A new European Child & Adolescent Psychiatry follow-up by Skarphedinsson, Weidle, Torp, and colleagues examined 50 children and adolescents ages 7–17 who had not responded sufficiently to an initial 14-week course of exposure-based CBT. The participants were treated at clinics in Denmark, Norway, and Sweden and were randomized to either another 16 weeks of CBT or treatment with sertraline.
OCD symptoms continued to decline across the three-year follow-up, with no statistically significant differences between the continued-CBT and sertraline groups. Among participants assessed at three years, 77% met the study’s remission criterion and another 15% had only mild OCD symptoms. The finding offers an encouraging message for families: an incomplete response to the first course of treatment does not mean that the young person is unlikely to improve.
The results should not, however, be interpreted as proving that continued CBT and sertraline are equivalent. The sample was small, approximately 46% were not assessed at the three-year point, and the reported remission percentages were based on participants who completed that assessment. In addition, nine participants initially assigned to continued CBT later received sertraline, and some received CBT booster sessions. These factors make the long-term results more reflective of flexible stepped care than of a pure head-to-head treatment comparison.
Clinical Takeaway: Treat an incomplete response to an initial course of ERP as a point for reassessment rather than a declaration that CBT has failed. Review whether exposures adequately activated the relevant obsessional fear, whether response prevention included covert rituals and reassurance seeking, whether family accommodation or avoidance remained active, and whether between-session practice was sufficient. Depending on the formulation, reasonable next steps may include extending or intensifying ERP, addressing engagement barriers, adding booster sessions, or discussing an SSRI with the young person, caregivers, and prescriber. When medication is used, activation symptoms such as restlessness or impulsivity require monitoring. Most importantly, families can be given a realistic but hopeful message: improvement may continue over a substantially longer period than the first treatment course.