Pharmacological and psychotherapeutic interventions for management of obsessive-compulsive disorder in adults: a systematic review and network meta-analysis.
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.


RESULTS
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).


CONCLUSIONS
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.


BACKGROUND
National Institute for Health Research.
Division of Psychiatry, University College London, London, UK; Department of Psychiatry, University of Ioannina School of Medicine, University of Ioannina, Ioannina, Greece. Electronic address: p.skapinakis@gmail.com.
Petros
P
Skapinakis
School of Social and Community Medicine, University of Bristol, Bristol, UK.
Deborah M
DM
Caldwell
School of Social and Community Medicine, University of Bristol, Bristol, UK.
William
W
Hollingworth
School of Social and Community Medicine, University of Bristol, Bristol, UK.
Peter
P
Bryden
Department of Postgraduate Medicine, University of Hertfordshire, Hatfield, UK; Highly Specialised Obsessive-Compulsive Disorder and Body Dysmorphic Disorder Services, Hertfordshire Partnership University NHS Foundation Trust, Hertfordshire, UK.
Naomi A
NA
Fineberg
Department of Psychology, University of Bath, Bath, UK.
Paul
P
Salkovskis
School of Social and Community Medicine, University of Bristol, Bristol, UK.
Nicky J
NJ
Welton
School of Social and Community Medicine, University of Bristol, Bristol, UK.
Helen
H
Baxter
School of Social and Community Medicine, University of Bristol, Bristol, UK.
David
D
Kessler
Centre for Reviews and Dissemination, University of York, York, UK.
Rachel
R
Churchill
Division of Psychiatry, University College London, London, UK.
Glyn
G
Lewis
D000328:Adult; D006801:Humans; D009771:Obsessive-Compulsive Disorder / Q000188:drug therapy / Q000628:therapy*; D011613:Psychotherapy; D011619:Psychotropic Drugs / Q000627:therapeutic use*; D016032:Randomized Controlled Trials as Topic; D016896:Treatment Outcome
D011619:Psychotropic Drugs