Prevalence of Suicidality in Patients of Obsessive–Compulsive Disorder with Depression and without Depression: A Cross-sectional Study

INTRODUCTION

Involving irresistible thoughts, acts, or both, obsessive–compulsive disorder (OCD) is a neuropsychiatric condition that can be brought on by psychotropic drugs or chemical, structural, or functional abnormalities in the brain.¹ The severe emotional distress or social instability that OCD produces is well-known.² Obsessive–compulsive disorder has become relatively common in the past few decades and is marked with the typical obsessions that are persistent, unwanted, and compulsive thoughts and behaviors that a person feels compelled to carry out. The demand for symmetry or precision, unwanted violent thoughts, other taboo thoughts regarding sex or religion, and fears of disease and contamination are among the most prevalent themes. Obsessional anxiety is usually mitigated by compulsions, such as obsessive cleaning, arranging, checking, counting, rehearsing, or seeking reassurance. But periodically, the compulsions alone can grow to be so time-consuming or demanding that they are a cause for concern. Avoiding things that induce these obsessions and compulsions is a common trait of OCD.³

Alike most of the neuropsychiatric illnesses, the prevalence of OCD is often characterized by inter-related and interdependent disorders like depression. One of the leading causes of ill health and disability worldwide is depression.

Depression is often characterized by despair, lack of interest, and concentration in work and pleasures in life, marked guilt or feeling unworthy, and marked fatiguability and lethargy⁴; affects several aspects of life, including physical health, participation in social activities, satisfaction with life, and occupation. Adults with depression are significantly less physically fit and socially active than their nondepressed counterparts. They are more likely to be absent from work and often have deficiencies in their work, compared to adults who are not depressed.⁵

In contrast to other diseases or disorders, depression lacks an evident fundamental root cause. In general, a variety of factors, such as modest-to-severe hardships and vulnerability, can increase the likelihood or cause a propensity for depression that may be brought on by biological, genetic, or psychosocial reasons.⁶

Suicide is a serious public health issue that affects all communities. It can take many different forms, from simply having thoughts of death or wanting to end one’s life due to helplessness to thorough planning, attempting, and succeeding in one’s attempt.⁷ Significant risk factors for self-harm or suicide incorporate psychiatric diseases. Studies on suicide tend to emphasize on mood disorders, psychotic illnesses, addiction to substances, and issues with personalities.⁸ According to previous study data and analysis, 3–4% of OCD patients had attempted suicide in the past,⁹ and less than 1% had in fact succeeded.¹⁰ However, recent research has revealed that OCD patients are more likely than healthy people to attempt and die by suicide.¹¹

Until just recently, there was a dearth of research regarding the suicide risk factors in OCD patients, making this topic largely overlooked.⁸ Comorbid disorders of mood have been found in studies to act as an intermediary variable in these patients terminating their life.¹²

MATERIALS AND METHODS

RESULTS

As Table 1 illustrates, majority of the patients were aged through 21–40 years (71.1%). Mean age was 33.43 ± 9.40 years and ranging between 18 and 56. Women made up the majority of the patients. About 55.6% were married (56.7%). None of the patients were widows/widower. Education qualifications of majority of the patients were up to intermediate (72.2%). The monthly family income of majority of the patients was <Rs. 30,831 (68.8%). Businessmen/self-employed/homemakers made up the largest proportion of the cases (46.7%). Majority of the patients were from nuclear family (57.8%), urban area (66.67%), and were Muslims (65.6%).

Mean age at the onset of OCD was 30.08 ± 7.98 years and ranged between 16 and 51 years. Age at onset in majority of the patients was 21–40 years (78.9%), while in only 1 case was ≥51 years (1.1%). Mean age of duration of OCD was 3.37 ± 3.28 years and ranging between 2 months and 18 years. Duration of disease for majority of the patients was 1–2 years (54.4%), and in the majority of the patients, no family history of OCD could be traced (62.2%), while the remaining 37.8% had positive family history of OCD, which is demonstrated in Tables 2 and 3.

Majority of the patients had mild-to-moderate OCD (50.0%). Extreme OCD was found in 26.7% and severe OCD was in 23.3% of the patients as seen in Table 4. Using PHQ-9 scores, depression was screened in every patient. Individuals who scored less than 10 as per PHQ-9 were kept as the depression-absent subgroup, while those with PHQ-9 score of more than 10 were taken as the depression-present subgroup. Depression was seen in 65.6% of the patients using PHQ scale as seen in Table 5. Using the HAMD scale for severity of depression, majority of the patients had moderate-to-severe depression (51.1%), while very severe depression was observed in 14.4%. Patients with mild or normal HAMD were considered to not have depression (34.4%) shown in Table 6.

On CSSR evaluation, most of the patients did not have suicidal tendency (47.8%), while ideation was found in 24.4% and behavior/attempt was reported in 27.8%. Based on the CSSR findings, the suicidality was absent in 47.8% of the patients, while it was present (ideation to attempt) in 52.2%, demonstrated in Table 7.

Table 8 shows majority of the patients without depression had mild-to-moderate OCD (87.1%), while on the other hand, majority of the patients with depression had severe-to-extreme OCD (69.5%). On comparing statistically, a significant association was found for increasing the severity of OCD with depression status. As seen in Table 9, those with very severe OCD had very severe depression (45.8%), followed by severe depression (37.5%), moderate depression (12.5%), and mild depression (4.2%). On the other hand, majority of severe OCD patients had moderate depression (81.0%), while majority of the moderate OCD patients had moderate-to-severe depression (78.6%). Majority of the mild OCD patients had no depression (82.4%). On comparing statistically, a significant association was found for severity of OCD with severity of depression. Table 10 shows that 42 out of a total of 59 patients (71.19%) with depression had suicidal behavior and ideation, while the remaining were normal. On the other hand, majority of the patients without depression had no suicidality (83.9%), while a small proportion of them had suicidal behavior (16.1%).

Table 11 demonstrates the majority of those with very severe OCD had suicidal behavior (83.3%), while a majority of the patients with severe OCD had ideation (61.9%) and majority of moderate OCD (78.6%) and mild OCD (82.4%), no suicidality signs at all. On comparing, a statistically significant relation was noted between suicidality and severity of OCD, with the increase in severity of OCD, suicidal behavior increases.

As seen in Table 12, in majority of the patients with suicidal behavior, severe depression was found (52.0%), majority of patients with ideation had moderate depression (54.5%), while most of the normal (without suicidality) patients too had moderate depression (44.2%), however, on comparing statistically, a significant association was found for suicidality with severity of depression with suicidal attempts seen in severe–very severe depression.

While Table 13 shows that on comparing statistically, no significant association was found for suicidality with age, gender, marital status, family type, income, occupation, domicile, and religion. Majority of the patients, irrespective of suicidality status, were aged from 21 to 40 years. Majority of patients with each suicidal status were female and were married. Most of them belonged to nuclear family and had monthly family income of <Rs. 30,831. Majority of the patients were self-employed/homemaker/businessmen. Majority were from urban region and practiced Muslim religion.

Similarly, as seen in Table 14, on comparing statistically, no significant association was found for severity of OCD with age, gender, marital status, family type, income, occupation, domicile, and religion. Majority of the patients, irrespective of OCD status, were aged from 21 to 40 years. Majority of patients with each suicidal status were female and were married. Most of them belonged to nuclear family and had monthly family income of < Rs. 30,831. Majority of the patients were Muslim by religion, were self-employed/homemaker/businessmen, and residing in urban locality.

DISCUSSION

Suicidality, or the propensity to engage in suicidal ideation, attempts, or completed suicides, is a complex and multifaceted phenomenon that is of great concern in individuals with OCD as it is a debilitating psychiatric condition.

While OCD is frequently comorbid with depression, the impact of depression on suicidality in individuals with OCD remains a subject of debate. Some studies suggest that depression increases the risk of suicidality in individuals with OCD, while others argue that OCD itself, rather than depression, is a more significant predictor of suicidal behavior in this population.

Furthermore, individuals with OCD may experience substantial deterioration of social and professional functioning, as well as a reduction in quality of life, which may further contribute to feelings of despair and hopelessness. These elements could raise the possibility of suicide thoughts and actions in OCD patients, particularly in those who do not respond to treatment or experience significant side effects from medications.

Comparing the prevalence of suicidality among OCD patients was the goal of the current study. We found that the age of patients ranged between 18 and 56 years with mean age 33.43 ± 9.40 years. Majority of patients were aged between 21 and 40 years (71.1%), were females (55.6%), and Muslims (65.6%), hence the gender ratio was 0.8. Majority of the patients were married (56.7%), were of urban domicile (66.7%), and were undergraduates (72.2%), while the highest educational qualification was postgraduate (4.4%). Further in the majority, monthly family income was < Rs. 30,831 (68.8%). Maximum of the patients had no family history of OCD (62.2%). In this present study, the duration of OCD ranged from 2 months to 18 years. Mean duration of OCD was 3.73 ± 3.28 years. Maximum of the patients had total duration of illness of <2 years (57.7%).

In our study, OCD severity using the Y-BOCS scale was found to be moderate-to-severe in majority of the patients (54.4%). The prevalence of depression in OCD patients was 65.6%, while severity of depression was mostly moderate (37.8%), followed by very severe (14.4%) and severe (13.3%). Chaudhary et al.¹³ reported “mild depression was found in 40%, followed by 16% suffering from moderate depression, while 10% had severe and 14% were seen to have very severe depression; additionally it was seen 52% of the OCD patients had suicidal ideation, while 16% had behavior/attempt in past”.¹³

In our present study, we found using the Columbia Suicide Severity Rating scale (CSSR), the incidence of suicidality was seen in 52.2% of patients.

The incidence of depression in individuals with OCD is high, with studies suggesting that up to 50% of individuals with OCD also experience comorbid depression. In people with OCD, depression is linked to higher degrees of functional impairment, a worse prognosis, and a higher likelihood of suicidal thoughts and actions. According to the results of our present research, OCD patients can frequently develop depression, a sense of hopelessness, and suicidal ideation. Findings of the present study were similar to the study by Bowen et al.¹⁴ who reported that “independent of manifestations of depression and mood lability, personality traits and obsessive–compulsive symptoms are intimately connected to outcomes paired with suicide”.¹⁴

The risk of being diagnosed with depression, anxiety, and other comorbidities increases with the severity of OCD symptoms. Additionally, the chronic and refractory nature of OCD symptoms can contribute to increased levels of stress and impairment in daily functioning, leading to further negative emotional states and a greater risk of developing depression.

In this present study, we found that the incidence of suicidal behavior was present in much higher proportions of very severe depression (52.0%), while a majority of the patients with no suicidality were normal or mildly depressed (55.8%). The majority of the patients with ideation were moderately depressed (54.5%).

CONCLUSION

The present study adds to one of the most important gray areas in the literature connecting suicidality, depression, and OCD. Even though depression and OCD are considered different disorders, there is controversy regarding their association due to the high occurrence of comorbidity and the significant correlations between their scores. Suicidality in OCD is a complex and multifaceted circumstance that may be influenced by several factors. The existence of concomitant depression, the severity and length of OCD symptoms, and impaired social and vocational functioning all add to the complexity of the patient’s condition.

The present study is suggestive that effective treatment options should be implemented promptly to reduce the risk of comorbidities and suicidal behavior in individuals with OCD. Further, the presence of hopelessness, the severity of OCD symptoms, and the incidence of depression in individuals with OCD are important factors to consider in both academic and clinical settings. Early identification and intervention for comorbid depression in individuals with OCD are essential in reducing the risk of negative outcomes and improving overall quality of life. Treatment approaches that address both OCD symptoms and comorbid depression should be implemented to reduce the risk of negative outcomes such as hopelessness, impairment, and suicide risk.

LIMITATIONS OF THE STUDY

The present study’s small sample size of only 90 OCD patients was a limitation. Further, the study was conducted after two consecutive waves of COVID-19, which not only resulted in mortalities but also resulted in lockdown and “dull”, “no-work” regimes that might have affected the severity of depression and OCD, while contributing to the increased hopelessness in the patients included in the study.

Self-report measures were used for data making them susceptible to bias. Additional research, such as longitudinal or follow-up studies, may shed light on whether suicidality or hopelessness are the results of OCD severity or comorbid depression as a reinforcing factor or both.

ETHICAL CONSIDERATIONS

The Ethical Review Board of the institute granted approval. Patients were made aware that participation was optional, that findings would only be disclosed as a whole, and that declining to participate would not have any negative effects. Only patients with signed consent papers were given anonymous instruments. The confidentiality of study responses and data management was promised to the patients.

ORCID

Kushagra Varma https://orcid.org/0000-0001-7839-1644

Jai Singh https://orcid.org/0000-0002-0045-2977

Abdul Qadir Jilani https://orcid.org/0000-0002-6222-5788

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