Consistent with previous studies, the present study found that individuals with OCD and comorbid disorders tend to be significantly more impaired than individuals with OCD without comorbidity, both of whom have significantly worse QOL and functioning and than healthy controls. The level of functioning and QOL in individuals in remission tended to fall between that of healthy controls and individuals with OCD only. In terms of severity of QOL and functional impairment, individuals with comorbid OCD were in the moderate to severe range, individuals with OCD only were in the mild to moderate range, and OCD patients in remission were in the very mild range. While QOL and functional impairment were generally related to severity of OCD, the relationship was attenuated when controlling for depression. The simplest scales for measuring functional impairment (the Sheehan Disability Scales) seemed to be quite sensitive to OCD severity and less influenced by depression. These findings extend the literature by including healthy controls and individuals with various levels of OCD symptoms, and therefore provide some evidence for the clinical significance of ranges of scores on various measures of QOL and functional impairment in patients with OCD.
One could interpret the findings regarding the remitted OCD group as either promising (individuals in remission were similar to healthy individuals who never had a psychiatric disorder), or more guardedly (individuals in remission did not differ from patients with OCD except on the SDS). The lack of differences with either group could be due to lack of power or insensitivity of the QOL and functioning measures. Alternatively, the lack of difference from the OCD group could suggest that while improvements in QOL and functioning occur, there are persistent deficits in OCD even after successful treatment. This would not be surprising in a chronic condition such as OCD that is likely to have impacted development in such a way that continues even if symptoms remit (i.e., new skills that others have learned in childhood may have to be developed). This deserves additional study in a larger sample.
Our finding that comorbid patients had the poorest QOL and greatest functional impairment is consistent with the studies showing that comorbidity in general negatively influences most areas of life (e.g., Sanderson & Andrews, 2002
). Our findings are also consistent with the reports by Quilty et al. (2003)
, Rapaport et al., (2005)
, and Rodriguez-Salgado et al., (2006)
, though inconsistent with those of Masellis et al. (2003)
and Eisen et al. (2006)
. Specifically, our results suggest that depression accounts for the relationship between either obsessions or compulsions and QOL or functional impairment. We also examined the relationship between symptom subtypes and QOL and functional impairment. Obsessing (e.g., harm thoughts, sexual thoughts, scrupulosity), washing, and hoarding were all more related to QOL than checking, ordering, and neutralizing. However, depression seemed to account for much of the relationship, even in hoarders. More research is needed to examine impairment in subtypes, and its possible interaction with treatment outcome (c.f., Mataix-Cols, et al., 2002
, Abramowitz et al., 2003
Our findings suggested a linear relationship between the QLESQ and OCD severity as well as with measures of functional impairment and OCD. These results are inconsistent Eisen et al., (2006)
, who found a nonlinear relationship between QLES-Q and YBOCS and suggested a cutscore of 20 on the Y-BOCS on the basis of the nonlinear relationship. The best method of determining a cutscore to determine diagnostic thresholds would be by using ROC analyses after administering the Y-BOCS to a large, unselected population along with a structured diagnostic interview to determine presence or absence of the diagnosis of OCD (see Swets, 1996
). Measuring QOL and functioning in the same population could be useful additional information for further analysis.
There are several limitations of this study. First, the sample size for individuals in remission and those with comorbidity was small, and could result in an inability to detect some differences among groups. In addition, QOL and functioning measures were self-report, and there was no independent verification of functioning. Finally, this study used a sample of convenience of individuals who had consented to participate in a clinical trial and evaluated them years after their consent. Thus, this was a mixed sample of individuals with varied history and levels of current treatment, making it difficult to ascertain the role that treatment played in changing QOL and functioning. On the other hand, the data were collected substantially after study treatments occurred, and therefore allowed the full impact of symptom reduction on QOL and functioning to take place. Given our cross-sectional data, we can not exclude the possibility that those in remission had better functioning and QOL even prior to treatment, and that better functioning could be a predictor of remission instead of remission leading to better functioning. Studies examining immediate effects of treatment on QOL and functional impairment may underestimate the long-term effects of treatments. To better determine this, it would have been useful to determine duration of remission to see if this was related to QOL and functional impairment. Prospective studies will be the best method to determine this in future research.
A number of tentative conclusions may be reached from the current study. Patients in remission from OCD appear to be able to function better than OCDs, but may not function as well as extremely healthy controls who have no history of psychiatric disorders. Next, the Sheehan Disability Scales, which are the simplest and easiest to administer seemed to hold up quite well in comparison to other measures of disability. In addition, it is important to consider co-occurring symptoms of anxiety and depression when attempting to optimize functioning and QOL in individuals with OCD. More research is needed on the relationships among long-term course of OCD symptoms and QOL and functioning, and the best methods to optimize both.