Duration of Untreated Illness in Obsessive-Compulsive Disorder and its Associated Factors

Abstract

Introduction

The period before effective treatment is administered, is known as the duration of untreated illness (DUI). It has been found to relate to prognoses and sensitivity to treatment. The DUI is yet to be fully investigated in relation to obsessive-compulsive disorder (OCD).

Method

The present study examined a sample of 89 patients who presented with OCD over a span of two years and who were treated at a clinic in Khartoum, the capital city of Sudan. We examined the mean DUI before the patients received an effective psychiatric intervention. We also gauged different sociodemographic and clinical presentations associated with DUI.

Results

The sample comprised 55 male (61.8%) and 34 female patients (38.2%). Around 75% were single (N = 67); 34 participants (38.2%) were students; 28 (31.5%) were employed; and 27 (30.3%) were unemployed. The mean age of the participants was 27.12 years (SD ± 8.72) and the mean age at the first onset of the disorder was 21.72 years (SD ± 7.51). The mean of DUI was 5.41 years (SD ± 5.53). There was no significant difference in DUI in respect of age or gender. It was significantly longer in unemployed patients (7.59 years ± 5.93) than in employed (6.37 years ± 6.64) or students (2.88 years ± 2.59); p = 0.002. Married OCD patients had a longer DUI than single patients.

Conclusion

The present study highlighted a considerable delay before OCD patients received effective treatment. Although many intractable cultural and socioeconomic factors were tested, the strongest associations were found to be unemployment and marital status.

Introduction

Obsessive-compulsive disorder (OCD) is a common chronic and disabling psychiatric illness leading to considerable morbidity and socioeconomic burden.¹ It is the fourth most common mental disorder worldwide with a lifetime prevalence between 0.5-3% amongst the general population.^2,3,4 The principal characteristic features of the disorder are intrusive unwanted thoughts, urges, or images (obsessions), and repetitive ritualistic behaviors or mental acts (compulsions).⁵ The age of onset in OCD varies widely from childhood to late-life stages, with two peaks; between 9-11 and 20-23 years.^6,7 The mean age of onset of OCD was found to be 19.5 years (SE = 1.0) in a United States national survey.⁸ In spite of this relatively early onset, OCD patients usually delay seeking treatment. This may be due to their awareness of the senseless nature of their thoughts and behavior, which may make them feel ashamed and disinclined to ask for help.^9,10 However, research has revealed other reasons for the prolongation of duration of untreated illness, such as the fluctuating course of illness, and, the acceptance of less distressing symptoms as normal extensions of inherent premorbid personality characteristics.¹¹ The period between disorder onset and the first appropriate pharmacological treatment, which is conditional upon patient compliance, is termed duration of untreated illness (DUI).^12,13 It is considered to be an important factor in predicting prognosis and outcome for several psychiatric disorders.^12,14,15 Many long-term outcome studies have indicated that those who experienced short-duration OCD symptoms in early and middle childhood and who had intensive therapy had better outcomes, whereas those who experienced long-duration symptoms and who had less intensive therapy had unfavorable outcomes.^14–16 Early recognition of the illness is therefore important; a longer DUI, especially in adulthood, can prove to be more intractable.^14–16 The DUI is a predictor of outcomes in schizophrenia and affective disorders. There is also emerging evidence to show that DUI plays a predictive role in OCD outcomes.^12,13 Many studies have examined socio-demographic factors that may be associated with DUI in cases of OCD, such as age of onset and gender.^17–20 A Canadian study of OCD patients found that DUI correlated negatively with the age of onset,¹⁷ a finding which was similar to an older study by Grant et al. that showed that patients who developed OCD at a later age had presented in psychiatric facilities previously.¹⁸ Vigne et al. did not find a significant association between DUI and patients’ gender.²⁰

Some studies have investigated the clinical features of OCD in relation to DUI. Dell’Osso et al. found a significant association between a longer DUI and the aggressive/checking subgroup of the study sample compared with other subgroups.²¹ Other studies failed to find a significant association between DUI and symptom severity and most comorbid mood or anxiety disorders.²⁰ Exploring different aspects of DUI in OCD may help towards an understanding of the factors that contribute to delays in seeking treatment; the development of longer DUI cases; and outcomes. In Sudan, research on OCD patients -especially regarding the effect of DUI- is scarce. The present study aims to bridge the gap in the literature by examining a number of factors that are thought to play a role in determining DUI using a sample of Sudanese patients with OCD.

Materials and Methods

Ethical approval of the present study was obtained from the Ministry of Health Research Ethics Committee of Sudan. The participants comprised patients who had presented at a clinic in Khartoum, the capital city. Data were collected using a questionnaire prepared for the purpose of the study. The information that was gathered included socio-demographic data (e.g., age, gender, marital status, and occupation); duration of illness before treatment; OCD symptoms (i.e., obsessions about contamination, aggression, sex, religious thoughts, doubting, compulsive washing, checking, repeating, and counting); type of OCD (predominantly obsessive, predominantly compulsive, or mixed); and comorbidities with psychotic or depressive disorders.

The participants were Sudanese OCD patients who visited the specialist psychiatry clinic Ibn Elhaithum Diagnostic Centre, which is located in the central area of Khartoum. It serves patients from the city and elsewhere. The study included all patients who received a diagnosis of OCD based on DSM-5 diagnostic criteria during 2015 and 2016. The patients were registered by specialist doctors. Any cases where the records were not complete were excluded. The data were analyzed using the statistics package SPSS version 24 (IBM). Descriptive data are presented in numbers and percentages. The DUI means of different patient groups were compared using an ANOVA test. A p-value < .05 was used to determine statistical significance.

Results

The total number of patients included in the study was 89 candidates, 55 males (61.8%) and 34 females (38.2%). Around three-quarters were single; 34 (38.2%) were students; 28 (31.5%) were employed; and the remainder were unemployed (Table 1). The mean age of all participants was 27.12 years (SD ± 8.72) and the mean age of the first onset of the disorder was 21.72 years (SD ± 7.51). The DUI mean was 5.41 years (SD ± 5.53). There was no significant difference in DUI regarding age or gender. The duration of untreated illness was significantly longer in the unemployed participants (7.59 years ± 5.93) than in the employed (6.37 years ± 6.64) or student (2.88 years ± 2.59) participants; p = 0.002 (Table 1).

Table 1. Duration of Untreated Illness in OCD Patients in Relation to Gender, Marital Status, Occupation, and Age of Onset (N = 89).

					Duration of untreated illness (years)
Sociodemographic factors				N (%)
						Mean		SD		P-value
Gender		Male		55 (61.8%)		5.28		6.10		0.784
		Female		34 (38.2%)		5.61		4.54
Occupation		Student		34 (38.2%)		2.88		2.59		0.002*
		Employed		28 (31.5%)		6.37		6.64
		Non-employed		27 (30.3%)		7.59		5.93
Age of onset		< 18		26 (29.2%)		6.31		6.03		0.615
		18–22		38 (42.7%)		4.98		5.02
		> 22		25 (28.1%)		5.11		5.86
Marital status		Single		67 (75.3%)		4.32		4.52		0.001*
		Married		22 (24.7%)		8.73		6.99
Total				89 (100%)		5.41		5.53

The married participants had a longer DUI; the means of the married and single participants were 8.73 years (SD ± 6.99) and 4.32 years (SD ± 4.52, p = 0.001), respectively. The mean of DUI amongst participants with psychotic comorbidities was 9.64 years (SD ± 6.66), which was significantly longer than those without (M = 5.04 years, SD ± 5.31, p = 0.034; Table 2).

Table 2. Duration of Untreated Illness in OCD Patients in Relation to Comorbidity and Types of OCD (N = 89).

					Duration of untreated illness (in years)
				N (%)		Mean		SD		P-value
Comorbidity with psychosis		Yes		7 (7.9%)		9.64		6.66		0.034*
		No		82 (92.1%)		5.04		5.31
Comorbidity with depressive disorder		Yes		33 (37.1%)		5.29		5.60		0.898
		No		56 (62.9%)		5.45		5.55
Types of OCD		Mixed		57 (64%)		5.33		5.23		0.987
		Predominantly obsessive		31 (34.8%)		5.48		6.22
		Predominantly compulsive		1 (1.2%)		6.00		0
Total				89 (100%)		5.41		5.53

There was no significant difference in DUI between comorbid cases with depression or other cases. Also, there was no significant difference between types of OCD (i.e., predominantly obsessive, predominantly compulsive, or mixed).

Table 3 shows DUI mean comparisons amongst the different groups of participants according to clinical features after the exclusion of OCD cases with psychotic comorbidities (N = 82). Participants who suffered from obsessive sexual thoughts had a significantly shorter DUI (1.49 years ± 1.04) than those who did not (5.40 years ± 5.46, p = 0.047). Also, participants who washed compulsively showed a significantly longer DUI (6.68 years ± 6.22) than the others (3.99 years ± 4.40, p = 0.024). Other OCD features did not appear to be associated with a longer or shorter DUI.

Table 3. Duration of Untreated Illness in OCD Patients in Relation to Clinical Features (N = 82).

								Duration of untreated illness (in years)
						N (%)		Mean		SD		P-value
Obsessions		Contamination		Yes		21 (25.6%)		5.37		6.00		0.741
				No		61 (74.4%)		4.92		5.10
		Aggressive thoughts		Yes		3 (3.7%)		8.67		10.69		0.231
				No		79 (96.3%)		4.90		5.09
		Sexual thoughts		Yes		8 (9.6%)		1.49		1.04		0.047*
				No		74 (90.4%)		5.40		5.46
		Religious thoughts		Yes		26 (31.7%)		4.31		3.97		0.399
				No		56 (68.3%)		5.38		5.84
		Doubting		Yes		72 (87.8%)		4.95		4.93		0.700
				No		10 (12.2%)		5.65		7.88
		Others		Yes		10 (12.2%)		4.65		4.40		0.807
				No		72 (87.8%)		5.09		5.45
Compulsions		Washing		Yes		32 (39.0%)		6.68		6.22		0.024*
				No		50 (61.0%)		3.99		4.40
		Checking		Yes		26 (31.7%)		5.61		5.07		0.511
				No		56 (68.3%)		4.77		5.45
		Repeating		Yes		19 (23.2%)		4.24		3.31		0.456
				No		63 (76.8%)		5.28		5.78
		Counting		Yes		9 (10.8%)		5.72		2.39		0.685
				No		73 (89.2%)		4.95		5.57
		Others		Yes		8 (9.8%)		4.13		4.12		0.612
				No		74 (90.2%)		5.14		5.44
Total						82 (100%)		5.04		5.31

Discussion

The present study aimed to examine DUI amongst a sample of Sudanese patients with OCD and its possible associations. The findings showed that the mean of DUI was 5.41 years (SD ± 5.53), or 64.9 months (± 66.63). This was shorter than in some studies; e.g., the mean DUI was 7.02 (± 8.52) years in a Turkish study¹¹ and 7.3 years in a sample of 114 patients in an Italian study.²¹ In another Italian study, which involved 251 individuals, the mean DUI was approximately 9 years.¹⁵ By contrast, DUI in the present study was longer than in Matsumoto et al.’s Japanese study, where it was 4.7 years.²² However, all studies on OCD have revealed that there was a considerable delay before patients received effective treatment. This was probably because many of the patients saw OCD as a normal feature of their character, despite the considerable distress and dysfunction the symptoms may have caused.^11,22,23 The internal locus of control and the fluctuating nature of the condition often give patients an elusive feeling that they will self-recover. In addition, mentally ill patients refrain from seeking help because of the associated stigma, the prohibitive cost of treatment, and the cultural tolerance of doubting within religious communities.^11,23–25 The present study did not find a correlation between DUI and age of onset; De Luca V et al. and Grant et al. discovered a negative correlation.^17,18 No association was found between DUI and participants’ gender, which accords with Vigne et al.’s findings.²⁰ The participants who were unemployed at the time of the study appeared to have a longer delay in accessing psychiatric facilities to receive treatment than the employed and student participants. Significantly, more married OCD patients sought psychiatric help than their unmarried counterparts. This may have been because spousal support triggered relatively early help seeking behavior.

The present study did not find a relationship between the DUI of OCD and its type of presentation and comorbidity with depression, which is similar to a study finding from Japan,²² but the DUI was significantly longer among those who had comorbid psychosis. This delay in seeking psychiatric help among those patients is likely to be due to poor judgment and lack of insight associated with psychosis, or due to a higher level of self-stigmatization associated with psychotic disorders compared with pure OCD.²⁶ However, in contrast with some studies, our study revealed that the patient’s age had no effect on DUI.^11,22 According to our results; having obsessive sexual thoughts was associated with shorter DUI, which can be attributed to the distressing nature of such annoying thoughts pushing the patient to seek help. On the other hand, having compulsive washing was associated with longer DUI, which may be due to the cultural background of some participants who misinterpret their compulsive washing as a sort of carefulness in performing religious rituals. This may lead to some acceptance of the symptoms and delay in seeking help. The associations described above should be measured alongside other identified barriers to psychiatric services, for instance, stigma, service accessibility, cultural attitudes to mental illness, and psychiatric awareness.^11,23,24

The present study has several limitations. The correlations were tentative, so it was not possible to establish the predictive determinants of DUI. Likewise, it does not address the complex relationship between these associations and other deterrents that make it difficult for OCD sufferers to access psychiatric services.

Conclusions

The present study has stressed the considerable delay before OCD patients receive effective treatment. As has been noted, the mean duration in the sample was 5.41 years. To the best of our knowledge, the study is the first to highlight the significance of socio-demographic factors in DUI of obsessive-compulsive disorder in Sudan. These include age of onset, marital status, and employment status, in addition to more widely known obstacles. It is recommended to conduct more studies on DUI of obsessive-compulsive disorder in a larger sample with a longitudinal study design to examine its relation to treatment outcome.