Cost-Effectiveness of Treatment Alternatives for Treatment-Refractory Pediatric Obsessive-Compulsive Disorder

Pediatric Treatment-Resistant Obsessive Compulsive Disorder: Treatment Options and Challenges

Pediatric obsessive-compulsive disorder (OCD) is a chronic, potentially debilitating psychiatric condition. Although effective treatments exist, at least 10% of youth do not achieve remission despite receiving first-line treatments. This article reviews the extant, albeit limited, evidence supporting treatment approaches for youth with treatment-resistant OCD. A literature search for articles addressing pediatric treatment-resistant OCD was conducted through April 11, 2024. These results were augmented by searching for treatment-resistant OCD in adults; treatment strategies discovered for the adult population were then searched in the context of children and adolescents. In general, intensive treatment programs and antipsychotic augmentation of an antidepressant had the most substantial and consistent evidence base for treatment-resistant youth with OCD, although studies were limited and of relatively poor methodological quality (i.e., open trials, naturalistic studies). Several pharmacological approaches (clomipramine, antipsychotics [e.g., aripiprazole, risperidone], riluzole, ketamine, D-cycloserine, memantine, topiramate, N-acetylcysteine, ondansetron), largely based on supporting data among adults, have received varying levels of investigation and support. There is nascent support for how to treat pediatric treatment-resistant OCD. Future treatment studies need to consider how to manage the significant minority of youth who fail to benefit from first-line treatment approaches.

Cost-effectiveness analysis of deep transcranial magnetic stimulation relative to evidence-based strategies for treatment-refractory obsessive-compulsive disorder

OBJECTIVE

This study examined the cost-effectiveness of deep transcranial magnetic stimulation (dTMS) for treatment refractory obsessive-compulsive disorder (OCD) relative to other established treatment options, including antidepressant medication (ADM), ADM + antipsychotic augmentation, real-world cognitive-behavioral therapy (ADM + CBT Effectiveness), clinical trial CBT (ADM + CBT), intensive outpatient program (IOP), partial hospitalization program (PHP), and PHP to IOP stepdown.

METHODS

A decision analytic model was developed to evaluate the cost-effectiveness of dTMS relative to other established treatment alternatives for adults (18-64 years old) with refractory OCD. Building on Gregory et al. (2018), the model was parameterized with probabilistic and deterministic parameters from the literature and an outcomes database to perform a Monte Carlo simulation of a hypothetical cohort of 100,000 adults with OCD to estimate costs, and incremental cost-effectiveness ratio (ICER) for dTMS relative to each treatment strategy. Encounters took place from 2012 to 2015. Data for dTMS were taken from a recent multisite study.

RESULTS

Although dTMS fit between ADM and ADM + CBT in overall costs, ADM + CBT had the lowest ICER and thus would be chosen before dTMS. dTMS was determined to be more cost effective relative to PHP/IOP stepdown, PHP, and IOP.

CONCLUSION

dTMS is cost-effective, along the treatment continuum from outpatient medication management and CBT to more intensive, facilities-based approaches, and may be an incremental strategy to employ when higher intensity strategies are either not available, not financially feasible, or whilst on extended waits for admission to these higher levels of care.

Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder: 2021 Update

In this update of a previous review, the authors discuss cognitive-behavioral therapy (CBT) with exposure and response prevention for obsessive-compulsive disorder (OCD). This efficacious modality avoids side effects common to psychotropic medication and reduces risk of relapse once treatment has ended. Psychotherapy involves identification and ranking of stimuli that provoke obsessions, exposure to these stimuli while preventing compulsions, and cognitive restructuring. The family of the OCD patient plays a significant role in treatment. This article includes expanded research on family-focused CBT and treatment of pediatric OCD. The family's accommodation and emotional response to a patient's symptoms may interfere with therapy and perpetuate the disorder. The treatment of pediatric OCD involves the same considerations. However, the form of obsessions and compulsions may differ and therapeutic techniques are modified to make them age appropriate.

Effects of Acceptance and Commitment Therapy and Repetitive Transcranial Magnetic Stimulation on Obsessive-Compulsive Disorder

Objective: This study aims to explore the difference of clinical efficacy and psychological flexibility of sertraline hydrochloride combined with acceptance and commitment therapy (ACT) or repeated transcranial magnetic stimulation (rTMS) in patients with obsessive-compulsive disorder (OCD). Materials and Methods: Sixty-three inpatients diagnosed with OCD were randomly divided into ACT group (N = 32) and rTMS group (N = 31), both of which were combined with sertraline hydrochloride. The following assessments were completed by the Hamilton Depression Scale (HAMD), Hamilton Anxiety Scale (HAMA), Yale-Brown Obsessive Compulsive Scale (Y-BOCS), Symptom Checklist 90 (SCL-90), Acceptance and Action Questionnaire (AAQ-II), and Cognitive Fusion Questionnaire (CFQ) during pretreatment, 4 weeks posttreatment, and 8-week follow-up. Results: After treatment: (1) the SCL-90 score of two groups significantly decreased from pretreatment to 8-week follow-up (P < 0.01 and P < 0.001); (2) The HAMA, HAMD, and Y-BOCS scores of the two groups significantly decreased from pretreatment to 8-week follow-up (P < 0.001 and P < 0.05); (3) No statistically significant difference of the SCL-90, HAMA, HAMD and Y-BOCS between two groups; (4) The AAQ-II and CFQ scores of the ACT group significantly decreased from 4 weeks posttreatment to 8-week follow-up (P < 0.01). However, no statistically significant difference was observed in the rTMS group (P > 0.05). Conclusions: Overall, our study suggested that sertraline hydrochloride combined with ACT or rTMS can improve the obsessive-compulsive symptoms, anxiety, and depression and has equivalent efficacy. Moreover, ACT can more effectively and durably improve the psychological flexibility of patients compared with rTMS.

Effects of Treatment Setting on Outcomes of Flexibly-Dosed Intensive Cognitive Behavioral Therapy for Pediatric OCD: A Randomized Controlled Pilot Trial

Introduction: Optimizing individual outcomes of cognitive-behavioral therapy (CBT) remains a priority. Methods: Youth were randomized to receive intensive CBT at a hospital clinic (n = 14) or within their home (n = 12). Youth completed 3 × 3 h sessions (Phase I) and up to four additional 3-h sessions as desired/needed (Phase II). An independent evaluator assessed youth after Phase I, Phase II (when applicable), and at 1- and 6-months post-treatment. A range of OCD-related (e.g., severity, impairment) and secondary (e.g., quality of life, comorbid symptoms) outcomes were assessed. Results: Families' satisfaction with the treatment program was high. Of study completers (n = 22), five youth (23%) utilized no Phase II sessions and 9 (41%) utilized all four (Median Phase II sessions: 2.5). Large improvements in OCD-related outcomes and small-to-moderate benefits across secondary domains were observed. Statistically-significant differences in primary outcomes were not observed between settings; however, minor benefits for home-based treatment were observed (e.g., maintenance of gains, youth comfort with treatment). Discussion: Intensive CBT is an efficacious treatment for pediatric OCD. Families opted for differing doses based on their needs. Home-based treatment, while not substantially superior to hospital care, may offer some value, particularly when desired/relevant. Clinical Trial Registration: www.ClinicalTrials.gov; https://clinicaltrials.gov/ct2/show/NCT03672565, identifier: NCT03672565.