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Accepted Manuscript
See Lancet version here:
Authors reply - Overlooking concurrent psychotherapy when evaluating
effectiveness of pharmacotherapy for Obsessive Compulsive Disorder.

Jeremy Johnson and colleagues agree that the concurrent use of specific
anti-obsessive drugs in psychotherapy trials of OCD is an important limitation,
but they argue that this might be counterbalanced by the concurrent use of
psychotherapy in medication trials. First, I note that not all psychotherapy is
effective in OCD; it is specialized cognitive / behavior therapy (including
exposure and response prevention) which is effective1. Moreover, this type of
treatment is very intensive and requires a lot of resources and effort both from
the patient and the health-care provider2. Therefore, it is unlikely that patients
participating in medication trials for OCD would have concurrent intensive
specialized psychotherapy treatment for their condition. This is contrasted to the
easy delivery of pharmacotherapy which makes very likely that patients on
psychotherapy trials might continue such treatments during the trial.
Johnson and colleagues made an effort to estimate how many of the
pharmacotherapy studies included patients receiving concurrent psychotherapy.
However, their rough estimate is inaccurate. The results of our complete data
extraction, which was omitted from the original manuscript for brevity, are the
following: Our network meta-analysis included 33 medication trials (see table 1
of our original manuscript); 23 of these 33 trials (70%) explicitly excluded
patients on specialized psychotherapy. Only one paroxetine study3 explicitly
allowed patients on specialized psychotherapy to take part in their trial. One
fluvoxamine trial4 provided sessions of supportive, not specialized,
psychotherapy during the conduct of the trial. Finally, 8 of the 33 trials (24%)
did not explicitly mention whether patients on specialized psychotherapy were
allowed. For comparison, 80% (12 out of the 15) of the psychotherapy trials
included in the network meta-analysis explicitly allowed the inclusion of patients
who were taking specific anti-obsessive drugs.

I believe it is clear from the above description that this limitation is

specific to psychotherapy trials. I would agree with the authors, however, that in
the future either pharmacotherapy or psychotherapy trials should aim to give
complete details of all concurrent treatments of their patients.

I declare no competing interests

Petros Skapinakis

Department of Psychiatry, University of Ioannina School of Medicine, Greece and

Division of Psychiatry, University College London, UK.

1. Sookman D, Fineberg NA; Accreditation Task Force of The Canadian Institute
for Obsessive Compulsive Disorders. Specialized psychological and
pharmacological treatments for obsessive-compulsive disorder throughout the
lifespan: a special series by the Accreditation Task Force (ATF) of The Canadian
Institute for Obsessive Compulsive Disorders (CIOCD, Psychiatry
Res 2015; 227:74-77.
2. McKay D, Sookman D, Neziroglu F, et al. Efficacy of cognitive-behavioral
therapy for obsessive-compulsive disorder. Psychiatry Res. 2015; 225:236-246.
3. Kamijima K, Murasaki M, Asai M, et al. Paroxetine in the treatment of
obsessive-compulsive disorder: randomized, double-blind, placebo-controlled
study in Japanese patients. Psychiatry Clin Neurosci 2004; 58: 427-433.
4. Goodman WK, Price LH, Rasmussen SA, et al. Efficacy of fluvoxamine in
obsessive-compulsive disorder. A double-blind comparison with placebo. Arch
Gen Psychiatry. 1989; 46:36-44.