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Publication - Dr Helen Baxter

    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

    Citation

    Skapinakis, P, Caldwell, D, Welton, N, Hollingworth, W, Kessler, D & Baxter, H, 2016, ‘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 Technology Assessment, vol 20.

    Abstract

    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.





    Study registration

    The study is registered as PROSPERO CRD42012002441.





    Funding details
    The National Institute for Health Research Health Technology Assessment programme

    Full details in the University publications repository