Screening for depression in primary care with Patient Health Questionnaire-9 (PHQ-9): A systematic review

BACKGROUND

Depression is a leading cause of disability. International guidelines recommend screening for depression and the Patient Health Questionnaire 9 (PHQ-9) has been identified as the most reliable screening tool. We reviewed the evidence for using it within the primary care setting.

METHODS

We retrieved studies from MEDLINE, Embase, PsycINFO, CINAHL and the Cochrane Library that carried out primary care-based depression screening using PHQ-9 in populations older than 12, from 1995 to 2018.

RESULTS

Forty-two studies were included in the systematic review. Most of the studies were cross-sectional (N=40, 95%), conducted in high-income countries (N=27, 71%) and recruited adult populations (N=38, 90%). The accuracy of the PHQ-9 was evaluated in 31 (74%) studies with a two-stage screening system, with structured interview most often carried out by primary care and mental health professionals. Most of the studies employed a cut-off score of 10 (N=24, 57%, total range 5 - 15). The overall sensitivity of PHQ-9 ranged from 0.37 to 0.98, specificity from 0.42 to 0.99, positive predictive value from 0.09 to 0.92, and negative predictive value from 0.8 to 1.

LIMITATIONS

Lack of longitudinal studies, small sample size, and the heterogeneity of primary-care settings limited the generalizability of our results.

CONCLUSIONS

PHQ-9 has been widely validated and is recommended in a two-stage screening process. Longitudinal studies are necessary to provide evidence of long-term screening effectiveness.

Comorbidity, age of onset and suicidality in obsessive-compulsive disorder (OCD): An international collaboration

OBJECTIVES

To collate data from multiple obsessive-compulsive disorder (OCD) treatment centers across seven countries and five continents, and to report findings in relation to OCD comorbidity, age of onset of OCD and comorbid disorders, and suicidality, in a large clinical and ethnically diverse sample, with the aim of investigating cultural variation and the utility of the psychiatric diagnostic classification of obsessive-compulsive and related disorders.

METHODS

Researchers in the field of OCD were invited to contribute summary statistics on current and lifetime psychiatric comorbidity, age of onset of OCD and comorbid disorders and suicidality in their patients with OCD.

RESULTS

Data from 3711 adult patients with primary OCD came from Brazil (n=955), India (n=802), Italy (n=750), South Africa (n=565), Japan (n=322), Australia (n=219), and Spain (n=98). The most common current comorbid disorders were major depressive disorder (28.4%; n=1055), obsessive-compulsive personality disorder (24.5%, n=478), generalized anxiety disorder (19.3%, n=716), specific phobia (19.2%, n=714) and social phobia (18.5%, n=686). Major depression was also the most commonly co-occurring lifetime diagnosis, with a rate of 50.5% (n=1874). OCD generally had an age of onset in late adolescence (mean=17.9years, SD=1.9). Social phobia, specific phobia and body dysmorphic disorder also had an early age of onset. Co-occurring major depressive disorder, generalized anxiety disorder and psychotic disorders tended to have a later age of onset than OCD. Suicidal ideation within the last month was reported by 6.4% (n=200) of patients with OCD and 9.0% (n=314) reported a lifetime history of suicide attempt.

CONCLUSIONS

In this large cross-continental study, comorbidity in OCD was common. The high rates of comorbid major depression and anxiety disorders emphasize the need for clinicians to assess and monitor for these disorders. Earlier ages of onset of OCD, specific phobia and social phobia may indicate some relatedness between these disorders, but this requires further study. Although there do not appear to be significant cultural variations in rates or patterns of comorbidity and suicidality, further research using similar recruitment strategies and controlling for demographic and clinical variables may help to determine whether any sociocultural factors protect against suicidal ideation or psychiatric comorbidity in patients with OCD.

A Meta-Analysis of the Effectiveness of Different Cortical Targets Used in Repetitive Transcranial Magnetic Stimulation (rTMS) for the Treatment of Obsessive-Compulsive Disorder (OCD)

Randomised and sham-controlled trials (RCTs) of repetitive transcranial magnetic stimulation (rTMS) in the treatment of obsessive-compulsive disorder (OCD) have yielded conflicting results, which may be due to the variability in rTMS parameters used. We performed an updated systematic review and meta-analysis on the effectiveness of rTMS for the treatment of OCD and aimed to determine whether certain rTMS parameters, such as cortical target, may be associated with higher treatment effectiveness. After conducting a systematic literature review for RCTs on rTMS for OCD through to 1 December 2016 using MEDLINE, PubMed, Web of Science, PsycINFO, Google, and Google Scholar, we performed a random-effects meta-analysis with the outcome measure as pre-post changes in Yale-Brown Obsessive Compulsive Scale (Y-BOCS) scores. To determine whether rTMS parameters may have influenced treatment effectiveness, studies were further analysed according to cortical target, stimulation frequency, and length of follow-up. Data were obtained from 18 RCTs on rTMS in the treatment of OCD. Overall, rTMS yielded a modest effect in reducing Y-BOCS scores with Hedge's g of 0.79 (95% CI = 0.43-1.15, p < 0.001). Stimulation of the supplementary motor area yielded the greatest reductions in Y-BOCS scores relative to other cortical targets. Subgroup analyses suggested that low frequency rTMS was more effective than high frequency rTMS. The effectiveness of rTMS was also greater at 12 weeks follow-up than at four weeks follow-up. Our meta-analysis implies that low frequency rTMS applied over the supplementary motor area may offer the greatest effectiveness in the treatment of OCD. The therapeutic effects of rTMS also appear to persist post-treatment and may offer beneficial long-term effectiveness. With our findings, it is suggested that future large-scale studies focus on the supplementary motor area and include follow-up periods of 12 weeks or more.

An experimental investigation of mentalization ability in borderline personality disorder

OBJECTIVE

Deficits in mentalization ability have been theorized to underlie borderline personality disorder (BPD) and have led to mentalization-based treatments. Yet there has been little empirical investigation into whether mentalization deficits do differentiate the BPD population from healthy controls, and the specific nature of these differences.

METHOD

Five pre-existing Theory of Mind (ToM) tasks that assessed simple to complex mentalization capacity in both the affective and cognitive domains were administered to the same groups of age and gender matched patients with BPD and controls. Self-report measures assessed cognitive and affective empathy and childhood trauma and abuse.

RESULTS

The BPD group did not differ significantly from the healthy control group on basic cognitive false-belief picture-sequencing tasks, or on overall accuracy when discriminating mental states from viewing images of eyes, and attributing emotions based on social events. They were, however, significantly less accurate in identifying positive mental states on the Reading the Mind in the Eyes (RME) task and showed significantly more mentalization errors on affective and cognitive understanding of faux pas (faux pas total score p<.01) and on a Joke Appreciation task (p=.01), that required integration of multiple perspectives. They also self-reported less empathic perspective taking (p<.01). Observation of patterns of performance hinted at specific underlying biases (e.g. a default tendency to use superficial black-and-white attributions to others, such as, "he is mean", when explaining behavior). It was also found that as childhood experiences of punishment increased, adulthood mentalization ability decreased on all affective ToM tasks and on the cognitive and affective components of understanding faux pas.

CONCLUSIONS

The BPD group was as capable as controls in undertaking simple mentalization. However, deficits in mentalization capacity became evident when mentalization tasks became more complex and required the integration of multiple perspectives. Increasing childhood experiences of punishment were related to decreasing mentalization ability in adulthood. Findings support the use of treatments to improve mentalization skills in BPD, however, further research is needed to better specify the nature of underlying mentalizing biases in this population.

Functions of compulsions in obsessive-compulsive disorder

OBJECTIVES

The key function of compulsions in obsessive-compulsive disorder (OCD) is to alleviate anxiety or distress caused by the obsessions, but compulsions may also have other functions. The main aim of this study was to systematically ascertain what motivates individuals with OCD to perform compulsions.

METHOD

A total of 108 adults with OCD were assessed with the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and the Functions of Compulsions Interview. The latter instrument elicits the functions of identified compulsions.

RESULTS

The functions of 218 compulsions were identified. The mean number of functions per compulsion in the whole sample was 2.94 and the vast majority of compulsions (85.3%) were performed for more than one reason. The total number of functions of compulsions endorsed for the three main compulsions correlated with Y-BOCS total scores (r = 0.37, p < 0.001). Compulsions were most frequently performed automatically and to decrease distress or anxiety, but there was substantial variation, depending on the type of compulsion. Hoarding was often performed for reasons not related to any other compulsion (involving a perceived need for collected objects), whereas ordering/symmetry/repeating compulsions were frequently performed to achieve a 'just right' feeling. Checking was frequently performed because of the belief that something bad or unpleasant would happen if one failed to check; washing/cleaning compulsions were most frequently performed to decrease distress or anxiety and automatically, and mental compulsions were performed automatically far more often than for other reasons.

CONCLUSIONS

The majority of compulsions have more than one function and they are often performed automatically. The finding of different functions of compulsions in different types of compulsions provides some support to the subtyping of OCD on the basis of obsessions and compulsions. Identifying functions of compulsions allows better understanding of the functional relationship between obsessions and compulsions, which may have implications for cognitive-behavioural therapy of OCD.

Clinical advances in obsessive-compulsive disorder: a position statement by the International College of Obsessive-Compulsive Spectrum Disorders

In this position statement, developed by The International College of Obsessive-Compulsive Spectrum Disorders, a group of international experts responds to recent developments in the evidence-based management of obsessive-compulsive disorder (OCD). The article presents those selected therapeutic advances judged to be of utmost relevance to the treatment of OCD, based on new and emerging evidence from clinical and translational science. Areas covered include refinement in the methods of clinical assessment, the importance of early intervention based on new staging models and the need to provide sustained well-being involving effective relapse prevention. The relative benefits of psychological, pharmacological and somatic treatments are reviewed and novel treatment strategies for difficult to treat OCD, including neurostimulation, as well as new areas for research such as problematic internet use, novel digital interventions, immunological therapies, pharmacogenetics and novel forms of psychotherapy are discussed.

The characteristics of unacceptable/taboo thoughts in obsessive-compulsive disorder

BACKGROUND

In the quest to unravel the heterogeneity of obsessive-compulsive disorder (OCD), an increasing number of factor analytic studies are recognising unacceptable/taboo thoughts as one of the symptom dimensions of OCD.

AIMS

This study aims to examine the characteristics associated with unacceptable/taboo thoughts.

METHODS

Using the Yale-Brown Obsessive-Compulsive Scale Symptom Checklist (YBOCS-SC) with 154 individuals with OCD, obsessive-compulsive symptoms were subjected to principal components analysis. The characteristics associated with the resulting symptom dimensions were then assessed using logistic and linear regression techniques.

RESULTS

Unacceptable/taboo thoughts comprised of sexual, religious and impulsive aggressive obsessions, and mental rituals. Higher scores on an unacceptable/taboo thoughts symptom dimension were predicted by higher Y-BOCS obsession subscores, Y-BOCS time preoccupied by obsessions scores, Y-BOCS distress due to obsessions scores, importance of control of thought ratings, male gender, and having had treatment prior to entering into the study. Unacceptable/taboo thoughts were also predicted by greater levels of hostility, and a past history of non-alcohol substance dependence.

CONCLUSIONS

An unacceptable/taboo thought symptom dimension of OCD is supported by a unique set of associated characteristics that should be considered in the assessment and treatment of individuals with these symptoms.

Disgust propensity in obsessive-compulsive disorder: cross-sectional and prospective relationships

BACKGROUND AND OBJECTIVES

Findings from non-clinical samples suggest that disgust propensity is associated with contamination concerns in obsessive-compulsive disorder (OCD). However, studies of clinical samples have yielded conflicting results. We investigated the relationship between disgust propensity and OCD symptoms in a clinical sample and examined whether changes in disgust propensity are associated with changes in OCD symptoms.

METHODS

One hundred and nine OCD participants completed measures of disgust propensity and OCD symptoms. Sixty of these underwent a six-month follow-up assessment.

RESULTS

At the baseline assessment, disgust propensity was associated with all OCD symptom dimensions except hoarding. Changes in overall disgust propensity between baseline and the six-month follow-up assessment were associated with changes in overall self-reported OCD symptoms but not with changes in contamination-based OCD symptoms or changes in interviewer-assessed OCD symptoms.

LIMITATIONS

There was substantial participant attrition between the baseline and follow-up assessments.

CONCLUSIONS

Our study is the first to investigate prospective relationships between disgust propensity and OCD across a six-month interval. Our findings suggest that if there is an association between changes in disgust propensity and changes in contamination-based OCD symptoms its magnitude is likely to be small.

Symptom subtypes of obsessive-compulsive disorder: are they relevant for treatment?

Several symptom subtypes of obsessive-compulsive disorder (OCD) have been identified on the basis of the predominant obsessions and compulsions. The objectives of the present article were to review the literature on the relationship between OCD symptom subtypes and treatment response and to suggest strategies that might assist with the choice of treatment and improve treatment outcome in patients with various subtypes. An extensive literature search was performed, relevant studies were identified, and their results reported. Overt compulsions were generally associated with a relatively good response to the behaviour therapy technique of exposure and response prevention (ERP) and with poorer response to serotonin re-uptake inhibitors (SRIs). Washing/cleaning and checking compulsions tend to respond well to ERP, whereas the majority of studies show that washing/cleaning compulsions are associated with a poorer response to SRIs. Most studies suggest that patients with the symmetry, ordering and arranging subtype do not fare worse with ERP and SRIs than patients with other symptom subtypes. Some studies suggested that obsessions might respond to SRIs somewhat better than to ERP. In the majority of the studies, hoarding and the subtype characterized by sexual or religious obsessions and absence of overt compulsions ('pure obsessions') have been associated with poor response to ERP and SRIs. It was concluded that treatment strategies cannot be precisely tailored to OCD symptom subtypes. Many other factors influence the outcome of treatment and need to be considered along with the symptom subtypes when making decisions about treatment. While ERP and SRIs remain the mainstay of treatment regardless of the symptom subtype, the addition of cognitive therapy techniques and/or antipsychotic medications may enhance treatment response in the presence of certain features discussed in the article.

The relationships between obsessive-compulsive symptom dimensions and cognitions in obsessive-compulsive disorder

Several studies have linked obsessive-compulsive symptoms to specific obsessive-compulsive cognitions, however methodologies have varied, and no study has determined obsessive-compulsive symptoms using the most widely used clinician rating scale, the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). Considering that almost all studies that used factor analysis to ascertain OCD symptom dimensions were based on the Y-BOCS and that self-report instruments assessing obsessive-compulsive symptoms correlate poorly with the Y-BOCS, there is a need to use the Y-BOCS to examine the relationship between obsessive-compulsive cognitions and obsessive-compulsive symptom dimensions. This study examined the relationship between five Y-BOCS-derived obsessive-compulsive symptom dimensions and the three obsessive-compulsive cognitive domains identified by the obsessive-beliefs questionnaire (OBQ). The symmetry/ordering symptom dimension was associated with increased perfectionism/intolerance of uncertainty, the unacceptable/taboo thoughts symptom dimension was associated with increased importance/control of thoughts and the doubt/checking symptom dimension was associated with increased responsibility/threat estimation. There was no statistical evidence of an association between any OBQ belief sub-scale and the hoarding symptom dimension nor the contamination/cleaning symptom dimension. The findings encourage symptom-based approaches to cognitive-behavioural therapy for some OCD symptoms and call for further research on cognitions associated with contamination/cleaning symptoms and hoarding.

A meta-analysis of the response of pathological hoarding to pharmacotherapy

This meta-analysis aimed to identify all studies that have assessed treatment response for pathological hoarding treated with pharmacological agents. Seven studies were identified with a total of 92 participants. Most participants had a diagnosis of obsessive-compulsive disorder. Studies assessed response to serotonin-reuptake inhibitors (SRIs); venlafaxine; methylphenidate; and augmentation of SRIs with quetiapine, minocycline and naltrexone. More than half (ER=0.58, 95% CI=0.37-0.76) of the participants treated with pharmacotherapy responded. This study encourages us to consider the use of SRIs in patients with hoarding disorder. The study also encourages more studies of pharmacotherapy for pathological hoarding, noting that these studies should use validated outcome measures that specifically assess pathological hoarding and novel agents that target the unique neurobiological correlates of pathological hoarding.

Level of Insight in Patients With Obsessive-Compulsive Disorder: An Exploratory Comparative Study Between Patients With "Good Insight" and "Poor Insight"

Introduction: Insight may be defined as the ability to perceive and evaluate external reality and to separate it from its subjective aspects. It also refers to the ability to self-assess difficulties and personal qualities. Insight may be a predictor of success in the treatment of obsessive-compulsive disorder (OCD), so that individuals with poor insight tend to become refractory to treatment. The objective of this study is to investigate factors associated with poor insight in individuals with OCD. Methods: This cross-sectional exploratory study used the Brown Belief Assessment Scale as a parameter for the creation of the comparison groups: individuals who obtained null scores (zero) composed the group with preserved or good insight (n = 148), and those with scores above the 75% percentile composed the group with poor insight (n = 124); those with intermediate scores were excluded. Sociodemographic characteristics and clinical and psychopathological aspects, intrinsic and extrinsic to the typical symptoms of OCD, were compared in a univariate analysis. A logistic regression was used to determine which factors associated with critical judgment remained significant. Results: Individuals in the poor insight group differed from those with good insight in regard to: more prevalent use of neuroleptics (p = 0.05); higher untreated time interval (p < 0.001); higher total Yale-Brown obsessive-compulsive scale score and the obsessions and compulsions factors (all factors with p < 0.001); higher dimensional Yale-Brown obsessive-compulsive scale total and dimensional scores (p from 0.04 to 0.001); higher prevalence of contamination/cleaning (p = 0.006) and hoarding (p < 0.001) symptoms dimensions; more prevalent sensory phenomena (p = 0.023); higher levels of depression (p = 0.007); and more prevalent comorbidity with bipolar affective disorder (p = 0.05) and post-traumatic stress disorder (PTSD) (p = 0.04). After analyzing the logistic regression, we conclude that the most important factors associated with poor insight are: the presence of any sensory phenomena (OR: 2.24), use of neuroleptics (OR: 1.66), and hoarding symptoms (OR: 1.15). Conclusion: The variability of insight in patients with OCD seems to be an important psychopathological characteristic in the differentiation of possible subtypes of OCD, since the poor insight is associated with sensory phenomena and greater use of neuroleptics, which makes it possible to conjecture the role of dopaminergic neurocircuits in the neurobiology of this disorder. In addition, there is also an association with the symptoms of hoarding content, admittedly one of the symptomatic contents with less response to conventional OCD treatments. Studies based on neurobiological aspects such as neuroimaging and neuropsychology may help to elucidate more consistently the role of insight in patients with OCD and the repercussions concerning available treatments.

Obsessive-compulsive personality disorder co-occurring with obsessive-compulsive disorder: Conceptual and clinical implications

OBJECTIVES

There are ongoing uncertainties in the relationship between obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder (OCPD). This study aimed to test the proposition that OCPD may be a marker of severity of OCD by comparing groups of OCD individuals with and without OCPD on a number of variables.

METHOD

A total of 148 adults with a principal diagnosis of OCD were administered the Mini International Neuropsychiatric Interview, Yale-Brown Obsessive-Compulsive Scale, Sheehan Disability Scale, Vancouver Obsessional Compulsive Inventory and Symptom Checklist 90-Revised. Participants with a DSM-IV diagnosis of OCPD were compared with those without OCPD.

RESULTS

Some 70 (47.3%) participants were diagnosed with OCPD. The groups of participants with and without OCPD did not differ significantly with respect to any of the demographic variables, clinician-rated severity of OCD, levels of disability and mean age of onset of OCD. All self-rated OCD symptom dimensions except for contamination and checking were significantly more prominent in participants with OCPD, as were all self-rated dimensions of psychopathology. Participants with OCPD had significantly more frequent hoarding compulsions and obsessions involving a need to collect and keep objects. Of Axis I disorders, only panic disorder was significantly more frequent in participants with OCPD than in those without OCPD.

CONCLUSIONS

A high frequency of OCPD among individuals with OCD suggests a strong, although not necessarily a unique, relationship between the two conditions. This finding may also be a consequence of the blurring of the boundary between OCD and OCPD by postulating that hoarding and hoarding-like behaviours characterise both disorders. Results of this study do not support the notion that OCD with OCPD is a marker of clinician-rated severity of OCD. However, individuals with OCPD had more prominent OCD symptoms, they were more distressed and exhibited various other psychopathological phenomena more intensely, which is likely to complicate their treatment.

Treatments used for obsessive-compulsive disorder-An international perspective

OBJECTIVE

The objective of this study was to characterise international trends in the use of psychotropic medication, psychological therapies, and novel therapies used to treat obsessive-compulsive disorder (OCD).

METHODS

Researchers in the field of OCD were invited to contribute summary statistics on the characteristics of their samples. Consistency of summary statistics across countries was evaluated.

RESULTS

The study surveyed 19 expert centres from 15 countries (Argentina, Australia, Brazil, China, Germany, Greece, India, Italy, Japan, Mexico, Portugal, South Africa, Spain, the United Kingdom, and the United States) providing a total sample of 7,340 participants. Fluoxetine (n = 972; 13.2%) and fluvoxamine (n = 913; 12.4%) were the most commonly used selective serotonin reuptake inhibitor medications. Risperidone (n = 428; 7.3%) and aripiprazole (n = 415; 7.1%) were the most commonly used antipsychotic agents. Neurostimulation techniques such as transcranial magnetic stimulation, deep brain stimulation, gamma knife surgery, and psychosurgery were used in less than 1% of the sample. There was significant variation in the use and accessibility of exposure and response prevention for OCD.

CONCLUSIONS

The variation between countries in treatments used for OCD needs further evaluation. Exposure and response prevention is not used as frequently as guidelines suggest and appears difficult to access in most countries. Updated treatment guidelines are recommended.

Obsessive-compulsive spectrum disorders: a comorbidity and family history perspective

OBJECTIVE

The concept of obsessive-compulsive spectrum disorders (OCSDs) has become so influential that there are proposals to introduce it into new diagnostic classificatory systems. The aim of this paper was to assess whether rates of comorbidity and family history of OCSDs in patients with obsessive-compulsive disorder (OCD) supported this concept.

METHOD

Comorbidity and family history were assessed in a group of participants with a primary diagnosis of OCD, using structured clinical interviews. Rates of OCSDs and other anxiety disorders (OADs), excluding OCD, were compared.

RESULTS

Of the 77 OCD participants assessed, the most prevalent comorbid conditions were OADs: generalized anxiety disorder (34.6%), specific phobia (26.9%), social phobia (21.8%) and panic disorder (19.2%). The proposed OCSDs were less frequently comorbid: tic disorder (12.8%), trichotillomania (5.1%), hypochondriasis (3.8%) and body dysmorphic disorder (BDD) (3.8%). Similar trends were observed for a family history of these disorders. No participant reported a family history of an OCSD without a family history of an OAD.

CONCLUSIONS

Although the concept of OCSDs has invigorated thinking in this complex diagnostic field, these results support the current association of OCD with OADs rather than with OCSDs.

International prescribing practices in obsessive-compulsive disorder (OCD)

OBJECTIVES

To assess rates of psychotropic medication use in patients with obsessive-compulsive disorder (OCD) in seven different countries on five continents and to compare these with international treatment guidelines.

METHODS

Researchers in the field of OCD were invited to contribute summary statistics on the characteristics of their patients with OCD and on their incidence of psychotropic use. Consistency of summary statistics across countries was evaluated.

RESULTS

The data came from Brazil (n = 955), Italy (n = 750), South Africa (n = 555), Japan (n = 382), Australia (n = 213), India (n = 202) and Spain (n = 82). The majority (77.9%; n = 2445) of the total sample of 3139 participants received a psychotropic medication. Consistent with international guidelines, selective serotonin reuptake inhibitors (SSRIs) were most commonly used (73.5%, n = 1796), but their use ranged from 59% in Australia to 96% in Japan. Clomipramine use varied from 5% in Japan and South Africa to 26% in India and Italy. Atypical antipsychotic use ranged from 12% in South Africa to 50% in Japan.

CONCLUSIONS

Pharmacotherapy for OCD varied significantly across sites. Prospective studies are required to determine the cultural, pharmacoeconomic and pharmacogenomic factors that may play a role in the variation in prescribing practices internationally and whether these variations influence treatment outcomes. Copyright © 2016 John Wiley & Sons, Ltd.

Interpersonal reassurance seeking in obsessive-compulsive disorder and its relationship with checking compulsions

This study aimed to examine interpersonal reassurance seeking (IRS) in obsessive-compulsive disorder (OCD) and the relationship between IRS and checking compulsions. One hundred and forty adults with OCD underwent a comprehensive assessment, which included obtaining information on seeking reassurance from others because of their obsessions. Sixty-seven (47.9%) participants reported IRS. They exhibited more psychopathology than participants without IRS, tended to have a greater overall severity of OCD and were far more likely to have checking compulsions. Participants with IRS also had more severe obsessions, suggesting that IRS plays a role as an additional coping strategy when obsessions are more prominent. The severity of obsessions and the absence of obsessions about a need to collect and keep objects were independent predictors of IRS, whereas the presence of obsessions about unintentional harm and not being married or in a de facto relationship independently predicted checking compulsions. Although a close relationship exists between IRS and checking compulsions, these results suggest important differences, with implications for understanding the factors that contribute to IRS and checking compulsions.

The clinical characteristics of obsessive compulsive disorder associated with high levels of schizotypy

OBJECTIVES

This study aims to examine the characteristics of obsessive compulsive disorder (OCD) associated with high levels of schizotypy.

METHODS

Using the Schizotypal Personality Questionnaire (SPQ) with 177 individuals with OCD, patients with OCD and high levels of schizotypy (OCD-HS) were compared to patients with OCD and low levels of schizotypy (OCD-LS) on a range of clinical characteristics. Self-report and clinician-administered instruments were used. Results were adjusted for the severity of OCD symptoms, age, marital status and comorbidity using logistic regression.

RESULTS

Patients with OCD-HS were younger and less likely to have been married. OCD-HS was associated with higher rates of symmetry/order obsessions, ordering/arranging compulsions, checking compulsions, co-occurring major depression, post-traumatic stress disorder, substance use disorders and greater general psychopathology. Previously reported associations, such as higher total scores on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) were not significant when adjusted for differences in demographic variables and comorbidity.

CONCLUSIONS

Patients with OCD-HS were associated with specific OCD symptoms and comorbid conditions and may warrant a specific treatment approach.

An evaluation of monitoring practices in patients on second generation antipsychotics

OBJECTIVE

Treatment with second generation antipsychotics (SGAs) can increase the risk of patients with schizophrenia developing obesity, hyperlipidaemia and diabetes. Routine monitoring is recommended, but clinical practice suggests monitoring is not conducted at a rate necessary for these comorbidities. The aim was to audit what proportion of patients were having their weight, height, girth, body mass index, lipids and blood sugar levels monitored and recorded.

METHOD

An audit of patients with schizophrenia, discharged from three psychiatric wards, was conducted. Two data sheets were recorded for every patient and inter-rater reliability was calculated. Data were then entered into SPSS and statistical significance calculated.

RESULTS

The sample consisted of 93 patients; SGAs were taken by 31% of admitted and 88% of discharged patients. Of these, 65% had their weight recorded, 61% height, 31% random blood sugar levels, 3% postprandial blood sugar levels, 2% glycosylated haemoglobin, and 7.5% cholesterol and triglycerides. Girth and BMI were not recorded. Abnormalities were detected in 29% of recorded BSL and 2% of recorded cholesterol.

CONCLUSIONS

Patients with schizophrenia on antipsychotics have an alarmingly low rate of monitoring of these common adverse effects and comorbidities. Clinicians need to be aware of this, so that they can improve their practice.

Diagnostic processes in mental health: GPs and psychiatrists reading from the same book but on a different page

OBJECTIVE

To explore the clinical reasoning processes underpinning diagnostic and management decision-making in treating patients presenting with psychological distress in general practice.

METHOD

Practising GPs were invited to attend small-group workshops in which two case histories were presented. Discussion was GP-facilitated and recorded for thematic analysis. GPs provided demographic data, completed personality and attitudinal questionnaires, and answered a series of multiple-choice questions embedded in the cases.

RESULTS

GPs recognize the possibility of psychiatric disorders early in the clinical reasoning process, but are cautious about applying definitive diagnoses. GPs perceive that patients may be resistant to a psychiatric diagnosis and instead emphasize the need to build rapport and explore and exclude physical comorbidities. GPs see patients with a broad spectrum of distress, illness and impairment, in whom the initial presentation of psychological symptoms is often poorly differentiated and somatically focused, requiring elucidation over time. GPs therefore adopt a longitudinal strategy for diagnosis rather than investing heavily in cross-sectional assessment.

CONCLUSION

GPs appear cognizant of possible psychiatric disorders and management strategies, but employ diagnostic strategies and decision-making processes that, in addition to experience and expertise, likely reflect key differences between the primary care and specialist practice settings.

The characterization of beliefs in obsessive-compulsive disorder

Beliefs are associated with most obsessions and compulsions in obsessive-compulsive disorder (OCD). The characteristics of these beliefs can vary considerably, which has led to some of them being regarded as overvalued ideas or delusions and has contributed to confusion regarding the conceptualization and classification of OCD. This article proposes that beliefs arising in the context of OCD be assessed along the following, well-defined characteristics: conviction, fixity, fluctuation, resistance (to beliefs), insight pertaining to an awareness of the inaccuracy of one's belief, and insight referring to the ability to attribute the belief to an illness. This approach to the assessment of OCD-related beliefs may allow a clearer distinction between non-delusional beliefs, overvalued ideas, and delusions. Although the characteristics of non-delusional beliefs may vary, especially on the dimension of awareness of the inaccuracy of belief, these beliefs can generally be distinguished from overvalued ideas and delusions in terms of lower levels of conviction and fixity and greater fluctuation, resistance and ability to attribute the belief to OCD. The development of an assessment tool using these well-defined characteristics will test the proposed model, which may lead to a more objective evaluation of OCD-related beliefs. This is likely to have implications for diagnostic conceptualization and subtyping of OCD.

The nature and correlates of avoidance in obsessive-compulsive disorder

OBJECTIVES

Avoidance in obsessive-compulsive disorder (OCD) has been neglected by research. This study aimed (i) to collect information on the nature and frequency of avoidance in people with OCD and ascertain the types of obsessions related to avoidance; (ii) compare OCD individuals with and without avoidance, and (iii) determine predictors of avoidance in people with OCD.

METHOD

A total of 124 OCD adults underwent a comprehensive assessment. Participants were asked whether they engaged in any avoidance behaviour because of their OCD, and the nature and number of instances of such avoidance were recorded. The instances of avoidance were grouped according to the type of obsession and compulsion that they were related to.

RESULTS

A total of 74 (59.7%) participants reported OCD-related avoidance. Avoidance was most commonly related to contamination obsessions. Almost 80% of all contamination obsessions and more than 50% of all aggressive obsessions were associated with avoidance, and contamination obsessions were significantly more common among the participants with avoidance. In contrast, very few obsessions about a need to collect and keep objects and obsessions about a need for ordering, arranging and doing things right or in an exact way were associated with avoidance; these types of obsessions were also significantly more common among the participants without avoidance. The strongest predictor of avoidance was the presence of contamination obsessions. Participants with avoidance had a significantly more severe OCD than those without avoidance.

CONCLUSIONS

Avoidance is common in OCD, and it is particularly frequently associated with contamination obsessions. There is a weak link between avoidance and hoarding and between avoidance and ordering/arranging/symmetry obsessions and compulsions. These results, along with the finding that OCD with avoidance is a more severe illness, have implications for the future diagnostic criteria, description, subtyping and treatment of OCD and for its relationship with other anxiety disorders.