A new study is challenging the status quo with data suggesting that
obsessive-compulsive disorder (OCD) in children and adolescents is more
amenable to treatment with psychotherapy than with the standard medications
prescribed for many years.
The Pediatric OCD Treatment Study (POTS) was a randomized, controlled trial
looking at the efficacy of cognitive-behavioral therapy (CBT) alone compared
with the SSRI sertraline (Zoloft) alone, combined CBT and sertraline, and
placebo over the course of 12 weeks. The study was funded by the National
Institute of Mental Health.
"The basic take-home message from this study is that initial
treatment for children and adolescents with OCD needs to include
cognitive-behavioral psychotherapy—either alone or in combination with
medicine," said John March, M.D., M.P.H., a professor of psychiatry at
Duke University Medical Center and principal investigator of the trial. The
POTS results were published in the October 27 Journal of the American
"While medication alone is effective for OCD," March told
Psychiatric News, "it is not as effective as the CBT-containing
treatments, and it is troubling and probably no longer acceptable just to rely
on medications as monotherapy for pediatric OCD."
POTS is the third combined-modality treatment study sponsored by NIMH in
pediatric populations, March noted. The first was the Multimodal Treatment of
ADHD (MTA) study, led by Columbia University's Peter Jensen, M.D.; the second
was March's Treatment of Adolescent Depression Study (TADS) (Psychiatric
News, September 3). Interestingly, he added, the MTA noted no advantage
to combined treatment with medication and psychotherapy, while the TADS found
that combined treatment was more effective than either treatment alone.
"With POTS, the combination was superior, but not all that much so,
to CBT alone," March said, "and both the CBT-containing treatments
were better than medication alone, which was better than placebo. So unlike
depression in kids and teens, with OCD it seems to be the psychotherapy that
is the big winner."
March emphasized that the disparate results with medication compared with
therapy or the combination for treating pediatric disorders "tells us
something about these disorders and what their etiology is."
He continued, "We really have to think about these disorders as
individual conditions that require treatments that are tightly coupled to
their targets—whether you conceptualize those targets as
behavioral/symptomatic targets or intermediate phenotypes, as in the
allocation of attentional resources, or whether you conceptualize them as
neural networks with their own particular neuroanatomy. You have to
conceptualize these disorders as highly individualized, and one can no longer
simply say that one size [of treatment] fits for all."
POTS enrolled 112 patients aged 7 through 17 at three academic medical
centers in the United States, all with a DSM-IV-TR diagnosis of OCD
and a score of 16 or higher on the Children's Yale-Brown Obsessive Compulsive
Scale (CY-BOCS). Patients were randomly assigned to one of the three treatment
modalities or placebo for 12 weeks. The primary outcome measure was the change
in CY-BOCS scores over the 12 weeks of treatment, as rated by an independent
evaluator who was kept blind to treatment status. A secondary outcome measure
was the rate of clinical remission of OCD, defined as a CY-BOCS score of 10 or
All three active treatments showed statistically significantly greater
improvement over the study's 12 weeks, compared with placebo. Combined
treatment also proved superior to CBT alone and to sertraline alone; however,
CBT and sertraline did not differ statistically significantly from one another
Rates of clinical remission were 53.6 percent for combined treatment, 39.3
percent for CBT alone, 21.4 percent for sertraline alone, and 3.6 percent for
placebo. Statistically, remission rates were not different between the
combined treatment and CBT alone, and CBT alone did not differ significantly
from sertraline alone, but was statistically superior to placebo. Sertraline
alone was not statistically superior to placebo on remission rates.
With regard to safety, two patients taking sertraline experienced"
activation" that presented as "increased motor
activity" or "impulsivity." The activation subsided with
dosage adjustments. Five patients on sertraline and one on placebo exhibited
mild activation symptoms that included mild increases in motor activity but no
corresponding increase in impulsivity.
"We had 56 kids on sertraline and 28 allocated to placebo,"
March noted. According to the FDA's estimate of suicidal thoughts and
behaviors associated with SSRI antidepressants, the researchers would have
expected to have two subjects with suicidality, but "we found none. This
study was really too small to say anything except that we saw really no hint
at all of any suicidality in any of these kids. Also, we saw no mania,
hypomania, disinhibition, or increased anxiety—all things that people
point to in support of the suicidal association."
March and his team are continuing their work with the same group of
children. "The kids who were responders went on into a discontinuation
trial, where we stopped their treatment. The nonresponders were referred for
treatment that was appropriate for their particular clinical situation. But
what we really want to see, using survival analysis," he concluded,"
is how many patients relapse over the subsequent four
Those data have not been analyzed yet, March said. He hypothesized that
youngsters on CBT would relapse less than the those on sertraline, but it will
be interesting to see whether that hypothesis pans out, he said.
An abstract of "Cognitive-Behavior Therapy, Sertraline, and
Their Combination for Children and Adolescents With Obsessive-Compulsive
Disorder" is posted online at<http://jama.ama-assn.org/cgi/content/abstract/292/16/1969>.▪