To,
The Editor
Malaysian Journal of Psychiatry
Subject: submission of edited manuscript
Dear Sir/ Madam,
We are submitted the answers to the queries of the reviewers of our manuscript “Comorbidity in obsessive-compulsive disorder in an Indian patient population”. We have
also made the necessary changes suggested by the reviewers.
Thanking you.
Yours’ sincerely,
Corresponding contributor:
Dr. Chetali V. Dhuri
Department of Psychiatry, Seth G.S. Medical College and KEM Hospital,
Parel, Mumbai 400012, Maharashtra, India.
E-mail: chetali.dhuri@gmail.com
1
ANSWERS TO QUERIES:
1. Specify whether subjects with alcohol use not amounting to disorder
excluded.
Answer: Subjects with alcohol use not amounting to disorder were not
excluded.
2. Any separate scale other than MINI used to diagnose nicotine dependence?
Answer: Only MINI was used to diagnose nicotine dependence.
3. Any of Suicidality scales used or not?
Answer: Separate scales of suicidality were not used, assessment for suicidality
was done using MINI.
4. Any of the subjects diagnosed with OCD with poor insight?
Answer: The mini international neuropsychiatric interview (MINI) english version
6.0.0 DSM- IV used to diagnose axis I comorbidity by us does not have questions
to distinguish OCD with good insight from poor insight. Hence, it would be difficult
to comment on the number of subjects with poor insight.
5. The low prevalence of these disorders with OCD as evident in this and other
Indian studies may be related to socio cultural differences, as prevalence of both
bipolar disorder and eating disorders even among general population is high in
industrialized, affluent countries linking the disorders to affluent society.
Please quote the reference for this statement. Or else statement should be
modified.
2
Answer: The statement is modified as- The low prevalence of these disorders
with OCD as evident in this and other Indian studies may be related to socio
cultural differences, as prevalence of both bipolar disorder and eating disorders
even among general population is high in industrialized, affluent countries linking
the disorders to high socio economic status.
The following references have been added in support of the statement.
i.
Lenzi A, Lazzerini F, Marazziti D, Raffaelli S, Rossi G, Cassano GB.
Social class and mood disorders: clinical features. Soc Psychiatry
Psychiatr Epidemiol. 1993; 28:56-9.
ii.
Okasha A, Kamel M, Sadek A, et al. Psychiatric morbidity among
university students in Egypt. British Journal of Psychiatry 1977; 131: 149154.
iii.
Verdoux H, Bourgeois M. Social class in unipolar and bipolar probands
and relatives. J Affect Disord. 1995; 33: 181-7.
6. Our subjects also reported high level of fear, anxiety about the effect of alcohol &
other substances on their general health and OCD particularly thus avoiding it.
Whether any particular scale was used?
Answer: No particular scale was used. The above statement is made as most of
our patients reported worry about effect of alcohol and other addictive drugs and
quoted it as the reason to avoid it.
7. The references have been edited to follow the uniform reference style according
to author guidelines of the journal.
3
Abstract:
Introduction: Obsessive-compulsive disorder (OCD) is associated with substantial comorbidity, not only with anxiety and mood disorders but also with psychotic and
substance use disorders. The Epidemiological Catchment Area (ECA) study, reported
co-morbid psychiatric illness in two third of its OCD subjects. The Indian research in this
aspect is sparse. Methods: The objective was to assess the prevalence of psychiatric
co-morbidities in patients with OCD in an Indian setting. Fifty patients meeting the
DSM-IV TR diagnostic criteria for OCD were selected for the study. The mini
international neuropsychiatric interview (MINI) english version 6.0.0 DSM- IV, a brief
structured interview for the major axis I psychiatric disorders was used to measure
psychiatric co-morbidity. Results: Sixty four percent of the sample was male and the
mean age was 30.62 years. One or more co-morbid psychiatric disorder was seen in
96% of the sample. The most common psychiatric disorder associated was major
depressive disorder (90%) followed by suicidality (62%), anxiety disorders (50%) and
psychotic disorder (22%). Nine patients (18%) had comorbid nicotine dependence.
Conclusion: The prevalence of co-morbid major depression, anxiety disorders and
suicidal risk in our sample is similar to the western data. Certain co-morbities like bipolar
disorder, eating disorder, alcohol and non alcohol substance use disorders other than
nicotine were absent in this sample, a finding distinct in our setting in comparsion to
western studies.
Keywords: Obsessive-Compulsive Disorder, Co-morbidity, Major Depressive Disorder,
Psychosis
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Introduction:
Psychiatric co-morbidity may be defined as the co-occurrence of two or more psychiatric
disorders in any combinations in the same person. Co-morbid psychiatric conditions
influence the treatment response, prognosis and also influence help seeking behavior 1.
Obsessive-compulsive disorder (OCD) is associated with substantial co-morbidity, not
only with anxiety and mood disorders but also with psychotic and substance use
disorders. In the Epidemiological Catchment Area (ECA) study, two thirds of those with
OCD had a co-morbid psychiatric illness commonly major depressive disorder (MDD)
and anxiety disorders 2. For mood disorders, prevalence co-morbid rates range from 12
to 85 % 3-5 and for anxiety disorders 24 to 70 percent 2, 4. The ECA study also reported
other concurrent co-morbidities like problem drinking( 24%), social phobia(11-23%),
generalized anxiety disorder (18-20%), simple phobia (7-21%), panic disorder (6-12%)
,eating disorder (8-15%), amongst the OCD patients. The available data suggests that
nearly 15% of OCD patients have bipolar disorder; mainly hypomania
6, 7;
also psychotic
symptoms are reported in the range of 6% to 32% in OCD patients 8-10. However, there
is considerable variability amongst these studies in the reported prevalence rates of comorbid disorders. There are few studies from India investigating the prevalence of comorbidities in OCD. Our study is an attempt to study these co-morbidities in comparison
with the western data.
Materials and Methods:
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Study design and sample: A descriptive study of out-patients at a tertiary care center
in Mumbai, India was conducted. 50 OCD subjects above 18yrs satisfying the DSM-IV
TR diagnostic criteria were consecutively included in the study. Individuals with history
of or concurrent neurological or medical disorder or psychosis as primary diagnosis
were excluded. The group consisted of 18 women and 32 men. Ethical clearance was
obtained from the Ethics Review Committee of the institution. Informed consent was
obtained from all patients who participated in the study. Those who agreed to participate
were engaged in a detailed clinical interview by the authors using a semi-structured
questionnaire to study the sociodemographic profile and the psychiatric co-morbidities.
Tools: The mini international neuropsychiatric interview (MINI) english version 6.0.0
DSM- IV, a brief structured interview for the major axis I psychiatric disorders was used
to measure psychiatric co-morbidity in the OCD subjects. It is divided into 16 modules
each corresponding to a diagnostic category namely, major depressive episode, manic
/hypomanic episode/ bipolar I/II disorder, panic disorder agoraphobia, social phobia,
obsessive‐compulsive disorder, posttraumatic stress disorder, alcohol dependence/
abuse, substance dependence/abuse (non‐alcohol), psychotic disorders, anorexia
nervosa, bulimia nervosa, generalized anxiety disorder, medical/ organic/ drug cause
and antisocial personality disorder.
Statistical analysis: The data was entered using MS-Excel-2007 and analysed using
SPSS-16 software. Proportions were calculated to identify the rates of comorbidity.
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Results:
The sample characteristics are summarized in Table 1. The mean age of the sample
was 30.62 years with their ages between the ranges of 18-59 years. Males were more
in number than females (64 vs 36%). Most patients were Hindus (66%). More than half
of the sample was higher secondary or more educated (56%) and employed (52%). The
age of onset of OCD was 21.88 years for males and 25.89 years for females. The
mean duration of illness for males and females was 6.56 years and 8.72 years
respectively.
The co-morbid psychiatric diagnosis is given in table 2. Forty eight patients had one or
more co-morbid psychiatric diagnosis (96%). The most frequent co-morbidity was the
MDD (90%), with 70% patients satisfying criteria for current MDD. 62% also reported
suicidal ideation. Co-morbid anxiety disorder reported were, panic disorder current
(12%), panic disorder lifetime(14%), agoraphobia(14%) and social phobia (10%). 28%
of the patients also met criteria for psychotic disorder. No subject in our study satisfied
criteria for manic episode/ hypomanic episode/ bipolar I disorder/ bipolar II disorder/
bipolar disorder NOS, post traumatic stress disorder, generalized anxiety disorder and
eating disorder. Nine patients (18%) had comorbid nicotine dependence.
Discussion:
In this study the prevalence of psychiatric co-morbidity was high (96%), MDD (90%)
was the most common co-morbidity followed by anxiety disorders (50%). These findings
are similar to the high prevalence of co-morbid mood and anxiety disorders as reported
7
in the ECA and other western studies2-5. Rasmussen reported over the course of their
lifetime, up to 80% OCD patients may experience depressive episodes11. This is at
variance with the finding of the only Indian study by Bhattacharyya et al (2005) where
prevalence of co-morbidity was low, with depression in 17%, dysthymia in 6% and in 7
% any anxiety disorder12. A significant proportion of the subjects in our sample also
reported suicidal ideation (62%). Co-morbid MDD was the risk factor for suicidality, as
all the subjects with suicidal ideation satisfied criteria for MDD current or past. In an
Indian study of OCD patients, 59% reported worst ever life time suicidal ideation, 28%
had current suicidal ideation and 27% had history of suicidal attempt
13.
The relation
between depression and OCD is complex, with some believing depression to be
complication of OCD9, whilst others believe that OCD and depression are two separate
entities which often coexist14. Studies by Perugi et al and Tukel et al have reported
association between MDD in OCD with older age, severity and chronicity of OCS,
number of hospitalizations, greater co-morbidity with generalized anxiety disorder,
simple phobias and caffeine abuse, higher number of suicide attempts, and disability15,
16.
Serotonin reuptake inhibitors are an effective treatment for both the conditions ,
however severe MDD in OCD is also associated with poor response to behavioral
therapy17.
28% of our OCD subjects also met criteria for psychotic disorder. Psychosis can
emerge in OCD when resistance to obsessions is abandoned and insight is lost or when
there is subsequent onset of paranoid ideas 18, 19. Psychosis can also be secondary to
disturbed affect i.e. guilty preoccupation may get transformed into a delusional
conviction that one is being subject to persecution18. Also, more than two third (78.5%)
8
of our subjects with psychotic disorder also had co-morbid depressive disorder. Thus,
this strong association between depressive features and psychotic features in OCD is of
interest from phenomenological point of view i.e. whether psychotic features are part of
OCD or are due to coexisting depression. Also, treatment of co-morbid OCD and
psychosis may be difficult because of the risk of atypical antipsychotic drug induced
obsessive compulsive symptoms 20. Typical antipsychotic drugs constitute a safer
option in such patients.
There is dearth of Indian studies on OCD co-morbid with mania. In a study investigating
psychiatric co-morbidity in children and adolescent with OCD only 1 of 54 subjects had
bipolar disorder21. Similarly for eating disorders; an Indian study had reported eating
disorder in 1 patient of 231 patients with OCD 22. None of our subject reported
symptoms of co-morbid bipolar disorder or eating disorder. The low prevalence of these
disorders with OCD as evident in this and other Indian studies may be related to socio
cultural differences, as prevalence of both bipolar disorder and eating disorders even
among general population is high in industrialized, affluent countries linking the
disorders to high socio economic status 23, 24, 25.
Also, no subjects in our study met criteria for alcohol abuse/dependence or non alcohol
substance abuse/ dependence other than nicotine dependence (18%). Though, there is
no Indian study of alcohol or substance use in OCD, the prevalence is extremely low
compared to 21% prevalence of alcohol use disorders amongst general Indian
population26. This unusual finding could be partly explained by high levels of harm
avoidance, low novelty seeking and dependent personality traits like exaggerated
anxiety, concern, and fear of uncertainty seen in OCD patients 27, 28. Our subjects also
9
reported high level of fear, anxiety about the effect of alcohol & other substances on
their general health and OCD particularly thus avoiding it. Also many avoided it for the
religious and social reasons suggestive of rigid attitudes. The same could be true for
none of our patients satisfying criteria of antisocial personality disorder characterized by
low harm avoidance, high novelty seeking.
Conclusion:
This study highlights the high prevalence of one or more co-morbid psychiatric disorder
in OCD. Early recognition and adequate treatment of these co-morbid disorders is
crucial. Further exploration with a larger sample size is needed to assess the
prevalence and impact of less frequent disorders like bipolar disorder and eating
disorders on OCD patients.
References
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outpatients seek treatment. Psychiatr Serv 2000; 51(10): 1299– 1304.
2. Karno M, Golding JM, Sorenson SB, et al. The epidemiology of obsessivecompulsive disorder in five US communities. Archives of General Psychiatry 1988; 45:
1094–99.
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3. Overbeek T, Schruers K, Vermetten E, et al. Comorbidity of obsessive-compulsive
disorder and depression: prevalence, symptom severity, and treatment effect. J. Clin.
Psychiatry 2002; 63: 1106–1112
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5. Torres AR, Prince MJ, Bebbington PE, et al. Obsessive-Compulsive Disorder:
Prevalence, Comorbidity, Impact, and Help-Seeking in the British National Psychiatric
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6. Perugi G, Akiskal HS, Pfanner C, et al. The clinical impact of bipolar and unipolar
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23
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features:---A Phenomenological study. Hong Kong Journal of Psychiatry 1999; 9(1): 2125.
11
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2006; 256: 240–245
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12
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24. Okasha A, Kamel M, Sadek A, et al. Psychiatric morbidity among university
students in Egypt. British Journal of Psychiatry 1977; 131: 149-154.
25. Verdoux H, Bourgeois M. Social class in unipolar and bipolar probands and
relatives. J Affect Disord. 1995; 33: 181-7.
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13
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Table 1: Sample characteristics
Age
Mean
30.62
Percentage
Sex
Female
36.0
Male
64.0
Marital status
Married
50.0
Single/separated
50.0
Religion
Hindu
66.0
Muslim
22.0
Buddhist
10.0
Sikh
2.0
Educational status
Illiterate
4.0
Primary
6.0
Secondary
34.0
Higher secondary or more
56.0
Occupation
15
Employed
52.0
Housewife
28.0
Student / unemployed
20.0
Table 2: Comorbid disorders
16
Number (%)
Major depressive episode
Current
35 (70%)
Past
33 (66%)
Recurrent
3 (6%)
Suicidality
Low
19 (38%)
Moderate
7 (14%)
High
5 (10%)
Panic disorder
Current
6 (12%)
Lifetime
7 (14%)
Agoraphobia Current
7 (14%)
Nicotine dependence Current
9 (18%)
Social Phobia Current
5 (10%)
Psychotic disorders
Current
11 (22%)
Lifetime
3 (6%)
The above table includes only the psychiatric disorders for which the subject group
satisfied the diagnostic criteria.
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