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

Petros Skapinakis, Deborah Caldwell, William Hollingworth, Peter Bryden, Naomi Fineburg, Paul Salkovskis, Nicky Welton, Helen Baxter, David Kessler, Rachel Churchill, Glyn Lewis

Research output: Contribution to journalArticle

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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.
Original languageEnglish
Pages (from-to)730-739
Number of pages10
JournalThe Lancet Psychiatry
Volume3
Issue number8
Early online date16 Jun 2016
DOIs
Publication statusPublished - 31 Aug 2016

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Obsessive-Compulsive Disorder
Pharmacology
Clomipramine
Cognitive Therapy
Antidepressive Agents
Fluvoxamine
Network Meta-Analysis
Placebo Effect
Therapeutics
Bipolar Disorder
Mental Disorders
Psychotherapy
Uncertainty
Comorbidity
Schizophrenia
Randomized Controlled Trials
Placebos

Cite this

Pharmacological and psychotherapeutic interventions for management of obsessive-compulsive disorder in adults: a systematic review and network meta-analysis. / Skapinakis, Petros; Caldwell, Deborah; Hollingworth, William; Bryden, Peter; Fineburg, Naomi; Salkovskis, Paul; Welton, Nicky; Baxter, Helen; Kessler, David; Churchill, Rachel; Lewis, Glyn.

In: The Lancet Psychiatry, Vol. 3, No. 8, 31.08.2016, p. 730-739.

Research output: Contribution to journalArticle

Skapinakis, P, Caldwell, D, Hollingworth, W, Bryden, P, Fineburg, N, Salkovskis, P, Welton, N, Baxter, H, Kessler, D, Churchill, R & Lewis, G 2016, 'Pharmacological and psychotherapeutic interventions for management of obsessive-compulsive disorder in adults: a systematic review and network meta-analysis', The Lancet Psychiatry, vol. 3, no. 8, pp. 730-739. https://doi.org/10.1016/S2215-0366(16)30069-4
Skapinakis, Petros ; Caldwell, Deborah ; Hollingworth, William ; Bryden, Peter ; Fineburg, Naomi ; Salkovskis, Paul ; Welton, Nicky ; Baxter, Helen ; Kessler, David ; Churchill, Rachel ; Lewis, Glyn. / Pharmacological and psychotherapeutic interventions for management of obsessive-compulsive disorder in adults: a systematic review and network meta-analysis. In: The Lancet Psychiatry. 2016 ; Vol. 3, No. 8. pp. 730-739.
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AU - Skapinakis, Petros

AU - Caldwell, Deborah

AU - Hollingworth, William

AU - Bryden, Peter

AU - Fineburg, Naomi

AU - Salkovskis, Paul

AU - Welton, Nicky

AU - Baxter, Helen

AU - Kessler, David

AU - Churchill, Rachel

AU - Lewis, Glyn

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N2 - BackgroundSeveral 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.

AB - BackgroundSeveral 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.

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