Depression is one of the most common mental health conditions, affecting nearly 10 percent of the population. The disorder is even more common among individuals with other mental health conditions, including obsessive-compulsive disorder (OCD). For example, the International OCD Foundation (IOCD) estimates that 25 to 50 percent of individuals with OCD also have depression.
Such a dramatic rise in the prevalence of depression among individuals with OCD raises several questions. Does OCD cause depression? If so, how or why could this happen? What is the prognosis for people who have both conditions? We spoke with Dr. Mia Nuñez, the Clinical Director for the West Region here at NOCD, to answer these questions and more.
What is OCD?
OCD is a mental health condition characterized by two primary symptoms: obsessions and compulsions. Obsessions involve involuntary and distressing thoughts, images, and urges that are misaligned with one’s genuine values, intentions, and beliefs.
In response to obsessions, people with OCD engage in compulsions, which are physical or mental actions performed to alleviate obsession-induced stress or prevent bad outcomes. For example, in response to the obsessive thought “What if I am sexually attracted to children?” someone with OCD may repeatedly examine memories or prior experiences with children in order to feel certain that they have never been attracted to children.
What is depression?
Depression or depressive disorders are characterized by prolonged feelings of low mood, emptiness, or sadness. They are also accompanied by other symptoms, such as:
- Persistent fatigue
- Low self-esteem
- Loss of interest in activities
- Diminished ability to think or concentrate
- Feelings of hopelessness
- Recurrent thoughts of death or suicide
There are several different forms that depressive disorders can take. The most common form of depression is called major depressive disorder, which involves a discrete episode of depression that lasts at least two weeks. Very long-lasting episodes, like those that persist over a year with milder symptoms, receive a different diagnosis called a persistent depressive disorder or dysthymia. Other forms of depression differ in timing, duration, and causes.
Can OCD cause depression?
We know that OCD and depression are correlated, but can OCD cause depression or make it more likely for someone to develop it? For this to be true, we’d need to know not only that OCD and depression occur together but that OCD happens first. As Dr. Nuñez shares, this is what we often see in patients: “In the majority of cases, we see that OCD comes before depression, rather than depression coming before OCD, when they are co-occurring.”
But how does OCD result in depression? Dr. Nuñez describes several possibilities, each highlighting different effects of OCD. For example, she notes that OCD often limits one’s ability to engage with the outside world and participate in activities they enjoy. Understandably, this can result in feelings of depression. “When you’re not able to engage in things that provide sources of pleasure and mastery and are in line with your values, then people tend to feel depressed,” she says.
Studies have shown that prolonged stress can result in a greater vulnerability to depression. Since OCD symptoms frequently involve high degrees of stress, its correlation with depression seems natural. Obsessions themselves directly cause stress, and compulsions only provide temporary relief, leaving individuals in a vicious cycle of upsetting intrusive thoughts followed by compulsions that only reinforce their fears over time. Moreover, obsession and compulsions can interfere with one’s ability to function, leading to various stressful outcomes, from falling behind at work to straining one’s relationships.
Aside from feelings of stress, OCD can give rise to several other thoughts and emotions that are closely linked with depression. For example, Dr. Nuñez notes that “OCD can lead to feelings of hopelessness, which is one of the hallmark symptoms of depression.” Similarly, depending on the types of obsessions one has, OCD can result in intense feelings of shame and guilt, which also characterize depression. Lastly, OCD can erode one’s self-esteem or sense of self-efficacy. From the inability to control one’s obsessions and compulsions to the functional impairments mentioned above, OCD can chip away at one’s feelings of self-worth and ability to achieve their goals.
Can depression make OCD worse?
Depression can undoubtedly make OCD worse. For example, studies have found that individuals who have both OCD and depression tend to have more severe obsessions and compulsions and that the effect is similar across various themes of OCD. Researchers have also found depression results in greater functional impairments, less insight or awareness into one’s condition, and worse treatment outcomes in people with OCD.
Collectively, this highlights the importance of seeking effective treatments for people with both OCD and depression.
Can OCD and depression be treated at the same time?
OCD and depression can effectively be treated at the same time. However, as Dr. Nuñez notes, depression can make it more difficult for patients with both conditions to engage in OCD treatment.
The gold standard for OCD is exposure and response prevention (ERP) therapy. In this treatment, patients confront objects, situations, or scenarios that trigger obsessions, without resorting to compulsions that reinforce their fears. Over time, this helps them learn to sit with discomfort, anxiety, and uncertainty, while reducing the frequency and intensity of their obsessions and compulsive urges.
Though highly effective, success can be more challenging to achieve in patients who are also struggling with depression. One of the main reasons for this is that people with depression often experience a significant drop in motivation. “People who are depressed may experience difficulty doing everyday tasks, or even just getting out of bed,” shares Dr. Nuñez. “A depressed person will likely have a harder time showing up for a session and doing the homework they’re assigned, and that would be for any kind of treatment.” For patients who are already having trouble showing up, ERP can pose an extra challenge as it asks patients to confront anxiety-inducing situations, which requires additional, intentional effort. Low self-esteem and feelings of hopelessness can make matters worse, as patients may believe either that they are not capable of completing ERP or that it’s unlikely to be effective if they do.
Fortunately, there are steps clinicians can take to help patients with OCD and depression get the most out of ERP. Dr. Nuñez recommends that mental health professionals supplement ERP with therapy that targets depression. Specifically, she suggests utilizing a form of cognitive behavioral therapy (CBT) called behavioral activation. This intervention “helps people reintroduce activities into their day-to-day lives that are a source of pleasure, that build mastery, are in line with their values, and also allow them to tend to themselves and their daily needs.” Importantly, this can be done gradually, just like ERP, where individuals start with the activities that require little additional effort and slowly build up from there. As this technique relieves symptoms of depression, ERP can then be utilized more effectively.
It’s worth noting that while this variety of CBT is useful in patients with OCD, others may be counter-productive. For example, CBT often involves cognitive restructuring, where individuals are taught to notice and challenge their negative thinking patterns. For individuals with OCD, who usually already recognize that their thinking is irrational, this strategy may not be helpful, or could even be counterproductive for some. “When you have somebody who’s also struggling with OCD and has the potential to get caught up with obsessions and rumination, this approach might not be as effective,” says Dr. Nuñez. “So, I always suggest leading with the behavioral piece.”
A final option is to supplement ERP and behavioral activation with antidepressant medication, such as a selective serotonin reuptake inhibitor (SSRI). These medications have been shown to improve both the symptoms of depression and OCD and may prove especially useful in individuals dealing with both conditions.
