Abstract
SummaryBackgroundSeveral 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.MethodsIn 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.FindingsWe 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).InterpretationA 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.FundingNational Institute for Health Research.
Highlights
Obsessive compulsive disorder is considered the fourth most common mental disorder in high-income countries and ranks as the tenth leading cause of disability worldwide.[1,2] It is associated with increased mortality[3] and can have a substantial impact on quality of life for both patients and family members or carers.[2]
Added value of this study We found small differences in efficacy between medications, and the hypothesis of clomipramine being better than SSRIs was not confirmed
Patients were not excluded if they were taking a stable dose of antidepressants for at least 3 months before inclusion (13 [72%] of all 18 psychotherapeutic trials and 12 [80%] of the 15 psychotherapeutic trials included in the network meta-analysis explicitly allowed antidepressants)
Summary
Obsessive compulsive disorder is considered the fourth most common mental disorder in high-income countries and ranks as the tenth leading cause of disability worldwide.[1,2] It is associated with increased mortality[3] and can have a substantial impact on quality of life for both patients and family members or carers.[2]. Previous systematic reviews and meta-analyses have generally compared the efficacy of pharmacological interventions with placebo, not with each other.[8,9,10] Psychotherapeutic interventions have typically been compared with a waiting list or other inactive therapy.[7,11] Only a few studies have directly compared psychotherapeutic with pharmacological interventions or combinations of them, and their results are inconclusive.[7] In the absence of available head-to-head comparisons, indirect evidence can be used to enhance the existing evidence base. Indirect comparisons between different medications have been done in the past, but statistical methods appropriate for such comparisons were poorly developed at that time.[10] Network meta-analysis is a method of synthesising information from a network of trials addressing the same question, but involving www.thelancet.com/psychiatry Vol 3 August 2016
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