Treatment strategies for serotonin reuptake inhibitor-resistant obsessive-compulsive disorder: A network meta-analysis of randomised controlled trials - BrainsWay

Treatment strategies for serotonin reuptake inhibitor-resistant obsessive-compulsive disorder: A network meta-analysis of randomised controlled trials


Authors: Satish Suhasa, Palash Kumar Malob, Vijay Kumara, Thomas Gregor Issaca,Nellai K. Chithraa, Binukumar Bhaskarapillaib, Y. C. Janardhan Reddyaand Naren P. Rao


In the last couple of decades, newer treatment modalities, including neuromodulation through brain stimulation and psychosurgery have been examined to treat SRI-resistant OCD. A systematic review of brain stimulation treatments for resistant OCD suggested the efficacy of low-frequency TMS over the supplementary motor area or the orbitofrontal cortex as more efficacious. Additionally, Transcranial Direct Current Stimulation (tDCS) has shown promise in resistant OCD as well.While the available meta-analyses in scientific literature compare the efficacy of treatment options within an individual treatment modality, an NMA comparing the available treatments across modalities has not been conducted. 


Treatment-resistant obsessive-compulsive disorder is a chronic debilitating illness. We conducted a network meta-analysis [NMA] to compare the efficacy of all interventions in SRI-resistant OCD from published Randomised controlled trials [RCT].


We performed an NMA of RCTs in SRI resistant OCD from all modalities of treatments; pharmacological, psychological, neuromodulation, neurosurgery including deep brain stimulation. The design-by-treatment interaction inconsistency model within the frequentist framework was adopted with a change in Yale-Brown Obsessive-Compulsive Scale score as the primary outcome. We conducted sensitivity analyses excluding studies examining neurosurgical interventions, deep brain stimulation, studies in the paediatric population, and studies from a single geographical region. We also conducted analyses of interventions categorised into treatment groups. 


55 RCTs examining 19 treatments or placebo involving 2011 participants were included in the NMA. Ondansetron [Standardised mean difference −2.01 (95% CI: −3.19, −0.83)], deep TMS [– 1.95 (−3.25, −0.65)], therapist administered Cognitive Behavioural Therapy [CBT-TA] [−1.46 (−2.93, 0.01)] and aripiprazole [−1.36 (−2.56, −0.17)] were ranked as the best four treatments on using the Surface Under the Cumulative Ranking [SUCRA] percentage values (85.4%, 83.2%, 80.3%, 67.9% respectively). While all four interventions had large effect sizes, CBT[TA] narrowly missed statistical significance in our analysis. In sensitivity analyses, deep TMS was ranked as the best treatment strategy for SRI-resistant OCD. The small number of subjects in individual studies, higher confidence interval limits, and wider prediction interval for most agents warrant a cautious interpretation. 


Considering the principal analysis and sensitivity analyses together, deep TMS, ondansetron, CBT[TA], and aripiprazole may be considered a first-line intervention for SRI-resistant OCD in adults. 

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