26 - Initiation of treatment with medication

Initiation of treatment with medication

Prescribing in children and adolescents CHAPTER 5 Initiation of treatment with medication Clomipramine and SSRIs show a similar incremental effect on obsessions and compulsions from as early as ­1–­2 weeks after initiation and placebo-­referenced improvements continue for at least 24 weeks. In some cases, a positive impact on mood may be seen before the initial changes in OCD symptoms.16 In the UK, NICE therefore recommends two treatment trials of SSRIs for OCD and BDD of 3 months and increasing towards the maximum tolerated effective dosage. Carefully explaining these temporal effects to patients can be important in sustaining compliance. In addition, the earliest signs of improvement may be apparent to an informant before the patient. Use of an observer-­ rated quantitative measure such as the CY-­BOCS or BDD-­YBOCS may therefore be helpful to monitor progress in clinical settings.17 Expert consensus typically suggests starting at the lowest dose known to be effective, titrating upwards and waiting for up to 12 weeks before evaluating effectiveness.18 Careful dose titration is particularly recommended if there is insufficient clinical response. In clinical practice a balance must clearly be struck between tolerability and the rate of dosage increase. It is worth noting that the majority of young people with OCD will require a higher dose of SSRI, and as such it may well be clinically indicated to increase the dose more quickly after starting an SSRI. Mild functional impairment Moderate or severe functional impairment Consider guided self-help support and information for family/carers Ineffective or refused Ineffective or refused Consider an SSRI (with careful monitoring) Multidisciplinary review Consider either (especially if previous good response to): Different SSRI Clomipramine SSRI + ongoing CBT (including ERP): Consider use in 8–11-year age group Offer to 12–18-year age group Carefully monitor for adverse events, especially at start of treatment Offer CBT (+ERP); involve family/carers (individual or group formats) Figure 5.1  Treatment options for children and young people with obsessive compulsive disorder. CBT, cognitive behaviour therapy; ERP, exposure and response prevention. Adapted from NICE guidance.13 Reprinted with permission.15