Academic journal article Journal of Cognitive Psychotherapy

Dissemination of Evidence-Based Treatment for Pediatric Obsessive-Compulsive Disorder in the Southern Region of Brazil: Challenges and Future Directions

Academic journal article Journal of Cognitive Psychotherapy

Dissemination of Evidence-Based Treatment for Pediatric Obsessive-Compulsive Disorder in the Southern Region of Brazil: Challenges and Future Directions

Article excerpt

Pediatric obsessive-compulsive disorder (OCD) is a prevalent condition that responds well to specialized treatment including cognitive behavioral therapy (CBT) or serotonin reuptake inhibitors or their combination. In Brazil, the dissemination of evidence-based treatment for pediatric OCD is hindered because of the peculiarities of the health system. The presence of a multitiered health system (public, insured, and private) with insufficient investment in public mental health and relative inaccessibility of insured/private care for most of the Brazilian population make the implementation of specialized OCD treatment centers largely unavailable in Brazil. Furthermore, lack of appropriate training in child mental health, CBT, and evidencebased approaches to OCD in current psychiatry and psychology training programs further impede improvement in diagnosis and treatment. The challenges faced in the current system in Brazil will be discussed and also strategies and programs that are currently being implemented in the south of Brazil to help address the gaps in treatment for pediatric patients with OCD.

Keywords: pediatric OCD; evidence-based treatment dissemination; CBT; Southern Brazil

Obsessive-compulsive disorder (OCD) is a common neuropsychiatric illness with frequent onset in childhood. Obsessive-compulsive symptoms commonly begin in adolescence with 10%-25% of adult patients with OCD reporting onset of symptoms between the ages of 10 and 14 years and up to 50% reporting onset by the age of 18 years (Flament et al., 1988; Fullana et al., 2009; Ruscio, Stein, Chiu, & Kessler, 2010; Valleni-Basile et al., 1994; Zohar et al., 1992). However, many OCD-affected children and adolescents wait years before an appropriate diagnosis is made. The average time to diagnosis is estimated to be 10 years (Pauls, 2008). Epidemiological data from different international, nonclinical, youth populations reveals lifetime prevalence rates of OCD ranging between 1% and 3% (Apter et al., 1996; Flament et al., 1988; Heyman et al., 2003; Maina, Albert, Bogetto, & Ravizza, 1999; Valleni-Basile et al., 1994; Zohar et al., 1992), and although no similar epidemiological studies have been performed in children and adolescents recruited from the community in Brazil, similar rates are expected based on the worldwide prevalence.

The treatments of choice for pediatric OCD include cognitive behavioral therapy (CBT) and serotonin reuptake inhibitors (SRI; American Academy of Child and Adolescent Psychiatry [AACAP], 2012). The use of CBT alone or an SRI alone are significantly superior to placebo in reducing pediatric OCD severity, but a combination of CBT and SRI was demonstrated to be superior to either CBT or SRI alone (O'Kearney, Anstey, & von Sanden, 2006; Study, 2004). More recent studies have indicated a better response to CBT alone than to SRI alone (O'Kearney, 2007; Watson & Rees, 2008). Evidence has shown that the CBT-SRI treatment combination results in 53.6% clinical remission in youth suffering from pediatric OCD (POTS Team, 2004).

Although OCD is prevalent in adolescence and commonly persists across the lifespan (throughout adulthood), it frequently goes undiagnosed and untreated, despite being highly treatable. Epidemiological data from a U.S. national survey has shown that approximately two-thirds of adults with moderate to severe OCD had not received specific treatment for OCD (Ruscio et al., 2010). Similarly, the vast majority of adolescents identified by international community surveys as having OCD reported being previously undiagnosed and untreated (Apter et al., 1996; Flament et al., 1988; Heyman et al., 2003; Maina et al., 1999; Valleni-Basile et al., 1994; Zohar et al., 1992). Furthermore, a time lag from the onset of symptoms to receiving specific treatment for OCD has been demonstrated in adolescents as well. For example, in an epidemiological study of obsessive-compulsive symptoms in nonreferred adolescents in the United States, only 3 of the 18 cases identified with OCD were receiving current psychotherapy despite an average of 3 years since onset of OCD symptoms (Flament et al. …

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