The place of and evidence for serotonin reuptake inhibitors (SRIs) for obsessive compulsive disorder (OCD) in children and adolescents: Views based on a systematic review and meta-analysis

• We reviewed and meta-analysed the literature on serotonin re-uptake inhibiting drugs for paediatric obsessive compulsive disorder (OCD), using both comparison with placebo and cognitive behavior therapy the latter in both treatment naive-, in SRI non-responding, and in CBT non-responding patients.
• SRI drugs were compared with placebo and found to have a moderate effect size but to have a lower effect size than CBT, which appears to be robust across comparison contingencies.
• SRI drugs used in combination with CBT do not add efficacy as compared with CBT only.
• The current guidelines stating that children and adolescents with OCD should first be treated with CBT and CBT non-responders treated with SSRI are in line with our findings.
• The evidence base for SRI efficacy in CBT non- or partial responders needs to be developed further.

Serotonin reuptake inhibiting drugs (SRI) have been used in the treatment of paediatric obsessive-compulsive disorder over the past 30 years. We performed a systematic review and meta-analysis of the literature to discuss the place of and evidence for the use of SRI in paediatric OCD, based on 14 publications of methodologically sound, randomized and controlled studies. Both SRI and specific SRIs were examined and comparisons of SRI, placebo, cognitive behaviour therapy (CBT), combined (COMBO) treatments (SRI+CBT) made to investigate their relative efficacy. Using the Cochrane methodology, and as measures of effect size mean difference and Hedge’s g, SRIs proved to be superior to drug placebo, with a modest effect size. From direct comparisons of CBT and SRI treatments, we conclude that CBT has the superior efficacy. COMBO versus CBT shows that SRI treatment adds little to concomitant CBT, while COMBO shows favourable outcome versus SRI alone. In pre-trial partial treatment responders, those who failed a SRI had better outcome from adding CBT as compared to continuing a SRI. Those who failed CBT treatment did as well with continued CBT as with switching to a SRI. The studies of combinations and sequences of treatments need to be developed further.