Editorial: Cognitive-Behavioral Therapy Versus Serotonin Reuptake Inhibitors for Pediatric Obsessive-Compulsive Disorder.

How should treatment be initiated for children with obsessive-compulsive disorder (OCD)? This editorial comments on an article by Melin and colleagues,1 published in this issue, from the NordLOTS study, which reports excellent outcomes from cognitive behavior therapy (CBT) for children with OCD. Children continued to improve after CBT was discontinued; at 3 year follow-up, they enjoyed a 90% response rate. Such continuing improvement contrasts markedly with other studies finding, among patients treated with selective serotonin reuptake inhibitors (SSRIs), high relapse rates upon discontinuation. Evidence has accumulated that upon discontinuation of SSRIs, there is often not simply a return to baseline, but a withdrawal state for which opposites of the therapeutic effects can be prominent symptoms-these may include anxiety, dysphoria, irritability, and insomnia. The duration of such symptoms is highly variable, and the possibility of permanent deleterious effects has not been ruled out. Embarking upon lifelong treatment with medication, especially with children, is not a good solution to the withdrawal problem, given findings of antidepressant tachyphylaxis after chronic administration. The long-term dependency and tolerance risks to children started on serotonin reuptake inhibitors are largely unquantified. The NordLOTS study strengthens prior conclusions that cognitive behavior therapy without medication should usually be the initial treatment for children with OCD. Nonetheless, economic influences, which have spurred an exodus of psychiatrists from the psychotherapy workforce, continue to foster treatment with medication alone rather than with cognitive behavior therapy alone.