- Both obsessive-compulsive disorder (OCD) and major depressive disorder (MDD) are common mental health disorders, affecting millions of Americans each year.
- Around 25% to 50% of people with OCD also meet the diagnostic criteria for a major depressive episode, according to the International OCD Foundation.
- OCD symptoms like unwanted intrusive thoughts lead people to isolation, loneliness and withdrawal, which can lead to depression.
- ERP is the gold standard for the treatment of OCD.
- For more stories, visit the NOCD blog.
Both obsessive-compulsive disorder (OCD) and major depressive disorder (MDD) are common mental health disorders, affecting millions of Americans each year. Studies have shown that people who have OCD are more likely to develop other forms of mental illness, and depression is no exception. According to the International OCD Foundation, around 25% to 50% of people with OCD also meet the diagnostic criteria for a major depressive episode. While there is no doubt a correlation between OCD and depression, could one cause the other? Researchers think the answer is yes.
If you have OCD, your intrusive thoughts and need to engage in compulsions may wear on your interpersonal relationships, your performance at school or work and your overall daily functioning. This can undoubtedly be overwhelming and difficult to manage, potentially leading you to feel hopeless and exhausted.
In short, dealing with OCD may lead to a diagnosis of depression. Although common, a dual diagnosis is tricky to handle: OCD may be a root cause of your depression, while being in a depressive episode may affect your ability to adhere to your OCD treatment.
What is major depressive disorder (MDD)?
One of the most commonly known mood disorders, depression is classified as a persistent feeling of sadness and a loss of interest in things previously found enjoyable. Having depression isn’t just feeling sad; the symptoms last much longer than a bout of sadness. Furthermore, symptoms affect someone daily during a depressive episode, upsetting their ability to engage in normal daily activities. Symptoms may look like:
- Trouble sleeping or excessive sleeping
- Extreme lethargy
- Loss of interest or pleasure in most activities
- Feelings of worthlessness, hopelessness or emptiness
- Loss of appetite or binge eating
- Brain fog, lack of concentration, inability to make decisions
Do intrusive thoughts from OCD cause depression?
For someone who receives a dual diagnosis of both depression and OCD, the depressive episode typically occurs after the onset of the OCD symptoms. What this means is that the depression may be a result of the stress accompanied by OCD symptoms, such as intrusive thoughts. As mentioned previously, OCD can significantly interfere with one’s functioning and overall quality of life. People with OCD may endure hours per day of scary thoughts that lead them to engage in compulsions that take time and effort, and can have negative consequences for their relationships, work, school or overall health and well-being. It makes sense that depression might arise from fighting OCD every day.
In addition, depression can have a number of causes, including biochemical factors. Both OCD and MDD are characterized by imbalances in serotonin. Similar parts of the brain play a role in both depression and anxiety, increasing the likelihood that someone would develop both.
Depression and intrusive thoughts
Often, OCD symptoms like unwanted intrusive thoughts lead people to isolation, loneliness and withdrawal, which can lead to depression. According to researchers, depression is the most common comorbidity in OCD.
Intrusive thoughts from OCD can make people feel isolated from their social circle and distant from what matters the most to them in their lives. Intrusive thoughts are often disturbing and involuntary. The increased anxiety and the obsessions that are a result of intrusive thoughts can cause people to withdraw from their primary relationships, feel anxious about activities and hobbies that give them pleasure, or disrupt their daily life and ability to engage with their work and personal lives. This can lead to a feeling of hopelessness that, over time, can result in depression. For this reason, people often experience OCD and depression as part of a negative cycle.
Online forums for depression and OCD
Many people turn to online forums like Reddit and Quora as a place to discuss the intrusive thoughts they are experiencing from OCD, depression or both. At times, it can be helpful to share your experience with other people, even if they are people you’ve never met in person.
At the same time, seeking validation on online forums can often become a compulsion for people with OCD. Reassurance seeking, where you look to someone else for validation that your fears won’t come true, is a common OCD compulsion. People often turn to online forums to get that reassurance and satisfy their compulsion.
On the other hand, for many people, the internet and online forums are one of the few places they feel their condition is fully understood by others. For people with OCD, there is a fine balance between sharing information online and using that information as fuel for further obsessions and compulsions. (The NOCD app offers an online forum for people to share their stories and learn from and support others, and there is a no-reassurance-seeking policy.)
Postpartum intrusive thoughts and depression
Postpartum depression is a prolonged period of sadness, fatigue, anxiety and other symptoms that follow childbirth. It robs up to 15% of mothers of their vitality in an already difficult period, and is probably caused by a variety of factors including hormonal changes. An estimated 10% of new fathers are affected too, with partners of depressed mothers more likely to develop the condition.
Postpartum OCD is less common than postpartum depression. It is a subtype of OCD that parents experience shortly after or right before their baby is born. It’s characterized by unwanted intrusive thoughts that their baby is in danger or that they may hurt their baby. Some common intrusive thoughts from postpartum OCD include:
- The idea that the baby could die in their sleep (S.I.D.S.)
- An image of the baby dead
- Thoughts of the baby choking and not being able to save them
- Unwanted impulses to shake the baby to see what would happen
- Unwanted thoughts of stabbing the baby
- Unwanted thoughts of drowning the baby during a bath
It’s expected that parents are nervous about their newborn baby, but people with postpartum OCD experience ongoing obsessions about something terrible happening to their baby, and these fears are impossible to let go of. These intrusive thoughts cause increased anxiety that drives a person to engage in compulsions meant to alleviate their distress. Some common compulsions from postpartum OCD include:
- Checking on their child over and over, even throughout the night
- Avoiding being around the child alone
- Mentally repeating prayers or assertions about how much they care for the child
- Looking up unwanted thoughts on the internet
- Asking others if their child will be okay, or if they’re a good parent
Rather than keeping their child safe, these obsessions and compulsions only exhaust the parents, and can even make it difficult for them to care for their newborn. Although the condition primarily affects new mothers (1% to 3%), fathers can also demonstrate symptoms. The good news is postpartum OCD is highly treatable in the same way all types of OCD are treated.
How is a dual diagnosis of depression and OCD treated?
Typically, OCD is a highly treatable disorder, often through a form of cognitive behavioral therapy called exposure and response prevention. ERP, the gold standard for the treatment of OCD, works by exposing a patient to their OCD fears and triggers in a safe space. It helps them resist the urge to engage in their compulsions.
A dual diagnosis of OCD and MDD may affect progress in ERP. The depression symptoms may cause someone to feel an overwhelming sense of hopelessness, leading to a number of complications in their therapy. They may feel like the process is not worth it or that there’s no point in continuing their treatment. The extreme lethargy that often accompanies depression may also make it difficult for someone to even make it to their sessions or complete assigned exposure practice.
When someone is suffering from both disorders, mental health professionals will treat the most prevalent one first. “You have to sort out if the depression is primary or secondary,” April Kilduff, a licensed therapist specializing in OCD, explains. “Secondary depression is a result of OCD. The OCD gets so bad that the person gets depressed. If you treat the OCD, the depression lifts. If depression is primary, it’s separate from the OCD, though the OCD may have exacerbated it.
“If the depression is severe and the person is having a hard time getting out of bed or completing work or school tasks, then they likely don’t have the motivation and energy to do ERP,” Kilduff adds. “We’d ask them to stabilize the depression first before doing ERP.”
If you feel you may have depression alongside your OCD diagnosis, it’s important to talk with your doctor to make any necessary changes to your treatment. This may include being prescribed selective serotonin reuptake inhibitors (SSRIs) to help manage your depression symptoms enough to continue therapy.
How depression affects ERP therapy
One of the biggest obstacles for dealing with depression and OCD at the same time is that ERP requires a high level of participation from the patient and can be particularly emotionally or psychologically demanding. During ERP, people are intentionally exposing themselves to the cause of their compulsions. Depression, on the other hand, can make people feel lethargic. It can make any action, let alone a purposefully challenging one, feel impossible.
“When I first started treatment, my depression was extremely bad. It also didn’t help that we were going into the Covid shutdown,” says Casie David, a peer advocate at NOCD. “I think it’s hard because depression kind of takes away your motivation to do things, and ERP is a very active form of treatment. It’s almost like it’s working against you, and it makes it harder because you need to work so hard to get better.”
Fortunately, therapists have come up with ways of addressing this challenge. Jonathan Abramowitz, Ph.D., a clinical psychologist specializing in treating both OCD and depression, found it most effective to address the feelings that are causing depression and only then guide patients through ERP therapy. “Once we have addressed how patients feel about themselves and have motivated them to work hard to reduce their OCD, we introduce the exposure and response prevention techniques, which are practiced repeatedly until the end of treatment — usually about 16 to 20 sessions (including homework practice),” he wrote in an article from 2010 for the International OCD Foundation. “The results were encouraging, with about two-thirds of patients showing greater than a 50% reduction in their OCD symptoms.”
David was encouraged to find that her symptoms of depression declined when she treated her OCD. “My depression actually got a lot better as I got my OCD under control,” she says.
For David, her depressive symptoms were secondary, and they improved once she directly treated her OCD. “That was cool to notice, too. As I was improving my OCD, I was looking at my anxiety scores, and my depression scores, and my stress level scores, and all of them were going down as I was going through the program. I got more than one thing out of it.” I encourage you to learn about NOCD’s accessible, evidence-based approach to treatment. All of our therapists specialize in OCD and receive ERP-specific training and ongoing guidance from our clinical leadership team. Many of them have dealt with OCD themselves and understand how crucial ERP therapy is.