What is the recommended treatment for a 17-year-old with Obsessive-Compulsive Disorder (OCD)?

Treatment of OCD in a 17-Year-Old

Start with cognitive-behavioral therapy (CBT) incorporating exposure and response prevention (ERP) as the first-line treatment, which can be combined with an SSRI (sertraline or fluoxetine) for moderate-to-severe symptoms. 1, 2

First-Line Treatment Strategy

Cognitive-Behavioral Therapy with ERP

• CBT with ERP is the gold-standard psychological intervention and should be initiated first, demonstrating superior efficacy with a number needed to treat of 3 compared to 5 for SSRIs. 1, 2
• ERP involves gradual exposure to fear-provoking stimuli (obsession triggers) combined with instructions to abstain from compulsive behaviors. 1, 2
• Treatment typically consists of 10-20 sessions delivered individually or in groups, either in-person or via internet-based protocols. 2
• Patient adherence to between-session homework (practicing ERP exercises) is the strongest predictor of treatment success, so emphasize this from the outset. 1, 2

When to Add or Choose Pharmacotherapy

• Add an SSRI from the start if symptoms are moderate-to-severe, as combined treatment yields larger effect sizes than either monotherapy alone. 1
• Choose an SSRI as first-line if the patient prefers medication, has severe OCD preventing engagement with CBT, or if trained CBT clinicians are unavailable. 1, 2

Pharmacotherapy Details

SSRI Selection and Dosing

• Sertraline and fluoxetine have FDA approval specifically for OCD in pediatric patients (ages 6-17 for sertraline) and should be considered first-line SSRIs. 1, 3
• Alternative SSRIs include paroxetine, fluvoxamine, and citalopram, all with similar efficacy but different adverse effect profiles. 1
• Use higher doses than typically prescribed for depression or other anxiety disorders, as OCD requires more aggressive dosing for efficacy. 1, 2
• For sertraline in adolescents, initiate at 50 mg/day and titrate over 4 weeks to a maximum of 200 mg/day as tolerated; mean effective dose in trials was approximately 178-186 mg/day. 3

Treatment Duration

• Maintain treatment for 8-12 weeks at maximum recommended or tolerated dose before determining efficacy, though early response by 2-4 weeks predicts ultimate treatment success. 1
• Continue pharmacotherapy for a minimum of 12-24 months after achieving remission to prevent relapse, with many patients requiring longer-term treatment. 1, 2, 4

Treatment-Resistant Cases

If inadequate response after 8-12 weeks at therapeutic doses:

• Ensure CBT with ERP is added if not already being delivered, as this is more effective than medication augmentation strategies. 5
• Consider switching to a different SSRI if the first one is ineffective. 1, 2
• Augmentation with atypical antipsychotics can be considered, though ERP augmentation is superior to risperidone augmentation based on head-to-head trials. 5
• Intensive CBT protocols with multiple sessions over condensed timeframes (days to weeks) may be effective for severely treatment-resistant cases. 1, 6

Critical Pitfalls to Avoid

• Never use inadequate SSRI doses or insufficient trial duration (less than 8-12 weeks), as this is the most common cause of apparent treatment resistance. 1
• Avoid premature medication discontinuation before 12-24 months of remission, as relapse risk is substantial. 1, 2
• Do not neglect family involvement and psychoeducation, particularly regarding accommodation behaviors where family members participate in rituals or provide excessive reassurance, as this maintains the disorder. 1
• Monitor for SSRI adverse effects in adolescents, particularly gastrointestinal symptoms, sexual dysfunction, behavioral activation, and weight loss (approximately 7% of children experienced >7% body weight loss in trials). 3

Monitoring and Follow-Up

• Assess treatment response using standardized measures such as the Yale-Brown Obsessive Compulsive Scale (YBOCS) to track symptom severity objectively. 1
• Consider monthly booster CBT sessions for 3-6 months after initial treatment to maintain gains. 1
• Periodically reassess the need for continued treatment in patients on long-term pharmacotherapy, though most require extended maintenance. 1