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Obsessive-compulsive disorder is uncommon but associated with high levels of comorbid neuroses, impaired function and increased suicidal acts in people in the UK
  1. Professor Paul Martin Salkovskis
  1. Institute of Psychiatry, King’s College, London, UK

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Q How common is obsessive-compulsive disorder in people in the UK?

METHODS

Embedded ImageDesign:

Cross-sectional study.

Embedded ImageSetting:

General population, UK; 2000.

Embedded ImagePopulation:

8580 people aged 16–74 years (56% female; 91% Caucasian) living in private households. Postcode areas from the Postcode Address File were stratified by socioeconomic status and geographical area and 438 selected at random. 36 households were selected randomly from each postcode area, and one individual selected randomly from each household to participate in the survey.

Embedded ImageAssessment:

Non-clinical interviewers carried out computer-assisted structured interviews to assess neurotic disorders, impairment, substance misuse and suicide attempts. Neurotic disorders were assessed using the Clinical Interview Schedule-Revised and diagnosed according to ICD-10 criteria based on symptoms experienced in the past month. A second interview assessed psychosis and personality disorder. Non-response and differing selection probabilities were accounted for by weighting of final prevalence estimates. Logistic regression analysis was used to estimate prevalence of obsessive-compulsive disorder and examine comorbidity, impairment, drug dependence and suicide risk. Comparisons were made between people with obsessive-compulsive disorder and people with other neuroses.

Embedded ImageOutcomes:

Obsessive-compulsive disorder (ICD-10 criteria).

MAIN RESULTS

The weighted one month prevalence of obsessive-compulsive disorder (OCD) was 1.1%. The majority of people with OCD had purely obsessive symptoms (purely obsessive: 55%; both obsessive and compulsive symptoms: 34%; purely compulsive: 11%). The prevalence of OCD was slightly higher in women than in men (1.3% in women vs 0.9% in men; statistical comparison not provided), and higher in younger people than in older people (0.2% in people aged 65–74 vs 1.1% in people aged 45–64 vs 1.2% in people aged 25–44 vs 1.4% in people aged 16–24). Comorbid neuroses were more common in people with obsessive-compulsive disorder compared with people with other neuroses (62% vs 10%). Social- and work-related impairments were higher in people with obsessive-compulsive disorder compared with people with other neuroses (social impairment: OR 2.8, 95% CI 1.7 to 4.4; work impairment: OR 3.0, 95% CI 1.7 to 5.1). Suicidal acts were also more common in people with obsessive-compulsive disorder compared with other neuroses (OR 2.0, 95% CI 1.2 to 3.4).

CONCLUSIONS

About 1 in 100 people in the UK have OCD. Although prevalence is low, OCD is associated with high levels of comorbid neuroses, high social- and work-related impairments and increased suicidal acts compared with other neuroses.

Commentary

Those working in a particular field of psychiatry tend to assert that the problem they work on is especially common, severe and disabling; such assertions are usually based on fragmentary evidence. This paper provides high quality UK epidemiological data in obsessive compulsive disorder (OCD). A realistic point prevalence of 1.1% (lower than obtained in a raft of poorly conducted studies and consistent with the best) is balanced by convincing evidence of the malignant nature of OCD relative to other “neurotic” disorders, malignancy expressed in terms of comorbidity, disability and elevated suicidality. Comorbidity is associated with considerably higher help seeking rates (56% vs 14% of people with OCD alone). The greatest surprise is the prevalence of obsessions without overt rituals (“ruminations”); at 55% of those identified, this is radically different from the figures obtained clinical settings, where ruminations are much rarer. One possibility, given that lay interviewers were used, is that “worriers” may have been misclassified in this study. However, differences between the clinic and community are not unusual; for example, agoraphobia without panic is much commoner in the community than in the clinic. The authors make a convincing case for removing OCD from “common mental disorders” group; OCD is relatively uncommon but undoubtedly a “severe mental illness”. If reinforcement is needed, then this study makes yet clearer the need for properly delivered specialist treatment by appropriately trained staff.

This study makes it clear that help seeking for this disabling problem is extremely low; other work suggests that, even among those who seek treatment, recognition of the diagnosis and offer of treatment tends to be very slow, and treatment itself is more often than not inappropriate.1 The availability of clear clinical guidelines (such as those from the National Institute for Health and Clinical Excellence2) should ensure that patients and clinicians are well informed about the treatment options. There remains the problem, highlighted by this paper, of how to ensure that those who are likely to benefit will come forward for such treatment in a timely way.

References

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Footnotes

  • For correspondence: Dr Torres, Departamento de Neurologia e Psiquiatria, Faculdade de Medicina de Botucatu, UNESP, 18618-970, Botucatu (SP), Brazil; torresar{at}fmb.unesp.br

  • Source of funding: Office for National Statistics, on behalf of the Department of Health.

Footnotes

  • Competing interests: None.

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