National Trends in Pediatric Obsessive compulsive disorder Management: Insights from a Retrospective Cohort Study

Objectives: Obsessive compulsive disorder (OCD) is a chronic psychiatric condition that significantly impairs various domains, including social, academic, and overall functioning. While antidepressants and psychotherapy-specifically cognitive behavioral therapy-are the standard first-line treatments, there is considerable variability in the use of augmenting agents, particularly antipsychotics. This study examines treatment patterns in children and adolescents with OCD. Methods: This population-based retrospective cohort study utilized the TriNetX research network to identify patients aged 6-18 with an OCD diagnosis (F42, N = 37,355). Treatment patterns were analyzed based on sociodemographic factors (age, gender, and race/ethnicity) and clinical settings (inpatient vs. outpatient). Odds ratios (ORs), hazard ratios (HRs), and 95% confidence intervals (CIs) were calculated, with Cox proportional hazards models used to adjust for potential confounders. Results: The average age of OCD diagnosis in youth was 10.9 years, with a balanced gender distribution. Psychiatric comorbidities were common, particularly anxiety disorders (53%), attention-deficit hyperactivity disorder (47%), and mood disorders (37%). Antidepressants were prescribed to 55% of patients, with sertraline and fluoxetine being the most common, while 22% were prescribed antipsychotics, primarily aripiprazole and risperidone. In addition, 31% had billable therapy codes. Racial and ethnic minority groups received less treatment overall, with lower odds of receiving antidepressants (OR 0.51-0.74) and therapy (OR 0.75) among Black youth. In contrast, Black youth were more likely to be prescribed antipsychotics (OR 1.18). Among those prescribed antipsychotics, 47% had prior antidepressant use, 22% had billed psychotherapy, and only one-sixth had both before starting antipsychotics. Inpatient hospitalization, as an indicator of symptom severity, was strongly associated with antipsychotic prescriptions (adjusted HR: 3.03, 95% CI: 2.85, 3.21). Conclusions: There is considerable variability in the pharmacological management of pediatric OCD, with frequent use of antipsychotics even before first-line treatments. The low utilization of psychotherapy suggests gaps in adherence to evidence-based care. These findings highlight the need for improved adherence to OCD treatment guidelines, with a focus on increasing access to psychotherapy.