Obsessive-compulsive disorder often begins in childhood or adolescence, and parents and young people commonly want to know which treatment has the best support. A systematic review and meta-analysis by Uhre and colleagues pooled the results of randomised trials of cognitive-behavioural therapy (CBT) for children and adolescents with OCD.
The review included 9 trials (645 participants) that compared CBT with no intervention. CBT decreased OCD severity and improved level of functioning, and it was associated with a lower risk of still having OCD afterwards. The proportion of participants with adverse events was similar in both groups. A further 3 trials (146 participants) compared CBT with selective serotonin reuptake inhibitors (SSRIs), a class of medication. In those trials CBT led to similar decreases in OCD severity.
The authors are careful about how far the findings can be pushed. The certainty of the evidence was low or very low, and there was not enough data to assess serious adverse events or quality of life. Their conclusion is that CBT may be more effective than no intervention and comparable to SSRIs, but that the effect estimates are very uncertain. That is a careful conclusion.
For families, this means CBT is a reasonable option to discuss with a clinician, with the understanding that the research base is still developing. If OCD is affecting your child or you, speaking with a GP or a psychologist is a good first step.
What the study did
Uhre and colleagues carried out a systematic review and meta-analysis, which means they searched for all the randomised clinical trials of cognitive-behavioural therapy (CBT) for obsessive-compulsive disorder (OCD) in children and adolescents, and then combined the results statistically. They set out to assess both the benefits and the harms of CBT, compared with no intervention or with other interventions.
The primary outcomes were OCD severity, serious adverse events and level of functioning. Quality of life and adverse events were secondary outcomes, and remission from OCD was included as an exploratory outcome. The authors assessed the risk of bias in each trial and rated the certainty of the evidence using a system called GRADE, which grades how much confidence we can place in an estimate.
What it found
Nine trials (645 participants) compared CBT with no intervention. Compared with no intervention, CBT decreased OCD severity, with a mean difference of -8.51 (95% CI -10.84 to -6.18). It also improved level of functioning, as rated by the patients and as rated by their parents. CBT was associated with a reduced risk of still having OCD, with a risk ratio of 0.50. The proportion of participants with adverse events was similar between the groups (risk ratio 1.06).
Three trials (146 participants) compared CBT with selective serotonin reuptake inhibitors (SSRIs). Compared with SSRIs, CBT led to similar decreases in OCD severity (mean difference -0.75), and it was associated with a similar risk of still having OCD (risk ratio 0.85). Neither of those differences was statistically distinguishable from no difference.
How certain are these results?
This is the part of the paper that deserves the most attention. The certainty of the evidence was rated low for the effect on OCD severity and the adverse events comparison, and very low for functioning, for the risk of still having OCD, and for both comparisons with SSRIs. In plain terms, the authors judge that further research could well change these estimates.
There were also gaps. The authors had insufficient data to assess the effect of CBT versus no intervention on serious adverse events and quality of life. For the comparison with SSRIs, there was insufficient data on serious adverse events, level of functioning, quality of life and adverse events. A finding that CBT and medication look similar on OCD severity is therefore limited to the outcomes that could be compared, and it rests on only 3 trials.
Why it matters
The authors conclude that CBT may be more effective than no intervention and comparable to SSRIs for paediatric OCD, but that they are very uncertain about the effect estimates. That is a measured conclusion, and it is the right one to hold. The results support CBT as a treatment worth considering for young people with OCD, and they show that no clear signal of extra harm was seen in the adverse events that were reported. They do not settle questions about long-term outcomes, serious adverse events or quality of life, because the data to answer those questions was not available.
For parents, this is a reminder that treatment decisions are best made with a clinician who can look at the individual child, the severity of symptoms and the family's circumstances. For researchers, it is a clear call for larger, better-designed trials.
If you are worried about OCD in your child or in yourself, a conversation with your GP or a psychologist can help you work out the next step. Support is available, and you do not have to manage this alone.