Suicidal behaviour of Indian patients with obsessive compulsive disorder.

BACKGROUND SETTING AND
DESIGN: The chronicity, distress, high rates of comorbidity and varying degree of non response to treatment in Obsessive Compulsive Disorder (OCD) may contribute to suicidal behavior. There is relatively little information on suicidal behavior in OCD subjects. Our study design is Single point non-invasive, cross sectional, clinical study of new and follow up cases.
MATERIALS AND METHODS: Assessment of Suicidal Behavior in patients of OCD attending the adult Psychiatry O.P.D. of Chatrapati Shahuji Maharaj Medical University (CSMMU) U.P. Lucknow using (DSM-IV) criteria for diagnosis of Obsessive Compulsive Disorder, Structured Clinical Interview for DSM-IV Axis-I disorders, Yale Brown Obsessive Compulsive Rating Scale, Scale for Suicidal Ideation (SSI), Beck's Hopelessness Scale (BHS). STATISTICAL ANALYSIS: Mean standard deviation and t test for independent samples, Pearson's correlation coefficient.
RESULTS: Statistically significant differences were seen in the SSI score between the "Clinical" and "Sub-Clinical" cases with Clinical group having higher scores. Value of correlation coefficient between YBOCS score and SSI and BHS score is positive and statistically significant (P<0.01).
CONCLUSION: "Clinical" group of patients had significantly higher scores of suicidal ideation measured by Scale of Suicidal Ideation (SSI). There was a significantly positive correlation between disease severity (YBOCS Score) and degree of suicidal ideation (SIS Score).

INTRODUCTION

Suicidal Behavior is defined as an act through which an individual harms himself (self aggression) whatever may be the degree of lethal intention or recognition of genuine reason for their action.[12] Suicidal behavior is the result of a complex interaction of biological, genetic, psychological, sociological, environmental factors. Life threatening attempts are more common than fatalities. 15% of untreated depressed patients may commit suicide. Obsessive Compulsive Disorder (OCD) is chronic distressing anxiety disorder associated with significant functional impairment.[3] There is a reasonable probability that the patient of OCD have suicidal thoughts, plans or actually attempt suicide. As to best of our knowledge there is no published data on the suicidal behavior with OCD. In our study Clinical group of patients had significantly higher scores of suicidal ideation. There was a significantly positive correlation between disease severity and degree of suicidal ideation.

Review of the literature

It has been estimated that in the year 2000, 814000 people died by suicide worldwide.[4] Suicide is among the 10 leading causes of death for all ages in most of the countries for which information is available. In the year 2002, “suicide attempt” contributed for 1.8% of the “global burden of disease”, and it is estimated that it will reach 2.4% in 2020.[5] Suicidal ideation refers to cognitions that can vary from fleeting thoughts that life is not worth living to very concrete well thought out plans for killing oneself, to an intense delusional preoccupation with self-destruction.[6] They also reported a cumulative probability of 34% for transition from ideation to a plan, 72% from a plan to an attempt and 26% from ideation to an unplanned attempt. The more detailed and specific the plan, the greater will be the lever of risk.

In a prospective study on 1958 outpatients, Beck et al.[7] found that hopelessness was highly correlated with eventual suicide. In addition to hopelessness, Hendin[8] identified desperation as another important factor in suicide. Desperation implies not only a sense of hopelessness about change but also a sense that life is impossible without such a change.

Well identified risk factors consistently associated with completed suicide in the general population include male gender, older age, white race, widowed status, poor health (especially if painful serious illness is present), and lack of social support.[91011] Patients with previous serious attempts, a family history of completed suicide, extensive psychiatric co-morbidity, psychosis, alcohol intoxication and emotional feelings of hopelessness are also at a significantly higher risk of killing themselves.[2] Additionally, the severity and lethality of the most serious period of suicidality in a patient's history has been found to be predictive of future suicide risk.[12]

Suicide and psychiatric disorders

Suicide is a multidimensional concomitant of psychiatric diagnoses, especially mood disorders, and is complex in both its causation and in the treatment of those at risk. Psychiatric diagnoses classically associated with completed suicide include mood disorders, schizophrenia, and addiction disorders.[13] The highest risk of suicide occurs in the presence of multiple co-morbid conditions, particularly combinations of affective or psychotic disorders with abuse of alcohol or drugs.

Obsessive compulsive disorder

OCD has emerged from being considered a rare, neglected, untreatable and trivial illness to one of the most prominent and disabling mental disorders. OCD is an anxiety disorder characterized by recurrent obsession or compulsions that are recognized as excessive or unreasonable symptoms which cause a marked distress, are time consuming and/or interfere with normal function.[14] It is fourth commonest mental disorder.[15] Epidemiological studies across the world have estimated lifetime prevalence of it to be ranging from 1.9 to 3.3%.[151617]

Patient with OCD often suffer from one or more co-morbid disorders. Major depression has been the most common co-morbid syndrome, lifetime prevalence of which is reported between 12 and 70%.[15] Lifetime prevalence of co-morbid anxiety disorders in OCD patients was noticed to be 25 to 75%.[17]

In earlier studies, comorbid depression was reported to predict good response.[18] However, some recent studies have depression as a poor prognostic factor[1920] but many others[21] have reported response to be independent of co morbid depression. Discontinuation of medication carries a high risk of relapse.

The ECA survey reported that individuals with OCD are more likely to be divorced or separated than individuals without OCD.[22]

Understandably, OCD patients harbor hopelessness and suicidal ideation. However, current literature examining the relationship between suicidal behavior and OCD is sparse. Most of the studies have examined suicidal patients and looked at the diagnostic comorbidity.[23]

In a study by Rudd[24] and colleagues, 6.7% of suicidal patients received a diagnosis of OCD. Among the 18571 respondents in NIMH-ECA study, 140 were diagnosed with DSM-III OCD and 266 with OCD as a co-morbid disorder. Uncomplicated OCD increased the risk of suicide attempts to 3.2 times (95% CI 1.3-8.1) compared to healthy respondents. Even after the removal of those with major depression or agoraphobia, the odds ratio for suicide attempts in comorbid OCD was 3.7%.[24]

It is evident from the review that there is relatively little information on suicidal behavior in OCD subjects. The paucity of data is surprising considering the chronicity, distress, high rates of comorbidity and varying degree of non response to treatment in OCD, all of these may contribute to suicidal behavior. Therefore this study aims to examine the prevalence of suicidal behavior (ideation and attempts) and its clinical correlates in clinically ill OCD subjects seeking treatment in a psychiatric hospital.

MATERIALS AND METHODS

Aim

To assess the Suicidal Behavior in patients of Obsessive Compulsive Disorder (OCD) attending the adult Psychiatry O.P.D. of Chatrapati Shahuji Maharaj Medical University (CSMMU) U.P. Lucknow.

Study design

The present work is a single point non-invasive, cross sectional, clinical study of new and follow up cases of OCD attending psychiatric outpatient section, which involves the assessment of suicidal behavior in the patients. Informed consent was taken from all the subjects. The study was conducted between June, 2005 and May, 2006.

Study sample

The study sample consisted of patients of obsessive compulsive disorder, attending the outpatient section of the Department of Psychiatry, CSMMU U.P. Lucknow. Patients fulfilling the following selection criteria were included in the study.

Inclusion criteria

Willingness to give informed consent

The age of the patient was 18 years to 45 years

Diagnosis of Obsessive Compulsive Disorder according to DSM-IV

Duration of illness one year or more

The subject should have passed at least Class eighth, according to Indian Standards.

Exclusion criteria

Presence of any other Axis I disorder on the DSM-IV

History of psychoactive substance dependence or significant abuse (except nicotine)

Presence of any serious physical disorder.

Procedure

The patients attending the adult out patient clinic of the Department of Psychiatry CSMMU were screened. The patients fulfilling the above mentioned inclusion and exclusion criteria were invited to participate in the study. The patients were assessed on the same day or were asked to come for evaluation on a mutually convenient day

Tools

Semi-structured proforma for details, history and diagnosis of patient

Diagnostic and Statistical Manual of mental disorders-IV (DSM-IV) criteria for diagnosis of Obsessive Compulsive Disorder

Structured Clinical Interview for DSM-IV Axis-I disorders

Yale Brown Obsessive Compulsive Rating Scale

Scale for Suicidal Ideation (SSI)[25]

Beck's Hopelessness Scale (BHS).[26]

OBSERVATION AND RESULTS

In all 167 patients were screened, out of which 101 were excluded for reasons as specified above. Out of the 66 patients included, 14 patients did not turn up on the prearranged date for assessment and were thus excluded from the study. In all, assessment of 52 patients was completed and these patients formed the sample for this study.

Two subgroups were formed: (a) ‘subclinical’ group (Y-BOCS Score seven or less) which was having 22 subjects and (b) ‘clinical’ group (YBOCS score of eight or more) and this group had in all 30 subjects. All the ‘subclinical’ cases were the follow up cases of OCD who were in remission and under treatment. The ‘clinical’ group comprised of mild, moderate and severe categories clubbed together.

Comparison of suicide attempters and non attempters on different scales

Comparison of scores of severity of OCD (YBOCS), hopelessness (BHS) and suicidal ideation (SSI) between the patients having history of suicide attempt and those who had no history of suicide attempts has been done above. The patients with suicide attempt had a significantly higher score on the BHS and SSI. There was no significant difference between the scores of YBOCS in the two patient populations.

The above table depicts value of Pearson correlation coefficient between YBOCS score with score on scale (BHS) and suicide intent scale (SSI). On both the scales the value of correlation coefficient is positive and statistically significant (P<0.01).

DISCUSSION

The domain of suicidal behavior is multidimensional with many factors. The present study was carried out to assess the suicidal behavior in OCD.

Out of 66 patients included in the study only 52 patients completed the assessment. To minimize the attrition on follow up where possible the assessment of patients were completed on the same day.

Most of the patients included in the study were aged 35 years or less. 42.3% patients were in the age group of 18 to 25 years and 46.15% were in the age group of 26 to 35 years. This finding is in conformity with an occurrence of this disorder in a younger age group.[27] The younger age of the study population is also due to the fact that patients who were aged 45 or more were excluded to reduce the age related factors for suicidal behavior.

In the study the male subjects (65.38%) outnumbered the females (34.62%) in the study. However, majority of the studies[28293031] have reported a female predominance. The inclusion of more male patients is in conformity with the general trends observed at our set up where most of the patients attending the out patient department (OPD) from where the patients were selected are male. This may be due to cultural factors that promote a greater health seeking behavior in men resulting in a greater attendance at the OPD.

Majority of patients were unemployed (50%). This finding concurs with the fact that OCD is a disabling disorder. Similar findings have also been reported and emphasized in studies by Koran et al.[32] and Eisen et al.[33]

The mean duration of illness in the patient group was 5.01±2.47 years. Longer duration of illness in the present as well as past studies substantiates the fact that OCD is a chronic disease marked with a prolonged waxing and waning course.

The severity of the obsessive compulsive disorder in the patients was measured by the Y-BOCS scale. Majority of the patients (57.69%) were symptomatic and were having a Y-BOCS score of 8 or more.

For the purpose of comparison the patients who were having an YBOCS score of 8 or more were clubbed together into a “clinical” group. This group comprised of mild, moderate and severe cases clubbed together. The patients having YBOCS score of 7 or less were included in the “sub-clinical” group.

The phenomenological analysis of patients in the study revealed that multiple obsessions were present in 78.85% of the patients and that the most common obsessions found were that of contamination (65.38%) followed by obsessions of doubts (59.61%). Similarly multiple compulsions were present in 76.92% of the patients and the most common compulsions were that of cleaning/washing (69.23%) and checking (53.85%).

A history of suicide attempt in the past is considered to be a strong predictor for future suicide attempts.[343536] In the present study past suicidal attempts were present in 10 (19.23%) patients and this is significantly higher than the attempted suicide rates in the general population. The rate in the general population in different parts of India ranges from 8.1 to 58.3 per 1 lac.[37] However the reported rates are misleading in this part of the world because the population counts are unreliable and identifying suicides is problematic because of inefficient civil registration systems, non-reporting of deaths, variable standards in certifying death, and suicide's legal and social consequences.[38] Therefore comparison of the suicide rates with general population and the significance of this finding in present study remains debatable.

The suicide attempt reported in this study are however comparable to other disorders which have an established relationship with suicidal behavior. Lifetime suicide attempt rates in bipolar disorder were reported to be 29.2% and in unipolar disorders to be 15.9%.[39] In another study on patients with schizophrenia a lifetime attempt of suicide was found to be 30.2%.[40] The present study therefore indicates that suicidality in OCD may be comparable to that in psychiatric disorders such as schizophrenia and depression.

The most common method of attempting suicide in the present study was by poisoning (60%). Other studies have also noted that pesticides have become common for intentional poisoning in developing countries.[414243] The easy availability of pesticides in the developing countries may be the probable reason for a high rate of suicide by poisoning.

The incidence of suicide attempts was more in female compared to male but this difference was not significant. Similar findings of a higher incidence of suicide attempt among females have been reported in other studies, while high rates of completed suicides are reported among men.[4445]

On the Scale for Suicidal Ideation (SSI), 55.76% of the patients in the present study had a score of two or more. This indicates that about half of the patients in the study had recently contemplated about ending their lives. This is significant and is comparable to depression where studies have shown similar incidence of suicidal ideators.[46]

There is no consensus on what is an ideal cut off score on the scale for suicidal ideation to predict future suicide attempt. A score of six or more has been used in earlier studies to differentiate the patients with a serious suicidal risk.[4647] In the present study 14 (26.92%) patients had a score of 6 or more signifying that about one fourth patients had significant suicidal ideation. Therefore based on SSI scores alone a significant number of patients had a future suicidal risk.

On analysis of the SIS score among the patient population for the relationship with different correlates a significant difference between the score of “clinical” and “subclinical” patients was found. The clinical group had significantly higher SIS score than that of the subclinical group. This indicates that patient having symptoms of OCD were more at risk of suicide. To further assess the correlation coefficients were obtained between the severity of illness (Y-BOCS Score) and suicidal ideation (SIS Score). Pearson correlation was 0.680 and it was statistically significant. This further strengthens the argument that severity of OCD and suicidal behavior has a positive correlation.

There was no significant difference in the SIS score between male and female, rural and urban and married and unmarried groups.

Another measure of suicidal behavior is hopelessness and this was also observed in a significant number of patients in the present study. The mean score on the Beck Hopelessness Scale (BHS) was 5.17±3.46. The hopelessness scale varied across the patients, (48.07%) (n=25) had a score of 4 or less. There were 13 (25%) patients who had a BHS score of 9 or more.

A BHS score of 9 or more is considered to be a significant risk for future suicidal attempt as demonstrated by a prospective study by Beck et al.,[26] on 1958 outpatients suffering from depression. In the study it was found that hopelessness, as measured by the Beck Hopelessness Scale, was significantly related to eventual suicide. A scale cut off score of nine or above identified 16 (94.2%) of the 17 patients who eventually committed suicide. In the present study 13 (25%) patients of OCD had a score of nine or more on the BHS. Thus taking hopelessness as an independent factor also identified a significant number of patients in our study having significant suicidal risk.

The relationship between hopelessness scores among different groups was carried out for ascertaining the relationship if any that may exist between different variables and hopelessness. The comparison of means between the sub clinical and the clinical group demonstrated a significantly higher score of hopelessness in the clinical group. This implies that in the study the symptomatic patients are at a greater risk for suicide. To further study the relationship between the severity of illness and the hopelessness a correlation coefficient between the score on YBOCS and BHS was obtained. The Pearson Correlation coefficient was 0.549 and it was significant at the 0.01 level. The result establishes that there is a significant correlation between the severity of illness and hopelessness.

The findings of the present study suggest that there is a significant risk of suicide among the patient of OCD. This is noteworthy that depression is common co morbidity with OCD, and is a risk factor for suicide in itself. In the present work however patients with co-morbid depression were excluded and do not contribute to the findings of the study.

Limitations

The results of the study should be interpreted in view of the following limitations:

The high attrition rate (14 out of 66) could have affected the findings of the study. The sample of patients was selected from a tertiary care center and the patients were on treatment and follow up. The assessment was cross sectional. It is debatable if the findings from the study can be generalized to all the patients of OCD. Also recently diagnosed patients (duration less than one year) were excluded.

The present study addressed and tried to exclude a number of confounding factors such as co-existing psychiatric disorders including depression, substance abuse extremes of age etc., however the suicidal behavior is affected by many psychosocial and personality factors and the findings of the study may be limited by them. Owing to limited time factor and resources the suicidal behavior was assessed only on the parameters that have been repeatedly used to assess the suicidal behavior and especially predict future suicidal attempts.

Strengths

The present study included patients who did not have any co-morbid psychiatric illness. Depression is commonly co-morbid with OCD and is a confounding factor for assessing suicidal behavior. A reliable and valid instrument (Structured Clinical Interview for DSM-IV Axis-I disorders) was used for making a diagnosis, as well as ruling out other Axis 1 disorder, in the present study and the patients with depression; either past or present were excluded.

The patients were rated by a single rater and therefore the inter-rater reliability did not affect the study results. More than one parameter was assessed to ascertain the suicidal behavior. These parameters included past suicidal attempt, hopelessness and suicidal ideation. The use of more than one validated instrument further lessens the probability of chance findings.

Implications

The findings from the present study indicate that a significant percentage of OCD patients exhibit suicidal risk and this suicidal behavior is correlated with the severity of the illness. In the light of the findings from the present study it may be relevant to screen the patients of the Obsessive Compulsive Disorder for suicidal risk especially the patients who are symptomatic.

Future studies may be carried out to see if an intervention which improves the disease severity in turn also has an impact on the suicidal behavior to further test this association.

CONCLUSION

A significant number (19.23%) of patients had a history of past suicidal attempt. This finding is important as past suicidal attempt is considered to be a strong predictor for future suicidal attempt

Hopelessness a predictor of future suicidal risk was significantly high in 25% of the patients on the Beck Hopelessness Scale

26.9% of patients had a significantly high degree of suicidal ideation, with score of 6 or more on Scale of Suicidal Ideation

The “Clinical” group of patients had significantly higher scores of hopelessness measured by the Beck Hopelessness Scale (BHS) when compared to “Sub Clinical” group

The “Clinical” group of patients had significantly higher scores of suicidal ideation measured by Scale of Suicidal Ideation (SSI) when compared to “Sub Clinical” group

Patients having a past history of suicide attempt had significantly higher score of hopelessness and suicidal ideation compared to the patients having no history of suicide attempt

There was a significantly positive correlation between the disease severity (YBOCS Score) and hopelessness (BHS Score)

There was a significantly positive correlation between disease severity (YBOCS Score) and degree of suicidal ideation (SIS Score)

Females had significantly higher score on hopelessness (BHS).