by Jonathan Abramowitz, PhD

This article was initially published in the Fall 2010 edition of the OCD Newsletter. 

Obsessive-compulsive disorder (OCD) is not only one of the most common psychological disorders, it is also among the most personally distressing, and disabling. OCD can be devastating to interpersonal relationships, leisure activities, school or work functioning, and to general life satisfaction.  Not surprisingly, OCD is commonly associated with depression.  After all, OCD is a depressing problem and it is easy to understand how one could develop clinical depression when your daily life consists of unwanted thoughts and urges to engage in senseless and excessive behaviors (rituals).  Many research studies also bear this out.  In fact, studies suggest that one quarter to one half of people with OCD also meet the diagnostic criteria for a major depressive episode, which includes constantly feeling blue for a few weeks or more, having trouble enjoying activities, becoming isolated, having trouble with your appetite, sleep, sex drive, and increased crying, hopelessness, and worthlessness.  Most people with both OCD and depression report that their difficulties with OCD started before their depressive symptoms, and this suggests that the depression occurs as a response to the distress and devastation associated with having OCD.  Less commonly, depression and OCD begin at the same time (or the depression begins before the OCD).

Why is all of this important? What’s so important about having depression and OCD together? Well, it turns out that having severe depression can interfere with the effects of the most effective treatment for OCD: cognitive behavioral therapy using exposure and response prevention.  As you might know, exposure therapy involves gradually confronting the situations and thoughts that trigger your obsessions; and response prevention means working on refraining from the corresponding compulsive rituals.  For example, if you have contamination fears and compulsive hand washing rituals, your therapist might help you practice touching “contaminated” items (e.g., a shoe), and then help you resist washing your hands until your level of anxiety subsides on its own.  As I mentioned earlier, this treatment is the most effective therapy for OCD, resulting in significant improvement for between 60% and 80% of people who get this form of treatment. However, that still leaves many people with OCD who do not benefit substantially, or at all, from exposure therapy.  Some of my own research has been focused on trying to better understand who gets well and who does not with exposure therapy for OCD. And in this work, I have found that one of the best predictors of treatment outcome is the patient’s level of depression.  To put it simply, on the average, seriously depressed people with OCD do not do as well as non-depressed or less depressed OCD patients. This got me thinking about ways to help depressed OCD patients.

But first, you might be wondering why depressed patients don’t fare as well as non-depressed patients. How might depression interfere with exposure and response prevention therapy for OCD?  There are a few explanations.  For one thing, when you’re very depressed it is difficult to stick with a treatment that is as challenging as exposure and response prevention.  In fact, it might be difficult to stick with anything that requires lots of energy and hard work because depression makes you lethargic. Depression also makes you feel badly about yourself and your future. Therefore, you might feel like it’s not even worth trying to get over OCD. Depression might also make you so upset that the normal reduction in anxiety and distress that should occur with exposure therapy doesn’t happen, and therefore you can’t learn that obsessional anxiety decreases on its own during exposure treatment. The fact that people who have OCD and are also seriously depressed do not benefit as well from exposure therapy is a significant problem given the number of people with OCD who also have depression.

When I became interested in working with depressed OCD patients I first read up on the treatment strategies that had been described in the past.  The most common strategy had been to use antidepressant medication along with exposure therapy for these patients.  This seemed to make sense since selective serotonin reuptake inhibitors (e.g., Prozac, Luvox, Zoloft) can be helpful for both depression and OCD.  There had even been a few (mostly older) studies examining whether adding antidepressants to exposure therapy facilitated improvement in OCD symptoms for depressed patients.  However, the results from these studies were not very encouraging: although antidepressants seem to improve the symptoms of depression, they don’t seem to add to the effects of exposure therapy on OCD symptoms.  The other interesting observation I made was that most of the people with OCD who were also depressed had already tried many different medications before they even came to get treatment in our clinic. This told me that such a strategy was not working to their satisfaction (after all, they were still seeking more help!) and that it was time to consider non-medication treatments to help bolster outcome for depressed OCD patients.

My research group at the University of North Carolina, and formerly at the Mayo Clinic, was fortunate enough to receive funding from the Obsessive-Compulsive Foundation (now the IOCDF) to develop and test a form of psychological treatment (cognitive behavioral therapy) that could be used for severely depressed people with OCD to help them be able to benefit from exposure and response prevention.  This treatment includes elements of cognitive therapy and behavioral therapy for depression along with exposure and response prevention for OCD.  Specifically, during the first few therapy sessions we teach patients new strategies for thinking and behaving that help them overcome some of their depressed feelings enough to increase their motivation to engage successfully in exposure and response prevention for OCD.

For example, when very depressed, people have extremely negative and pessimistic beliefs about themselves (e.g., “I am a failure and I don’t deserve to get better”), the world (“No one likes me; the world is a terrible place”), and the future (e.g., feelings of hopelessness; “I’ll never get better; there’s no hope for me”). Cognitive therapy for depression helps individuals challenge these beliefs and change the way they think. The goal is to develop more realistic beliefs—but not necessarily just positive ones. For example, viewing one’s strengths and limitations, rather than seeing one’s self as a “total” failure. For a person who believes, “I’m a complete failure,” cognitive therapy might help this person change the belief to “Everyone has strengths and limitations. Having OCD is one of my problems, but that doesn’t mean I am a complete failure. There are some things I can do well.” Behavioral therapy for depression helps people to reinforce their new ways of thinking by acting accordingly. Thus, we help the person schedule enjoyable activities—interacting with others, engaging in hobbies, etc.—into their day. We have found that a few weeks of challenging negative thinking styles and engaging in pleasurable activities helps many depressed people with OCD to feel more confident and ready to address their obsessions and compulsions.

Once we have addressed how patients feel about themselves and have motivated them to work hard to reduce their OCD, we introduce the exposure and response prevention techniques, which are practiced repeatedly until the end of treatment—usually about 16 to 20 sessions (including homework practice). The results were encouraging, with about two-thirds of patients showing greater than a 50% reduction in their OCD symptoms.  In comparison, a study we conducted several years ago indicated that over half of very depressed OCD patients did not show significant improvement when their depression was not specifically addressed.

In our OCD program at the University of North Carolina, we use this therapy when people with OCD want to begin treatment but are experiencing serious depression.  While our therapy has been very successful in helping many patients that might not have otherwise benefited, it admittedly has not helped everyone.  In some cases, our depressed OCD patients have had to be hospitalized or even put on antidepressant medication to stabilize their depressive symptoms before they are able to work on OCD.

One of the most important jobs of a researcher is to make available any findings that might be helpful to clinicians and patients. Accordingly, we have done our best to spread the word about this comprehensive program for depression and OCD by giving workshops, presenting the results of our studies at conferences, and by writing research articles. I am very pleased to contribute this article to the OCD Newsletter, and am also willing to make available my previous research presentations and articles on this topic.