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Obsessive Compulsive Disorder: Seven Effective Behavioral Strategies
Obsessive Compulsive Disorder: Seven Effective Behavioral Strategies

Manual of Articles Sections 8 - 19
Section 8
Treatment of Obsessive-Compulsive Disorder in Patients
who have Comorbid Major Depression Part One

CEU Question 8 | Answer Booklet | Table of Contents | OCD
Social Worker CEUs, Counselor CEUs, Psychologist CEs, MFT CEUs, Nurse CEUs

Obsessive-compulsive disorder (OCD) is characterized by recurrent obsessive thoughts, images, or impulses that evoke anxiety and by compulsive behaviors (e.g., hand washing) or mental acts (e.g., ritualistic depression Obsessive Compulsive Disorder psychology continuing edpraying) that are performed to reduce obsessional distress.

Epidemiological data suggest a lifetime prevalence of 2–3%. Very often, despite suffering significant functional impairments, individuals who have OCD do not receive appropriate treatment until long after the onset of the disorder. When the relatively high prevalence and associated functional impairment are considered along with the lengthy time lag between symptom onset and treatment, one recognizes that OCD is a significant public health concern.

Individuals who have OCD are at an increased risk for comorbid Axis I and Axis II psychopathology; mood disorders are among the most commonly cooccurring difficulties. Table 1 shows the rates of major depressive disorder (MDD) among a sample of adult OCD patients in six recent studies. A cross-national study found that the lifetime prevalence of MDD among OCD patients ranged from 12.4% to 60.3% across seven countries (mean=29%). In the eastern United States, researchers found a lifetime comorbidity rate of 54.1%, and a concurrent comorbidity rate of 36% (Nestadt et al., 2001; Steketee et al., 1999). For the most part, OCD predates depression, suggesting that depressive symptoms usually occur in response to the distress and functional impairment associated with OCD. In addition, depressive symptoms seem to be more strongly associated with obsessional than with compulsive symptoms (Ricciardi & McNally, 1995).

A number of studies indicate that OCD is often compounded by additional anxiety problems. Table 2 shows comorbidity rates for particular anxiety disorders from three research samples. In addition, researchers have found significantly higher lifetime rates of social phobia, panic and generalized anxiety disorder (GAD), but not specific phobia or agoraphobia, among individuals who have OCD compared to control subjects (Nestadt et al., 2001). About 20% of 381 patients enrolled in the DSM-IV field study for OCD also had a concurrent diagnosis of GAD (Abramowitz & Foa, 1998).

Table 1  Rates of MDD in Six Samples of Adult OCD Patients




Comorbidity Percentage

Antony et al. (1998)




Yaryura-Tobias et al. (1996)




Crino & Andrews (1996) *




Ricciardi & McNally (1995)




Nestadt et al. (2001)




Sanderson et al. (1990)




Note. MDD = major depressive disorder; OCD = obsessive-compulsive disorder; DSM = Diagnostic and Statistical Manual.   *Lifetime comorbidity.

Table 2  Percentages of OCD Patients Who Have Other Anxiety Disorders

Anxiety Disorder

Crino & Andrews
(N = 108)

Antony et al.
(N = 87)

Nestadt et al.
(N = 80)

Social phobia




Specific phobia



Panic disorder










a Concurrent diagnosis.  b Lifetime comorbidity rate.  c GAD = generalized anxiety disorder.

Investigators have also reported the prevalence of personality disorders among individuals who have OCD. Estimates of comorbidity with at least one personality disorder vary widely (from 8.7% to 87.5%), depending on the methodology used to assess Axis II psychopathology. However, studies generally agree that personality disorders in the anxiety cluster (e.g., obsessive-compulsive, avoidant) are more common than those of other clusters.

The importance of recognizing that people who have OCD tend to suffer from comorbid conditions is highlighted by the fact that comorbidity impacts treatment response, particularly to exposure and response prevention (ERP), the most effective treatment for OCD (Franklin et al., 2000). Several studies have reported that more severe depression was predictive of less improvement after ERP (e.g., Foa et al., 1983). Perhaps severely depressed patients were overreactive and did not show reductions in anxiety (habituation) that normally occur during exposure to feared situations. Other studies, however, reported no relationship between initial depression and outcome (e.g., Basoglu et al., 1988). One likely explanation for these inconsistent results is that only severe depression hinders outcome of ERP. Evidence indicates that many of the existing predictor studies were secondary analyses of larger controlled treatment trials in which patients who had severe depression had been excluded (to maximize experimental control). Thus, the range of depression severity on the continuous measures used in predictor analyses was restricted, perhaps eclipsing a relationship between severe depression and poor outcome.

In a more definitive study, Abramowitz and colleagues (Abramowitz et al., 2000) investigated the relationship between pretreatment levels of depression and outcome of ERP in a large clinic-based sample of OCD patients (N =87) who had a wide range of depression severity. After grouping patients on the basis of their baseline Beck Depression Inventory (BDI) scores, they found that the most severely depressed OCD patients (e.g., BDI=30) evidenced significantly lower rates of improvement with ERP compared to those who had moderate, mild, or no depression (BDI=30). This finding leads to the conclusion that OCD patients who have comorbid MDD show less improvement than those who have no depression. The effects of concurrent diagnoses on outcome of ERP for OCD have been examined in two recent studies (Abramowitz & Foa, 2000; Steketee, Chambless, & Tran, 2001); both indicated that the presence of MDD is related to poorer outcome on symptom variables and social functioning at posttreatment and follow-up.

Treatment manuals for OCD do not routinely address the common comorbid depressive symptoms that are now known to present challenges. The prevalence of depression in OCD and the evidence that severe depression impedes response to ERP suggest the need to develop and apply specific strategies for OCD patients who have comorbid MDD. Such an advance would reduce the sheer amount of therapy and increase cost-effectiveness for these patients, who are often referred for treatment of their depression before beginning a course of treatment. Our group is currently developing and testing a cognitive behavioral therapy program that aims to address both OCD and MDD symptoms in comorbid patients.

What Should Treatment for Depressed OCD Patients Involve?
Effective Treatments for OCD
Exposure involves confrontation with feared situations both in vivo (in real life) and in imagination. Response prevention entails refraining from compulsive rituals. For example, a patient who has contamination fears and compulsive hand washing is coached to confront feared “contaminants” that actually pose low levels of risk and simultaneously refrain from cleaning or washing.

Many studies report significant and lasting improvement in obsessive thoughts and compulsive rituals after ERP. In a review of 12 outcome studies, Foa and Kozak (1996) found that 83% of treatment completers (N = 330) were responders (defined as exhibiting at least 30% improvement) immediately after treatment. In 16 studies reporting longterm outcome (N=376, mean follow-up interval=29 months), 76% were responders. A recent study on the effectiveness of ERP (Franklin et al, 2000) indicated that improvement for nonresearch OCD patients was equal to that of participants in controlled research trials, suggesting that ERP is generally effective for patients outside research settings.

Cognitive conceptualizations of OCD have led to the inclusion of cognitive therapy (CT) strategies along with ERP in treatment manuals for OCD (e.g., Salkovskis, 1985; Steketee, 1999). CT techniques for OCD include education about OCD symptoms, restructuring of cognitive distortions present in OCD (e.g., inflated sense of responsibility, erroneous appraisal of intrusive thoughts), and behavioral experiments to test the validity of irrational beliefs. The efficacy of this approach is suggested by a number of outcome studies.

Biological approaches to OCD have led to the use of certain medications. Currently, the serotonin reuptake inhibitors (SRIs) are the most effective of the pharmacological treatments. These medications block the reuptake of serotonin, which is suspected to be related to OCD symptoms. On average, rates of improvement with adequate trials of SRIs (at least 12 weeks) range from 20% to 40% (e.g., Pigott & Seay, 1998). However, response varies widely from patient to patient and side effects such as nausea, sleep disturbances, or decreased sex drive are common. Importantly, once pharmacotherapy is stopped, OCD symptoms recur in 85% of patients.

Possible Treatments for Depressed OCD Patients
Given that OCD patients who have depression show attenuated response to treatment when compared to nondepressed patients, it is worthwhile to consider ways to enhance treatment for the depressed subpopulation of OCD sufferers.

Cognitive Therapy. Perhaps CT techniques that are used for depression could be added to ERP for depressed OCD patients. Indeed, CT yields high responder rates, few adverse effects, and good durability of gains in depressed patients (e.g., Elkin et al., 1989). Numerous studies report significant and lasting improvement in dysphoric mood and other MDD symptoms after CT. Typically, 50–70% of MDD patients who complete CT no longer meet criteria for MDD at posttreatment, and only 20–30% show significant relapse at follow-up (Craighead et al., 1992).

Another reason CT is a good choice for the treatment of depressed OCD patients is efficiency: that is, the skills and techniques used to reduce depression (e.g., cognitive restructuring, self-monitoring) are largely identical to those used in CT protocols developed for reducing OCD symptoms. For example, cognitive restructuring can be used to modify dysfunctional cognitions relevant to OCD (e.g., faulty appraisals of threat from intrusive thoughts), as well as those relevant to depression (e.g., “I can’t ever be happy again”). Thus, patients would learn to use the same skill to reduce both MDD and OCD symptoms.

Perhaps engaging in CT to reduce depressive symptoms before beginning ERP increases motivation and compliance with difficult exposure assignments, thereby enhancing reductions in OCD symptoms. The effects of adding CT to traditional ERP programs for OCD have yet to be evaluated systematically in a sample of OCD patients who have comorbid MDD. Thus, the purpose of our ongoing study is to examine the effectiveness of using CT for depression and OCD to augment traditional ERP in the management of this more treatment-resistant subpopulation of OCD patients. The following case description illustrates the use of CT in combination with ERP in the treatment of depressed OCD patients.
- Abramowitz, Jonathan S.  Mayo Clinic Journal of Clinical Psychology 2004.

Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 150 words in length. However, since the content of these “Personal Reflection” Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a “work in progress.” You will not be required to provide us with these Journaling Activities.

Personal Reflection Exercise #1
The preceding section contained information about treatment of obsessive-compulsive disorder in patients who have comorbid major depression. Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 8
According to Abramowitz, what did a cross-national study find to be the lifetime prevalence of Major Depressive Disorder, MDD, among OCD patients? Record the letter of the correct answer the CEU Answer Booklet

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Obsessive Compulsive Disorder: Seven Effective Behavioral Strategies

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