Hostname: page-component-89b8bd64d-r6c6k Total loading time: 0 Render date: 2026-05-11T11:37:21.278Z Has data issue: false hasContentIssue false
  • English
  • Français

Effectiveness and acceptability of different psychotherapies for obsessive–compulsive disorder: network meta-analysis

Published online by Cambridge University Press:  11 May 2026

Yingying Wang Open the ORCID record for Yingying Wang [Opens in a new window] ,
Clara Miguel Open the ORCID record for Clara Miguel [Opens in a new window] ,
Marketa Ciharova Open the ORCID record for Marketa Ciharova [Opens in a new window] ,
Arpana Amarnath ,
Jingyuan Lin ,
Ruiying Zhao ,
Marieke B. J. Toffolo ,
Sascha Y. Struijs ,
Leonore M. de Wit  and
Pim Cuijpers Open the ORCID record for Pim Cuijpers [Opens in a new window]
Yingying Wang*
Affiliation:
Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, The Netherlands
Clara Miguel
Affiliation:
Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, The Netherlands
Marketa Ciharova
Affiliation:
Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, The Netherlands
Arpana Amarnath
Affiliation:
Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, The Netherlands
Jingyuan Lin
Affiliation:
The Institute of Brain and Psychological Science, Sichuan Normal University, China
Ruiying Zhao
Affiliation:
Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, The Netherlands
Marieke B. J. Toffolo
Affiliation:
Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, The Netherlands
Sascha Y. Struijs
Affiliation:
Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, The Netherlands
Leonore M. de Wit
Affiliation:
Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, The Netherlands
Pim Cuijpers
Affiliation:
Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, The Netherlands International Institute of Psychotherapy, Babeș-Bolyai University, Romania
*
Correspondence: Yingying Wang. Email: y.w.yingying.wang@vu.nl
Rights & Permissions [Opens in a new window]

Abstract

Background

Various psychotherapies are available for individuals with obsessive–compulsive disorder (OCD). However, the comparative effectiveness and acceptability of these therapies remain unclear.

Aims

To examine the comparative effectiveness and acceptability of different psychotherapies for OCD.

Method

A living database of psychological interventions for OCD was utilised, and randomised controlled trials comparing psychotherapies with each other/control groups were included. Pairwise and network meta-analyses were conducted using a random-effects model. Comparative standardised mean differences (SMDs) were pooled for effectiveness in reducing OCD symptom severity post-treatment. Relative risks were calculated for acceptability. Sensitivity analyses were conducted by repeating the main analyses while controlling for specific variables to test the robustness of the findings.

Results

A total of 68 controlled trials (76 comparisons, 4019 patients) were included, involving 7 psychotherapeutic approaches. All psychotherapies were significantly more effective than both waitlist (SMD −1.40 to −0.96) and pill placebo (SMD −1.44 to −1.00). Except for mindfulness-based therapy, all approaches were more effective than both care-as-usual (SMD −0.98 to −0.67) and psychological placebo (SMD −0.95 to −0.63). Sensitivity analyses excluding outliers, studies with comorbidities, comparisons with waitlist controls and comparisons supported by only a single study, as well as analyses restricted to adults with OCD, yielded results consistent with the main analyses. When restricted to studies rated as low risk of bias, all therapies except mindfulness-based therapy and the inference-based approach remained significantly more effective than waitlist. No significant differences were found among psychotherapies regarding effectiveness and acceptability.

Conclusions

Psychotherapies are similarly effective and acceptable for treating OCD. However, these findings should be interpreted with caution due to limited statistical power, substantial heterogeneity and a high risk of bias across many included studies. More methodologically rigorous research is needed to validate and strengthen the current evidence base.

Keywords

Obsessive–compulsive disorderspsychological treatmentsnetwork meta-analyseseffectivenessacceptability

Information

Type
Review
Information
The British Journal of Psychiatry , First View , pp. 1 - 10
Check for updates
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited.
Copyright
© The Author(s), 2026. Published by Cambridge University Press on behalf of Royal College of Psychiatrists

Obsessive–compulsive disorder (OCD), characterised by recurrent, persistent and unwanted obsessions and/or compulsions, is a chronic and debilitating mental disorder. Reference Abramowitz and Jacoby1 OCD has a lifetime prevalence ranging from 1 to 3% worldwide, Reference Fawcett, Power and Fawcett2–Reference Ruscio, Stein, Chiu and Kessler5 and it is ranked among the top 10 most disabling illnesses in terms of lost income and reduced quality of life by the World Health Organization (WHO), 6 adversely impacting both individuals and their families. Reference Steketee7,Reference Stengler-Wenzke, Kroll, Matschinger and Angermeyer8

Psychological interventions have demonstrated a large overall effect in treating OCD. Reference Wang, Miguel, Ciharova, Amarnath, Lin and Zhao9 Currently, seven main types of psychotherapy are available for individuals with OCD, each focusing on specific aspects of treatment. Exposure and response prevention (ERP Reference Lindsay, Crino and Andrews10–Reference Bolton and Perrin12 ) involves gradually confronting anxiety-provoking situations while resisting avoidance or neutralising behaviours. Cognitive therapy Reference van Balkom, de Haan, van Oppen, Spinhoven, Hoogduin and van Dyck13,Reference Alcolado and Radomsky14 manages OCD by targeting maladaptive cognitive appraisals, and cognitive–behavioural therapy (CBT Reference Baruah, Pandian, Narayanaswamy, Bada Math, Kandavel and Reddy15–Reference Mancebo, Yip, Boisseau, Rasmussen and Zlotnick17 ) typically combines ERP and cognitive therapy. Mindfulness-based therapy (MBT Reference Mathur, Sharma, Balachander, Kandavel and Reddy18,Reference Zhang, Lu, Didonna, Wang, Zhang and Fan19 ) teaches individuals with OCD to observe their thoughts without judgement; metacognitive therapy (M Reference Glombiewski, Hansmeier, Haberkamp, Rief and Exner20,Reference Melchior, van der Heiden, Deen, Mayer and Franken21 ) focuses on modifying patients’ beliefs about the importance of intrusive thoughts and the necessity of performing rituals; acceptance and commitment therapy (ACT Reference Twohig, Hayes, Plumb, Pruitt, Collins and Hazlett-Stevens22,Reference Lee, Choi and Lee23 ) encourages patients to respond flexibly to obsessions, anxiety and uncertainty while moving towards their values rather than being driven by fears; and the inference-based approach (IBA Reference Visser, van Megen, van Oppen, Eikelenboom, Hoogendorn and Kaarsemaker24 ) helps patients trust their inner and outer senses, addressing the underlying reasoning processes and reducing obsessional doubts.

A range of randomised controlled trials (RCTs) have demonstrated the effectiveness of various psychotherapies for OCD compared with control groups, including ERP, Reference Baruah, Pandian, Narayanaswamy, Bada Math, Kandavel and Reddy15–Reference Mancebo, Yip, Boisseau, Rasmussen and Zlotnick17 cognitive therapy, Reference van Balkom, de Haan, van Oppen, Spinhoven, Hoogduin and van Dyck13,Reference Alcolado and Radomsky14 CBT, Reference Baruah, Pandian, Narayanaswamy, Bada Math, Kandavel and Reddy15–Reference Mancebo, Yip, Boisseau, Rasmussen and Zlotnick17 MBT, Reference Mathur, Sharma, Balachander, Kandavel and Reddy18,Reference Zhang, Lu, Didonna, Wang, Zhang and Fan19 MCT, Reference Glombiewski, Hansmeier, Haberkamp, Rief and Exner20,Reference Melchior, van der Heiden, Deen, Mayer and Franken21 ACT Reference Twohig, Hayes, Plumb, Pruitt, Collins and Hazlett-Stevens22,Reference Schneider, Wittekind, Talhof, Korrelboom and Moritz25 and IBA. Reference Visser, van Megen, van Oppen, Eikelenboom, Hoogendorn and Kaarsemaker24 However, to our knowledge, the comparative effectiveness and acceptability of these therapies remain unclear. Previous controlled trials have directly compared different psychotherapies for OCD, such as ERP versus cognitive therapy, Reference van Balkom, de Haan, van Oppen, Spinhoven, Hoogduin and van Dyck13,Reference Emmelkamp and Beens26,Reference Rodrigues, Fechine, Oliveira, Matos, Passarela and Hemanny27 CBT versus ERP, Reference Rector, Richter, Katz and Leybman28,Reference McLean, Whittal, Thordarson, Taylor, Söchting and Koch29 CBT/ERP versus IBA, Reference Visser, van Megen, van Oppen, Eikelenboom, Hoogendorn and Kaarsemaker24,Reference O’Connor, Aardema, Bouthillier, Fournier, Guay and Robillard30 MBT versus CBT, Reference Aardema, Bouchard, Koszycki, Lavoie, Audet and O’Connor31 MCT versus ERP Reference Glombiewski, Hansmeier, Haberkamp, Rief and Exner20,Reference Melchior, van der Heiden, Deen, Mayer and Franken21 and ACT versus ERP. Reference Twohig, Abramowitz, Smith, Fabricant, Jacoby and Morrison32 The findings from these trials are, however, inconsistent. For example, whereas one RCT reported ERP as marginally more effective than CBT, Reference McLean, Whittal, Thordarson, Taylor, Söchting and Koch29 another Reference Rector, Richter, Katz and Leybman28 found that CBT led to significantly greater symptom reduction compared with ERP. These discrepancies highlight the need for more robust and conservative estimates of the relative effectiveness of psychotherapies for OCD. The most recent meta-analysis Reference Wang, Miguel, Ciharova, Amarnath, Lin and Zhao9 examining the overall effectiveness of psychotherapies over the past 30 years found that cognitive therapy and third-wave CBT demonstrated significantly lesser effect sizes compared with CBT and ERP. Whereas that study provided important insights, its analyses were limited to direct head-to-head comparisons and excluded indirect evidence – i.e. comparisons made through a shared comparator. Incorporation of indirect comparisons is essential for estimating the relative efficacy of treatments not directly compared within individual trials, thereby offering a more comprehensive understanding of the evidence base. Furthermore, that study grouped MBT, MCT, ACT and IBA together as ‘third-wave CBT’ therapies, failing to evaluate their specific effectiveness individually.

Therefore, we aimed to conduct a network meta-analysis (NMA) to compare the effectiveness and acceptability of different psychotherapies for OCD. NMA enables the combination of both direct and indirect evidence, thereby providing a comprehensive evaluation of treatments. Reference White33 Drawing on existing knowledge, Reference Wang, Miguel, Ciharova, Amarnath, Lin and Zhao9 we hypothesise that all psychotherapies will be significantly more effective than control conditions, with no specific expectations regarding effectiveness between therapies and their acceptability.

Method

Identification and selection of studies

We utilised a living database of psychological interventions for OCD, which was built through comprehensive searches in both international (PubMed, Embase, PsycINFO, international clinical trials registry platform of WHO) and Chinese (China National Knowledge Infrastructur, WeiPu, WanFang, Chinese Clinical Trial Registry) databases, spanning the period from inception to 1 September 2024. China, as the second most populous country globally, has a substantial number of individuals suffering from OCD. 34 However, although many Chinese researchers have explored OCD, Reference Zejuan and Hailing35–Reference Yanmeng, Zhipeng and Changhai37 their work might not be accessible in international databases due to language barriers. The living database has facilitated the publication of several meta-analytic studies on OCD. Reference Wang, Miguel, Ciharova, Amarnath, Lin and Zhao9,Reference Wang, Amarnath, Miguel, Ciharova, Lin and Zhao38,Reference Wang, Duan, Cao and Xu39 Detailed search strings can be found in Appendix A. Data extraction commenced on 8 October 2024. The study protocol was prospectively registered at the Open Science Framework (https://doi.org/10.17605/OSF.IO/KG3J8) prior to initiation of the literature search and analyses.

RCTs that compared psychotherapies with each other or with control groups for individuals with a primary diagnosis of OCD, as determined by valid clinical interviews, were included. The definitions of psychotherapies and control groups are detailed in Table 1. All delivery formats of psychotherapy were eligible for inclusion, except unguided self-help interventions Reference Cuijpers and Schuurmans40 in which individuals work independently on the programme/treatment protocol to learn and apply psychotherapeutic strategies. This exclusion was based on evidence indicating that unguided self-help interventions yield smaller treatment effects compared with professionally delivered interventions. Reference Pearcy, Anderson, Egan and Rees41

Table 1

Definitions of psychotherapy and control groups

No restrictions were placed on gender, age or setting. There were no limitations on the duration of treatment, number of sessions or minimal number of participants. However, trials examining interventions such as stepped-care management, maintenance treatment or relapse prevention were excluded, as were comparisons of different delivery formats of the same psychotherapy. In addition, unpublished studies were not included due to concerns regarding methodological rigour, transparency and the reliability of reported outcomes.

All records were screened and selected by two independent researchers (Y.W., C.M.), with any disagreements, such as the classification of psychotherapy types, resolved through discussion or by a third senior researcher (M.B.J.T.).

Data extraction and risk of bias assessment

We extracted data across four key domains: (a) effect size calculation, including mean and standard deviation; (b) characteristics of participants, including mean age, proportion of females and proportion of participants using psychiatric medication; (c) characteristics of the intervention, including type of psychotherapy, whether the treatment was administered by trained therapists, and treatment integrity implementation; and (d) characteristics of the study, including region of study origin and recruitment method for participants.

The revised risk-of-bias tool for randomised trials (RoB 2 Reference Sterne, Savović, Page, Elbers, Blencowe and Boutron42 ) was used to assess the risk of bias in included RCTs across five domains: randomisation process, deviations from intended interventions, missing outcome data, outcome measurement and selective outcome reporting. An overall rating of ‘high risk of bias’ was assigned if any domain was rated as high risk or if three or more domains were rated as raising some concerns. An overall rating of ‘some concerns’ was given when no domains were rated as high risk and no more than two domains were rated as having some concerns. Studies were rated as ‘low risk of bias’ only if all domains were rated as low risk.

Data extraction and RoB 2 assessment were conducted by two independent researchers (Y.W., C.M.), and any disagreements were solved through discussion.

Outcomes

The main outcomes were effectiveness and acceptability at post-treatment. Effectiveness was evaluated using a single outcome measuring OCD symptom severity in each study, determined via a hierarchy algorithm (see Appendix B) based on its frequency of usage in preceding literature. Reference Wang, Miguel, Ciharova, Amarnath, Lin and Zhao9 Acceptability was operationalised as the all-cause study drop-out rate at the end-of-treatment assessment.

Statistical analyses

A series of pairwise meta-analyses were performed for all direct comparisons using a random-effects pooling model. Heterogeneity was assessed with the I 2 statistic Reference Ioannidis, Patsopoulos and Evangelou43 and its 95% confidence interval, as well as τ 2. Small-study effects were inspected visually using a funnel plot and tested with Egger’s test. Reference Egger, Smith, Schneider and Minder44 Additionally, prediction intervals were estimated to represent the 95% confidence interval of the predictive distribution of effects in future comparable trials.

Network meta-analyses were conducted to evaluate the comparative effectiveness of all treatments by combining both direct and indirect evidence. Initially, we depicted the geometry of the network of evidence using network plots. Reference Hutton, Salanti, Caldwell, Chaimani, Schmid and Cameron45 Subsequently, network meta-analyses were conducted for both effectiveness and acceptability utilising a frequentist network meta-analysis method, Reference Rücker46 with the random-effects model. Reference Higgins, Jackson, Barrett, Lu, Ades and White47 Effectiveness was estimated using standardised mean differences (SMDs), calculated by dividing the mean difference by the pooled standard deviation, with acceptability measured by relative risk with 95% confidence interval. The ranking of treatments was assessed based on the surface under the cumulative ranking curve (SUCRA Reference Salanti, Ades and Ioannidis48 ).

To assess the assumption of transitivity, we created a table of characteristics of patients and interventions for direct comparisons, verifying whether potential effect modifiers were similarly distributed across the network. Consistency of the network was checked through both local and global inconsistency tests. The net heat plot Reference Krahn, Binder and König49 visualised the degree of inconsistency within the network using colour gradients, as determined in the local test. The node-splitting method Reference Dias, Welton, Caldwell and Ades50 was employed to scrutinise consistency across the entire network of treatments, assessing the consistency assumption for each node (treatment comparison) in the network during the global test.

Three sensitivity analyses were conducted: (a) exclusion of outliers, defined as studies in which 95% confidence intervals around their effect sizes did not overlap with those of the pooled effect size in any pairwise meta-analyses; Reference Viechtbauer and Cheung51,Reference Harrer, Cuijpers, Furukawa and Ebert52 (b) restriction to studies rated as low risk of bias; and (c) exclusion of studies with comorbidities in which participants presented at least one co-occurring mental disorder.

Additionally, four post hoc analyses were conducted. First, a sensitivity analysis restricted the sample to adults with OCD; second, a sensitivity analysis excluded comparisons involving waitlist controls; and third, a sensitivity analysis excluded comparisons supported by only a single study. Finally, acceptability was assessed using odds ratios with 95% confidence intervals. These analyses were performed to explore potential factors influencing treatment effects and acceptability.

The analyses were conducted in R 4.3.3 (R Foundation for Statistical Computing, Vienna, Austria; see https://www.Rproject.org/) using the ‘netmeta’ package on Windows 11. Reference Balduzzi, Rücker, Nikolakopoulou, Papakonstantinou, Salanti, Efthimiou and Schwarzer53 The network plot and certainty of evidence for the network estimates were examined through the web application Confidence In Network Meta-Analysis (CINeMA Reference Papakonstantinou, Nikolakopoulou, Higgins, Egger and Salanti54 ; see https://cinema.ispm.unibe.ch/).

Results

Identification, inclusion and characteristics of studies

The results are reported in accordance with Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines. Figure 1 presents the PRISMA flowchart of study selection and inclusion. In total, 12 449 records were identified through database searches. Following removal of duplicates, 8766 records were screened based on abstracts and titles, and 581 full-text articles were assessed for eligibility. Ultimately 68 studies Reference Lindsay, Crino and Andrews10–Reference Alcolado and Radomsky14,Reference Fals-Stewart and Schafer16–Reference Visser, van Megen, van Oppen, Eikelenboom, Hoogendorn and Kaarsemaker24,Reference Emmelkamp and Beens26–Reference Twohig, Abramowitz, Smith, Fabricant, Jacoby and Morrison32,Reference Zejuan and Hailing35,Reference Anderson and Rees55–Reference Hong, Jing and Yanyan100 were included, with 3 published in Chinese.

Fig. 1

The Preferred Reporting Items for Systematic Reviews flowchart of study selection and inclusion.

Table 2 provides an overview of the key characteristics of the included studies. The 68 RCTs contained 76 comparisons and involved 4019 patients with OCD, with a mean age of 29 years (s.d. = 8.3). Fourteen studies targeted children/adolescents, encompassing 767 patients. Regarding treatment arms, 36 were CBT, 32 were ERP, 12 were cognitive therapy, 5 were IBA, 4 were ACT, 3 were MBT and 3 were MCT. In terms of control group, 29 were waitlist, 17 were psychological placebo, 8 were care-as-usual and 3 were pill placebo. Over half of the studies (60%) were published in the past 15 years. Geographically, 26 studies (38%) were conducted in North America, 24 (35%) in Europe, 9 (13%) in Asia, 6 (9%) in Australia and 3 (4%) in South America. Participants were recruited almost evenly from clinical (49%) and community (47%) settings. Regarding treatment, the majority of interventions spanned 8–15 sessions delivered over 8–15 weeks. Most studies (91%) utilised treatment manuals or protocols, 90% delivered treatments by professionals such as clinical psychologists or licensed psychotherapists and 78% checked treatment fidelity. In terms of outcome assessment, 64 studies (94%) used the (Children’s) Yale–Brown Obsessive–Compulsive Scale ((C)Y-BOCS) to evaluate treatment effectiveness. The remaining four studies employed other measures, including the Vancouver Obsessional Compulsive Inventory, the National Institute of Mental Health Obsessive–Compulsive Scale and the Maudsley Obsessional–CompulsiveCompulsive Inventory (MOCI). Details of study and intervention characteristics can be found in Appendices C and D.

Table 2

Key characteristics of the included studies

Regarding risk of bias, 7% of the included RCTs were rated as ‘low risk’, 32% as having ‘some concerns’ and 60% as ‘high risk’. Specifically, 56% of RCTs utilised adequate sequence generation, 43% employed allocation concealment, 62% performed intent-to-treat analysis and 78% reported self-reported or blinded clinician-rated outcomes. However, only 24% of RCTs reported outcomes unselectively. A detailed risk of bias assessment is provided in Appendix E.

Network plot

The network plot is shown in Fig. 2. Overall, the network was well connected. CBT and ERP were the psychotherapies most studied, followed by cognitive therapy. ACT, MBT, IBA and MCT were primarily connected through comparisons with ERP. Waitlist was the most connected control group, followed by psychological placebo and care-as-usual. Pill placebo was the control group least studied, with only three comparisons.

Fig. 2

The network plot of meta-analysis. The size of node and thickness of edge were based on the number of studies on that comparison. CBT, cognitive behaviour therapy; ERP, exposure and response prevention; CT, cognitive therapy; MBT, mindfulness-based therapy; MCT, metacognitive therapy; ACT, acceptance commitment therapy; IBA, inference-based approach; WL, waitlist; CAU, care-as-usual; Psy placebo, psychological placebo.

Pairwise meta-analyses

The results of pairwise meta-analyses are presented in Appendix F. The most frequently examined head-to-head comparison was between CBT and waitlist. CBT, ERP, cognitive therapy, MBT and ACT were significantly more effective than control groups (waitlist, care-as-usual, pill/psychological placebo) in reducing OCD symptom severity (SMD −1.62 to −0.42). Additionally, no significant differences were observed among the psychotherapies.

Network meta-analyses

Figure 3 shows the results of NMAs on effectiveness and acceptability (without adjustment for modifiers). Regarding effectiveness, all psychotherapies were significantly more effective than waitlist: CBT (SMD −1.20, 95% CI [−1.42, −0.98]; SUCRA, 45.1%; low certainty); ERP (SMD −1.39, 95% CI [−1.68, −1.10]; SUCRA, 58%; low certainty); cognitive therapy (SMD −1.40, 95% CI [−1.79, −1.01]; SUCRA, 27%; low certainty); MBT (SMD −0.96, 95% CI [−1.60, −0.33]; SUCRA, 37%; moderate certainty); MCT (SMD −1.32, 95% CI [−1.95, −0.70]; SUCRA, 75%; moderate certainty); IBA (SMD −1.14, 95% CI [−1.68, −0.59]; SUCRA, 83%; moderate certainty); and ACT (SMD −1.09, 95% CI [−1.60, −0.57]; SUCRA, 64%; low certainty). Global heterogeneity across the network was moderate to high (I 2 = 65.7%). All psychotherapies were also significantly more effective than pill placebo (SMD −1.44 to −1.00). Except for MBT, all psychotherapies were significantly more effective than both psychological placebo (SMD −0.95 to −0.63) and care-as-usual (SMD −0.95 to −0.76). Additionally, psychological placebo was significantly more effective than waitlist (SMD −0.45, 95% CI [−0.78; −0.13]). However, no significant differences were identified among psychotherapies. In regard to acceptability, no significant differences were observed between psychotherapies and control groups or among psychotherapies themselves. Additionally, in a post hoc analysis in which acceptability was calculated using odds ratios, the findings were generally consistent with those based on relative risks, showing no significant differences among psychotherapies. However, CBT (odds ratio 1.75, 95% CI [1.19, 2.58]), IBA (odds ratio 2.73, 95% CI [1.23, 6.08]) and psychological placebo (odds ratio 1.94, 95% CI [1.14, 3.31]) were significantly more acceptable than waitlist controls (see Appendix G).

Fig. 3

Network meta-analyses of psychotherapies for obsessive–compulsive disorder. Standardised mean differences (SMDs) and 95% confidence intervals (CIs) for effectiveness are reported below the diagonal. SMDs lower than 0 favour the column-defining treatment, with 95% CIs not including the point of no difference (0) highlighted in bold. Relative risks (RRs) and 95% confidence intervals for acceptability are reported above the diagonal. RRs greater than 1 favour the row-defining treatment, with 95% CIs not including the point of no difference (1) highlighted in bold. CBT, cognitive behaviour therapy; ERP, exposure and response prevention; CT, cognitive therapy; MBT, mindfulness-based therapy; MCT, metacognitive therapy; ACT, acceptance commitment therapy; IBA, inference-based approach; CAU, care-as-usual; Psy placebo, psychological placebo; WL, waitlist.

Ranking of psychotherapies

In regard to effectiveness, ERP and cognitive therapy ranked highest, followed by MCT, CBT, IBA, ACT and MBT. In terms of acceptability, IBA ranked highest, followed by MCT, ACT, ERP, CBT, MBT and cognitive therapy. The ranking forest of psychotherapies relative to waitlist – the most frequently used comparator – can be found in Appendix H, along with a scatterplot combining effectiveness and acceptability. Regarding confidence in the quality of evidence assessed through CINeMA, none of the comparisons were rated as ‘high confidence’, primarily due to within-study bias. Confidence in the estimate ranged from moderate to low (see Appendix I).

Consistency examination

Visual inspection of the distribution of potential effect modifiers indicated that potential modifiers were similarly distributed across the comparisons in the network (see Appendix J). Both local and global tests generally demonstrated substantial consistency between direct and indirect evidence. However, some comparisons – such as CBT versus ERP – were informed by a limited number of studies, which may reduce the reliability of consistency assumptions for those specific comparisons due to low statistical power (see Appendix K).

Sensitivity analyses

Sensitivity analyses excluding outliers and studies with comorbidities yielded results consistent with the main analyses. Similarly, post hoc sensitivity analyses restricted to adults with OCD, those excluding waitlist comparisons and those excluding comparisons supported by only a single study produced comparable findings. In the sensitivity analysis for studies with a low risk of bias, 13 comparisons were identified and the results were generally similar, with minor deviations from the main analyses. No significant differences were found among psychotherapies. All psychotherapies, except for MBT and IBA, were significantly more effective than waitlist. Detailed results of sensitivity analyses can be found in Appendix L.

Discussion

To our knowledge, this network meta-analysis is the largest study to date to simultaneously evaluate the effectiveness and acceptability of various psychotherapies for OCD. All psychotherapies were significantly more effective than control conditions. No significant differences were found among the psychotherapies in terms of either effectiveness or acceptability, and these findings were robust across most sensitivity analyses. Although minor deviations emerged in the analysis restricted to studies rated as low risk of bias, these differences may reflect the limited number of studies included. Although the findings offer valuable insights for research and clinical practice, they should be interpreted with caution due to substantial heterogeneity, high risk of bias across the included studies and their limited statistical power to detect differences between psychotherapies.

In terms of effectiveness, CBT and ERP remain the most extensively studied psychotherapies for OCD, and demonstrated large significant effects consistent with prior research. Reference Wang, Miguel, Ciharova, Amarnath, Lin and Zhao9–Reference Rosa-Alcázar, Sánchez-Meca, Gómez-Conesa and Marín-Martínez101 Cognitive therapy demonstrated effect sizes comparable to CBT and ERP, which aligns with an earlier meta-analysis. Reference Rosa-Alcázar, Sánchez-Meca, Gómez-Conesa and Marín-Martínez101 However, those findings contrast with a more recent meta-analysis Reference Wang, Miguel, Ciharova, Amarnath, Lin and Zhao9 that found lesser effects of cognitive therapy compared with CBT and ERP. Notably, these two analyses were limited to direct comparisons within individual studies and included a small number of cognitive therapy studies. MBT, MCT, ACT and IBA showed significant effectiveness in reducing OCD symptom severity, corroborating earlier research. Reference Evey and Steinman102–Reference Trent, Guzick, Viana and Storch105 Additionally, these approaches demonstrated effects comparable to CBT, ERP and cognitive therapy. These findings position cognitive therapy, MBT, MCT, ACT and IBA as potential alternatives to the widely recognised CBT and ERP. However, they also raise a critical question: should further research efforts prioritise novel psychotherapies when current evidence does not suggest superior outcomes in treating OCD? Nonetheless, because the current evidence may be influenced by limited statistical power – largely stemming from the predominance of RCTs on CBT and ERP and the relatively small number of trials investigating other approaches, as well as a high risk of bias across studies – further methodologically rigorous research is required to draw definitive conclusions. Moreover, comparable efficacy across psychotherapies does not necessarily imply uniform effectiveness in practice. Effect sizes may be influenced by potential moderators, such as individual characteristics. For instance, IBA has shown potential advantages for OCD patients with extremely poor insight. Reference O’Connor, Aardema, Bouthillier, Fournier, Guay and Robillard30 Future research should focus on identifying specific populations or individuals who may derive the greatest benefit from specific psychotherapies. This effort would help optimise treatment strategies and enhance personalisation in OCD management, ultimately improving patient outcomes. Regarding control groups, although waitlist was used as the reference comparator due to its prevalence across studies, we also evaluated the effects of psychotherapies relative to other control conditions, including psychological placebo, care-as-usual and pill placebo. The consistent superiority of psychotherapies across these comparisons supports their specific efficacy beyond non-specific treatment effects. Additionally, psychological placebo demonstrated significantly greater effectiveness than waitlist. This finding aligns with a meta-analysis in depression, Reference Michopoulos, Furukawa, Noma, Kishimoto, Onishi and Ostinelli106 but contrasts with a more recent meta-analysis Reference Wang, Miguel, Ciharova, Amarnath, Lin and Zhao9 which found that psychological placebo yielded the smallest effects compared with waitlist, care-as-usual and pill placebo. These discrepancies highlight the need for further research examining how different types of control conditions influence effect size estimates in psychotherapy trials.

The development of various psychotherapies is closely associated with the limitations of ERP. Although ERP demonstrates strong efficacy, an estimated 62% of participants are classified as ‘non-responders’. Reference Cuijpers, Miguel, Ciharova, Harrer, Basic and Cristea107 Moreover, the nature of ERP, which requires that participants resist anxiety-reduction behaviours when confronted with anxiety-provoking situations, leads to treatment refusal in 25–30% of participants, Reference Ong, Clyde, Bluett, Levin and Twohig108 with an attrition rate of 18.7%. Reference Ong, Clyde, Bluett, Levin and Twohig108 Practical barriers, such as the limited availability of trained clinicians and the intensive time commitment required for ERP, further restrict its applicability. Reference Hirschtritt, Bloch and Mathews109 As a result, clinicians and researchers are actively seeking more treatment options for OCD. Our results indicate that, although these therapies demonstrate effects similar to ERP, no significant differences were found regarding acceptability (drop-out rates). Given the absence of significant differences among psychotherapies in terms of both effectiveness and acceptability, treatment rankings should be interpreted as general guidance rather than definitive conclusions. Other important considerations – such as cost-effectiveness – also play a critical role in treatment selection. Ultimately, when multiple evidence-based options are available, the choice of therapy should be guided by patient preference, clinical characteristics and contextual factors to optimise care. Importantly, the findings may be affected by the limited number of studies on these therapies. Future research focusing on treatment adherence is needed to validate these results. Additionally, studies examining patient-level predictors and moderators of treatment adherence are highly recommended, because they will help refine treatment strategies and improve outcomes for OCD patients.

The current study offers important strengths and implications. Methodologically, it combined both available direct and indirect evidence of comparison of different psychotherapies, providing an overview of the psychotherapy field for OCD. Notably, it analysed recently developed interventions – MBT, MCT, ACT and IBA – individually, rather than aggregating them under the broad category of third-wave CBT, thus offering more specific insights into their individual effectiveness. The findings also yield key implications for research and clinical practice. First, whereas cognitive therapy and ERP demonstrate efficacy similar to CBT, the unique advantages of CBT – where it integrates both cognitive therapy and ERP – remain to be fully explored. Second, given the current literature predominantly centred on CBT and ERP, more studies evaluating other psychotherapies such as cognitive therapy, MBT, MCT, ACT and IBA, as well as head-to-head comparisons, are needed to validate and expand current findings. Third, most existing studies focus on adults, highlighting the need for further research on the effectiveness of psychotherapies in children and adolescents with OCD. Fourth, the results emphasise the importance of identifying which psychotherapies are most effective for specific subgroups, thereby promoting more personalised treatment strategies. Fifth, detailed reporting of clinical characteristics – such as psychiatric medication use – is encouraged to better identify moderators and predictors of treatment outcomes. Sixth, cost-effective research is needed to guide evidence-based resource allocation in mental health services. Seventh, although psychotherapies show broadly comparable efficacy, future studies should examine how these interventions can be effectively implemented and adapted across diverse cultural and healthcare systems to improve accessibility and impact. Additionally, more rigorous assessment of potential adverse effects is essential to ensure treatment safety and support informed clinical decisions. Lastly, future studies should adopt methodologically robust designs to minimise heterogeneity and reduce the risk of bias, thereby improving the validity and reliability of findings in this field.

However, several limitations should be acknowledged. First, the transitivity assumption underlying network meta-analysis cannot be fully guaranteed, given the limited number of direct comparisons and the substantial heterogeneity observed across several comparisons. This heterogeneity reflects potential clinical or methodological variability among studies with similar designs and may affect the validity of indirect evidence. Future research using more methodologically rigorous designs is needed to examine the influence of potential effect modifiers, particularly clinically relevant variables such as baseline OCD severity. Second, the high risk of bias across included studies, primarily due to selective reporting, may compromise the validity, reliability, confidence and statistical power of the findings, thereby necessitating cautious interpretation. Third, although we selected a single effect size per comparison per study – a common approach in network meta-analyses – most studies used (C)Y-BOCS, with a few employing other instruments such as MOCI. This variation in measurement tools may affect the validity of the results. Future studies are recommended to examine the independence among multiple outcomes or the specific effects of different measurement instruments on treatment effects, using methodologies explicitly designed for this purpose, such as multivariate or three-level meta-analytic models. Fourth, we used drop-out rates as a proxy for treatment acceptability; however, this measure may not capture the full complexity of patient experiences or decision-making. Future studies should consider incorporating more direct and multidimensional assessments of acceptability, such as the proportion of planned sessions completed, patient-reported satisfaction or engagement metrics. In addition, discrepancies in acceptability findings based on relative risks versus odds ratios may partly reflect the limited number of available studies, underscoring the need for both further research on treatment acceptability and methodological investigations examining the impact of different analytic approaches. Fifth, the study did not assess the long-term effects of psychotherapies due to limited follow-up data, leaving uncertainty regarding the durability of treatment effects and highlighting the need for future research on sustained outcomes. Lastly, by including only published or in-press studies and excluding unpublished studies, the analysis may be subject to publication bias, potentially affecting the comprehensiveness and robustness of the findings. Taken together, although this study offers valuable insights into the comparative effectiveness and acceptability of psychotherapies for OCD, the interpretation of its findings should be tempered by these limitations.

In conclusion, psychotherapies are similarly effective and acceptable for treating OCD. However, the limited statistical power, substantial heterogeneity and high risk of bias across most included studies highlight the need for more rigorous, methodologically robust research to validate these findings. Ensuring the effective and acceptable application of psychotherapies across diverse populations and settings is crucial for optimisation of OCD management.

Supplementary material

The supplementary material is available online https://doi.org/10.1192/bjp.2026.10651

Data availability

The data that support the findings of this study are available from the corresponding author Y.W., upon reasonable request.

Acknowledgements

We thank C.M., M.C., A.A., J.L. and R.Z. for their contribution to data collection.

Author contributions

Y.W., S.Y.S., L.M.d.W. and P.C. designed the study. Y.W. conducted analyses and prepared the draft manuscript. Y.W., C.M., M.C., A.A., J.L. and R.Z. contributed to data collection. C.M., M.B.J.T., M.C., J.L., R.Z., S.Y.S., L.M.d.W. and P.C. provided critical and intellectual comments on the draft. All authors reviewed and approved the final manuscript.

Funding

Y.W. is financially supported by the Chinese Scholarship Council (grant no. 202108330055) for her PhD. The funding source had no role in the design of the research. Open Access funding is provided by Vrije Universiteit Amsterdam.

Declaration of interest

All authors declare there are no conflicts of interest. P.C. is member of the British Journal of Psychiatry editorial board and did not take part in the review or decision-making process of this paper.

References

Abramowitz, JS, Jacoby, RJ. Obsessive-compulsive disorder in the DSM-5. Clin Psychol Sci Pract 2014; 21: 221–35.10.1111/cpsp.12076CrossRefGoogle Scholar
Fawcett, EJ, Power, H, Fawcett, JM. Women are at greater risk of OCD than men: a meta-analytic review of OCD prevalence worldwide. J Clin Psychiatry 2020; 81: 13075.10.4088/JCP.19r13085CrossRefGoogle Scholar
Subramaniam, M, Abdin, E, Vaingankar, JA, Chong, SA. Obsessive–compulsive disorder: prevalence, correlates, help-seeking and quality of life in a multiracial Asian population. Soc Psychiatry Psychiatr Epidemiol 2012; 47: 2035–43.10.1007/s00127-012-0507-8CrossRefGoogle Scholar
Kessler, RC, Petukhova, M, Sampson, NA, Zaslavsky, AM, Wittchen, HU. Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. Int J Methods Psychiatr Res 2012; 21: 169–84.10.1002/mpr.1359CrossRefGoogle ScholarPubMed
Ruscio, AM, Stein, DJ, Chiu, WT, Kessler, RC. The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Mol Psychiatry 2010; 15: 53–63.10.1038/mp.2008.94CrossRefGoogle ScholarPubMed
World Health Organization. Projections of Mortality and Burden of Disease, 2004–2030. WHO, 2016.Google Scholar
Steketee, G. Disability and family burden in obsessive–compulsive disorder. Can J Psychiatry 1997; 42: 919–28.10.1177/070674379704200902CrossRefGoogle ScholarPubMed
Stengler-Wenzke, K, Kroll, M, Matschinger, H, Angermeyer, MC. Quality of life of relatives of patients with obsessive-compulsive disorder. Compr Psychiatry 2006; 47: 523–7.10.1016/j.comppsych.2006.02.002CrossRefGoogle ScholarPubMed
Wang, Y, Miguel, C, Ciharova, M, Amarnath, A, Lin, J, Zhao, R, et al. The effectiveness of psychological treatments for obsessive-compulsive disorders: a meta-analysis of randomized controlled trials published over last 30 years. Psychol Med 2024; 54: 2838–51.10.1017/S0033291724001375CrossRefGoogle ScholarPubMed
Lindsay, M, Crino, R, Andrews, G. Controlled trial of exposure and response prevention in obsessive-compulsive disorder. Br J Psychiatry 1997; 171: 135–9.10.1192/bjp.171.2.135CrossRefGoogle ScholarPubMed
Norman, LJ, Mannella, KA, Yang, H, Angstadt, M, Abelson, JL, Himle, JA, et al. Treatment-specific associations between brain activation and symptom reduction in OCD following CBT: a randomized fMRI trial. Am J Psychiatry 2021; 178: 39–47.10.1176/appi.ajp.2020.19080886CrossRefGoogle ScholarPubMed
Bolton, D, Perrin, S. Evaluation of exposure with response-prevention for obsessive compulsive disorder in childhood and adolescence. J Behav Ther Exp Psychiatry 2008; 39: 11–22.10.1016/j.jbtep.2006.11.002CrossRefGoogle ScholarPubMed
van Balkom, AJ, de Haan, E, van Oppen, P, Spinhoven, P, Hoogduin, KA, van Dyck, R. Cognitive and behavioral therapies alone versus in combination with fluvoxamine in the treatment of obsessive compulsive disorder. J Nerv Ment Dis 1998; 186: 492–9.10.1097/00005053-199808000-00007CrossRefGoogle ScholarPubMed
Alcolado, GM, Radomsky, AS. A novel cognitive intervention for compulsive checking: targeting maladaptive beliefs about memory. J Behav Ther Exp Psychiatry 2016; 53: 75–83.10.1016/j.jbtep.2015.02.009CrossRefGoogle ScholarPubMed
Baruah, U, Pandian, RD, Narayanaswamy, JC, Bada Math, S, Kandavel, T, Reddy, YCJ. A randomized controlled study of brief family-based intervention in obsessive compulsive disorder. J Affect Disord 2018; 225: 137–46.10.1016/j.jad.2017.08.014CrossRefGoogle ScholarPubMed
Fals-Stewart, W, Schafer, J. The treatment of substance abusers diagnosed with obsessive-compulsive disorder: an outcome study. J Subst Abuse Treat 1992; 9: 365–70.10.1016/0740-5472(92)90032-JCrossRefGoogle ScholarPubMed
Mancebo, MC, Yip, AG, Boisseau, CL, Rasmussen, SA, Zlotnick, C. Behavioral therapy teams for obsessive-compulsive disorder: lessons learned from a pilot randomized trial in a community mental health center. Behav Ther 2021: 52: 1296–309.10.1016/j.beth.2021.02.009CrossRefGoogle Scholar
Mathur, S, Sharma, MP, Balachander, S, Kandavel, T, Reddy, YCJ. A randomized controlled trial of mindfulness-based cognitive therapy vs stress management training for obsessive-compulsive disorder. J Affect Disord 2021; 282: 58–68.10.1016/j.jad.2020.12.082CrossRefGoogle ScholarPubMed
Zhang, T, Lu, L, Didonna, F, Wang, Z, Zhang, H, Fan, Q. Mindfulness-based cognitive therapy for unmedicated obsessive-compulsive disorder: a randomized controlled trial with 6-month follow-up. Front Psychiatry 2021; 12: 661807.10.3389/fpsyt.2021.661807CrossRefGoogle ScholarPubMed
Glombiewski, JA, Hansmeier, J, Haberkamp, A, Rief, W, Exner, C. Metacognitive therapy versus exposure and response prevention for obsessive-compulsive disorder – a pilot randomized trial. J Obsessive Compuls Relat Disord 2021; 30: 100650.10.1016/j.jocrd.2021.100650CrossRefGoogle Scholar
Melchior, K, van der Heiden, C, Deen, M, Mayer, B, Franken, IHA. The effectiveness of metacognitive therapy in comparison to exposure and response prevention for obsessive-compulsive disorder: a randomized controlled trial. J Obsessive Compuls Relat Disord 2023; 36: 100780.10.1016/j.jocrd.2023.100780CrossRefGoogle Scholar
Twohig, MP, Hayes, SC, Plumb, JC, Pruitt, LD, Collins, AB, Hazlett-Stevens, H, et al. A randomized clinical trial of acceptance and commitment therapy versus progressive relaxation training for obsessive-compulsive disorder. J Consult Clin Psychol 2010; 78: 705–16>.10.1037/a0020508CrossRefGoogle ScholarPubMed
Lee, SW, Choi, M, Lee, SJ. A randomized controlled trial of group-based acceptance and commitment therapy for obsessive-compulsive disorder. J Context Behav Sci 2023; 27: 45–53.10.1016/j.jcbs.2022.11.009CrossRefGoogle Scholar
Visser, HA, van Megen, H, van Oppen, P, Eikelenboom, M, Hoogendorn, AW, Kaarsemaker, M, et al. Inference-based approach versus cognitive behavioral therapy in the treatment of obsessive-compulsive disorder with poor insight: a 24-session randomized controlled trial. Psychother Psychosom 2015; 84: 284–93.10.1159/000382131CrossRefGoogle ScholarPubMed
Schneider, BC, Wittekind, CE, Talhof, A, Korrelboom, K, Moritz, S. Competitive Memory Training (COMET) for OCD: a self-treatment approach to obsessions. Cogn Behav Ther 2015; 44: 142–52.10.1080/16506073.2014.981758CrossRefGoogle ScholarPubMed
Emmelkamp, PMG, Beens, H. Cognitive therapy with obsessive-compulsive disorder: a comparative evaluation. Behav Res Ther 1991; 29: 293–300.10.1016/0005-7967(91)90120-RCrossRefGoogle ScholarPubMed
Rodrigues, EP, Fechine, AJB, Oliveira, AC, Matos, CFF, Passarela, CM, Hemanny, C, et al. Randomized trial of the efficacy of trial-based cognitive therapy for obsessive-compulsive disorder: preliminary findings. Trends Psychiatry Psychother 2023; 45: e20210247.Google ScholarPubMed
Rector, NA, Richter, MA, Katz, D, Leybman, M. Does the addition of cognitive therapy to exposure and response prevention for obsessive compulsive disorder enhance clinical efficacy? A randomized controlled trial in a community setting. Br J Clin Psychol 2019: 58: 1–18.10.1111/bjc.12188CrossRefGoogle Scholar
McLean, PD, Whittal, ML, Thordarson, DS, Taylor, S, Söchting, I, Koch, WJ, et al. Cognitive versus behavior therapy in the group treatment of obsessive-compulsive disorder. J Consult Clin Psychol 2001; 69: 205–14.10.1037/0022-006X.69.2.205CrossRefGoogle Scholar
O’Connor, KP, Aardema, F, Bouthillier, D, Fournier, S, Guay, S, Robillard, S, et al. Evaluation of an inference-based approach to treating obsessive–compulsive disorder. Cogn Behav Ther 2005; 34: 148–63.10.1080/16506070510041211CrossRefGoogle ScholarPubMed
Aardema, F, Bouchard, S, Koszycki, D, Lavoie, ME, Audet, J-S, O’Connor, K. Evaluation of inference-based cognitive-behavioral therapy for obsessive-compulsive disorder: a multicenter randomized controlled trial with three treatment modalities. Psychother Psychosom 2022; 91: 348–59.10.1159/000524425CrossRefGoogle ScholarPubMed
Twohig, MP, Abramowitz, JS, Smith, BM, Fabricant, LE, Jacoby, RJ, Morrison, KL, et al. Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: a randomized controlled trial. Behav Res Ther 2018; 108: 1–9.10.1016/j.brat.2018.06.005CrossRefGoogle ScholarPubMed
White, IR. Network meta-analysis. Stata J 2015; 15: 951–85.10.1177/1536867X1501500403CrossRefGoogle Scholar
Chinese Society of Psychiatry. Chinese Guidelines for the Prevention and Treatment of Obsessive-Compulsive Disorder 2016 (Concise Edition) . Chin J Psychiatry 2016; 49: 14.Google Scholar
Zejuan, F, Hailing, X. Evaluation of the effect of cognitive-behavioral intervention therapy on improving psychological status and quality of life in patients with obsessive-compulsive disorder. J Pract Clin Med 2016; 20: 17–20.Google Scholar
Sisi, H. A randomized controlled study on managing obsessive thoughts using anxiety identification method and mindfulness strategies. Chin J Ment Health 2016; 30: 273–80.Google Scholar
Yanmeng, G, Zhipeng, X, Changhai, W. Treatment of obsessive-compulsive disorder with hypnotherapy. J Mudanjiang Med Univ 2009; 30: 43–4.Google Scholar
Wang, Y, Amarnath, A, Miguel, C, Ciharova, M, Lin, J, Zhao, R, et al. The effectiveness of unguided self-help psychological interventions for obsessive-compulsive disorder: a meta-analysis of randomized controlled trials. Compreh Psychiatry 2024; 130: 152453.10.1016/j.comppsych.2024.152453CrossRefGoogle ScholarPubMed
Wang, X, Duan, T, Cao, Z, Xu, C. Childhood trauma and adulthood adverse experiences and risk of new-onset depression across the lifespan. Br J Psychiatry 2026; 2025: 1–7.10.1192/bjp.2026.10588CrossRefGoogle Scholar
Cuijpers, P, Schuurmans, J. Self-help interventions for anxiety disorders: an overview. Curr Psychiatry Rep 2007; 9: 284–90.10.1007/s11920-007-0034-6CrossRefGoogle ScholarPubMed
Pearcy, CP, Anderson, RA, Egan, SJ, Rees, CS. A systematic review and meta-analysis of self-help therapeutic interventions for obsessive-compulsive disorder: is therapeutic contact key to overall improvement? J Behav Ther Exp Psychiatry 2016; 51: 74–83.10.1016/j.jbtep.2015.12.007CrossRefGoogle ScholarPubMed
Sterne, JAC, Savović, J, Page, MJ, Elbers, RG, Blencowe, NS, Boutron, I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 2019; 366: l4898.10.1136/bmj.l4898CrossRefGoogle ScholarPubMed
Ioannidis, JPA, Patsopoulos, NA, Evangelou, E. Uncertainty in heterogeneity estimates in meta-analyses. BMJ 2007; 335: 914–16.10.1136/bmj.39343.408449.80CrossRefGoogle ScholarPubMed
Egger, M, Smith, GD, Schneider, M, Minder, C. Bias in meta-analysis detected by a simple, graphical test. BMJ 1997; 315: 629–34.10.1136/bmj.315.7109.629CrossRefGoogle ScholarPubMed
Hutton, B, Salanti, G, Caldwell, DM, Chaimani, A, Schmid, CH, Cameron, C, et al. The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations. Ann Intern Med 2015; 162: 777–84.10.7326/M14-2385CrossRefGoogle ScholarPubMed
Rücker, G. Network meta-analysis, electrical networks and graph theory. Res Synth Methods 2012; 3: 312–24.10.1002/jrsm.1058CrossRefGoogle ScholarPubMed
Higgins, JPT, Jackson, D, Barrett, JK, Lu, G, Ades, AE, White, IR. Consistency and inconsistency in network meta-analysis: concepts and models for multi-arm studies. Res Synth Methods 2012; 3: 98–110.10.1002/jrsm.1044CrossRefGoogle ScholarPubMed
Salanti, G, Ades, AE, Ioannidis, JPA. Graphical methods and numerical summaries for presenting results from multiple-treatment meta-analysis: an overview and tutorial. J Clin Epidemiol 2011; 64: 163–71.10.1016/j.jclinepi.2010.03.016CrossRefGoogle ScholarPubMed
Krahn, U, Binder, H, König, J. A graphical tool for locating inconsistency in network meta-analyses. BMC Med Res Methodol 2013; 13: 35.10.1186/1471-2288-13-35CrossRefGoogle ScholarPubMed
Dias, S, Welton, NJ, Caldwell, DM, Ades, AE. Checking consistency in mixed treatment comparison meta-analysis. Stat Med 2010; 29: 932–44.10.1002/sim.3767CrossRefGoogle ScholarPubMed
Viechtbauer, W, Cheung, MW-L. Outlier and influence diagnostics for meta-analysis. Res Synth Methods 2010; 1: 112–25.10.1002/jrsm.11CrossRefGoogle ScholarPubMed
Harrer, M, Cuijpers, P, Furukawa, T, Ebert, D. Doing Meta-analysis with R: A Hands-on Guide. Chapman and Hall/CRC, 2021.10.1201/9781003107347CrossRefGoogle Scholar
Balduzzi, S, Rücker, G, Nikolakopoulou, A, Papakonstantinou, T, Salanti, G, Efthimiou, O, Schwarzer, G. An R package for network meta-analysis using frequentist methods. J Stat Softw 2023; 106: 1–40.10.18637/jss.v106.i02CrossRefGoogle Scholar
Papakonstantinou, T, Nikolakopoulou, A, Higgins, JPT, Egger, M, Salanti, G. Cinema: software for semiautomated assessment of the confidence in the results of network meta-analysis. Campbell Syst Rev 2020; 16: e1080.10.1002/cl2.1080CrossRefGoogle ScholarPubMed
Anderson, RA, Rees, CS. Group versus individual cognitive-behavioural treatment for obsessive-compulsive disorder: a controlled trial. Behav Res Ther 2007; 45: 123–37.10.1016/j.brat.2006.01.016CrossRefGoogle ScholarPubMed
Andersson, E, Enander, J, Andrén, P, Hedman, E, Ljótsson, B, Hursti, T, et al. Internet-based cognitive behaviour therapy for obsessive-compulsive disorder: a randomized controlled trial. Psychol Med 2012; 42: 2193–203.10.1017/S0033291712000244CrossRefGoogle ScholarPubMed
Barrett, P, Healy, L, March, JS. Behavioral avoidance test for childhood obsessive-compulsive disorder: a home-based observation. Am J Psychother 2003; 57: 80–100.10.1176/appi.psychotherapy.2003.57.1.80CrossRefGoogle ScholarPubMed
Barrett, P, Healy-Farrell, L, March, JS. Cognitive-behavioral family treatment of childhood obsessive-compulsive disorder: a controlled trial. J Am Acad Child Adolesc Psychiatry 2004; 43: 46–62.10.1097/00004583-200401000-00014CrossRefGoogle ScholarPubMed
Belloch, A, Cabedo, E, Carrió, C. Empirically grounded clinical interventions: cognitive versus behaviour therapy in the individual treatment of obsessive-compulsive disorder: changes in cognitions and clinically significant outcomes at post-treatment and one-year follow-up. Behav Cogn Psychother 2008; 36: 521–40.10.1017/S1352465808004451CrossRefGoogle Scholar
Bolton, D, Williams, T, Perrin, S, Atkinson, L, Gallop, C, Waite, P, et al. Randomized controlled trial of full and brief cognitive-behaviour therapy and wait-list for paediatric obsessive-compulsive disorder. J Child Psychol Psychiatry 2011; 52: 1269–78.10.1111/j.1469-7610.2011.02419.xCrossRefGoogle ScholarPubMed
Braga, DT, Abramovitch, A, Fontenelle, LF, Ferrão, YA, Gomes, JB, Vivan, AS, et al. Neuropsychological predictors of treatment response to cognitive behavioral group therapy in obsessive-compulsive disorder. Depress Anxiety 2016; 33: 848–61.10.1002/da.22509CrossRefGoogle ScholarPubMed
Challacombe, FL, Salkovskis, PM, Woolgar, M, Wilkinson, EL, Read, J, Acheson, R. A pilot randomized controlled trial of time-intensive cognitive–behaviour therapy for postpartum obsessive–compulsive disorder: effects on maternal symptoms, mother–infant interactions and attachment. Psychol Med 2017; 47: 1478–88.10.1017/S0033291716003573CrossRefGoogle ScholarPubMed
Volpato Cordioli, A, Heldt, E, Braga Bochi, D, Margis, R, Basso de Sousa, M, Fonseca Tonello, J, et al. Cognitive-behavioral group therapy in obsessive-compulsive disorder: a randomized clinical trial. Psychother Psychosom 2003; 72: 211–16.10.1159/000070785CrossRefGoogle ScholarPubMed
Emmelkamp, PMG, Visser, S, Hoekstra, RJ. Cognitive therapy vs exposure in vivo in the treatment of obsessive-compulsives. Cogn Ther Res 1988; 12: 103–14.10.1007/BF01172784CrossRefGoogle Scholar
Exner, C, Kleiman, A, Haberkamp, A, Hansmeier, J, Milde, C, Glombiewski, JA. Metacognitive therapy versus exposure and response prevention for obsessive-compulsive disorder – a non-inferiority randomized controlled trial. J Anxiety Disord 2024; 104: 102873.10.1016/j.janxdis.2024.102873CrossRefGoogle ScholarPubMed
Foa, EB, Liebowitz, MR, Kozak, MJ, Davies, S, Campeas, R, Franklin, ME, et al. Randomized, placebo-controlled trial of exposure and ritual prevention, clomipramine, and their combination in the treatment of obsessive-compulsive disorder. Am J Psychiatry 2005; 162: 151–61.10.1176/appi.ajp.162.1.151CrossRefGoogle ScholarPubMed
Freeman, J, Sapyta, J, Garcia, A, Compton, S, Khanna, M, Flessner, C, et al. Family-based treatment of early childhood obsessive-compulsive disorder: the Pediatric Obsessive-Compulsive Disorder Treatment Study for Young Children (POTS Jr) – a randomized clinical trial. JAMA Psychiatry 2014; 71: 689–98.10.1001/jamapsychiatry.2014.170CrossRefGoogle Scholar
Freeman, JB, Garcia, AM, Coyne, L, Ale, C, Przeworski, A, Himle, M, et al. Early childhood OCD: preliminary findings from a family-based cognitive-behavioral approach. J Am Acad Child Adolesc Psychiatry 2008; 47: 593–602.10.1097/CHI.0b013e31816765f9CrossRefGoogle ScholarPubMed
Freeston, MH, Ladouceur, R, Gagnon, F, Thibodeau, N, Rhéaume, J, Letarte, H, et al. Cognitive-behavioral treatment of obsessive thoughts: a controlled study. J Consult Clin Psychol 1997; 65: 405–13.10.1037/0022-006X.65.3.405CrossRefGoogle ScholarPubMed
Gomes, JB, Cordioli, AV, Bortoncello, CF, Braga, DT, Gonçalves, F, Heldt, E. Impact of cognitive-behavioral group therapy for obsessive-compulsive disorder on family accommodation: a randomized clinical trial. Psychiatry Res 2016; 246: 70–6.10.1016/j.psychres.2016.09.019CrossRefGoogle ScholarPubMed
Greist, JH, Marks, IM, Baer, L, Kobak, KA, Wenzel, KW, Hirsch, MJ, et al. Behavior therapy for obsessive-compulsive disorder guided by a computer or by a clinician compared with relaxation as a control. J Clin Psychiatry 2002; 63: 138–45.10.4088/JCP.v63n0209CrossRefGoogle ScholarPubMed
Herbst, N, Voderholzer, U, Thiel, N, Schaub, R, Knaevelsrud, C, Stracke, S, et al. No talking, just writing! Efficacy of an Internet-based cognitive behavioral therapy with exposure and response prevention in obsessive compulsive disorder. Psychother Psychosom 2014; 83: 165–75.10.1159/000357570CrossRefGoogle ScholarPubMed
Hollmann, K, Hohnecker, CS, Haigis, A, Alt, AK, Kühnhausen, J, Pascher, A, et al. Internet-based cognitive behavioral therapy in children and adolescents with obsessive-compulsive disorder: a randomized controlled trial. Front Psychiatry 2022; 13: 989550.10.3389/fpsyt.2022.989550CrossRefGoogle ScholarPubMed
Jaurrieta, N, Jimenez-Murcia, S, Menchón, JM, Alonso, MDP, Segalas, C, ÁLvarez-Moya, EM, et al. Individual versus group cognitive–behavioral treatment for obsessive–compulsive disorder: a controlled pilot study. Psychother Res 2008; 18: 604–14.10.1080/10503300802192141CrossRefGoogle ScholarPubMed
Katz, DE, Rector, NA, McCabe, RE, Hawley, LL, Rowa, K, Richter, MA, et al. The effect of aerobic exercise alone and in combination with cognitive behavioural therapy on obsessive compulsive disorder: a randomized control study. J Anxiety Disord 2023; 98: 102746.10.1016/j.janxdis.2023.102746CrossRefGoogle ScholarPubMed
Kobayashi, Y, Kanie, A, Nakagawa, A, Takebayashi, Y, Shinmei, I, Nakayama, N, et al. An evaluation of family-based treatment for OCD in Japan: a pilot randomized controlled trial. Front Psychiatry 2020; 10: 932.10.3389/fpsyt.2019.00932CrossRefGoogle ScholarPubMed
Kyrios, M, Ahern, C, Fassnacht, DB, Nedeljkovic, M, Moulding, R, Meyer, D. Therapist-assisted internet-based cognitive behavioral therapy versus progressive relaxation in obsessive-compulsive disorder: randomized controlled trial. J Med Internet Res 2018; 20: e242.10.2196/jmir.9566CrossRefGoogle ScholarPubMed
Launes, G, Hagen, K, Sunde, T, Öst, LGG, Klovning, I, Laukvik, I-L, et al. A randomized controlled trial of concentrated ERP, self-help and waiting list for obsessive-compulsive disorder: the Bergen 4-day treatment. Front Psychol 2019; 10: 2500.10.3389/fpsyg.2019.02500CrossRefGoogle ScholarPubMed
Lenhard, F, Andersson, E, Mataix-Cols, D, Rück, C, Vigerland, S, Högström, J, et al. Therapist-guided, internet-delivered cognitive-behavioral therapy for adolescents with obsessive-compulsive disorder: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry 2017; 56: 10–9.e2.10.1016/j.jaac.2016.09.515CrossRefGoogle ScholarPubMed
Lewin, AB, Park, JM, Jones, AM, Crawford, EA, De Nadai, AS, Menzel, J, et al. Family-based exposure and response prevention therapy for preschool-aged children with obsessive-compulsive disorder: a pilot randomized controlled trial. Behav Res Ther 2014; 56: 30–8.10.1016/j.brat.2014.02.001CrossRefGoogle ScholarPubMed
Matsumoto, K, Hamatani, S, Makino, T, Takahashi, J, Suzuki, F, Ida, T, et al. Guided internet-based cognitive behavioral therapy for obsessive-compulsive disorder: a multicenter randomized controlled trial in Japan. Internet Intervent 2022; 28: 100515.10.1016/j.invent.2022.100515CrossRefGoogle ScholarPubMed
OConnor, K, Todorov, C, Robillard, S, Borgeat, F, Brault, M. Cognitive-behaviour therapy and medication in the treatment of obsessive-compulsive disorder: a controlled study. Can J Psychiatry 1999; 44: 64–71.10.1177/070674379904400108CrossRefGoogle ScholarPubMed
O’Connor, KP, Aardema, F, Robillard, S, Guay, S, Pélissier, M‐C, Todorov, C, et al. Cognitive behaviour therapy and medication in the treatment of obsessive–compulsive disorder. Acta Psychiatr Scand 2006; 113: 408–19.10.1111/j.1600-0447.2006.00767.xCrossRefGoogle ScholarPubMed
Piacentini, J, Bergman, RL, Chang, S, Langley, A, Peris, T, Wood, JJ, et al. Controlled comparison of family cognitive behavioral therapy and psychoeducation/relaxation training for child obsessive-compulsive disorder. J Am Acad Child Adolesc Psychiatry 2011; 50: 1149–61.10.1016/j.jaac.2011.08.003CrossRefGoogle ScholarPubMed
Russell, AJ, Jassi, A, Fullana, MA, Mack, H, Johnston, K, Heyman, I, et al. Cognitive behavior therapy for comorbid obsessive-compulsive disorder in high-functioning autism spectrum disorders: a randomized controlled trial. Depress Anxiety 2013; 30: 697–708.10.1002/da.22053CrossRefGoogle ScholarPubMed
Russman Block, S, Norman, LJ, Zhang, X, Mannella, KA, Yang, H, Angstadt, M, et al. Resting-state connectivity and response to psychotherapy treatment in adolescents and adults with OCD: a randomized clinical trial. Am J Psychiatry 2023; 180: 89–99.10.1176/appi.ajp.21111173CrossRefGoogle ScholarPubMed
Storch, EA, Caporino, NE, Morgan, JR, Lewin, AB, Rojas, A, Brauer, L, et al. Preliminary investigation of web-camera delivered cognitive-behavioral therapy for youth with obsessive-compulsive disorder. Psychiatry Res 2011; 189: 407–12.10.1016/j.psychres.2011.05.047CrossRefGoogle ScholarPubMed
Strauss, C, Lea, L, Hayward, M, Forrester, E, Leeuwerik, T, Jones, A-M, et al. Mindfulness-based exposure and response prevention for obsessive compulsive disorder: findings from a pilot randomised controlled trial. J Anxiety Disord 2018; 57: 39–47.10.1016/j.janxdis.2018.04.007CrossRefGoogle ScholarPubMed
Team POTSP. Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: the Pediatric OCD Treatment Study (POTS) randomized controlled trial. JAMA 2004; 292: 1969–76.10.1001/jama.292.16.1969CrossRefGoogle Scholar
Van Oppen, P, De Haan, E, Van Balkom, AJLM, Spinhoven, P, Hoogduin, K, Van Dyck, R. Cognitive therapy and exposure in vivo in the treatment of obsessive compulsive disorder. Behav Res Ther 1995; 33: 379–90.10.1016/0005-7967(94)00052-LCrossRefGoogle ScholarPubMed
Vogel, PA, Solem, S, Hagen, K, Moen, EM, Launes, G, Håland, ÅT, et al. A pilot randomized controlled trial of videoconference-assisted treatment for obsessive-compulsive disorder. Behav Res Ther 2014; 63: 162–8.10.1016/j.brat.2014.10.007CrossRefGoogle ScholarPubMed
Whittal, ML, Thordarson, DS, McLean, PD. Treatment of obsessive–compulsive disorder: cognitive behavior therapy vs. exposure and response prevention. Behav Res Ther 2005; 43: 1559–76.10.1016/j.brat.2004.11.012CrossRefGoogle ScholarPubMed
Whittal, ML, Woody, SR, McLean, PD, Rachman, SJ, Robichaud, M. Treatment of obsessions: a randomized controlled trial. Behav Res Ther 2010; 48: 295–303.10.1016/j.brat.2009.11.010CrossRefGoogle ScholarPubMed
Wilhelm, S, Steketee, G, Fama, JM, Buhlmann, U, Teachman, BA, Golan, E. Modular cognitive therapy for obsessive-compulsive disorder: a wait-list controlled trial. J Cogn Psychother 2009; 23: 294–305.10.1891/0889-8391.23.4.294CrossRefGoogle ScholarPubMed
Williams, TI, Salkovskis, PM, Forrester, L, Turner, S, White, H, Allsopp, MA. A randomised controlled trial of cognitive behavioural treatment for obsessive compulsive disorder in children and adolescents. Eur Child Adolesc Psychiatry. 2010; 19: 449–56.10.1007/s00787-009-0077-9CrossRefGoogle ScholarPubMed
Wolters, LH, de Haan, E, Hogendoorn, SM, Boer, F, Prins, PJM. Severe pediatric obsessive compulsive disorder and co-morbid autistic symptoms: effectiveness of cognitive behavioral therapy. J Obsessive Compuls Relat Disord 2016; 10: 69–77.10.1016/j.jocrd.2016.06.002CrossRefGoogle Scholar
Wootton, BM, Dear, BF, Johnston, L, Terides, MD, Titov, N. Remote treatment of obsessive-compulsive disorder: a randomized controlled trial. J Obsessive Compuls Relat Disord 2013; 2: 375–84.10.1016/j.jocrd.2013.07.002CrossRefGoogle Scholar
Wu, Y, Li, X, Zhou, Y, Gao, R, Wang, K, Ye, H, et al. Efficacy and cost-effectiveness analysis of internet-based cognitive behavioral therapy for obsessive–compulsive disorder: randomized controlled trial. J Med Internet Res 2023; 25: e41283.10.2196/41283CrossRefGoogle ScholarPubMed
Nan, Z. Observation of the effects of mindfulness cognitive therapy on patients with obsessive-compulsive disorder. China Urban Rural Enterp Hyg 2023; 38: 89–91.Google Scholar
Hong, X, Jing, C, Yanyan, F. Application effect of humanized psychological care combined with cognitive-behavioral intervention in patients with obsessive-compulsive disorder. Psychol Month 2023; 18:158–160, 163.Google Scholar
Rosa-Alcázar, AI, Sánchez-Meca, J, Gómez-Conesa, A, Marín-Martínez, F. Psychological treatment of obsessive-compulsive disorder: a meta-analysis. Clin Psychol Rev 2008; 28: 1310–25.10.1016/j.cpr.2008.07.001CrossRefGoogle ScholarPubMed
Evey, KJ, Steinman, SA. A systematic review of the use of acceptance and commitment therapy to treat adult obsessive-compulsive disorder. Behav Ther 2023; 54: 1006–19.10.1016/j.beth.2022.02.009CrossRefGoogle ScholarPubMed
Pseftogianni, F, Panagioti, M, Birtwell, K, Angelakis, I. Mindfulness interventions for obsessive–compulsive and related disorders: a systematic review and meta-analysis of randomized controlled trials. Clin Psychol Sci Pract 2023; 30: 233–43.10.1037/cps0000132CrossRefGoogle Scholar
Soondrum, T, Wang, X, Gao, F, Liu, Q, Fan, J, Zhu, X. The applicability of acceptance and commitment therapy for obsessive-compulsive disorder: a systematic review and meta-analysis. Brain Sci 2022; 12: 656.10.3390/brainsci12050656CrossRefGoogle ScholarPubMed
Trent, ES, Guzick, AG, Viana, AG, Storch, EA. Third-wave cognitive behavioral therapy for obsessive compulsive disorder? A promising approach if it includes exposure. Adv Psychiatry Behav Health 2021; 1: 37–51.10.1016/j.ypsc.2021.05.004CrossRefGoogle Scholar
Michopoulos, I, Furukawa, TA, Noma, H, Kishimoto, S, Onishi, A, Ostinelli, EG, et al. Different control conditions can produce different effect estimates in psychotherapy trials for depression. J Clin Epidemiol 2021; 132: 59–70.10.1016/j.jclinepi.2020.12.012CrossRefGoogle ScholarPubMed
Cuijpers, P, Miguel, C, Ciharova, M, Harrer, M, Basic, D, Cristea, IA, et al. Absolute and relative outcomes of psychotherapies for eight mental disorders: a systematic review and meta-analysis. World Psychiatry 2024; 23: 267–75.10.1002/wps.21203CrossRefGoogle ScholarPubMed
Ong, CW, Clyde, JW, Bluett, EJ, Levin, ME, Twohig, MP. Dropout rates in exposure with response prevention for obsessive-compulsive disorder: what do the data really say? J Anxiety Disord 2016; 40: 8–17.10.1016/j.janxdis.2016.03.006CrossRefGoogle Scholar
Hirschtritt, ME, Bloch, MH, Mathews, CA. Obsessive-compulsive disorder: advances in diagnosis and treatment. JAMA 2017; 317: 1358–67.10.1001/jama.2017.2200CrossRefGoogle ScholarPubMed
Figure 0

Table 1 Definitions of psychotherapy and control groups

Figure 1

Fig. 1 The Preferred Reporting Items for Systematic Reviews flowchart of study selection and inclusion.

Figure 2

Table 2 Key characteristics of the included studies

Figure 3

Fig. 2 The network plot of meta-analysis. The size of node and thickness of edge were based on the number of studies on that comparison. CBT, cognitive behaviour therapy; ERP, exposure and response prevention; CT, cognitive therapy; MBT, mindfulness-based therapy; MCT, metacognitive therapy; ACT, acceptance commitment therapy; IBA, inference-based approach; WL, waitlist; CAU, care-as-usual; Psy placebo, psychological placebo.

Figure 4

Fig. 3 Network meta-analyses of psychotherapies for obsessive–compulsive disorder. Standardised mean differences (SMDs) and 95% confidence intervals (CIs) for effectiveness are reported below the diagonal. SMDs lower than 0 favour the column-defining treatment, with 95% CIs not including the point of no difference (0) highlighted in bold. Relative risks (RRs) and 95% confidence intervals for acceptability are reported above the diagonal. RRs greater than 1 favour the row-defining treatment, with 95% CIs not including the point of no difference (1) highlighted in bold. CBT, cognitive behaviour therapy; ERP, exposure and response prevention; CT, cognitive therapy; MBT, mindfulness-based therapy; MCT, metacognitive therapy; ACT, acceptance commitment therapy; IBA, inference-based approach; CAU, care-as-usual; Psy placebo, psychological placebo; WL, waitlist.

Supplementary material: File

Wang et al. supplementary material

Wang et al. supplementary material
Download Wang et al. supplementary material(File)
File 593.9 KB

This journal is not currently accepting new eletters.

eLetters

No eLetters have been published for this article.