Asian Journal of Psychiatry 4 (2011) 178–182

Quality of life in patients with obsessive compulsive disorder: A longitudinalstudy from India

Shruti Srivastava, M.S. Bhatia *, Rajat Thawani, Anurag Jhanjee

Department of Psychiatry, University College of Medical Sciences & G.T.B.Hospital, Delhi 110095, India

A R T I C L E I N F O

Article history:

Received 4 January 2011

Received in revised form 10 May 2011

Accepted 15 May 2011

Keywords:

QoL

OCD

Follow up

India

A B S T R A C T

Obsessive Compulsive Disorder (OCD) is one of most frequently diagnosed psychiatric illness, tends to

run a chronic course and severely affects the patient’s quality of life (QoL). The aim of this study was to

assess QoL in patients with OCD and compare it with QoL of patients with major depressive disorder

(MDD) and healthy controls. Forty-five patients with OCD, fifty patients with the diagnosis of MDD and

one hundred and fifty healthy controls were evaluated using WHOQoL-BREF, Hindi version and their QoL

scores were compared. Symptom severity of the OCD group was measured using Yale Brown Obsessive

Compulsive Scale (YBOCS) and was charted longitudinally over a period of 6 months. The QoL of patients

with OCD was found to be significantly lower in the domains of physical, psychological well-being and

social domains as compared to the healthy controls. When compared with patients with MDD, the pre-

treatment QoL of patients with OCD was found to be significantly higher. Six months follow up found

Psychological health domains of QoL better in the MDD group than the OCD group. Between MDD and

OCD groups, statistically significant differences were noted in the environment domains, though overall

improvement in QoL scores was noted in both the groups in all domains. YBOCS scores significantly

improved with treatment in OCD patients, as did the scores on WHOQoL-BREF. Minimal correlation was

found between changes in YBOCS scores and QoL scores in OCD subjects at 6 months follow up. These

findings indicate that all aspects of QoL are markedly affected in individuals with OCD, QoL scores

improve with treatment and the changes in QoL scores over a period of 6 months are not necessarily

correlated with corresponding changes in YBOCS scores (indicative of symptom severity in OCD

subjects).

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1. Introduction

Obsessive compulsive disorder (OCD) is a severe and debilitat-ing anxiety disorder afflicting about 1 in 40, approximately 2.5% ofthe population, at some time in their lifetime (Robins et al., 1984;Regier et al., 1988; Kolada et al., 1994). It is twice as prevalent asschizophrenia and bipolar disorder, and the fourth most commonpsychiatric disorder (Karno et al., 1988). In severe cases, whichmay define more than 20% of those with the diagnosis, obsessionsand compulsions can occupy the entire day and result in profounddisability (NAMHC, 1993). In untreated cases, the probability ofsymptom remission is extremely low (Steketee, 1999).

The definition of health by WHO, 1948 emphasises theimportance of well-being besides absence of disease as anessential component of health, and not much attention has beenpaid to this component for a considerable period of time. Thesubjective components of health experience (‘quality of life’ (QoL),

* Corresponding author. Tel.: +91 11 25894550; fax: +91 11 22590495.

E-mail address: manbhatia1@rediffmail.com (M.S. Bhatia).

1876-2018/$ – see front matter � 2011 Elsevier B.V. All rights reserved.

doi:10.1016/j.ajp.2011.05.008

‘subjective well-being’) have also acquired a definite place in theunderstanding of health and its consequences (Saxena, 2005). Areview of the impact of anxiety disorders on QoL enumerated theprofound personal, social, and financial costs, though there is astriking dearth of studies on patients with OCD (Mendlowicz andStein, 2000).

OCD has not received its due share of attention from theclinicians, researchers and the policy-makers because it isprimarily a non-psychotic illness. There has been little examina-tion of the extent to which the presence of persistent obsessionsand compulsions has an impact on the QoL of persons with OCD. Asurvey by Hollander et al. (1996) demonstrated that 73% of OCDpatients had impaired family relationships, 62% had impairedfriendships, 58% experienced academic underachievement, 47%experience interference with work, and 40% were chronicallyunder-employed or simply unemployed.

Two subsequent studies with more reliable and valid QoLmeasures have also found important decrements in the QoL ofthose with OCD. Koran et al. (1996) found that QoL (that is,instrumental role performance and social functioning) was moreseverely impaired in those with OCD than in those with chronic

Table 1Socio demographic profile of OCD group (N = 45), and MDD group (N = 50).

OCD group

(N = 45)

MDD group

(N = 50)

X2/t P

Age 28.7 (7.96) 34.84 (10.37) 3.435 0.000953

Education status 12.78 (5.24) 11.55(4.650) 3.426 0.000937

Occupation

Employed 24 (53.33%) 32 (64%) 5.44 0.127

Housewife 10 (22.22%) 14 (28%)

Students 8 (17.78%) 4 (8%)

Unemployed 3 (6.67%) 0 (0%)

Gender

Male 29 (64.44%) 28 (56%) 1.23 0.26

Female 16 (35.56%) 22 (44%)

Marital status

Married 25 (55.56%) 42 (84%) 13.3 0.000

Unmarried 20 (44.44%) 8 (16%)

S. Srivastava et al. / Asian Journal of Psychiatry 4 (2011) 178–182 179

medical conditions (for example, diabetes mellitus) or in thegeneral population.

We undertook this study with the aims to assess, quantify, andcompare QOL in patients suffering from OCD and compared it withthose having MDD and healthy control subjects.

Symptom severity of the OCD group was measured using YaleBrown Obsessive Compulsive Scale (YBOCS). An attempt was madeto find out if any association existed between changes in QOLscores and the YBOCS scores of the OCD group when assessed overa period of 6 months.

2. Materials and methods

Forty five consecutive subjects with the diagnosis of OCD,according to the DSM-IV-TR criteria, from the psychiatry out-patients’ services of the University College of Medical Sciences andG. T. B. Hospital, a tertiary care hospital in Delhi were recruited forthe study. The participants gave informed consent and the studywas carried out after obtaining approval of the Institutional EthicalCommittee.

The inclusion criteria of the OCD group were

a) Subjects of either gender, aged �18 years with diagnosisaccording to the DSM-IV-TR criteria;

b) Subjects included only newly diagnosed cases.

The study excluded

a) Subjects with past history or current evidence of schizophrenia,bipolar affective disorder, major depressive disorder, organicmental disorders and seizure disorders;

b) Subjects having clinically significant and unstable renal,hepatic, cardio-vascular, respiratory or cerebro-vascular diseaseor any other serious and progressive physical disease.

A group of 150 healthy volunteers were included afterexcluding evidence of any psychiatric or medical/surgical illnessafter thorough history, physical examination and routine inves-tigations (complete blood count, urinalysis, chest radiograph andelectrocardiogram). The healthy control group was carefullymatched with the OCD group with respect to potentiallyconfounding variables like age and gender. A group of 50consecutive subjects with diagnosis of major depressive disorder(MDD) according to DSM-IV-TR criteria was included. Theinclusion criteria for this group included a) subjects of eithergender, aged �18 years

b) Only newly diagnosed cases.The exclusion criteria were

a) Subjects with past history or current evidence of schizophrenia,obsessive compulsive disorder, bipolar affective disorder,organic mental disorders and seizure disorders;

b) Subjects having clinically significant and unstable renal,hepatic, cardiovascular, respiratory or cerebro-vascular diseaseor any other serious and progressive physical disease.

Patients’ diagnoses of obsessive compulsive disorder and majordepressive disorder were established by senior psychiatrist on thebasis of history and clinical interview in accordance with DSM-IVcriteria. The socio-demographic data was collected using a semistructured Performa by interview of the participants and theimmediate family member (i.e. primary care giver). The diagnosiswas reconfirmed by the principal author using the Mini-International Neuropsychiatry Interview (MINI). (Sheehan et al.,1998)

The WHO-QoL (BREF) (Saxena et al., 1998) Hindi version wasused in the study. WHO-QoL (BREF version) assesses the QoL infour important domains—physical health, psychological health,social relationships and environment. The participants of all the3 groups—the OCD group, the MDD group, the healthy controlgroup were assessed and their respective QoL scores werecompared for statistical significance. In OCD subjects, the YBOCSwas employed to assess the severity of obsessive compulsivesymptoms of the patients. The subjects in the OCD group wereput on capsule Fluoxetine (40–60 mg/day). They were longitudi-nally assessed on WHOQoL (BREF version) and YBOCS at theintervals of 3 months and 6 months, after the prescribedtreatment regimen.

A longitudinal comparison of MDD and OCD subjects wascarried out for 6 months to study changes in QoL scores in bothdiseased groups. MDD subjects received capsule Fluoxetine (20–60 mg/day) from the hospital. Both the MDD and OCD groups wereprovided with free drug treatments from the government supply.

An attempt was made to find out if any association existedbetween changes in QoL scores and the YBOCS scores of the OCDgroup when assessed over a period of 6 months. Statistical analysiswas performed using the Statistical Package for Social Sciences(SPSS) version 17.0. Socio-demographic data were analyzed usingfrequencies, percentages, student’s t-test and chi-square test.Comparison of the physical, psychological, social and environ-mental domains of the Quality of Life of OCD patients, MDDpatients and healthy controls were done by ANOVA. All tests ofsignificance were 2-tailed (p value of <0.05), and Tukey correctionwas used to reduce the risk of type I errors in pair wise post hoctests. Pearson product-moment correlations were calculated toexamine the associations between the change in QOL scores andchanges in symptom severity.

Repeated measures ANOVA was applied to compare QoL scoresof MDD and OCD subjects at baseline, 3 months and 6 months. Thesubjects lost to follow up were compared to the subjects whocompleted 6 months follow up using t-test.

3. Results

Table 1 shows the comparison of socio-demographic param-eters of patients with OCD and MDD. Mean age, education andmarital status were significantly different in the OCD group ascompared to the MDD group. Gender, employment, family andmonthly income were comparable in both groups.

Tables 2 and 3 show significant differences in all the fourbaseline domain scores (physical, psychological, social andenvironment) of QoL between OCD patients, MDD group andhealthy controls.

Table 2Scores on the WHO QOL-BREF: OCD versus healthy controls versus depression.

Domains of WHO-QoL BREF (baseline) Patients OCD (N = 45)

mean (SD)

Patients MDD (N = 50)

mean (SD)

Healthy controls (N = 150)

mean (SD)

Physical health 20.53 (5.806) 16.18 (4.222) 23.95 (3.405)

Psychological health 16.02 (4.644) 13.24 (4.475) 20.44 (2.962)

Social relationships 9.38 (2.839) 7.72 (2.850) 10.61 (2.130)

Environment 26.13 (6.196) 22.16 (5.589) 27.00 (4.116)

Table 3Scores on the WHO QOL-BREF:OCD versus healthy controls versus depressive disorder patients (ANOVA).

Domain Sum of squares df Mean squares F value Significance

Physical health Between group 2341.602 2 1170.801 69.374 0.000

Within group 4084.153 242 16.877

Total 6425.755 244

Psychological health Between group 2195.734 2 1097.867 82.076 0.000

Within group 3237.058 242 13.376

Total 5432.792 244

Social relationships Between group 321.933 2 160.966 27.270 0.000

Within group 1428.451 242 5.903

Total 1750.384 244

Environment Between group 882.790 2 441.395 18.597 0.000

Within group 5743.920 242 23.735

Total 6626.710 244

S. Srivastava et al. / Asian Journal of Psychiatry 4 (2011) 178–182180

When compared with that of the healthy controls, the QoL ofpatients with OCD was significantly lower in the domains ofphysical well-being, psychological well-being, social and environ-ment domains. Compared with patients of MDD, the QoL ofpatients with OCD before treatment was significantly higher inpsychological health, social relationships and environment asshown in Table 4.

The scores on all the four domains of the quality of life—physical, psychological, social and environment, significantlyimproved on the prescribed treatment regimen on longitudinalassessment at intervals of 3 and 6 months as shown in Table 5.

Table 5Scores on the WHO QOL-BREF scores across 3 contact points at baseline,3 months, 6 m

Domains of WHOQol BREF Baseline mean (SD) 3 months mean (SD) 6 months m

Physical Health 20.23

(5.531)

24.33

(4.576)

26.58

(3.720)

Psychological health 15.63

(4.639)

19.55

(4.120)

22.28

(3.210)

Social relationship 9.33

(2.877)

10.63

(2.488)

11.35

(2.058)

Environment 25.98

(5.361)

28.98

(4.655)

30.40

(3.733)

Table 4Post hoc analysis (Tukey test) WHO QOL BREF scores in OCD versus depression patien

Dependant variable MDD group (I) OCD Group (J) Mean diffe

Physical health �1.345

Psychological health �2.345

Social relationship �1.605

Environment �3.875

Table 6 shows reduction in YBOCS scores from the baselinewhen assessment was done at intervals of 3 months and 6months.

There was a statistically signicant correlation between OCDseverity (YBOCS) and environment domain of WHOQoL BREF atbaseline but not at 3 and 6 months (Table 7).

Repeated measures ANOVA taking co-variates, age and maritalstatus was applied to compare baseline, 3 months and 6 monthsQoL scores of MDD and OCD groups. Between groups, there issignificant difference in the 2 groups at all the average time point(Table 8).

onths in OCD patients.

ean (SD) Mean squares F Significance values

3 months vs. baseline 672.400 23.762 0.0

6 months vs. baseline 1612.900 52.197

3 months vs. baseline 616.225 52.385 0.0

6 months vs. baseline 1768.900 181.021

3 months vs. baseline 67.600 17.075 0.0

6 months vs. baseline 164.025 33.496

3 months vs. baseline 360.00 21.018 0.0

6 months vs. baseline 783.225 41.856

ts.

rence (I-J) Std error Significance

0.812 0.224

0.774 0.008

0.515 0.006

0.992 0.000

Table 6Reduction in the mean YBOCS scores from baseline, 3 months and 6 months.

YBOCS scores Mean SD

Baseline (N = 45) 30.11 6.080

3 Months (N = 40) 18.10 8.070

6 Months (N = 40) 10.85 7.908

S. Srivastava et al. / Asian Journal of Psychiatry 4 (2011) 178–182 181

4. Discussion

The study found greater impairment in QoL in individuals withOCD in comparison to healthy controls, similar to those reportedby another study from India (Gururaj et al., 2008) and others(Bobes et al., 2001; Jonathan et al., 2009). The patients with OCDhad statistically significant differences in QoL domain scores inpsychological health, social relationships and environment ascompared to patients with MDD. Vikas et al., 2009 reported thatOCD patients had a better quality of life compared with MDDpatients. In the present study, physical functioning of OCD patientswas not significantly different in comparison to patients of MDD.

Chaturvedi (1991) reported that Indians gave priority to peaceof mind and spiritual satisfaction over physical and psychologicalfunctioning, while Western people give highest priority to physicalfunctioning. Changes in YBOCS scores were significantly correlatedwith changes in the environment domains of QoL. Koran et al.(1996) also found a minimal association between YBOCS scoresand QoL scores. Bystritsky et al., 1999 also reported that thechanges in YBOCS scores were not associated with changes in QoLsubscales. Gururaj et al. (2008) also reported no correlation inphysical, social and environment domain scores and YBOCS scores.In contrast, Jonathan et al. (2009) had reported significantassociations between QoL and YBOCS.

Table 7Correlation between YBOCS & WHO QOL BREF at 3 contacts-baselines, 3 months, 6 mo

WHO QOL domain Pearson correlation Physical health

Baseline (N = 45) r 0.135

p 0.375

3 months (N = 40) r �0.245

p 0.127

6 months (N = 40) r �0.238

p 0.138

Table 8Scores on the WHO QOL-BREF Scores across 3 contact points at baseline,3months, 6 m

WHO QOL Domain Baseline 3 month

Physical health OCD 16.60 (4.427) 22.65 (5

MDD 20.23 (5.531) 24.32 (4

Between groups P value 0.109

Psychological health OCD 13.30 (4.350) 19.20 (4

MDD 15.62 (4.639) 19.55 (4

Between groups P value 0.183

Social relationship OCD 7.90 (2.560) 9.80 (2

MDD 9.33 (2.877) 10.63 (2

Between groups P value 0.162

Environment OCD 22.35 (5.342) 26.22 (5

MDD 25.98 (5.361) 28.98 (4

Between groups P value 0.020

The socio-demographic profile of the sample shows that theOCD and depression groups had no difference with regards togender, employment and income. There was significant differ-ence in two groups with regard to religion; Hindus comprisedthe majority in OCD whereas Muslims comprised the majority inMDD group. In the Psychiatry outpatients department of ourhospital, majority of people were Hindus followed by Muslims,Sikhs and Christians during the study period. The two groupsalso showed significant difference in marital status where morepatients with OCD were unmarried than MDD. This might be dueto OCD being a more severe psychiatric illness than MDD.Twenty-four patients with OCD continued to work, althoughthey reported lowering of their work efficiency due to thedisorder. Housewives and students also reported that they werespending a significant amount of their time on obsessions andcompulsions. Three patients had to discontinue their workbecause of the disorder. Being employed could have been relatedto better scores on QoL domain scores as reported in anotherrecent study. The OCD group had severe obsessive compulsivesymptoms as reflected in the mean YBOCS score of 30.11.(SD = 6.08).

Five subjects in the OCD group and ten subjects in MDD groupdropped out of the study. We used socio-demographic scores andquality of life scores for comparing cases lost to follow up versusthe cases which completed 6 months follow up by independentsample t-test. There is no statistically significant difference and noimputation methods were applied.

We studied the changes in QoL scores of OCD and MDD groupsover 6 months. Between MDD and OCD groups, statisticallysignificant differences were noted in the environment domains,though overall improvement in QoL scores was noted in both thegroups in all domains. Psychological health domains of QoL werebetter in MDD groups than OCD group.

nths.

Psychological health Social relationship Environment

0.017 0.134 0.303

0.913 0.379 0.043

�0.127 0.123 0.074

0.436 0.449 0.648

0.075 �0.017 0.109

0.647 0.916 0.504

onths in OCD and MDD subjects.

s 6 months Within subject P value P value interaction

.026) 24.40 (5.300) 0.088 0.483

.576) 26.58 (3.720)

.416) 21.05 (4.809) 0.002 0.333

.120) 22.23 (3.182)

.574) 8.61 (2.799) 0.450 0.155

.488) 11.35 (2.058)

.456) 28.77 (4.209) 0.105 0.273

.655) 30.40 (3.733)

S. Srivastava et al. / Asian Journal of Psychiatry 4 (2011) 178–182182

5. Conclusion

The findings of the study indicate that all aspects of QOL aremarkedly affected in individuals with OCD .The existing treatmentmodalities though bring about improvement in severity of illnessover 6 months but QOL still remains impaired. The findings,however, must be interpreted in the context to some limitations.The small sample size of forty patients followed up; secondly theywere followed up for only 6 months before and after treatment.This could result in an inability to detect some differences amongsub-groups of OCD. OCD being a chronic disorder with remissionsand relapses, a longer follow up is better. Moreover, WHOQoL BREFis not designed specifically to measure health related quality of lifein patients with OCD. There is a need for future studies with largersample size and more longitudinal assessments with differenttreatment modalities.

Conflict of interest

None.

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