Pharmacological and Psychotherapeutic Interventions for Management of Obsessive-compulsive Disorder in Adults: A Systematic Review and Network Meta-analysis
Abstract
Background:
Several interventions are available for management of obsessive-compulsive disorder in adults, but few studies have compared their relative efficacy in a single analysis. We aimed to simultaneously compare all available treatments using both direct and indirect data.
Methods:
In this systematic review and network meta-analysis, we searched the two controlled trials registers maintained by the Cochrane Collaboration Common Mental Disorders group for trials published up to Feb 16, 2016. We selected randomised controlled trials in which an active psychotherapeutic or pharmacological intervention had been used in adults with obsessive-compulsive disorder. We allowed all comorbidities except for schizophrenia or bipolar disorder. We excluded studies that focused exclusively on treatment-resistant patient populations defined within the same study. We extracted data from published reports. The primary outcome was symptom severity as measured by the Yale-Brown Obsessive Compulsive Scale. We report mean differences with 95% credible intervals compared with placebo. This study is registered with PROSPERO, number CRD42012002441.
Findings:
We identified 1480 articles in our search and included 53 articles (54 trials; 6652 participants) in the network meta-analysis. Behavioural therapy (mean difference -14-48 [95% credible interval -18-61 to -10-23]; 11 trials and 287 patients), cognitive therapy (-13-36 [-18-40 to -8-21]; six trials and 172 patients), behavioural therapy and clomipramine (-12-97 [-19-18 to -6-74]; one trial and 31 patients), cognitive behavioural therapy and fluvoxamine (-7-50 [-13-89 to -1-17]; one trial and six patients), cognitive behavioural therapy (-5-37 [-9-10 to -1-63]; nine trials and 231 patients), clomipramine (-4-72 [-6-85 to -2-60]; 13 trials and 831 patients), and all SSRIs (class effect -3-49 [95% credible interval -5-12 to -1-81]; 37 trials and 3158 patients) had greater effects than did drug placebo. Clomipramine was not better than were SSRIs (-1-23 [-3-41 to 0-94]). Psychotherapeutic interventions had a greater effect than did medications, but a serious limitation was that most psychotherapeutic trials included patients who were taking stable doses of antidepressants (12 [80%] of the 15 psychotherapy trials explicitly allowed antidepressants).
Interpretation:
A range of interventions is effective in the management of obsessive-compulsive disorder, but considerable uncertainty and limitations exist regarding their relative efficacy. Taking all the evidence into account, the combination of psychotherapeutic and psychopharmacological interventions is likely to be more effective than are psychotherapeutic interventions alone, at least in severe obsessive-compulsive disorder.
Funding:
National Institute for Health Research.
(Appeared originally in Lancet Psychiatry 2016; 3:730–739)
Reprinted under Creative Commons CC-BY license
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Published in print: Fall 2021
Published online: 5 November 2021
Authors
Competing Interests
PSk has received non-financial support from Lundbeck to attend a conference during the conduct of this study. GL is a board member of the National Institute for Health Research Efficacy and Mechanism Evaluation programme. NAF reports grants and non-financial support from the National Institute for Health Research during the conduct of this study; grants and personal fees from GlaxoSmithKline and AstraZeneca; non-financial support from Novartis; personal fees and non-financial support from the European College of Neuropsychopharmacology and Bristol-Myers Squibb; grants from the Medical Research Council and Wellcome Foundation; non-financial support from Janssen, the International College of Obsessive Compulsive Spectrum Disorders, the Journal of Behavioural Addiction, and WHO; grants, personal fees, non-financial support, and reimbursed registration to attend scientific meetings from Lundbeck; informal consultation without receiving payment for Transcept Pharmaceuticals; grants, personal fees, non-financial support, and reimbursed registration to attend scientific meetings from Servier; grants, non-financial support, and reimbursed registration to attend scientific meetings from Cephalon; personal fees, non-financial support, and reimbursed registration to attend scientific meetings from Jazz Pharmaceuticals; non-financial support and reimbursed registration to attend scientific meetings from the Royal College of Psychiatrists; and non-financial support and reimbursed registration to attend scientific meeting from the British Association for Psychopharmacology, all outside the submitted work. She is also medical lead to a National Health Service service that provides treatment for treatment-refractory obsessive-compulsive and related disorders, has been a council member for the British Association for Psychopharmacology, and sits on the Royal College of Psychiatrists Psychopharmacology Special Committee and the European College of Neuropsychopharmacology Education Committee and Research Network. DMC reports grants from the Medical Research Council Population Health Scientist fellowship during the conduct of this study. All other authors declare no competing interests.
Funding Information
PSk led the review, was responsible for managing the project, and drafted the report. DMC provided statistical support and did the network meta-analyses with PB. WH was a member of the review team, provided statistical support, and helped in the analysis. NAF was a member of the review team providing expert clinical advice (psychopharmacology) and helped in the writing of the report. PSa was a member of the review team providing expert clinical advice (psychotherapy). NJW provided statistical advice and helped with the statistical modelling. HB contributed to data extraction and the systematic review. DK was a member of the review team providing expert clinical advice. RC provided advice for the data searches, the systematic review, and methods. GL provided advice on the methods and systematic review and helped in writing of sections of the report. DMC, PB, NJW, and GL helped in interpretation of the results. WH, NAF, PSa, DK, RC, and GL made critical comments that helped in interpretation of the results.
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