Abstract
Introduction
Obsessions or compulsions that cause personal distress or social dysfunction have been reported to affect about 3% of children and adolescents. In children, the disorder often presents at around 10 years of age. It persists in about 40% of children and adolescents at mean follow-up of 5.7 years. The disorder is disabling with adverse impact on functioning, including education and social/family life.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical question: What are the effects of maintenance drug treatment for obsessive compulsive disorder in children and adolescents? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2014 (BMJ Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
Two studies were included that addressed the question of maintenance drug treatment for Obsessive Compulsive Disorder (OCD) in children and adolescents.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following intervention: optimum duration of maintenance drug treatment with serotonin reuptake inhibitors (SRIs) in children and adolescents.
Key Points
Obsessions or compulsions that cause personal distress or social dysfunction have been reported to affect about 3% of children and adolescents.
In children the disorder often presents at around 10 years of age.
The disorder persists in about 40% of children and adolescents at mean follow-up of 5.7 years.
The disorder is disabling with adverse impact on functioning, including education and social/family life.
We searched for evidence from RCTs and systematic reviews of RCTs.
We do not know what the optimum duration of maintenance drug treatment with serotonin reuptake inhibitors (SRIs) is for children and adolescents with OCD, as we found no evidence.
Current guidelines recommend a minimum duration of maintenance treatment as being 6 months.
CAUTION: SSRIs have been associated with an increase in suicidal ideation in children and adolescents.
Clinical context
General background
OCD is generally more common in children and adolescents than adults, and it can become a chronic and disabling condition for many sufferers.
Focus of the review
There is uncertainty about how long maintenance drug treatment should be continued after initial improvement. Thus, we reviewed the question of optimal duration of maintenance drug treatment with serotonin re-uptake inhibitors (SRIs) for OCD in children and adolescents.
Comments on evidence
We performed a comprehensive systematic literature search, but we did not find any eligible RCTs. There is currently a lack of good-quality RCT evidence addressing this clinical issue. Although the RCT evidence-base is lacking, current guidelines recommend that the minimum duration of maintenance drug treatment should be 6 months after initial improvement for OCD in children and adolescents.
Search and appraisal summary
The update literature search for this review was carried out from the date of the last search, April 2011, to June 2014. For more information on the electronic databases searched and criteria applied during assessment of studies for potential relevance to the review, please see the Methods section. Searching of electronic databases retrieved 47 studies. After deduplication and removal of conference abstracts, 27 records were screened for inclusion in the review. Appraisal of titles and abstracts led to the exclusion of 21 studies and the further review of six full publications. Of the six full articles evaluated, two systematic reviews were included, which found no RCTs.
Additional information
This review only deals with the question of optimal duration of maintenance drug treatment for OCD in children and adolescents. At the next update, our plan is to review the latest evidence for the effectiveness and safety of interventions for OCD in children and adolescents.
About this condition
Definition
Obsessive compulsive disorder (OCD) involves obsessions, compulsions (or both) that are not caused by drugs or by a physical disorder, and which cause significant personal distress or social dysfunction. The disorder may have a chronic or an episodic course. Obsessions are recurrent and persistent ideas, images, or impulses that cause pronounced anxiety, and that the person perceives to be self-produced. Compulsions are repetitive behaviours or mental acts performed in response to obsessions or according to certain rules, which are aimed at reducing distress or preventing certain imagined dreaded events. People with OCD may have insight into their condition, in that obsessions and compulsions are usually recognised and resisted. There are minor differences in the criteria for OCD between the DSM-III, DSM-III-R, DSM-IV, and DSM-5, and the ICD-10. Unlike other classification systems which refer to OCD as a type of anxiety disorder, the DSM-5 classifies OCD as a separate disorder under the category ‘Obsessive-compulsive and related disorders’.
Incidence/ Prevalence
In the US, prevalence of OCD in children and adolescents was reported to be about 3% in a community study conducted by the National Institute of Mental Health (NIMH) Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. The study evaluated a community sample of 1285 carer-child pairs, where both members of the pair were interviewed using structured interview DISC 2.3 with DSM-III-R criteria. In the UK, prevalence of OCD in children and adolescents was reported to be 0.25% in a UK nationwide epidemiological study that surveyed 10,438 children aged 5 to 15 years.
Aetiology/ Risk factors
About half of children and adolescents display 'micro-episodes of OCD', characterised by excessive rigidity and repetitive rituals some years before developing the disorder. Tics in childhood may also predict an increase in OCD symptoms in late adolescence. Age of onset of OCD is reported to be bi-modal with one peak at about 10 to 11 years of age, and another during early adulthood. Childhood OCD appears to be more common in boys. There is a strong co-morbidity with disruptive behavioural problems, developmental disorders (including autistic disorder), depression, and other anxiety disorders.
Prognosis
In children, OCD often presents around 10 years of age. One systematic review (search date not reported, 22 studies with mean follow-up period of 5.7 years) examining the course of OCD in children and adolescents (mean age of onset 10.4 years, mean study entry age 13.3 years) found that the rate of persistent, full OCD was 41% and the rate of persistent, full, or subclinical OCD was 60%. Greater persistence was predicted by early onset of the disorder, increased OCD duration, and history of inpatient status. The disorder is disabling with adverse impact on functioning, including education and social/family life.
Aims of intervention
To improve symptoms, and to reduce the impact of illness on social functioning and quality of life, with minimal adverse effects of treatment.
Outcomes
Symptom improvement; social functioning; quality of life; and adverse effects. Commonly used instruments for measuring symptoms include the Yale-Brown Obsessive Compulsive Scale (YBOCS), the children’s version of this (CY-BOCS), the Hamilton Anxiety Rating Scale, and the Hamilton Depression Rating Scale.
Methods
Search strategy BMJ Clinical Evidence search and appraisal June 2014. Databases used to identify studies for this systematic overview included: Medline 1966 to June 2014, Embase 1980 to June 2014, and The Cochrane Database of Systematic Reviews 2014, issue 6 (1966 to date of issue), Database of Abstracts of Reviews of Effects (DARE), and the Health Technology Assessment (HTA) database. Inclusion criteria Study design criteria for inclusion in this systematic overview were systematic reviews and RCTs published in English, at least single-blinded, and containing 20 or more children/adolescents (10 in each arm) aged 18 years or younger, of whom more than 80% were followed up. There was no minimum length of follow-up. We excluded all studies described as 'open', 'open label', or not blinded unless blinding was impossible. BMJ Clinical Evidence does not necessarily report every study found (e.g., every systematic review). Rather, we report the most recent, relevant and comprehensive studies identified through an agreed process involving our evidence team, editorial team, and expert contributors. Evidence evaluation A systematic literature search was conducted by our evidence team, who then assessed titles and abstracts, and finally selected articles for full text appraisal against inclusion and exclusion criteria agreed a priori with our expert contributors. In consultation with the expert contributors, studies were selected for inclusion and all data relevant to this overview extracted into the benefits and harms section of the review. In addition, information that did not meet our predefined criteria for inclusion in the benefits and harms section, may have been reported in the 'Further information on studies' or 'Comment' section (see below). Adverse effects All serious adverse effects, or those adverse effects that are reported as statistically significant, were included in the harms section of the overview. Pre-specified adverse effects identified as being clinically important were also reported, even if the results were not statistically significant. Although BMJ Clinical Evidence presents data on selected adverse effects reported in included studies, it is not meant to be, and cannot be, a comprehensive list of all adverse effects, contraindications, or interactions of included drugs or interventions. A reliable national or local drug database must be consulted for this information. Comment and Clinical guide sections In the Comment section of each intervention, our expert contributors may have provided additional comment and analysis of the evidence, which may include additional studies (over and above those identified via our systematic search) by way of background data or supporting information. As BMJ Clinical Evidence does not systematically search for studies reported in the Comment section, we cannot guarantee the completeness of the studies listed there or the robustness of methods. Our expert contributors add clinical context and interpretation to the Clinical guide sections where appropriate. Data and Quality To aid readability of the numerical data in our reviews, we round many percentages to the nearest whole number. Readers should be aware of this when relating percentages to summary statistics such as relative risks (RRs) and odds ratios (ORs). BMJ Clinical Evidence does not report all methodological details of included studies. Rather, it reports by exception any methodological issue or more general issue which may affect the weight a reader may put on an individual study, or the generalisability of the result. These issues may be reflected in the overall GRADE analysis. A GRADE evaluation of the quality of evidence for interventions included in this review will be performed. The categorisation of the quality of the evidence (into high, moderate, low, or very low) reflects the quality of evidence available for our chosen outcomes in our defined populations of interest. These categorisations are not necessarily a reflection of the overall methodological quality of any individual study, because the BMJ Clinical Evidence population and outcome of choice may represent only a small subset of the total outcomes reported, and population included, in any individual trial. For further details of how we perform the GRADE evaluation and the scoring system we use, please see our website (www.clinicalevidence.com).
Glossary
- Chronic OCD
Continuous course without periods of remission since first onset.
- Diagnostic Interview Schedule for Children, version 2.3 (DISC 2.3)
A structured diagnostic interview designed for administration by lay interviewers for use with children aged 9 to 17 years to assess most commonly occurring mental disorders of children and adolescents included in the DSM diagnostic system. It is one of the most extensively tested diagnostic interviews for children and adolescents.
- Episodic OCD
Episodic course with periods of remission since first onset.
- Hamilton Anxiety Rating Scale
A 14-item observer-rated scale for measuring the severity of anxiety. It has been investigated for validity and reliability. Each item is rated on a 5-point scale from 0 (no symptoms) to 4 (severe or grossly disabling symptoms). Total score ranges from 0 to 56, with 14 or higher indicating clinically significant anxiety.
- Hamilton Depression Rating Scale
A 21-item observer-rated scale for measuring the severity of depression. Hamilton recommended that the first 17 items only be used for this purpose, as the last 4 items do not measure the severity of depression. It has been investigated for validity and reliability. Items are measured on a scale of 0–4 or 0–2 (with a higher score indicating more severe symptoms). Total score ranges from 0 to 50, with a score of 8 or above indicating clinically significant depression.
- Tic disorder
Characterised by motor tics, vocal tics, or both.
- Yale-Brown Obsessive Compulsive Scale (YBOCS)
A validated, observer-rated scale for measuring symptom scores. It rates the severity of both obsessions and compulsions across 5 dimensions (time spent, interference with functioning, distress, resistance, and control), each on a 5-point scale from 0 (the dimension is absent) to 4 (dimension is present to an extremely severe degree). The total score range of obsessions and compulsions combined is 0–40 (the higher the score, the more severe the condition). Most trials use a 25% or 35% reduction in YBOCS scores from baseline as indicative of clinically important improvement.
Obsessive compulsive disorder in adults
Disclaimer
The information contained in this publication is intended for medical professionals. Categories presented in Clinical Evidence indicate a judgement about the strength of the evidence available to our contributors prior to publication and the relevant importance of benefit and harms. We rely on our contributors to confirm the accuracy of the information presented and to adhere to describe accepted practices. Readers should be aware that professionals in the field may have different opinions. Because of this and regular advances in medical research we strongly recommend that readers' independently verify specified treatments and drugs including manufacturers' guidance. Also, the categories do not indicate whether a particular treatment is generally appropriate or whether it is suitable for a particular individual. Ultimately it is the readers' responsibility to make their own professional judgements, so to appropriately advise and treat their patients. To the fullest extent permitted by law, BMJ Publishing Group Limited and its editors are not responsible for any losses, injury or damage caused to any person or property (including under contract, by negligence, products liability or otherwise) whether they be direct or indirect, special, incidental or consequential, resulting from the application of the information in this publication.
Contributor Information
Sara Kakhi, Solent NHS Foundation Trust, Southampton, UK.
G. Mustafa Soomro, St James Hospital, Portsmouth, UK.
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