Systematic Review: Pharmacological and Behavioral Treatment for Trichotillomania

Trichotillomania is a psychiatric condition characterized by compulsive hair pulling. Three interventions have been studied in the treatment of trichotillomania: habit-reversal therapy (HRT) and pharmacotherapy with either selective-serotonin reuptake inhibitors (SSRI) or clomipramine. This systematic review compared the efficacy of these interventions in blinded, randomized clinical trials. The electronic databases of Medline, Premedline, PsychINFO, Embase, and the Cochrane Central Register of Controlled Trials were searched for relevant trials using the search terms "trichotillomania" or "hair pulling." Trials were eligible for inclusion if they compared habit-reversal therapy, SSRI pharmacotherapy, or clomipramine pharmacotherapy to each other or placebo and employed randomization and blinded assessment of outcome. Our primary outcome measure was mean change in trichotillomania severity. The summary statistic was standardized mean difference. Seven studies were eligible for inclusion in this review. Overall, meta-analysis demonstrated that habit-reversal therapy (effect size [ES] = -1.14, 95% confidence interval [CI] = -1.89, -.38) was superior to pharmacotherapy with clomipramine (ES = -.68, 95% CI = -1.28, -.07) or SSRI (ES = .02, 95% CI = -.32, .35). Clomipramine was more efficacious than placebo, while there was no evidence to demonstrate that SSRI are more efficacious than placebo in the treatment of trichotillomania. Future studies on trichotillomania should seek to determine if HRT can demonstrate efficacy against more rigorous control conditions that account for non-specific effects of therapy and determine if HRT can be an effective intervention for trichotillomania beyond the few sites where it is currently practiced in research studies. Future therapy and pharmacotherapy studies in trichotillomania should employ larger sample sizes and intention-to-treat analysis and seek to validate clinical rating scales of trichotillomania severity.