Professional Documents
Culture Documents
discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/299862268
CITATIONS READS
0 44
2 authors:
All content following this page was uploaded by Shannon M. Blakey on 07 April 2016.
Jonathan S. Abramowitz
Shannon M. Blakey
Chapter appears in E. Storch & D. McKay (eds.). Obsessive Compulsive Disorder and its
Corresponding Author:
Jonathan Abramowitz
Campus Box 3270
UNC-Chapel Hill
Department of Psychology
Chapel Hill, NC 27599
jabramowitz@unc.edu
Ph: 919-843-8170
Fax: 919-962-2537
Comorbid Depression 2
capacity to experience pleasure or interest in activities that are typically enjoyed. The
following other signs and symptoms are also often present: reduced appetite and weight
loss (or in some cases weight gain), insomnia or hypersomnia, psychomotor agitation or
syndromes, as well as in non-clinical individuals, a person meets the criteria for a major
depressive episode if the aforementioned symptoms persist for at least a two-week period
and interfere with daily functioning (American Psychiatric Association [APA], 2000).
Major depressive disorder (MDD) is defined by the occurrence of one or more major
depressive episodes at any point during the lifetime (APA, 2000). Dysthymia, a similarly
chronic but less severe form of depression, involves a chronically depressed mood and
reduced interest, but does not grossly disable the persons daily functioning (APA, 2000).
conditions1. Anxiety (OCD is an anxiety disorder; APA, 2000) is the single best
1
Considerable disagreement existson both conceptual and empirical grounds
regarding what constitutes an OC-related disorder. In this chapter we define an OCD
spectrum disorder as one involving (a) anxiety-provoking intrusive thoughts and (b)
safety behaviors, avoidance, and compulsive rituals performed to reduce anxiety (e.g.,
Storch, Abramowitz, & Goodman, 2008). When this definition is used, body dysmorphic
disorder (BDD) and hypochondriasis (HC), along with OCD, fit within the OCD
spectrum category (Abramowitz & Deacon, 2005).
Comorbid Depression 3
Hirschfeld, 2001). Depression also ranks as the most commonly co-occurring problem
among anxiety diagnoses (Kessler, 1998), affecting up to 90% of people with anxiety
disorders (Gorman, 1996). We next review the rates of comorbid depression across the
OCD spectrum.
OCD
Table 1 shows the rates of MDD among adult OCD samples. Across 7 countries,
the lifetime prevalence ranged from 12.4% to 60.3%. In the United States, researchers
found a lifetime comorbidity rate of 54.1%, and a concurrent comorbidity rate of 36%
(e.g., Nestadt et al., 2001). Studies on the temporal nature of this comorbidity have long
found that in most (but not all) instances, OCD symptoms predate the depressive
symptoms (Bellodi et al., 1992; Demal et al., 1993). This suggests that the mood
OCD patients with depression also show an earlier age of OCD onset and more
Storch, Keely, & Cordell, 2007). Depressive symptoms are also more strongly associated
with the severity of obsessions than with compulsions (Ricciardi & McNally, 1995), and
may be specifically associated with sexual and religious obsessions (Hasler et al., 2005).
Finally, relative to non-depressed OCD patients, those with depression more strongly
believe that their intrusive obsessional thoughts are significant and meaningful
BDD
Comorbid Depression 4
defect in appearance that causes subjective distress and interference with functioning
(APA, 2000). Examples include perceived flaws in the size or shape of the face, skin,
hair, and muscles. The preoccupations often lead to anxiety-reducing behaviors such as
mirror gazing (or mirror avoidance), camouflaging the perceived defect with makeup or
clothing, or performing other checking and grooming behaviors. Some people with BDD
MDD is the primary comorbid condition among individuals with BDD (Gunstad
& Phillips, 2003). Table 2 shows the rates of lifetime MDD among BDD patients, which
range from 36% to 87% in adult samples. Although there are instances where MDD
arises before the onset of BDD symptoms, depression generally presents after the
symptoms (Phillips, 1999). Indeed, this is not surprising: feelings associated with BDD
(i.e., beliefs that one is unattractive) are similar to core dysfunctional beliefs
characteristic of MDD.
with more severe BDD symptoms, increased anxiety and personality disorder
comorbidity, and decreased quality of life (Phillips, Didie, & Menard, 2007). Comorbid
BDD and MDD diagnoses are also associated with an earlier age of onset of depression
(mid-adolescence versus mid-20s) and more chronic depression (Nierenberg et al., 2002).
Thus, a comorbid MDD and BDD diagnosis may forecast exacerbated psychiatric
HC
HC involves a persistent fear or belief that one has a serious disease (e.g., cancer)
good health from medical professionals (and other sources), avoidance of health cues,
and taking unreasonable preventative measures (APA, 2000). Although these behaviors
might provide an immediate relief from anxiety, they ultimately maintain HC symptoms
MDD being among the most common (Creed & Barsky, 2004). Table 3 shows the rates
of MDD in patients diagnosed with HC. As can be seen, a majority of adults with HC
experience MDD at some point in their lifetime. It is also worth noting that patients with
MDD frequently present with somatic symptoms, a reverse pattern that has clinical
implications for patients prognosis and treatment (see Kirmayer & Robbins, 1991). As
with OCD and BDD, HC symptoms tend to temporally precede the onset of MDD
(Barsky et al., 1992; Creed & Barsky, 2004; Noyes et al., 1994). Additionally, those with
comorbid MDD and HC have greater overall functional impairment and endorse more
depressive symptoms than those with HC in the absence of MDD (Noyes et al., 1994).
disorders. Ricciardi and McNally (1995) found that depression was associated with more
Comorbid Depression 6
severe obsessional symptoms, but not with compulsive rituals. Later studies revealed that
intrusions concerning sexual and religious themes (Hassler, LaSalle, Ricci, & Ronquillo,
2005). Moreover, relative to non-depressed OCD patients, those with MDD showed more
obsessional thoughts) and poorer insight into the senselessness of obsessions and rituals.
Thus, the presence of depression is not only associated with greater overall OCD
symptom severity, but also with certain presentations of this highly heterogeneous
condition.
Treatment
Treatment Outcome
(e.g., Abramowitz, Deacon, & Whiteside, 2011; Taylor & Asmundson, 2004). Yet these
techniques require hard work and practice, some of which involves deliberately
confronting ones fears and provoking anxiety. Individuals suffering with depression,
however, might lack the willpower to complete such challenging work and fall prey to
depression can interfere with the effects of this treatment. Serotonin reuptake inhibitor
(SRI) medications are the first line pharmacological treatments for OCD, BDD, and HC.
outcome literature with respect to comorbid MDD in OCD and BDD. There are presently
OCD. Studies with OCD patients consistently show that in addition to reducing
OCD symptoms, CBT and SRIs are associated with improvement in depressive
symptoms, yielding large pre- to posttest effects (e.g., Eddy, Dutra, Bradey, & Westen,
2004; Franklin et al., 2000). Two studies with OCD patients receiving CBT (primarily
involving exposure and response prevention [ERP]) have examined the effects of
comorbid MDD on treatment response. Abramowitz and Foa (2000) compared outcome
for 15 depressed OCD patents to that for 33 nondepressed OCD patients following 15
sessions of this treatment. While immediate and long-term improvement was observed in
both groups (respectively, 87.9% and 73.3% showed at least a 30% reduction in OCD
symptoms at posttest), at posttest and at follow up, the depressed patients had more
severe symptoms. Steketee, Chambless, and Tran (2001) examined 63 OCD patients who
had received CBT, 9 of whom had MDD. Among treatment completers, the presence of
clinical observations suggest that depressed OCD patients require higher doses of SRIs
response to pharmacotherapy among comorbid patients are lacking (e.g., Fineberg &
Craig, 2010).
behavioral) therapies in 13 studies of BDD patients with comorbid MDD. They found
large effect sizes for improvement in both BDD and MDD symptoms for both forms of
Comorbid Depression 8
treatment. When these effects were compared meta-analytically, however, CBT was
significantly more effective in reducing comorbid BDD and MDD symptoms than was
pharmacotherapy. These findings suggest that while both SRIs and psychological
treatments are effective for comorbid MDD and BDD, CBT provides a greater and more
There are a number of factors that might contribute to depression interfering with
treatment outcome, especially where CBT for OCD and related disorders is concerned.
For example, depressed individuals can show decreased compliance with treatment
instructions. Yet to be effective, CBT requires that the patient repeatedly practice the
treatment techniques (e.g., confronting feared stimuli and remaining exposed until
anxiety subsides on its own). Depressed individuals might not be able to properly comply
(Seligman, 1975), less deserving of a happy life, or if they hold low expectations of
improvement (Bandura, 1977). Depressed patients might also suffer with psychomotor
retardation, which would attenuate their ability to do the work required to improve.
With respect to medication, depressed patients have reduced hope and optimism,
thereby depleting medications of their nonspecific (i.e., placebo) effects. They might also
attribute any treatment gains to external or circumstantial sources, and therefore evidence
less improvement and more relapses than non-depressed patients. In the remainder of this
chapter we discuss possible approaches to managing patients with OCD and related
For the most part, research on the treatment of OCD and related disorders has
(e.g., Foa et al., 2005). Less attention has been paid to complex cases, such as those
involving comorbid depression. Yet as we have discussed, a great many individuals with
OCD and related disorders present with complexities of one sort or anothercomorbid
stimulialong with help refraining from subtle and overt avoidance and safety-seeking
behaviors (i.e., response prevention) is the centerpiece of CBT for OCD, BDD, and HC
helped to confront sources of feared germs (e.g., public bathrooms) while simultaneously
Exposure-based CBT can be highly effective for OCD, BDD, and HC, producing an
average of 60% to 70% reduction in fear, avoidance, and the use of safety behaviors
(Abramowitz et al., 2011). A drawback of this approach, however, is that patients must
confront their fear-evoking stimuli and resist urges to immediately reduce anxiety via
escape or avoidance. Because exposure therapy requires compliance with these somewhat
alleviating anxiety and fear, and does not directly address comorbid problems such as
depression.
Cognitive conceptualizations of OCD (e.g., Clark, 2004), BDD (e.g., Veale &
Neziroglu, 2010), and HC (e.g., Taylor & Asmundson, 2004) have led to the inclusion of
Comorbid Depression 10
cognitive therapy (CT) strategies along with exposure in many treatment protocols (e.g.,
techniques are used to (a) educate patients about the nature of anxiety and how
pathological anxiety is maintained, and (b) help patients correct dysfunctional beliefs and
automatic thoughts that lead directly to anxiety and fear (e.g., misinterpretations of
benign physical sensations). For example, someone with BDD would be helped to
recognize that others are unlikely to notice or judge her based on the imagined defect in
test out the validity of these (and corrected) beliefs using real life experiments (that are
Treatment protocols developed for OCD, BDD, and HC have not routinely
addressed the common comorbid depressive symptoms that are known to present
challenges. There are, however, a few possible ways in which CBT could be
implemented to address comorbid depression. These are described below, along with the
such as the serotonin reuptake inhibitors (SRIs), are the most widely used treatments for
both depression and OCD related disorders. Thus, intuitively, the use of these agents
should improve outcome for patients suffering from both types of these problems
comorbidly. Very few studies, however, have addressed whether antidepressants offer an
Comorbid Depression 11
advantage over exposure-based CBT, specifically for comorbid samples; and the existing
studies have numerous methodological difficulties which limit the conclusions that can
be drawn. The OCD literature provides the best examples of such studies. In one
investigation with OCD patients, Marks et al. (1980) found that clomipramine (CMI)
helped severe depression and OCD symptoms more than did placebo. However, the
comparison included only five patients on CMI and five on placebo, and the statistical
analysis was conducted at the 4-week point in treatment, which may not have been
In another study, Foa, Kozak, Steketee, and McCarthy (1992) examined whether
using imipramine (IMI) prior to CBT would facilitate improvement in OCD symptoms
once CBT began. In their prospective study, mildly and severely depressed OCD patients
received either pill placebo or IMI for six weeks prior to CBT. Results indicated that
although IMI improved the symptoms of depression, it did not potentiate the effects of
CBT on OCD symptoms. Abramowitz et al. (2000) also included a comparison between
severely depressed OCD patients who either were or were not using SRI medications
during CBT. No difference between groups were reported, although the small size of the
severely depressed group in that study (n = 11) limits the generalizability of this finding.
To date, there is little compelling evidence that medication potentiates the effects of CBT
One explanation for the above conclusion is that because SRI medications are the
most widely used therapy for anxiety, patients with anxiety disorders have often already
tried these agents before presenting for psychological treatment. Thus, many depressed
anxiety disorder patients in treatment studies might have been medication resistant,
Comorbid Depression 12
thus putting a ceiling on the effects of medications. Nevertheless, since the average
improvement with SRI medication is somewhat modest (about 20-40% on average) there
intervention for all OCD related disorders and for depression. Indeed, CT yields high
responder rates, few adverse effects, and good durability of gains in depressed patients
(e.g., Elkin et al., 1989). Cognitive therapy for depression involves identifying and
challenging overly negative beliefs about oneself, world, and the future that lead to
overly negative and biased interpretations of events, giving rise to feelings of extreme
hopelessness, helplessness, and personal failure. It also includes the use of behavioral
activation in which the patient increases his or her engagement with other people and in
activities he or she finds enjoyable. This helps reinforce behavior that is the opposite of
dysphoric mood and other MDD symptoms following CT (Dobson, 1989). Typically, 50-
70% of MDD patients who complete CT no longer meet criteria for MDD at post-
treatment, and only 20-30% show significant relapse at follow-up (Craighead et al.,
1992).
Another reason CT is a good choice to use in the treatment of patients with OCD
and related disorders who also suffer from comorbid depression is efficiency: that is, the
and challenging beliefs) are largely similar to those used in CT for OCD, BDD, and
HCalthough the content of the dysfunctional beliefs that are targeted is different. For
Comorbid Depression 13
actually molesting the child), as well as those relevant to depression (e.g., everyone
else has a better life than me). Thus, patients could learn to make use of the same skills
techniques might alleviate some depressive symptoms and help patients with OCD and
related conditions increase motivation and compliance with difficult exposure therapy
might also increase hopefulness about this treatment, helping patients tap into any
evaluations of such treatment programs have been conducted; although we are currently
conducting a study involving the use of CT and exposure therapy for patients with OCD
To date, the following can be said about the influence of comorbid depression on
OCD spectrum disorders such as BDD and HC: (a) at least half of all patients with OCD-
related disorders also suffer from depressive symptoms or meet criteria for a unipolar
mood disorder; (b) in most instances, depressive symptoms emerge following the onset of
associated with these symptoms; and (c) the presence of comorbid depression hinders
outcome of both CBT and SRIs, which are the most effective treatments for OC-related
Comorbid Depression 14
disorders. The precise mechanisms for how depression hinders treatment outcome,
CBT for OCD spectrum disorders would be the best approach to managing this pattern of
effectiveness and cost effectiveness of this approach. It will, for example, be necessary
to determine whether or not such a treatment package is more effective than exposure
psychological treatment and medication in this population. We await this next phase of
References
Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. (2011). Exposure therapy for
Abramowitz, J.S. & Foa, E.B. (2000). Does comorbid major depressive disorder
Abramowitz, J. S., Storch, E. A., Keeley, M., & Cordell, E. (2007). Obsessive-
compulsive disorder with comorbid major depressive disorder: What is the role of
Barsky, A. J., Wyshak, G., & Klerman, G. L. (1992). Psychiatric comorbidity in DSM-
Bellodi, L., Scioto, G., Diaferia, G., Ronchi, P., & Smiraldi, E. (1992). Psychiatric
Craighead, W., Evans, D., & Robins, C. (1992). Unipolar depression. In S. M. Turner,
K. S., Calhoun, & H. Adams, (Eds.). Handbook of clinical behavior therapy (2nd
Creed, F., & Barsky, A. (2004). A systematic review of the epidemiology of somatization
Demal, U., Lenz, G., Mayrhofer, A., Zapotoczky, H-G., & Zitterl, W. (1993). Obsessive-
Eddy, K., Dutra, L., Bradley, R., & Westen, D. (2004). A multidimensional meta-analysis
Elkin, I., Shea, M., Watkins, Imber, S., Sotsky, S., Cllins, J., Glass, D., Pilkonis, P.,
Leber, W., Docherty, J., Fiester, S., & Parloff, M. (1989). National Institute of
982.
Foa, E. B., Kozak, M. J., Steketee, G., & McCarthy, P. (1992). Treatment of depressive
Foa, E. B., Liebowitz, M. R., Kozak, M. J., Davies, S., Campeas, R., Franklin, M. E.,
Huppert, J. D., Kjernisted, K., Rowan, V., Schmidt, A. B., Simpson, H. B., & Tu,
Comorbid Depression 17
Gorman, J.M. (1996). Comorbid depression and anxiety spectrum disorders. Depression
Gunstad, J., & Phillips, K. A. (2003). Axis I comorbidity in body dysmorphic disorder.
Kessler, R.C., Stang, P.E., Wittchen, H.U. (1998). Lifetime panic-depression comorbidity
Marks, I., Stern, R., Mawson, D., Cobb, J., & McDonald, R. (1980) Clomipramine and
25.
disorder and anxiety and affective disorders: Results from the Johns Hopkins
Nierenberg, A. A., Phillips, K. A., Petersen, T. J., Kelly, K. E., Alpert, J. E.,
Worthington, J. J., Tedlow, J. R., Rosenbaum, J. F., & Fava, M. (2002). Body
Comorbid Depression 18
Noyes, R., Kathol, R. G., Fisher, M. M., Phillips, B. M., Suelzer, M. T., & Woodman, C.
Phillips, K. A., Didie, E. R., & Menard, W. (2007). Clinical features and correlates of
Ricciardi, J. & McNally, R. J. (1995). Depressed mood is related to obsessions but not
249-256.
Steketee, G., Chambless, D.L., and Tran, G.Q. (2001). Effects of Axis I and II
Veale, D. (2000). Outcome of cosmetic surgery and DIY surgery in patients with body
Oxford: Wiley-Blackwell.
Comorbid Depression 19
Table 2
(1993)
(2007)
Table 3
Fichter (2005)
(1996)