Outpatient Treatment Patterns of Pediatric Obsessive-Compulsive Disorder

Introduction

Obsessive-compulsive disorder (OCD) affects 1%–2% of youth (Zohar 1999) and is associated with significant impairment (Piacentini et al. 2003) and reduced quality of life (Lack et al. 2009). Without treatment, OCD persists (Stewart et al. 2004; Bloch et al. 2013), contributing to risk for compounded functional impairment (Storch et al. 2010), familial impairment (Lebowitz et al. 2016; Wu et al. 2016), and psychiatric comorbidity (Langley et al. 2010; Ruscio et al. 2010). Therefore, provision of effective treatment is critical.

Empirically supported treatments for pediatric OCD include cognitive-behavioral therapy (CBT) involving exposure and response prevention, serotonin reuptake inhibitors (SRIs), or their combination (Pediatric OCD Treatment Study [POTS] Team 2004; Abramowitz et al. 2006; Franklin et al. 2011; McGuire et al. 2012). As such, the evidence-based and clinical guidelines recommend CBT as the first-line for most patients, while combined CBT-SRI treatment may be more appropriate for those with severe symptoms (Geller and March 2012). Despite the evidence supporting CBT, pharmacotherapy is more commonly used than CBT in practice (Olfson et al. 2004). Nonetheless, rates of any evidence-based treatment (i.e., CBT or SRI, CBT, and SRI) for adults with OCD are low (Blanco et al. 2006; Marques et al. 2010) with correspondingly limited data reported in children.

To date, few studies have examined office-based physician care for individuals with OCD. Patel et al. (2014) broadly examined OCD treatments for adults seen in office-based physician practices and found that 39% of patients received psychotherapy overall, 69% received SRI medication overall, and 84% received psychotherapy, SRI medication, or both (Patel et al. 2014). The percentage of visits with psychotherapy and an SRI medication were not reported. Approximately 13% of their sample was prescribed antipsychotic medication either with or without an SRI medication (Patel et al 2014). The only large, naturalistic study of children and adults with OCD analyzed data from the nationwide Swedish Prescribed Drug Register (Isomura et al. 2016). The researchers found that 87% of children received an SRI medication overall and individuals with OCD alone (i.e., no comorbidities) were more likely to receive SRI monotherapy compared to those with OCD plus comorbidities (Isomura et al. 2016).

Although Patel et al. (2014) provide insight into treatment modalities provided to adults with OCD seeking treatment from office-based physicians, no U.S.-based studies have examined community-based treatment among youth with OCD. Attention is warranted to this population because ≥50% of adults with OCD report a childhood onset (Ruscio et al. 2010). Furthermore, established interventions (i.e., SRI medication and psychotherapy) have demonstrated strong efficacy. The extent to which practice guidelines are adhered to is an important public health issue given the incidence of OCD and associated disability. This study describes treatment modalities (i.e., psychotherapy and medications) provided to youth with OCD by office- and outpatient department (OPD)-based physicians.

Methods

This study was exempted from IRB review because it used only publicly available, deidentified data. To study treatment of pediatric OCD, this study utilizes the 2003–2011 National Ambulatory Medical Care Survey (NAMCS) and 2003–2011 National Hospital Ambulatory Medical Care Survey (NHAMCS), both of which have been conducted annually by the National Center for Health Statistics since 1991 (National Center for Health Statistics 2012). The NAMCS is a nationally representative sample of nonfederal office-based physicians providing direct patient care, while NHAMCS is a nationally representative sample of ambulatory care departments in nonfederal general and short-stay hospitals. Details of the respective sample designs can be found in detail elsewhere (National Center for Health Statistics 2012). The mean, unweighted survey response rate for all 2003–2011 survey years was 62.3% (range: 58.3%–66.9%) for the NAMCS and 72.5% (range: 68.3%–74.1%) for the NHAMCS.

Diagnosis of OCD was determined by examining International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Cases were identified by a coding of OCD (300.3) for the primary or secondary diagnosis codes: three codes were available in total. Cases with primary or comorbid schizophrenic, affective, and related disorders (e.g., any psychotic disorders) were excluded because the first-line treatment varies significantly from evidence-based treatment of OCD. Cases with any listed comorbid mood, externalizing disorders (i.e., attention-deficit hyperactivity disorder [ADHD], oppositional-defiant disorder [ODD], and conduct disorder [CD]) and other anxiety disorders were included given that recommended treatments are similar and the frequency with which comorbidity presents in pediatric OCD (Geller et al. 2003; Storch et al. 2008; Torp et al. 2015).

We controlled for patient demographics including age, sex, race and ethnicity, U.S. region, primary payer, care setting, visit status, visits in the past 12 months, chronicity, and primary care provider were provided in survey data. Race and ethnicity were combined and imputed by NCHS in years that high percentages were missing; for details see NAMCS and NHAMCS documentation (National Center for Health Statistics 2012). Care setting was classified by NCHS as office-based or outpatient department of a hospital or health system. Visit status referred to whether a patient was new or existing. Chronicity was classified as new/acute, chronic routine, chronic flare-up, or other. Providers were determined to be the primary care provider or not (i.e., specialist or other).

Treatment was determined by examining listed services and prescriptions provided at the visit. The survey assessed whether psychotherapy was provided, but did not include information on the nature of therapy (e.g., CBT) or session duration. Pharmacotherapy data included up to eight medication listings consisting of drug name and therapeutic class (see Supplementary Table S1; Supplementary Data are available online at www.liebertpub.com/cap). Consistent with Patel et al. (2014), we examined number and class of medication individually and in combination.

Results

There were 246 unique pediatric patients who made at least one visit to an office- and OPD-based physician from 2003 to 2010, which resulted in a diagnosis of OCD. Patient demographics are in Table 1. The mean age of patients was 11.9 ± .22 years. Most visits were made by patients who were male (62%), Caucasian (86%), and had private insurance (61%) or Medicaid (26%), existing patients (87%), and those who had seen the same provider on ≥6 prior occasions in the last year (42%). Approximately 36% of visits were due to OCD alone, 24% with only comorbid externalizing disorders, 11% with only comorbid anxiety disorders, 10% with only comorbid mood disorders, and 18% with two or more comorbid diagnoses (i.e., OCD + anxiety + mood, OCD + anxiety + externalizing, or OCD + mood + externalizing).

The descriptive statistics for psychotherapy and pharmacotherapy received are in Table 2. A minority of patients (11%) received no psychotherapy or any psychotropic medication, while 22% received psychotherapy only, 22% received an SRI medication only, and 26% received both psychotherapy and an SRI medication. Therefore, nearly three-fourths of the visits resulted in psychotherapy and/or an SRI medication. Seventy-seven percent of patients received at least one psychotropic medication and 35% received combined therapies. There was significant variation in the proportions of patients receiving each mode of treatment by chronicity (F = 3.41, p < 0.001) and for whether the physician was the patient's primary care provider (F = 3.01, p = 0.031). These differences were elucidated in the multinomial logistic regression models. For example, patients with chronic flare-ups were less likely to receive psychotherapy relative to pharmacotherapy (OR: 0.06, 95% CI: 0.01–0.57, p < 0.001); the same was true of patients with a visit for routine problem (OR: .06, 95% CI: 0.01–0.37, p = 0.002). Routine visits for a chronic problem were negatively associated with no treatment (OR: 0.07, 95% CI: 0.01–0.44, p = 0.005) relative to new patients, meaning patients with chronic conditions were more likely to receive pharmacotherapy than no treatment. In addition, patients seen by their primary care physician were 8.21 times less likely (95% CI: 2.05–32.81, p = 0.003) to have received both psychotherapy and pharmacotherapy versus only pharmacotherapy, relative to patients seeing a physician who was not their primary care provider. The odds of receiving both psychotherapy and pharmacotherapy increased by 1.13 (95% CI: 1.01–1.27, p = 0.032) for each year older relative to pharmacotherapy only.

There were differences in the proportions of men and women receiving alpha-2 agonists (F = 5.38, p = 0.022); however, this difference did not persist in the multivariable logistic regression model. There was a difference in proportions of patients receiving atypical antipsychotics (F = 6.86, p = 0.01), but this difference was not observed in the logistic model. The odds of men receiving atypical antipsychotics were 1.95 times (95% CI: 1.03–3.68, p = 0.039) that of women and patients with comorbid ODD were 5.64 times (95% CI: 1.17–27.22, p = 0.032) more likely to receive atypical antipsychotics compared to patients without ODD. There were some differences in the proportions of patients receiving stimulants by sex (F = 9.54, p = 0.0024), chronicity (F = 3.41, p = 0.0192), and comorbid diagnosis (F = 26.00, p < 0.001). Follow-up logistic models showed that the odds of receiving a stimulant was 90.49 (95% CI: 11.5–712.95, p < 0.001) for patients with routine visits for chronic problems and 20.06 (95% CI: 1.77–226.99, p < 0.001) for patients with flare-ups of chronic problems, relative to patients with new or acute problems. The presence of comorbid ADHD resulted in 163.00 greater odds (95% CI: 38.37–692.49, p < 0.001) of receiving a stimulant relative to no ADHD.

The proportions of patients receiving SRIs varied by insurance (F = 5.76, p < 0.001), setting (F = 6.03, p = 0.016), chronicity (F = 3.85, p = 0.052), and primary care provider (F = 4.74, p = 0.032). None of these factors were significant in the logistic model, but each increasing year of age was associated with 1.2 greater odds (95% CI: 1.10–1.31, p < 0.001) of receiving an SRI.

Receipt of anxiolytic medications varied significantly by primary payer (F = 5.43, p < 0.001), but this difference did not remain in the multivariable logistic model. However, each increasing year of age was associated with an increase in odds of receiving an anxiolytic medication by 1.15 (95% CI: 1.01–1.32, p = 0.036). In terms of anticonvulsants, the only significant difference was among primary payer (F = 2.55, p = 0.0417). However, there were factors significantly associated with anticonvulsant use in the logistic regression model.

Discussion

We report on treatment practices of OPD- and office-based physicians treating pediatric patients with OCD, which was not previously described using naturalistic design for U.S. patients. Over three quarters of visits involved psychotropic medication alone, or in combination with psychotherapy. Only 12% of visits involved psychotherapy alone, while 35% involved a combination of psychotherapy and pharmacotherapy. The most frequently prescribed medication classes were SRIs, followed by stimulants, and atypical antipsychotics. There was not a common factor that predicted greater adjusted ORs for medication use; however, significant factors were age, chronicity of problems, and comorbid disorders.

Patients seen for a chronic problem, whether a routine visit or flare-up, were more likely to receive pharmacotherapy than psychotherapy. It might suggest that routine visit patients were seen for medication management whereas the approach for acute problems was characterized by receipt of pharmacotherapy, psychotherapy, combined treatment, or nontreatment. These findings imply that chronic problems are more likely to treated by pharmacotherapy, which would potentially suggest that treatment guidelines were followed in a broad sense (i.e., medication is not first line treatment).

Pharmacotherapy was prescribed to 77% of the sample, which is not surprising since patients presented to a physician rather than a therapist. While we were unable to ascertain physician specialty from OPD visits, we found that 75% of the office-based visits involved psychiatrists. The high proportion of patients being prescribed medications follows the shift away from psychotherapy toward pharmacotherapy among psychiatrists (Mojtabai and Olfson 2008). On balance, some providers in this sample were primary care physicians who typically do not provide psychotherapy, and only ∼10% of psychiatrists report providing psychotherapy in practice (Mojtabai and Olfson 2008). Given that primary care physicians were over 8 times more likely to provide pharmacotherapy only compared to combined treatment supports this notion.

Over half of the sample was prescribed an antidepressant, primarily SRI medications, which have a strong evidence-base in pediatric OCD (McGuire et al. 2015) as well as in anxiety and depressive disorders (Cuijpers et al. 2013). We observed that increasing age was positively associated with SRIs being prescribed, which suggests caution is used when prescribing SRIs due to the black box warnings for potentially increased suicide risk in children and adolescents. This may also reflect parents' attitudes toward medication for younger children (Lewin et al. 2014) and/or reflect compounded impairment during adolescence that may be more severe relative to younger children.

Other than SRI pharmacotherapy, approaches to augmenting CBT therapy in children and adolescents with OCD are limited (Marien et al. 2009; Franklin et al. 2011). Antipsychotics in combination with SRI pharmacotherapy were infrequently prescribed in the sample, while one-fifth were prescribed an antipsychotic overall (i.e., in combination with any medication including SRIs, in combination with psychotherapy, or as monotherapy). Approximately 14% of the sample received antipsychotic medication in combination with medication classes other than SRIs, which may reflect the difficulty of managing complex cases on an outpatient basis and/or limited adherence to practice guidelines (Simpson et al. 2013). Despite a lack of systematic data supporting prescribing atypical antipsychotics for obsessive-compulsive symptoms among children, there are preliminary data to suggest its benefit among youth with SRI-resistant OCD (Masi et al. 2009, 2010) although findings in adults are mixed (Simpson et al. 2013; Veale et al. 2014; Fineberg et al. 2015; Wheaton et al. 2015). In a review of the present data, of the 55 youth who were prescribed antipsychotic medication, only 4 had a tic disorder diagnosis and 4 had an ODD/CD diagnosis for which an antipsychotic medication might be expected (Jimenez-Jimenez and Garcia-Ruiz 2001; Tcheremissine and Lieving 2006). It is possible that some of the youth receiving antipsychotic medications had undocumented disorders for which they were concurrently treated, but we cannot say for sure from the present data.

In our sample, only atypical antipsychotic (i.e., second generation) medications were prescribed. However, even atypical antipsychotic medications can have significant adverse effects (Cohen et al. 2012) including weight gain, increased glucose levels, increased cholesterol, increased triglycerides, hyperprolactinemia, extrapyramidal syndrome, and somnolence/sedation (Cohen et al. 2012). Considering these adverse effects, Simpson et al. (2013) suggested that augmentation with antipsychotics should only be used if OCD patients fail to respond to adequate CBT with SRI pharmacotherapy.

It is also possible that relatively frequent use may reflect multiple comorbidities (i.e., tic disorders, psychoses) in which atypical antipsychotic medication may be indicated (Murphy et al. 2013). For example, patients with comorbid ODD/CD were more likely to receive atypical antipsychotics compared to patients without ODD/CD suggesting that antipsychotic medications are used when the patient's behavior may be of concern. Given the limited number of diagnoses available in the record, some of these comorbid conditions were perhaps omitted. Nonetheless, the high prevalence of antipsychotic medications prescribed warrants further examination given mixed evidence of effectiveness and adverse effects.

Nearly 28% of the sample received a stimulant medication, which is slightly more than the proportion of patients diagnosed with comorbid ADHD for which such pharmacotherapy would be indicated. In addition, logistic regression showed that ADHD was positively associated with being prescribed a stimulant, controlling for other factors and diagnoses. Current guidelines suggest that OCD be treated before addressing ADHD since stimulants may exacerbate the symptoms of OCD (Murphy et al. 2013); however, there are instances were ADHD might be treated as primary, particularly if believed to be the most severe problem and/or interfering significantly with functioning.

There were several study limitations. First, since this study relied on survey data, we were unable to ascertain the type or content of psychotherapy sessions beyond the fact that one occurred nor were we able to examine any longitudinal effects (i.e., received psychotherapy or medication in subsequent appointments). It would be more informative to this study and others if the type of psychotherapy provided was documented in future surveys. Second, due to the small number of cases, we were not able to use survey weighting to generalize to the U.S. population. Although the sample was modest, it was obtained from a nationally representative sample, which approximates practices across the United States compared to single site or even multisite studies. Third, inherent in all large cross-sectional datasets, there are some issues of nonresponse bias. The response rate was acceptable in this survey (62.3%–72.5%) and only represents responses on the part of the provider rather than the patient. Fourth, it was difficult to parse out treatment for OCD versus treatment for other disorders. Furthermore, because we could not determine whether a documented treatment was intended to treat OCD or another comorbid disorder, we excluded comorbid disorders with drastically different first-line treatments (e.g., psychotic disorders). Finally, the NAMCS and NHAMCS were restricted to physician practices, which excludes nonphysician clinicians, who tend to provide the majority of psychotherapy sessions.

Conclusions

Less than half of pediatric patients with OCD received psychotherapy, while over three-fourths received pharmacotherapy. Most patients received an SRI, consistent with evidence-based guidelines, yet a sizable percentage of patients received antipsychotic medications despite mixed efficacy in treating OCD and the potential for serious adverse effects. Stimulants were also frequently prescribed in this population. Chronic problems, comorbid disorders, and age were the most important factors related to type of therapy received and class of medications prescribed. The lack of specificity in the data did not allow us to assess whether treatment was concordant with guidelines set forth by the American Academy of Child and Adolescent Psychiatry (Geller and March 2012). The low number of patients reported as receiving psychotherapy speaks to the need for greater dissemination of evidence-based treatment to physicians and other mental health providers to improve access to integrated mental healthcare across both hospital OPD and office-based settings.

Clinical Significance

Treatment guidelines for pediatric OCD are regularly updated and published by the American Academy of Child and Adolescent Psychiatry, but it is unclear how these guidelines are implemented in clinical practice. This study examines treatment patterns in pediatric OCD, finding little evidence that treatments are applied systematically, with the exception stimulant use in patients with comorbid ADHD. The current guidelines support the use of CBT and/or SRI medications as first-line treatments. The presence of comorbid disorders, especially those causing greater perceived problems, often guide treatment decisions. The published evidence-based guidelines should be used to maximize effectiveness, while minimizing potential adverse effects.

Disclosures

Joseph L. Smith and Nicole M. McBride have nothing to disclose.

Eric A. Storch: research support from the following: NIH: 1R01HD080096-01A1; the (Australian) National Health and Medical Research Council; the International OCD Foundation; and the All Children's Hospital Research Foundation. E.A.S. also receives publication royalties from Wiley, Elsevier, Springer, and the American Psychological Association. E.A.S. is a consultant for Ruijin Hospital, China.