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

Abstract

BackgroundObsessive–compulsive disorder (OCD) is a relatively common and disabling condition.ObjectivesTo determine the clinical effectiveness, acceptability and cost-effectiveness of pharmacological and psychological interventions for the treatment of OCD in children, adolescents and adults.Data sourcesWe 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 methodsWe 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; seewww.openbugs.net).ResultsWe 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.LimitationsThe majority of psychological trials included patients who were taking medications. There were few studies in children and adolescents.ConclusionsIn 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.Study registrationThe study is registered as PROSPERO CRD42012002441.Funding detailsThe National Institute for Health Research Health Technology Assessment programme.

Alexithymia, Ego-Dystonicity, and Obsessive-Compulsive Symptoms: A Path Modeling Analysis

“…Previous studies have shown the comorbidity between OCD, alexithymia, and anxiety or depression [14][15][16][17]. For example, a study [18] in Finland with a large sample size (> 2,000) reported that compared to type A alexithymia (characterized by significantly higher scores in DDF and externally oriented cognitive style), type B alexithymia (characterized by significantly higher scores in DIF) was associated with a higher prevalence of self-reported diagnosis of major depressive disorder (30.2 vs. 8.3%) and anxiety disorder (18.9 vs. 3.3%).…”

Cognitive behavioral therapy improves adherence to antiretroviral therapy in HIV-infected patients: a prospective randomized controlled trial from eastern India

“…Cognitive behavioral therapy is a form of psychotherapy, which is flexible, individualized and can be adapted to a wide range of individuals and a variety of settings. Worldwide, it has been successfully applied in various psychiatric ailments like depression, anxiety, obsessive-compulsive disorder, phobias and eating disorders [16][17][18]. It has also been used as an adjunct to the existing therapy in various chronic diseases (e.g.…”

Pharmacotherapy for treatment-respondent vs. refractory obsessive–compulsive disorder in children and adults: strategies, meta-analyses and clinical guidelines

“…The remaining 14 meta-analyses included patients with treatment-respondent OCD. Of these 14 studies, 6 were about double-blind, randomized, placebo-controlled trials on pediatric patients with OCD that showed superiority of SRIs for the treatment of OCD with a moderate effect size and a non-significant risk of suicidality, as well as that combined therapy was no more effective irrespective of the initial severity of the samples [14,[45][46][47][48][49]. All meta-analyses found that high doses of SSRIs were more effective as first-line therapy for patients with OCD; however, combined therapy was more effective than monotherapy.…”