When Depression Complicates OCD Treatment Jonathan Hoffman Ph.D., ABPP & E. Katia Moritz, Ph.D., ABPP NeuroBehavioral Institute, Weston FL www.nbiweston.com www.academic-options.com

Depression & OCD Co-Morbidity with MDD about 1/3 (Rasmussen et al., 1997) 60% to 80% of OCD patients will develop a major depressive episode in their lifetime (Saxena et al., 2001) Mood Disorders common in specialized OCD treatment centers

Bipolar and OCD Co-Morbidity with Bipolar Disorder about 15% - vast majority Bipolar 2 ( Lensi et al., 1996, Perugi et al., 1997) OCD Bipolar comorbidity associated with less severe OCD than among non Bipolar OCD subjects (Zutshi, Kamath & Reddy, 2007) OCD symptoms tent to persist during Bipolar episodes , (Perugi et al., 200) - Contrary to clinical beliefs?

In OCD treatment: Is Depression: Primary? Secondary? Both? AND DOES IT MATTER? Depressive symptoms occurring in OCD patients were associated with decreased rather than increased basal ganglia and thalamic activity, suggesting a pathophysiologic difference between primary and secondary MDD (Saxena et. Al., 2001)

MDD and OCD – Continued Utilizing medication to differentiate primary and secondary MDD Hoehn-Sarie et al., 2000 found sertraline vs, desipramie improved MDD Sx in patients with both MDD & OCD; Implying: MDD in the context of OCD might have differing biological pathways than primary MDD In most with OCD onset of OCD predates MDD MDD is associated with earlier onset of OCD and more severe symptoms (Hong et. Al., 2004)

Forms of OCD More Prone for Development of Depression: Sexual, Aggressive and Religious/ Moral Obsessions Perfectionism about Self vs Performance Role of Avoidance in Depression for OCD patients Autogenous vs reactive obsessions (Yapa,Moganb, Kyrios, 2012 & Besiroglu et al., 2007) are positively related to depression.

What can research tell us? (Rampacher et al., 2010) The neurophysiological correlates of unipolar depression partially overlap with OCD, but this does not necessarily mean cognitive deficits found in OCD patients with depression are CAUSED by depression, or EPIPHENOMENON of OCD

RATHER… OCD-specific cognitive deficits may have a stronger effect on the clinical presentation than depression- specific effects These include spatial working memory & spatial recognition (Purcell et. al., 1998b) Working memory dysfunction (Nakeo et al., 2008) Broad executive function deficits- scanning, planning, time concept formation, decision-making, nonverbal memory encoding- (Kashyap et al., 2013)

Implications: Re-examining the rationale for treating depression first (meds, CBT), even when depression is severe Vs. Treating OCD first Vs. Treating OCD and depression concurrently

22 year old Female College student Case Example Diagnosed at 6 with severe and debilitating OCD Received intensive treatment for OCD – very positive outcome Currently having difficulties leaving her home No specific OCD symptoms accounting for her functioning Changes in eating patterns 22 year old Female College student

Important questions we should ask her?

Treatment Conceptualization

When,Why & How does Depression need to be treated before OCD? Primary Severe Functioning Effect on OCD Treatment Risk

Strategies for Affective Disorders in OCD Cognitive Restructuring Behavioral Activation Mindfulness-Based CBT – I don’t mindfulness ???? Motivational Interviewing Acceptance & Commitment Therapy (ACT)

OCD + Affective Disorders + … Autistic Spectrum Disorders (ASDs) ADHD Bipolar Disorder Younger Children Tics/ Tourette’s Syndrome

Discussion