Paroxetine open-label treatment of pediatric outpatients with obsessive-compulsive disorder

Efficacy of pharmacological treatment in OCD comorbid with tic disorder: Systematic review and meta-analysis

Up to 30% of subjects with obsessive compulsive disorder (OCD) also have a lifetime tic disorder. Several meta-analyses of pharmaceutical or psychotherapeutic interventions for the management of OCD have been published, but none specifically on patients with OCD comorbid with tics. The literature regarding pharmacological treatments of patients with this condition is mainly focused on studies of OCD. After a search of the Cochrane, EMBASE, PubMed, PsychINFO and Science Direct databases, we performed a proportion meta-analysis of the percentage of patients whose condition improved and a paired meta-analysis of the change in the OCD score (Y-BOCS). Twelve case reports were retained for qualitative analysis and 14 articles for meta-analysis. Case reports showed better efficacy of combined antidepressant-antipsychotic treatment for OCD comorbid with tic disorder. The meta-analysis showed an improvement in 29% [18-42] of patients with antidepressants. Although there was no significant difference with placebo add-on, in antidepressant-resistant OCD patients, adding an antipsychotic to the antidepressant regimen led to an increase in the number of patients who improved (67% [45-86] vs 7% [0-35]) and seemed to show a decrease in the Y-BOCS score (-10.06 [-20.38; 0.26] vs (-3.61 [-9.08; 13.85]). Our study provides new evidence on the pharmacological treatment of OCD comorbid with tics. In some patients, the condition is improved by a first-line antidepressant. In case of non-response or insufficient efficacy of antidepressants, add-on treatment with certain antipsychotics can be implemented.

A systematic review of sleep problems in children and adolescents with obsessive compulsive disorder

There is growing interest in the relationship between obsessive-compulsive disorder (OCD) and sleep problems in youth, including the development of a theoretical model proposing how these disorders maintain each other. The model suggests that OCD symptoms are proposed to interfere with sleep duration (e.g., via increased arousal and delayed bedtime), which compounds OCD symptom severity during the daytime and into the evening, feeding back into the model. Whether the recent influx of research on sleep problems in youth with OCD supports this model is unknown. The primary aim of this systematic review was to characterize sleep problems in youth with OCD and evaluate whether current research supports previous theoretical inferences. Findings across 20 studies revealed a high prevalence of sleep problems among youth with OCD and support a bidirectional relationship. Studies largely did not assess hypothesized relationships proposed by the model; support for the model is therefore preliminary. A secondary aim was to assess the impacts of comorbidity and developmental stage. Findings suggest that in childhood, comorbid anxiety disorders may initially predate sleep problems, but they become mutually maintained over time; the role of comorbid depression appears to increase with age. Limitations, future directions, and clinical implications are discussed.

Latinos with obsessive-compulsive disorder: Mental healthcare utilization and inclusion in clinical trials

Previous research has documented that ethnic minorities, particularly Latinos, obtain fewer mental health services than Caucasians (Kearney, Draper, & Baron 2005; Sue, Fujino, Hu, Takeuchi, & Zane, 1991). Conceivably, this may be due to a wide array of cultural issues (e.g., negative stigma attached to mental health, and language, socio-economic, and acculturation barriers), symptom disparities across Caucasian and Latino groups, or lack of effective outreach methods by clinicians and researchers. However, research is limited. As a result, Latinos may be insufficiently represented in clinical studies for OCD, making it unclear whether evidence-based treatments demonstrate the same efficacy and effectiveness for Latinos as has been demonstrated for Caucasians. The current study takes an in-depth analysis of 98 efficacy and effectiveness studies for OCD from across the Western hemisphere and reports the rates of Latino inclusion from each sample. Ninety clinical studies in the US and Canada, as well as eight clinical studies in Mexico and Central America were reviewed. Findings showed that only 11 (24%) US and Canadian studies included Latino participants, illustrating an overwhelming underrepresentation of Latinos in clinical studies for OCD. Further explanation of the results and their implications are discussed, along with suggestions for effectively improving access to mental health research and appropriate treatments.

Still Struggling: characteristics of youth with OCD who are partial responders to medication treatment

The primary aim of this paper is to examine the characteristics of a large sample of youth with OCD who are partial responders (i.e., still have clinically significant symptoms) to serotonin reuptake inhibitor (SRI) medication. The sample will be described with regard to: demographics, treatment history, OCD symptoms/severity, family history and parental psychopathology, comorbidity, and global and family functioning. The sample includes 124 youth with OCD ranging in age from 7 to 17 with a primary diagnosis of OCD and a partial response to an SRI medication. The youth are a predominantly older (age 12 and over), Caucasian, middle to upper income group who had received significant past treatment. Key findings include moderate to severe OCD symptoms, high ratings of global impairment, and significant comorbidity, despite partial response to an adequate medication trial. Considerations regarding generalizability of the sample and limitations of the study are discussed.

The Pediatric Obsessive-Compulsive Disorder Treatment Study II: rationale, design and methods

This paper presents the rationale, design, and methods of the Pediatric Obsessive-Compulsive Disorder Treatment Study II (POTS II), which investigates two different cognitive-behavior therapy (CBT) augmentation approaches in children and adolescents who have experienced a partial response to pharmacotherapy with a serotonin reuptake inhibitor for OCD. The two CBT approaches test a "single doctor" versus "dual doctor" model of service delivery. A specific goal was to develop and test an easily disseminated protocol whereby child psychiatrists would provide instructions in core CBT procedures recommended for pediatric OCD (e.g., hierarchy development, in vivo exposure homework) during routine medical management of OCD (I-CBT). The conventional "dual doctor" CBT protocol consists of 14 visits over 12 weeks involving: (1) psychoeducation, (2), cognitive training, (3) mapping OCD, and (4) exposure with response prevention (EX/RP). I-CBT is a 7-session version of CBT that does not include imaginal exposure or therapist-assisted EX/RP. In this study, we compared 12 weeks of medication management (MM) provided by a study psychiatrist (MM only) with two types of CBT augmentation: (1) the dual doctor model (MM+CBT); and (2) the single doctor model (MM+I-CBT). The design balanced elements of an efficacy study (e.g., random assignment, independent ratings) with effectiveness research aims (e.g., differences in specific SRI medications, dosages, treatment providers). The study is wrapping up recruitment of 140 youth ages 7-17 with a primary diagnosis of OCD. Independent evaluators (IEs) rated participants at weeks 0,4,8, and 12 during acute treatment and at 3,6, and 12 month follow-up visits.

TRIAL REGISTRATION

NCT00074815.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of anxiety, obsessive-compulsive and post-traumatic stress disorders - first revision

In this report, which is an update of a guideline published in 2002 (Bandelow et al. 2002, World J Biol Psychiatry 3:171), recommendations for the pharmacological treatment of anxiety disorder, obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) are presented. Since the publication of the first version of this guideline, a substantial number of new randomized controlled studies of anxiolytics have been published. In particular, more relapse prevention studies are now available that show sustained efficacy of anxiolytic drugs. The recommendations, developed by the World Federation of Societies of Biological Psychiatry (WFSBP) Task Force for the Pharmacological Treatment of Anxiety, Obsessive-Compulsive and Post-traumatic Stress Disorders, a consensus panel of 30 international experts, are now based on 510 published randomized, placebo- or comparator-controlled clinical studies (RCTs) and 130 open studies and case reports. First-line treatments for these disorders are selective serotonin reuptake inhibitors (SSRIs), serotonin-noradrenaline reuptake inhibitors (SNRIs) and the calcium channel modulator pregabalin. Tricyclic antidepressants (TCAs) are equally effective for some disorders, but many are less well tolerated than the SSRIs/SNRIs. In treatment-resistant cases, benzodiazepines may be used when the patient does not have a history of substance abuse disorders. Potential treatment options for patients unresponsive to standard treatments are described in this overview. Although these guidelines focus on medications, non-pharmacological were also considered. Cognitive behavioural therapy (CBT) and other variants of behaviour therapy have been sufficiently investigated in controlled studies in patients with anxiety disorders, OCD, and PTSD to support them being recommended either alone or in combination with the above medicines.

Predictors of treatment response in pediatric obsessive-compulsive disorder

OBJECTIVE

To examine predictors of treatment response in pediatric obsessive-compulsive disorder (OCD).

METHOD

A literature review of psychotherapy (i.e., cognitive-behavioral therapy) and medication studies for pediatric OCD published from 1985 to 2007 was conducted using several databases.

RESULTS

The literature search produced a total of 21 studies (6 cognitive-behavioral therapy, 13 medication, and 2 combination studies) that met specific methodological criteria. Across studies, the following nine predictors were examined: child sex, child age, duration of illness/age at onset, baseline severity of obsessive-compulsive symptoms, type of obsessive-compulsive symptoms, comorbid disorders/symptoms, psychophysiological factors, neuropsychological factors, and family factors. Among all of the studies, there was little evidence that sex, age, or duration of illness (age at onset) was associated with treatment response. Baseline severity of obsessive-compulsive symptoms and family dysfunction were associated with poorer response to cognitive-behavioral therapy, whereas comorbid tics and externalizing disorders were associated with poorer response in medication-only studies.

CONCLUSIONS

Overall, there are limited data on predictors of treatment response for pediatric OCD. The majority of studies are plagued with methodological limitations and post hoc approaches. Additional research is needed to better delineate the predictors of treatment response in pediatric OCD with the goal of developing individualized treatment approaches.

Do all obsessive-compulsive disorder subtypes respond to medication?

Obsessive-compulsive disorder (OCD) in children is strikingly similar in clinical presentation and treatment responsiveness to OCD in adults. While treatment is commonly effective for OCD not all subtypes of OCD are similarly responsive to treatment. Numerous studies describe the differential responsiveness of OCD subtypes to pharmacological treatment in adults, yet few such studies exist in pediatric OCD. This manuscript reviews the extant literature that addresses differential response of OCD subtypes to medication intervention. Specific OCD subtypes can be derived utilizing the following strategies: symptom factor analysis, comorbidity latent class analysis, concurrent internalizing disorders, concurrent externalizing disorders, tic-related subtype and early-onset subtype are reviewed in relation to data on differential pharmacotherapy response. Only externalizing disorders moderate treatment response in pediatric OCD. Specifically, attention-deficit hyperactivity disorder, oppositional defiant disorder and conduct disorder are associated with poorer response to medication treatment. Hoarding appears to be associated with a poor response to medication in adults, but data are sparse in children. The presence of tic disorders may also predict poorer response to pharmacotherapy in pediatric OCD. Strategies for treatment of the tic-related subtype of OCD, while strongly supporting the use of antipsychotic-augmentation for enhanced response in adults, are lacking controlled data in pediatric OCD.

Novel mutations of the extraneuronal monoamine transporter gene in children and adolescents with obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a disease of complex aetiology with a marked genetic component. Impact of the serotonergic system has been reported but the contribution of additional transmitter systems to the pathogenesis seems likely. The extraneuronal monoamine transporter, EMT (SLC22A3), is implicated in non-neuronal termination of noradrenergic signalling in the central nervous system and a candidate gene for a variety of neuropsychiatric disorders. We conducted a case-control study of 84 Caucasian children and adolescents with OCD according to DSM-IV criteria, and healthy adults by comprehensive sequencing of the EMT gene. Additionally, targeted genotype analysis was done with patient-parent trios. Known polymorphisms and frequent haplotypes were not associated with OCD in the present sample. Transmission disequilibrium test was negative for the presumptive cryptic splice site 1233G>A polymorphism. However, we identified two novel independent mutations exclusively in affected patients. A thus far unknown -106/107delAG mutation was detected in three male patients of unaffected parents but was not prevalent in 204 healthy subjects (p=0.024). In a luciferase reporter assay the mutant allele conferred increased promoter activity by 36%. Furthermore, we describe the first non-synonymous substitution in the EMT gene, Met370Ile, in a family of affected female members that co-segregated with the disease. The residue exhibits a high degree of inter-species conservation. Heterologous expression of mutant cDNA revealed a 40% decline of transport capacity for norepinephrine. Rare mutations in the EMT gene suggest a causative or modulating role in genetic subtypes of OCD.

Tic- und Zwangsstörungen

Zusammenfassung. In diesem Übersichtsartikel werden die Gemeinsamkeiten und Unterschiede von Tic- und Zwangsstörungen auf verschiedenen Ebenen dargestellt. In der Psychopathologie unterscheiden sich beide Phänomene zunächst deutlich - Tics sind plötzlich auftretende, unwillkürliche, motorische Bewegungen oder Vokalisationen. Zwänge sind wiederholte, zweckmäßige und beabsichtigte Verhaltensweisen. Es gibt jedoch fließende Übergänge, die sich vor allem bei den Just-Right-Zwängen manifestieren, die bei Tourette-Störungen gehäuft auftreten. Die diagnostischen Strategien und die dabei hilfreichen Instrumente werden vorgestellt. In der Therapie haben sich bei beiden Störungen sowohl verhaltenstherapeutische als auch pharmakotherapeutische Verfahren bewährt. Es wird eine Übersicht über den Stand der empirischen Evidenz gegeben. Die Behandlung von kombinierten Tic- und Zwangsstörungen wird speziell erörtert.

Efficacité des antidépresseurs inhibiteurs sélectifs de la recapture de la sérotonine chez l’enfant et l’adolescent

Selective serotonin reuptake inhibitors (SSRIs) have been used increasingly since the early 1990s to treat anxiety disorders and depression in children and adolescents. Several recent reports, however, cast doubt on their efficacy and especially raise questions about their role in serious adverse effects (increase in suicidal ideation and suicide attempts as well as reactions involving irritability, hostility, self-harm and self-destructive actions). The efficacy of SSRIs (fluoxetine, sertraline, fluvoxamine, paroxetine) in the treatment of obsessive-compulsive disorders in this population is clear today, although their effects are globally relatively modest. SSRIs remain notably less effective than clomipramine for this indication, although a variety of factors (age, family history, and psychiatric comorbidity) are also likely to influence response to treatment. Only several placebo-controlled studies suggest that the SSRIs (fluoxetine, sertraline and fluvoxamine) may have some utility in the treatment of anxiety disorders (generalized anxiety, separation anxiety, social phobias) in children and teens. The additional benefits from SSRIs for this indication nonetheless require confirmation. Imipramine and related tricyclic antidepressants are ineffective in the treatment of depressive disorders in children and adolescents. Among the SSRIs, only fluoxetine has proven its efficacy for this indication, although its effect here too appears relatively modest. The efficacy of sertraline and paroxetine cannot be considered more than probable, requiring confirmation, and that of citalopram has not been demonstrated. Moreover, because of the risk of suicidal behavior observed in some studies, SSRIs are inadvisable for the treatment of depressive disorders in this population. Overall, although the currently available data show SSRIs to be moderately effective and useful in treating anxiety disorders and depression in children and adolescents, future studies must focus on more precise identification of their indications, especially relative to psychotherapeutic strategies, which are still considered to be the first-line treatment in these disorders. From a legal point of view, only sertraline has been authorized in France for the treatment of obsessive-compulsive disorders in this population.

Obsessive-compulsive disorder

Compulsions are meant to relieve anxiety or to prevent a dreaded event. An adolescent or adult may recognize that the ritual is unreasonable or excessive, but that is not necessarily true for the young child. Children and adolescents will attempt to hide their rituals, although with more severe symptoms, this is not usually possible. To meet the diagnostic criteria for the disorder, the person must experience distress, spend more than 1 hour a day in either obsessions or compulsions, or experience significant interference in his/her life. This article reviews the phenomenology, causes, treatment, and outcome of children and adolescents with obsessive-compulsive disorder.

Heart rate variability: measurement and clinical utility

Electrocardiographic RR intervals fluctuate cyclically, modulated by ventilation, baroreflexes, and other genetic and environmental factors that are mediated through the autonomic nervous system. Short term electrocardiographic recordings (5 to 15 minutes), made under controlled conditions, e.g., lying supine or standing or tilted upright can elucidate physiologic, pharmacologic, or pathologic changes in autonomic nervous system function. Long-term, usually 24-hour recordings, can be used to assess autonomic nervous responses during normal daily activities in health, disease, and in response to therapeutic interventions, e.g., exercise or drugs. RR interval variability is useful for assessing risk of cardiovascular death or arrhythmic events, especially when combined with other tests, e.g., left ventricular ejection fraction or ventricular arrhythmias.

Paroxetine treatment in children and adolescents with obsessive-compulsive disorder: a randomized, multicenter, double-blind, placebo-controlled trial

OBJECTIVE

To assess the efficacy and safety of paroxetine for the treatment of pediatric obsessive-compulsive disorder.

METHOD

Children (7-11 years of age) and adolescents (12-17 years of age) meeting DSM-IV criteria for obsessive-compulsive disorder were randomized to paroxetine (10-50 mg/day) or placebo for 10 weeks. The primary efficacy measure was change from baseline in the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) total score at week 10 last observation carried forward end point. Safety was assessed primarily through adverse event monitoring.

RESULTS

A total of 207 patients were randomized to treatment. Of these, 203 were included in the intention-to-treat population. Adjusted mean changes from baseline at week 10 observation carried forward end point in CY-BOCS total score for patients receiving paroxetine and placebo were -8.78 (SE=0.82) and -5.34 points (SE=0.77), respectively. The adjusted mean difference, -3.45 in favor of paroxetine, was statistically significant (95% confidence interval=-5.60 to -1.29, p=.002). Adverse events were generally mild to moderate in intensity. A total of 10.2% (10/98) of patients in the paroxetine group and 2.9% (3 of 105) in the placebo group discontinued treatment because of adverse events.

CONCLUSIONS

Paroxetine is an effective and generally well-tolerated treatment for obsessive-compulsive disorder in children and adolescents.

Global assessment of psychosocial functioning in child and adolescent psychiatry. A review of three unidimensional scales (CGAS, GAF, GAPD)

Global assessment of functioning represents an important aspect of assessment in clinical practice and research. It can help identify persons in need of psychiatric treatment, have predictive value and measure change over time, including treatment effects. This review examines publications concerning development, psychometric properties and usefulness of three scales for children: Axis-VI in ICD-10 Global Assessment of Psychosocial Disability (GAPD), Children's Global Assessment Scale (CGAS) and Axis-V in DSM-IV Global Assessment of Functioning Scale (GAF). It is based on literature searches in PubMed and PsycInfo (1977-2003), and screening of Scandinavian and English textbooks on child psychiatry. The three scales differ in theoretical guidelines, descriptions of codes/anchor points and psychometric aspects. CGAS has been evaluated in 69 papers and 33 have been published on GAF used for children. The one paper comparing GAPD and CGAS found both scales sufficiently reliable for clinical practice. Reliability of CGAS and GAF has been found to vary from fair to substantial, depending on raters, training and diagnostic groups. International consensus for the use of one scale for global assessment of functioning for children 4-18 years would improve reliability in clinical practice and ease comparisons of studies across countries. A training programme would assist in this.

Selective serotonin reuptake inhibitor-induced sexual dysfunction in adolescents: a review

OBJECTIVE

To review the existing literature on selective serotonin reuptake inhibitor (SSRI)-induced sexual dysfunction in adolescents.

METHOD

A literature review of SSRI-induced adverse effects in adolescents focusing on sexual dysfunction was done. Nonsexual SSRI-induced adverse effects were compared in adult and pediatric populations. Information regarding SSRI-induced sexual dysfunction was extracted from pediatric SSRI clinical trials, clinical reviews, treatment guidelines, case reports, and MedWatch reports.

RESULTS

Although the incidences of nonsexual SSRI-induced adverse effects seemed to be similar for both adult and pediatric populations, only one male of 1,346 pediatric subjects receiving an SSRI reported sexual dysfunction. Approximately one third of the clinical reviews and treatment guidelines reviewed raised some concern about SSRI-induced sexual dysfunction. In 11 years, only eight MedWatch reports regarding SSRI-induced sexual dysfunction in adolescents have been filed. Only one letter to the editor describing impaired sexual functioning in three of five adolescents on SSRIs could be found.

CONCLUSIONS

Information on SSRI-induced sexual dysfunction in adolescents is lacking. Researchers and clinicians may be failing to ask adolescents about sex and sexual functioning in the context of SSRI treatment.

Disordered gambling in adolescents : epidemiology, diagnosis, and treatment

Rapid expansion of legalized gambling has been associated with increased rates of gambling disorders among adults and adolescents worldwide. Epidemiologic studies suggest that, in North America, up to 6% of adults and 20% of adolescents have a gambling problem. Despite increasing prevalence rates of gambling disorders, little research is available on how to treat such disorders in adolescents. Much of what is known about how to treat adolescent problem and pathological gambling comes from research on psychosocial and psychopharmacologic treatments for adult pathological gambling. Risk factors for adolescent gambling disorders include male gender, alcohol and drug use, deviant peers, family history of gambling, and impulsive behavior. While several risk factors characterize disordered gambling among adolescents, the extent to which these characteristics are related remains to be determined. In terms of screening for adolescent problem and pathological gambling, several instruments designed to reflect the Diagnostic and Statistical Manual of Mental Disorders diagnostic criteria for pathological gambling are available. Psychosocial approaches used to treat adult pathological gambling include Gamblers Anonymous, cognitive-behavioral therapy (CBT), and motivational enhancement therapy (MET). Among adolescents, CBT as well as an eclectic therapy have been helpful in reducing problematic gambling behavior. In terms of pharmacotherapy, three classes of psychotropic drugs have been used to treat adult pathological gambling - serotonin reuptake inhibitors, opioid antagonists, and mood stabilizers. While some of these pharmacotherapies have been efficacious in treating adult pathological gambling, additional double-blind, placebo-controlled studies are needed to determine the long-term effectiveness of these treatments. No known study has evaluated the use of psychopharmacologic agents in treating adolescent pathological gambling. Possible reasons for the lack of research on treatment for adolescent gambling disorders include lack of motivation to pursue treatment, feelings of self-control, and negative perception of therapy. Referrals from parents, teachers, and peers of adolescents, as well as community outreach programs, may be useful in successfully deriving a treatment population. Clinicians are advised to be sensitive to behavioral risk factors and to screen for disordered gambling in high risk adolescents. A combination of CBT and MET, as well as medication for any comorbid psychiatric condition, is recommended.

[Pharmacotherapy of compulsive disorders in childhood and adolescence]

OBJECTIVES

The review addresses the issue of the extent to which pharmacological treatment of obsessive-compulsive disorders (OCD) in childhood and adolescence is based on empirical studies.

METHODS

Current literature is evaluated, including studies of adult cohorts if these contain approaches relevant for the pharmacological treatment of children and adolescents.

RESULTS

The number of qualified empirical studies is few. These studies have shown clomipramine and serotonin-reuptake inhibitors to be very effective in the therapy of obsessive-compulsive disorders in childhood and adolescence. On the basis of the studies available, no specific recommendation can be made with regard to pharmacological dosage. For clomipramine the effective daily dose probably ranges somewhere between 75-150 mg, for fluoxetin between 20-60 mg, and for fluvoxamine between 100-250 mg. However, it must be kept in mind that in individual cases, improvement sometimes will not be noticeable until after 8 to 10 weeks of treatment have elapsed.

CONCLUSION

Clomipramine and serotonin-reuptake inhibitors are effective in the treatment of obsessive-compulsive disorders in children and adolescents. There is an urgent need for therapy studies of obsessive-compulsive disorders in childhood and adolescence. Placebo-controlled studies of pharmacological treatment, controlled studies of psychotherapeutic treatment, and comparative studies of pharmacological and psychotherapeutic approaches are necessary.

Focus on paroxetine

This review of paroxetine is based on Medline and PsycLit searches and a manual search of the available research literature. It aims to cover the pharmacology of this frequently prescribed SSRI antidepressant in terms of its indications, efficacy and adverse effects. Overall, paroxetine is a well-tolerated and safe first-line SSRI antidepressant with anxiolytic qualities. It has been found useful in depression, anxiety and other conditions such as obsessive compulsive disorder and post-traumatic stress disorder. The antidepressant has some advantages over earlier tricyclic medication in terms of a lack of cardiovascular side-effects and relative safety in overdose. Cessation of use, however, is associated with withdrawal or discontinuation symptoms and patients should be counselled as to how these might be avoided. A 3- or 4-week graded withdrawal regimen, perhaps with concomitant fluoxetine to cover serotonergic discontinuation symptoms, may be advisable.

Ten-year review of rating scales. II: Scales for internalizing disorders

OBJECTIVE

This article, the second in the Journal's series of 10-year updates on rating scales, summarizes scales assessing internalizing disorders.

METHOD

The authors sampled articles on mood and anxiety disorders over the past 25 years, selected scales with multiple citations over many years, and reviewed their properties. Those with adequate psychometric properties, plus continued wide literature citations or a current special niche, are presented here.

RESULTS

Rating scales for depression were developed and/or examined in the 1980s. Despite generally strong properties, they lack clear construct validity. Most have parent-report forms that broaden their suitability with youths. Anxiety scales were developed bimodally. Those developed in the 1960s to 1970s were downward modifications of adult scales. They have been criticized for unclear constructs and unsuitability for youths. Newer scales developed in the 1990s have addressed these problems and have parent-report forms. However, their utility is still being determined.

CONCLUSIONS

Rating scales can reliably, validly, and efficiently measure youths' internalizing psychopathology. They have great utility in research, treatment planning, and accountability in practice. However, the user must define the goals of measurement, consider the construct the scale measures, and use the scale within its defined capabilities. The use of more than one scale for a task is recommended.

Cognitive behavior therapy in treatment-naive children and adolescents with obsessive-compulsive disorder: an open trial

This work aims is to evaluate the therapeutic efficacy of cognitive behavior therapy (CBT) in pediatric patients with obsessive-compulsive disorder (OCD) who had not previously been treated with either pharmacotherapy or psychotherapy and who remained medication-free during CBT. Sixteen OCD outpatients, 8-17 years of age, were treated in a 12-week open trial with manualized CBT. Target symptoms were rated at two-week intervals with the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), the National Institute of Mental Health Global Obsessive-Compulsive Scale (NIMH Global), the Clinical Global Impression Scale (CGI), and the Hamilton Anxiety Rating Scale (Ham-A). Statistical analyses showed a significant benefit for treatment. Ten patients experienced at least a 50% reduction in symptoms on the CY-BOCS; seven were asymptomatic on the NIMH Global. These results build on previous reports that CBT may be effective in the acute treatment of pediatric OCD. Further, the results of this study suggest that CBT can be efficacious in alleviating OCD symptoms in the absence of pharmacotherapy. These results must be considered preliminary, given the small sample size and open administration of treatment.

Paroxetine in child and adolescent outpatients with panic disorder

Paroxetine has repeatedly been shown to be effective in the treatment of panic disorder (PD) in adults, and, according to previous case observations, it may be useful in treating children and adolescents with PD as well. This preliminary naturalistic study examines effectiveness and safety of paroxetine in the treatment of children and adolescents with PD. A chart review was conducted on 18 patients with Diagnostic and Statistical Manual of Mental Disorders PD admitted to the Division of Child Neurology and Psychiatry and to the Department of Psychiatry at the University of Pisa. Paroxetine was given at an initial mean dosage of 8.9 +/- 2.1 mg/day and was gradually increased up to 40 mg/day, depending on clinical response and side effects. Clinical status was assessed with the Clinical Global Impression (CGI) and adverse effects were assessed retrospectively at each visit. Patients with final CGI-Improvement scores of 1 or 2 were considered responders. Mean paroxetine treatment duration was 11.7 +/- 8.3 months, with a mean final dosage of 23.9 +/- 9.8 mg/day (range, 10-40 mg/day). No patient had to interrupt the treatment because of side effects. Fifteen patients (83.3%) were considered responders. The mean change on the CGI-Severity scale was statistically significant (p < 0.0001). Paroxetine was well tolerated and effective in the treatment of PD in these children and adolescents.

Attention-deficit/hyperactivity disorder in children and adolescents with obsessive-compulsive disorder: fact or artifact?

OBJECTIVE

To clarify whether the symptoms of inattention and distractibility commonly seen in children and adolescents with obsessive-compulsive disorder (OCD) represent true comorbidity with attention-deficit/hyperactivity disorder (ADHD) or a manifestation of obsessional anxiety.

METHOD

Phenotypic features and functional correlates of ADHD-like symptoms were examined in youths with and without OCD from a large sample of pediatric psychiatry patients consecutively referred since 1997.

RESULTS

The number, frequency, and types of core ADHD symptoms as well as ADHD-associated functional indices were identical in all youths with DSM-IV-diagnosed ADHD irrespective of the presence or absence of comorbid OCD.

CONCLUSION

These findings suggest that when ADHD-like symptoms are seen in youths with OCD, they reflect a true comorbid state of OCD plus ADHD and that the ADHD syndrome may be independent of OCD in comorbid youths.

[Evaluated treatment approaches in child and adolescent psychiatry II]

OBJECTIVES

The principle of evidence-based medicine is to integrate data concerning the efficacy of interventions into clinical practice. This article assesses the level of evaluation of psychosocial, psychopharmacological and combined interventions for mental disorders in childhood and adolescence (schizophrenic disorders, affective disorders, phobias and anxiety disorders, obsessive-compulsive disorder, posttraumatic stress disorder, anorexia nervosa, and bulimia nervosa).

METHODS

Three different levels of evaluation were defined for both psychosocial and psychopharmacological interventions: A (> or = 2 randomized controlled studies), B (1 randomized controlled study), and C (open studies and case studies). The level of evaluation was judged on the basis of original papers found in a comprehensive literature search.

RESULTS

The number of controlled studies examining these disorders in children and adolescents is small, especially with regard to pharmacotherapy. However, the efficacy of (cognitive) behavior therapy for depressive disorders, phobias and anxiety disorders, as well as posttraumatic stress disorder has been demonstrated.

CONCLUSIONS

There is still a considerable need to evaluate pharmacological treatment approaches for schizophrenic and affective disorders. Looking at psychosocial interventions in schizophrenic disorders, obsessive-compulsive disorder and eating disorders, specific aspects of treatment for young patients should be examined. Overall, the psychotherapy approach evaluated best is (cognitive) behavioral therapy.

Case study: caudate glutamatergic changes with paroxetine persist after medication discontinuation in pediatric OCD

Proton magnetic resonance spectroscopy (1H-MRS) was used to examine glutamatergic (Glx) abnormalities in the caudate nucleus in pediatric obsessive-compulsive disorder (OCD), associated with severity of illness and response to acute (12 weeks) treatment with paroxetine. In this report, OCD symptoms improved markedly in an 8-year-old girl treated for 14 months with the selective serotonin reuptake inhibitor paroxetine (titrated from 10 to 40 mg/day). Paroxetine dose was then decreased in 10-mg decrements and discontinued without symptom recurrence. Serial 1H-MRS examinations were acquired before and after 12 weeks of paroxetine treatment (40 mg/day) and 3 months after medication discontinuation. A striking decrease in caudate Glx was observed after 12 weeks of treatment which persisted after medication discontinuation. These data provide further support for a reversible glutamatergically mediated dysfunction of the caudate nucleus in OCD that may serve as a pathophysiological and treatment response marker.

Effects of combination psychotropic drug treatment on heart rate variability in psychiatric patients

The aim of this study was to evaluate the effects of combination psychotropic drug treatment on heart rate variability (HRV), which was mainly controlled by the parasympathetic nervous system. Mean R-R intervals (mRR) and coefficient of variation (CV), an index of HRV, were studied in 22 psychiatric patients and 21 age- and sex-matched healthy controls. Next, in the patient group focusing on both anticholinergic and antidopaminergic properties, combination psychotropic drug daily doses were converted into biperiden milligram equivalents (BPDeq) and chlorpromazine milligram equivalents (CPZeq), respectively. The relationship between mRR and CV and these equivalent dosages was examined. A significant reduction in both mRR (P < 0.05) and CV (P < 0.05) was found in the patient group. In addition, significant negative correlations were observed between the dose of BPDeq and mRR (P < 0.05), and between the dose of BPDeq and CV (P < 0.005). In contrast, no significant correlations were observed between the dose of CPZeq and either parameter. These findings suggest that the effects of combination psychotropic drug treatment on HRV are mainly due to their anticholinergic properties. Therefore, CV is a useful indicator to assess the parasympathetic activity of psychiatric patients under combination psychotropic drug treatment.

Fluoxetine treatment for obsessive-compulsive disorder in children and adolescents: a placebo-controlled clinical trial

OBJECTIVE

This study assesses the efficacy and tolerability of fluoxetine in the acute treatment of child and adolescent obsessive-compulsive disorder (OCD) during a 13-week, double-blind, placebo-controlled study.

METHOD

Eligible patients aged 7 to 17 (N = 103) were randomized at a ratio of 2:1 to receive either fluoxetine or placebo. Dosing was initiated at 10 mg daily for 2 weeks, then increased to 20 mg daily. After 4 weeks of treatment, and again after 7 weeks of treatment, non-responders could have their dosage increased by 20 mg daily, for a maximum possible dosage of 60 mg daily. Primary measure of efficacy was improvement in OCD symptoms as measured by the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). All analyses were intent-to-treat.

RESULTS

Fluoxetine was associated with significantly greater improvement in OCD as assessed by the CY-BOCS (p = .026) and other measures than was placebo. Fluoxetine was well tolerated and had a rate of discontinuation for adverse events similar to that of placebo (p = 1.00).

CONCLUSIONS

Fluoxetine 20 to 60 mg daily was effective and well tolerated for treatment of OCD in this pediatric population.

Obsessive-compulsive disorder in children

Childhood OCD is a chronic and commonly disabling disorder with a lifetime prevalence of 2% to 3%. Traditionally OCD was a neglected diagnosis, but renewed research interest over the past decade has led to significant advances in the understanding of the disorder in young people. OCD is relatively consistent across the age span in terms of prevalence, phenomenology, etiology, and response to treatment. Comorbidity, especially depression and other anxiety disorders, is common in children with OCD and may exert a negative influence on treatment response and long-term outcome. Nevertheless, CBT and SSRI therapy have been shown to be effective and well-tolerated therapies for children with OCD.

Decrease in caudate glutamatergic concentrations in pediatric obsessive-compulsive disorder patients taking paroxetine

OBJECTIVE

To measure in vivo neurochemical changes in the caudate nucleus in pediatric obsessive-compulsive disorder (OCD) before and after treatment.

METHOD

Single-voxel proton magnetic resonance spectroscopic (1H-MRS) examinations of the left caudate were conducted in 11 psychotropic drug-naive children, aged 8 to 17 years, with OCD before and after 12 weeks of monotherapy with the selective serotonin reuptake inhibitor paroxetine (10-60 mg/day) and 11 healthy children aged 8 to 17 years. A different sample of 8 pediatric OCD patients and 8 healthy children had a 1H-MRS examination of occipital cortex.

RESULTS

Caudate glutamatergic concentrations (Glx) were significantly greater in treatment-naive OCD patients than in controls but declined significantly after paroxetine treatment to levels comparable with those of controls. Decrease in caudate Glx was associated with decrease in OCD symptom severity. Occipital Glx did not differ between OCD patients and controls.

CONCLUSIONS

These preliminary findings provide new evidence of Glx abnormalities in the caudate nucleus in pediatric OCD and suggest that paroxetine treatment may be mediated by a serotonergically modulated reduction in caudate Glx.

Therapeutic approaches to the treatment of refractory obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a debilitating condition that afflicts approximately 1% to 3% of the world population. The primary treatments are selective serotonin reuptake inhibitors and behavioral therapy. Despite therapy, approximately 30% to 40% of patients continue to suffer from disabling OCD symptoms. This article addresses the range of treatment options for patients with refractory OCD, focusing upon novel strategies and the most recent research.

Childhood obsessive-compulsive disorder: a review

Obsessive-compulsive disorder (OCD) holds a particular interest for child psychiatrists because of the high proportion of cases with onset in childhood and adolescence. Over the last two decades, substantial progress has been made in describing OCD in children and adolescents and in developing and implementing effective treatments. In addition, research on the phenomenology, neurobiology, and psychopharmacology of OCD has led to its current conceptualization as a developmental neuropsychiatric disorder. In this article, the fourth in a series on OCD, the authors summarize the most recent data on the phenomenology, etiology, neurobiology, and treatment of OCD in children and adolescents.