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.