Relevant Publications

Suicide in obsessive-compulsive disorder: a population-based study of 36788 Swedish patients - L Fernandez de al Cruz et al

The risk of death by suicide in individuals with obsessive-compulsive disorder (OCD) is largely unknown. Previous studies have been small and methodologically flawed. We analyzed data from the Swedish national registers to estimate the risk of suicide in OCD and identify the risk and protective factors associated with suicidal behavior in this group. We used a matched case-cohort design to estimate the risk of deaths by suicide and attempted suicide in individuals diagnosed with OCD, compared with matched general population controls (1:10). Cox regression models were used to study predictors of suicidal behavior. We identified 36 788OCD patients in the Swedish National Patient Register between 1969 and 2013. Of these, 545 had died by suicide and 4297 had attempted suicide. In unadjusted models, individuals with OCD had an increased risk of both dying by suicide (odds ratio(OR) = 9.83 (95% confidence interval (CI), 8.72-11.08)) and attempting suicide (OR = 5.45 (95% CI, 5.24-5.67)), compared with matched controls. After adjusting for psychiatric comorbidities, the risk was reduced but remained substantial for both death by suicide and attempted suicide. Within the OCD cohort, a previous suicide attempt was the strongest predictor of death by suicide. Having a comorbid personality or substance use disorder also increased the risk of suicide. Being a woman, higher parental education and having a comorbid anxiety disorder were protective factors. We conclude that patients with OCD are at a substantial risk of suicide. Importantly, this risk remains substantial after adjusting for psychiatric comorbidities. Suicide risk should be carefully monitored in patients with OCD. Molecular Psychiatry (2017) 22, 1626-1632; doi:10.1038/mp.2016.115; published online 19 July 2016

Prevalence of suicide attempt and clinical characteristics of suicide attempters with obsessive-compulsive disorder: a report from the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS) - Bernardo Dell'Osso et al

Objective: Obsessive-compulsive disorder (OCD) is associated with variable risk of suicide and prevalence of suicide attempt (SA). The present study aimed to assess the prevalence of SA and associated sociodemographic and clinical features in a large international sample of OCD patients.

Methods: A total of 425 OCD outpatients, recruited through the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS) network, were assessed and categorized in groups with or without a history of SA, and their sociodemographic and clinical features compared through Pearson's chi-squared and t tests. Logistic regression was performed to assess the impact of the collected data on the SA variable.

Results: 14.6% of our sample reported at least one SA during their lifetime. Patients with an SA had significantly higher rates of comorbid psychiatric disorders (60 vs. 17%, p<0.001; particularly tic disorder), medical disorders (51 vs. 15%, p<0.001), and previous hospitalizations (62 vs. 11%, p<0.001) than patients with no history of SA. With respect to geographical differences, European and South African patients showed significantly higher rates of SA history (40 and 39%, respectively) compared to North American and Middle-Eastern individuals (13 and 8%, respectively) (χ2=11.4, p<0.001). The logistic regression did not show any statistically significant predictor of SA among selected independent variables.

Conclusions: Our international study found a history of SA prevalence of ~15% in OCD patients, with higher rates of psychiatric and medical comorbidities and previous hospitalizations in patients with a previous SA. Along with potential geographical influences, the presence of the abovementioned features should recommend additional caution in the assessment of suicide risk in OCD patients.

CNS Spectr. 2018 Feb;23(1):59-66. doi: 10.1017/S1092852917000177. Epub 2017 Mar 16. 

Suicide ideation and attempts in obsessive-compulsive disorder. Elsie Breet et al, 

Background: Obsessive-compulsive disorder (OCD) places individuals at risk for suicidality. Inconsistencies regarding the associated features of suicidality and OCD remain.

Methods: Regression analysis determined the extent to which psychiatric comorbidity, illness severity, OCD symptom dimensions, childhood trauma history, and the Val66Met (rs6265) polymorphism of the brain derived neurotrophic factor (BDNF) gene predict lifetime suicidal ideation and attempts in adults with OCD.

Results: Among the 496 participants, 51.8% reported suicidal ideation and 16.5% reported ≥1 suicide attempts. Females and individuals with borderline personality disorder (BPD) were at higher risk of presenting with suicide attempts (female: odds ratio [OR] = 2.75; 95% confidence interval [CI], 1.28 to 5.94; BPD: OR = 7.35; 95% CI, 3.25 to 16.61). Major depressive disorder (MDD), BPD, and avoidant personality disorder (AVPD) were significant predictors of suicidal ideation (MDD: OR = 2.4; 95% CI, 1.5 to 3.86; BPD: OR = 2.8; 95% CI, 1.36 to 5.73; AVPD: OR = 1.96; 95% CI, 1.02 to 3.75). No significant association was observed between BDNF Val66Met and suicidality.

Conclusions: Suicidality is common among patients with OCD. Several variables were associated with risk, including female sex, depression, and personality pathology. Further research into the underlying mechanisms is warranted. Emphasis is placed on assessment of suicidality risk and addressing modifiable features associated with suicidality to ensure better outcomes. 

Ann Clin Psychiatry. 2019 Aug 1;31(3):192-199. 

Suicide Risk in Obsessive-Compulsive Disorder and Exploration of Risk Factors: A Systematic Review. Umberto Albert et al 

Background: Historically, OCD has been considered to be associated with a relatively low risk of suicide. Recent studies, on the contrary, revealed a significant association between OCD and suicide attempts and ideation. A huge variation in prevalence rates, however, is reported.

Objective: To estimate prevalence rates of suicide attempts and suicidal ideation in individuals with OCD, and to identify predictors of suicide risk among subjects with OCD.

Methods: We systematically reviewed the literature on suicide risk (ideation and/or attempts) and OCD. We included studies with appropriate definition of OCD, cross-sectional or prospective design, separating clinical samples from epidemiological studies, that employed a quantitative measure of suicidality and/or reported an outcome measure of the association between suicidality and OCD or examined factors associated with suicidality.

Results: In clinical samples, the mean rate of lifetime suicide attempts is 14.2% (31 studies: range 6- 51.7%). Suicidal ideation is referred by 26.3-73.5% of individuals (17 studies, mean 44.1%); current suicidal ideation rate ranges between 6.4 and 75% (13 studies, mean 25.9). Epidemiological studies found that OCD increases significantly the odds of having a lifetime suicidal ideation as compared to the general population (OR: 1.9-10.3) and a history of lifetime suicide attempts (OR: 1.6- 9.9). Predictors of greater suicide risk are severity of OCD, the symptom dimension of unacceptable thoughts, comorbid Axis I disorders, severity of comorbid depressive and anxiety symptoms, past history of suicidality and some emotion-cognitive factors such as alexithymia and hopelessness.

Curr Neuropharmacol. 2019;17(8):681-696. doi: 10.2174/1570159X16666180620155941. 

Suicidal behavior in obsessive-compulsive disorder.  Prakash Kamath et al

Objective: There are limited data on suicidal behavior in obsessive-compulsive disorder (OCD). This study examines suicidal behavior and its clinical correlates in OCD subjects.

Method: One hundred consecutive DSM-IV OCD subjects attending the specialty OCD clinic and the inpatient services of a major psychiatric hospital in India from November 1, 2003, to October 31, 2004, formed the sample of this study. Subjects were assessed systematically by using structured interviews and various rating scales. The Scale for Suicide Ideation-worst ever (lifetime) and -current measured suicidal ideation. The 24-item Hamilton Rating Scale for Depression (HAM-D) measured severity of depression, and the Beck Hopelessness Scale (BHS) measured hopelessness. We performed assessments at study entry. We employed binary logistic regression (Wald) forward stepwise analysis for prediction of suicidal ideation and suicide attempt, and we used structural equation modeling for identifying the potential factors contributing to suicidal ideation.

Results: The rates of suicidal ideation, worst ever and current, were 59% and 28%, respectively. History of suicide attempt was reported in 27% of the subjects. For past suicide attempt, worst ever suicidal ideation (p < .001) was the only significant predictor, with an overall prediction of 89%, and accounted for 60% of the variance. For worst ever suicidal ideation, major depression (p = .043), HAM-D score (p = .013), BHS score (p = .011), and history of attempt (p = .009) were significant predictors, with an overall prediction of 82% and variance of 56%. Somewhat similar predictors emerged as significant for current suicidal ideators, with an overall prediction of 85% and variance of 50%. In the structural equation model, too, presence of depression and high BHS score contributed to suicidal ideation.

Conclusions: OCD is associated with a high risk for suicidal behavior. Depression and hopelessness are the major correlates of suicidal behavior. It is vital that patients with OCD undergo detailed assessment for suicide risk and associated depression. Aggressive treatment of depression may be warranted to modify the risk for suicide. Future studies should examine suicidal behavior in a prospective design in larger samples to examine if severity of OCD and treatment nonresponse contribute to suicide risk.

J Clin Psychiatry. 2007 Nov;68(11):1741-50. doi: 10.4088/jcp.v68n1114.