Disability associated with psychiatric disorders is considered an important public health problem in developing countries like India [1]. Disability due to psychiatric illness refers to dysfunction or inadequate performance in specific activities of daily living which are normally expected from a person according to his age, sex and societal role [2]. About one-third of patients having Major Depressive Disorder (MDD) and Bipolar Affective Disorder (BPAD) have a severe disability. Self-care and work were the dysfunctional areas in MDD while BPAD affected all areas of functioning [3,4].
Non-psychotic disorders such as OCD, anxiety disorders, DD, and somatoform disorder also run a chronic course and can cause disability. It is reported that about 16-17% OCD and anxiety disorders result in significant disability [3]. However, Olfson M et al., did not observe any significant disability in OCD [5]. OCD is the only non-psychotic illness for which the government of India sanctions disability benefits. Effective treatment and the issue of monetary benefit for the disabled by the government assume importance in this context. In this background, it is important to assess the extent of disability in OCD and compare it with another non-psychotic illness, DD.
There is limited available literature which assessed disability among non psychotic illnesses in Indian setup. However, there are some community-based studies to assess mental disability in mental disorders [6]. Hence, the present study was planned to assess disability in OCD and compare it with another non-psychotic illness, DD.
Materials and Methods
Setting and Sample Size
This was a cross-sectional hospital-based comparison study conducted in the Department of Psychiatry attached to a medical institution in central Karnataka, India. The sample size consisted of two group of 30 patients each diagnosed to have OCD and DD. The consecutive sampling method was used to select the study subjects.
Inclusion and Exclusion Criteria
All the subjects between 18-45 years age group with duration of at least two years illness of OCD (as OCD has bimodal onset with late adolescent and adult onset of illness, the subjects were recruited in the above age group) and DD (as it may be early onset i.e., before 21 years and late onset i.e., after 21 years) period were included in the study. Patients having co-morbid organic brain syndromes, psychosis, bipolar affective disorder, maniac depressive disorder, alcohol and substance dependence, personality, disorder and mental retardation, patients having a concomitant chronic physical illness, past history of psychiatric illness and family history of psychiatric illness were excluded from the study.
Ethical Clearance
The study was approved by the Ethical Committee of the medical institution. Informed consent was obtained after explaining the study details to the subjects. This part of the study presented the comparison of mental disability in OCD and DD.
Tools
Diagnostic and Statistical Manual for mental disorders (DSM-IV-TR) criteria for OCD and DD [7];
Yale Brown Obsessive Compulsive Scale (Y-BOCS) [8];
Hamilton Depression Rating Scale (HAM-D) [9];
Indian Disability Evaluation and Assessment Scale (IDEAS) [10].
Method of Data Collection
Following the inclusion of the patients in the study the socio-demographic details like age, sex, urban/rural, address, type of family, number of persons in the family, education, occupation, and income of family from all sources was collected by interviewing the patient using a standard structured questionnaire. Socioeconomic status was assessed by modified Prasad classification scale. The duration of illness in OCD and DD was taken from the history given by the patients. This was followed by the administration of Yale Brown Obsessive Compulsive scale. The Hamilton depression rating scale was used to measure depression. The IDEAS was used to quantify disability.
Statistical Analysis
The scores were tabulated using SPSS version-16.0 software. For continuous data, Student’s t-test was used. For categorical data ‘chi-square test’ was used. Information was presented in proportion; mean score value and its Standard Deviation (SD) and 95% confidence interval. A p-value of less than 0.05 was considered significant.
Results
The baseline characteristics were comparable to most of the variables in both the groups [Table/Fig-1]. Mean disability score was not found to be different within the various groups of socio demographic parameters in OCD and DD conditions [Table/Fig-2,3]. The percentage of moderately disabled patients was more in the DD group than in the OCD group though the difference was not statistically significant [Table/Fig-4].
Socio-demographic profile of subjects with OCD and DD.
| Characteristics | Subjects with OCD (n=30) (%) | Subjects with DD (n=30) (%) |
|---|
| Age in years (Mean±SD) | 27.33±7.49 | 32.33±9.97 |
| Sex | Male | 14 (46.7) | 12 (40.0) |
| Female | 16 (53.3) | 18 (60.0) |
| Place | Rural | 7 (23.3) | 14 (46.7) |
| Urban | 23 (76.7) | 16 (53.3) |
| Religion | Hindu | 28 (93.3) | 23 (76.7) |
| Muslim | 2 (6.7) | 7 (23.3) |
| Type of Family | Nuclear | 23 (76.7) | 26 (86.7) |
| Joint | 7 (23.3) | 4 (13.3) |
| Education | Upto class 10 | 10 (33.3) | 22 (73.3) |
| Above class 10 | 20 (66.7) | 8 (26.7) |
| Occupation | Unemployed | 15 (50) | 6 (20.0) |
| House wife | 7 (23.3) | 8 (26.7) |
| Agriculture | 1 (3.3) | 8 (26.7) |
| Business | 6 (20) | 6 (20.0) |
| Employed | 1 (3.3) | 2 (6.7) |
| Socioeconomic Status | Higher Class | 11 (36.7) | 7 (23.3) |
| Middle Class | 11 (36.7) | 12 (40.0) |
| Lower Class | 8 (26.7) | 11 (36.7) |
| Marital Status | Married | 15 (50.0) | 21 (70.0) |
| Unmarried | 15 (50.0) | 9 (30.0) |
Comparison of socio-demographic features and disability in OCD.
| Socio-demographic features | Mean disability score | p-value |
|---|
| Age | <30 years (n=22) | 6.57±1.65 | 1.04 NS |
| >30 years (n=8) | 5.92±0.96 |
| Sex | Male (n=14) | 6.25±0.84 | 0.47 NS |
| Female (n=16) | 6.52±1.94 |
| Place | Urban (n=23) | 6.5±1.65 | 0.72 NS |
| Rural (n=7) | 6.03±0.95 |
| Education | <SSLC (n=10) | 6.76±2.4 | 0.92 NS |
| >SSLC (n=20) | 6.21±0.81 |
| Marital status | Married (n=15) | 6.19±0.96 | 0.73 NS |
| Unmarried (n=15) | 6.59±1.93 |
| Socioeconomic status in OCD | Higher Class (n=11) | 6.26±0.7 | 0.682 NS |
| Middle Class (n=11) | 6.8±2.27 |
| Lower Class (n=8) | 6.01±0.97 |
NS: Not significant
Comparison of socio-demographic features and disability in DD.
| Socio-demographic features | Mean total score | p-value |
|---|
| Age | <30 years (n=16) | 6.31±1.08 | 0.92 NS |
| >30 years (n=14) | 5.93±1.21 |
| Sex | Male (n=12) | 6.42±0.99 | 1.12 NS |
| Female (n=18) | 5.94±1.2 |
| Place | Urban (n=16) | 6.0±1.15 | 0.68 NS |
| Rural (n=14) | 6.28±1.14 |
| Education | <SSLC (n=22) | 6.0±1.11 | 1.07 NS |
| >SSLC (n=8) | 6.5±1.19 |
| Marital status | Married (n=21) | 6.0±1.14 | 0.98 NS |
| Unmarried (n=9) | 6.4±1.13 |
| Socioeconomic status in OCD | Higher Class (n=7) | 6.43±1.5 | 2.63 NS |
| Middle Class (n=12) | 5.58±0.79 |
| Lower Class (n=11) | 6.55±1.3 |
Severity of disability in OCD and DD.
| Disability | OCD | DD | Statistical significance |
|---|
| Mild | 19 (63.33%) | 14 (46.66%) | χ2=1.68 df=1, NS |
| Moderate | 11 (36.66%) | 16 (53.33%) |
In the domain of self care of IDEAS there was significant difference between the OCD and DD group. In the domains of interpersonal relationship communication and work there was no significant difference between the two groups. Duration of illness in OCD group was more compared to DD and this difference was statistically significant [Table/Fig-5]. Mild (n=19) and moderate (n=11) disability when compared with obsession and compulsion score showed no significant significance in the mean score [Table/Fig-6].
Comparison of Disability score in OCD and DD.
| IDEAS domains | OCD (n=30) | DD (n=30) | Statistical significance df=58 |
|---|
| Self care | 0.41±0.28 | 0.56±0.22 | t=2.23 p<0.05 |
| Interpersonal relations | 0.66±0.39 | 0.67±0.30 | t=0.08 NS |
| Communication | 1.25±0.46 | 1.38±0.37 | t=1.19 NS |
| Work | 1.45±0.93 | 1.33±0.89 | t=0.88 NS |
| Duration | 2.53±0.73 | 2.23±0.43 | t=1.94 p<0.05 |
| Total score | 6.39±1.5 | 6.13±1.14 | t=0.76 NS |
Comparison of disability score with Y-BOCS in OCD.
| Y-BOCS | Ideas disability | p-value |
|---|
| Mild (n=19) | Moderate (n=11) |
|---|
| Obsession | 12.95±3.44 | 13.0±3.32 | 0.48 NS |
| Compulsion | 12.63±3.42 | 13.64±3.0 | 0.36 NS |
Discussion
Out of the 30 patients with OCD, 19 (63.33%) had a mild disability and 11 (36.66%) had the moderate disability. There was no severe disability in the current study. This finding differs from the findings of other authors who have found significant disability in OCD. Steketee G found disability in OCD was equal to that of schizophrenia [11]. Chaudhury PK et al., noted that about 16% of OCD had significant disability and disability associated with alcohol use disorder and anxiety was comparable to disability on account of OCD [3]. In the current study, work was affected more followed by communication and then interpersonal relationship among those with OCDs. The least to be affected was self-care. This is in accordance with the earlier study which found significant work, social, and family disability using Sheehan’s disability scale [12]. Similar findings have been observed by others who noted that OCD with an occupational disability was associated with greater functional impairment in completing household duties and social functioning [13]. OCD patients could be relatively more disabled in the area of work because of interference by obsessions and compulsions in patients work. Self-care domain of disability was least affected because OCD is a non-psychotic disorder where in activities of daily living are not grossly impaired as insight is not lost.
About 14 (46.66%) patients out of 30 patients with DD a had mild disability and 16 (53.33%) patients had the moderate disability. None had a severe disability. This finding differs from the earlier studies which have found severe disability. Disability was more in DD than in MDD [14]. Secondary depression in chronic physical illness causes significant disability [15]. DD was more disabling than acute depression (MDD of >2 years without lifetime DD) and the general population [16]. In DD the distress is experienced internally and may not show up in the external behaviour of the patient. Hence, the patient may be compelled to carry on with life due to socioeconomic constraints. In the present study, communication was the most affected domain among subjects with DDs, followed by work and interpersonal relationship. The least to be affected was self-care. Earlier studies in this area have not addressed this issue. DD patients could be relatively more disabled in the communication domain of disability because of interference of depressed mood in communication with others. Self-care domain of disability was least affected because DD is a non-psychotic disorder wherein activities of daily living are not grossly impaired as insight is not lost.
The percentage of people who were moderately disabled was more in the DD group than OCD group. However, this was not statistically significant. When OCD was compared with DD on the domains of self-care, interpersonal relationship, communication and work, there was no significant statistical difference between the two illnesses. There is no available literature as far as present knowledge is concerned in this area comparing the disability between OCD and DD. In the current study, duration of illness had no bearing on the severity of disability in OCD and DD. No study available in this regard. Another study which assessed quality of life and disability among schizophrenia and OCD patients in remission revealed that schizophrenics have poor QOL and greater disability burden than patients of OCD [17].
In a study which examined Association between DD and Disability, with Religiosity as moderator found that there is a statistically significant association between DD and the functional disability and religiosity has not shown a significant effect on the association between DD and functional disability [18]. At present Government of India extends a disability benefit to certain psychiatric categories like Schizophrenia, BPAD, Dementia, and OCD having more than 40% disability i.e., for moderate and severe disability. OCD is the only “non-psychotic” disorder included in the above category. In the present study, since disability in DD was equal to OCD, future research may be warranted to include disability benefits for DD.
Limitation
The sample size was small hence may not represent the homogeneity of the population in the community. OCD and minor depression subjects of less than two years of illness duration though having a disability have not been included in the study.
Conclusion
The present study found disability in both obsessive compulsive disorder and dysthymic disorder group. Total disability score had no statistical difference between the two groups. However, patients with OCD are getting disability benefits whereas patients who are having dysthymic disorders are not.
Further research are needed to assess the extent of disability in non-psychotic disorders and their consideration for eligibility to get disability benefits from Government of India.
NS: Not significant