NIHR Signal Both psychological therapies and antidepressants are effective for obsessive compulsive disorder

Published on 30 August 2016

For adults with obsessive compulsive disorder (OCD), behavioural therapy, cognitive therapy and antidepressants such as clomipramine all reduce symptoms and have good tolerability. The strongest evidence of effectiveness for children and young people with OCD is for cognitive behavioural therapy with or without the antidepressant sertraline.

Findings from this review generally support previously published NICE guidelines on the management of OCD, particularly for children and young people. The review had attempted to rank treatment strategies by effectiveness, tolerability and cost but was hampered by low quality evidence. Because each type of treatment was shown to be effective, side effect profile and personal preference will be most important in treatment choice.

The review did not look at therapies for different severities of OCD impairment so whether certain therapies are more effective for mild, moderate or severe impairment is unknown.

Both psychological therapies and antidepressants are effective for obsessive compulsive disorder

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Why was this study needed?

OCD is the fourth most common mental disorder in the UK. It is estimated around 12 in every 1,000 people in the UK are affected by the condition equating to almost 750,000 people.

OCD symptoms can range from mild to severe. Some people with OCD may spend an hour or so a day engaged in obsessive compulsive thinking but for others the condition can be more debilitating.

Despite its prevalence, the disorder is under-recognised and under-treated. Several psychological therapies and drugs have been found to reduce OCD symptoms and increase quality of life but direct comparisons of these therapies is lacking. Cost-effectiveness data of treatments is also limited.

What did this study do?

This was a network meta-analysis of 86 randomised controlled trials (7,306 adults; 1,305 children and young people). It combined trials where treatments were compared directly (head to head) with trials of treatments compared with placebo controls (indirect comparisons).

Psychological interventions included behavioural therapy (exposure and response therapy), cognitive therapy and cognitive behavioural therapy. Drug interventions included any antidepressant with some action on the serotonin neurotransmitters such as selective serotonin reuptake inhibitors (SSRIs) and clomipramine. Controls included placebo pills, psychological placebo (such as supportive therapy) and waiting list.

The underlying trials in the review were not of high quality and prone to several biases in favour of the intervention. Over half did not include the people who dropped out of the study in their analysis. Most psychotherapy trials also included people taking medication and used waiting list controls. There was also wide variation between the studies which reduces the reliability of the pooled analyses, so the results should be viewed with some caution.

What did it find?

  • In adults, behavioural and cognitive therapies were more effective than psychological placebo according to average differences in scores on the Yale-Brown-Obsessive Compulsive Scale (range 0 to 40). Behavioural therapy reduced the mean difference [MD] by ‑10.33 (95% credible interval [CrI] ‑13.38 to ‑7.29) and cognitive therapy by MD ‑9.21, (95% CrI ‑13.10 to ‑5.34).
  • Cognitive behavioural therapy was no more effective than psychological placebo (MD ‑1.22 (95% CrI ‑5.54 to 3.03).
  • No SSRI is more effective than another and they were all moderately more effective compared to drug placebo with good tolerability (combined MD ‑3.49, 95% CrI ‑5.12 to ‑1.81). Clomipramine was also more effective than placebo but less tolerable than SSRIs (MD ‑4.72, 95% CrI ‑6.85 to ‑2.60). Studies of venlafaxine or hypericum (St John’s wort) were too small to provide conclusive results.
  • In children and young people (17 trials; 991 people) cognitive behavioural therapy combined with sertraline had the largest effect, with good tolerability. It appeared to be as effective as cognitive behavioural therapy alone but there were small numbers of people for each type of treatment or combination of treatments.
  • Results for cost-effectiveness were inconclusive.

What does current guidance say on this issue?

NICE’s 2005 guidance on OCD was placed on the static list in February 2014 as no major on-going studies were due to be published within the next three to five years. The decision will be reviewed in 2019.

The 2005 guidance recommends low intensity (up to 10 hours) cognitive behavioural therapy or behavioural therapy for adults with mild OCD. An SSRI, more intensive cognitive behavioural therapy or behavioural therapy is recommended if response is inadequate and for moderate OCD. Combined treatment is recommended for severe impairment.

For children and young people with mild OCD, guided self-help and support is recommended and cognitive behavioural therapy or behavioural therapy for moderate to severe impairment.

What are the implications?

Findings from this review generally support previously published guidelines on the management of OCD, that psychological therapies and SSRI drugs are of benefit either alone or in combination. There was insufficient evidence to reliably rank the different types of psychological therapies or drug treatments in order of likely success. This was partly due to the majority of psychological trials including people who were taking medications (mostly SSRIs). Therefore there is less certainty in the finding that behavioural therapy and cognitive therapy were more effective than medication because the way study was conducted may have favoured psychotherapies unfairly.

This means that treatments will continue to be chosen on an individual basis according to preferences, side effect profiles and comorbid conditions such as depression and anxiety.

Citation and Funding

Skapinakis P, Caldwell D, Hollingworth W, et al. A systematic review of the clinical effectiveness and cost-effectiveness of pharmacological and psychological interventions for the management of obsessive-compulsive disorder in children/adolescents and adults. Health Technol Assess 2016;20 (43).

This project was funded by the National Institute for Health Research Health Technology Assessment programme (project number 10/104/41).

Bibliography

NHS Choices. Obsessive compulsive disorder. London. Department of Health; updated 2014.

NICE. Obsessive-compulsive disorder and body dysmorphic disorder: treatment. CG31. London: National Institute for Health and Care Excellence; 2005.

Why was this study needed?

OCD is the fourth most common mental disorder in the UK. It is estimated around 12 in every 1,000 people in the UK are affected by the condition equating to almost 750,000 people.

OCD symptoms can range from mild to severe. Some people with OCD may spend an hour or so a day engaged in obsessive compulsive thinking but for others the condition can be more debilitating.

Despite its prevalence, the disorder is under-recognised and under-treated. Several psychological therapies and drugs have been found to reduce OCD symptoms and increase quality of life but direct comparisons of these therapies is lacking. Cost-effectiveness data of treatments is also limited.

What did this study do?

This was a network meta-analysis of 86 randomised controlled trials (7,306 adults; 1,305 children and young people). It combined trials where treatments were compared directly (head to head) with trials of treatments compared with placebo controls (indirect comparisons).

Psychological interventions included behavioural therapy (exposure and response therapy), cognitive therapy and cognitive behavioural therapy. Drug interventions included any antidepressant with some action on the serotonin neurotransmitters such as selective serotonin reuptake inhibitors (SSRIs) and clomipramine. Controls included placebo pills, psychological placebo (such as supportive therapy) and waiting list.

The underlying trials in the review were not of high quality and prone to several biases in favour of the intervention. Over half did not include the people who dropped out of the study in their analysis. Most psychotherapy trials also included people taking medication and used waiting list controls. There was also wide variation between the studies which reduces the reliability of the pooled analyses, so the results should be viewed with some caution.

What did it find?

  • In adults, behavioural and cognitive therapies were more effective than psychological placebo according to average differences in scores on the Yale-Brown-Obsessive Compulsive Scale (range 0 to 40). Behavioural therapy reduced the mean difference [MD] by ‑10.33 (95% credible interval [CrI] ‑13.38 to ‑7.29) and cognitive therapy by MD ‑9.21, (95% CrI ‑13.10 to ‑5.34).
  • Cognitive behavioural therapy was no more effective than psychological placebo (MD ‑1.22 (95% CrI ‑5.54 to 3.03).
  • No SSRI is more effective than another and they were all moderately more effective compared to drug placebo with good tolerability (combined MD ‑3.49, 95% CrI ‑5.12 to ‑1.81). Clomipramine was also more effective than placebo but less tolerable than SSRIs (MD ‑4.72, 95% CrI ‑6.85 to ‑2.60). Studies of venlafaxine or hypericum (St John’s wort) were too small to provide conclusive results.
  • In children and young people (17 trials; 991 people) cognitive behavioural therapy combined with sertraline had the largest effect, with good tolerability. It appeared to be as effective as cognitive behavioural therapy alone but there were small numbers of people for each type of treatment or combination of treatments.
  • Results for cost-effectiveness were inconclusive.

What does current guidance say on this issue?

NICE’s 2005 guidance on OCD was placed on the static list in February 2014 as no major on-going studies were due to be published within the next three to five years. The decision will be reviewed in 2019.

The 2005 guidance recommends low intensity (up to 10 hours) cognitive behavioural therapy or behavioural therapy for adults with mild OCD. An SSRI, more intensive cognitive behavioural therapy or behavioural therapy is recommended if response is inadequate and for moderate OCD. Combined treatment is recommended for severe impairment.

For children and young people with mild OCD, guided self-help and support is recommended and cognitive behavioural therapy or behavioural therapy for moderate to severe impairment.

What are the implications?

Findings from this review generally support previously published guidelines on the management of OCD, that psychological therapies and SSRI drugs are of benefit either alone or in combination. There was insufficient evidence to reliably rank the different types of psychological therapies or drug treatments in order of likely success. This was partly due to the majority of psychological trials including people who were taking medications (mostly SSRIs). Therefore there is less certainty in the finding that behavioural therapy and cognitive therapy were more effective than medication because the way study was conducted may have favoured psychotherapies unfairly.

This means that treatments will continue to be chosen on an individual basis according to preferences, side effect profiles and comorbid conditions such as depression and anxiety.

Citation and Funding

Skapinakis P, Caldwell D, Hollingworth W, et al. A systematic review of the clinical effectiveness and cost-effectiveness of pharmacological and psychological interventions for the management of obsessive-compulsive disorder in children/adolescents and adults. Health Technol Assess 2016;20 (43).

This project was funded by the National Institute for Health Research Health Technology Assessment programme (project number 10/104/41).

Bibliography

NHS Choices. Obsessive compulsive disorder. London. Department of Health; updated 2014.

NICE. Obsessive-compulsive disorder and body dysmorphic disorder: treatment. CG31. London: National Institute for Health and Care Excellence; 2005.

A systematic review of the clinical effectiveness and cost-effectiveness of pharmacological and psychological interventions for the management of obsessive-compulsive disorder in children/adolescents and adults

Published on 16 June 2016

Skapinakis P, Caldwell D, Hollingworth W, Bryden P, Fineberg N, Salkovskis P, Welton N, Baxter H, Kessler D, Churchill R, Lewis G.

Health Technology Assessment Volume 20 Issue 43 , 2016

Background Obsessive–compulsive disorder (OCD) is a relatively common and disabling condition. Objectives To determine the clinical effectiveness, acceptability and cost-effectiveness of pharmacological and psychological interventions for the treatment of OCD in children, adolescents and adults. Data sources We searched the Cochrane Collaboration Depression, Anxiety and Neurosis Trials Registers, which includes trials from routine searches of all the major databases. Searches were conducted from inception to 31 December 2014. Review methods We undertook a systematic review and network meta-analysis (NMA) of the clinical effectiveness and acceptability of available treatments. Outcomes for effectiveness included mean differences in the total scores of the Yale–Brown Obsessive–Compulsive Scale or its children’s version and total dropouts for acceptability. For the cost-effectiveness analysis, we developed a probabilistic model informed by the results of the NMA. All analyses were performed using OpenBUGS version 3.2.3 (members of OpenBUGS Project Management Group; see www.openbugs.net). Results We included 86 randomised controlled trials (RCTs) in our systematic review. In the NMA we included 71 RCTs (54 in adults and 17 in children and adolescents) for effectiveness and 71 for acceptability (53 in adults and 18 in children and adolescents), comprising 7643 and 7942 randomised patients available for analysis, respectively. In general, the studies were of medium quality. The results of the NMA showed that in adults all selective serotonin reuptake inhibitors (SSRIs) and clomipramine had greater effects than drug placebo. There were no differences between SSRIs, and a trend for clomipramine to be more effective did not reach statistical significance. All active psychological therapies had greater effects than drug placebo. Behavioural therapy (BT) and cognitive therapy (CT) had greater effects than psychological placebo, but cognitive–behavioural therapy (CBT) did not. BT and CT, but not CBT, had greater effects than medications, but there are considerable uncertainty and methodological limitations that should be taken into account. In children and adolescents, CBT and BT had greater effects than drug placebo, but differences compared with psychological placebo did not reach statistical significance. SSRIs as a class showed a trend for superiority over drug placebo, but the difference did not reach statistical significance. However, the superiority of some individual drugs (fluoxetine, sertraline) was marginally statistically significant. Regarding acceptability, all interventions except clomipramine had good tolerability. In adults, CT and BT had the highest probability of being most cost-effective at conventional National Institute for Health and Care Excellence thresholds. In children and adolescents, CBT or CBT combined with a SSRI were more likely to be cost-effective. The results are uncertain and sensitive to assumptions about treatment effect and the exclusion of trials at high risk of bias. Limitations The majority of psychological trials included patients who were taking medications. There were few studies in children and adolescents. Conclusions In adults, psychological interventions, clomipramine, SSRIs or combinations of these are all effective, whereas in children and adolescents, psychological interventions, either as monotherapy or combined with specific SSRIs, were more likely to be effective. Future RCTs should improve their design, in particular for psychotherapy or combined interventions. Funding details The National Institute for Health Research Health Technology Assessment programme.

Selective serotonin reuptake inhibitors: These antidepressants include fluoxetine, sertraline, citalopram, escitalopram, paroxetine and fluvoxamine.

Clomipramine: An antidepressant that has some effect on the serotonin system but is classed as a tricyclic antidepressant. It therefore has other side effects such as a dry mouth, constipation, and blurred vision.

Yale-Brown-Obsessive Compulsive Scale and the Children’s Yale Brown-Obsessive Compulsive Scale: This scale combines scores for severity of obsessions and compulsions into a final score ranging from 0 to 40. The severity of OCD is considered subclinical (0 to 7), mild (8 to 15), moderate (16 to 23), severe (24 to 31) and extreme (32 to 40).

Trial biases: less than half of the adult trials reported results on an intention to treat basis, so most did not include drop-outs in their analysis which will bias results in favour of the intervention. In addition, several psychological trials were prone to subjective treatment bias as they compared the therapy to people on a waiting list so the participants were not blinded to whether or not they received an active treatment. Most of these trials were further biased as they included people who were already on an antidepressant.

Expert commentary

This review demonstrates that treatment with SSRIs and psychological therapy involving behavioural or cognitive interventions produce significant improvements in patients with OCD. This is encouraging for anyone working in the field. As pointed out by the authors, the surprisingly good result with pure cognitive therapy could be explained by these studies being completer analyses only and also by a relatively small number of studies. The major question, however, of whether treatment with SSRIs is as good as or less effective than psychological treatment is not fully answered. Drug trials often have larger numbers and can be sponsored by industry, whereas studies examining psychological interventions are generally smaller. The urgent need for suitably powered head to head evaluations of exposure and response prevention against drug treatment therefore is underlined.

Dr Lynne M Drummond, National and Trustwide Services for OCD/BDD, SW London and St George's NHS Trust