Recognizing and Attending to Obsessive-Compulsive Symptoms in Depression

A woman comes to your office complaining of feeling severely depressed and no longer wanting to live. You check off the symptoms of major depression one by one. Low energy? Yes. Lack of pleasure? Yes. Insomnia? Yes. Disinterest? Yes. Guilt? Yes. Poor concentration? Yes. Poor appetite? Yes. But, will you also ask her whether she worries that she might act or speak violently toward someone without meaning to? Or whether she frequently gets unwanted nasty thoughts? Or whether she checks to ensure that she has not already unknowingly harmed someone? These are taboo obsessive-compulsive symptoms (OCS), often comorbid with depression, that sufferers are unlikely to volunteer to clinicians for fear of stigmatization. Perhaps these patients’ fears are justified.

Three recent studies found that, although OCS involving contamination fears or symmetry concerns were usually correctly diagnosed by psychiatrists, psychologists, and primary care physicians—who provided appropriate first-line treatment recommendations of CBT and SSRI medications—these professionals consistently misdiagnosed vignettes of patients with OCS involving aggressive or sexual obsessions and were significantly less likely to recommend first-line treatment. Clinicians were more likely to recommend antipsychotic medication and, despite the extremely low risk of violence associated with this population, frequently included involuntary psychiatric admission and reports to child welfare agencies among treatment recommendations.

My colleagues and I recently sought to determine the frequency and impact of OCS in patients with major depression who participated in the NIMH Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial, the largest study of depression treatment ever conducted, with over 4,000 participants from across the United States from 41 community, private practice, and academic sites. Although STAR*D has generated dozens of scientific papers, none had previously assessed OCS, likely because current primary obsessive-compulsive disorder was a STAR*D exclusion criterion. This study condition allowed us to conservatively estimate how often OCS were unattended to in these patients with major depression because any OCS that subjects reported on a self-report scale were either (a) not disclosed to the study doctors, or (b) not believed by the doctor to be significant clinical problems. Our results indicated that more than half of these depressed patients endorsed having one or more OCS, most commonly taboo obsessions of causing harm to someone. And, after controlling for depression severity, the presence of these unattended obsessions predicted both poorer rates of depression remission with SSRI treatment and elevated rates of suicidality.

I believe that many (perhaps most) OCS, particularly taboo obsessions, go unrecognized in the context of depression and are not adequately treated because patients do not volunteer them and are rarely asked about them. Thus, brief screening for OCS in patients with depression is an important first step. However, even when OCS are recognized, their treatment is often inappropriate, according to the studies cited above. We have much work to do in educating patients, as well as psychiatric and nonpsychiatric clinicians, about these disabling but treatable symptoms.

Financial disclosure:Dr Baer has no personal affiliations with any commercial interest to disclose.​