Pharmacological and psychotherapeutic interventions for the management of Obsessive-Compulsive Disorder in adults: Systematic review and Network meta-analysis

Background Several interventions are available for the management of obsessive-compulsive disorder (OCD) in adults. Few studies, however, have compared the relative effectiveness of these interventions in a single analysis. We conducted a systematic review and network meta-analysis with the aim to simultaneously compare all available treatments using both direct and indirect data.
Methods We searched the controlled trials registers maintained by the “Cochrane Common Mental Disorders” group from inception to 16 February 2016. We selected randomized controlled trials in which an active psychotherapeutic or pharmacological intervention had been used in adults with OCD. The primary outcome measure was symptom severity as measured by the Yale-Brown obsessive compulsive scale. We report mean differences (MD) with 95% credible intervals (95% CrI) compared to placebo as reference. The study is registered with PROSPERO, number CRD42012002441.
Findings We included 54 trials (6652 participants) in the network meta-analysis. Behavioral therapy (MD: -14⋅48, 95% CrI: -18⋅61 to -10⋅23), cognitive therapy (-13⋅36, -18⋅40 to -8⋅21), cognitive-behavioral therapy (CBT) (-5⋅37, -9⋅10 to -1⋅63), clomipramine (MD: -4⋅72, 95% CrI: -6⋅85 to -2⋅60) and all selective serotonin reuptake inhibitors (SSRIs) (class effect -3⋅49, -5⋅12 to -1⋅81) had greater effects compared to drug placebo. Behavioural therapy in the main analysis and the combination of behavioural therapy with clomipramine in the secondary analysis (excluding waiting list controlled trials) were more likely to be the most effective treatments but with considerable uncertainty. Psychotherapeutic interventions had a greater effect compared to medications but a serious limitation was that, in most psychotherapeutic trials, patients who were taking stable doses of antidepressants were not excluded and therefore these cannot be considered as pure “monotherapies”.

Interpretation The combination of certain psychotherapies with medications is likely more effective in the management of severe OCD. Pragmatic trials with improved research design are needed to establish the differential efficacy between psychotherapies and medications.

Funding National Institute for Health Research.