OCD and depression are very difficult conditions to cope with individually. They also often occur together. Understanding how they relate and how to think of treatment when you are diagnosed with both may provide you with better mental and physical health.
Belonging to the anxiety disorders group, obsessive-compulsive disorder (OCD) is a chronic and long-lasting disorder with two main components: persistent thoughts, called obsessions, and an urge to perform certain behaviors, called compulsions. In this anxiety disorder, a person has uncontrollable and recurring thoughts that lead them to repeat behaviors.
The anxiety family includes generalized anxiety disorder, panic disorder, post-traumatic stress disorder, separation anxiety disorder, and social anxiety disorder. Obsessive-compulsive disorders come with frequent unreasonable thoughts, worries, or fears that may come in the form of unwanted or disturbing images. Intrusive and obsessive thoughts, feelings, sensations, or ideas cause a person suffering from obsessive-compulsive disorder to feel driven to behave in a ritual or repetitive way, in an attempt to prevent, reduce or manage severe anxiety.
Obsessive Compulsive Disorder symptoms can reduce a person's quality of life, and can result in significant disability. Several factors determine a better outcome for people with obsessive-compulsive disorder, including early diagnosis, family support, and intensive intervention.
Obsessive-compulsive symptoms range from mild to severe and could come and go, as well as become better or worse over time. According to the National Institute of Mental Health obsessive-compulsive disorder can be caused by differences in the frontal cortex and subcortical regions of the brain, childhood trauma, streptococcal infection, or genetics.
While many suggest that familial and background characteristics play a role in the risk of developing OCD, other researchers have found that obsessive-compulsive disorder is linked to low levels of serotonin. Serotonin is a neurotransmitter that performs various functions in the body, which is why a serotonin deficiency can lead to anxiety-provoking OCD symptoms.
There is usually a theme to the threat-inducing cognitive mode in obsessive-compulsive disorder. It could be needing things to be orderly or perfectly symmetrical, a fear of potential contamination causing objects or dirt, aggressive thoughts about the loss of control and harming oneself and others, difficulty with uncertainty, or unwanted thoughts on sexual or religious subjects.
Obsessive signs appear as having a fear of touching others or touching objects that others may have touched, or stress and anxiety when objects are placed in an unorderly way or are not facing a certain direction. Other signs include:
Compulsive behavior usually includes body-focused repetitive behaviors, such as skin picking hair pulling, or hand washing to the point that the skin becomes raw.
Other behavioral OCD symptoms include:
Depression is a persistent lack of interest in pleasure and persistent sadness, that leads to symptoms that interfere with a person's daily life.
As one of the most common mood disorders, depression affects the way someone thinks, feels, and interacts, and can therefore influence the way they sleep, eat, work, or socially interact. Emotionally, depression comes with feelings of sadness and loneliness, emptiness and hopelessness, while on a cognitive level it gives rise to ruinous beliefs.
Different kinds of depression come with different symptoms and different durations. Major depression, or clinical depression, is a mood disorder that can cause a substantial decrease in well-being. In 2008, the World Health Organization ranked major depressive disorder as the third cause of the burden of disease worldwide, and they also projected that it will rank first by 2030.
Various risk factors increase the chances of developing major depressive disorder. Biochemical factors, genetics, a childhood environment and later life events, a temperamental inclination, and additional medical or mental health conditions all contribute.
A depressive episode – during which a person may feel tired, low, or worthless, eat differently, and have negative or suicidal thoughts – lasts for at least two weeks. Depressive episodes are common; an estimated 21 million adults in the United States had at least one major depressive episode in 2020.
Depression symptoms in major depressive disorders include constantly having trouble enjoying activities, isolating, changes in appetite, sleep, and sex drive, as well as feeling hopeless, worthless, and sad, for a few weeks. But it could also last between six and 18 months and could recur.
Common major depression symptoms include:
Those with major depressive disorder are at high risk of developing substance use disorders and comorbid anxiety disorders.
OCD and anxiety disorders stem from a similar core system, but do they have any theoretical and clinical relevance to depression?
As a starting point, both OCD and depression have an impact on a person's mood, cause challenges in everyday life and relationships, and involve negative thinking patterns. Both conditions may be managed with therapy and medication.
OCD and depression are distinct in their classification; OCD is considered an anxiety disorder, while depression is considered a mood disorder. Yet the two commonly co-occur, and OCD is considered to be one of the co-morbid anxiety disorders to depression or vice versa.
While in older versions of the Diagnostic and Statistical Manual OCD was classified as an anxiety disorder and depression a mood disorder, the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), has separated OCD by listing it as a mental disorder. That means that OCD and depression both share the fact of mental conditions affecting mood, thinking, and behavior.
Those who suffer from obsessive-compulsive disorder are at risk of developing other mental health conditions. OCD itself is a significant risk factor and may predispose someone to develop depression, as the mental disorder comes with various factors that may cause depression symptoms. Obsessive-compulsive disorder comorbidity with major depressive disorder is common, affecting more than one-third of OCD sufferers.
When an illness occurs comorbidly with another, it can decrease the daily functioning and quality of life of a person. It is also associated with more frequent hospitalizations. Comorbid OCD and depression are related to a poorer response to psychological and pharmacological treatments that are OCD-focused.
Studies have found that those with OCD and comorbid recurrent major depression – or recurrent depression disorder (RDD) – were more likely to have a family history of RDD and more frequently experienced other anxiety disorders too, such as separation anxiety disorder or social phobia.
There is also evidence that OCD sufferers who are depressed have an earlier age of OCD onset, and more severe obsessions and compulsions than non-depressed OCD sufferers. Additionally, those with OCD who are depressed may experience more severe general anxiety symptoms, greater functional disability, and higher unemployment rates than patients without depression.
The severity of comorbid depression affects the chances of suicide. In a study on depression and suicide risk in patients with OCD, 52% of patients experienced suicidal ideation. All patients with severe to very severe depression associated with OCD had suicidal ideations (100%), whereas moderate depression presented with 87.5%, and mild depression only presented with 35% suicidal ideation.
While the correlation between OCD and depression is clear, there is the question of whether one causes the other. Some researchers believe so, as the undoubtedly overwhelming and difficult intrusive thoughts and the need to engage in compulsive behaviors may affect work or school performance, interpersonal relationships, and overall function. Coping with OCD could cause depression symptoms to develop, or depression symptoms could make OCD symptoms worse.
The distinctive and overlapping features of anxiety and depression have been measured with depression anxiety stress scales – a 42-item self-report instrument for measuring depression, anxiety, and tension/stress – where a greater score indicates higher severity of these negative symptoms.
The two disorders share symptoms such as indecisiveness, perfectionism, hopelessness, negative cognitive errors, helplessness, excessive guilt, doubt, and self-blame. Self-report measures of obsessions and compulsions have some correlation with measures of depressive symptoms; a person suffering from OCD may find themselves unable to enjoy life, feeling hopeless or saddened – which are all symptoms of depression.
The reports of OCD difficulties starting before depressive symptoms suggest that depression may occur as a response to the distress and devastation of living with OCD, and OCD sufferers may experience enough stress to trigger a severe depressive episode.
The typical chronology is OCD development first, and depression subsequently taking hold. This common pattern is said to be due to the debilitating nature and great difficulty in the treatment of OCD lending itself to depressive symptoms.
Those suffering from OCD may endure hours per day of scary thoughts, which leads them to engage in compulsive behaviors that take effort, and can have negative consequences for their work and relationships. The nature of compulsive thoughts, difficulties as a result of compulsive actions, and problems caused by an obsessive-compulsive disorder in relationships and life can cause depression to develop.
In a recent study, the link between OCD, anxiety, and depressive symptoms was investigated. It reported that the frequency of obsessions, lack of control over obsessions, as well as feelings of perceived failure all related to depression.
Relationships among subscales of OCD symptoms and overall depression and anxiety severity were also addressed and it was found that behaviors such as obsessing, ordering, doubting, and checking were especially related to specific anxiety dimensions (primarily panic and generalized anxiety), which in turn were linked to depression. It also found that the severity of anxiety mediated the link between OCD and depression.
Self-criticism is strongly related to self-oriented perfectionism and perfectionism as prescribed socially. Associations between the need to fulfill perfectionism and their self-critical appraisal in OCD relate to earlier studies of patients with both depression and OCD holding negative views of themselves. Self-criticism has been related to depression through past research showing that people with depression commonly engage in self-scrutiny because of their perfectionist tendencies.
In a 2007 study, patients with OCD and depression were significantly more likely to interpret their obsessive intrusions in a negative manner than those without depression symptoms. They were significantly more likely to overestimate the importance of these thoughts, had a greater need to control these thoughts, and felt more responsible for having obsessions than those without depression symptoms.
After the authors controlled the severity of OCD symptoms, the misinterpretations of obsessive thoughts still correlated with the severity of depression. Functional impairment, as well as a tendency to misinterpret intrusive thoughts as being significant proved to be unique predictors of depression within the whole sample of those with OCD.
Whether one disorder comes before the other, theoretical and clinical considerations show there is a strong relationship between the course of obsessive-compulsive symptoms and depression symptoms. A 2016 study found that this relationship exists irrespective of a current diagnosis of major depressive disorder (MDD) and the sequence of onset of OCD and MDD.
Another study concluded that the comorbidity between OCD and MDD among youth may be due to the unique mechanisms of emotional vulnerability, anxiety sensitivity, or tolerance for distress in this age group.
Many approaches have identified positive and negative affectivity as playing a role in the comorbidity of mental illness.
While positive affect refers to a pleasurable agreement or a state of full concentration and high energy, negative affect refers to feelings of emotional distress – a wide range of factors reflecting fear, anxiety, anger, sadness, guilt, and shame – or unpleasant emotions. A correlation between OCD and negative affect and depression and negative affect has been seen as a possible reason for the two conditions co-occurring.
Since these negative terms describe aspects of both OCD and depression and both disorders share overlapping symptom factors, such as anxious and depressive cognitions, hopelessness, and self-criticism, researchers investigated whether they would prove to be common predictors of OCD and depression symptoms.
A recent study found that obsessions, particularly repugnant thoughts, were closely associated with negative affect and mind-body changes associated with depression, suggesting these symptoms may influence the co-occurring depression symptoms in OCD.
Literature hypothesizes that the symptoms of both OCD and depression will be consistent with a shared negative affectivity factor, that symptoms of both depression and OCD will be predicted by self-criticism, hostility, and hopelessness, and that anxious and depressive cognitions will be positively related and predict scores on both depression and OCD scales.
But a recent study aiming to determine whether OCD and depression are subsumed by the common factor of negative affectivity found some differences. It found that while OCD positively predicted depression in various studies, depression is a stronger indicator of negative affect, and in general there is a weaker relationship between OCD and negative affectivity. Depressive cognitions and hostility predicted both depression and OCD, while anxious cognitions predicted symptoms of OCD and were less predictive of depression.
There are overlapping risk factors for both OCD and depression, these being a combination of genetics and environment.
Neural structures do seem to play a part in the development of comorbid anxiety, OCD, and depression. A measure of cognitive flexibility shows that dysfunctional frontal-striatal circuits in the brain have been implicated in both disorders.
The amygdala's role in processing emotions has been linked to the development of the disorders, especially when combined with classical conditioning; an inability to cope with stress plays a big role in developing depression, and an overactive amygdala is a key element involved in this process.
Hyperactivation of the amygdala – misregulated by the prefrontal cortex– is present across OCD symptom dimensions, and in addition, could create a cognitive bias toward the negative interpretation of self and the world.
Both OCD and depression are associated with similar types of biochemical changes, which led some researchers to believe that the same genetic traits may be risk factors for both these disorders and that they share family background characteristics.
While both these mental health conditions may be long-lasting, they are luckily both treatable. On their own, obsessive-compulsive disorder and depression require specific treatment delivered long-term. When the two occur together, there are therapeutic implications and a person may require a dual diagnosis.
Although common, a dual diagnosis may be complicated, as while OCD may be a root cause of a person's depression, being in a depressive episode may affect a person's ability to adhere to OCD treatment. Feelings of hopelessness may cause a person to be less interested in taking their medicine, which can be very problematic for anyone undergoing OCD treatment.
Exposure and response prevention therapy (ERP) is considered the best treatment for OCD. As behavioral therapy under the guidance of a therapist, ERP gradually exposes a person to situations that are designed to provoke their obsessions, in a safe environment.
The exposure part of ERP practices confronting thoughts, objects, images, or situations that provoke anxiety or obsessions, while the response prevention element addresses choosing to not engage in compulsive behaviors once these obsessions have been provoked.
But having severe depression interferes with the results of the most effective treatment for obsessive-compulsive disorder. Since a person must be motivated and willing to follow through on homework assignments in the practice of ERP consistently, depression makes it difficult. Decreased motivation, energy, and interest get in the way of consistent practice.
Treatment that focuses on cognitive approaches to target rumination, behavioral activation to boost functionality, and medication management for depression after ERP are important interventions for OCD patients.
Those suffering from OCD comorbid major depression may experience both depressive and anxious symptoms and could benefit from cognitive therapy. Addressing feelings of hopelessness or other negative beliefs that come with OCD and depression helps to challenge the way of thinking or believing in depressed patients, as well as in OCD patients, and also helps them to better engage in OCD treatment.
OCD and depression treatment may also use pharmacotherapy. As depression often limits the continuation of OCD treatment, a person may be prescribed selective serotonin reuptake inhibitors in order to manage depression symptoms.
At the same time, some of the selective serotonin reuptake inhibitors commonly used to treat depression are also known to be effective in managing OCD symptoms. These include Prozac, Luvox, or Zoloft, and when used to treat obsessive-compulsive disorder they are typically used at higher doses and for longer periods than in depression.
Even though 70% of patients can experience symptomatic relief with pharmacotherapy, remission is unfortunately uncommon, and many patients who show response to these medications continue to have severe enough symptoms to still qualify for a diagnosis of obsessive-compulsive disorder.
TMS uses electromagnetic pulses to stimulate nerve cells in the brain. Produced by an electrical current that flows through a coil, magnetic fields pass through the skull and produce a field of electricity underneath it. The brief, repetitive magnetic pulses stimulate and excite underactive brain cells, causing them to release more neurotransmitters, resulting in altered connectivity and communication between neurons.
The ability of TMS to 'reset' pathways and communication allows it to treat major depression and other mental illnesses including obsessive-compulsive disorder. In major depression, it is especially effective in treating people who are treatment resistant – meaning that they have not responded to antidepressants or other traditional treatments for depression.
While more than half of patients undergoing TMS therapy experience fewer depression symptoms and others experience none at all, TMS also has clinical benefits since it does not involve the use of substances or drugs. For those who have tried first-line treatment, such as ERP and/or medication, and are still struggling with OCD and depression, TMS can be very beneficial.
In a study where patients with OCD and depression received 36 rTMS sessions, a therapeutic response was seen in both OCD and depression symptoms, while five out of seven patients showed a full OCD and depression response.
High-frequency deep TMS (dTMS) over specific areas of the brain – the medial prefrontal cortex and anterior cingulate cortex – has also been shown to improve OCD symptoms in a randomized control trial. A reduction in YBOCS score – the Yale-Brown Obsessive Compulsive Scale – was greater among those who received dTMS treatment versus sham treatment, and a month follow-up showed response rates of 45.2% in the dTMS group versus 17.8% in the sham group.
If you or a loved one is seeking treatment for OCD and depression, GIA Miami can help. We recognize how obsessive-compulsive disorder and depressive disorder can place a heavy strain on your life. OCD is a unique condition, and we know that symptoms can manifest in many ways. GIA Miami also understands that depression is different in every person, which is why the combination of our state-of-the-art diagnostic technologies and extensive knowledge enable us to design an individualized treatment plan for you.
We believe it is important to access help and support without disrupting your daily life or giving up responsibilities, which is why our treatment is built around an outpatient model and can fit into your life with flexibility and fluidity. By fulfilling your responsibilities and continuing the healthy elements of your life, a strong and sustained recovery is encouraged. It also allows you to test the techniques you learn in therapy in a real-life setting.
Half of those with OCD do not respond to traditional OCD treatment, while the challenging adverse effects of pharmacological treatment make reducing symptoms hard.
But with GIA Miami, those who are treatment resistant now have alternative options for treatment. We offer transcranial magnetic stimulation (TMS) for OCD and other mental health disorders. To improve its effectiveness, we provide other treatment options such as ERP, cognitive behavioral therapy, or medication alongside it. Additional GIA Miami therapies that may help you with OCD and depression include group therapy, family therapy, psychiatric services, and functional medicine.
