28 - Duration of treatment and long term follow up

Duration of treatment and long-term follow-up

Prescribing in children and adolescents CHAPTER 5 Duration of treatment and long-­term follow-up Untreated OCD runs a chronic course. A series of adult studies have shown that discontinuation of medication tends to result in a varying degree of symptomatic relapse.27 Some authors have suggested that those with comorbidities are at the greatest risk of relapse.28 Given that studies frequently exclude cases with additional comorbidities, it is likely that the relapse rates have been underestimated. In the UK, NICE guidelines recommend that if a young person has responded to medication, treatment for OCD or BDD should continue for at least 6 months after remission. This recommendation was based on clinical consensus rather than the product of carefully conducted research trials. Clinical experience would also suggest that when discontinuation of treatment is attempted it should be done slowly, cautiously and in a transparent manner with the patient and their family. Once again, the careful use of clinical outcome measures should be considered when stopping medication. There is a considerable evidence base and expert clinical consensus suggesting that discontinuing medication is associated with a deterioration in symptoms of either OCD or BDD. Increasingly adults and young people are being counselled to consider whether they wish to remain on SSRI medication longer term to mitigate the substantial risk of relapse of OCD or BDD symptoms. Thoughtful and honest discussion about the potential risks of stopping medication should be an active part of any care plan in OCD. Individuals with developmental disabilities often struggle to generalise the lessons taken from successful CBT. They also have a higher propensity for adverse effects such as activation syndromes with SSRIs, therefore titration may need to be slower.29 It is important that throughout childhood, adolescence and into adult life individuals with OCD or BDD should have rapid access to healthcare professionals, treatment opportunities and other support as needed. NICE recommends that if relapse occurs, people with OCD or BDD should be seen as soon as possible rather than placed on a routine waiting list because of the propensity for rapid deterioration of symptoms. Table 5.8  Alternative and experimental treatment of OCD in children and young people. Treatment Comment Aripiprazole augmentation of SSRI Evidence of clinical improvement in children and young people with OCD23,24,26,30 No evidence base for use in BDD Risperidone augmentation of SSRI Fewer studies than aripiprazole augmentation in children and young people25 Fluvoxamine with low-­dose clomipramine Better tolerated than clomipramine monotherapy31 N-­acetylcysteine (NAC) Limited evidence suggests children and adolescents with OCD refractory to SSRIs or CBT may benefit from NAC augmentation.32 Memantine Limited evidence suggests potential ­benefit.­­33–35 Lamotrigine Case studies have reported response.36 BDD, body dysmorphic disorder; CBT, cognitive behavioural therapy; OCD, obsessive compulsive disorder.