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 Comorbid Depression 1

Depression in the Obsessive-Compulsive Spectrum

Jonathan S. Abramowitz

Shannon M. Blakey

University of North Carolina at Chapel Hill

Chapter appears in E. Storch & D. McKay (eds.). Obsessive Compulsive Disorder and its

Spectrum across the Lifespan. Washington, DC: APA.

Corresponding Author:

Jonathan Abramowitz
Campus Box 3270
UNC-Chapel Hill
Department of Psychology
Chapel Hill, NC 27599
jabramowitz@unc.edu
Ph: 919-843-8170
Fax: 919-962-2537
 Comorbid Depression 2

Depression in the Obsessive-Compulsive Spectrum

Depression is a psychological state characterized by a chronically sad mood (e.g.,

feeling empty or hopeless) that is often associated with anhedoniathe diminished

capacity to experience pleasure or interest in activities that are typically enjoyed. The

following other signs and symptoms are also often present: reduced appetite and weight

loss (or in some cases weight gain), insomnia or hypersomnia, psychomotor agitation or

retardation, fatigue, feelings of guilt, diminished concentration, and recurrent thoughts of

death. Although depression is observed within the context of many psychological

syndromes, as well as in non-clinical individuals, a person meets the criteria for a major

depressive episode if the aforementioned symptoms persist for at least a two-week period

and interfere with daily functioning (American Psychiatric Association [APA], 2000).

Major depressive disorder (MDD) is defined by the occurrence of one or more major

depressive episodes at any point during the lifetime (APA, 2000). Dysthymia, a similarly

chronic but less severe form of depression, involves a chronically depressed mood and

reduced interest, but does not grossly disable the persons daily functioning (APA, 2000).

Depressive symptoms are often observed in individuals with OCD spectrum

conditions1. Anxiety (OCD is an anxiety disorder; APA, 2000) is the single best

predictor of the development of clinically severe depressive symptoms (Hranov, 2007;

1
Considerable disagreement existson both conceptual and empirical grounds
regarding what constitutes an OC-related disorder. In this chapter we define an OCD
spectrum disorder as one involving (a) anxiety-provoking intrusive thoughts and (b)
safety behaviors, avoidance, and compulsive rituals performed to reduce anxiety (e.g.,
Storch, Abramowitz, & Goodman, 2008). When this definition is used, body dysmorphic
disorder (BDD) and hypochondriasis (HC), along with OCD, fit within the OCD
spectrum category (Abramowitz & Deacon, 2005).
 Comorbid Depression 3

Hirschfeld, 2001). Depression also ranks as the most commonly co-occurring problem

among anxiety diagnoses (Kessler, 1998), affecting up to 90% of people with anxiety

disorders (Gorman, 1996). We next review the rates of comorbid depression across the

OCD spectrum.

OCD

Table 1 shows the rates of MDD among adult OCD samples. Across 7 countries,

the lifetime prevalence ranged from 12.4% to 60.3%. In the United States, researchers

found a lifetime comorbidity rate of 54.1%, and a concurrent comorbidity rate of 36%

(e.g., Nestadt et al., 2001). Studies on the temporal nature of this comorbidity have long

found that in most (but not all) instances, OCD symptoms predate the depressive

symptoms (Bellodi et al., 1992; Demal et al., 1993). This suggests that the mood

disturbance often occurs as a response to the distress and functional impairment

associated with obsessions and compulsions as described earlier.

OCD patients with depression also show an earlier age of OCD onset and more

severe symptoms as compared to non-depressed OCD sufferers (e.g., Abramowitz,

Storch, Keely, & Cordell, 2007). Depressive symptoms are also more strongly associated

with the severity of obsessions than with compulsions (Ricciardi & McNally, 1995), and

may be specifically associated with sexual and religious obsessions (Hasler et al., 2005).

Finally, relative to non-depressed OCD patients, those with depression more strongly

believe that their intrusive obsessional thoughts are significant and meaningful

(Abramowitz et al., 2007).

BDD
 Comorbid Depression 4

Body dysmorphic disorder involves excessive preoccupation with an imagined

defect in appearance that causes subjective distress and interference with functioning

(APA, 2000). Examples include perceived flaws in the size or shape of the face, skin,

hair, and muscles. The preoccupations often lead to anxiety-reducing behaviors such as

mirror gazing (or mirror avoidance), camouflaging the perceived defect with makeup or

clothing, or performing other checking and grooming behaviors. Some people with BDD

also undergo cosmetic surgeries to correct the flaw (Veale, 2000).

MDD is the primary comorbid condition among individuals with BDD (Gunstad

& Phillips, 2003). Table 2 shows the rates of lifetime MDD among BDD patients, which

range from 36% to 87% in adult samples. Although there are instances where MDD

arises before the onset of BDD symptoms, depression generally presents after the

development of BDD, supporting theoretical speculations that the distress and

dissatisfaction associated with body image preoccupation in BDD leads to depressive

symptoms (Phillips, 1999). Indeed, this is not surprising: feelings associated with BDD

(i.e., beliefs that one is unattractive) are similar to core dysfunctional beliefs

characteristic of MDD.

Compared to BDD without depression, BDD with comorbid MDD is associated

with more severe BDD symptoms, increased anxiety and personality disorder

comorbidity, and decreased quality of life (Phillips, Didie, & Menard, 2007). Comorbid

BDD and MDD diagnoses are also associated with an earlier age of onset of depression

(mid-adolescence versus mid-20s) and more chronic depression (Nierenberg et al., 2002).

Thus, a comorbid MDD and BDD diagnosis may forecast exacerbated psychiatric

symptoms and more complicated treatment.

 Comorbid Depression 5

HC

HC involves a persistent fear or belief that one has a serious disease (e.g., cancer)

resulting in distress and functional impairment as well as urges to seek reassurance of

good health from medical professionals (and other sources), avoidance of health cues,

and taking unreasonable preventative measures (APA, 2000). Although these behaviors

might provide an immediate relief from anxiety, they ultimately maintain HC symptoms

in the long run (Warwick & Salkovskis, 1990).

Hypochondriasis is frequently comorbid with other psychiatric disorders, with

MDD being among the most common (Creed & Barsky, 2004). Table 3 shows the rates

of MDD in patients diagnosed with HC. As can be seen, a majority of adults with HC

experience MDD at some point in their lifetime. It is also worth noting that patients with

MDD frequently present with somatic symptoms, a reverse pattern that has clinical

implications for patients prognosis and treatment (see Kirmayer & Robbins, 1991). As

with OCD and BDD, HC symptoms tend to temporally precede the onset of MDD

(Noyes et al., 1994).

Compared to non-depressed HC patients, most patients with comorbid MDD and

HC experience more chronic and persistent HC symptoms, especially disease fears

(Barsky et al., 1992; Creed & Barsky, 2004; Noyes et al., 1994). Additionally, those with

comorbid MDD and HC have greater overall functional impairment and endorse more

depressive symptoms than those with HC in the absence of MDD (Noyes et al., 1994).

Predictors of depressive symptoms in OC spectrum disorders

There are limited data on predictors of depressive symptoms in OCD spectrum

disorders. Ricciardi and McNally (1995) found that depression was associated with more
 Comorbid Depression 6

severe obsessional symptoms, but not with compulsive rituals. Later studies revealed that

depression was particularly strongly associated with the presence of obsessional

intrusions concerning sexual and religious themes (Hassler, LaSalle, Ricci, & Ronquillo,

2005). Moreover, relative to non-depressed OCD patients, those with MDD showed more

severe cognitive distortions (i.e., the tendency to misinterpret the significance of

obsessional thoughts) and poorer insight into the senselessness of obsessions and rituals.

Thus, the presence of depression is not only associated with greater overall OCD

symptom severity, but also with certain presentations of this highly heterogeneous

condition.

Treatment

Treatment Outcome

Effective psychological treatment for OCD, BDD, and HC emphasizes

psychoeducation, exposure therapy, response prevention, and cognitive restructuring

(e.g., Abramowitz, Deacon, & Whiteside, 2011; Taylor & Asmundson, 2004). Yet these

techniques require hard work and practice, some of which involves deliberately

confronting ones fears and provoking anxiety. Individuals suffering with depression,

however, might lack the willpower to complete such challenging work and fall prey to

dysfunctional self-defeating beliefs (e.g., I dont deserve to get better). Although

cognitive-behavioral therapy (CBT) can be effective in reducing OC and related

symptoms, the cognitive, physiological, behavioral, and affective symptoms of

depression can interfere with the effects of this treatment. Serotonin reuptake inhibitor

(SRI) medications are the first line pharmacological treatments for OCD, BDD, and HC.

Next, we turn to a review of the pharmacological and cognitive-behavioral treatment

 Comorbid Depression 7

outcome literature with respect to comorbid MDD in OCD and BDD. There are presently

no treatment data on comorbid depression in HC.

OCD. Studies with OCD patients consistently show that in addition to reducing

OCD symptoms, CBT and SRIs are associated with improvement in depressive

symptoms, yielding large pre- to posttest effects (e.g., Eddy, Dutra, Bradey, & Westen,

2004; Franklin et al., 2000). Two studies with OCD patients receiving CBT (primarily

involving exposure and response prevention [ERP]) have examined the effects of

comorbid MDD on treatment response. Abramowitz and Foa (2000) compared outcome

for 15 depressed OCD patents to that for 33 nondepressed OCD patients following 15

sessions of this treatment. While immediate and long-term improvement was observed in

both groups (respectively, 87.9% and 73.3% showed at least a 30% reduction in OCD

symptoms at posttest), at posttest and at follow up, the depressed patients had more

severe symptoms. Steketee, Chambless, and Tran (2001) examined 63 OCD patients who

had received CBT, 9 of whom had MDD. Among treatment completers, the presence of

MDD significantly predicted poorer outcome on measures of OCD symptoms. Although

clinical observations suggest that depressed OCD patients require higher doses of SRIs

than do nondepressed OCD patients, empirical findings demonstrating an attenuated

response to pharmacotherapy among comorbid patients are lacking (e.g., Fineberg &

Craig, 2010).

BDD. Williams, Hadjistavropoulos, and Sharpe (2006) conducted a meta-analysis

to examine the relative effectiveness of pharmacological and psychological (CBT and

behavioral) therapies in 13 studies of BDD patients with comorbid MDD. They found

large effect sizes for improvement in both BDD and MDD symptoms for both forms of
 Comorbid Depression 8

treatment. When these effects were compared meta-analytically, however, CBT was

significantly more effective in reducing comorbid BDD and MDD symptoms than was

pharmacotherapy. These findings suggest that while both SRIs and psychological

treatments are effective for comorbid MDD and BDD, CBT provides a greater and more

inclusive benefit (Williams et al., 2006).

Why Does Depression Attenuate Treatment Outcome?

There are a number of factors that might contribute to depression interfering with

treatment outcome, especially where CBT for OCD and related disorders is concerned.

For example, depressed individuals can show decreased compliance with treatment

instructions. Yet to be effective, CBT requires that the patient repeatedly practice the

treatment techniques (e.g., confronting feared stimuli and remaining exposed until

anxiety subsides on its own). Depressed individuals might not be able to properly comply

with these demanding instructions if they perceive themselves as more helpless

(Seligman, 1975), less deserving of a happy life, or if they hold low expectations of

improvement (Bandura, 1977). Depressed patients might also suffer with psychomotor

retardation, which would attenuate their ability to do the work required to improve.

With respect to medication, depressed patients have reduced hope and optimism,

thereby depleting medications of their nonspecific (i.e., placebo) effects. They might also

attribute any treatment gains to external or circumstantial sources, and therefore evidence

less improvement and more relapses than non-depressed patients. In the remainder of this

chapter we discuss possible approaches to managing patients with OCD and related

disorders with depression.

Treatment Approaches to Address Comorbid Depression

 Comorbid Depression 9

For the most part, research on the treatment of OCD and related disorders has

focused on more or less straightforward or clean presentations of these problems

(e.g., Foa et al., 2005). Less attention has been paid to complex cases, such as those

involving comorbid depression. Yet as we have discussed, a great many individuals with

OCD and related disorders present with complexities of one sort or anothercomorbid

depression being among the most common.

As mentioned, exposurerepeated and prolonged confrontation with feared

stimulialong with help refraining from subtle and overt avoidance and safety-seeking

behaviors (i.e., response prevention) is the centerpiece of CBT for OCD, BDD, and HC

(Abramowitz et al., 2011). Someone with contamination obsessions, for example, is

helped to confront sources of feared germs (e.g., public bathrooms) while simultaneously

refraining from any avoidance or anxiety-reducing behavior (e.g., hand washing).

Exposure-based CBT can be highly effective for OCD, BDD, and HC, producing an

average of 60% to 70% reduction in fear, avoidance, and the use of safety behaviors

(Abramowitz et al., 2011). A drawback of this approach, however, is that patients must

confront their fear-evoking stimuli and resist urges to immediately reduce anxiety via

escape or avoidance. Because exposure therapy requires compliance with these somewhat

demanding procedures, a significant minority of patients either refuse this form of

therapy or terminate prematurely. Moreover, exposure therapy is highly focused on

alleviating anxiety and fear, and does not directly address comorbid problems such as

depression.

Cognitive conceptualizations of OCD (e.g., Clark, 2004), BDD (e.g., Veale &

Neziroglu, 2010), and HC (e.g., Taylor & Asmundson, 2004) have led to the inclusion of
 Comorbid Depression 10

cognitive therapy (CT) strategies along with exposure in many treatment protocols (e.g.,

Abramowitz & Braddock, 2008). In CT, a number of verbal and skill-development

techniques are used to (a) educate patients about the nature of anxiety and how

pathological anxiety is maintained, and (b) help patients correct dysfunctional beliefs and

automatic thoughts that lead directly to anxiety and fear (e.g., misinterpretations of

benign physical sensations). For example, someone with BDD would be helped to

recognize that others are unlikely to notice or judge her based on the imagined defect in

appearance. In addition to verbally challenging dysfunctional thinking patterns, patients

test out the validity of these (and corrected) beliefs using real life experiments (that are

similar to exposure exercises), such as walking through a shopping mall without

concealing an imagined facial defect. The efficacy of CT is suggested by numerous

outcome studies, yet CT does not appear to be quite as effective as exposure-based

therapy for OCD and conditions related to it (Abramowitz et al., 2011).

Treatment protocols developed for OCD, BDD, and HC have not routinely

addressed the common comorbid depressive symptoms that are known to present

challenges. There are, however, a few possible ways in which CBT could be

implemented to address comorbid depression. These are described below, along with the

theoretical and practical considerations relevant to each.

Combining antidepressant medication and CBT. Antidepressant medications,

such as the serotonin reuptake inhibitors (SRIs), are the most widely used treatments for

both depression and OCD related disorders. Thus, intuitively, the use of these agents

should improve outcome for patients suffering from both types of these problems

comorbidly. Very few studies, however, have addressed whether antidepressants offer an
 Comorbid Depression 11

advantage over exposure-based CBT, specifically for comorbid samples; and the existing

studies have numerous methodological difficulties which limit the conclusions that can

be drawn. The OCD literature provides the best examples of such studies. In one

investigation with OCD patients, Marks et al. (1980) found that clomipramine (CMI)

helped severe depression and OCD symptoms more than did placebo. However, the

comparison included only five patients on CMI and five on placebo, and the statistical

analysis was conducted at the 4-week point in treatment, which may not have been

enough time for CMI to yield full benefit in all patients.

In another study, Foa, Kozak, Steketee, and McCarthy (1992) examined whether

using imipramine (IMI) prior to CBT would facilitate improvement in OCD symptoms

once CBT began. In their prospective study, mildly and severely depressed OCD patients

received either pill placebo or IMI for six weeks prior to CBT. Results indicated that

although IMI improved the symptoms of depression, it did not potentiate the effects of

CBT on OCD symptoms. Abramowitz et al. (2000) also included a comparison between

severely depressed OCD patients who either were or were not using SRI medications

during CBT. No difference between groups were reported, although the small size of the

severely depressed group in that study (n = 11) limits the generalizability of this finding.

To date, there is little compelling evidence that medication potentiates the effects of CBT

with severely depressed anxiety patients.

One explanation for the above conclusion is that because SRI medications are the

most widely used therapy for anxiety, patients with anxiety disorders have often already

tried these agents before presenting for psychological treatment. Thus, many depressed

anxiety disorder patients in treatment studies might have been medication resistant,
 Comorbid Depression 12

thus putting a ceiling on the effects of medications. Nevertheless, since the average

improvement with SRI medication is somewhat modest (about 20-40% on average) there

is a need to consider non-medication strategies for augmenting psychological treatment

for depressed anxiety disorder patients.

Adding cognitive therapy for depression. Cognitive therapy is a useful

intervention for all OCD related disorders and for depression. Indeed, CT yields high

responder rates, few adverse effects, and good durability of gains in depressed patients

(e.g., Elkin et al., 1989). Cognitive therapy for depression involves identifying and

challenging overly negative beliefs about oneself, world, and the future that lead to

overly negative and biased interpretations of events, giving rise to feelings of extreme

hopelessness, helplessness, and personal failure. It also includes the use of behavioral

activation in which the patient increases his or her engagement with other people and in

activities he or she finds enjoyable. This helps reinforce behavior that is the opposite of

depressive behavior. Numerous studies report significant and lasting improvement in

dysphoric mood and other MDD symptoms following CT (Dobson, 1989). Typically, 50-

70% of MDD patients who complete CT no longer meet criteria for MDD at post-

treatment, and only 20-30% show significant relapse at follow-up (Craighead et al.,

1992).

Another reason CT is a good choice to use in the treatment of patients with OCD

and related disorders who also suffer from comorbid depression is efficiency: that is, the

conceptual approach and implementation of CT as used for depression (e.g., identifying

and challenging beliefs) are largely similar to those used in CT for OCD, BDD, and

HCalthough the content of the dysfunctional beliefs that are targeted is different. For
 Comorbid Depression 13

example, cognitive restructuring can be used to modify dysfunctional cognitions relevant

to intrusive thoughts (e.g., thinking about molesting a child is as morally wrong as

actually molesting the child), as well as those relevant to depression (e.g., everyone

else has a better life than me). Thus, patients could learn to make use of the same skills

to reduce both anxiety and depressive symptoms.

Engaging in CT to reduce depressive symptoms prior to beginning exposure

techniques might alleviate some depressive symptoms and help patients with OCD and

related conditions increase motivation and compliance with difficult exposure therapy

assignments. Engaging in CT prior to, or concomitant with, serotonergic medication use

might also increase hopefulness about this treatment, helping patients tap into any

psychological effects of using these medications. Unfortunately, however, no systematic

evaluations of such treatment programs have been conducted; although we are currently

conducting a study involving the use of CT and exposure therapy for patients with OCD

and comorbid depression.

Conclusions and Future Directions

To date, the following can be said about the influence of comorbid depression on

OCD spectrum disorders such as BDD and HC: (a) at least half of all patients with OCD-

related disorders also suffer from depressive symptoms or meet criteria for a unipolar

mood disorder; (b) in most instances, depressive symptoms emerge following the onset of

OC symptoms, and perhaps in response to the distress and functional impairment

associated with these symptoms; and (c) the presence of comorbid depression hinders

outcome of both CBT and SRIs, which are the most effective treatments for OC-related
 Comorbid Depression 14

disorders. The precise mechanisms for how depression hinders treatment outcome,

however, are not completely understood.

Although it intuitively seems that adding CT for depression to exposure-based

CBT for OCD spectrum disorders would be the best approach to managing this pattern of

comorbidity, important questions need to be answered in order to determine the clinical

effectiveness and cost effectiveness of this approach. It will, for example, be necessary

to determine whether or not such a treatment package is more effective than exposure

therapy, CT, or SRI medication alone, or that it is superior to the combination of

psychological treatment and medication in this population. We await this next phase of

treatment development for OCD and related disorders.

 Comorbid Depression 15

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 Comorbid Depression 20

Table 1. Rates of Lifetime MDD in Samples of Adult OCD Patients

Study DSM N % comorbidity

Antony et al. (1998) IV 87 24

Yaryura-Tobias et al. (1996) III-R 391 29

Crino & Andrews (1996)* III-R 108 50

Ricciardi & McNally (1995) III-R 125 21

Andrews et al., 2002 IV 641 17

Nestadt et al. (2001) IV 80 54

Sanderson et al. (1990) III-R 12 33

 Comorbid Depression 21

Table 2

Rates of Lifetime MDD in Samples of Adult BDD Patients

Study DSM N % comorbidity

Hollander, Cohen, & Simeon III-R 50 68

(1993)

Veale et al. (1996) III-R 50 36

Perugi et al. (1997) III-R 58 41

Zimmerman & Mattia (1998) IV 16 69

Gunstad & Philips (2003) IV 293 76

Phillips, Didie, & Menard IV 178 74

(2007)

Phillips et al. (2007) IV 45 87

 Comorbid Depression 22

Table 3

Rates of Lifetime MDD in Samples of Adult HC Patients

Study DSM N % comorbidity

Hiller, Liebbrand, Rief, & IV 46 72 Lifetime

Fichter (2005)

Bach, Nutzinger, & Hartl III-R 37 68 Lifetime

(1996)

Barsky, Wyshak, & III-R 42 43 Lifetime

33 Current
Klerman (1992)

Noyes et al. (1994) III-R 50 28 Current

Escobar et al. (1998) IV 49 84 Unspecified

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