When Depression
Complicates OCD
Treatment
Jonathan Hoffman Ph.D., ABPP & E. Katia Moritz, Ph.D., ABPP
NeuroBehavioral Institute, Weston FL
www.nbiweston.com
www.academic-options.com
Depression & OCD
 Co-Morbidity with MDD about 1/3 (Rasmussen et al.,
1997)
 60% to 80% of OCD patients will develop a major
depressive episode in their lifetime (Saxena et al.,
2001)
 Mood Disorders common in specialized OCD treatment
centers
Bipolar and OCD
 Co-Morbidity with Bipolar Disorder about 15% - vast
majority Bipolar 2 ( Lensi et al., 1996, Perugi et al.,
1997)
 OCD Bipolar comorbidity associated with less severe
OCD than among non Bipolar OCD subjects (Zutshi,
Kamath & Reddy, 2007)
 OCD symptoms tent to persist during Bipolar episodes ,
(Perugi et al., 200) - Contrary to clinical beliefs?
In OCD treatment:
 Is Depression:
 Primary?
 Secondary?
 Both?
AND DOES IT MATTER?
Depressive symptoms occurring in OCD patients
were associated with decreased rather than
increased basal ganglia and thalamic activity,
suggesting a pathophysiologic difference between
primary and secondary MDD (Saxena et. Al., 2001)
MDD and OCD – Continued
 Utilizing medication to differentiate primary and secondary
MDD
 Hoehn-Sarie et al., 2000 found sertraline vs, desipramie
improved MDD Sx in patients with both MDD & OCD;
 Implying: MDD in the context of OCD might have differing
biological pathways than primary MDD
 In most with OCD onset of OCD predates MDD
 MDD is associated with earlier onset of OCD and more severe
symptoms (Hong et. Al., 2004)
Forms of OCD More Prone for
Development of Depression:
 Sexual, Aggressive and Religious/ Moral Obsessions
 Perfectionism about Self vs Performance
 Role of Avoidance in Depression for OCD patients
 Autogenous vs reactive obsessions (Yapa,Moganb, Kyrios,
2012 & Besiroglu et al., 2007) are positively related to
depression.
What can research tell us?
(Rampacher et al., 2010)
The neurophysiological correlates of
unipolar depression partially overlap
with OCD, but this does not
necessarily mean cognitive deficits
found in OCD patients with
depression are CAUSED by
depression, or EPIPHENOMENON of
OCD
RATHER…
 OCD-specific cognitive deficits may have a stronger
effect on the clinical presentation than depressionspecific effects
 These include spatial working memory & spatial
recognition (Purcell et. al., 1998b)
 Working memory dysfunction (Nakeo et al., 2008)
 Broad executive function deficits- scanning, planning,
time concept formation, decision-making, nonverbal
memory encoding- (Kashyap et al., 2013)
Implications:
Re-examining the rationale for treating
depression first (meds, CBT), even
when depression is severe
Vs. Treating OCD first
Vs. Treating OCD and depression
concurrently
Case Example
22 year old Female College
student
 Diagnosed at 6 with severe
and debilitating OCD
 Received intensive
treatment for OCD – very
positive outcome
 Currently having difficulties
leaving her home
 No specific OCD symptoms
accounting for her
functioning
 Changes in eating patterns
Important questions we
should ask her?
Treatment
Conceptualization
When,Why & How does
Depression need to be treated
before OCD?
Primary
Severe
Functioning
Effect on OCD Treatment
Risk
Strategies for Affective Disorders
in OCD
 Cognitive Restructuring
 Behavioral Activation
 Mindfulness-Based CBT – I don’t mindfulness ????
 Motivational Interviewing
 Acceptance & Commitment Therapy (ACT)
OCD + Affective Disorders + …
 Autistic Spectrum Disorders (ASDs)
 ADHD
 Bipolar Disorder
 Younger Children
 Tics/ Tourette’s Syndrome
Discussion