Obsessive Compulsive Disorder (OCD)
part 9

Usually a person will be assessed and then given some homework.  They will be seen briefly every couple weeks at the maximum to see how it is going.

Usually three months is a long enough trial with pediatric OCD to tell how things are going to go.  If a child has been doing their homework and really trying and is not better in two to four months, it is time to think about medications.  If behavioral treatments work, the child is seen until the OCD is not disabling anymore.  Then the child is seen less often, like every few months for a year or so.  Rarely do people do behavioral treatment intensively in Canada with the aim of getting rid of all signs of OCD.

Definitely yes.  Most studies have shown that the most effective treatment for OCD involves behavior treatment and medications.  Also, you have a better chance of getting off the medications and not relapsing if you have learned behavior treatment.

You don't.  This is a nice problem to face - why am I better?  When both treatments are given and there is improvement, I usually continue both for about a year and then stop the medications (see below on this point).

This gives you an idea of how cognitive behavioral treatment works and doesn't work in OCD.  Overall, about 60-70 % of children will improve with this treatment.  To do this type of treatment, a child has to be motivated to do the homework, believe that she or he really needs help, and be patient enough to wait a while.  In children, the behavioral techniques are used more frequently than the cognitive ones.  However, making the OCD into something that the child is fighting sometimes works well.  The other good thing about behavioral treatments is that people have a great sense of accomplishment if they can get better without medications.

The medications used for OCD are the same ones that are used for severe depression and other anxiety disorders in children and adolescents.  These drugs all affect serotonin, a chemical in the brain which is used to communicate between different the different parts of the brain.  We don't know exactly how this works yet.  We do know one thing for certain.  If a drug has no effect on the serotonin system, it won't be effective alone in OCD. At present, there are five drugs in this group.  The are Prozac (fluoxetine), Paxil (Paroxetine), Zoloft ( Sertraline), Luvox (fluvoxamine), and Anafranil (Clomipramine).  All of these drugs have been used in pediatric OCD.  Clomipramine has been used the longest.

There are three principles to make sure you do things safely and carefully in this area of medicine

All of the drugs we use in pediatric psychiatry can actually cause unwanted psychiatric signs or symptoms as side effects.  It is impossible to predict ahead of time who is going to be very sensitive to these drugs and who isn't.  If you start someone on a high dose of a drug and they are very sensitive to it, they will have a lot of side effects.  This could be dangerous.  It might convince a child or family not to try medications again.  Furthermore, it might have been effective it you had just started out with a small dose.  If some one is very sensitive to medications and you start low, you have a manageable amount of side effects or good effect.  If they aren't particularly sensitive to medications, then you usually see no effect.  That's just fine.  I start drugs at a dose which will probably do nothing good or bad in 90% of children.  That way I can pick up the 10% who are very sensitive.

If you have a severe infection, you want to get a lot of medicine in right away.  The same is true with some other serious diseases.  It is not true in pediatric psychopharmacology, for the most part.  Most of the time, if a person has OCD, he or she has had it a long time and waiting a little bit longer isn't going to make that much difference.  Lots of children will tolerate these drugs if you slowly increase the dose, but not if you quickly increase the dose.  It is safer and a lot easier to figure out what is going on if you "Go slow"

No drug is completely safe.  There are things that need to be watched for with every drug, and these drugs are no different.  What needs to be checked depends on the drug.  For monitoring to be effective, both families and the doctor need to know what can go wrong.  This is especially true of the psychiatric side effects.  In some cases, these drugs can make an already anxious person more anxious and restless.  You need to know if this could be a possible side effect of the drug.  The doctor should have enough experience with the drug in your child's age group to know what to look for.  Almost all the horror stories about these drugs involve either a physician or family or both who were not monitoring things carefully.

In adults, when these drugs work, which is 60-80% of the time, they do not work overnight.  Usually a person will see a change in the first month, but sometimes a person can have no change for 6-8 weeks and then start to improve.  However, some recent work suggests that they may work faster in children.  A very large study of Fluvoxamine (Luvox) in children with OCD showed after only one week there were signs of improvement and most of the improvemtn was seen within the first three weeks.   In some people, the obsessions and compulsions just start to drop away.  In other cases, the obsessive thoughts still go through their mind, but only to a mild degree.  In other cases, the medicines just make it easier to do the behavior treatment.  Sometimes they help certain parts of OCD and not others. Sometimes, of course, they don't do anything at all for OCD.