Treatment of obsessive-compulsive disorder with clomipramine and desipramine in children and adolescents. A double-blind crossover comparison

Off-label higher doses of serotonin reuptake inhibitors in the treatment of obsessive-compulsive disorder: Safety and tolerability

OBJECTIVE

To examine the long-term safety and tolerability of off-label high-dose serotonin reuptake inhibitors (OLHD-SRIs) in the treatment of obsessive-compulsive disorder (OCD).

METHODS

A retrospective longitudinal study was performed on 105 randomly selected outpatients diagnosed with OCD and were treated with OLHD-SRIs for at least 6 months. Patients received sertraline >200 mg/day, escitalopram >20 mg/day, fluvoxamine >300 mg/day, and fluoxetine >60 mg/day, combined with exposure and response prevention therapy. Patients were divided into three dosing groups: sertraline equivalent dose (SED) ≤ 200 mg/day (n = 26, 24.7%), 201-400 mg/day (n = 51, 48.5%) and 401-650 mg/day (n = 28, 26.6%). Safety and tolerability were assessed with an electrocardiogram, blood biochemistry, complete blood count, and side-effects monitoring.

RESULTS

SED ranged from 100 to 650 mg/day and the mean duration of OLHD-SRI treatment was 20.8 months. The most common side-effects reported were sexual dysfunction (n = 36, 34%), weight gain (n = 28, 27%), sedation (n = 27, 26%), hyperhidrosis (n = 20, 19%), and tremor (n = 11, 10%). Abnormal ECG was documented in one patient, and another patient experienced a first-time seizure, whereas elevated liver enzymes were seen in 4.8% of the sample (n = 5). None of the patients had serotonin syndrome or drug-induced liver injury. Side-effects did not differ among the three dosing groups.

CONCLUSION

OLHD-SRIs appear to be safe and well tolerated in OCD patients in SED ≤ 650 mg/day doses and the side-effects did not differ between the three dosing groups.

Editorial: Outcome Measurement in Pediatric Obsessive-Compulsive Disorder: Current Considerations and Future Directions

Our understanding of pediatric obsessive-compulsive disorder (OCD) has come a long way since the important book by Paul Adams. In ;this 1973 book, Obsessive Children: A Sociopsychiatric Study, Adams described 49 youth with OCD, albeit with some blurring of OCD and obsessive-compulsive personality disorder. The proposed etiology of OCD rested on psychoanalytic principles and the social psychiatric perspective. This perspective emphasized the importance of social factors in the emergence of mental illness, including OCD. A prevailing view at the time asserted that OCD was a rare, episodic condition often with childhood onset.

Harmonizing the Neurobiology and Treatment of Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is a common, chronic, and oftentimes disabling disorder. The only established first-line treatments for OCD are exposure and response prevention, and serotonin reuptake inhibitor medications (SRIs). However, a subset of patients fails to respond to either modality, and few experience complete remission. Beyond SRI monotherapy, antipsychotic augmentation is the only medication approach for OCD with substantial empirical support. Our incomplete understanding of the neurobiology of OCD has hampered efforts to develop new treatments or enhance extant interventions. This review focuses on several promising areas of research that may help elucidate the pathophysiology of OCD and advance treatment. Multiple studies support a significant genetic contribution to OCD, but pinpointing the specific genetic determinants requires additional investigation. The preferential efficacy of SRIs in OCD has neither led to discovery of serotonergic abnormalities in OCD nor to development of new serotonergic medications for OCD. Several lines of preclinical and clinical evidence suggest dysfunction of the glutamatergic system in OCD, prompting testing of several promising glutamate modulating agents. Functional imaging studies in OCD show consistent evidence for increased activity in brain regions that form a cortico-striato-thalamo-cortical (CSTC) loop. Neuromodulation treatments with either noninvasive devices (e.g., transcranial magnetic stimulation) or invasive procedures (e.g., deep brain stimulation) provide further support for the CSTC model of OCD. A common substrate for various interventions (whether drug, behavioral, or device) may be modulation (at different nodes or connections) of the CSTC circuit that mediates the symptoms of OCD.

The Psychopharmacology of Obsessive-Compulsive Disorder: A Preclinical Roadmap

This review evaluates current knowledge about obsessive-compulsive disorder (OCD), with the goal of providing a roadmap for future directions in research on the psychopharmacology of the disorder. It first addresses issues in the description and diagnosis of OCD, including the structure, measurement, and appropriate description of the disorder and issues of differential diagnosis. Current pharmacotherapies for OCD are then reviewed, including monotherapy with serotonin reuptake inhibitors and augmentation with antipsychotic medication and with psychologic treatment. Neuromodulatory therapies for OCD are also described, including psychosurgery, deep brain stimulation, and noninvasive brain stimulation. Psychotherapies for OCD are then reviewed, focusing on behavior therapy, including exposure and response prevention and cognitive therapy, and the efficacy of these interventions is discussed, touching on issues such as the timing of sessions, the adjunctive role of pharmacotherapy, and the underlying mechanisms. Next, current research on the neurobiology of OCD is examined, including work probing the role of various neurotransmitters and other endogenous processes and etiology as clues to the neurobiological fault that may underlie OCD. A new perspective on preclinical research is advanced, using the Research Domain Criteria to propose an adaptationist viewpoint that regards OCD as the dysfunction of a normal motivational system. A systems-design approach introduces the security motivation system (SMS) theory of OCD as a framework for research. Finally, a new perspective on psychopharmacological research for OCD is advanced, exploring three approaches: boosting infrastructure facilities of the brain, facilitating psychotherapeutic relearning, and targeting specific pathways of the SMS network to fix deficient SMS shut-down processes. SIGNIFICANCE STATEMENT: A significant proportion of patients with obsessive-compulsive disorder (OCD) do not achieve remission with current treatments, indicating the need for innovations in psychopharmacology for the disorder. OCD may be conceptualized as the dysfunction of a normal, special motivation system that evolved to manage the prospect of potential danger. This perspective, together with a wide-ranging review of the literature, suggests novel directions for psychopharmacological research, including boosting support systems of the brain, facilitating relearning that occurs in psychotherapy, and targeting specific pathways in the brain that provide deficient stopping processes in OCD.

Pharmacotherapy for obsessive—compulsive disorder

We present a narrative review of evidence-based treatment for obsessive–compulsive disorder (OCD), covering first-line pharmacological treatment, augmentation strategies, approaches for treatment-refractory OCD and the management of OCD in special populations (children and adolescents, pregnant and breast-feeding women, and elderly people).

Obsessive–compulsive disorder in young people

Obsessive–compulsive disorder (OCD) is one of the most debilitating psychiatric conditions in young people. In DSM-5 it is no longer characterised as an anxiety disorder, but instead is part of a group of ‘obsessive–compulsive and related disorders'. In the past 10 years, cognitive—behavioural therapy (CBT) has become well established as the first-choice treatment. This article explains some of the elements of CBT and describes new directions in research which might improve interventions.

Validity of Quinpirole Sensitization Rat Model of OCD: Linking Evidence from Animal and Clinical Studies

Obsessive-compulsive disorder (OCD) is a neuropsychiatric disorder with 1–3% prevalence. OCD is characterized by recurrent thoughts (obsessions) and repetitive behaviors (compulsions). The pathophysiology of OCD remains unclear, stressing the importance of pre-clinical studies. The aim of this article is to critically review a proposed animal model of OCD that is characterized by the induction of compulsive checking and behavioral sensitization to the D2/D3 dopamine agonist quinpirole. Changes in this model have been reported at the level of brain structures, neurotransmitter systems and other neurophysiological aspects. In this review, we consider these alterations in relation to the clinical manifestations in OCD, with the aim to discuss and evaluate axes of validity of this model. Our analysis shows that some axes of validity of quinpirole sensitization model (QSM) are strongly supported by clinical findings, such as behavioral phenomenology or roles of brain structures. Evidence on predictive validity is contradictory and ambiguous. It is concluded that this model is useful in the context of searching for the underlying pathophysiological basis of the disorder because of the relatively strong biological similarities with OCD.

An interrogation of cognitive findings in pediatric obsessive-compulsive and related disorders

Current findings in the field of psychology have led to increased interest and a new conceptualization of disorders characterized by repetitive behaviors, namely the obsessive compulsive and related disorders (OCRDs). Scant research, however, has sought to collect and categorize the extant research on pediatric OCRDs. Particularly, no adequate review of the pediatric cognitive literature existed until now, despite the clear implication of abnormalities in neuroanatomical structures and cognitive functioning in adult samples. While evidence for cognitive dysfunction in pediatric samples is presented, this paper also suggests that differences in cognitive dysfunction may indeed exist between adults and youth with OCRDs. Specifically, those irregularities present in said youth at varying developmental stages may impact the origination and maintenance of OCRDs across time. Finally, this paper seeks to formulate potential future goals for the research field, particularly through transdiagnostic approaches to processes linked with symptom presentations. This is of particular importance as an improved understanding of the interaction of cognitive function and growth is key to further comprehension of the OCRDs.

Obsessive-compulsive Disorder in Children and Adolescents

This selective review shows that childhood obsessive-compulsive disorder (OCD) is a serious condition that requires early identification and treatment. Initially, we examine the relationship of childhood rituals to OCD, and discuss recent findings on the epidemiology of childhood OCD. The DSM-IV criteria for OCD are presented, along with recent findings on psychopathology. Clinical management of childhood OCD is a challenging and difficult task for mental health professionals. We briefly describe and evaluate advances in behavioural treatment — mainly in vivo exposure and response prevention. The adjunctive use of antidepressant medication is also examined. Whilst these clinical innovations are promising, further controlled evaluations are necessary before the efficacy of behavioural intervention can be confidently asserted.

Obsessive-compulsive disorder

This article reviews the clinical features and neurochemical hypotheses of obsessive-compulsive disorder (OCD) with a focus on the serotonin system. In DSM-5, OCD was moved from the anxiety disorders to a new category of Obsessive-Compulsive and Related Disorders. OCD is a common, typically persistent disorder marked by intrusive and disturbing thoughts (obsessions) and repetitive behaviors (compulsions) that the person feels driven to perform. The preferential efficacy of serotonin reuptake inhibitors (SRIs) in OCD led to the so-called serotonin hypothesis. However, direct support for a role of serotonin in the pathophysiology (e.g., biomarkers in pharmacological challenge studies) of OCD remains elusive. A role of the glutamatergic system in OCD has been gaining traction based on imaging data, genomic studies and animal models of aberrant grooming behavior. These findings have spurred interest in testing the efficacy of medications that modulate glutamate function. A role of glutamate is compatible with circuit-based theories of OCD.

Compulsivity, impulsivity, and the DSM-5 process

Compulsivity and impulsivity are cross-cutting, dimensional symptom domains that span traditional diagnostic boundaries. We examine compulsivity and impulsivity from several perspectives and present implications for these symptom domains as they relate to classification. We describe compulsivity and impulsivity as general concepts, from the perspectives of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) Research Planning Agenda, and from the DSM-5 workgroups, literature reviews, and field trials. Finally, we detail alternative modes of classification for compulsivity and impulsivity in line with the Research Domain Criteria (RDoC) and International Classification of Diseases (ICD-11).

Stereotypic behavior in nonhuman primates as a model for the human condition

Stereotypies that develop spontaneously in nonhuman primates can provide an effective model for repetitive stereotyped behavior in people with neurodevelopmental or obsessive-compulsive disorders. The behaviors are similar in form, are similarly affected by environmental conditions, and are improved with similar treatment methods such as enrichment, training, and drug therapy. However, because of a greater number of commonalities in these factors, nonhuman primates may serve as a better model for stereotyped behavior in individuals with autism or intellectual disability than for compulsions in individuals with obsessive-compulsive disorder. Because animal models may not be exact in all features of the disorder being studied, it is important to investigate the strengths and weaknesses of using a nonhuman primate model for stereotyped behavior in people with psychological disorders.

Comparison among clomipramine, fluoxetine, and placebo for the treatment of anxiety disorders in children and adolescents

OBJECTIVE

The purpose of this study was to test the efficacy of clomipramine and fluoxetine, controlled by placebo, and compare their action in children and adolescents with anxiety disorders.

METHOD

Thirty subjects (ages 7-17 years), who were diagnosed with generalized anxiety disorder and/or separation anxiety disorder and/or social phobia, were submitted to a 12 week double-blind, randomized, placebo-controlled trial of clomipramine and fluoxetine. The instruments included: the Schedule for Affective Disorders and Schizophrenia, the Multidimensional Anxiety Scale for Children, the Children's Depression Inventory, the Clinical Global Impressions, and the Children's Global Assessment Scale.

RESULTS

All groups (clomipramine [n=9], fluoxetine [n=10], placebo [n=11]) showed a significant improvement after 12 weeks of treatment. There were significant differences between the fluoxetine and placebo groups in some ratings of anxiety severity and impairment. No significant differences were observed between clomipramine and placebo groups or between fluoxetine and clomipramine groups.

CONCLUSIONS

Treatment with placebo showed an unusual high response rate. Clomipramine showed similar efficacy compared with fluoxetine, although it was not superior to placebo.

Sex- and endocrine-stage-differences in middle-aged rats in an animal model of OCD

Various clinical studies suggest that many features of OCD are influenced by sex, age and fluctuations in hormonal levels. Animal models have confirmed these differences, and suggest they are mediated by the serotonergic system. We compared the perseveration behavior in a T-maze after the administration of the 5-HT1A agonist, 8-OH-DPAT (2.0 mg/kg) and the preventive action of subchronic fluoxetine (10 mg/kg, 3 times) in middle-aged (11-14 months) males and female rats in two endocrine states: irregular cycles (tested in diestrus) or persistent diestrus. After 8-OH-DPAT, females with persistent diestrus presented higher perseveration scores than males and females with irregular cycles. Fluoxetine produced an anticompulsive-like effect only in females with persistent diestrus. Females in persistent diestrus showed higher estradiol levels than those in irregular cycles or males. In all groups 8-OH-DPAT increased ambulation and fluoxetine did not modify this action. In males, the combined administration of fluoxetine and 8-OH-DPAT impaired motor coordination. Data are discussed on the basis of estradiol levels and sex differences.

Effects of ketamine in treatment-refractory obsessive-compulsive disorder

BACKGROUND

Treatments for obsessive-compulsive disorder (OCD) usually lead to incomplete symptom relief and take a long-time to reach full effect. Convergent evidence suggests that glutamate abnormalities contribute to the pathogenesis of OCD. Ketamine is a potent noncompetitive antagonist of the N-methyl-D-aspartate glutamate receptor. Trials have reported rapid antidepressant effects after low-dose ketamine infusion.

METHODS

We conducted an open-label trial of ketamine (.5 mg/kg IV over 40 min) in 10 subjects with treatment-refractory OCD. Response was defined as >35% improvement in OCD symptoms and >50% improvement in depression symptoms from baseline at any time between 1 and 3 days after infusion.

RESULTS

None of 10 subjects experienced a response in OCD symptoms in the first 3 days after ketamine. Four of seven patients with comorbid depression experienced an antidepressant response to ketamine in the first 3 days after infusion. Both OCD and depression symptoms demonstrated a statistically significant improvement in the first 3 days after infusion compared with baseline, but the OCD response was <12%. The percentage reduction in depressive symptoms in the first 3 days after ketamine infusion was significantly greater than the reduction in OCD symptoms.

CONCLUSIONS

Ketamine effects on OCD symptoms, in contrast to depressive symptoms, did not seem to persist or progress after the acute effects of ketamine had dissipated.

Psychopharmacologic treatment for pediatric anxiety disorders

Anxiety is an innate emotion that all humans experience, especially during early childhood in periods of significant growth and development. Treatment strategies exist for anxiety disorders that cause significant dysfunction and impairment in youth. This article provides a current overview of the literature on psychopharmacologic management of pediatric anxiety disorders. Potential side effects and complications of psychotropic medications are reviewed. The treatment of anxiety disorders in patients with comorbid conditions is explored, addressing the impact on treatment course and pharmacologic recommendations. A clinical vignette describing a 10-year-old boy with increasing anxiety is presented describing in-hospital and outpatient treatment and therapies.

Efficacy of antidepressant medications in children and adolescents with obsessive-compulsive disorder: a systematic appraisal

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.

Still Struggling: characteristics of youth with OCD who are partial responders to medication treatment

The primary aim of this paper is to examine the characteristics of a large sample of youth with OCD who are partial responders (i.e., still have clinically significant symptoms) to serotonin reuptake inhibitor (SRI) medication. The sample will be described with regard to: demographics, treatment history, OCD symptoms/severity, family history and parental psychopathology, comorbidity, and global and family functioning. The sample includes 124 youth with OCD ranging in age from 7 to 17 with a primary diagnosis of OCD and a partial response to an SRI medication. The youth are a predominantly older (age 12 and over), Caucasian, middle to upper income group who had received significant past treatment. Key findings include moderate to severe OCD symptoms, high ratings of global impairment, and significant comorbidity, despite partial response to an adequate medication trial. Considerations regarding generalizability of the sample and limitations of the study are discussed.

Evidence-based pharmacotherapy for pediatric obsessive-compulsive disorder and chronic tic disorders

In recent years, much progress has been made in pharmacotherapy for pediatric obsessive-compulsive disorder (OCD) and chronic tic disorders (CTDs). What were previously considered relatively intractable conditions now have an array of efficacious medicinal (and psychosocial) interventions available at clinicians’ disposal, including selective serotonin reuptake inhibitors, atypical antipsychotics, and alpha-2 agonists. The purpose of this review is to discuss the evidence base for pharmacotherapy with pediatric OCD and CTDs with regard to efficacy, tolerability, and safety, and to put this evidence in the context of clinical management in integrated behavioral healthcare. While there is no single panacea for these disorders, there are a variety of medications that provide considerable relief for children with these disabling conditions.

Predictors and moderators of treatment outcome in the Pediatric Obsessive Compulsive Treatment Study (POTS I)

OBJECTIVE

To identify predictors and moderators of outcome in the first Pediatric OCD Treatment Study (POTS I) among youth (N = 112) randomly assigned to sertraline, cognitive behavioral therapy (CBT), both sertraline and CBT (COMB), or a pill placebo.

METHOD

Potential baseline predictors and moderators were identified by literature review. The outcome measure was an adjusted week 12 predicted score for the Children's Yale Brown Obsessive Compulsive Scale (CY-BOCS). Main and interactive effects of treatment condition and each candidate predictor or moderator variable were examined using a general linear model on the adjusted predicted week 12 CY-BOCS scores.

RESULTS

Youth with lower obsessive-compulsive disorder (OCD) severity, less OCD-related functional impairment, greater insight, fewer comorbid externalizing symptoms, and lower levels of family accommodation showed greater improvement across treatment conditions than their counterparts after acute POTS treatment. Those with a family history of OCD had more than a sixfold decrease in effect size in CBT monotherapy relative to their counterparts in CBT without a family history of OCD.

CONCLUSIONS

Greater attention is needed to build optimized intervention strategies for more complex youth with OCD. Youth with a family history of OCD are not likely to benefit from CBT unless offered in combination with an SSRI.

CLINICAL TRIALS REGISTRATION INFORMATION

Treatment of Obsessive Compulsive Disorder (OCD) in Children, http://www.clinicaltrials.gov, NCT00000384.

Should an obsessive-compulsive spectrum grouping of disorders be included in DSM-V?

The obsessive-compulsive (OC) spectrum has been discussed in the literature for two decades. Proponents of this concept propose that certain disorders characterized by repetitive thoughts and/or behaviors are related to obsessive-compulsive disorder (OCD), and suggest that such disorders be grouped together in the same category (i.e. grouping, or "chapter") in DSM. This article addresses this topic and presents options and preliminary recommendations to be considered for DSM-V. The article builds upon and extends prior reviews of this topic that were prepared for and discussed at a DSM-V Research Planning Conference on Obsessive-Compulsive Spectrum Disorders held in 2006. Our preliminary recommendation is that an OC-spectrum grouping of disorders be included in DSM-V. Furthermore, we preliminarily recommend that consideration be given to including this group of disorders within a larger supraordinate category of "Anxiety and Obsessive-Compulsive Spectrum Disorders." These preliminary recommendations must be evaluated in light of recommendations for, and constraints upon, the overall structure of DSM-V.

Pharmacotherapy for anxiety disorders in children and adolescents

BACKGROUND

Anxiety disorders are a potentially disabling group of disorders which are prevalent in childhood and adolescence. The recognition of the early onset of anxiety disorders, and their successful treatment with medication in adults, has led to the growing interest in using medication for paediatric anxiety disorders.

OBJECTIVES

To assess the efficacy and tolerability of medication for treating paediatric anxiety disorders.

SEARCH STRATEGY

We searched the Cochrane Depression, Anxiety & Neurosis Group specialised register (CCDANCTR-Studies), MEDLINE (via PubMed 1966 to August 2008), EMBASE (1966 to August 2008), and PsycINFO (1972 to August 2008). Various electronic registers were searched for unpublished studies. Reference lists of retrieved articles were searched for additional studies.

SELECTION CRITERIA

All randomised controlled trials (RCTs) of pharmacotherapy in childhood/adolescent anxiety disorders.

DATA COLLECTION AND ANALYSIS

Two raters independently assessed RCTs for inclusion in the review, collated trial data, and assessed trial quality. Investigators were contacted to obtain missing data. Summary statistics were stratified by medication class, and by medication agent for the selective serotonin reuptake inhibitors (SSRIs). Dichotomous and continuous measures were calculated using a random effects model, heterogeneity was assessed, and subgroup/sensitivity analyses were undertaken.

MAIN RESULTS

22 short-term (<= 16 weeks) RCTs were included in the analysis (2519 participants). The majority of the trials assessed the efficacy of the SSRIs (N = 15).Medication and placebo response occurred in 58.1% and 31.5% of patients, respectively (Number of studies (N) = 14, Number needed to treat (NNT) = 4). Medication was more effective than placebo in reducing overall symptom severity in OCD in a post-hoc comparison (N = 7, Weighted Mean Difference (WMD) = -4.45, 95%CI = -5.94, -2.97, n = 765). Medication was less well tolerated than placebo overall, though the absolute proportion of participants who withdrew due to drug-related adverse events was low (4.9%).

AUTHORS' CONCLUSIONS

Medication treatments can be effective in paediatric anxiety disorders, acting to reduce core symptoms, and should be considered as part of the treatment of these disorders. The greatest number of trials showing efficacy to date have assessed the SSRIs in treating paediatric OCD.There is no clear evidence to show that any particular class of medication is more effective or better tolerated than any other. As quantitative data was only available for the SSRIs and venlafaxine the routine use of benzodiazepines cannot be recommended, especially given concerns of dependency and treatment -related emergent adverse events associated with this class of drugs.Future RCTs could help identify potential clinical moderators of treatment efficacy. Studies of the long-term efficacy of medication treatment, optimal dosage, as well as direct comparisons of pharmacotherapy and psychotherapy are also warranted.

Children with obsessive-compulsive disorder: are they just "little adults"?

Childhood-onset obsessive-compulsive disorder (OCD) affects 1%-2% of children and adolescents. It is characterized by recurrent obsessions and compulsions that create distress and interfere with daily life. The symptoms reported by children are similar to those seen among individuals who develop OCD in adulthood, and the two groups of patients are treated with similar symptom-relieving behavior therapies and medications. However, there are differences in sex ratios, patterns of comorbidity, and the results of neuroimaging studies that might be important. Here we review the diagnosis and treatment of childhood-onset OCD in light of pediatric and adult studies. We also discuss current knowledge of the pathophysiology of the disorder. Despite advances in this area, further research is needed to understand better the etiopathogenesis of the disorder and to develop new, more effective therapeutic options.

The Pediatric Obsessive-Compulsive Disorder Treatment Study II: rationale, design and methods

This paper presents the rationale, design, and methods of the Pediatric Obsessive-Compulsive Disorder Treatment Study II (POTS II), which investigates two different cognitive-behavior therapy (CBT) augmentation approaches in children and adolescents who have experienced a partial response to pharmacotherapy with a serotonin reuptake inhibitor for OCD. The two CBT approaches test a "single doctor" versus "dual doctor" model of service delivery. A specific goal was to develop and test an easily disseminated protocol whereby child psychiatrists would provide instructions in core CBT procedures recommended for pediatric OCD (e.g., hierarchy development, in vivo exposure homework) during routine medical management of OCD (I-CBT). The conventional "dual doctor" CBT protocol consists of 14 visits over 12 weeks involving: (1) psychoeducation, (2), cognitive training, (3) mapping OCD, and (4) exposure with response prevention (EX/RP). I-CBT is a 7-session version of CBT that does not include imaginal exposure or therapist-assisted EX/RP. In this study, we compared 12 weeks of medication management (MM) provided by a study psychiatrist (MM only) with two types of CBT augmentation: (1) the dual doctor model (MM+CBT); and (2) the single doctor model (MM+I-CBT). The design balanced elements of an efficacy study (e.g., random assignment, independent ratings) with effectiveness research aims (e.g., differences in specific SRI medications, dosages, treatment providers). The study is wrapping up recruitment of 140 youth ages 7-17 with a primary diagnosis of OCD. Independent evaluators (IEs) rated participants at weeks 0,4,8, and 12 during acute treatment and at 3,6, and 12 month follow-up visits.

TRIAL REGISTRATION

NCT00074815.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of anxiety, obsessive-compulsive and post-traumatic stress disorders - first revision

In this report, which is an update of a guideline published in 2002 (Bandelow et al. 2002, World J Biol Psychiatry 3:171), recommendations for the pharmacological treatment of anxiety disorder, obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) are presented. Since the publication of the first version of this guideline, a substantial number of new randomized controlled studies of anxiolytics have been published. In particular, more relapse prevention studies are now available that show sustained efficacy of anxiolytic drugs. The recommendations, developed by the World Federation of Societies of Biological Psychiatry (WFSBP) Task Force for the Pharmacological Treatment of Anxiety, Obsessive-Compulsive and Post-traumatic Stress Disorders, a consensus panel of 30 international experts, are now based on 510 published randomized, placebo- or comparator-controlled clinical studies (RCTs) and 130 open studies and case reports. First-line treatments for these disorders are selective serotonin reuptake inhibitors (SSRIs), serotonin-noradrenaline reuptake inhibitors (SNRIs) and the calcium channel modulator pregabalin. Tricyclic antidepressants (TCAs) are equally effective for some disorders, but many are less well tolerated than the SSRIs/SNRIs. In treatment-resistant cases, benzodiazepines may be used when the patient does not have a history of substance abuse disorders. Potential treatment options for patients unresponsive to standard treatments are described in this overview. Although these guidelines focus on medications, non-pharmacological were also considered. Cognitive behavioural therapy (CBT) and other variants of behaviour therapy have been sufficiently investigated in controlled studies in patients with anxiety disorders, OCD, and PTSD to support them being recommended either alone or in combination with the above medicines.

Personal reflections on observational and experimental research approaches to childhood psychopathology

The past 50 years have seen dramatic changes in childhood psychopathology research. The goal of this overview is to contrast observational and experimental research approaches; both have grown more complex such that the boundary between these approaches may be blurred. Both are essential. Landmark observational studies with long-term follow-up (Robins, 1966; Yarrow, Campbell, & Burton, 1970) have had - and continue to have - unique impact on clinical research and practice. Epidemiological studies showed high rates of psychological disorder and their close tie to neurological impairment (Rutter, Tizard, & Whitemore, 1970). These studies have current impact with respect to brain imaging correlates of clinical outcome. Pharmacological studies, particularly those on stimulants and on treatment of pediatric obsessive compulsive disorder (OCD), have propelled experimental methodology and inspired translational approaches. Predicted future trends are: more informed subgrouping of our heterogeneous phenotypes, reliance on multicenter trials, and documentation of non-conventional methods of care delivery.

Psychopharmacologic interventions for repetitive behaviors in autism spectrum disorders

This article provides an overview of psychopharmacological treatments for repetitive behaviors in autism spectrum disorders (ASDs) in the context of current conceptualizations of this understudied core symptom domain. The available literature on the widely used selective serotonin reuptake inhibitors (SSRIs), including fluvoxamine, fluoxetine, citalopram, escitalopram, and sertraline, are reviewed. In addition to SSRIs, research on effects of other pharmacologic interventions such as divalproex sodium, risperidone, and the neuropeptide oxytocin are presented. To date, data are mixed for interventions commonly prescribed in clinical practice and suggest several areas of investigation in advancing research on the medication management of repetitive behaviors.

Neurobiology and treatment of compulsive hoarding

Compulsive hoarding is a common and often disabling neuropsychiatric disorder. This article reviews the phenomenology, etiology, neurobiology, and treatment of compulsive hoarding. Compulsive hoarding is part of a discrete clinical syndrome that includes difficulty discarding, urges to save, clutter, excessive acquisition, indecisiveness, perfectionism, procrastination, disorganization, and avoidance. Epidemiological and taxometric studies indicate that compulsive hoarding is a separate but related obsessive-compulsive spectrum disorder that is frequently comorbid with obsessive-compulsive disorder (OCD). Compulsive hoarding is a genetically discrete, strongly heritable phenotype. Neuroimaging and neuropsychological studies indicate that compulsive hoarding is neurobiologically distinct from OCD and implicate dysfunction of the anterior cingulate cortex and other ventral and medial prefrontal cortical areas that mediate decision-making, attention, and emotional regulation. Effective treatments for compulsive hoarding include pharmacotherapy and cognitive-behavioral therapy. More research will be required to determine the etiology and pathophysiology of compulsive hoarding, and to develop better treatments for this disorder.

Predictors of treatment response in pediatric obsessive-compulsive disorder

OBJECTIVE

To examine predictors of treatment response in pediatric obsessive-compulsive disorder (OCD).

METHOD

A literature review of psychotherapy (i.e., cognitive-behavioral therapy) and medication studies for pediatric OCD published from 1985 to 2007 was conducted using several databases.

RESULTS

The literature search produced a total of 21 studies (6 cognitive-behavioral therapy, 13 medication, and 2 combination studies) that met specific methodological criteria. Across studies, the following nine predictors were examined: child sex, child age, duration of illness/age at onset, baseline severity of obsessive-compulsive symptoms, type of obsessive-compulsive symptoms, comorbid disorders/symptoms, psychophysiological factors, neuropsychological factors, and family factors. Among all of the studies, there was little evidence that sex, age, or duration of illness (age at onset) was associated with treatment response. Baseline severity of obsessive-compulsive symptoms and family dysfunction were associated with poorer response to cognitive-behavioral therapy, whereas comorbid tics and externalizing disorders were associated with poorer response in medication-only studies.

CONCLUSIONS

Overall, there are limited data on predictors of treatment response for pediatric OCD. The majority of studies are plagued with methodological limitations and post hoc approaches. Additional research is needed to better delineate the predictors of treatment response in pediatric OCD with the goal of developing individualized treatment approaches.

Are child and adolescent responses to placebo higher in major depression than in anxiety disorders? A systematic review of placebo-controlled trials

BACKGROUND

In a previous report, we hypothesized that responses to placebo were high in child and adolescent depression because of specific psychopathological factors associated with youth major depression. The purpose of this study was to compare the placebo response rates in pharmacological trials for major depressive disorder (MDD), obsessive compulsive disorder (OCD) and other anxiety disorders (AD-non-OCD).

METHODOLOGY AND PRINCIPAL FINDINGS

We reviewed the literature relevant to the use of psychotropic medication in children and adolescents with internalized disorders, restricting our review to double-blind studies including a placebo arm. Placebo response rates were pooled and compared according to diagnosis (MDD vs. OCD vs. AD-non-OCD), age (adolescent vs. child), and date of publication. From 1972 to 2007, we found 23 trials that evaluated the efficacy of psychotropic medication (mainly non-tricyclic antidepressants) involving youth with MDD, 7 pertaining to youth with OCD, and 10 pertaining to youth with other anxiety disorders (N = 2533 patients in placebo arms). As hypothesized, the placebo response rate was significantly higher in studies on MDD, than in those examining OCD and AD-non-OCD (49.6% [range: 17-90%] vs. 31% [range: 4-41%] vs. 39.6% [range: 9-53], respectively, ANOVA F = 7.1, p = 0.002). Children showed a higher stable placebo response within all three diagnoses than adolescents, though this difference was not significant. Finally, no significant effects were found with respect to the year of publication.

CONCLUSION

MDD in children and adolescents appears to be more responsive to placebo than other internalized conditions, which highlights differential psychopathology.

Meta-analysis of randomized, controlled treatment trials for pediatric obsessive-compulsive disorder

OBJECTIVE

To conduct a meta-analysis on randomized, controlled treatment trials of pediatric obsessive-compulsive disorder (OCD).

METHOD

Studies were included if they employed randomized, controlled methodology and treated young people (19 years or under) with OCD. A comprehensive literature search identified 13 RCTs containing 10 pharmacotherapy to control comparisons (N = 1016) and five cognitive-behavioral therapy (CBT) to control comparisons (N = 161).

RESULTS

Random effects modeling yielded statistically significant pooled effect size (ES) estimates for pharmacotherapy (ES = .48, 95% CI = .36 to .61, p < .00001) and CBT (ES = 1.45, 95% CI = .68 to 2.22, p = .002). The results were robust to publication bias.

CONCLUSIONS

This is the first meta-analysis of treatment RCTs for pediatric OCD. CBT and pharmacotherapy were the only treatments effective beyond control in alleviating OCD symptoms. CBT showed a greater ES than pharmacotherapy. Previous meta-analyses that included uncontrolled trials exaggerated the efficacy of both treatments.

Association study between obsessive-compulsive disorder and serotonergic candidate genes

BACKGROUND

To date, research examining the relationship between serotonergic genes and obsessive-compulsive disorder (OCD) has yielded conflicting results. The purpose of this study is to investigate the association between four serotonergic polymorphisms (STin2 VNTR and 5-HTTLPR of the SLC6A4 gene, and A-1438G (rs6311) and T102C (rs6313) of the HTR2A gene) and OCD.

METHODS

99 OCD patients, 456 non-OCD psychiatric patients, and 420 healthy controls from a homogeneous Spanish Caucasian population were genotyped using standard methods.

RESULTS

All groups showed Hardy-Weinberg equilibrium for the analyzed genetic variability. A-1438G and T102C polymorphisms were in complete linkage disequilibrium. OCD patients showed an excess of STin2.12 carriers (12/12, 12/10, and 12/9 genotypes) compared with healthy controls (chi(2) (1)=7.21, corrected p=0.021; OR=3.38, 95% CI=1.32-8.62) and non-OCD psychiatric patients (chi(2) (1)=6.70, corrected p=0.030; OR=3.24, 95% CI=1.27-8.26). However, no differences were found between non-OCD patients and healthy controls (chi(2) (1)=0.05, corrected p>1; OR=1.04, 95% CI=0.72-1.51). No significant differences were found with respect to A-1438G and 5-HTTLPR polymorphisms.

CONCLUSIONS

Our data provide supporting evidence of an association between the STin2 VNTR polymorphism of the SLC6A4 gene and OCD.

Clinical features associated with treatment-resistant pediatric obsessive-compulsive disorder

OBJECTIVE

The objective of the study was to identify clinical and sociodemographic characteristics that may differentiate youth with obsessive-compulsive disorder (OCD) who are resistant to treatment vs those who have a favorable response.

METHOD

Participants included 60 outpatients, aged 7-17 years, who were determined to have previously received an adequate trial of a first-line treatment (ie, serotonin reuptake inhibitors, cognitive behavioral therapy). Patients who were treatment-resistant were compared with responders on a number of factors, including severity and nature of OCD symptoms, levels of internalizing and externalizing symptoms, family accommodation of OCD symptoms, and functional impairment.

RESULTS

The treatment-resistant group endorsed significantly more obsessions and compulsions, greater levels of internalizing symptoms, higher parental stress related to accommodation, and greater functional impairment than treatment responders. However, relative to treatment-resistant patients, treatment responders reported higher levels of depressive symptoms, perhaps indicating that they were more distressed by their OCD symptoms, as well as greater insight into their symptoms.

CONCLUSIONS

This study indicates that youth with more severe symptoms of OCD, higher related parental stress, and greater functional impairment tend to be more resistant to first-line treatments, and that perhaps they may require more intensive or family-based interventions. Treatment responders report more depressive symptoms and insight into their OCD, which may suggest a greater readiness for treatment. Further research likely would help to identify which types of treatment would be most beneficial for individual youth.

Tic- und Zwangsstörungen

Zusammenfassung. In diesem Übersichtsartikel werden die Gemeinsamkeiten und Unterschiede von Tic- und Zwangsstörungen auf verschiedenen Ebenen dargestellt. In der Psychopathologie unterscheiden sich beide Phänomene zunächst deutlich - Tics sind plötzlich auftretende, unwillkürliche, motorische Bewegungen oder Vokalisationen. Zwänge sind wiederholte, zweckmäßige und beabsichtigte Verhaltensweisen. Es gibt jedoch fließende Übergänge, die sich vor allem bei den Just-Right-Zwängen manifestieren, die bei Tourette-Störungen gehäuft auftreten. Die diagnostischen Strategien und die dabei hilfreichen Instrumente werden vorgestellt. In der Therapie haben sich bei beiden Störungen sowohl verhaltenstherapeutische als auch pharmakotherapeutische Verfahren bewährt. Es wird eine Übersicht über den Stand der empirischen Evidenz gegeben. Die Behandlung von kombinierten Tic- und Zwangsstörungen wird speziell erörtert.

Risk of adverse behavioral effects with pediatric use of antidepressants

OBJECTIVES

This article reviews evidence that led the Food and Drug Administration to issue a "black box" warning about the risk of "suicidality" (suicidal thoughts and behavior) in children and adolescents during treatment with antidepressants.

RESULTS

Re-analysis of data from randomized clinical trials of antidepressants in the pediatric population revealed a significantly greater overall (all drugs across all indications) risk ratio for drug 1.95 (95% Cl, 1.28-2.98) compared to placebo in this sample of approximately 4,000 subjects.

DISCUSSION

The essential message of the "black box" is to remind prescribers and consumers about the importance of monitoring closely for adverse behavioral changes during the initiation of (or changes in) antidepressant therapy. Possible mechanisms that might account for this phenomenon, particularly the so-called activation syndrome, are discussed.

CONCLUSION

Empirical studies are needed to identify the precursors of suicidality and to predict which individuals are most susceptible to adverse behavioral side effects of antidepressants.

The pharmacological management of childhood anxiety disorders: a review

RATIONALE

Pediatric anxiety is a prevalent psychiatric disorder that may have important implications for school, social, and academic function. Psychopharmacological approaches to the treatment of pediatric anxiety have expanded over the past 20 years and increasing empirical evidence helps guide current clinical practice.

OBJECTIVE

To review studies which examine the pharmacological treatment of pediatric anxiety disorders, including obsessive-compulsive disorder and to summarize treatment implications.

METHODS

All relevant studies were searched using MEDLINE and PsycINFO search engines, supplemented by a manual bibliographical search; studies published between 1985 and 2006 that met inclusion criteria were examined.

RESULTS

This article provides a systematic review of the psychopharmacological treatment of pediatric anxiety disorders based on available empirical evidence, with a focus on randomized controlled trials. General treatment principles and pharmacological management of specific pediatric anxiety disorders are also reviewed.

CONCLUSION

There is good evidence to support the efficacy of several pharmacological agents including the selective serotonin reuptake inhibitors to treat pediatric anxiety and obsessive-compulsive disorder, although there are still many unanswered questions.

Association studies of serotonin system candidate genes in early-onset obsessive-compulsive disorder

BACKGROUND

Family-based evidence for association at serotonin system genes SLC6A4, HTR1B, HTR2A, and brain-derived neurotrophic factor (BDNF) has been previously reported in obsessive-compulsive disorder (OCD). Early-onset OCD is a more familial form of the disorder.

METHODS

We used the transmission-disequilibrium test of association at common polymorphisms in each of these genes in 54 parent-child trios ascertained through probands with early-onset OCD.

RESULTS

No evidence for association was detected at any of the polymorphisms in the entire set of subjects. Nominally significant association was found at the HTR2A rs6311 polymorphism in subjects with tic disorder and OCD (p = .05), replicating a previous finding in Tourette syndrome and OCD. Nominally significant association was also found for the SLC6A4 HT transporter gene-linked polymorphic region (5-HTTLPR) polymorphism for female subjects (p = .03). Neither association would remain significant after statistical correction for multiple testing. Despite no individual study reporting replication, a pooled analysis of five replication studies of the SLC6A4 5-HTTLPR polymorphism supports association (p = .02).

CONCLUSIONS

Low power across individual association studies in OCD may lead to a false acceptance of the null hypothesis. Accumulation of evidence from multiple studies will be necessary to evaluate the potential role for these genes in contributing to susceptibility to OCD.

Efficacité des antidépresseurs inhibiteurs sélectifs de la recapture de la sérotonine chez l’enfant et l’adolescent

Selective serotonin reuptake inhibitors (SSRIs) have been used increasingly since the early 1990s to treat anxiety disorders and depression in children and adolescents. Several recent reports, however, cast doubt on their efficacy and especially raise questions about their role in serious adverse effects (increase in suicidal ideation and suicide attempts as well as reactions involving irritability, hostility, self-harm and self-destructive actions). The efficacy of SSRIs (fluoxetine, sertraline, fluvoxamine, paroxetine) in the treatment of obsessive-compulsive disorders in this population is clear today, although their effects are globally relatively modest. SSRIs remain notably less effective than clomipramine for this indication, although a variety of factors (age, family history, and psychiatric comorbidity) are also likely to influence response to treatment. Only several placebo-controlled studies suggest that the SSRIs (fluoxetine, sertraline and fluvoxamine) may have some utility in the treatment of anxiety disorders (generalized anxiety, separation anxiety, social phobias) in children and teens. The additional benefits from SSRIs for this indication nonetheless require confirmation. Imipramine and related tricyclic antidepressants are ineffective in the treatment of depressive disorders in children and adolescents. Among the SSRIs, only fluoxetine has proven its efficacy for this indication, although its effect here too appears relatively modest. The efficacy of sertraline and paroxetine cannot be considered more than probable, requiring confirmation, and that of citalopram has not been demonstrated. Moreover, because of the risk of suicidal behavior observed in some studies, SSRIs are inadvisable for the treatment of depressive disorders in this population. Overall, although the currently available data show SSRIs to be moderately effective and useful in treating anxiety disorders and depression in children and adolescents, future studies must focus on more precise identification of their indications, especially relative to psychotherapeutic strategies, which are still considered to be the first-line treatment in these disorders. From a legal point of view, only sertraline has been authorized in France for the treatment of obsessive-compulsive disorders in this population.

Obsessive-compulsive disorder in Tourette syndrome

Several lines of evidence suggest a meaningful association between obsessive-compulsive disorder and Tourette syndrome, including comorbidity, phenomenologic overlap, evidence from family and genetic studies, and the possible role of basal ganglia circuitry in both conditions. Obsessive-compulsive behaviors occur frequently in patients who have Tourette syndrome and tend to have a later onset than tics. Despite commonalities, the approaches to treating tics and obsessive-compulsive symptoms are actually quite distinct. A specialized form of cognitive behavior therapy and pharmacotherapy with a potent serotonin reuptake inhibitor are the two established first-line therapies for obsessive-compulsive disorder. An adequate trial of a serotonin reuptake inhibitor is 10 to 12 weeks in duration at doses near the upper end of the recommended range for age and weight. Cases of obsessive-compulsive disorder that do not sufficiently improve with serotonin reuptake inhibitors might benefit from adjunctive low-dose antipsychotic (eg, risperidone) medication whether or not tics are present. Warnings about an increased risk of suicidality among children and adolescents taking antidepressants for pediatric depression extend to those taking the medications for obsessive-compulsive disorder, but the risk-to-benefit ratio is more favorable in this latter population because several serotonin reuptake inhibitors have been shown to be efficacious in obsessive-compulsive disorder.

The signal attenuation rat model of obsessive-compulsive disorder: a review

During the last 30 years, there have been many attempts to develop animal models of obsessive-compulsive disorder (OCD), in the hope that they may provide a route for furthering our understanding and treatment of this disorder. The present paper reviews a recently developed rat model of OCD, namely, signal attenuation. Results of pharmacological and lesion studies are presented and evaluated with respect to the pharmacology and pathophysiology of OCD. It is argued that signal attenuation is a rat model of OCD with construct (derived from similarity in the underlying mechanisms), predictive (derived from similarity in response to treatment), and face (derived from phenomenological similarity between "compulsive" behavior in the model and compulsions in OCD patients) validity.

Pharmacotherapies in the management of obsessive-compulsive disorder

Few medications are effective in treating obsessive-compulsive disorder (OCD). As monotherapy, only potent serotonin (5-HT) reuptake inhibitors (SRIs) consistently exert an intrinsic therapeutic action in OCD. Their use in OCD, however, differs from their use in depression. This paper first reviews the evidence supporting the key role of 5-HT as a pivotal neurotransmitter in the anti-OCD response. Then, we describe the practicalities of SRI use, followed by the steps that can be taken when these medications do not produce an adequate clinical response. We provide specifics for the treatment of children and adolescents with OCD. We include a brief description of the brain circuitry involved in OCD and the mechanisms of action of the pharmacologic agents reported to be effective in this disorder, as well as those that are useful in depression but not in OCD. We present this information to promote better understanding of the research endeavours needed to develop new pharmacotherapeutic approaches.

Contemporary assessment and pharmacotherapy of Tourette syndrome

To develop a guide to clinical assessment and pharmacotherapy for children and adults with Tourette syndrome (TS), we reviewed published literature over the past 25 years to identify original articles and reviews on the assessment and pharmacological treatment of Tourette syndrome, attention-deficit/hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD). The literature search also included a survey of reviews published in book chapters. The assessment section was compiled from several reviews. Pharmacological treatments were classified into those with strong empirical support (as evidenced by two positive placebo-controlled studies for tics, OCD, or ADHD in TS samples); modest empirical support (one positive placebo-controlled study), or minimal support (open-label data only). We conclude that accurate diagnosis, including identification of comorbid conditions, is an essential step toward appropriate treatment for patients with TS. In many patients with TS, symptom management requires pharmacotherapy for tics or coexisting conditions. The evidence supporting efficacy and safety for medications used in patients with TS varies. But this evidence offers the best guide to clinical practice.

Cognitive-behavioural theory and therapy for obsessive-compulsive disorder in children and adolescents: current status and future directions

Obsessive-compulsive disorder is recognised to be much more common than once thought, and increased awareness of prevalence has been associated with an increase in clinical and research attention. However, while the cognitive behavioural model of OCD has received considerable empirical support from adult studies, there has been relatively little investigation of this model in childhood populations. Although this literature is beginning to emerge, initial evaluations suggest there may be important differences between childhood and adult OCD with regard to the cognitive, behavioural, and family factors implicated in the etiology and maintenance of the disorder. Despite this, cognitive-behavioural interventions have been largely modelled on their adult counterparts, and there has been little evaluation of the effectiveness of various treatment components. This paper therefore seeks to critically review the current status of CBT for children and adolescents with OCD, addressing both cognitive behavioural theory and therapy. Current issues in clinical practice will be identified, gaps in the knowledge base will be highlighted, and the paper will conclude by making specific recommendations regarding the integration of research and practice.