Combination therapy, not medication alone, most effective for treating children with OCD

October 26, 2004

Treating children and adolescents with obsessive-compulsive disorder (OCD) with a combination of cognitive-behavior therapy (CBT) and the medication sertraline is more effective than CBT or sertraline alone, according to a study in the October 27 issue of JAMA.

Epidemiologic data suggest that approximately 1 in 200 young people suffers from OCD, which in many cases severely disrupts academic, social, and vocational functioning, according to background information in the article. Among adults with OCD, one-third to one-half develop the disorder during childhood or adolescence, which suggests that early intervention in childhood may prevent long-term illness in adulthood. Previous research has shown the effectiveness of short-term CBT or medical management with a selective serotonin reuptake inhibitor (such as sertraline, an antidepressant). However, little is known about their relative and combined efficacy. CBT is a form of psychotherapy that helps patients change their thought patterns and behaviors related to obsessive thoughts and compulsions.

OCD is characterized by recurrent obsessions and/or compulsions that are intense enough to cause severe discomfort. Obsessions are recurrent and persistent thoughts, impulses, or images that are unwanted and cause marked anxiety or distress. Compulsions are repetitive behaviors or rituals (such as hand washing, hoarding, checking something over and over) or mental acts (such as counting, repeating words silently).

John S. March, M.D., M.P.H., of the Duke University Medical Center, Durham, N.C., and members of the Pediatric OCD Treatment Study (POTS) team, evaluated the efficacy of CBT alone, medication management with the SSRI sertraline alone, or combined treatment consisting of CBT and sertraline as initial treatment for children and adolescents with OCD. POTS, a randomized controlled trial, was conducted at three academic centers in the U.S. and included 112 patients aged 7 through 17 years with a diagnosis of OCD. Patients were recruited between September 1997 and December 2002. Participants were randomly assigned to receive CBT alone, sertraline alone, combined CBT and sertraline, or pill placebo for 12 weeks.

Ninety-seven of 112 patients (87 percent) completed the full 12 weeks of treatment. The researchers found that "patients treated with CBT either alone or in combination with medication showed a substantially higher probability of improvement, with the edge going to combination treatment over CBT alone in one site but not in the other. Sertraline alone proved statistically superior to placebo, confirming the efficacy of medication used to treat OCD in youth; however, the effect size of CBT alone was larger than that for sertraline alone, and more patients receiving CBT alone entered remission than did those receiving sertraline alone (39.3 percent vs. 21.4 percent, respectively), though these differences did not reach statistical significance. Thus, we conclude that children and adolescents with OCD should begin treatment with CBT alone or with CBT plus an SSRI."

The three active treatments proved acceptable and well tolerated, with no evidence of treatment-emergent harm to self or to others.

"... the POTS carries significant public health implications for the management of OCD in youth and for future directions in research. Pediatric OCD is a common, chronic, and often undiagnosed psychiatric disorder that, if not adequately treated, is associated with considerable morbidity extending into adulthood. As illustrated by the fact that the overwhelming majority of POTS patients completed treatment as intended using treatment protocols intended for use by frontline clinicians, POTS treatments are both acceptable and practical in routine clinical practice," the authors write.
(JAMA. 2004; 292: 1969-1976. Available post-embargo at

Editor's Note: The Pediatric OCD Treatment Study was supported by a NIMH grant. Sertraline and matching placebo were provided to the POTS under an independent educational grant from Pfizer Inc. to Dr. March. Dr. March has received speaker fees from Pfizer, consulting fees from Pfizer and Wyeth, and research support from Pfizer and Lilly, and has served as a scientific advisor for Pfizer and on the data safety and monitoring board for Organon, Astra-Zeneca, and Pfizer. Co-author Dr. Rynn has served as a consultant and speaker for Pfizer and as a consultant for Wyeth and Lilly.

The JAMA Network Journals

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