# 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.