No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Change in Obsessive Compulsive Symptoms Mediates Subsequent Change in Depressive Symptoms during Exposure and Response Prevention
... Despite extant research highlighting the negative implications of comorbid MDD and OCD, the temporal relationship between OCD symptoms and depression symptoms remains unclear. Although some treatment studies suggest that depression resolves following OCD treatment (Anholt et al., 2011;Zandberg et al., 2015), other studies have found that a reduction in depression precedes improvements in OCD (Olatunji et al., 2013). In a randomized control trial of 121 patients with OCD, Anholt et al. (2011) found that across all five years of their study, reductions in depression symptoms were largely driven by reductions in OCD symptoms. ...
... Additionally, changes in depressive symptoms only explained a small percentage of changes in OCD symptoms. Similarly, Zandberg et al. (2015) found that reductions in co-morbid depressive symptoms during combined behavioral and pharmacological OCD treatment were largely driven by reductions in OCD symptoms. Indeed, reduced OCD severity accounted for 65% of the reduction in depression symptoms, while the reduction in depression symptoms only accounted for 20% of the reduction in OCD symptoms. ...
... Our findings suggest that treating OCD first is the most appropriate treatment approach that will likely also reduce depression symptoms. This is largely consistent with prior treatment research (Anholt et al., 2011;Zandberg et al., 2015). ...
Major Depressive Disorder (MDD) is often comorbid with obsessive-compulsive disorder (OCD) yet little is known about the directionality of the association between OCD and depression symptoms. We aim to investigate the effect OCD symptoms has on depression symptoms and vice versa over an extended period of time. This is one of the first longitudinal studies to evaluate the relationship between OCD and depression in a large clinical sample. Participants (n = 324) were treatment-seeking adults with a primary diagnosis of OCD. OCD and depression symptoms were assessed annually over the six-year follow-up period. Random intercepts cross-lagged panel models (RI-CLPM) were conducted to compare unidirectional and bidirectional models over time. The best-fitting and most parsimonious model included paths with OCD symptoms predicting depression symptoms, but not vice versa. OCD symptom severity in a given year predicted next year depression severity. However, depression severity did not predict next-year OCD symptom severity in this sample. Our results suggest that depression severity may be secondary to OCD symptoms and treating OCD should be prioritized over treating depression.
... Meanwhile, others have proposed a role for severe comorbid depression as a clinical predictor of outcome among youth receiving OCD treatment and advocated for treating depression in these cases (Keeley, Storch, Merlo, & Geffken, 2008;Wilhelm et al., 2018). To address this inconsistency, recent work has attempted to investigate this issue using rigorous analytical methods, conducting mediational research on processes of change in OC and depressive symptoms during the course of OCD treatments (Olatunji et al., 2013;Zandberg et al., 2015). Specifically, by examining the temporal precedence of the change in depressive symptoms and the change in obsessive-compulsive symptoms for each other, these studies have attempted to elucidate the processes of symptom change in OCD treatments. ...
... Specifically, by examining the temporal precedence of the change in depressive symptoms and the change in obsessive-compulsive symptoms for each other, these studies have attempted to elucidate the processes of symptom change in OCD treatments. Unfortunately, these efforts have led to more inconsistent findings and ongoing debate (Anholt et al., 2011;Olatunji et al., 2013;Zandberg et al., 2015). ...
... The only study to date that has examined this issue with a sole focus on exposure and response prevention (ERP) yielded different results. In this study, in a sample of 40 adult OCD patients, Zandberg and colleagues found that both changes in obsessive-compulsive symptoms and depressive symptoms mediated the effect of ERP on each other over 32 weeks (Zandberg et al., 2015). However, these effects were much larger for the mediating role of obsessive-compulsive symptoms than depressive symptoms; obsessive-compulsive symptoms accounted for 64.8% of the change in depressive symptoms while depressive symptoms only accounted for 19.6% of the change in obsessive-compulsive symptoms (Zandberg et al., 2015). ...
The current study examined the temporal precedence of change in obsessive-compulsive symptoms and change in depressive symptoms during the course of an Exposure and Response Prevention (ERP) for pediatric OCD. Participants included 142 children and adolescents (7–17 years; mean age = 12.39, SD = 2.92; 51.40% female; 60.40% Non-Hispanic White) with a primary or co-primary diagnosis of OCD who received ERP in a two-site randomized controlled trial on d-cycloserine augmentation of CBT for pediatric OCD. Participants completed clinician-administered assessments of OC symptoms (Children's Yale-Brown Obsessive Compulsive Scale) and depressive symptoms (Children's Depression Rating Scale-Revised) from baseline to post-treatment follow-up. Lagged mediational analyses did not yield evidence in support of a mediating role for the change in OC symptoms in the effect of ERP on the change in depressive symptoms. In contrast, change in depressive symptoms mediated the effect of ERP treatment on the subsequent change in OC symptoms (95% confidence interval for indirect effect = −0.04 to −0.001), though the effect size was small. Controlling for the prior levels of the depressive symptoms this indirect effect became non-significant. Theoretical and clinical implications of the findings for the youth with OCD and comorbid depression are discussed.
... Similarly, meta-analytic studies have found that CBT for OCD seems to improve anxiety and depression symptoms from pre-to-post treatment (Olatunji, Davis, Powers, & Smits, 2013;Rosa-Alcázar, Sánchez-Meca, Gómez-Conesa, & Marín-Martínez, 2008), although these effects may be attenuated (i.e., anxiety/depression symptom reduction does not meet clinically significant change) as a function of treatment solely targeting OCD (Turner et al., 2018). Two CBT studies for adults with OCD have further demonstrated temporal precedence of symptom change such that OCD symptom reduction preceded and predicted depression symptom reduction, but not vice versa, (Anholt et al., 2011;Zandberg et al., 2015). This work provides preliminary support that, at least in adult patients, anxiety and depression symptoms might be expected to decrease as a function of OCD symptom improvement during CBT. ...
... Hypotheses were based on findings that targeting either anxiety or depression resulted in parallel reductions in the other set of symptoms (Albano et al., 2018;Weisz et al., 2006), and on limited findings from the adult literature suggesting that CBT for OCD produces reductions in depression (Anholt et al., 2011;Zandberg et al., 2015). In the present investigation, we predicted that anxiety and depression symptoms would improve as a function of CBT for OCD (Aim a), that this change would occur subsequent to improvements in OCD severity and impairment (Aim b) and that treatment responders would evidence a steeper slope of anxiety and depression symptom change than nonresponders (Aim c). ...
... Interestingly, we did not find support for the hypothesis that changes in anxiety and depression symptomatology would be linked to the course of improvement in OCD severity and impairment. This finding is inconsistent with prior findings in the adult literature (Anholt et al., 2011;Zandberg et al., 2015), and with theories that OCD drives anxiety and depression symptoms, and that directly targeting OCD symptoms leads to downstream change in anxiety and depression (e.g., Brown et al., 2015). Given that anxiety and depression symptoms demonstrated greater improvements for treatment responders than non-responders, it is unclear whether treatment responders evidenced benefit in anxiety and depression symptoms because their OCD symptoms improved sufficiently to be rated as achieving treatment response, or because something about CBT more generally was beneficial for their anxiety/depression symptoms and OCD symptoms simultaneously. ...
Pediatric obsessive-compulsive disorder (OCD) co-occurs frequently with other mental health conditions, adding to the burden of disease and complexity of treatment. Cognitive behavioral therapy (CBT) is efficacious for both OCD and two of its most common comorbid conditions, anxiety and depression. Therefore, treating OCD may yield secondary benefits for anxiety and depressive symptomatology. This study examined whether anxiety and/or depression symptoms declined over the course of OCD treatment and, if so, whether improvements were secondary to reductions in OCD severity, impairment, and/or global treatment response. The sample consisted of 137 youths who received 12 sessions of manualized CBT and were assessed by independent evaluators. Mixed models analysis indicated that youth-reported anxiety and depression symptoms decreased in a linear fashion over the course of CBT, however these changes were not linked to specific improvements in OCD severity or impairment but to global ratings of treatment response. Results indicate that for youth with OCD, CBT may offer benefit for secondary anxiety and depression symptoms distinct from changes in primary symptoms. Understanding the mechanisms underlying carryover in CBT techniques is important for furthering transdiagnostic and/or treatment-sequencing strategies to address co-occurring anxiety and depression symptoms in pediatric OCD.
... Perhaps the most common view is that depression may arise as a result of the functionally impairing, chronic nature of OCD (Anholt et al., 2011;Huppert et al., 2009;Ricciardi & McNally, 1995;Storch et al., 2009;Zandberg et al., 2015). Thus, many researchers support the view that OCD symptoms should be given precedence in treatment (Meyer et al., 2014;Storch et al., 2009;Zandberg et al., 2015). ...
... Perhaps the most common view is that depression may arise as a result of the functionally impairing, chronic nature of OCD (Anholt et al., 2011;Huppert et al., 2009;Ricciardi & McNally, 1995;Storch et al., 2009;Zandberg et al., 2015). Thus, many researchers support the view that OCD symptoms should be given precedence in treatment (Meyer et al., 2014;Storch et al., 2009;Zandberg et al., 2015). Indeed, comorbid depression does not usually impede treatment outcomes for OCD (Olatunji, Davis, Powers, & Smits, 2013). ...
... In our averaged model, OCD symptoms predicted depression symptoms. This direction of prediction is consistent with many previous reports in the literature (Anholt et al., 2011;Meyer et al., 2014;Millet et al., 2004;Ricciardi & McNally, 1995;Zandberg et al., 2015) as well as with the DAG presented in McNally et al. (2017b). The actual nodes involved, however, departed from the aforementioned adult model: the Nodes represent symptoms of OCD or depression, and edges represent zero-order correlations between symptoms. ...
People with obsessive-compulsive disorder [OCD] frequently suffer from depression, a comorbidity associated with greater symptom severity and suicide risk. We examined the associations between OCD and depression symptoms in 87 adolescents with primary OCD. We computed an association network, a graphical LASSO, and a directed acyclic graph (DAG) to model symptom interactions. Models showed OCD and depression as separate syndromes linked by bridge symptoms. Bridges between the two disorders emerged between obsessional problems in the OCD syndrome, and guilt, concentration problems, and sadness in the depression syndrome. A directed network indicated that OCD symptoms directionally precede depression symptoms. Concentration impairment emerged as a highly central node that may be distinctive to adolescents. We conclude that the network approach to mental disorders provides a new way to understand the etiology and maintenance of comorbid OCD-depression. Network analysis can improve research and treatment of mental disorder comorbidities by generating hypotheses concerning potential causal symptom structures and by identifying symptoms that may bridge disorders.
... Individual Likert scales range from 0 to 3, and total raw scores range from 0 to 63. Total score is classified as minimal (0-7), mild (8)(9)(10)(11)(12)(13)(14)(15), moderate (16)(17)(18)(19)(20)(21)(22)(23)(24)(25), or severe anxiety (30-63). 15 ...
... When OCD symptoms of the primary diagnosis reduce, symptoms of comorbid depression and anxiety often alleviate as well. 19 Our cohort was quite homogenous in manifestation of OCD. The majority of patients had checking, forbidden thoughts, or cleaning/contamination manifestations. ...
Aim
Anterior capsulotomy (AC) is one of the last therapeutic options for obsessive–compulsive disorder (OCD) refractory to conservative treatments. Several forms of cognitive dysfunction have been identified following assessment of neuropsychological outcomes in OCD patients, however few studies focused on cognitive changes in OCD patients following surgery. In the present study, we evaluated the effects of AC on cognitive performance and mood status in patients with refractory OCD.
Method
Twelve patients underwent bilateral AC between 2012 and 2019 at our institution. The patients (N = 12 F:M 5:7; mean age 39.7 years; duration ≥5 years) were assessed before and 6 months after intervention. The diagnosis of treatment‐refractory OCD was based on recommended criteria for surgical treatment. Patients were assessed using a neuropsychological battery and questionnaires focused on anxiety‐depressive symptomatology. The Yale‐Brown Obsessive–Compulsive Scale (Y‐BOCS) was administered as a measure of severity of OCD symptoms.
Results
We detected a significant decrease of OCD, anxiety and depressive symptomatology assessed by Y‐BOCS, BDI‐II and BAI (p < 0.05) 6 months after AC in 8 patients and a partial decrease in 4 patients. Four patients underwent repeated AC with more pronounced improvement achieved after the first procedure. We did not detect decline in cognitive performance in any patients, but did find better visual memory performance (p < 0.05).
Conclusion
AC reduced OCD and anxiety‐depressive symptoms and did not appear to influence cognitive performance, even after repeated surgery.
... Our findings also have implications for the body of evidence that exposure-based treatment for OCD results in significant improvements in depressive symptoms (Meyer et al., 2014;Rozenman et al., 2019;Zandberg et al., 2015). One theory underlying this phenomenon is that ERP may "behaviorally activate" patients with OCD or help them come into contact with more sources of positive reinforcement (Blakey, Abramowitz, Leonard, & Riemann, 2019). ...
... One theory underlying this phenomenon is that ERP may "behaviorally activate" patients with OCD or help them come into contact with more sources of positive reinforcement (Blakey, Abramowitz, Leonard, & Riemann, 2019). Investigators who have studied this topic have also proposed that relief from OCD symptoms may come with an increased sense of self-efficacy and mastery and decreased hopelessness and depression that may arise from a fear-based disorder (Zandberg et al., 2015). More directly, Schwartz et al. (2017) indicated that mastery experiences and changes in self-esteem are critical change factors in ERP treatment for OCD, each associated with subsequent decreases in Y-BOCS scores (though they did not investigate their relationship with depression). ...
The cognitive-behavioral model of obsessive-compulsive disorder, along with several contemporary theories, suggests that self-esteem is likely an important component of OCD psychopathology and treatment. Little research, however, has explored the association between self-esteem and OCD. The study of self-esteem is itself a complex pursuit. A comprehensive investigation of self-esteem requires consideration of state and trait aspects of this construct and a longitudinal perspective, particularly when self-esteem is studied during the course of psychological treatment. In this study, adults participating in psychological treatment for OCD provided repeated self-reports of self-esteem throughout the course of therapy. The aims of this study were to evaluate the relationship between self-esteem and severity of OCD and depressive symptoms; to examine whether temporal variability (i.e., fluctuation) in self-esteem was associated with symptom reduction; and to measure changes in self-esteem over time. Our results indicated the following: average self-esteem across treatment, variability in self-esteem, and depressive symptomatology were significantly correlated with post-treatment OCD severity; self-esteem did not affect the rate of OCD symptom change over treatment but did significantly affect the rate of depressive symptom change; self-esteem increased significantly before and after sessions, on average, and over the course of treatment. Implications and further directions are discussed.
... Abramowits indicates that ERP treatment is associated with significant changes in the reduction of depressive symptoms (Abramowitz, Foa, & Franklin, 2003). Zandberg, McLean, Yeh, Simpson, & Foa (2015) have argued that changes in OCD and depressive symptoms affected each other, and OCD improvement has a greater impact on depression than the other way around. Changes in OCD symptoms had an overall effect on treating depressive symptoms. ...
... The reduction of depressive symptoms, which has occurred in response to ERP treatment, may have reduced the OCD symptoms. This decrease appears to be due to the reduced symptoms of the main illness (Zandberg, et al. 2015). The results of a case study by Alizadeh Goradel, Pouresmali, Mowlaie, & Sadeghi Movahed (2016) demonstrated that tDCS significantly affected depressive and obsessive-compulsive symptoms (Alizadeh Goradel, et al. 2016). ...
Introduction: Obsessive-Compulsive Disorder (OCD) belongs to the categories of psychiatric disorders with the potential to turn into a chronic condition without receiving the necessary treatments. The main feature of OCD is the frequent or intense obsession and compulsion that might induce great pain and suffering in patients. Moreover, as one of the most prevalent abnormalities, depression usually follows OCD. The present study aimed to compare the effects of Exposure and Response Prevention (ERP) and Transcranial Direct Current Stimulation (tDCS) treatments adjunct to pharmacotherapy on decreasing the severity of obsession-depression symptoms and improving the quality of life in OCD patients.
Methods: This was a quasi-experimental study with a pre-test, post-test design and a follow-up stage. The statistical population comprised all the patients diagnosed with OCD in Zanjan Province, Iran. Besides, 26 OCD patients referring to Shahid Beheshti Medical Center in Zanjan were selected using a purposive sampling method. Then, they were randomly assigned to two treatment groups. The study subjects completed the Yale Brown Obsessive-Compulsive Scale (Y-BOCS), Beck Depression Inventory-II (BDI 2), and the Quality of Life Questionnaire at the pre-treatment, post-treatment, and follow-up stages (1 month and 2 months after the treatment). Analysis of Covariance (ANCOVA) and Reliable Change Index (RCI) methods were used to measure statistical and clinical significances, respectively. The collected data were analyzed using SPSS.
Results: The obtained data suggested no significant difference between the ERP and tDCS groups concerning the symptoms of OCD and depression at the post-test stage (P>0.05). Conversely, in terms of life quality, there was a significant difference between the ERP and tDCS groups at the post-test phase (P
... Depression and anxiety in OCD, at the symptom and disorder levels, are associated with more severe OCD Peris et al., 2010;Peris et al., 2017), higher levels of family conflict , greater functional impairment (Storch et al., 2010), poorer insight (Peris et al., 2010), worse treatment outcomes (Keeley et al., 2008;Storch et al., 2008), and an increased risk of relapse after OCD treatment (Geller et al., 2003). Reasons for the high cooccurrence include diagnostic practices (e.g., the tendency to ascribe additional diagnoses to psychiatric patients), shared genetic risk factors (Bolhuis et al., 2014;Lopez-Sola et al., 2016a), and possibly direct causal mechanisms through which changes in OCD symptoms give rise to changes in symptoms of anxiety and depression, and vice versa (Rickelt et al., 2016;Voltas et al., 2014;Zandberg et al., 2015). ...
... This suggests that anxiety symptoms may be highly important to, and possibly mediate, the relationship between OCD and depression in youth. This is supported by evidence showing that first-line treatment for pediatric OCD positively affects co-occurring symptoms of anxiety and depression (Bolton et al., 2011;Storch et al., 2013;Zandberg et al., 2015) and that these effects are strongest in relation to anxiety (Conelea et al., 2017). Currently, treatments of pediatric OCD do not include interventions directly targeting panic and generalized anxiety. ...
Background: Symptoms of depression and anxiety are common in children with obsessive-compulsive disorder (OCD) and associated with more severe OCD, greater impairment, and worse treatment outcome. Beyond twin studies showing that genetic factors contribute to the high co-occurrence, few studies have examined how OCD, depression, and anxiety are linked in youth, and current studies often fail to account for OCD and anxiety heterogeneity.
Methods: Network analysis was used to investigate how OCD were linked to depression and anxiety in multinational youth diagnosed with OCD (total n = 419) and in school-recruited, community-based samples of youth (total n = 2 991).
Results: Initial results aligned with earlier work showing that severity of obsession-related symptoms are important in linking OCD to depression in youth with OCD. However, when symptom content of OCD (e.g., washing, ordering) was fully taken into account and when measures of anxiety were included, specific OCD symptom dimensions (primarily obsessing and doubting/checking) were linked to specific anxiety dimensions (primarily panic and generalized anxiety) which in turn were linked to depression. These results were replicated in three separate community-based samples from Chile, Italy, and Spain using different measures of anxiety and depression.
Limitations: Cross-sectional data were analyzed which precludes causal inference. Self-report measures were used.
Conclusions: Youth with OCD with symptoms related to doubting/checking and obsessing should be carefully assessed for symptoms of panic and generalized anxiety. Non-responders to standard OCD treatment may benefit from interventions targeting panic and generalized anxiety, but more research is needed to test this hypothesis.
... Studies show that patients with OCD often have depressive symptoms, and depression is a common comorbidity of OCD, with a comorbidity rate of 50-60% (Overbeek et al., 2002;Besiroglu et al., 2007). Previous longitudinal studies have shown that the improvement of depressive symptoms can partially mediate the improvement of obsessive-compulsive symptoms; therefore, the study of anxiety and depressive symptoms in patients with OCD is necessary to explore the pathogenesis of OCD (Anholt et al., 2011;Zandberg et al., 2015). ...
Objective: This study aimed to explore the relationship among cognitive fusion, experiential avoidance, and obsessive–compulsive symptoms in patients with obsessive–compulsive disorder (OCD).
Methods: A total of 118 outpatient and inpatient patients with OCD and 109 healthy participants, gender- and age-matched, were selected using cognitive fusion questionnaire (CFQ), acceptance and action questionnaire−2nd edition (AAQ-II), Yale–Brown scale for obsessive–compulsive symptoms, Hamilton anxiety scale, and Hamilton depression scale for questionnaire testing and data analysis.
Results: The levels of cognitive fusion and experiential avoidance in the OCD group were significantly higher than those in the healthy control group ( P < 0.05). Regression analysis results showed that, in predicting the total score of obsessive–compulsive symptoms, AAQ-II ( β = 0.233, P < 0.05) and CFQ ( β = 0.262, P < 0.01) entered the equation, which explained 17.1% variance. In predicting anxiety, only AAQ-II ( β = 0.222, P < 0.05) entered the equation, which explained 13% variance. In the prediction of depression, AAQ-II ( β = 0.412, P < 0.001) entered the equation, which explained 17.7% variance.
Conclusion: Cognitive fusion and experiential avoidance may be important factors for the maintenance of OCD, and experiential avoidance can positively predict the anxiety and depression of OCD patients.
... The reduction in anxiety is easily understandable, since very often this emotion accompanies obsessive symptoms. Zandberg et al. (92) found a reduction in depression following the improvement in obsessive symptoms. This is understandable considering that, in many cases, depression is related to the frustration and distress of having obsessive symptoms. ...
Background and objectives: Criticism is thought to play an important role in obsessive-compulsive disorder (OCD), and obsessive behaviors have been considered as childhood strategies to avoid criticism. Often, patients with OCD report memories characterized by guilt-inducing reproaches. Starting from these assumptions, the aim of this study is to test whether intervening in memories of guilt-inducing reproaches can reduce current OCD symptoms. The emotional valence of painful memories may be modified through imagery rescripting (ImRs), an experiential technique that has shown promising results.
Methods: After monitoring a baseline of symptoms, 18 OCD patients underwent three sessions of ImRs, followed by monitoring for up to 3 months. Indexes of OCD, depression, anxiety, disgust, and fear of guilt were collected.
Results: Patients reported a significant decrease in OCD symptoms. The mean value on the Yale−Brown Obsessive Compulsive Scale (Y-BOCS) changed from 25.94 to 14.11. At the 3-month follow-up, 14 of the 18 participants (77.7%) achieved an improvement of ≥35% on the Y-BOCS. Thirteen patients reported a reliable improvement, with ten reporting a clinically significant change (reliable change index = 9.94). Four reached the asymptomatic criterion. Clinically significant changes were not detected for depression and anxiety.
Conclusions: Our findings suggest that after ImRs intervention focusing on patients’ early experiences of guilt-inducing reproaches there were clinically significant changes in OCD symptomatology. The data support the role of ImRs in reducing OCD symptoms and the previous cognitive models of OCD, highlighting the role of guilt-related early life experiences in vulnerability to OCD.
... Furthermore, in Obsessive-Compulsive Disorder (OCD), depression affect 15-30 % and anxiety disorders 19-70 % of young sufferers (Storch et al., 2008;Tibi et al., 2017). According to most researchers, depression may arise as a result of the functionally impairing and persistent nature of OCD (e.g., Zandberg et al., 2015). ...
Background
Anxiety, depression, and obsessive-compulsive symptoms often onset during middle childhood and are major causes of disability in young individuals. A better understanding of how these symptoms are linked and unfold over time is important to develop valid etiological models and effective prevention and treatment.
Methods
In the present study, 950 community children (8–14 years) reported on a broad range of internalised symptoms at three time points over the course of a year. First, factor analysis was used to examine the overarching dimensions of these symptoms. Second, network analysis was used to examine unique cross-sectional associations among these empirically supported symptom dimensions. Last, longitudinal structural equation models (SEMs) were used to examine temporal associations among the symptom dimensions.
Results
Six broad symptom dimensions fitted the self-report data well at all time points. These dimensions were conceptualized as depression, general anxiety, situational fears, compulsivity, intrusive thoughts, and somatic anxiety. Network analysis showed that these dimensions formed a highly interconnected network with general anxiety and somatic anxiety being most central (i.e., most strongly associated with other dimensions) at all time points. Longitudinal SEMs supported the central role played by general anxiety in the temporal associations among these dimensions.
Conclusions
Overarching expressions of internalized psychopathology are highly interconnected in middle childhood with possible central roles played by general and somatic anxiety. Interventions aimed at a general proneness for anxiety may be warranted in preventing and treating internalizing symptoms in middle childhood.
... This hypothesis is supported by the timeline of HDRS improvement and separation from sham that is delayed compared to the YBOCS, in contrast to pharmacotherapy, where SRIs require twice the duration for OCD (8-12weeks) than for MDD (4-6weeks). Similarly, Zandberg et al. [7] used lagged multilevel mediational analyses, to demonstrate that reducing OCD symptoms with exposure therapy accounted for 65% of the reduction in depressive symptoms of comorbid OCD-MDD patients. Alternatively, it is possible that stimulation over the dmPFC and ACC directly improved the MDD symptoms irrespective of the OCD. ...
... Intensive ERP treatment improves not only OCD symptoms but reduces depressive symptoms too. Improvements in OCD symptoms seem to predict reductions in depressive symptoms during ERP and pharmacotherapy (Meyer et al. 2014); however, reductions in depressive symptoms do not appear to mediate reductions in OCD symptoms (Zandberg et al. 2015). Improvements in depressive symptoms could be secondary to improvements in OCD symptoms, and/or improvements in global functioning that are themselves the result of lessening of OCD symptoms. ...
Objective: Obsessive-compulsive disorder (OCD) is associated with impaired functioning and depression. Our aim was to examine relationships between OCD symptoms, depression, and functioning before and after exposure and response prevention (ERP), a type of cognitive-behavioral therapy for OCD, specifically examining whether functioning, depression and other cognitive factors like rumination and worry acted as mediators.
Methods: Forty-four individuals with OCD were randomized to four weeks of intensive ERP treatment first (n = 23) or waitlist then treatment (n = 21). We used a bootstrapping method to examine mediation models.
Results: OCD symptoms, depression and functioning significantly improved from pre- to post-intervention. Functioning mediated the relationship between OCD symptoms and depression and the relationship between functioning and depression was stronger at post-treatment. Depression mediated the relationship between OCD symptoms and functioning, but only at post-intervention. Similarly, rumination mediated the relationship between OCD symptoms and depression at post-intervention.
Conclusions: Our findings suggest that after ERP, relationships between depression and functioning become stronger. Following ERP, treatment that focuses on depression and functioning, including medication management for depression, cognitive approaches targeting rumination, and behavioral activation to boost functionality may be important clinical interventions for OCD patients.
... 61) producing high rates of co-morbid disorders, including depression, in people with OCD. Tackling this issue, Zandberg et al. (2015) conducted lagged multilevel mediational analyses to test whether improvement in OCD symptoms mediated improvement in depressive symptoms or vice versa in 40 patients with primary OCD who had undergone behavior therapy while taking a serotonin reuptake inhibitor. They found that reduction in OCD symptoms accounted for 65% of the reduction in depressive symptoms, whereas improvement in depressive symptoms only partially mediated subsequent improvement in OCD symptoms, accounting for only 20% of the variance. ...
Background:
Obsessive-compulsive disorder (OCD) is often co-morbid with depression. Using the methods of network analysis, we computed two networks that disclose the potentially causal relationships among symptoms of these two disorders in 408 adult patients with primary OCD and co-morbid depression symptoms.
Method:
We examined the relationship between the symptoms constituting these syndromes by computing a (regularized) partial correlation network via the graphical LASSO procedure, and a directed acyclic graph (DAG) via a Bayesian hill-climbing algorithm.
Results:
The results suggest that the degree of interference and distress associated with obsessions, and the degree of interference associated with compulsions, are the chief drivers of co-morbidity. Moreover, activation of the depression cluster appears to occur solely through distress associated with obsessions activating sadness - a key symptom that 'bridges' the two syndromic clusters in the DAG.
Conclusions:
Bayesian analysis can expand the repertoire of network analytic approaches to psychopathology. We discuss clinical implications and limitations of our findings.
... However, the initial benefit to depressive symptoms were not sustained at 1-month follow-up. This initial improvement to comorbid symptoms may likely be accounted for by improvement in OCD (Zandberg et al., 2015). The rebound of depressive symptoms at follow-up was somewhat unexpected and inconsistent with prior research (Stewart et al., 2005 ). ...
Obsessive-compulsive disorder (OCD) is often a severe and highly debilitating disorder, in which many patients inadequately respond to standard outpatient care. While specialized intensive residential treatment (IRT) for OCD provides promise, factors to improve treatment adherence in these settings is currently unknown but crucial to optimize treatment response. This naturalistic study examined the rates and predictors of patient adherence to exposure and response preventions (EX/RP) for 49 patients attending IRT. A therapist assessed between-session adherence to EX/RP, and participants completed self-report measures at pre- and post-treatment, and 1-month follow-up. Linear mixed effects models analyses revealed that IRT resulted in significant improvements in OCD and comorbid symptoms. Treatment readiness, specific obsessional beliefs, depression and stress symptoms, level of insight, avoidance, and responsibility for harm were significantly associated with patient adherence. Directions for future research that may interact with adherence to EX/RP and lead to targeted interventions are discussed.
... Consistent with Wilhelm et al.'s (2015) results and the cognitive mediation hypothesis, we hypothesized that all three categories of obsessive beliefs would mediate OCD symptom changes during EX/RP. Depression was included as an alternative mediator, given its positive association with OCD change in previous investigations (Olantunji et al., 2013;Zandberg et al., 2015). ...
This study examined cognitive mediators of symptom change during exposure and response prevention (EX/RP) for obsessive compulsive disorder (OCD). Based on cognitive models of OCD, obsessive beliefs were hypothesized as a mediator of symptom change. Participants were 70 patients with primary OCD receiving EX/RP either as part of a randomized controlled trial (n = 38) or in open treatment following non-response to risperidone or placebo in the same trial (n = 32). Blinded evaluations of OCD severity and self-report assessments of three domains of obsessive beliefs (i.e., responsibility/threat of harm, importance/control of thoughts, and perfectionism/intolerance of uncertainty) were administered during acute (weeks 0, 4 and 8) and maintenance treatment (weeks 12 and 24). Study hypotheses were examined using cross-lagged multilevel modeling. Contrary to predictions, the obsessive beliefs domains investigated did not mediate subsequent OCD symptom reduction. In addition, OCD symptoms did not significantly mediate subsequent change in obsessive beliefs. The present study did not find evidence of cognitive mediation during EX/RP for OCD, highlighting the need to investigate other plausible mediators of symptom improvement.
... The Y-BOCS has been widely used in various randomized controlled trials [12][13][14][15], demonstrating its ability to detect changes before and after treatment [16,17]. Its scores ...
The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) is a widely used clinician-rated measure for assessing obsessive-compulsive symptoms. Although numerous studies have supported its reliability and validity, improved phenomenological understanding of obsessive-compulsive disorder (OCD) suggests the need for modifications to item content, structure, and scoring. Consequently, the Yale-Brown Obsessive Compulsive Scale – Second Edition (Y-BOCS-II) was developed. While the Y-BOCS-II shows initial promise, minimal data exist in examining the psychometric properties of the Y-BOCS-II English version. In response, the Y-BOCS-II was administered to 61 adult patients with a principal diagnosis of obsessive-compulsive disorder. The internal consistency for the scores on the Obsession Severity (α = .83), Compulsion Severity (α = .75), and Total Severity (α = .86) scales were acceptable to good. The inter-rater reliability for the severity scale scores was excellent (ICC = .97 - .99) and the test-retest reliability was acceptable (r = .64 - .81). Strong convergent validity was observed between the Y-BOCS-II Total Severity scale and other measures of obsessive-compulsive symptom severity and related impairment. Good divergent validity was supported by non-significant correlations between the Total Severity score and measures of anxiety and impulsiveness, though a moderate correlation was observed with depressive symptoms. Collectively, the Y-BOCS-II generally possesses sound psychometric properties and appears to be a viable alternative to the original Y-BOCS.
... Then, a multilevel regression analysis was conducted for each mental health outcome in four steps, which are the prerequisites of mediation as presented in Figure 2 (Baron & Kenny, 1986). The steps were based on earlier research that investigated mediation models in multilevel data (Zandberg et al., 2015). ...
Objectives:
Living donor kidney transplantation offers advantages to the patient, however involves risks to the donor. To optimize donors' mental health after donation, we studied the influence of psychological factors on this outcome. Potential predictors were based on models of Lazarus () and Ursin and Eriksen () that describe predictors of mental health mediated by stress.
Design:
Prospective design.
Methods:
Living kidney donors (n = 151) were interviewed before donation and completed questionnaires 2.5 months before and 3 and 12 months post-donation. Using multilevel regression models, we examined whether appraisals, expectations, knowledge, social support, coping, life events, and sociodemographic characteristics predicted psychological symptoms and well-being and whether these relationships were mediated by stress.
Results:
A greater increase in psychological symptoms over time was found among donors without a partner. Younger age, lack of social support, expectations of interpersonal benefit, lower appraisals of manageability, and an avoidant coping style were related to more psychological symptoms at all time points. The latter three were mediated by stress. No religious affiliation, unemployment, history of psychological problems, less social support, expectations of negative health consequences, and less positive appraisals were related to lower well-being at all time points.
Conclusions:
This study identified indicators of a lower mental health status among living kidney donors. Professionals should examine this profile before donation and the need for extra psychological support in relation to the number and magnitude of the identified indicators. Interventions should be focused on the changeable factors (e.g., expectations), decreasing stress/psychological symptoms, and/or increasing well-being. Statement of contribution What is already known on this subject? Until now, research on psychological outcomes after living kidney donation revealed that mental health remained the same for the majority of living kidney donors, while mental health improved or deteriorated for a minority after donation. In reaction to these findings, many psychosocial screening guidelines have been developed for potential donors; however, the components of these guidelines are based on professional opinions and experience rather than on longitudinal empirical data. There is a lack of research that identifies pre-donation donor characteristics that are related to a lower mental health among donors. Such studies are essential in order to tailor psychosocial support during the donation process. What does this study add? Components that are mostly included in psychosocial screening guidelines for potential living kidney donors are not predictive of deterioration, nor increase, in mental health after donation, except for the lack of a partner. Therefore, there is little evidence on the necessity of rejecting potential donors based on these psychological criteria. The following psychological risk factors are predictive of the absolute level of donors' mental health during the donation process: A history of psychological problems, expectations of interpersonal benefit and negative health outcomes, an avoidant coping style, lack of social support, appraisals of the donation process as an unmanageable and/or negative event, a younger age, no religious affiliation, and unemployment. We argue that potential donors should not be rejected for donation based on these factors, but the indicators should be used to identify donors who might be in need for more psychological support.
... Although fewer studies have examined how changes in OCD and depressive symptoms are related to each other during treatment, the research to date suggests that reductions in OCD symptoms account for a greater proportion of reductions in depressive symptoms than the reverse. In a recent study of 40 OCD patients receiving EX/RP, Zandberg et al. (2015) used lagged multilevel mediational analysis to examine the temporal relationship between changes in OCD symptoms and changes in depressive symptoms. The findings indicated that reductions in OCD symptoms fully mediated the subsequent change in depressive symptoms, accounting for 65% of the variance in depressive symptoms. ...
In this review we describe the intricate interrelationship among basic research, conceptualization of psychopathology, treatment development, treatment outcome research, and treatment mechanism research and how the interactions among these areas of study further our knowledge about psychopathology and its treatment. In describing the work of Edna Foa and her colleagues in anxiety disorders, we demonstrate how emotional processing theory of anxiety-related disorders and their treatment using exposure therapy have generated hypotheses about the psychopathology of posttraumatic stress disorder and obsessive-compulsive anxiety disorder that have informed the development and refinement of specific treatment protocols for these disorders: prolonged exposure and exposure and response (ritual) prevention. Further, we have shown that the next step after the development of theoretically driven treatment protocols is to evaluate their efficacy. Once evidence for a treatment's efficacy has accumulated, studies of the mechanisms involved in the reduction of the targeted psychopathology are conducted, which in turn inform the theory and further refine the treatments. We conclude our review with a discussion of how the knowledge derived from Foa and colleagues' programmatic research together with knowledge emerging from basic research on extinction learning can inform future research on the psychopathology of anxiety disorders and their treatments. Expected final online publication date for the Annual Review of Clinical Psychology Volume 12 is March 28, 2016. Please see http://www.annualreviews.org/catalog/pubdates.aspx for revised estimates.
Obsessive-compulsive disorder (OCD) is characterized by the presence of debilitating obsessions and compulsions. Cognitive and behavioral models of OCD provide a strong theoretic and empirical foundation for informing effective psychotherapeutic treatment. Cognitive-behavioral therapy (CBT) for OCD, which includes a deliberate emphasis on exposure and response/ritual prevention, has consistently demonstrated robust efficacy for the treatment of pediatric and adult OCD and is the front-line psychotherapeutic treatment for OCD. Two case vignettes describing CBT for OCD in practice as well as recommendations for clinicians are provided.
Objective
To systematically evaluate the effectiveness of exposure and response prevention (ERP) combined with medication on obsessive-compulsive disorder (OCD).Methods
PubMed, Web of Science, EBSCO, Cochrane, Embase, and Science Direct databases were searched to include randomized controlled trials of ERP combined with medication for OCD that met the criteria. The Yale Brown Obsessive Compulsive Scale was used as the primary outcome indicator, and Depression scales were used as secondary outcome indicators. An evaluation of bias risk was conducted to identify possible sources of bias based on methodological and clinical factors. Review Manager 5.3 and Stata 16.0 software was used to perform meta-analysis of the extracted data.ResultsA total of 21 studies with 1113 patients were included. Meta-analysis showed that ERP combined with medication therapy was significantly better than medication therapy alone including selective serotonin reuptake inhibitors, clomipramine and risperidone (MD = –6.60, 95% CI: –8.35 to –4.84, P < 0.00001), but D-cycloserine (DCS) drugs do not enhance the effect of ERP intervention in patients with OCD (MD = 0.15, 95% CI: –0.87 to 1.17, P = 0.77). There is more significant maintenance by combined treatment method of medication plus ERP than medication treatment alone during the follow-up period (MD = –7.14, 95% CI: –9.17 to –5.10, P < 0.00001). DCS drugs did not enhance the effect of ERP intervention on depression in patients with OCD (SMD = –0.08, 95% CI: –0.31 to 0.15, P = 0.50). ERP combined with drug improved patients’ depression levels significantly better than providing drug alone (SMD = –0.40, 95% CI: –0.68 to –0.11, P = 0.006).Conclusion
Patients with OCD have significant improvement in symptoms of obsessive-compulsive disorder and depression when ERP is combined with medication, however, not enough to prove that DCS can enhance ERP effectiveness.
Background
Depressive and obsessive-compulsive (OCD) symptoms often co-occur and a number of possible explanations for this co-occurrence have been explored, including shared biological and psychosocial risk factors. Network approaches have offered a novel hypothesis for the link between depressive and OCD: functional inter-relationships across the symptoms of these conditions. The few network studies in this area have relied largely on item, rather than process-level constructs, and have not examined relationships dimensionally.
Methods
Network analytic methods were applied to data from 463 treatment-seeking adults with OCD. Patients completed self-report measures of OCD and depression. Factor analysis was used to derive processes (i.e., nodes) to include in the network. Networks were computed, and centrality, bridge, and stability statistics examined.
Results
Networks showed positive relations among specific OCD and depressive symptoms. Obsessions (particularly repugnant thoughts), negative affectivity, and cognitive-somatic changes (e.g., difficulty concentrating) were central to the network. Unique relations were observed between symmetry OCD symptoms and cognitive-somatic changes. No direct link between harm-related OCD symptoms and depression was observed.
Conclusions
Our results bring together prior findings, suggesting that both negative affective and psychomotor changes are important to consider in examining the relationship between OCD and depression. Increased consideration of heterogeneity in the content of OCD symptoms is key to improving clinical conceptualizations, particularly when considering the co-occurrence of OCD with other disorders.
Objective
To systematically evaluate the efficacy of repetitive transcranial magnetic stimulation (rTMS) in reducing comorbid anxiety and depressive symptoms in patients with obsessive-compulsive disorder (OCD).
Methods
Three electronic databases were searched for randomized, sham-controlled clinical trials evaluating rTMS for the treatment of OCD. Hedge's g was calculated as the effect size for anxiety/depression symptom severity (primary outcome) and OCD severity (secondary outcome). Subgroup analyses and meta-regression analyses were carried out to evaluate the most promising target and whether a reduction in OCD severity moderates the change in anxiety or depression scores.
Results
Twenty studies ( n = 688) were included in the meta-analysis. rTMS had small-medium effect size on OCD (Hedge's g = 0.43; 95% confidence interval [CI]: [0.20, 0.65]; P < 0.001), anxiety (Hedge's g = 0.3; 95% CI: [0.11, 0.48]; P = 0.001) and depression (Hedge's g = 0.24; 95% CI: [0.07, 0.40]; P = 0.003) symptoms. Subgroup analysis showed that protocols targeting dorsolateral prefrontal cortex (DLPFC) were effective for 3 outcome measures. The change in anxiety, but not depression severity, was moderated by a change in OCD symptom scores. However, the findings are uncertain as a majority of the studies had some concerns or a high risk of bias.
Conclusions
Active rTMS protocol targeting DLPFC is effective in reducing the comorbid anxiety/depression symptoms along with OCD severity. The antidepressant effect is not moderated by the anti-obsessive effect of rTMS. Abrégé
Background and objectives
We know little about how symptoms of obsessive-compulsive disorder and depression interact during psychological therapy. Although some previous research suggests that reductions in the severity of depression are driven by reductions in OCD, support for this conclusion is limited due to the exclusion of individuals with severe depression and limitations of the statistical approaches used.
Methods
This study re-examined the interaction between symptoms of OCD and depression during therapy in a sample of 137 adults with a primary diagnosis of OCD and a full range of depression severity. All participants received a 12 to 16-week specialist residential treatment. Participants completed the Florida Obsessive Compulsive Inventory and Patient Health Questionnaire for depression weekly. The relationship between severity of OCD and depression was examined using a random intercept cross-lagged panel model.
Results
Both cross-lagged paths were significant, with prior levels of OCD influencing subsequent levels of depression, and prior levels of depression influencing subsequent levels of OCD.
Limitations
The present study was conducted in a residential setting, meaning the findings may not generalise to outpatient settings characterised by less severe OCD and depression.
Conclusions
Contrary to previous findings, which suggest that the influence of OCD on depression is far greater than the reverse, our findings suggest that OCD and depression influence each other equally. As improvements in mood can help to improve symptoms of OCD, it appears important to target depression concurrently during treatment for OCD. This would be a new treatment target for improvement outcomes in OCD.
Background
Obsessive compulsive disorder (OCD) and depression commonly co-occur. Past research has evaluated underlying mechanisms of depression in the context of other diagnoses, but few to no studies have done this within OCD.
Aims
This study examines the relationships between distress tolerance (DT), experiential avoidance (EA), depression, and OCD symptom severity across intensive/residential treatment (IRT) for OCD. It was hypothesized that all variables would be significantly moderately related and EA would emerge as a potential contributing factor to change in depression and OCD symptoms across IRT for OCD.
Method
The sample included 311 participants with a primary diagnosis of OCD seeking IRT. Correlations were performed between all variables at both admission and discharge. A two-step hierarchical regression with change in OCD symptoms and change in DT in the first block and change in EA in the second block examined if change in EA explained change in depression above and beyond change in OCD and DT ability.
Results
At both admission and discharge, higher EA, lower DT, and higher OCD symptom severity were significantly associated with more depressive symptoms. Change in EA explained a significant amount of variance in change in depression above and beyond change in OCD symptom severity and change in DT.
Conclusions
This study expands past results within an OCD sample, emphasizing EA as an important treatment target in OCD. Future studies could utilize samples from other treatment contexts, use a measure of EA specific to OCD, and utilize a longitudinal model that takes temporal precedence into account.
McNally and colleagues (2017) provide preliminary evidence for the hypothesis that obsessive compulsive disorder (OCD) and depression symptoms co-occur because they create a network of interacting symptoms. Given the need to understand comorbidity between these symptoms and replicating network models, the aim of the current study was to examine a cross-sectional network of OCD and depression symptoms in an adult clinical sample diagnosed with OCD (n = 290). Participants completed self-report measures of OCD and depression symptoms. A network of regularized partial correlation coefficients was estimated using the graphical least absolute shrinkage and selection operator (GLASSO) with the Extended Bayesian Information Criterion (EBIC). Parameter estimates were also compared between McNally and colleagues’ (2017) results and the current findings to determine the consistency of trends. OCD and depression symptom clusters were bridged by an association between interference from obsessions and low energy, suggesting this is a key feature in the development of comorbidity. Distress related to obsessions emerged as the most highly central node in the network. Low energy, interference from compulsions, and resisting compulsions were also central to the network. These symptoms may be important targets for treatment. Overall, the majority of comparable parameters were consistent with previous work.
Aims: The current study explore the relationship between the trajectories of primary panic disorder symptoms and secondary depressive symptoms during guided internet-delivered cognitive behaviour therapy for panic disorder.
Materials and methods: The patients (N=143) were recruited from an ongoing effectiveness study in secondary mental health outpatient services in Norway. Weekly self-reported primary panic disorder symptoms and secondary depressive symptoms were analysed.
Results: primary panic disorder symptoms and secondary depressive symptoms improved significantly during the course of treatment, and at six months follow-up. Parallel process latent growth curve modelling showed that the trajectory of depressive symptoms and trajectory of panic disorder symptoms were significantly related. A supplementary analysis with cross-lagged panel modelling showed that (1) pre-treatment depressive symptoms predicted a positive effect of panic disorder symptoms early in treatment; (2) high early treatment panic disorder symptoms predicted low depressive symptoms at post-treatment.
Conclusions: Guided ICBT for panic disorder is effective for both primary panic disorder symptoms and secondary depressive symptoms. Patients with high pre-treatment secondary depressive symptoms may constitute a vulnerable subgroup. A high level of panic disorder symptoms early in treatment seems beneficiary for depressive symptoms outcome. A time-dependent model may be necessary to describe the relationship between PAD symptoms and depressive symptoms during the course of treatment.
Obsessive-compulsive disorder (OCD) frequently co-occurs during a major depressive episode (i.e., Major depressive disorder, MDD). Concurrent depressive episodes may present additional challenges and barriers in OCD treatment; therefore, clinicians should address both symptom domains simultaneously. The present case study illustrates an example of an individual presenting with OCD symptoms falling under aggressive and sexual domains. The treatment utilized was exposure and response prevention (ERP), which is empirically supported to address OCD symptoms. Additional treatment elements, such as behavioral activation, building self-concept through mastery, and emotional processing were incorporated to specifically address depression symptoms, which enhanced the efficacy of ERP. The current case presentation provides evidence that the utilized combination of treatment modalities is feasible to implement and may effectively reduce OCD symptoms during a depressive episode.
Background:
Depression is the most common comorbidity in obsessive-compulsive disorder (OCD). However, the mechanisms of depressive comorbidity in OCD are poorly understood. We assessed the directionality and moderators of the OCD-depression association over time in a large, prospective clinical sample of OCD patients.
Methods:
Data were drawn from 382 OCD patients participating at the Netherlands Obsessive-Compulsive Disorder Association (NOCDA) study. Cross-lagged, structural equation modeling analyses were used to assess the temporal association between OCD and depressive symptoms. Assessments were conducted at baseline, two-year and four-year follow up. Cognitive and interpersonal moderators of the prospective association between OCD and depressive symptoms were tested.
Results:
Cross-lagged analyses demonstrated that OCD predicts depressive symptoms at two-year follow up and not vice a versa. This relationship disappeared at four-year follow up. Secure attachment style moderated the prospective association between OCD and depression.
Conclusions:
Depressive comorbidity in OCD might constitute a functional consequence of the incapacitating OCD symptoms. Both OCD and depression symptoms demonstrated strong stability effects between two-year and four-year follow up, which may explain the lack of association between them in that period. Among OCD patients, secure attachment represents a buffer against future depressive symptoms.
Objective:
Despite the frequent occurrence of depressive symptoms in obsessive-compulsive disorder (OCD), little is known about the reciprocal influence between depressive and obsessive-compulsive symptoms during the course of the disease. The aim of the present study is to investigate the longitudinal relationship between obsessive-compulsive and depressive symptoms in OCD patients.
Method:
We used the baseline and 1-year follow-up data of the Netherlands Obsessive Compulsive Disorder Association (NOCDA) study. In 276 patients with a lifetime diagnosis of obsessive-compulsive disorder, depressive and obsessive-compulsive symptoms were assessed at baseline and at one-year follow-up with the Beck Depression Inventory (BDI) and the Yale-Brown Obsessive Compulsive Symptom (Y-BOCS) scale. Relations were investigated using a cross-lagged panel design.
Results:
The association between the severity of depressive symptoms at baseline and obsessive-compulsive symptoms at follow-up was significant (β=0.244, p<0.001), while the association between the severity of obsessive-compulsive symptoms at baseline and depressive symptoms at follow-up was not (β=0.097, p=0.060). Replication of the analyses in subgroups with and without current comorbid major depressive disorder (MDD) and subgroups with different sequence of onset (primary versus secondary MDD) revealed the same results.
Limitations:
There may be other factors, which affect both depressive and obsessive-compulsive symptoms that were not assessed in the present study.
Conclusion:
The present study demonstrates a relation between depressive symptoms and the course of obsessive-compulsive symptoms in OCD patients, irrespective of a current diagnosis of MDD and the sequence of onset of OCD and MDD.
Objective:
To examine symptom change over time, the effect of attrition on treatment outcome, and the putative mediators of cognitive therapy (CT) versus behavior therapy (BT) for obsessive-compulsive disorder (OCD) using archival data.
Method:
Sixty-two adults with OCD were randomized to 20 sessions of CT (N = 30) or BT (N = 32) that consisted of 4 weeks of intensive treatment (16 hr total) and 12 weeks of maintenance sessions (4 hr). Independent evaluators assessed OCD severity using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) at baseline and at Weeks 4, 16 (posttreatment), 26, and 52 (follow-up). Behavioral avoidance, depressive symptoms, and dysfunctional beliefs regarding responsibility were also measured at each assessment. Study hypotheses were tested using multilevel modeling.
Results:
The slope of change in Y-BOCS scores was significantly greater in BT than in CT (d = 0.69), and those receiving BT had lower Y-BOCS scores at the final assessment than those receiving CT (d = 1.17). The greater slope of change in BT versus CT did not differ for dropouts versus completers. Reduction in depressed mood mediated changes in Y-BOCS across the 2 treatments, but a reduction in sense of responsibility and a decrease in avoidance did not. Instead, Y-BOCS improvements appeared to precede a decrease in avoidance.
Conclusions:
BT may have some therapeutic advantage over CT in the treatment of OCD, and this advantage does not appear to be due to a differential pattern of responding for treatment dropouts versus completers. Further, inconsistent with hypotheses, improvements in OCD symptoms were mediated by reductions in depressed mood instead of decreases in avoidance and responsibility. Theoretical, methodological, and clinical implications are discussed.
Objective:
In the present study, we examined the relationship between posttraumatic and depressive symptoms during prolonged exposure (PE) treatment with and without cognitive restructuring (CR) for the treatment of posttraumatic stress disorder (PTSD).
Method:
Female assault survivors (N = 153) with PTSD were randomized to either PE alone or PE with added CR (PE/CR). During treatment, bi-weekly self-report measures of posttraumatic and depressive symptoms were administered.
Results:
Multilevel mediational analyses indicated that during PE, changes in posttraumatic symptoms accounted for 80.3% of changes in depressive symptoms, whereas changes in depressive symptoms accounted for 45.0% of changes in posttraumatic symptoms. During PE/CR, changes in posttraumatic symptoms accounted for 59.6% of changes in depressive symptoms, and changes in depressive symptoms accounted for 50.7% of changes in posttraumatic symptoms.
Conclusions:
This pattern of results suggests that PE primarily affects posttraumatic symptoms, which in turn affect depressive symptoms. In contrast, PE/CR results in a more reciprocal relationship between posttraumatic and depressive symptoms.
We present a meta-analytic review of 16 controlled treatment studies of cognitive behavioral therapy for obsessive-compulsive disorder (OCD). Specifically, we examined the efficacy of exposure-based therapy, cognitive therapy, and their combination; and we investigated the relative efficacy of exposure and cognitive treatment programs. Consistent with previous research, our results revealed that exposure therapy was significantly more effective than control (effect size = 1.50; percent symptom reduction = 48.32). Although, cognitive and combined treatments were also superior to controls, effect sizes did not differ reliably from zero, probably due to the small number of studies. Results of direct comparisons between exposure and cognitive therapy are difficult to interpret due to 1) the use of behavioral experiments (which are similar to elements of exposure) in several cognitive treatment programs; and 2) the absence of therapist supervision in many exposure programs. The use of cognitive and exposure procedures in both types of treatment is discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The benefits of cognitive–behavioral treatment for obsessive–compulsive disorder (OCD) have been evidenced by several meta-analyses. However, the differential effectiveness of behavioral and cognitive approaches has shown inconclusive results. In this paper a meta-analysis on the effectiveness of psychological treatment for OCD is presented by applying random- and mixed-effects models. The literature search enabled us to identify 19 studies published between 1980 and 2006 that fulfilled our selection criteria, giving a total of 24 independent comparisons between a treated and a control group. The effect size index was the standardized mean difference in the posttest. The effect estimates for exposure with response prevention (ERP) alone (d+ = 1.127), cognitive restructuring (CR) alone (d+ = 1.090), and ERP plus CR (d+ = 0.998) were very similar, although the effect estimate for CR alone was based on only three comparisons. Therapist-guided exposure was better than therapist-assisted self-exposure, and exposure in vivo combined with exposure in imagination was better than exposure in vivo alone. The relationships of subject, methodological and extrinsic variables with effect size were also examined, and an analysis of publication bias was carried out. Finally, the implications of the results for clinical practice and for future research in this field were discussed.
This article describes the RMediation package,which offers various methods for building confidence intervals (CIs) for mediated effects. The mediated effect is the product of two regression coefficients. The distribution-of-the-product method has the best statistical performance of existing methods for building CIs for the mediated effect. RMediation produces CIs using methods based on the distribution of product, Monte Carlo simulations, and an asymptotic normal distribution. Furthermore, RMediation generates percentiles, quantiles, and the plot of the distribution and CI for the mediated effect. An existing program, called PRODCLIN, published in Behavior Research Methods, has been widely cited and used by researchers to build accurate CIs. PRODCLIN has several limitations: The program is somewhat cumbersome to access and yields no result for several cases. RMediation described herein is based on the widely available R software, includes several capabilities not available in PRODCLIN, and provides accurate results that PRODCLIN could not.
Our objective in the present study was to examine the temporal sequencing of posttraumatic and depressive symptoms during prolonged exposure therapy for posttraumatic stress disorder (PTSD) among children and adolescents.
Participants were 73 children and adolescents (56.2% female) between the ages of 8 and 18. Participants completed self-report measures of posttraumatic stress and depression prior to every session. Measures included the Child PTSD Symptom Scale, Beck Depression Inventory, and Children's Depression Inventory.
Multilevel mediational analyses indicated reciprocal relations during treatment: Changes in posttraumatic symptoms led to changes in depressive symptoms and vice versa. Posttraumatic symptoms accounted for 64.1% of the changes in depression, whereas depressive symptoms accounted for 11.0% of the changes in posttraumatic stress.
Prolonged exposure therapy may work primarily by reducing posttraumatic stress, which in turn reduces depression.
Despite significant advances in the study of obsessive-compulsive disorder (OCD), important questions remain about the disorder's public health significance, appropriate diagnostic classification, and clinical heterogeneity. These issues were explored using data from the National Comorbidity Survey Replication, a nationally representative survey of US adults. A subsample of 2073 respondents was assessed for lifetime Diagnostic and Statistical Manual of Mental Disorders, 4th edn (DSM-IV) OCD. More than one quarter of respondents reported experiencing obsessions or compulsions at some time in their lives. While conditional probability of OCD was strongly associated with the number of obsessions and compulsions reported, only small proportions of respondents met full DSM-IV criteria for lifetime (2.3%) or 12-month (1.2%) OCD. OCD is associated with substantial comorbidity, not only with anxiety and mood disorders but also with impulse-control and substance use disorders. Severity of OCD, assessed by an adapted version of the Yale-Brown Obsessive Compulsive Scale, is associated with poor insight, high comorbidity, high role impairment, and high probability of seeking treatment. The high prevalence of subthreshold OCD symptoms may help explain past inconsistencies in prevalence estimates across surveys and suggests that the public health burden of OCD may be greater than its low prevalence implies. Evidence of a preponderance of early onset cases in men, high comorbidity with a wide range of disorders, and reliable associations between disorder severity and key outcomes may have implications for how OCD is classified in DSM-V.
Comorbid diagnoses were examined in 55 principal generalized anxiety disorder (GAD) clients, and the effect of treatment for the principal disorder on those conditions was evaluated. High rates of comorbid diagnoses were present at pretherapy, with social and simple phobia being most common. The presence of additional diagnoses declined dramatically from pretherapy to follow-up and was significantly greater among clients for whom the GAD therapy had been successful than among clients for whom GAD outcome had been ambiguous. This was generally true regardless of whether clients reported at follow-up that they had received further therapy since the posttherapy assessment.
Mediation is said to occur when a causal effect of some variable X on an outcome Y is explained by some intervening variable M. The authors recommend that with small to moderate samples, bootstrap methods (B. Efron & R. Tibshirani, 1993) be used to assess mediation. Bootstrap tests are powerful because they detect that the sampling distribution of the mediated effect is skewed away from 0. They argue that R. M. Baron and D. A. Kenny's (1986) recommendation of first testing the X --> Y association for statistical significance should not be a requirement when there is a priori belief that the effect size is small or suppression is a possibility. Empirical examples and computer setups for bootstrap analyses are provided.
Multilevel models are increasingly used to estimate models for hierarchical and repeated measures data. The authors discuss a model in which there is mediation at the lower level and the mediational links vary randomly across upper level units. One repeated measures example is a case in which a person's daily stressors affect his or her coping efforts, which affect his or her mood, and both links vary randomly across persons. Where there is mediation at the lower level and the mediational links vary randomly across upper level units, the formulas for the indirect effect and its standard error must be modified to include the covariance between the random effects. Because no standard method can estimate such a model, the authors developed an ad hoc method that is illustrated with real and simulated data. Limitations of this method and characteristics of an ideal method are discussed.
To investigate the interactive process of changes in social anxiety and depression during treatment, the authors assessed weekly symptoms in 66 adult outpatients with social phobia (social anxiety disorder) who participated in cognitive- behavioral group therapy. Multilevel mediational analyses revealed that improvements in social anxiety mediated 91% of the improvements in depression over time. Conversely, decreases in depression only accounted for 6% of the decreases in social anxiety over time. Changes in social anxiety fully mediated changes in depression during the course of treatment. The theoretical and clinical implications of these findings for the relationship between anxiety and depression are discussed. reserved).
Designed to be used in conjunction with its companion online patient workbook, this Therapist Guide includes supporting theoretical, historical and research background information, diagnostic descriptions, differential diagnoses, session by session treatment outlines, case examples, sample dialogues, practice assignments, and tailored application to the vast variety of presentations and nuances of the disorder. It contains the 'nuts and bolts' of how to provide the treatment and is a comprehensive resource for therapists. It is an invaluable guide for clinicians in overcoming the barriers and difficulties that are part and parcel of every treatment.
Presents an integrative theoretical framework to explain and to predict psychological changes achieved by different modes of treatment. This theory states that psychological procedures, whatever their form, alter the level and strength of self-efficacy. It is hypothesized that expectations of personal efficacy determine whether coping behavior will be initiated, how much effort will be expended, and how long it will be sustained in the face of obstacles and aversive experiences. Persistence in activities that are subjectively threatening but in fact relatively safe produces, through experiences of mastery, further enhancement of self-efficacy and corresponding reductions in defensive behavior. In the proposed model, expectations of personal efficacy are derived from 4 principal sources of information: performance accomplishments, vicarious experience, verbal persuasion, and physiological states. Factors influencing the cognitive processing of efficacy information arise from enactive, vicarious, exhortative, and emotive sources. The differential power of diverse therapeutic procedures is analyzed in terms of the postulated cognitive mechanism of operation. Findings are reported from microanalyses of enactive, vicarious, and emotive modes of treatment that support the hypothesized relationship between perceived self-efficacy and behavioral changes. (21/2 p ref)
Many problems in randomized clinical trial design, execution, analysis, presentation and interpretation stem in part from an inadequate understanding of the roles of moderators and mediators of treatment outcome. As a result, 1) the results of clinical research are slow to have an impact on clinical decision making and thus to benefit patients; 2) it is difficult for clinicians or patients to apply randomized clinical trial results comparing two treatments (treatment versus control); 3) when such trials are conducted at various sites, the results often do not replicate; 4) when the results influence clinical decision making, the results clinicians obtain do not match what researchers report; and 5) the treatment effects comparing treatment and control conditions, particularly for psychiatric treatments, often seem trivial. In this review article, the author reviews and integrates the methodological literature concerning dealing with covariates in trials to emphasize their impact on clinical decision making. The goal of trials should ultimately be to establish who should get the treatment condition rather than the control condition (moderators) and to determine how to obtain the best outcomes with whatever is the preferred treatment (mediators). The author makes recommendations to clinicians as to which trials might best be ignored and which carefully considered, and urges clinical researchers to focus on studies best designed to reduce the burden of mental illness on patients.
• The development design and reliability of the Yale-Brown Obsessive Compulsive Scale have been described elsewhere. We focused on the validity of the Yale-Brown Scale and its sensitivity to change. Convergent and discriminant validity were examined in baseline ratings from three cohorts of patients with obsessive-compulsive disorder (N = 81). The total Yale-Brown Scale score was significantly correlated with two of three independent measures of obsessive-compulsive disorder and weakly correlated with measures of depression and of anxiety in patients with obsessive-compulsive disorder with minimal secondary depressive symptoms. Results from a previously reported placebo-controlled trial of fluvoxamine in 42 patients with obsessive-compulsive disorder showed that the Yale-Brown Scale was sensitive to drug-induced changes and that reductions in Yale-Brown Scale scores specifically reflected improvement in obsessive-compulsive disorder symptoms. Together, these studies indicate that the 10-item Yale-Brown Scale is a reliable and valid instrument for assessing obsessive-compulsive disorder symptom severity and that it is suitable as an outcome measure in drug trials of obsessive-compulsive disorder.
Obsessive-compulsive disorder (OCD) is a disabling disorder that can be successfully treated. However, a high percentage of sufferers neither ask for nor receive treatment for their symptoms, or they delay seeking treatment. The factors underlying the treatment-seeking behaviour of OCD patients are still not clear. This review includes 12 studies published before April 2014 that analyse the possible variables related to the delayed help-seeking behaviour of OCD patients. Studies showed that individuals who asked for help were more impaired and reported poorer quality of life. Help-seeking behaviour was associated with greater insight, severity, specific obsessive-compulsive symptoms, such as aggressive and other unpleasant obsessions, and comorbidity. Common barriers to seeking treatment were shame about the symptoms or about asking for treatment, not knowing where to find help, or inconveniences associated with treatment. Inconsistencies among the reviewed studies highlight the need to further evaluate the variables that keep OCD patients from seeking help. The review highlights the need for educational campaigns designed to detect underdiagnosed OCD individuals and improve access to mental health services, which could shorten delays in seeking treatment and, therefore, reduce the personal and financial costs of OCD. Guidelines for educational programs and future lines of research are discussed.
Obsessive-compulsive disorder (OCD) is a disabling disorder that can be successfully treated. However, a high percentage of sufferers neither ask for nor receive treatment for their symptoms, or they delay seeking treatment. The factors underlying the treatment-seeking behaviour of OCD patients are still not clear. This review includes 12 studies published before April 2014 that analyse the possible variables related to the delayed help-seeking behaviour of OCD patients. Studies showed that individuals who asked for help were more impaired and reported poorer quality of life. Help-seeking behaviour was associated with greater insight, severity, specific obsessive-compulsive symptoms, such as aggressive and other unpleasant obsessions, and comorbidity. Common barriers to seeking treatment were shame about the symptoms or about asking for treatment, not knowing where to find help, or inconveniences associated with treatment. Inconsistencies among the reviewed studies highlight the need to further evaluate the variables that keep OCD patients from seeking help. The review highlights the need for educational campaigns designed to detect underdiagnosed OCD individuals and improve access to mental health services, which could shorten delays in seeking treatment and, therefore, reduce the personal and financial costs of OCD. Guidelines for educational programs and future lines of research are discussed.
Importance:
Obsessive-compulsive disorder (OCD) is one of the world's most disabling illnesses according to the World Health Organization. Serotonin reuptake inhibitors (SRIs) are the only medications approved by the Food and Drug Administration to treat OCD, but few patients achieve minimal symptoms from an SRI alone. In such cases, practice guidelines recommend adding antipsychotics or cognitive-behavioral therapy consisting of exposure and ritual prevention (EX/RP).
Objective:
To compare the effects of these 2 SRI augmentation strategies vs pill placebo for the first time, to our knowledge, in adults with OCD.
Design, setting, and participants:
A randomized clinical trial (conducted January 2007-August 2012) at 2 academic outpatient research clinics that specialize in OCD and anxiety disorders. Patients (aged 18-70 years) were eligible if they had OCD of at least moderate severity despite a therapeutic SRI dose for at least 12 weeks prior to entry. Of 163 who were eligible, 100 were randomized (risperidone, n = 40; EX/RP, n = 40; and placebo, n = 20), and 86 completed the trial.
Interventions:
While continuing their SRI at the same dose, patients were randomized to the addition of 8 weeks of risperidone (up to 4 mg/d), EX/RP (17 sessions delivered twice weekly), or pill placebo. Independent assessments were conducted every 4 weeks.
Main outcome and measure:
The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) to measure OCD severity.
Results:
Patients randomized to EX/RP had significantly greater reduction in week 8 Y-BOCS scores based on mixed-effects models (vs risperidone: mean [SE], -9.72 [1.38]; P < .001 vs placebo: mean [SE], -10.10 [1.68]; P < .001). Patients receiving risperidone did not significantly differ from those receiving placebo (mean [SE], -0.38 [1.72]; P = .83). More patients receiving EX/RP responded (Y-BOCS score decrease ≥25%: 80% for EX/RP, 23% for risperidone, and 15% for placebo; P < .001). More patients receiving EX/RP achieved minimal symptoms (Y-BOCS score ≤12: 43% for EX/RP, 13% for risperidone, and 5% for placebo; P = .001). Adding EX/RP was also superior to risperidone and placebo in improving insight, functioning, and quality of life.
Conclusions and relevance:
Adding EX/RP to SRIs was superior to both risperidone and pill placebo. Patients with OCD receiving SRIs who continue to have clinically significant symptoms should be offered EX/RP before antipsychotics given its superior efficacy and less negative adverse effect profile.
Trial registration:
clinicaltrials.gov Identifier: NCT00389493.
Obsessive-compulsive disorder (OCD) is defined both by intrusive, unwanted thoughts, images, or impulses and by repetitive behavioral or mental acts that are often performed to try to alleviate anxiety. The ultimate goal of treatment for OCD is to reduce the symptoms as well as help patients achieve "wellness." Currently, however, there are no widely accepted, empirically supported criteria for determining wellness in OCD.
Building on previous research, the current study examined the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score that most reliably identified patients who responded to treatment, those who achieved symptom remission, and those who achieved wellness. The current study pooled data from 4 randomized controlled OCD treatment trials (N = 288), which took place between 1990 and 2011 at 2 academic sites. Participants (mean age = 36.8 years) had a primary diagnosis of DSM-IV-TR OCD (mean Y-BOCS score = 25.9).
Signal detection analyses showed that a pretreatment-to-posttreatment reduction of ≥ 35% on the Y-BOCS was most predictive of treatment response as defined by the Clinical Global Impressions (CGI)-Improvement scale. A posttreatment Y-BOCS score of ≤ 14 was the best predictor of symptom remission, whereas a score of ≤ 12 was the best predictor of wellness, as defined by symptom remission (defined by the CGI-Severity scale), good quality of life (as measured by the Quality of Life Enjoyment and Satisfaction Questionnaire), and a high level of adaptive functioning (as assessed by the Social Adjustment Scale-Self-Report). Because efficiency (0.86) and specificity (0.88) were highest at the cutoff of ≤ 12, this cutoff score was determined to be the best indicator of wellness.
The present findings support the convergent validity of the Y-BOCS with other measures of well-being (quality of life, adaptive functioning) and highlight the utility of a Y-BOCS score ≤ 12 as a solo indicator of wellness in outcome studies. The use of empirically supported criteria for defining wellness in OCD is recommended to facilitate comparisons across treatment outcome studies and to inform clinical treatment planning.
Pooled data analyzed in this study were from 4 clinical trials, 3 of which are registered at ClinicalTrials.gov (identifiers: NCT00045903, NCT00389493, NCT00316316).
Anxiety and depression frequently co-occur and are viewed by many theorists as aspects of a unitary disorder. In contrast, the diagnostic nomenclature views anxiety and depression as discrete disorders, and current protocols for anxiety and depression treat the disorders separately. To test the hypothesis (based on the unitary view) that anxiety and depression are tightly related and change together over the course of treatment, we monitored week-by-week changes in symptoms of anxiety and depression in 58 outpatients treated naturalistically in private practice with cognitive-behavior therapy. Results were more supportive of a unitary than a discrete view, and showed that anxiety and depression were highly predictive of one another over the course of treatment. These findings lend support to a view of anxiety and depression as more unitary than discrete, and suggest the need to consider changes in the diagnostic nomenclature and in treatment strategies for anxious depressed patients.
Despite severe functional impairment, only 35% to 40% of individuals with obsessive-compulsive disorder (OCD) seek treatment, and fewer than 10% receive evidence-based treatment. The current study examined the characteristics of 525 individuals who contacted the clinic of the Center for the Treatment and Study of Anxiety at the University of Pennsylvania to inquire about OCD treatment and completed a phone screen. Callers who were deemed appropriate for the clinic (n=396, 75%) were invited to participate in an in-person intake evaluation. Only 137 (35%) of the eligible individuals completed the intake evaluation ("treatment intake group") whereas the majority (n=259, 65%) did not ("phone screen-only group"). Compared to individuals in the phone screen-only group, those in the treatment intake group were younger, less likely to endorse depressed mood, and more likely to have received a diagnosis of OCD, to have previously sought psychological services, and to have taken psychotropic medication. The findings suggest that familiarity with their diagnosis and past contact with mental health professionals enhance openness to explore yet another treatment. In contrast, lack of awareness about the problem and depressed mood may reduce openness to seek treatment.
This article describes the long-term effects of augmenting serotonin reuptake inhibitors (SRIs) with exposure and ritual prevention or stress management training in patients with DSM-IV obsessive-compulsive disorder (OCD).
Between November 2000 and November 2006, 111 OCD patients from 2 academic outpatient centers with partial SRI response were randomized to the addition of exposure and ritual prevention or stress management training, delivered twice weekly for 8 weeks (acute phase); 108 began treatment. Responders (38 of 52 in the exposure and ritual prevention condition, 11 of 52 in the stress management training condition) entered a 24-week maintenance phase. The Yale-Brown Obsessive Compulsive Scale (YBOCS) was the primary outcome measure.
After 24 weeks, patients randomized to and receiving exposure and ritual prevention versus stress management training had significantly better outcomes (mean YBOCS scores of 14.69 and 21.37, respectively; t = 2.88, P = .005), higher response rates (decrease in YBOCS scores ≥ 25%: 40.7% vs 9.3%, Fisher exact test P < .001), and higher rates of excellent response (YBOCS score ≤ 12: 24.1% vs 5.6%, Fisher exact test P = .01). During the maintenance phase, the slope of change in YBOCS scores was not significant in either condition (all P values ≥ .55), with no difference between exposure and ritual prevention and stress management training (P > .74). Better outcome was associated with baseline variables: lower YBOCS scores, higher quality of life, fewer comorbid Axis I diagnoses, and male sex.
Augmenting SRIs with exposure and ritual prevention versus stress management training leads to better outcome after acute treatment and 24 weeks later. Maintenance outcome, however, was primarily a function of OCD severity at entrance. Greater improvement during the acute phase influences how well patients maintain their gains, regardless of treatment condition.
ClinicalTrials.gov identifier: NCT00045903.
present evidence for four phenomena or features of comorbidity between anxiety and depression that we believe should be addressed and explained by any theoretical model of the pathogenesis and course of these disorders / we then describe the basic postulates of a cognitive-behavioral theory of anxiety and depression, the helplessness-hopelessness theory, and show how this theoretical perspective explains and, in many cases, predicts these four comorbidity phenomena / we then briefly review three other cognitive-behavioral theories of depression and anxiety and examine their ability to account for the four features of comorbidity / finally, we suggest directions for future research designed to test the helplessness-hopelessness perspective that may advance understanding of comorbidity, as well as its implications for common etiologies of some anxiety and depressive disorders (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Replicating and extending our prior work (Tsao, Lewin, & Craske, 1998), the present study examined the impact of cognitive-behavioral treatment (CBT) for principal panic disorder/agoraphobia (PDA) on the frequency and severity of comorbid conditions in 51 principal PDA patients diagnosed using the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV; Brown, Di Nardo, & Barlow, 1994). Patients with at least 1 additional diagnosis of clinical severity declined from 60.8% (n = 31) at pretreatment to 37.3% (n = 19) at posttreatment, and 35.3% (n = 18) at follow-up. ADIS-IV severity ratings for comorbid generalized anxiety disorder (GAD), depression, and specific phobia also declined significantly following treatment. Reductions in comorbidity were maintained at 6-month follow-up. Baseline comorbidity was not associated with increased severity of PDA at pretreatment and did not adversely impact outcome for PDA immediately posttreatment or at follow-up. Possible mechanisms, as well as implications for clinical practice and policy decisions, are discussed.
We examined the effects of comorbid depression on response to treatment for obsessive-compulsive disorder (OCD) using cognitive-behavioral therapy with and without medication. Eighty-seven OCD patients were divided into nondepressed and mildly, moderately, and severely depressed groups on the basis of their pretreatment Beck Depression Inventory (BDI) scores. Each received an intensive cognitive-behavioral treatment program involving exposure with response prevention (EX/RP); 59 (68%) were also taking medication for OCD. Patients with severe initial depression (BDI ≥30) showed significantly less improvement compared to those less depressed or nondepressed; yet, even highly depressed patients showed moderate treatment gains. Failure to habituate to anxiety-evoking stimuli during exposure and a lack of motivation for therapy are considered possible causes of attenuated outcome.
Studies that have examined the effects of comorbid depression on response to treatment in obsessive-compulsive disorder (OCD) have yielded inconsistent results. We examined treatment outcome for 15 OCD patients with comorbid major depressive disorder (MDD) and 33 OCD patients without MDD. All patients received intensive cognitive-behavioral therapy by exposure and response (ritual) prevention. Improvement in OCD symptoms was observed in both patient groups, and treatment gains were maintained at follow-up. Whereas the presence of a comorbid MDD diagnosis in OCD was not related to treatment failure, nondepressed patients had significantly lower posttreatment and follow-up OCD severity scores.
Many OCD patients present with comorbid conditions, and major depression is one of the most frequent comorbidities observed. OCD patients with comorbid depression exhibit functional disability and poor quality of life. However, it is unclear whether depressive symptoms are predictive of treatment response, and debate remains whether they should be targeted in the treatment of comorbid patients. The current study aimed at assessing the predictive value of depression and OCD symptoms in the long term outcome of OCD treatment.
In the current study, relations between OCD and depressive symptoms were systematically investigated in a group of 121 OCD patients who received 16 sessions of behavior or cognitive therapy either alone or with fluvoxamine.
Depression (either as a continuous or categorical variable) was not predictive of treatment response in any of the treatment modalities for up to 5 years of follow-up. Changes in OCD symptoms largely predicted changes in depressive symptoms but not vice versa.
Subsequent to participation in the RCT, almost two-thirds of the participants received some form of additional treatment (either pharmacological or psychological), and as a result, it is impossible to determine interaction effects with additional treatment received after the trial.
Treatment of OCD with comorbid depression should focus on amelioration of OCD symptoms. When OCD treatment is successful, depressive symptoms are likely to ameliorate as well.
To examine the effects of patient adherence on outcome from exposure and response prevention (EX/RP) therapy in adults with obsessive-compulsive disorder (OCD).
Thirty adults with OCD were randomized to EX/RP (n = 15) or EX/RP augmented by motivational interviewing strategies (n = 15). Both treatments included 3 introductory sessions and 15 exposure sessions. Because there were no significant group differences in adherence or outcome, the groups were combined to examine the effects of patient adherence on outcome. Independent evaluators assessed OCD severity using the Yale-Brown Obsessive Compulsive Scale. Therapists assessed patient adherence to between-session EX/RP assignments at each session using the Patient EX/RP Adherence Scale (PEAS). Linear regression models were used to examine the effects of PEAS scores on outcome, adjusting for baseline severity. The relationship between patient adherence and other predictors of outcome was explored using structural equation modeling.
Higher average PEAS ratings significantly predicted lower posttreatment OCD severity in intent-to-treat and completer samples. PEAS ratings in early sessions (5-9) also significantly predicted posttreatment OCD severity. The effects of other significant predictors of outcome in this sample (baseline OCD severity, hoarding subtype, and working alliance) were fully mediated by patient adherence.
Patient adherence to between-session EX/RP assignments significantly predicted treatment outcome, as did early patient adherence and change in early adherence. Patient adherence mediated the effects of other predictors of outcome. Future research should develop interventions that increase adherence and then test whether increasing adherence improves outcome. If effective, these interventions could then be used to personalize care.
The information criterion AIC was introduced to extend the method of maximum likelihood to the multimodel situation. It was obtained by relating the successful experience of the order determination of an autoregressive model to the determination of the number of factors in the maximum likelihood factor analysis. The use of the AIC criterion in the factor analysis is particularly interesting when it is viewed as the choice of a Bayesian model. This observation shows that the area of application of AIC can be much wider than the conventional i.i.d. type models on which the original derivation of the criterion was based. The observation of the Bayesian structure of the factor analysis model leads us to the handling of the problem of improper solution by introducing a natural prior distribution of factor loadings.
The present article presents an integrative theoretical framework to explain and to predict psychological changes achieved by different modes of treatment. This theory states that psychological procedures, whatever their form, alter the level and strength of self-efficacy. It is hypothesized that expectations of per- sonal efficacy determine whether coping behavior will be initiated, how much effort will be expended, and how long it will be sustained in the face of ob- stacles and aversive experiences. Persistence in activities that are subjectively threatening but in fact relatively safe produces, through experiences of mastery, further enhancement of self-efficacy and corresponding reductions in defensive behavior. In the proposed model, expectations of personal efficacy are derived from four principal sources of information: performance accomplishments, vicarious experience, verbal persuasion, and physiological states. The more de- pendable the experiential sources, the greater are the changes in perceived self- efficacy. A number of factors are identified as influencing the cognitive processing of efficacy information arising from enactive, vicarious, exhortative, and emotive sources. The differential power of diverse therapeutic procedures is analyzed in terms of the postulated cognitive mechanism of operation. Findings are reported from microanalyses of enactive, vicarious, and emotive modes of treatment that support the hypothesized relationship between perceived self-efficacy and be- havioral changes. Possible directions for further research are discussed.
The efficacy of behavioural treatment of obsessive-compulsive disorder (OCD) has been well documented. However, severely depressed OCD patients showed fewer short- and long-term benefits than less depressed patients. The present study tested the hypothesis that reduction of depression by imipramine prior to behaviour therapy would enhance the effects of behavioural therapy on depressed OC patients. Thirty-eight patients were divided into highly and mildly depressed groups according to their scores on the Beck Depression Inventory; half of each group received imipramine and half received placebo for six weeks. All patients then received three weeks of daily behavioural treatment (exposure and response prevention) followed by 12 weekly sessions of supportive psychotherapy. Results indicated that although imipramine improved depressive symptoms in depressed patients, it did not affect OC symptoms. Behaviour therapy markedly reduced OC symptoms but, contrary to our hypothesis, imipramine did not potentiate the effects of behaviour therapy. No differences between highly depressed and mildly depressed patients on OC symptoms were found in their responses to behavioural or supportive therapy.
The development design and reliability of the Yale-Brown Obsessive Compulsive Scale have been described elsewhere. We focused on the validity of the Yale-Brown Scale and its sensitivity to change. Convergent and discriminant validity were examined in baseline ratings from three cohorts of patients with obsessive-compulsive disorder (N = 81). The total Yale-Brown Scale score was significantly correlated with two of three independent measures of obsessive-compulsive disorder and weakly correlated with measures of depression and of anxiety in patients with obsessive-compulsive disorder with minimal secondary depressive symptoms. Results from a previously reported placebo-controlled trial of fluvoxamine in 42 patients with obsessive-compulsive disorder showed that the Yale-Brown Scale was sensitive to drug-induced changes and that reductions in Yale-Brown Scale scores specifically reflected improvement in obsessive-compulsive disorder symptoms. Together, these studies indicate that the 10-item Yale-Brown Scale is a reliable and valid instrument for assessing obsessive-compulsive disorder symptom severity and that it is suitable as an outcome measure in drug trials of obsessive-compulsive disorder.
The aim of the present study is to present a model of depressive vulnerability centered on anhedonia. After a review of the literature, we suggest a specific symptomatic profile associating anhedonia, introversion, low sensation-seeking, autonomy, dysfunctional attitudes, high displeasure capacity, obsessive-compulsive features, passitivity and pessimism. This symptomatic profile could constitute a mild chronic mood disorder which, following stress, might decompensate into unipolar endogenomorphic depression. Several methods of research are suggested to test the validity of our model.
After a millennium of preoccupation with heaven, Western civilization began, during the Florentine Renaissance, to attend again to the quality of this life. Slowly in the sixteenth through nineteenth centuries, and rapidly in the twentieth, the medical scientific revolution that began with Vesalius and Harvey has improved quality of life. Physicians (and others) now attempt to quantify medicine's contribution, first because they are advocates for the whole person, and second because politicians question the high cost of medical services and technology. The journal Quality of Life Research was created to communicate research findings, and an on-line search of journal articles reveals hundreds of publications within the past few years spanning a wide range of diseases and procedures.
Attempts to measure quality of life have forced the acknowledgment that the concept is multifaceted and culturally bound. After many years of study and with input from expert panels, the World Health Organization has organized its assessment questionnaire into six broad domains that can be examined cross-culturally: (1) physical; (2) psychological; (3) level of independence; (4) social relationships; (5) environment; and (6) spirituality, religion, and personal beliefs.40 But many other conceptual schemes have been applied.17 and 20 Thus, in assessing quality of life, an investigator must choose a focus, from global quality of life to one or more domains within one or more dimensions.
This article focuses on health-related quality of life (HRQL) in adult patients with obsessive-compulsive disorder (OCD). Included within this concept are the relationships of health to family, social and vocational functioning, sense of emotional and physical well-being, and global quality of life. This article reviews what little is known regarding the effects of OCD on HRQL and then considers future research directions.
This review considers statistical analysis of data from studies that obtain repeated measures on each of many participants. Such studies aim to describe the average change in populations and to illuminate individual differences in trajectories of change. A person-specific model for the trajectory of each participant is viewed as the foundation of any analysis having these aims. A second, between-person model describes how persons very in their trajectories. This two-stage modeling framework is common to a variety of popular analytic approaches variously labeled hierarchical models, multilevel models, latent growth models, and random coefficient models. Selected published examples reveal how the approach can be flexibly adapted to represent development in domains as diverse as vocabulary growth in early childhood, academic learning, and antisocial propensity during adolescence. The review then considers the problem of drawing causal inferences from repeated measures data.
The impact of concurrent axis I diagnoses and axis II traits on the efficacy of a 22-session exposure-based treatment program for 43 outpatients with panic disorder and agoraphobia (PDA) and 63 with obsessive-compulsive disorder (OCD) was examined. Trained interviewers used the Structured Clinical Interview for DSM-III-R (SCID) to assess axis I diagnoses and the SCID-II to identify the number of axis II criteria met for anxious, dramatic, and odd clusters. Among axis I diagnoses, secondary major depressive disorder (MDD), dysthymia, social phobia, and generalized anxiety disorder (GAD) were present in sufficient numbers to study their effects on treatment outcome. Outcomes were assessed on self-rated target fears and functioning and on a behavioral avoidance test at post-treatment and at 6 months follow-up. Only GAD comorbidity predicted dropout, whereas MDD and all three personality cluster traits predicted post-treatment outcomes. Follow-up analyses showed significant effects of MDD and GAD, but axis II cluster criteria were not predictive.
Randomized clinical trials (RCTs) not only are the gold standard for evaluating the efficacy and effectiveness of psychiatric treatments but also can be valuable in revealing moderators and mediators of therapeutic change. Conceptually, moderators identify on whom and under what circumstances treatments have different effects. Mediators identify why and how treatments have effects. We describe an analytic framework to identify and distinguish between moderators and mediators in RCTs when outcomes are measured dimensionally. Rapid progress in identifying the most effective treatments and understanding on whom treatments work and do not work and why treatments work or do not work depends on efforts to identify moderators and mediators of treatment outcome. We recommend that RCTs routinely include and report such analyses.
To explore clinical features of symptoms and comorbidity according to the age of onset of patients suffering from obsessive-compulsive disorder (OCD).
The survey involved collecting data from both patient members of an OCD association, and a sample of 175 OCD patients seen in OCD specialty practice. All the patients (n=617) responded to a questionnaire on family and personal psychiatric OCD history, phenomenological features of OCD and comorbidity. They were classified according to OCD age at onset [group early age of onset (EO): under 15, group late age of onset (LO): older than 15].
A higher percentage of patients from Group LO complained of OCD triggering by factors such as professional difficulties and childbirth (P<0.05); also they more often had (P=0.05) a sudden onset of symptoms. On the other hand, clinical features, such as superstition and magic thoughts, parasite obsessions and repeating, counting, hoarding, tapping/rubbing and collecting compulsions were significantly more frequent (P<0.05) in EO; likewise, history of tics was more frequent in this group. The existence of comorbid depression (at least one episode) did not show any significant difference between groups. However, depression preceding OCD was more frequent in LO. There was no significant difference in treatment response according to age of onset OCD.
The results showed a clear association of EO with obsessions of superstition and parasites, repetitive compulsions and motor and vocal tics, whereas a sudden onset, triggering factors and a more frequent depression preceding OCD characterized LO.
This article describes the method and intake findings of the Brown Longitudinal Obsessive Compulsive Study, the first comprehensive prospective investigation of the naturalistic course of obsessive-compulsive disorder (OCD) in a large clinical sample using longitudinal research methodology.
Intake data, collected between June 2001 and October 2004, are presented for 293 adult participants in a prospective, naturalistic study of OCD. Participants had a primary diagnosis of DSM-IV OCD and had sought treatment for the disorder.
Our findings indicate that OCD typically has a gradual onset and a continuous course regardless of age at onset. There is a substantial lag between the onset of the disorder and initiation of treatment. OCD, which almost always coexists with other psychiatric symptoms, leads to serious social and occupational impairment. Compared with participants with late-onset OCD, early-onset participants had higher rates of lifetime panic disorder, eating disorders, and obsessive-compulsive personality disorder. The groups also differed on the types of obsessive-compulsive symptoms that were first noticed, as well as on rates of current obsessions and compulsions.
The demographics, clinical characteristics, comorbidity rates, and symptom presentation of the sample are consistent with those reported for cross-sectional studies of OCD, including the DSM-IV Field Trial. The current sample has a number of advantages over previously collected prospective samples of OCD in that it is large, diagnostically well characterized, recruited from multiple settings, and treatment seeking. This unique data set will contribute to the identification of meaningful phenotypes in OCD based on stability of symptom dimensions, prospective course patterns, and treatment response.
The impact of depression on the treatment of obsessive-compulsive disorder: results from a 5-year follow-up Self-efficacy: toward a unifying theory of behavioral change Effects of psychotherapy on co-morbid conditions in generalized anxiety disorder
- G E Anholt
- I M Aderka
- A Balkom
- J H Smit
- H Hermesh
- E De Haan
Anholt, G. E., Aderka, I. M., van Balkom, A., Smit, J. H., Hermesh, H., de Haan, E., et al. (2011). The impact of depression on the treatment of obsessive-compulsive disorder: results from a 5-year follow-up. Journal of Affective Disorders, 135, 201e207. Bandura, A. (1977). Self-efficacy: toward a unifying theory of behavioral change. Psychological Review, 84, 191e215. Borkovec, T. D., Abel, J. L., & Newman, H. (1995). Effects of psychotherapy on co-morbid conditions in generalized anxiety disorder. Journal of Consulting and Clinical Psychology, 63, 479e483.
Exposure and response (Ritual) prevention for obsessive-compulsive disorder Factors associated with non-treatment or delayed treatment seeking in OCD sufferers: a review of the literature
- E B Foa
- E Yadin
- T K Lichner
- G Garcia-Soriano
- M Rufer
- A Delsignore
- S Weidt
Foa, E. B., Yadin, E., & Lichner, T. K. (2012). Exposure and response (Ritual) prevention for obsessive-compulsive disorder (2nd ed.). New York, NY: Oxford University Press. Garcia-Soriano, G., Rufer, M., Delsignore, A., & Weidt, S. (2014). Factors associated with non-treatment or delayed treatment seeking in OCD sufferers: a review of the literature. Psychiatry Research, 220, 1e10.
Patient adherence predicts outcome from cognitive behavioral therapy in obsessive-compulsive disorder Effects of axis I and II comor-bidity on behavior therapy outcome for obsessive-compulsive disorder and agoraphobia RMediation: an R package for mediation analysis confidence
- H B Simpson
- M J Maher
- Y Wang
- Y Bao
- E B Foa
- M Franklin
- G Steketee
- D L Chambless
- G Q Tran
Simpson, H. B., Maher, M. J., Wang, Y., Bao, Y., Foa, E. B., & Franklin, M. (2011). Patient adherence predicts outcome from cognitive behavioral therapy in obsessive-compulsive disorder. Journal of Consulting and Clinical Psychology, 79, 247e252. Steketee, G., Chambless, D. L., & Tran, G. Q. (2001). Effects of axis I and II comor-bidity on behavior therapy outcome for obsessive-compulsive disorder and agoraphobia. Comprehensive Psychiatry, 42, 76e86. Tofighi, D., & Mackinnon, D. P. (2012). RMediation: an R package for mediation analysis confidence. Behavior Research Methods, 43(3), 692e700. Trajkovic, G., Starcevic, V., Latas, M., Lestarevic, M., Ille, T., Bukumiric, Z., et al. (2011).
Factors associated with non-treatment or delayed treatment seeking in OCD sufferers: a review of the literature
- G Garcia-Soriano
- M Rufer
- A Delsignore
- S Weidt
- W K Goodman
- L H Price
- S A Rasmussen
- C Mazure
- P Delgado
- G R Heninger
Garcia-Soriano, G., Rufer, M., Delsignore, A., & Weidt, S. (2014). Factors associated
with non-treatment or delayed treatment seeking in OCD sufferers: a review of
the literature. Psychiatry Research, 220, 1e10.
Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Delgado, P.,
Heninger, G. R., et al. (1989). The Yale-Brown obsessive-compulsive scale: II.
Validity. Archives of General Psychiatry, 46, 1012e1016.