Cognitive Behavior Therapy Augmentation of Pharmacotherapy in Pediatric Obsessive-Compulsive Disorder: The Pediatric OCD Treatment Study II (POTS II) Randomized Controlled Trial | Cardiology | JAMA | JAMA Network
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Ruscio AM, Stein DJ, Chiu WT, Kessler RC. The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication.  Mol Psychiatry. 2010;15(1):53-6318725912PubMedGoogle ScholarCrossref
Piacentini J, Bergman RL. Obsessive-compulsive disorder in children.  Psychiatr Clin North Am. 2000;23(3):519-53310986725PubMedGoogle ScholarCrossref
Piacentini J, Bergman RL, Keller M, McCracken J. Functional impairment in children and adolescents with obsessive-compulsive disorder.  J Child Adolesc Psychopharmacol. 2003;13:(suppl 1)  S61-S6912880501PubMedGoogle ScholarCrossref
Swedo SE, Rapoport JL, Leonard HL, Lenane M, Cheslow D. Obsessive-compulsive disorder in children and adolescents: clinical phenomenology of 70 consecutive cases.  Arch Gen Psychiatry. 1989;46(4):335-3412930330PubMedGoogle ScholarCrossref
Watson HJ, Rees CS. Meta-analysis of randomized, controlled treatment trials for pediatric obsessive-compulsive disorder.  J Child Psychol Psychiatry. 2008;49(5):489-49818400058PubMedGoogle ScholarCrossref
Abramowitz JS, Whiteside SP, Deacon BJ. The effectiveness of treatment for pediatric obsessive-compulsive disorder: a meta-analysis.  Behav Ther. 2005;36(1):55-63Google ScholarCrossref
Pediatric OCD Treatment Study (POTS) Team.  Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: the Pediatric OCD Treatment Study (POTS) randomized controlled trial.  JAMA. 2004;292(16):1969-197615507582PubMedGoogle ScholarCrossref
March JS, Biederman J, Wolkow R,  et al.  Sertraline in children and adolescents with obsessive-compulsive disorder: a multicenter randomized controlled trial.  JAMA. 1998;280(20):1752-17569842950PubMedGoogle ScholarCrossref
Riddle MA, Reeve EA, Yaryura-Tobias JA,  et al.  Fluvoxamine for children and adolescents with obsessive-compulsive disorder: a randomized, controlled, multicenter trial.  J Am Acad Child Adolesc Psychiatry. 2001;40(2):222-22911211371PubMedGoogle ScholarCrossref
Simpson HB, Foa EB, Liebowitz MR,  et al.  A randomized, controlled trial of cognitive-behavioral therapy for augmenting pharmacotherapy in obsessive-compulsive disorder.  Am J Psychiatry. 2008;165(5):621-63018316422PubMedGoogle ScholarCrossref
Freeman JB, Choate-Summers ML, Garcia AM,  et al.  The Pediatric Obsessive-Compulsive Disorder Treatment Study II: rationale, design and methods.  Child Adolesc Psychiatry Ment Health. 2009;3:1-1519152690PubMedGoogle ScholarCrossref
Goodman WK, Price LH, Rasmussen SA,  et al.  The Yale-Brown Obsessive Compulsive Scale, I: development, use, and reliability.  Arch Gen Psychiatry. 1989;46(11):1006-10112684084PubMedGoogle ScholarCrossref
Scahill L, Riddle MA, McSwiggin-Hardin M,  et al.  Children's Yale-Brown Obsessive Compulsive Scale: reliability and validity.  J Am Acad Child Adolesc Psychiatry. 1997;36(6):844-8529183141PubMedGoogle ScholarCrossref
Silverman W, Albano A. The Anxiety Disorders Interview Schedule for DSM-IV, Child and Parent Versions. San Antonio, TX: Psychological Corp; 1996
March J, Mulle K. OCD in Children and Adolescents: A Cognitive-Behavioral Treatment Manual.  New York, NY: Guilford Press; 1998
Silverman WK, Saavedra LM, Pina AA. Test-retest reliability of anxiety symptoms and diagnoses with the Anxiety Disorders Interview Schedule for DSM-IV: child and parent versions.  J Am Acad Child Adolesc Psychiatry. 2001;40(8):937-94411501694PubMedGoogle ScholarCrossref
Tolin DF, Abramowitz JS, Diefenbach GJ. Defining response in clinical trials for obsessive-compulsive disorder: a signal detection analysis of the Yale-Brown obsessive compulsive scale.  J Clin Psychiatry. 2005;66(12):1549-155716401156PubMedGoogle ScholarCrossref
Conners C, March J. The Conners/March Developmental Questionnaire. Toronto, ON: MultiHealth Systems Inc; 1996
Guy W, ed, Bonato R, edCGI: Clinical Global Impressions. Chevy Chase, MD: National Institute of Mental Health; 1970
March J, Karayal O, Chrisman A. CAPTN: The Pediatric Adverse Event Rating Scale. Presented at: the Scientific Proceedings of the 2007 Annual Meeting of the American Academy of Child and Adolescent Psychiatry; October 23-28, 2007; Boston, MA. No. 241
 The R project for statistical computing. Institute for Statistics and Mathematics Resources Web site. R: A language and environment for statistical computing. Accessed
Rubin DB. Multiple Imputation for Nonresponse in Surveys. New York, NY: Wiley & Sons; 1987:258
Raghunathan TE, Lepkowski JM, Van Hoewyk J, Slenberger P. A multivariate technique for multiply imputing missing values using a sequence of regression models.  Surv Methodol. 2001;27:85-95Google Scholar
Miller RG. Simultaneous Statistical Inference. New York, NY: McGraw-Hill; 1966
Barnard J, Rubin DB. Small-sample degrees of freedom with multiple imputation.  Biometrika. 1999;86(4):948-955Google ScholarCrossref
Allison PD. SAS Macros. Updated June 14, 2011. Accessed June 14, 2011
Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed. Hillsdale, NJ: Erlbaum Associates; 1988
Williams M, Powers M, Yun YG, Foa EB. Minority participation in randomized controlled trials for obsessive-compulsive disorder.  J Anxiety Disord. 2010;24(2):171-17720143498PubMedGoogle ScholarCrossref
Franklin ME, Abramowitz JS, Kozak MJ, Levitt JT, Foa EB. Effectiveness of exposure and ritual prevention for obsessive-compulsive disorder: randomized compared with nonrandomized samples.  J Consult Clin Psychol. 2000;68(4):594-60210965635PubMedGoogle ScholarCrossref
Tenneij NH, van Megen HJ, Denys DA, Westenberg HG. Behavior therapy augments response of patients with obsessive-compulsive disorder responding to drug treatment.  J Clin Psychiatry. 2005;66(9):1169-117516187776PubMedGoogle ScholarCrossref
Rothbaum BO, Shahar F. Behavioral treatment of obsessive-compulsive disorder in a naturalistic setting.  Cognit Behav Pract. 2000;7:262-270Google ScholarCrossref
Warren R, Thomas JC. Cognitive-behavior therapy of obsessive-compulsive disorder in private practice: an effectiveness study.  J Anxiety Disord. 2001;15(4):277-28511474814PubMedGoogle ScholarCrossref
Nakatani E, Mataix-Cols D, Micali N, Turner C, Heyman I. Outcomes of cognitive behaviour therapy for obsessive compulsive disorder in a clinical setting: a 10-year experience from a specialist OCD service for children and adolescents.  Child Adolesc Ment Health. 2009;14(3):133-139Google ScholarCrossref
Valderhaug R, Larsson B, Götestam KG, Piacentini J. An open clinical trial of cognitive-behaviour therapy in children and adolescents with obsessive-compulsive disorder administered in regular outpatient clinics.  Behav Res Ther. 2007;45(3):577-58916836977PubMedGoogle ScholarCrossref
Original Contribution
September 21, 2011

Cognitive Behavior Therapy Augmentation of Pharmacotherapy in Pediatric Obsessive-Compulsive Disorder: The Pediatric OCD Treatment Study II (POTS II) Randomized Controlled Trial

JAMA. 2011;306(11):1224-1232. doi:10.1001/jama.2011.1344

Context The extant literature on the treatment of pediatric obsessive-compulsive disorder (OCD) indicates that partial response to serotonin reuptake inhibitors (SRIs) is the norm and that augmentation with short-term OCD-specific cognitive behavior therapy (CBT) may provide additional benefit.

Objective To examine the effects of augmenting SRIs with CBT or a brief form of CBT, instructions in CBT delivered in the context of medication management.

Design, Setting, and Participants A 12-week randomized controlled trial conducted at 3 academic medical centers between 2004 and 2009, involving 124 pediatric outpatients between the ages of 7 and 17 years with OCD as a primary diagnosis and a Children's Yale-Brown Obsessive Compulsive Scale score of 16 or higher despite an adequate SRI trial.

Interventions Participants were randomly assigned to 1 of 3 treatment strategies that included 7 sessions over 12 weeks: 42 in the medication management only, 42 in the medication management plus instructions in CBT, and 42 in the medication management plus CBT; the last included 14 concurrent CBT sessions.

Main Outcome Measures Whether patients responded positively to treatment by improving their baseline obsessive-compulsive scale score by 30% or more and demonstrating a change in their continuous scores over 12 weeks.

Results The medication management plus CBT strategy was superior to the other 2 strategies on all outcome measures. In the primary intention-to-treat analysis, 68.6% (95% CI, 53.9%-83.3%) in the plus CBT group were considered responders, which was significantly better than the 34.0% (95% CI, 18.0%-50.0%) in the plus instructions in CBT group, and 30.0% (95% CI, 14.9%-45.1%) in the medication management only group. The results were similar in pairwise comparisons with the plus CBT strategy being superior to the other 2 strategies (P < .01 for both). The plus instructions in CBT strategy was not statistically superior to medication management only (P = .72). The number needed-to-treat analysis with the plus CBT vs medication management only in order to see 1 additional patient at week 12, on average, was estimated as 3; for the plus CBT vs the plus instructions in CBT strategy, the number needed to treat was also estimated as 3; for the plus instructions in CBT vs medication management only the number needed to treat was estimated as 25.

Conclusions Among patients aged 7 to 17 years with OCD and partial response to SRI use, the addition of CBT to medication management compared with medication management alone resulted in a significantly greater response rate, whereas augmentation of medication management with the addition of instructions in CBT did not.

Trial Registration Identifier: NCT00074815