Depression in youth with obsessive-compulsive disorder: Clinical phenomenology and correlates
Introduction
Previously considered rare, pediatric obsessive-compulsive disorder (OCD) occurs with relative frequency in children and adolescents with prevalence rates of approximately 1-2% (Douglass et al., 1995, Zohar, 1999). As many as 80% of youth have a childhood onset of obsessive-compulsive symptoms (Pauls et al., 1995), which, in the absence of treatment, often have a protracted course (Murphy et al., 2004) and considerable psychosocial impairment (Piacentini et al., 2007). Clinically, many youth with OCD present with comorbid conditions that further complicate presentation and may negatively impact treatment course. In particular, the comorbidity of depressive disorders (DD) with OCD has long been recognized in the clinical literature due to its frequency and potential impact on treatment course (Geller et al., 2003, Storch et al., 2008). Rates of depressive comorbidity among pediatric OCD patients are roughly similar to that of adults; between 13-73% of children with OCD have comorbid DD (Geller et al., 1996, Geller et al., 2003) and approximately 50-80% of adults with OCD have comorbid DD (Besiroglu et al., 2007). Some data suggest that DD emerge secondary to OCD as a function of OCD-related distress and impairment (Valleni-Basile et al., 1996, Abramowitz et al., 2007). Co-occurring depressive symptoms contribute to worse illness presentation (Peris et al., 2010) and comorbid DD have been linked to attenuated cognitive-behavioral therapy (CBT) and pharmacotherapy treatment response (Geller et al., 2003, Storch et al., 2008).
Despite the frequent comorbidity of DD with OCD in children, little empirical attention has been given to understanding this comorbidity pattern. Among adults with OCD, a modest literature suggests that certain sociodemographic and clinical differences may be related to comorbid DD. For example, increased age has been directly associated with the likelihood of comorbid DD (Millet et al., 2004, Tukel et al., 2006), while gender has not been related to comorbid DD (e.g., (Abramowitz et al., 2007). Regarding clinical variables, comorbid DD has been directly associated with obsessive-compulsive symptom severity, functional impairment, and comorbid anxiety symptoms/disorders (Tukel et al., 2002, Tukel et al., 2006). Depressed patients showed reduced response to combined behavioral/pharmacotherapy (Overbeek et al., 2002). Some evidence suggests that sexual and religious obsessions are related to greater depressive symptoms (Hong et al., 2004, Hasler et al., 2005); this is consistent with previous research indicating that these particular types of obsessions are experienced as more distressing than are other obsessive-compulsive symptoms (Abramowitz et al., 2003).
Among children, considerably less research has been conducted. In a study contrasting 28 youth (ages 10-17 years) with OCD and comorbid DD and matched youth with OCD without DD on the Child Behavior Checklist and Family Environmental Scale (Canavera et al., 2010), youth with OCD and comorbid DD had more internalizing/externalizing problems, more socialization problems, and higher family conflict/lower family organization in contrast to the OCD group. Peris et al. (2010) showed that depressive symptoms in youth with OCD (N = 71) were inversely associated with several cognitive variables including insight, perceived contingencies, perceived competence and perceived control. As well, depressive symptoms were directly linked to obsessive-compulsive severity and older age (but not gender), with the latter suggesting that depressive symptoms and disorders may emerge secondary to OCD for some (Diniz et al., 2004, Abramowitz et al., 2007). While the Peris et al. (2010) study represents an important advance in the pediatric OCD literature, only one child in the sample met diagnostic criteria for DD.
Examining youth with OCD and comorbid DD may have clinical and scientific implications. First, as noted above, comorbid DD have been associated with attenuated CBT response in youth with OCD (Storch et al., 2008) and reduced response to combined behavioral/pharmacotherapy in adults with OCD (Overbeek et al., 2002). Depressive disorders may contribute to reduced anxiety habituation during exposures (Abramowitz, 2004), decreased hope for a positive treatment outcome, or reduced motivation/energy to engage in therapeutic tasks. Such factors complicate the use of exposure-based elements that rely on anxiety habituation and independent engagement in treatment tasks outside of session. Thus, treating OCD with comorbid DD may require a different approach compared to the treatment of OCD alone or OCD with other non-DD comorbidities. Nonetheless, the exact domains in which those youth with comorbid DD differ from those without remains unknown and is important for developing targeted interventions. Understanding the factors that directly relate to depressive symptoms/disorders will foster the development of interventions tailored to the individual child's needs. For example, if DD comorbidity is associated with greater obsessive-compulsive symptom severity, multi-modal intervention may be indicated as the treatment of choice. Second, these data may elucidate risk factors for DD comorbidity that may help understand illness course. Third, the extent to which certain factors are associated with greater depressive symptoms will provide information about domains that should be comprehensively assessed upon presentation and throughout treatment (e.g., anxiety, family accommodation) with the idea of tailoring interventions to address the individual child's needs.
The present study examined differences in clinical presentation and functional impairment in a sample of youth with OCD with or without current comorbid DD and sought to determine the predictors of youth-reported depressive symptoms. Specifically, we set out to answer the following four questions. First, are there differences in the clinical severity and phenomenology of those children with OCD with or without comorbid DD? Second, would the clinical variables of OCD-related functional impairment, comorbidity, and non-OCD anxiety symptoms predict child-rated depressive symptoms over and above OCD symptom severity? We hypothesized that the variables listed above would predict child-rated depressive symptoms after accounting for OCD symptom severity. Third, would the clinical variables of OCD-related functional impairment and non-OCD anxiety symptoms predict the presence of a DSM-IV major depressive disorder over and above OCD symptom severity? We hypothesized that the variables listed above would predict presence of major depressive disorder after accounting for OCD symptom severity. Finally, would obsessive-compulsive symptom severity be positively associated with depressive symptoms and would this relationship be mediated by functional impairment? This would test the hypothesis that obsessive-compulsive symptoms are associated with functional impairment, which then contributes to depressive symptoms.
Section snippets
Participants
One-hundred and sixty youth (90 male) between the ages of 7 and 20 years (M = 12.68, SD = 2.91) with a primary diagnosis of OCD obtained via the Anxiety Disorders Interview Schedule for DSM-IV: Parent Version (ADIS-IV-P; Silverman and Albano, 1996) and confirmed by an unstructured clinical interview by a clinical psychologist or board certified child/adolescent psychiatrist were included in the study. Participants were enrolled in several completed or ongoing studies of CBT response conducted
Descriptive analyses
As noted above, 16% (n = 25) of the sample had a comorbid diagnosis of a DD. Descriptive information for the youth with and without a comorbid diagnosis of DD are presented in Table 1. There were significantly more females than males with a comorbid DD; groups with and without a DD did not significantly differ in age. As expected, youth with a comorbid DD had significantly higher levels of depressive symptoms as measured by the CDI-S and internalizing symptoms as measured by the CBCL than their
Discussion
This research compared the clinical presentation and functional impairment of youth with OCD with and without comorbid DD. Of the total sample, 15.6% of individuals met DSM-IV-TR criteria for comorbid DD, which is consistent with other findings in pediatric OCD samples (Geller et al., 1996). That this figure is markedly lower than DD rates in adults with OCD may suggest increased risk as an affected individual increases in age. Indeed, the present findings and those of Peris et al. (2010) found
Acknowledgements
The contributions of Jessica Morgan and Anna Jones are acknowledged.
References (50)
- et al.
Obsessive-compulsive disorder with comorbid major depression: what is the role of cognitive factors?
Behaviour Research and Therapy
(2007) - et al.
Family distress and involvement in relatives of obsessive-compulsive disorder patients
Journal of Anxiety Disorders
(2000) - et al.
Reliability and validity of parent and child versions of the multidimensional anxiety scale for children in community samples
Journal of the American Academy of Child and Adolescent Psychiatry
(2007) - et al.
Cognitive-behavioral family treatment of childhood obsessive-compulsive disorder: a controlled trial
Journal of the American Academy of Child and Adolescent Psychiatry
(2004) - et al.
Factors associated with major depressive disorder occurring after the onset of obsessive-compulsive disorder
Journal of Affective Disorders
(2007) - et al.
Obsessive-compulsive disorder in a birth cohort of 18-year-olds: prevalence and predictors
Journal of the American Academy of Child and Adolescent Psychiatry
(1995) - et al.
The analytical epidemiology of obsessive-compulsive disorder: risk factors and correlates
Progress in Neuropsychopharmacology and Biological Psychiatry
(2008) - et al.
Convergent and discriminant validity of the Children's Yale-Brown Obsessive Compulsive Scale-Symptom Checklist
Journal of Anxiety Disorders
(2008) - et al.
Comorbidity of juvenile obsessive-compulsive disorder with disruptive behavior disorders
Journal of the American Academy of Child and Adolescent Psychiatry
(1996) - et al.
Obsessive-compulsive disorder symptom dimensions show specific relationships to psychiatric comorbidity
Psychiatry Research
(2005)
Interrater reliability of the Anxiety Disorders Interview Schedule for DSM-IV: child and parent version
Journal of the American Academy of Child and Adolescent Psychiatry
Test-retest reliability of the Multidimensional Anxiety Scale for Children
Journal of Anxiety Disorders
The Multidimensional Anxiety Scale for Children (MASC): factor structure, reliability, and validity
Journal of the American Academy of Child and Adolescent Psychiatry
Phenomenological and comorbid features associated in obsessive-compulsive disorder: influence of age of onset
Journal of Affective Disorders
Detecting pediatric autoimmune neuropsychiatric disorders associated with streptococcus in children with obsessive-compulsive disorder and tics
Biological Psychiatry
Children's Yale-Brown Obsessive Compulsive Scale: reliability and validity
Journal of the American Academy of Child and Adolescent Psychiatry
Test-retest reliability of anxiety symptoms and diagnoses with the Anxiety Disorders Interview Schedule for DSM-IV: child and parent versions
Journal of the American Academy of Child and Adolescent Psychiatry
Psychometric evaluation of the Children's Yale-Brown Obsessive-Compulsive Scale
Psychiatry Research
Family-based cognitive-behavioral therapy for pediatric obsessive-compulsive disorder: comparison of intensive and weekly approaches
Journal of the American Academy of Child and Adolescent Psychiatry
Impact of comorbidity on cognitive-behavioral therapy response in pediatric obsessive-compulsive disorder
Journal of the American Academy of Child and Adolescent Psychiatry
Comorbid conditions in obsessive-compulsive disorder
Comprehensive Psychiatry
Incidence of obsessive-compulsive disorder in a community sample of young adolescents
Journal of the American Academy of Child and Adolescent Psychiatry
Interrater reliability and clinical efficacy of Children's Yale-Brown Obsessive-Compulsive Scale in an outpatient setting
Comprehensive Psychiatry
The epidemiology of obsessive-compulsive disorder in children and adolescents
Child and Adolescent Psychiatric Clinics of North America
Treatment of obsessive-compulsive disorder in patients who have comorbid major depression
Journal of Clinical Psychology
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