title: Behavioral therapy and serotonin reuptake inhibitor pharmacotherapy in the treatment of obsessive-compulsive disorder: a systematic review and meta-analysis of head-to-head randomized controlled trials.
abstract: BACKGROUND
  Effective treatments for obsessive-compulsive disorder (OCD) include behavioral therapy (exposure and response/ritual prevention and cognitive behavioral therapy) and serotonin-reuptake inhibitors (SRIs); however, the relative efficacy of these treatments is not well established. We sought to review evidence from head-to-head randomized-controlled trials (RCTs) of behavioral therapy and SRIs in the treatment of OCD.
  
  
  METHODS
  A systematic search of multiple databases was conducted from first available date to June 30, 2012, for RCTs in the treatment of OCD among outpatients, comparing behavioral therapy and SRIs, alone or combined. Two independent reviewers evaluated studies for eligibility and risk of bias. The main outcome measure was posttreatment mean Yale-Brown Obsessive-Compulsive Scale (YBOCS) score.
  
  
  RESULTS
  We identified 2,186 unique articles. Fifteen articles were included, describing 13 RCTs. Pooled standardized mean difference (SMD; 95% confidence intervals) in YBOCS score significantly favored behavioral therapy over SRIs (0.37; 0.10, 0.64; P = .007), but not in a subset of trials that used selective SRIs (0.22; -0.02, 0.47; P = .070). Within individual trials, effect sizes significantly favored the combination of behavioral therapy plus an SRI over an SRI, but not behavioral therapy, alone.
  
  
  CONCLUSIONS
  This review provides evidence that, among outpatients with OCD, behavioral therapy is more effective than SRIs, overall, but not selective SRIs. Furthermore, the combination of behavioral therapy plus an SRI is more effective than an SRI alone. These data may be used to inform the development of evidence-based treatment guidelines; however, more studies are also needed to further evaluate the relative efficacy of these interventions.
authors.affiliation: Clinical Outcomes Research, Clinical Integration Department, Sutter Health, San Francisco, California.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Romanelli
authors.forename: Frances M
authors.initials: FM
authors.lastname: Wu
authors.forename: Ryan
authors.initials: R
authors.lastname: Gamba
authors.forename: Ramin
authors.initials: R
authors.lastname: Mojtabai
authors.forename: Jodi B
authors.initials: JB
authors.lastname: Segal
mesh_terms: D001521:Behavior Therapy / Q000379:methods*; D006801:Humans; D009771:Obsessive-Compulsive Disorder / Q000188:drug therapy / Q000628:therapy*; D016032:Randomized Controlled Trials as Topic / Q000706:statistics & numerical data*; D017367:Selective Serotonin Reuptake Inhibitors / Q000627:therapeutic use*
chemical_list: D017367:Selective Serotonin Reuptake Inhibitors
keywords: behavioral therapy; cognitive behavioral therapy; exposure and response/ritual prevention; meta-analysis; obsessive-compulsive disorder; pharmacotherapy; serotonin-reuptake inhibitors; systematic review