Correspondence
Author’s reply
Jeremy Johnson and colleagues agree
that the concurrent use of specific
antiobsessive drugs in psychotherapy
trials of obsessive-compulsive
disorder is an important limitation,
but they argue that this might be
counterbalanced by the concurrent
use of psychotherapy in medication
trials. Not all psychotherapy is effective
in obsessive-compulsive disorder; the
effective psychotherapy is specialised
cognitive-behavioural therapy
(including exposure and response
prevention).1 Moreover, this type of
treatment is very intensive and requires
a lot of resources and effort, both
from the patient and the health-care
provider.2 Therefore, it is unlikely that
patients participating in medication
trials for obsessive-compulsive
disorder would have concurrent,
intensive, specialised psychotherapy
treatment for their condition. This
notion is contrasted to the easy
delivery of pharmacotherapy, which
makes it very probable that patients
in psychotherapy trials might continue
such treatments during the trial.
Johnson and colleagues made an
effort to estimate how many of the
pharmacotherapy studies included
www.thelancet.com/psychiatry Vol 3 November 2016
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 as follows: our network
meta-analysis3 included 33 medication
trials (see table 1 of our study);
23 (70%) of these 33 trials explicitly
excluded patients on specialised
psychotherapy. Only one paroxetine
study4 explicitly allowed patients on
specialised psychotherapy to take
part in their trial. One fluvoxamine
trial5 provided sessions of supportive,
not specialised, psychotherapy
during the conduct of the trial.
Finally, eight (24%) of the 33 trials
did not explicitly mention whether
patients on specialised psychotherapy
were included. For comparison,
12 (80%) of the 15 psychotherapy
trials included in the network meta-
analysis explicitly allowed the inclusion
of patients who were taking specific
antiobsessive drugs.
I believe it is clear from the above
description that this limitation is
specific to psychotherapy trials.
However, I agree with Johnson and
colleagues that in the future both
pharmacotherapy and psychotherapy
trials should aim to give complete
details of all concurrent treatments of
their patients.
I declare no competing interests.
Petros Skapinakis
p.skapinakis@gmail.com
Department of Psychiatry, University of Ioannina
School of Medicine, Greece; and Division of
Psychiatry, University College London, London
W1T 7NF, 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, www.ciocd.ca).
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: 236–46.
3 Skapinakis P, Caldwell DM, Hollingworth W,
et al. Pharmacological and psychotherapeutic
interventions for management of
obsessive-compulsive disorder in adults:
a systematic review and network meta-analysis.
Lancet Psychiatry 2016; 3: 730–39.
4 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: 427–33.
5 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.
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