Serotonin reuptake inhibitor (SRI) medications are thought to work the best for treating pediatric OCD. The optimal dose of OCD medications must be found on an individual, case-by-case basis. It is always best to use the smallest amount of medication that effectively treats the OCD. However, most children and adolescents metabolize medications quickly, and therefore higher, adult-sized doses are usually used. In addition, higher doses than what are typically prescribed to treat depression are needed to be effective when treating OCD. It is very important to not ‘under treat’ OCD at low doses, when higher doses may further improve or remove the OCD symptoms if they are well tolerated.
OCD medications control symptoms but do not “cure” the disorder, much like insulin does not “cure” diabetes, but rather, helps to manage symptoms. This means that the positive effects of an OCD medication only occur while the drug is being taken and some symptoms often remain, although with lower severity. When the child stops taking the OCD medication, symptoms usually return within a period of months.
Clomipramine (Anafranil ®) was the first of the antidepressants (in the tricyclic antidepressant category) that was found to help control OCD symptoms. However, it appears that not all antidepressant medications have anti-OCD effects, but only those that strongly affect serotonin. This means that the standard and best-proven medications to treat OCD in youth include all of the SRI medications and also clomipramine.
All OCD medications work slowly. This can be frustrating for youth, families, and clinicians. It may take up to two to three months to see improvement. Also, ongoing further improvement of OCD may continue between twelve weeks to a year after starting medication.
Choosing an OCD Medication
No two children respond to anti-OCD medication in exactly the same way. In addition, an occasional child will not respond to any medication. It is common for children to have individualized responses to each of the anti-OCD medications. Some work well for a particular child, and some not at all. The occurrence of side effects also varies greatly. Because of this, it is impossible to pick ahead of time which medication will work the best for a particular child. It is important to understand that if the first medication chosen does not improve OCD, another one should be tried. Over time, the child may need a trial of each of the six available anti-OCD medications to find the one that works best.
As described above, the decision of which medication to use is left open to clinical judgment and discussion with the family. A study was recently done to compare past OCD medication research trials (including over 3000 OCD patients) and found no differences in how well these work to treat OCD. However, they did find differences in side effects that were described between medications. Both clomipramine and all of the studied SRIs have been shown to work equally better than a sugar pill (placebo). Other medications in the same ‘tricyclic’ category with less serotonergic activity than clomipramine are not effective in the treatment of OCD. Overall, clomipramine has a worse side effect profile than the SRIs, meaning that SRIs should generally be tried first.
Factors that may be helpful in making the selection of an SRI include a known family history of positive response or bad reaction to a specific SRI, potential interactions with other medications, and side effect profiles.
Not all of the OCD drugs have Food and Drug Administration (FDA) approval for use in children and adolescents. Presently, four OCD medications have been approved by the FDA for use in children, including clomipramine (Anafranil ®) (approval from 10 years of age), fluoxetine (Prozac ®), fluvoxamine (Luvox ®) (approval from 8 years of age), and sertraline (Zoloft ®). The FDA grants this approval when large studies have been completed using pediatric patients. Because these large studies are very expensive and difficult to accomplish, they have not been conducted with all the OCD medications. However, doctors may still prescribe any of the seven available medications to children of any age. A table is included below to describe some details about these medications.
Table 1: OCD MEDICATIONS, DOSAGES AND SIDE EFFECTS
First Line OCD Agents
Starting Dose (mg/d)
Target Dose (mg/d)
Before starting a medication the clinician will often conduct baseline laboratory assessments that may include measurements for weight, abdominal circumference, height, prone and supine blood pressure, lipid profile, liver and kidney enzymes and an electrocardiogram (EKG). A list of physical complaints prior to the medication trial should also be recorded to differentiate these from emergent adverse effects. Between each step in the treatment plan, assessment of adherence/compliance and adverse effects with the medication regime should be conducted.
Talking with Parents about Medication
Many parents are anxious about seeking psychiatric help for their child, especially when medication is recommended. Although most professionals will agree that exposure and response prevention (ERP) therapy should be tried first, a combination of ERP and medication is the best treatment in many cases, especially with moderate to severe symptoms.
Clinicians sometimes use the metaphor of “training wheels” with the child and the parents, as medication can often offer some relief from anxiety that enables the patient to engage in ERP therapy more readily.
Parents should be encouraged to make a pro and con list around the medication issue. Often times a child who is struggling with OCD may feel sad and depressed and may withdraw from social activities, peers, and family relationships. They may become consumed with their worries and exhausted by the energy it takes them to challenge their fears. The increased feelings of depression, helplessness, and hopelessness may have a more detrimental impact on psychosocial development and on school functioning. If the use of medication could halt this snowball effect of symptoms, then parents may decide to try it for initial relief of symptoms. Many young children make significant gains with behavior therapy once they have medication on board.
Adapted from text by S. Evelyn Stewart, MD.