent CBT sessions. Main Outcome Measures: Whether patients responded positively to treatment by improving their baseline obsessive-compulsive scale score by 30% or more and demonstrating a change in their continuous scores over 12 weeks. Results: The medication management plus CBT strategy was superior to the other 2 strategies on all outcome measures. In the primary intention-to-treat analysis, 68.6% (95% CI, 53.9%-83.3%) in the plus CBT group were considered responders, which was significantly better than the 34.0% (95% CI, 18.0%-50.0%) in the plus instructions in CBT group, and 30.0% (95% CI, 14.9%-45.1%) in the medication management only group. The results were similar in pairwise comparisons with the plus CBT strategy being superior to the other 2 strategies (P < .01 for both). The plus instructions in CBT strategy was not statistically superior to medication management only (P = .72). The number needed-to-treat analysis with the plus CBT vs medication management only in order to see 1 additional patient at week 12, on average, was estimated as 3; for the plus CBT vs the plus instructions in CBT strategy, the number needed to treat was also estimated as 3; for the plus instructions in CBT vs medication management only the number needed to treat was estimated as 25. Conclusions: Among patients aged 7 to 17 years with OCD and partial response to SRI use, the addition of CBT to medication management compared with medication management alone resulted in a significantly greater response rate, whereas augmentation of medication management with the addition of instructions in CBT did not. (PsycINFO Database Record (c) 2012 APA, all rights reserved) (journal abstract)
JAMA, 306(11) : 1224-1232
- Year: 2011
- Problem: Obsessive Compulsive Disorder
- Type: Randomised controlled trials
-
Stage: Disorder established (diagnosed disorder)
-
Treatment and intervention: Biological Interventions (any)
, Selective serotonin reuptake inhibitors (SSRIs), Psychological Interventions (any)
, Cognitive & behavioural therapies (CBT)
, Exposure therapy, Exposure and response prevention
Davis-III, TE., May, Anna., Whiting, Sara E.
Research on treatments for childhood anxiety disorders has increased greatly in recent decades. As a result, it has become increasingly necessary to synthesize the findings of these treatment studies into reviews in order to draw wider conclusions on the efficacy of treatments for childhood anxiety. Previous reviews of this literature have used varying criteria to determine the evidence base. For the current review, stricter criteria consistent with the original Task Force (1995) guidelines were used to select and evaluate studies. Studies were divided by anxiety disorder; however, many studies combine various anxiety disorders in their samples. As a result, these were included in a combined anxiety disorder group. Using more traditional guidelines, studies were assigned a status of well-established, probably efficacious, or experimental based on the available literature and the quality of the studies. While some treatments do meet the criteria for well-established status, it is clear from this examination that gaps remain and replication is necessary to establish many of these treatments as efficacious. In addition, there still appears to be a lack of research on the effects of treatment on the physiological and cognitive aspects of fear and anxiety. (PsycINFO Database Record (c) 2012 APA, all rights reserved) (journal abstract)
Clinical Psychology Review, 31(4) : 592-602
- Year: 2011
- Problem: Anxiety Disorders (any), Obsessive Compulsive Disorder, Post Traumatic Stress Disorder, Social phobia (social anxiety disorder)
, Specific Phobia
- Type: Systematic reviews
-
Stage: Disorder established (diagnosed disorder)
-
Treatment and intervention: Biological Interventions (any)
, Psychological Interventions (any)
Bolton, Derek, Williams, Tim, Perrin, Sean, Atkinson, Linda, Gallop, Catherine, Waite, Polly, Salkovskis, Paul
Background: Reviews and practice guidelines for paediatric obsessive-compulsive disorder (OCD) recommend cognitive-behaviour therapy (CBT) as the psychological treatment of choice, but note that it has not been sufficiently evaluated for children and adolescents and that more randomized controlled trials are needed. The aim of this trial was to evaluate effectiveness and optimal delivery of CBT, emphasizing cognitive interventions. Methods: A total of 96 children and adolescents with OCD were randomly allocated to the three conditions each of approximately 12 weeks duration: full CBT (average therapist contact: 12 sessions) and brief CBT (average contact: 5 sessions, with use of therapist-guided workbooks), and wait-list/delayed treatment. The primary outcome measure was the child version of the semi-structured interviewer-based Yale-Brown Obsessive Compulsive Scale. Clinical Trial registration: http://www.controlled-trials.com/ISRCTN/; unique identifier: ISRCTN29092580. Results: There was statistically significant symptomatic improvement in both treatment groups compared with the wait-list group, with no significant differences in outcomes between the two treatment groups. Controlled treatment effect sizes in intention-to-treat analyses were 2.2 for full CBT and 1.6 for brief CBT. Improvements were maintained at follow-up an average of 14 weeks later. Conclusions: The findings demonstrate the benefits of CBT emphasizing cognitive interventions for children and adolescents with OCD and suggest that relatively lower therapist intensity delivery with use of therapist-guided workbooks is an efficient mode of delivery. (PsycINFO Database Record (c) 2012 APA, all rights reserved) (journal abstract)
Journal of Child Psychology & Psychiatry, 52(12) : 1269-1278
- Year: 2011
- Problem: Obsessive Compulsive Disorder
- Type: Randomised controlled trials
-
Stage: Disorder established (diagnosed disorder)
-
Treatment and intervention: Service Delivery & Improvement, Psychological Interventions (any)
, Cognitive & behavioural therapies (CBT)
, Other service delivery and improvement interventions
Gentile, Salvatore
The aim of this article was to analyze systematically literature information published in English (between 1966 and January 2011) on the efficacy of antidepressants in pediatric obsessive-compulsive disorder. Data were identified through different databases by using variously combined patterns of search terms. Searches provided 85 articles, excluding duplicates, but only articles reporting primary data on use of antidepressants in this specific disorder were reviewed. Fifty-nine articles were excluded because they did not report primary efficacy data or investigated patients with different psychiatric diagnosis. Twenty-five electronically recognized articles met the inclusion criteria. Two additional studies, available as congress communication, were identified by manually checking the references' list of electronically identified articles. Reviewed studies show several methodological biases (the lack/limited number of long-term trials and head-to-head comparisons and the inclusion of patients who continued different forms of psychotherapy), which make it difficult to individuate the best pharmacological strategy. Despite these limitations, evidence-based information suggests that clomipramine and sertraline, especially for long-term treatments, should be considered as first-choice agents for treating obsessive-compulsive disorder at onset during childhood or adolescence.
Journal of Clinical Psychopharmacology, 31(5) : 625-632
- Year: 2011
- Problem: Obsessive Compulsive Disorder
- Type: Systematic reviews
-
Stage: Disorder established (diagnosed disorder)
-
Treatment and intervention: Biological Interventions (any)
, Selective serotonin reuptake inhibitors (SSRIs), Tricyclic antidepressants
Gomes, J. B., Matte, B. C., Vivan, A., Viana, A., Bortoncello, C. F., Salum, G. A., Aline Hartmann Zottis, G.
Obsessive-compulsive disorder (OCD) is a severe mental disorder with serious consequences to family dynamics. Therefore, parental involvement seems to be a key factor for the successful treatment of this psychiatric disorder. The aim of this study was to evaluate the level of evidence available to allow recommendation of cognitive behavioral therapy (CBT) with family intervention for the treatment of children and adolescents with OCD. The systematic search was performed on MEDLINE/PubMed, followed by analysis of abstracts and full-length articles by two independent evaluators. Subsequently, an analysis of the evidence available was conducted using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The effect size of the intervention was calculated using Cohen's d. We found 77 articles on PubMed, plus 12 articles via cross-reference search. Of these, seven articles were included in this review, according to the following criteria: intervention study, involving only children and/or adolescents, and a having a structured or clinical diagnosis of OCD. The Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) was used for outcome evaluation in all articles, thus enabling assessment of the effect size of non-controlled interventions (d = 1.43), resulting in a mean difference of 13.11 points (95%CI 11.84-14.39; p < 0.001). Conversely, a high heterogeneity was detected among the studies (I2= 67%). Family-based CBT seems to have an important effect on the reduction of OCD symptoms in children and adolescents. However, the small number of studies available do not allow us to establish an evidence level higher than C for this recommendation. New randomized clinical trials are needed to confirm this recommendation. (copyright) Revista de Psiquiatria do Rio Grande do Sul - APRS.
Revista de Psiquiatria do Rio Grande do Sul, 33(2) : 121-127
- Year: 2011
- Problem: Obsessive Compulsive Disorder
- Type: Systematic reviews
-
Stage: Disorder established (diagnosed disorder)
-
Treatment and intervention: Psychological Interventions (any)
, Cognitive & behavioural therapies (CBT)
Joseph, L., Grant, P., Swedo, S.
Background: Obsessive-Compulsive Disorder (OCD) affects 1 - 2% of children and adolescents, causing significant distress and impairments of functioning. Anti-obsessional medications (typically SSRIs) and cognitive-behavioral therapy are beneficial to many, but not all children. Preliminary data from studies of adults suggest that riluzole, a drug that affects glutamate within the CNS, may be effective for patients who have failed to respond to other medications. The purpose of this study was to conduct a randomized, placebo-controlled trial of riluzole in children and adolescents with OCD to determine if riluzole would reduce symptoms to a greater extent than placebo. Methods: Participants were 60 children and adolescents (44 males, 16 females; mean age 14.4 (plus or minus) 2.3 yrs) with moderate to severe OCD (CYBOCS mean total score=28.17(plus or minus)3.7). All had failed to respond adequately to standard therapies (on average, children were taking 2 psychotropic medications at baseline). 17 of the 60 subjects had an autism spectrum disorder in addition to OCD. Subjects were randomly assigned to receive capsules containing placebo (PLA) or riluzole (RIL; 50 mg q 12 hrs) for 12 weeks. Symptom ratings were completed at biweekly intervals; the final blinded ratings (at 12 weeks) of obsessive-compulsive symptoms, anxiety and depression were used for analyses. Those completing the 12 weeks doubleblind trial were offered open-label RIL and all elected to take RIL for the next nine months (total study duration=1 year). Results: 51 children completed the double-blind phase of the study. The drug was generally well-tolerated, but there was one serious adverse event (a child taking multiple drugs developed pancreatitis; he recovered fully after RILand other drugs were D/C0ed) 5 children had modest transaminase elevations during RIL administration. An intent-to-treat analysis (using last data point recorded) found no significant differences in ratings of OCD, depression or anxiety between the 30 children randomized to PLA and the 30 in the RIL group. Analysis of data from those completing 12 weeks of study drug (RIL n=22; PLA n=29) revealed significantly greater improvements in OCD symptoms during RIL administration (CY-BOCS total score from baseline to 12 weeks: RIL 27.3 (plus or minus) 3.7 to 20.6 (plus or minus) 6.4; PLA 29.0 (plus or minus) 3.5 to 23.3 (plus or minus) 4.7). RIL was also superior to PLA on ratings of compulsions (CY-BOCS Compulsions: RIL 13.8 (plus or minus) 1.9 to 10.4 (plus or minus) 3.7; PLA 14.6 (plus or minus) 1.9 to 11.9 (plus or minus) 2.5). Patients continued to improve throughout the 9 months of open-label RIL administration, with all subjects reporting less OCD, anxiety and depression at 1 yr than at baseline. Discussion: This small study of the efficacy and safety of riluzole for children and adolescents with OCD demonstrated some benefits, particularly following open-label administration for 9 months. However, the differences between riluzole and placebo were statistically significant only when examined for the cohort of children who completed the 12 weeks double-blind trial. The lack of significant differences on the intent-to-treat analysis appears to be due, at least in part, to the larger number of children withdrawn from the active study group due to adverse effects, including one episode of pancreatitis. Despite these limitations, the results of this trial are encouraging and warrant replication and extension to a cohort of children without a history of multiple treatment failures. It would also be interesting to test the efficacy of RIL as a solitary treatment, rather than as an nullaugmenting agentnull added to a current, non-effective treatment regimen (as was done in this study).
Neuropsychopharmacology, 36 : S228-S229
- Year: 2011
- Problem: Obsessive Compulsive Disorder
- Type: Randomised controlled trials
-
Stage: Treatment resistant/treatment refractory
-
Treatment and intervention: Biological Interventions (any)
, Other biological interventions
Schlup, Barbara, Farrell, Lara, Barrett, Paula
This waitlist-controlled study investigates the impact of a group-based cognitive-behavioral therapy with family involvement (CBT-F) on observed mother and child behaviors in children with obsessive-compulsive disorder (OCD). Forty-four children and adolescents with OCD and their mothers were observed during family discussions before and after treatment/waitlist. Participants were rated on behavioral dimensions of criticism, overinvolvement, doubt, avoidance, warmth, confidence, positive problem solving, and rewarding independence. Significant differences between treatment and waitlist condition occurred from pretreatment to posttreatment, with ratings of negative behaviors decreasing and ratings of positive behaviors increasing in the treatment group. Findings suggest that CBT-F has the potential to improve mother and child interactions in families with a child diagnosed with OCD. (PsycINFO Database Record (c) 2012 APA, all rights reserved) (journal abstract)
Child & Family Behavior Therapy, 33(4) : 322-336
- Year: 2011
- Problem: Obsessive Compulsive Disorder
- Type: Randomised controlled trials
-
Stage: Disorder established (diagnosed disorder)
-
Treatment and intervention: Psychological Interventions (any)
, Cognitive & behavioural therapies (CBT)