By Matthew C. McCann, MS, Catherine E. Bocksel, MA, Wayne K. Goodman, MD, and Eric A. Storch, PhD
This article was initially published in the Spring 2017 edition of the OCD Newsletter.
There had been a long-standing belief that those who suffer from OCD have a low incidence of suicidal behaviors and thoughts (Coryell, 1981; Goodwin, Guze, & Robins, 1969; Koran, Thienemann, & Davenport, 1996). However, in light of new research that notion has recently been called into question. This new research states that as many as two thirds of people who have OCD experience thoughts about death or suicide, with a similar number experiencing significant sadness and depression. For example, results from a recent Swedish study suggest that the risk of suicide is roughly 10 times higher in the OCD population as compared to people without OCD. Based on these findings, the researchers message was clear: “OCD should be added to the list of psychiatric disorders that are known to increase the risk of suicide in their own right. Suicide risk needs to be carefully monitored in these patients, particularly in those who have previously attempted suicide” (de la Cruz et al., 2016).
While previous research had suggested that suicide rates were fairly low in individuals with OCD (Alonso et al., 2010; Goodwin et al., 1969; Khan, Leventhal, Khan, & Brown, 2002; Koran et al., 1996), more recent studies of adults with OCD indicate that 36%-63% of OCD adults experience suicidal thoughts (Kamath, Reddy, & Kandavel, 2007; Storch et al., 2015; Torres et al., 2007; Torres et al., 2006; Torres et al., 2011), and about one fourth have attempted suicide (Torres et al., 2006). According to an examination of adults with OCD who were undergoing intensive therapy (Storch, Kay, Wu, Nadeau, & Riemann, 2017), 62.4% experienced thoughts of death in their lifetime, and 67% experienced these thoughts in the past month. As compared to people with OCD who did not experience suicidal thoughts, those patients who reported recent suicidal thoughts also had significantly more depressive and OCD symptoms, and less life satisfaction. The study also showed that the presence of suicidal thoughts was not found to be associated with treatment response.
Along these lines, research has also demonstrated that experiencing co-occurring conditions increases the risk of suicide in OCD patients. In particular, co-occurring major depressive disorder, posttraumatic stress disorder, substance use disorders, and impulse control disorders have been linked with suicidal behavior (Kamath et al., 2007; Torres et al., 2011). Greater obsessive-compulsive severity (Balci & Sevincok, 2010), depression (Alonso et al., 2010; Kamath et al., 2007), hopelessness (Balci & Sevincok, 2010; Kamath et al., 2007), and certain OCD symptom types (i.e., symmetry/ ordering obsessions, sexual, religious, and aggressive obsessions; Alonso et al., 2010; Balci & Sevincok, 2010; Torres et al., 2011) have also been linked to a higher frequency of suicidal thoughts. While information in children is more limited, evidence suggests that kids with OCD also experience high rates of suicidal thoughts, with such symptoms linked to more severe OCD symptoms and impairment due to OCD.
What We Can Do
While these findings suggest that a greater number of adults and children with OCD may have thoughts of harming themselves, they also present an opportunity to develop prevention strategies. Here are some points to keep in mind for both therapists and friends and families.
For mental health providers:
- If a clinician feels that a patient is an immediate danger to themselves, they should get them to a hospital or contact local authorities and remain with the patient until authorities arrive.
- If there is no immediate risk, and the patient is denying any intent to harm him or herself, the individual should be advised to continue their mental health care and/or to seek the help of a mental health professional who understands OCD.
- Once the topic of suicidal thoughts and/or intent has been broached, it should continue to be a subject of communication for all future sessions. It may feel uncomfortable to clinicians, but to ignore the potential after it has been brought up can cause the individual to feel even more shame and guilt.
For family and friends:
If someone is planning to harm him or herself, there are several potential warning signs to look for. These warning signs are indications that the person’s suicidal thoughts and/or intent needs to be addressed immediately:
- When someone openly tells their support system that they can no longer cope with feeling the way that they do, or that they see no way out of their situation.
- Someone contemplating suicide can be seen preparing for death in a variety of ways — taking out insurance policies, updating their wills, letting others know their final wishes, etc.
- It is common that someone having suicidal thoughts will give away their most valued possessions or exhibit drastic changes in their behavior.
- The person experiencing suicidal thoughts may engage in reckless and possibly dangerous actions and show little concern for the consequences.
- The person’s demeanor may noticeably change — they may go from being someone who is anxious and/or depressed to displaying a state of calm and/or cheerfulness.
With the help of a supportive social network, there are ways to approach these behaviors and create a plan to move forward:
- Empathizing with the person who is expressing these thoughts or showing these behaviors, and not minimizing what they are going through, is vital.
- Telling someone to “Think happy thoughts,” or asking them, “What do you have to be sad about?” can make the person feel more hopeless and isolated.
- Instead, loved ones and friends should engage with the person and let them know that you are listening, and that you understand how difficult it was for them to express these thoughts.
In addition to this, and most importantly,seek help. If you or someone you love is thinking about hurting themselves or ending their own life, please call the National Suicide Prevention Lifeline at 1-800- 273-8255 or visit their online chat at http://chat.suicidepreventionlifeline.org/GetHelp/LifelineChat.aspx for free, confidential help and support. Hope is available for all members of the OCD community, only a call or a click away.
Although more research needs to be conducted with children and adults with OCD, there is some preliminary evidence suggesting that the risk of suicide is greater than previously thought, and that it is a serious component of OCD. It is important that clinicians, and those providing care to individuals with OCD, are able to assess, monitor, and appropriately identify the warning signs of suicidal behaviors, as well as know how to address the symptoms. On a more positive note, research also indicates that the presence of suicidal thoughts does not predict treatment response. Therefore, if a loved one is experiencing significant OCD and also has thoughts about suicide, existing treatments (e.g., cognitive-behavioral therapy and medications) can still be very effective in achieving wellness .
- Alonso, P., Segalas, C., Real, E., Pertusa, A., Labad, J., Jiménez-Murcia, S., . . . Menchón, J. (2010). Suicide in patients treated for obsessive–compulsive disorder: A prospective follow-up study. Journal of affective disorders, 124(3), 300-308.
- Balci, V., & Sevincok, L. (2010). Suicidal ideation in patients with obsessive–compulsive disorder. Psychiatry research, 175(1), 104-108.
- Coryell, W. (1981). Obsessive-compulsive Disorder and Primary Unipolar Depression: Comparisons of Background, Family History, Course, and Mortality. The Journal of nervous and mental disease, 169(4), 220-224.
- de la Cruz, L. F., Rydell, M., Runeson, B., D’Onofrio, B., Brander, G., Rück, C., . . . Mataix-Cols, D. (2016). Suicide in obsessive–compulsive disorder: a population-based study of 36 788 Swedish patients. Molecular Psychiatry.
- Goodwin, D. W., Guze, S. B., & Robins, E. (1969). Follow-up studies in obsessional neurosis. Archives of General Psychiatry, 20(2), 182-187.
- Kamath, P., Reddy, Y., & Kandavel, T. (2007). Suicidal behavior in obsessive-compulsive disorder. Journal of Clinical Psychiatry.
- Khan, A., Leventhal, R. M., Khan, S., & Brown, W. A. (2002). Suicide risk in patients with anxiety disorders: a meta-analysis of the FDA database. Journal of affective disorders, 68(2), 183-190.
- Koran, L. M., Thienemann, M. L., & Davenport, R. (1996). Quality of life for patients with obsessive-compulsive disorder. The American Journal of Psychiatry, 153(6), 783.
- Storch, E. A., Bussing, R., Jacob, M. L., Nadeau, J. M., Crawford, E., Mutch, P. J., . . . Murphy, T. K. (2015). Frequency and correlates of suicidal ideation in pediatric obsessive–compulsive disorder. Child Psychiatry & Human Development, 46(1), 75-83.
- Storch, E. A., Kay, B., Wu, M. S., Nadeau, J. M., & Riemann, B. C. (2017). Suicide and death ideation among adults with obessive-compulsive disorder presenting for intensive intervention. Annals of Clinical Psychiatry.
- Torres, A. R., de Abreu Ramos-Cerqueira, A. T., Torresan, R. C., de Souza Domingues, M., Hercos, A. C., & Guimaraes, A. B. (2007). Prevalence and associated factors for suicidal ideation and behaviors in obsessive-compulsive disorder. CNS Spectr, 12(10), 771-778.
- Torres, A. R., Prince, M. J., Bebbington, P. E., Bhugra, D., Brugha, T. S., Farrell, M., . . . Singleton, N. (2006). Obsessive-compulsive disorder: prevalence, comorbidity, impact, and help-seeking in the British National Psychiatric Morbidity Survey of 2000. Am J Psychiatry, 163(11), 1978-1985. doi:10.1176/ajp.2006.163.11.1978
- Torres, A. R., Ramos-Cerqueira, A. T., Ferrao, Y. A., Fontenelle, L. F., do Rosario, M. C., & Miguel, E. C. (2011). Suicidality in obsessive-compulsive disorder: prevalence and relation to symptom dimensions and comorbid conditions. J Clin Psychiatry, 72(1), 17-26; quiz 119-120. doi:10.4088/JCP.09m05651blu