NEW YORK – Cognitive-behavioral therapy, when provided by a skilled therapist, can be just as effective as an SSRI or combined treatment for children with obsessive-compulsive disorder, Dr. Daniel S. Pine said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.
To reach that conclusion, Dr. Pine interpreted data from the Pediatric OCD Treatment Study differently than did the study's investigators.
The Pediatric OCD Treatment Study is the only published trial that compares cognitive-behavioral therapy (CBT) with an SSRI for the treatment of pediatric OCD, said Dr. Pine, chief of the section on development and affective neuroscience in the mood and anxiety disorders program at the National Institute of Mental Health.
In the study, 112 patients were randomized to receive sertraline (Zoloft), cognitive-behavioral therapy (CBT), a combination of the two modalities, or placebo for 12 weeks. Patients were treated at one of three sites, and were enrolled primarily at two of the sites (JAMA 2004;292:1969–76).
“There were robust site differences in the response to treatment,” he said. “When you look very carefully at the data that are published, what you see was that one site had a massive response to CBT and there was no benefit of adding an SSRI to CBT.” The other site had a “very weak” response to CBT, an “okay” response to an SSRI, and a “robust” response to the combination treatment, he noted.
The averaged data for the three sites showed a statistically significant benefit of combination therapy over CBT alone, sertraline alone, and placebo. The investigators concluded that pediatric patients with OCD should receive combination therapy.
“Personally, I think that's a misreading of the study,” Dr. Pine said. “I think what the study really tells us is that really well-executed CBT in kids with OCD is every bit as good as monotherapy [with an SSRI] and is every bit as good as combination therapy; however, not-so-great CBT really needs an SSRI to work.”
“It would be wonderful if CBT was always the same across therapists, patients, and cities, but it's not, and this study really shows it,” he added.
CBT might be the preferred method for treating pediatric OCD, especially in patients without a history of attention-deficit hyperactivity disorder or major depression, because the availability of a CBT therapist will vary depending on geographic location and the fact that there are “tremendous site differences in CBT,” he said.
“This recommendation only applies to the case where you have access to a very skilled CBT therapist who has worked with pediatric anxiety disorders,” Dr. Pine explained.
An SSRI should be used if a skilled CBT therapist is not available or if a child has a severe anxiety disorder and will not undergo the crucial part of CBT that involves exposure to the feared stimulus, he advised.