We performed a network meta-analysis to build clear hierarchies of efficacy and tolerability of
antipsychotics to augment
serotonin reuptake inhibitors (SRIs) for treatment-resistant
obsessive-compulsive disorder (OCD) in adults. PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched on September 8, 2018. Randomized controlled trials investigating
antipsychotics as augmentation agents were included. Network meta-analyses were performed using frequentist methods. Efficacy was measured by the Yale-Brown Obsessive-Compulsive Scale. Tolerability was measured by side-effect discontinuations. Mean differences (MDs) and odds ratios (
ORs) were reported with 95% confidence intervals (CIs). Twenty articles with 790 patients were included. Our analyses showed that there was no significant difference in efficacy between
antipsychotic agents. The order of efficacy rankings was inconsistent between primary analysis and sensitivity analyses. We found that there was considerable heterogeneity between studies. Comorbid
tics was identified as a significant moderator. All
antipsychotics except
paliperidone were significantly superior to placebo in the subgroup without comorbid
tics, while no
antipsychotics was significantly superior to placebo in the comorbid
tics subgroup. With respect to tolerability,
quetiapine (OR, 3.45; 95% CI, 1.04-11.11) and
paliperidone (20.00; 1.01->100) were significantly less tolerable than placebo. Based on this network meta-analysis,
antipsychotic agents as augmentations to SRIs might be more effective in treatment-resistant OCD patients without comorbid
tics. Definitive determination of which
drug is optimal cannot be drawn currently because of the limited numbers of studies and heterogeneity across studies.