Diagnosis and Management of Obsessive Compulsive Disorders in Children

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.

Individualized antidepressant therapy in patients with major depressive disorder: Novel evidence-informed decision support tool

Aubrey Delammermore — Sun, 11 Dec 2022 06:00:00 +0000

Date Added:

December 11, 2022

Journal/Publication:

Canadian Family Physician

Publisher:

The College of Family Physicians of Canada

Publication Date:

November 1, 2022

Issue:

Volume:

Pages:

807-814

URL:

Individualized antidepressant therapy in patients with major depressive disorder: Novel evidence-informed decision support tool

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

doi.org/10.46747/cfp.6811807

Keywords

Systematic Reviews as Topic

antidepressive agents

Serotonin Uptake Inhibitors

Major Depressive Disorder

SSRI

PMID (1):

36376052

MeSH

Antidepressive Agents / therapeutic use

Canada

Selective Serotonin Reuptake Inhibitors / adverse effects

quality of life

Depressive Disorder, Major* / drug therapy

Figures 1A and 1B provide an algorithm to help decide which of the many available antidepressants might be best for a particular patient. James W. Mold, MD, MPH.

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Objective: To introduce a visual clinical decision support tool to assist with individualizing first-line antidepressant pharmacotherapy for adults with major depressive disorder (MDD) in a Canadian context.

Sources of information: A literature review was conducted with Google Scholar, PubMed, the Cochrane Database of Systematic Reviews, and Trip Pro using the MeSH headings depression, antidepressive agents, primary care, practice patterns, medication adherence, and decision making, shared.

Main message: Major depressive disorder affects about 4.7% of Canadians annually and is a prevalent condition encountered and diagnosed in primary care. Untreated depression is associated with decreased quality of life, increased risk of suicide, and worsening physical health outcomes when depression co-occurs with other chronic medical conditions. In a network meta-analysis, antidepressant medications (such as selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, bupropion, and vortioxetine) reduced depressive symptoms by 50% or more when compared with placebo in acute treatment of adults with moderate to severe MDD. Poor treatment adherence and high discontinuation rates limit MDD treatment success. Factors such as strong therapeutic alliances between patients and prescribers, collaborative care, patient education, and supportive self-management have been shown to enhance treatment adherence. The most recent Canadian Network for Mood and Anxiety Treatments depression treatment guidelines (published in 2016) suggest 15 different first-line antidepressant medication options for the treatment of MDD. There is a need for evidence-informed decision support aids to individualize antidepressant therapy to treat patients diagnosed with MDD.

Conclusion: Recent studies on antidepressants have indicated no single antidepressant is superior to others in treating patients with MDD. This suggests there may be opportunities to enhance treatment adherence and success by tailoring antidepressant therapy to align with each patient's preferences. The Antidepressant Decision Support Tool was developed to help prescribers and adult patients engage in shared decision making to select an individualized and optimal first-line antidepressant for the treatment of acute MDD.

Author/s:

Chin, T., Huyghebaert, T., Svrcek, C., Oluboka, O.