Introduction
Previous research has shown that substance use disorders (SUDs) are linked to a variety of co-morbid conditions, including obsessive–compulsive disorder (OCD) [
1,
2]. The prevalence of OCD among methamphetamine users and the link between patterns of methamphetamine use and OCD have not been studied. Moreover, there is little information on the relationship between OCD and high-risk sexual behaviors, which are common among methamphetamine users [
3,
4]. We propose that successful treatment of individuals with OCD and methamphetamine use disorder may require addressing both conditions. To this end, it is important to identify behaviors and conditions that are associated with methamphetamine use and OCD comorbidity. The present study examines substance use patterns and sexual risk behaviors as correlates of OCD in a high-risk and high-need population of HIV-positive methamphetamine-using men who have sex with men (MSM).
Examining patterns of methamphetamine use, above and beyond SUD diagnosis, may improve our understanding of the links between OCD and SUDs. Although we were unable to find studies that link frequency of drug use or binge drug use to OCD, several studies have documented a positive relationship between binge eating and OCD [
5,
6]. Given that binge eating can have similar patterns to drug use by those with SUD [
7], a similar relationship may be present between OCD and SUD.
There is a lack of studies that report on the sexual risk behaviors of SUD patients with OCD comorbidity. However, in one study of non-substance users, the severity of OCD symptoms was negatively correlated with relationship intimacy, relationship satisfaction, and self-disclosure of the disorder. Severity of OCD symptoms was also positively associated with fears regarding contamination from sexual activity [
8]. In another study, 24.9% of OCD patients meeting DSM-IV criteria reported a history of sexual obsessions [
9], suggesting that this is a fairly common clinical feature of OCD.
In the general population, depressive disorders are common among OCD patients [
10]. McElroy et al. [
11] have suggested that OCD spectrum disorders belong to the broader family of affective orders. In a study of axis I comorbidity in OCD, major depression (MDD) was identified as the most common comorbidity, with 39.5% of OCD patients presenting with MDD [
12]. In another study that examined the co-occurrence of depressive disorders in OCD, one-third of the sample was diagnosed with comorbid depression [
13]. Moreover, studies that compared OCD patients who have major depression with those who do not have found significant differences in the presentation and clinical severity of symptoms [
10,
14,
15], suggesting the need to include a measure of depression in studies of obsessive–compulsive disorders.
Studies that have examined risk factors and correlates of obsessive–compulsive disorder have found few associations with demographic characteristics [
16,
17]. OCD symptoms typically begin before the age of 30, but cases with later onset have been documented [
18]. The onset of symptoms tends to be gradual, and their development is continuous regardless of age of onset [
19]. In an epidemiological study, OCD was found to affect mostly female adults and male children and adolescents. Individuals who were unmarried and abused drugs were also more likely to have OCD symptoms [
17].
The purpose of the current study is twofold: first, to examine the prevalence of OCD in a sample of HIV-positive, methamphetamine-using MSM, and second, to identify behavioral correlates of OCD in this target population. We hypothesized that methamphetamine use and risky sexual behaviors would be associated with clinical levels of OCD symptoms as measured by the Obsessive Compulsive Inventory, Revised (OCI-R) [
20].
Discussion
In our sample of HIV-positive, methamphetamine-using MSM, clinical levels of OCD were associated with more frequent use of methamphetamine, more depressive symptoms, and more risky sexual behaviors when “high” on methamphetamine, but fewer sexual acts in a 2-month period. This profile suggests that efforts to treat methamphetamine use and promote safer sex practices in this target population may require efforts to mitigate and treat severe OCD symptoms.
Our finding that frequency of methamphetamine use was positively associated with OCD is consistent with the literature on OCD and substance use (e.g., [
2,
29]). The clinical significance of the relationship between methamphetamine use and OCD may be that OCD patients who use stimulants have worse treatment outcomes. Brady et al. [
30] described an OCD-like, compulsive foraging syndrome in cocaine-dependent individuals who in laboratory tests were obsessed with finding misplaced cocaine. Since this behavior has not been observed in persons with other drug addictions [
31], it could be hypothesized that people who use stimulants and have severe OCD symptoms may not respond as well to conventional drug treatment programs. More research is needed to clarify the impact of the relationship between methamphetamine use and OCD on drug treatment outcomes.
Participants who met the threshold for a clinical level of OCD symptoms were also more likely to report seeking out risky sexual venues and risky sexual partners when “high” on methamphetamine. The novelty-seeking and exciting nature of risky sexual behaviors in the context of methamphetamine use may be reinforcing, thus making these behaviors more resistant to change. Accordingly, the effectiveness of sexual risk reduction programs may be enhanced by addressing OCD symptoms and teaching self-regulation techniques (e.g., cognitive reframing, delaying) that help individuals to manage their risky behaviors and their obsessions and compulsions. In addition, future studies should examine whether treatment for OCD is associated with reductions in sexual risk behaviors.
Contrary to expectation, total number of sex acts in the past 2 months was negatively associated with clinical levels of OCD symptoms. Although we cannot completely rule out Type 1 error in these analyses, the bivariate correlation indicates that the relationship is truly inverse. A plausible explanation for our finding derives from the literature regarding sexual dysfunction and OCD. In a study that compared patients with OCD, major depressive disorder (MDD), and generalized anxiety disorder (GAD), Kendurkar and Kaur [
32] reported that the rate of sexual dysfunction was 50% for OCD patients. As did MDD and GAD patients, OCD patients reported low sexual desire as the most common source of sexual dysfunction. Thus, it is not unreasonable to suggest that EDGE-II participants who met clinical criteria for OCD experienced low levels of sexual desire that was self-remedied by the use of methamphetamine. This hypothesis warrants attention in future studies.
Although this study focused on methamphetamine use and sexual risk behaviors as correlates of OCD, it was depressive symptoms, as measured by the cognitive-affective subscale of the BDI-II, that yielded the strongest relationship with OCD. This finding is consistent with previous research, which has demonstrated the co-occurrence of major depressive disorder and clinical levels of OCD [
12,
13]. There is also evidence that depressed OCD patients have more severe OCD symptoms compared to those without comorbid depression [
14,
15]. From a clinical perspective, methamphetamine users who present with depressive symptoms should also be screened for OCD symptoms. Treatment programs that aim to reduce methamphetamine use and depression might combine psycho-pharmacological and psychotherapeutic treatments for OCD. A review of pharmacological therapies [
33] concluded that administration of fluvoxamine or sertraline (two commonly used SSRIs) is the recommended treatment for OCD, with augmentation for refractory patients using risperidone, olanzapine, or quetiapine. The recommended psychotherapeutic treatment for OCD is cognitive behavioral therapy (CBT) [
34]. CBT has been shown clinically effective with OCD patients using various methods of delivery, including individual, group, and telephone [
35,
36].
A primary limitation of this study stems from its use of a convenience sample of HIV-positive, methamphetamine-using MSM who were volunteers in a sexual risk reduction intervention, since individuals who volunteer for research projects may not be representative of the larger target population. Another limitation stems from the self-report nature of the measures for OCD symptoms, methamphetamine use, and sexual risk behaviors. Self-report is subject to biases and inaccuracies in recall, particularly in relation to sexual and drug-use behaviors. This study is also limited by the use of a single question to measure binge use of methamphetamine. As noted by Lange and Voas [
37], the concept of binging is inherently difficult to measure among substance users, which may explain the absence of multi-dimensional, standardized assessment tools. The single-item measure used in this study appears to have face validity; however, future studies should explore the validity and reliability of this and other single-item measures. Although the OCI-R has been shown to discriminate between patients with OCD and anxious controls, sensitivity and specificity of the cutpoints should be examined in studies of patients with comorbid psychiatric disorders (e.g., depressive disorders). The cross-sectional nature of our data precludes us from making causal inferences regarding the association between methamphetamine use and OCD. Although some research has suggested that OCD symptoms precede substance use [
1], it is also possible that methamphetamine use might induce OCD-like symptoms that may or may not be reversible. Prospective research designs are needed to address the issue of temporality to inform inferences about causality. Lastly, it is also possible that the relationship between methamphetamine use and OCD is explained by a confounding variable (e.g., co-use of other drugs, comorbid personality disorder) not considered in this research.
Overall, the present study suggests a need to increase health care professionals’ awareness of OCD symptoms in methamphetamine users. Our findings also suggest that the combination of drug dependence, depressive symptoms, and OCD may be common in methamphetamine users. Future studies should seek to identify social, psychological, and behavioral factors as well as clinical consequences associated with this combination of morbidities.