Obsessive-Compulsive Disorder

Importance: Cognitive behavior therapy (CBT) is a first-line treatment for most mental disorders. However, no meta-analytic study has yet integrated the results of randomized clinical trials on CBT across different disorders, using uniform methodologies and providing a complete overview of the field.

Objective: To examine the effect sizes of CBT for 4 anxiety disorders, 2 eating disorders, major depression, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), and psychotic and bipolar disorders on symptoms of the respective disorders using uniform methodologies for data extraction, risk of bias (RoB) assessment, and meta-analytic techniques.

Data sources: Major bibliographical databases (PubMed, PsycINFO, and Embase for all disorders) were searched up to January 1, 2024, for each disorder separately. Data analysis was performed from August 2024 to January 2025.

Study selection: Randomized clinical trials comparing CBT with inactive control conditions in adults with 1 of the mental disorders established through a clinical interview were included.

Data extraction and synthesis: Basic characteristics of patients, CBT, and studies were extracted. RoB was assessed with the Cochrane RoB tool 2. Meta-analyses were conducted using random-effects models.

Main outcomes and measures: The primary outcome was the standardized mean difference (Hedges g) indicating the difference between CBT and controls at posttreatment on symptoms of the respective disorders.

Results: A total of 375 trials (423 comparisons) between CBT and controls were included among 32 968 patients. The overall mean (SD) patient age was 43.4 (13.7) years, and the mean (SD) proportion of women was 0.68 (0.24). Effect sizes for CBT compared to all control conditions (g) were lower than 0.5 for bipolar and psychotic disorder; between 0.5 and 1.0 for panic, social anxiety, and generalized anxiety disorders, bulimia nervosa, binge eating disorders, depression, and OCD; and larger than 1.0 for PTSD and specific phobias (range of effect sizes: 0.31 for bipolar disorder to 1.27 for PTSD). Large effect sizes (g > 0.94) were observed in waitlist-controlled trials, a control condition mostly used in anxiety and eating disorders, PTSD, and OCD. Trials using care as usual showed more modest effect sizes (0.22-1.13). Study dropout rates within the CBT conditions ranged from 8% for specific phobia to 24% for PTSD.

Conclusions and relevance: In this unified series of meta-analyses, CBT was probably effective in the treatment of mental disorders, including major depression, anxiety disorders, PTSD, OCD, and eating disorders, and possibly effective in psychotic and bipolar disorders. However, the effect sizes depended on the type of control condition.

Author/s:

Pim Cuijpers, Mathias Harrer, Clara Miguel, Marketa Ciharova, Davide Papola, Djordje Basic, Cristina Botella

Diagnosis and Management of Obsessive Compulsive Disorders in Children

Alex Haga — Tue, 17 Dec 2024 19:09:18 +0000

Date Added:

December 17, 2024

Journal/Publication:

Agency for Healthcare Research and Quality

Publication Date:

December 6, 2024

URL:

Diagnosis and Management of Obsessive Compulsive Disorders in Children

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

Keywords

Obsessive-Compulsive Disorder

cognitive behavioral therapy

MeSH

Selective Serotonin Reuptake Inhibitors / adverse effects

Cognitive Behavioral Therapy

Obsessive-Compulsive Disorder

An evidence review of the diagnosis and treatment of obsessive-compulsive disorder in children. James W. Mold, MD, MPH

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Background. Obsessive compulsive disorder (OCD) is a common, chronic, and impairing psychiatric disorder that often begins in childhood or adolescence. Early identification and treatment of OCD is important to prevent a cascade of developmental disruptions lasting into adulthood. The 2012 American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameter recommends cognitive behavioral therapy that incorporates exposure and response prevention (ERP) as a first-line treatment for mild-to-moderate OCD in youth and recommends combined treatment with ERP (if feasible) and a selective serotonin reuptake inhibitor (SSRI) for some patients, particularly those with more severe symptoms. Clinical uncertainty exists regarding the optimal treatment strategies (and treatment combinations) that work best for specific populations and settings. In this report, we seek to evaluate the accuracy of brief assessment tools to identify OCD in symptomatic youth (Key Question [KQ] 1) and the effects and harms of treatment options for youth with OCD (KQ2).

Methods. We searched Medline®, Cochrane, Embase®, CINAHL®, and ClinicalTrials.gov from inception to May 15, 2024. After double screening, we extracted study data, assessed risk of bias, and conducted network and pairwise meta-analyses. We evaluated the strength of evidence (SoE) using standard methods. The protocol was registered in PROSPERO (registration number CRD42023461212).

Results. We found 117 studies (reported in 161 papers) that met inclusion criteria. Of these, 31 cross-sectional studies pertained to KQ1, diagnosis of OCD. For KQ 2, treatment of OCD, we included 71 randomized controlled trials, 2 nonrandomized comparative studies, and 13 single-arm studies that reported potential treatment effect modifiers. For KQ1, there is insufficient evidence regarding most brief assessment tools. Based on nine studies, the Child Behavior Checklist-Obsessive Compulsive subscale (CBCL-OCS) may have sufficiently high sensitivity and specificity to identify patients for specialist referral and diagnostic evaluation (moderate SoE). For KQ2, meta-analyses indicate that in-person ERP is more effective for OCD symptoms when compared to either waitlist (high SoE) or behavioral control (moderate SoE), and for remission when compared to waitlist (high SOE) or behavioral control (moderate SoE). ERP via telehealth is more effective than waitlist for OCD symptoms (high SoE) and remission (moderate SoE). SSRIs are more effective than placebo for OCD symptoms and global severity (high SoE). Clomipramine is probably more effective than placebo (moderate SoE). When used together, ERP and an SSRI are probably more effective than treatment with an SSRI alone for OCD symptoms (moderate SoE). ERP combined with an SSRI are as effective as ERP alone for OCD symptoms (high SoE). The side effects of SSRIs and clomipramine were inconsistently reported, precluding graded conclusions. Augmentation of ERP with D-cycloserine is as effective as ERP alone to reduce OCD symptoms (high SoE) or global severity (moderate SoE). The evidence was insufficient regarding potential effect modifiers.

Conclusion. The diagnosis of OCD relies on expert clinical evaluation, sometimes augmented by semi-structured interviews. The CBCL-OCS may be sufficiently accurate to indicate which youth should be further evaluated for OCD. ERP, delivered in-person or via telehealth, is an effective treatment for OCD in children and adolescents. ERP, alone or in combination with an SSRI, is probably more effective than treatment with an SSRI alone.