Quality of life changes following inpatient and outpatient treatment in obsessive-compulsive disorder: a study with 12 months follow-up

Obsessive-compulsive disorder (OCD) is a prevalent mental disorder with a lifetime prevalence of 2% to 3% [1, 2]. OCD is characterized by recurrent intrusive thoughts or impulses (obsessions) and repetitive behavioral or mental acts (compulsions). The disorder frequently takes a chronic course [3]. Cognitive behavioral therapy (CBT) including exposure and response prevention (EX/RP) is the most effective treatment for persons with OCD [4, 5]. To date, research into treatment efficacy has largely focused on the effects at the symptom level, with the main outcome parameters being the reduction of obsessive/compulsive or depressive symptoms. In addition, the quality of life (QoL) has increasingly been recognized as an important but rather under-investigated outcome component [6, 7].

QoL has been conceptualized by the World Health Organization (WHO) as ‘a multidimensional construct describing an individual’s subjective perception of their position in life in the context of the culture and value system in which they live, and in relation to their goals, expectations, standards, and concerns’ (The WHOQOL Group, 1996).

Research on the QoL is important for a number of reasons: First, information on the domains of QoL that are particularly impaired in persons with distinct disorders might allow the therapists to specifically focus on these aspects. Furthermore, advanced knowledge about particular symptoms that have a high impact on the QoL might enable us to tailor the treatment to these symptoms [8]. Finally, QoL research might help to explain the frequently observed discrepancy between clinical symptom ratings and patients’ overall ratings of the treatment effects.

A diminished QoL in persons with OCD compared to population norms has been demonstrated by a number of studies, [7, 9]. However, QoL impairments in persons with OCD have not yet been well understood with respect to different QoL domains and the association between QoL and psychiatric symptoms [10]. This aspect is further complicated by the use of different QoL measures which depict different domains of the QoL.

Improvements of the QoL in persons with OCD have been described after CBT with EX/RP in several uncontrolled pre- and post-treatment studies [6, 7, 9, 11, 12] and one randomized controlled trial with a waiting-list control group [13]. Cordioli et al. [13] observed a significant improvement of the psychological, physical, social, and environmental QoL after CBT in a group format, but not after a waiting period. The therapeutic gains were maintained at 3 months follow-up. Diefenbach et al. [11] assessed the QoL in 70 outpatients with OCD before and directly after individual CBT and reported significant improvements of work, social and family functioning with large effect sizes. Norberg et al. [7] found a substantial impairment in the QoL before treatment. One subgroup showed a substantial improvement directly after CBT with EX/RP along with a reduction in OCD symptoms. In contrast, a second subgroup also demonstrated reductions in the severity of OCD symptoms but no QoL improvement, and a third subgroup did not improve on either measure. Stewart et al. [12] analyzed data of 403 persons with severe OCD and a high rate of comorbid disorders who had not responded to previous treatments. The authors observed a significant QoL improvement directly after an intensive residential treatment with daily CBT sessions in their sample. Concerning pharmacological treatment without CBT, statistically significant but small QoL improvements have been observed after treatment with either venlafaxine or paroxetine for 12 weeks [14]. Hollander et al. [10] reported that escitalopram and paroxetine were significantly superior to placebo in improving the QoL in most domains of the SF-36. However, another randomized placebo-controlled study by Koran et al. [15] found that fluvoxamine was not superior to placebo in improving the QoL.

Interestingly, QoL improvements in persons with OCD appear to be relatively independent from the reduction of OC symptoms [14]. Some studies have indicated that the severity of comorbid depressive symptoms might be more relevant than the severity of OCD symptoms [9, 16].

Until now, research into potential changes in the QoL in persons with OCD after psychotherapy has largely been limited to short-term outcomes. We found only two psychotherapy studies which provide data on the QoL at follow-up time points: Mawson et al. [17] demonstrated long-term effects (114 weeks) of a combined treatment (selective serotonin reuptake inhibitor (SSRI) and EX/RP) on a social adjustment scale, and Cordioli [13] reported that the effects of their cognitive behavioral group therapy on QoL remained stable over a period of 3 months. This situation has led several authors to recommend additional research on long-term changes of the QoL based on psychometrically sound measures [7, 9, 11]. Research in persons with other disorders suggests that the QoL can be improved on a long-term basis. For instance, QoL improvements over a period of 12 months have been demonstrated in persons with social phobia [18] and depression [19].

The aim of our data analysis was to investigate the QoL of persons with OCD prior to and 12 months after an intense multimodal inpatient treatment based on CBT (averaging 9 weeks) and subsequent outpatient treatment. Particularly, we addressed the following research questions: (1) Do persons with OCD suffer from a diminished QoL compared to population norms? (2) Do they exhibit an improved QoL 12 months after treatment? (3) If so, are the QoL scores comparable to population norms after treatment? (4) How are QoL changes over a 1-year period related to changes in depressive symptoms?

Our results are in line with previous reports on significantly reduced QoL in persons with OCD when compared to norm values from the general population [9, 10, 28]. The level of impairment observed in our study corresponds well to data by Hollander et al. [10] and Albert et al. [29] who reported that baseline scores were at least one z score below norm values for each mental health domain of the SF-36.

With regard to distinct QoL domains, reduced QoL in the psychological domain and social functioning have been reported based on different QoL measures [7, 9, 10]. Skevington and McCrate [30] recently published means and standard deviations for the WHOQOL-BREF for different conditions. The score for psychological QoL of our sample was lower than the scores of persons with chronic schizophrenia, sleep disorders, diabetes mellitus, and neurodegenerative disorders. Only persons with depression reported a lower quality of life in the respective domain.

The results concerning physical QoL are controversial: Some studies found that physical QoL in persons with OCD was not impaired [31], whereas others have reported impairments [9]. One possible explanation is that impaired physical QoL in persons with OCD might reflect comorbid depressive symptoms. Moritz and colleagues [9], who found that physical QoL was impaired, reported that the criteria for major depression or dysthymia were fulfilled by 37% of their participants. In contrast, Koran et al. [31] used the same QoL measure (SF-36) and observed that physical QoL was comparable to norm values. Of note, in their sample only 2% of the participants were diagnosed with major depression and 12% with dysthymia. The differences concerning physical QoL cannot be attributed to age, as the participants of the study by Moritz et al. were younger than the sample by Koran et al. In our sample, physical QoL was reduced at baseline, which might be driven by the relatively high severity of comorbid depression (mean baseline BDI 19). More specifically, it is to note that the physical domain of the WHOQoL-BREF includes questions about the ability to manage daily routines, working ability, sleep quality, and energy for daily living. It seems plausibe that persons with mood disorders according to ICD-10 criteria who suffer from energy loss, diminished interest, and sleep disorders score low on this domain.

Environmental QoL, which is covered by the WHOQOL-BREF, but not by the SF-36, was not reduced in our sample and was slightly higher than in most other samples of persons with OCD (e.g., Cordioli [13] who found a baseline score which was more than 10 points lower than ours). Interestingly, Stengler-Wenzke and colleagues [32], who analyzed a similar German OCD sample seeking help at a University Medical Center (Leipzig), found a very similar baseline score for environmental QoL. This might be due to a selection bias. Patients with a stable socioeconomic background may be more likely to seek help in a University Medical Center in an urban area. This line of arguments fits well to the high level of education reported in our sample. Only two participants did not finish school, and 73% had at least a secondary level of education.

In line with other results, our findings indicate that the QoL of persons with OCD can be improved in the long run. In the randomized trial by Cordioli [13], the QoL was found to be improved 3 months after cognitive behavioral group therapy in comparison to baseline. This observation comprised improvements on all four domains of the WHOQOL-BREF with effect sizes within the medium range (effect sizes were calculated by the authors of the present paper based on means and standard deviations reported by Cordioli et al.).

Furthermore, we observed that the different QoL domains improved to a different extent: Improvements were most prominent for psychological and physical QoL, whereas social QoL was not significantly changed. Other studies with 12-month follow-up periods also found that social QoL did not improve in persons with depression aged 65 years or older [19] and in persons with social phobia [18]. Possibly, profound changes concerning social relationships and social support require prolonged periods of time. Insufficient social support and impaired social networks might be an etiological and maintaining factor of various mental disorders rather than a consequence of psychiatric symptoms.

Another important observation is that—despite significant improvements—the QoL of persons with OCD remained below population norms. This is in line with other results [9].

With regard to potential mediators, we found that QoL improvement was strongly linked to a reduction of depressive symptoms. Previous studies indicated that QoL and QoL improvement might be more strongly associated with depression than with OCD severity [9, 16]. This implies that a careful diagnosis and, if applicable, treatment of comorbid depression is an important step in treating persons with OCD.

To the best of our knowledge, the present study is the first that repeatedly administered a psychometrically sound measure of QoL in persons with OCD over a course of 12 months. Thus, our results extend previous research by providing data on long-term changes of QoL in persons with OCD. However, a number of significant limitations need to be discussed. First, our study lacks a control group. Second, we did not control for medication. Thus, conclusions about potential causal relationships between the administration of inpatient CBT and subsequent outpatient treatment, QoL improvements, and symptomatic changes cannot be drawn. We can nevertheless draw on solid data demonstrating that OCD is a chronic disorder which does not show considerable improvement over time without treatment [33, 34]. Third, the current analysis is based on quality management data from our clinic that, within the period of observation, did not routinely include measures of OCD severity. For this reason, the baseline scores of our sample were compared to data reported in other studies in order to better characterize our sample. The baseline SCL-90-R global severity indices and OC-subscale scores of our sample correspond well to the scores of n = 43 persons with OCD reported by Grabe et al. [35]. The baseline GAF score of 41.6 in our sample indicates severe impairment and is considerably lower than scores reported by Ramirez et al. [36] for psychiatric outpatients belonging to several diagnostic groups, including mood, anxiety, and eating disorders. Another limitation is that structured interviews have not been used. Future studies are needed to further disentangle the impact of distinct changes in psychopathology on long-term changes in the QoL. Furthermore, it remains possible that we overestimated QoL improvements, as our study suffered from a considerable amount of missing data. Patients who were less satisfied with the treatment were possibly less likely to send back the follow-up questionnaires. However, we showed that the analyzed sample did not differ from the original dataset concerning psychological distress and sociodemographic data.

The present analysis shows that persons with OCD suffer from low QoL which, in the current study, improved over the course of 12 months. However, additional research on the long-term effects of CBT on QoL in the shape of a prospective, randomized, and controlled clinical trial is warranted because the present analysis has relevant limitations and does not allow for conclusive statements. Despite significant increases, four of five QoL domains remained diminished compared to healthy people. Only a minority of our patients achieved clinically significant long-term improvements of QoL. The replication of a persistently compromised QoL after state-of-the-art treatment would indicate the need for the development of novel and more effective treatments to improve the QoL in persons with OCD.