D-Cycloserine Augmentation of Exposure-Based Cognitive Behavior Therapy for Anxiety, Obsessive-Compulsive, and Posttraumatic Stress Disorders: A Systematic Review and Meta-analysis

David Mataix-Cols, Lorena Fernández de la Cruz, Benedetta Monzani, David Rosenfield, Erik Andersson, Ana Pérez-Vigil, Paolo Frumento, Rianne A de Kleine, JoAnn Difede, Boadie W Dunlop, Lara J Farrell, Daniel Geller, Maryrose Gerardi, Adam J Guastella, Stefan G Hofmann, Gert-Jan Hendriks, Matt G Kushner, Francis S Lee, Eric J Lenze, Cheri A Levinson, Harry McConnell, Michael W Otto, Jens Plag, Mark H Pollack, Kerry J Ressler, Thomas L Rodebaugh, Barbara O Rothbaum, Michael S Scheeringa, Anja Siewert-Siegmund, Jasper A J Smits, Eric A Storch, Andreas Ströhle, Candyce D Tart, David F Tolin, Agnes van Minnen, Allison M Waters, Carl F Weems, Sabine Wilhelm, Katarzyna Wyka, Michael Davis, Christian Rück, Margaret Altemus, Page Anderson, Judith Cukor, Claudia Finck, Gary R Geffken, Fabian Golfels, Wayne K Goodman, Cassidy Gutner, Isobel Heyman, Tanja Jovanovic, Adam B Lewin, Joseph P McNamara, Tanya K Murphy, Seth Norrholm, Paul Thuras

Whether and under which conditions D-cycloserine (DCS) augments the effects of exposure-based cognitive behavior therapy for anxiety, obsessive-compulsive, and posttraumatic stress disorders is unclear. To clarify whether DCS is superior to placebo in augmenting the effects of cognitive behavior therapy for anxiety, obsessive-compulsive, and posttraumatic stress disorders and to evaluate whether antidepressants interact with DCS and the effect of potential moderating variables. PubMed, EMBASE, and PsycINFO were searched from inception to February 10, 2016. Reference lists of previous reviews and meta-analyses and reports of randomized clinical trials were also checked. Studies were eligible for inclusion if they were (1) double-blind randomized clinical trials of DCS as an augmentation strategy for exposure-based cognitive behavior therapy and (2) conducted in humans diagnosed as having specific phobia, social anxiety disorder, panic disorder with or without agoraphobia, obsessive-compulsive disorder, or posttraumatic stress disorder. Raw data were obtained from the authors and quality controlled. Data were ranked to ensure a consistent metric across studies (score range, 0-100). We used a 3-level multilevel model nesting repeated measures of outcomes within participants, who were nested within studies. Individual participant data were obtained for 21 of 22 eligible trials, representing 1047 of 1073 eligible participants. When controlling for antidepressant use, participants receiving DCS showed greater improvement from pretreatment to posttreatment (mean difference, -3.62; 95% CI, -0.81 to -6.43; P = .01; d = -0.25) but not from pretreatment to midtreatment (mean difference, -1.66; 95% CI, -1.60 to 4.92; P = .32; d = -0.14) or from pretreatment to follow-up (mean difference, -2.98, 95% CI, -0.03 to 5.99; P = .05; d = -0.19). Additional analyses showed that participants assigned to DCS were associated with lower symptom severity than those assigned to placebo at posttreatment and at follow-up. Antidepressants did not moderate the effects of DCS. None of the prespecified patient-level or study-level moderators was associated with outcomes. D-cycloserine is associated with a small augmentation effect on exposure-based therapy. This effect is not moderated by the concurrent use of antidepressants. Further research is needed to identify patient and/or therapy characteristics associated with DCS response.