Download co-morbidity

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Netherlands Obsessive Compulsive Disorder Association (NOCDA)
Design and rationale of a longitudinal naturalistic
study on the course of OCD and clinical characteristics
and healthcare utilization of the sample at baseline.
Harold J.G.M. van Megen , Josien Schuurmans, Ton J.L.M. van Balkom,
Jan H. Smit, Merijn Eikelenboom, Maarten Kaarsenmaker, Gerrit Glas,
Gert-Jan Hendriks, Koen R.J. Schruers, Nic J.A. van der Wee, Patricia van
Oppen.
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NOCDA:
The formation of a nation- wide network of seven mental
health care centres devoted to the advancement of
knowledge about the prognosis and treatment of OCD.
GGZinGeest/VuMC
Amsterdam
LUMC/GGZ
Rivierduinen Leiden
Adhesie Almelo
Marina de Wolff Ermelo
GGZ Nijmegen/
Kliniek Overwaal Lent
GGZ Noord-en Midden
Limburg
Mondriaan Zorggroep 2
Maastricht
Why do we need longitudinal studies on the course of OCD?
• OCD is a debilitating and prevalent anxiety disorder
• It affects 2% of the population lifetime
• OCD is associated with a high use of health care services
(Bijl & Ravelli, 2000) and persistent impairment in work
functioning (Yaryura-Tobias et al., 2000; Steketee, 1997)
• Extensive economic ramifications
• OCD is listed as the 10th most disabling medical
disorder in the WHO burden of disease study (Murray et al.,
2004).
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Why do we need longitudinal studies on the course of OCD?
• A chronic course in approximately half of the cases
• Despite development and implementation of evidence
based treatments (ERP, CT en SSRI’s) (e.g. van Oppen et al.,
2005).
• Complete recovery of OCD is relatively rare: 25% of
cases (Fisher et al., 2005).
• Determining factors of this unfavourable outcome
remain unknown.
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Predictors of chronicity
1.
Early-onset OCD may have a stronger familial and hereditary
component than late onset OCD (do Rosario-Campos, 2005; Hanna et
al., 2005; Nestadt et al., 2000; Pauls et al., 1995).
Early-onset OCD may be related to higher co-morbidity patterns, a
worse outcome and/or higher baseline severity (e.g. de Mathis et al.,
2008; Pinto et al., 2006; Albert et al.,2002; Fontenelle e.a., 2003)
2. Known predictors of a detrimental course include:
–
–
–
–
Presence of compulsive symptoms (instead of obsessions alone)
Lower psychosocial functioning
schizotypic personality traits.
Presence of certain symptom dimensions, e.g. hoarding
3. Most available studies focus on environmental and psychosocial
factors
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Predictors of chronicity
HOWEVER:
• It is highly unlikely that any single environmental or psychosocial
factor or subset of psychosocial factors is responsible (Penninx et al.,
2008; Merikangas et al., 2002)
• A vulnerability-stress model incorporating both a genetic
predisposition to develop OCD as well as environmental factors that
trigger and sustain this disposition may be more appropriate
(Grisham et al., 2008).
•
Studies on genetic influences tend to disregard the influence of
environmental factors (and vice versa) (Moffit et al., 2005)
Therefore
• NOCDA integrates possible psychological and demographic
variabels as well as biological measures (blood and DNA sampling,
blood pressure, weight, abdominal & hip circumference) in a 6-year
prospective study in 419 clinically referred OCD patients.
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Main objectives
1.
To be able to evaluate which patients run a serious risk of
developing chronic symptomatology and becoming resistant to
treatment.
2.
To describe the long-term prognosis of OCD in terms of course, the
development of co-morbidity, the development of chronicity and
public health consequences as this relates to other anxiety
disorders and major depression (through NESDA).
3.
To examine biological and psychosocial determinants and their
mutual interaction in predicting the course of OCD.
4.
To identify possible new avenues for the tailored treatment of
patients at high risk for chronicity.
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Methods
• Inclusion of 419 clinically referred adult OCD patients in different stages of
the disease and with different degrees of illness severity.
• Naturalistic multi-centre 6-year longitudinal design
• All patients diagnosed with OCD that are referred to one of the
participating mental health care centres are asked permission to be
contacted for research purposes during the intake procedure.
• Included: persons aged 18 years and over, with a diagnosis of OCD, as
determined by the administration of the Structural Diagnostic Interview for
DSM-IV disorders (SCID I; First, Spitzer, Gibbon, & Williams, 1999).
• Exclusion criteria: inadequate understanding of the Dutch language for the
purposes of the completion of interviews and self report questionnaires.
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Methods
• Measurements at five times within a 6-year period; at baseline and
after 1, 2, 4 and 6 years.
• Measurements are performed by experienced and trained research
nurses or psychologists.
• Measurements include axis I diagnosis and
•
co-morbidity (SCID-I),
•
severity and
•
course of ocd and
•
co-morbid psychological symptoms (anxiety, depression, tic disorders, autism),
•
biological measures,
•
healthcare utlization,
•
work productivity,
•
disability,
•
health indicators and
•
psychosocial functioning (e.g. loneliness, trauma exposure and life events)
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Topic
Measurement instrument
Data collection
Severity Y-BOCS (10 items)
Beck Depression Inventory (21 items)
MADRS (21 items)
Beck Anxiety index (21 items)
Y-GTSS (10 items)
DSM-IV ADHD (18 items)
PI-R (41 items)
Y-BOCS symptoms (80 items)
LIFE-CHART
PDD-SQ (50 items)
Interpretation of Intrusion Inventory
(31 items)
Interview
Self-report
Interview
Self-report
Interview
Interview
Self-report
Self-report
Interview
Self-report
Self-report
TIC-P health care/Karasek
Questionnaire (16 items)
Interview/self report
Public health consequences
Disability
Work/ loss of productivity / content
Mortality / causes of death
EuroQol (16 items)
TIC-P (10 items)
CBS data
Self-report
Interview
Death records
Demographic information and
personality characteristics
Demographic and biographic info
Personality characteristics
58 items
FFPI (100 items)
Self-report
Self-report
Psychosocial functioning
Recent Events
Expressed emotion
Daily Hassles
Attachment
Social support/activity
Loneliness & affiliation
Recent events questionnaire (23)
LEE (39 items)
Daily Hassles (20 items)
AAS (5 items)
SSI (20 items)
Loneliness & Affiliation Scale (17)
Self-report
Self-report
Self-report
Self-report
Self-report
Self-report
Self-report
Self-report
Self-report
Self-report
Medical Exam
Blood pressure
Standard self-report questions
Standard self-report questions
Standard self-report questions
Standard self-report questions
Weight, height, waist + hip
circumference
Systolic and diastolic BP Assessment
Genetic determinants
DNA/lymphocytes
Family history
Full blood/buccal swabs
Family tree
Blood
Interview
Course of psychopathology
Severity:
- OCD
- depression
- anxiety
- Tics
- ADHD
Presence and severity of OCD
subtypes/symptom dimensions
History OCD
Autism
OCD cognitions
Patients' perspective
Health care use / need of care
(Physiological) health indicators
Presence of chronic illness
Alcohol and drug use
Smoking behaviour
Sleep
Body composition
Medical Exam
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Questions adressed
1. How does our sample relate to other international OCD
samples in terms of illness severity and co-morbidity
patterns?
2. Axis I Co-morbidity in OCD
3. Recent healthcare service utilization in OCD.
4. Is early onset ocd related to greater illness severity, as
established by - the level of ocd symptoms,
- levels of co-morbidity and
- use of health care services?
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Baseline demographic characteristics
• 419 OCD patients included.
• Approximately 91% (N=382) of the sample met full current DSM-IV
criteria for OCD at the time of enrolment into the study. Nine
percent had met full criteria for OCD in the past (N=37).
• 56% (N=234) female.
• Age at enrolment varies from 17 to 79 years old, mean age is 36.6
years (standard deviation (SD)=10.92). Vast majority (70%) is under
42 years old.
• 95% of the sample has the Dutch nationality.
• 36,5% of the participants have a higher vocational or university
degree (master)
• 48.7% of OCD patients are living together with a partner, 37.2% is
single.
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Clinical characteristics
Variable
Mean
SD
Range
Age at enrolment
36.60
10.92
17-79
Age at onset first obsessions
16.91
8.86
3-58
Age at onset first compulsions
16.94
9.41
3-58
Duration of illness (yrs)
18.57
12.52
0-64
Y-BOCS severity (0-40)
19.89
8.10
0-40
N
33
90
140
121
30
%
7.9
21.5
33.4
28.9
7.2
Y-BOCS OCD severity categories
Subclinical (0-7)
Mild (8-15)
Moderate (16-23)
Severe (24-31)
Extreme (32-40)
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Questions adressed
1. How does our sample relate to other international
OCD samples in terms of illness severity and comorbidity patterns?
2. Axis I Co-morbidity in OCD
3. Recent healthcare service utilization in OCD.
4. Is early onset ocd related to greater illness severity, as
established by - the level of ocd symptoms,
- levels of co-morbidity and
- use of health care services?
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Representativeness of the sample;
Comparison Y-Bocs severity categories Brown study (Pinto et al., 2006)
Y-BOCS OCD severity categories
NOCDA
N=419
Brown
n=293
7,9%
8,2%
Mild (8-15)
21,5%
19,5%
Moderate (16-23)
33,4%
29,4%
Severe (24-31)
28,9%
37,2%
7,2%
5,8%
Subclinical (0-7)
Extreme (32-40)
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Questions adressed
1. How does our sample relate to other international OCD
samples in terms of illness severity and co-morbidity
patterns?
2. Axis I Co-morbidity in OCD
3. Recent healthcare service utilization in OCD.
4. Is early onset ocd related to greater illness severity, as
established by - the level of ocd symptoms,
- levels of co-morbidity and
- use of health care services?
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Clinical characteristics; axis I co-morbidity
DSM-IV diagnosis
Lifetime
Current
N
%
N
%
92
22
172
41.1
265
63.2
96
22.9
17
4.1
10
2.4
195
46.5
151
36
Any substance use disorder
53
12.6
20
4.8
Any somatoform disorder
21
5
21
5
Any eating disorder
44
10.5
19
4.5
OCD only
Any mood disorder
Any psychotic disorder
Any anxiety disorder
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Representativeness of the sample
comparison lifetime co-morbidity rates Brown study (Pinto et al., 2006)
74,1%
80,0%
63,2%
70,0%
52,6%
60,0%
45,9%
50,0%
40,0%
30,0%
22,0%
20,0%
25,6%
9,2%
12,6%
4,1%
10,0%
2,7%
5,0%
7,5%
10,2%
5,0%
eating*
eating
somatoform*
somatoform
substance*
substance
psychotic*
psychotic
anxiety*
anxiety
any mood*
any mood
OCD only*
OCD only
0,0%
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Representativeness of the sample
comparison of current co-morbidity rates Brown study (Pinto et al., 2006)
58,0%
60,0%
50,0%
41,1%
36,0%
40,0%
30,0%
38,0%
22,9%
16,4%
20,0%
10,0%
5,8% 5,0% 6,1%
2,4% 2,0% 4,8%
5,0%
2,7%
eating*
eating
somatoform*
somatoform
substance*
substance
psychotic*
psychotic
anxiety*
anxiety
any mood*
any mood
OCD only*
OCD only
0,0%
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Questions adressed
1. How does our sample relate to other international OCD
samples in terms of illness severity and co-morbidity
patterns?
2. Axis I Co-morbidity in OCD
3. Recent healthcare service utilization in OCD.
4. Is early onset ocd related to greater illness severity, as
established by - the level of ocd symptoms,
- levels of co-morbidity and
- use of health care services?
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Healthcare utilization
• 92.6% of our sample had looked for help for OCD in the past.
• However: in majority of cases OCD symptoms had lasted for ≥ 7 yrs before
seeking help.
Mean duration 9.88 yrs.
Variable
last 6
months
Physician
75,9%
Mental health care institute
41,1%
Independent psychiatrist, psychotherapist
19,1%
Company doctor
19,1%
Social worker
Daytime or part-time treatment
Admitted to psychiatric hospital
6.4%
15%
6.9%
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Questions adressed
1. How does our sample relate to other international OCD
samples in terms of illness severity and co-morbidity
patterns?
2. Axis I Co-morbidity in OCD
3. Recent healthcare service utilization in OCD.
4. Is early onset ocd related to greater illness severity, as
established by - the level of ocd symptoms,
- levels of co-morbidity and
- use of health care services?
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Early vs late onset OCD
The majority of OCD patients have early onset OCD (70.2%)
• Indications for greater illness seveirty in early onset ocd?
NO.
 No significant differences with regard to
-illness severity,
-levels of axis I co-morbidity,
-use of health care services.
 No difference with regard to co-morbid panic disorder
 Higher co-morbidity of lifetime affective disorder (68.1% vs. 57.3%,
p<.05)
 Higher co-morbidity of bipolar disorder in early onset (4.7 vs 0%,
p=.01)
• BUT mean duration of symptoms before seeking treatment is much
higher in the early onset group (11.75 vs 5.44 yrs, p<.001).
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• This may contribute to a more detrimental course
Conclusions
1. High co-morbidity in OCD, especially with affective
disorders and other anxiety disorders
2. High use of health care services.
3. Dutch situation largely comparable to other
international OCD samples.
4. No indications for greater illness severity in early onset
vs late onset ocd.
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Futher questions/keep me posted?
Website nocda.amstad.nl
mail [email protected]
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