Across 54 trials, exposure therapy beat placebo for OCD by three times the margin of any drug
A network meta-analysis of 6,652 adults: behavioural therapy lowered the Y-BOCS by 14.5 points more than placebo, clomipramine by 4.7, SSRIs by 3.5. But 80% of the therapy trials let patients stay on antidepressants.
Top of the evidence hierarchy, independently funded. how we score evidence
Caveat on this rating: The psychotherapy effect was measured mostly in people who were also taking antidepressants; the authors call that a serious limitation and lean toward combination in severe OCD. The behavioural-therapy arm is 287 people. Treatment-resistant patients were excluded. The abstract does not separate OCD subtypes.
The largest single comparison of OCD treatments, and the source of the sentence "therapy first" in every guideline.
Significant findings
Skapinakis and colleagues pooled 54 randomised trials with 6,652 adult participants, comparing every psychological and drug treatment for obsessive compulsive disorder in one network. The outcome was the Yale-Brown Obsessive Compulsive Scale, reported as the mean difference against placebo.
Behavioural therapy, which for OCD means exposure and response prevention, came out at -14.48 points (95% credible interval -18.61 to -10.23; 11 trials, 287 patients). Cognitive therapy was -13.36 (six trials, 172 patients). Cognitive behavioural therapy, the two combined, was -5.37 (nine trials, 231 patients). Clomipramine was -4.72 (13 trials, 831 patients) and the SSRIs as a class -3.49 (37 trials, 3,158 patients). "Clomipramine was not better than were SSRIs (-1.23 [-3.41 to 0.94])."
The other direction
The authors flag the problem themselves: "Psychotherapeutic interventions had a greater effect than did medications, but a serious limitation was that most psychotherapeutic trials included patients who were taking stable doses of antidepressants (12 [80%] of the 15 psychotherapy trials explicitly allowed antidepressants)." The therapy numbers were mostly measured on top of medication, not instead of it. Their interpretation follows from that: "the combination of psychotherapeutic and psychopharmacological interventions is likely to be more effective than are psychotherapeutic interventions alone, at least in severe obsessive-compulsive disorder." The therapy arms were also small next to the drug arms: 287 people against 3,158.
What this does not show
Treatment-resistant populations were excluded, so these are numbers for a first course. The trials treated OCD as one condition; nothing in the abstract separates contamination, harm, relationship or religious themes. And nothing here says whether any one person should add, keep or change a medication. That is a conversation with a prescriber.
Worth asking
Is what you do exposure and response prevention, and if I am on an antidepressant, how does that change the plan?
Source
Pharmacological and psychotherapeutic interventions for management of obsessive-compulsive disorder in adults: a systematic review and network meta-analysis — Skapinakis P, Caldwell DM, Hollingworth W, Bryden P, Fineberg NA, Salkovskis P, Welton NJ, Baxter H, Kessler D, Churchill R, Lewis G (2016)
Top-tier peer-reviewed journal
Read the source: https://doi.org/10.1016/S2215-0366(16)30069-4
DOI: 10.1016/S2215-0366(16)30069-4
How this was scored
- Study design
- Meta-analysis of randomised trials
- Funding
- Independently funded
- Published in
- Top-tier peer-reviewed journal
- Sample size
- 6,652
- Preregistered
- Yes
- Conflicts disclosed
- not recorded
- Independent of proponent
- not recorded
- Retracted
- No
Read the full scoring rubric, including what it can't tell you.
Published September 29, 2026.
Questions
How strong is the evidence behind this?
veisund rates this source "gold standard". Top of the evidence hierarchy, independently funded. It scores 89 out of 100 on our published rubric. One caveat travels with that badge: The psychotherapy effect was measured mostly in people who were also taking antidepressants; the authors call that a serious limitation and lean toward combination in severe OCD. The behavioural-therapy arm is 287 people. Treatment-resistant patients were excluded. The abstract does not separate OCD subtypes. The score is calculated from recorded facts about the source — study design, funding, publication venue, sample size, preregistration — not typed in by an editor.
What is the source for this?
Pharmacological and psychotherapeutic interventions for management of obsessive-compulsive disorder in adults: a systematic review and network meta-analysis — Skapinakis P, Caldwell DM, Hollingworth W, Bryden P, Fineberg NA, Salkovskis P, Welton NJ, Baxter H, Kessler D, Churchill R, Lewis G (2016). Published in: Top-tier peer-reviewed journal. DOI: 10.1016/S2215-0366(16)30069-4. The full source is linked on this page so you can read it yourself.
Who paid for this research, and does that matter?
Study design: Meta-analysis of randomised trials. Funding: Independently funded. Independence from the proponent is not recorded. Industry sponsorship is one of the most reliably measured biases in medicine, which is why funding carries real weight in the score rather than sitting in a footnote.
Is this medical advice?
This is information to bring to your prescriber, not medical advice and not a reason to change anything on your own. Nothing here is an instruction to stop or reduce a medication. If you are in crisis, call or text 988.
This is information to bring to your prescriber, not medical advice and not a reason to change anything on your own. Nothing here is an instruction to stop or reduce a medication. If you are in crisis, call or text 988.