D-cycloserine Augmentation of Cognitive Behavioral Therapy (CBT) for Pediatric Obsessive-compulsive Disorder (OCD)
Condition: Obsessive-compulsive Disorder
MeSH terms: Compulsive Personality Disorder; Obsessive-Compulsive Disorder
Study type: Interventional
Phase: Phase 3

Summary: 
      The investigators are conducting a randomized double-blind placebo-controlled study to assess
      the efficacy of d-cycloserine augmentation of cognitive-behavioral therapy for the treatment
      of pediatric obsessive compulsive disorder. This study represents an innovative approach in
      translating bench research findings into clinical research and testing a new approach for
      optimizing an effective psychotherapy with a safe non-psychotropic medication.
    

Detailed description: 
      Obsessive-compulsive disorder (OCD) affects 1-2% of children, runs a chronic course without
      treatment, and is associated with considerable functional impairment and poor quality of
      life. Although most patients with OCD respond to cognitive-behavioral therapy (CBT) or
      pharmacotherapy with a serotonin reuptake inhibitor (SRI), a substantial number of youth
      remain symptomatic after receiving these therapies. Pharmacological interventions with SRIs
      are only moderately efficacious, rarely produce remission, may be accompanied by side
      effects, and may not be an acceptable intervention to some parents. Medication augmentation
      strategies such as atypical antipsychotics are often used in children with partial response
      but have concerning metabolic effects and no systematic supporting efficacy or safety data.
      Although CBT is the gold standard treatment for pediatric OCD, not all patients benefit and
      the availability of skilled therapists is quite limited. Thus, there is a critical need for
      interventions to optimize treatment outcome in pediatric OCD. The primary mechanism in CBT is
      repeated and prolonged exposure to feared situations while abstaining from OCD rituals. This
      treatment is based on animal models of extinction of conditioned fears. Basic research on the
      neural circuitry underlying fear extinction led to the examination of d-cycloserine (DCS), a
      partial agonist at the NMDA receptor in the amygdala, as an agent capable of enhancing
      extinction learning. Following successful validation of this strategy in animals, six trials
      in adult humans - and one study in youth with OCD - provide support for DCS dosing as
      facilitating extinction learning that occurs during exposure-based psychotherapy. However,
      experts and agencies responsible for regulating drug indications in the US, including the
      FDA, recognize that safety and efficacy findings in adults should not be routinely
      extrapolated to children. The present study furthers pilot work on DCS to augment the effects
      of CBT in children with OCD. The investigators are conducting a double-blind randomized
      controlled trial, conducted at two sites, to examine the relative benefit of 10 psychotherapy
      sessions of which sessions 4-10 will be augmented with weight-adjusted doses of DCS (25/50mg)
      compared to CBT augmented with placebo. 150 youth (ages 7-17) with OCD will be randomly and
      evenly assigned to one of the two treatment conditions. The primary outcome will be change in
      OCD symptom severity assessed by independent evaluators. The study recruitment sites are the
      University of South Florida (USF) and Massachusetts General Hospital/Harvard Medical School
      (MGH). This study extends the first report of DCS augmentation in youth with anxiety
      disorder/OCD by conclusively investigating an innovative research approach that manipulates
      glutamatergic pathways to mediate improved outcomes of exposure-based psychotherapy based
      upon a translational model of the neurobiology of OCD.
    

Intervention name(s): Cognitive-behavioral therapy; d-cycloserine; Pill placebo
Intervention type(s): Behavioral; Drug; Drug
Intervention description(s): All patients will receive 10 sessions of therapy over 8 weeks using the evidence-based CBT protocol in POTS (2004). Sessions 1-4 will be held twice weekly; sessions 5-10 will be held on a weekly basis. Sessions 1-3 do not include exposures and are devoted to psychoeducation, cognitive therapy, and hierarchy development. Sessions 4-10 involve E/RP exercises specific to each youth.; D-cycloserine will be encapsulated into 25mg with identical placebo capsules. Youth will take (1 or 2) DCS or identical placebo capsule 1 hour before sessions 4-10. A 0.7mg/kg dosage corresponds with dosages found to be effective in adult studies (50mg/estimated average adult weight of 70kg=.71mg/kg). Accordingly, doses for this study will be about 0.7mg/kg. Two dosing levels will be used based upon weight ranges to ensure comparable mg/kg levels: children weighing 25-45kg will be given a dosage of 25mg (~0.56-1.0 mg/kg/day), and children ≥46kg will be given 50mg provided in two 25mg capsules (~0.50-1.08mg/kg/day). Doses will be given 1 hour before therapy sessions 4-10.; The pill placebo will be identical to the active study medication in every respect (e.g., size, shape, number of capsules, etc.).
Other intervention name(s): exposure and response prevention; psychotherapy; counseling
Intervention MeSH terms: Cycloserine
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Primary purpose: Treatment
Keywords: Obsessive-compulsive disorder; OCD