key: cord-0699393-nfcii1sq
authors: Liao, Jinmin; Liu, Lijun; Fu, Xiaoyu; Feng, Yingying; Liu, Wei; Yue, Weihua; Yan, Jun
title: The immediate and long-term impacts of the COVID-19 pandemic on patients with obsessive-compulsive disorder: A one-year follow-up study
date: 2021-11-02
journal: Psychiatry Res
DOI: 10.1016/j.psychres.2021.114268
sha: bf780f65cca039f4750370a4e7c6f54f17ee546b
doc_id: 699393
cord_uid: nfcii1sq

Several recent publications have revealed that obsessive-compulsive disorder (OCD) patients were adversely affected during coronavirus disease 2019 (COVID-19); however, how long this negative impact will last is unclear. Our study aimed to investigate the impact of the COVID-19 pandemic on OCD patients after one year. Online questionnaires were administered, and clinical interviews were conducted to assess OCD symptoms, depression, anxiety, information about COVID-19 and mental resilience at baseline (1 December 2019–1 January 2020), during early COVID-19 (26 February–25 March 2020) and at the one-year follow-up (26 February–25 March 2021). A total of 110 OCD patients were enrolled. Our findings showed that OCD, depressive and anxiety symptoms worsened during early COVID-19, and the negative impact persisted at the one-year follow-up. Multivariate analysis showed that female gender, concern about COVID-19 and OCD symptom severity at baseline were risk factors for exacerbation of OCD symptoms during early COVID-19, while optimism, as one composite factor of resilience, was a protective factor against exacerbation of OCD symptoms both during early COVID-19 and at follow-up. Our study showed that COVID-19 had immediate and long-term impacts on the exacerbation of OCD symptoms, and interventions targeted at improving resilience are recommended.

The coronavirus disease 2019 (COVID-19) pandemic, initially detected in December 2019, has caused widespread social and economic disruption. Strict control measures such as quarantine, lockdown, and physical distancing were universally launched during the worst phase of the epidemic, which might have negatively affected mental health in those with depression, anxiety, or obsessive-compulsive disorder (OCD) (Pan et al., 2021) . A number of studies have reported that the COVID-19 pandemic could induce new-onset obsessive-compulsive symptoms and exacerbate preexisting OCD symptoms (Abba-Aji et al., 2020; Davide et al., 2020; Khosravani et al., 2021) . Many studies have found significant increases in contamination and cleaning symptoms of OCD during the pandemic period (Jelinek et al., 2021; Rajkumar, 2020; Samuels et al., 2021; Tanir et al., 2020) . In addition, OCD symptoms in other dimensions related to hoarding, concerns about symmetry, responsibility for harm and unacceptable thoughts were reported to be exacerbated (Khosravani et al., 2021) .

However, most evidence has focused on the impact of COVID-19 shortly after the outbreak of the pandemic, and few studies have investigated the mental status of OCD patients in the later stages. Since the outbreak, China was hit hard by the pandemic for a long time, a lockdown was imposed on Wuhan on 23 January, and later, the lockdown was extended to other cities. Since April 8, 2020, the date that Wuhan reopened, China has almost got the situation under control, where economic and social activities were gradually brought back on track, despite some temporary regional lockdowns because of sporadic occurrence and the occasional limited transmission of infection. Therefore, the data from China can provide an exploration of the long-term impact of the COVID-19 pandemic on OCD patients, which might provide other countries with a valuable reference.

Many risk factors might have contributed to exacerbating symptoms of OCD during COVID-19, and the evaluated factors have varied across studies, including reduced mobility, interpersonal conflicts, baseline insight, insomnia symptoms, family history of psychiatric disorders, higher severity of prepandemic OCD symptoms, and worsening of anxiety and depressive symptoms (Cox and Olatunji, 2021; Jelinek et al., 2021; Nissen et al., 2020) . Resilience is defined as the ability to adapt to changing environments and recover from stressful situations (Block and Kremen, 1996) .

Individuals among the public with high levels of mental resilience would have lower levels of anxiety and depression during the COVID-19 pandemic (Song et al., 2020) .

OCD patients had lower dispositional resilience scores than control groups, and resilience was negatively associated with OCD symptoms (Holm et al., 2019) . Studies have found that resilience is associated with many psychosocial factors, such as active coping and performance, cognitive flexibility, a feeling of control, harm avoidance and social support (Eley et al., 2013; Iacoviello and Charney, 2014) . These factors might also be relevant for OCD patients and might indicate an indirect link between resilience and OCD. Cognitive flexibility in OCD patients has been shown to be impaired, which has been associated with increased levels of obsessive beliefs (Şahin et al., 2018) . A higher desire for control and a lower sense of control were associated with higher levels of OCD-related beliefs and symptoms (Moulding et al., 2008) .

Both OCD patients and their unaffected first-degree relatives showed elevated levels of harm avoidance compared to healthy control subjects, and their findings supported the notion that harm avoidance represents a potential endophenotype of OCD (Bey et al., 2017) . Based on these data, a negative relation between OCD and resilience could be expected. Thus, we hypothesized that mental resilience may be a significant predictive factor for the exacerbation of OCD symptoms during the COVID-19 pandemic, which needed further study for verification. Our hypothesis was that COVID-19 had immediate and long-term impacts on the exacerbation of OCD symptoms. In addition, we speculated that mental resilience may be a protective factor for OCD patients to cope with the COVID-19 pandemic. This study aimed to investigate the impact of COVID-19 on OCD patients shortly after the pandemic and its long-term effects at a one-year follow-up and explore related factors associated with OCD in these patients.

The participants in this study were recruited from among patients with OCD who had been diagnosed and treated at Peking University Six Hospital, the National Clinical Research Center for Psychiatric and Mental Disorders in China. They joined the group through "WeChat" (a popular communication application in China that is similar to Facebook, Skype, etc.), and they had close connections to their psychologist and/or psychiatrist. From 26 February-25 March 2020, a questionnaire was sent to a total of 993 patients, and a total of 127 (12.8%) patients responded to the questionnaire. Then, all participants completed a detailed telephone interview by one of four experienced psychiatrists, confirming the diagnosis of OCD based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria (Regier et al., 2013) and assessing comorbidities. To reduce the recall bias of information before the COVID-19 pandemic as much as possible, we encouraged patients to provide information based on previous medical records and/or seek help from family members.

The enrollment criteria for the OCD patients included (a) a diagnosis of OCD based on DSM-5 criteria; (b) an age between 18 and 60 years old; and (c) an education level ≥6 years. The study was approved by the institutional ethics committee of the Peking University of Six Hospital (2020-2-21-4). All participants provided verbal informed consent prior to their enrollment.

The structured questionnaires covered six areas: demographic data, information about COVID-19, disease characteristics of OCD, severity of OCD symptoms, severity of depression and anxiety, and mental resilience. The severity of OCD symptoms, depression and anxiety were assessed at three time periods, namely, BASELINE (pre-COVID, 1 December 2019-1 January 2020) and EARLY March 2020) and one-year FOLLOW-UP (26 February-25 March 2021). Information about COVID-19 was assessed both at EARLY COVID-19 and one-year FOLLOE-UP.

The participants reported their age, gender, education, residential location, and number of members in the household during the COVID-19 outbreak.

The participants were asked to report their COVID-19 contact history, level of concern about COVID-19 and experience of quarantine. The level of concern about COVID-19 was evaluated by self-designed scales that included items such as "Surfing the internet for the information about the COVID-19 outbreak has become an important part of my life." Each item was rated on a five-point Likert-type scale, with scores ranging from 1 ('not at all') to 5 ('extremely'); higher scores indicated a greater focus on COVID-19.

The participants were asked to report their age at OCD onset, duration of illness, current treatment, and whether they were seeking medical services through outpatient, telephone or internet platforms at EARLY COVID-19 and one-year FOLLOW-UP.

OCD symptoms were evaluated with the Obsessive Compulsive Inventory-Revised (OCI-R) (Foa et al., 2002) , and the reliability and validity of the Chinese version of the OCI-R met psychometric standards (He et al., 2012) . Each item was rated on a five-point Likert-type scale, with scores ranging from 0 to 4 (from 'not at all' to 'extremely'), and higher scores reflected more severe symptoms.

The Self-Rating Depression Scale (SDS) and Self-Rating Anxiety Scale (SAS) were used to assess depressive and anxiety symptoms (Zung, 1965 (Zung, , 1971 ).

Resilience is a multidimensional variable that relates to cultural background, social conditions, and demographic characteristics (Wu et al., 2017) . In our study, resilience was evaluated by the Chinese version of the Connor-Davidson Resilience Scale (CD-RISC). The reliability coefficient of the Chinese version of the CD-RISC was 0.91 (Yu et al., 2007) . The scale consists of 25 self-reported questions, and each question was rated on a 5-point scale from 0 to 4 (from 'not at all' to 'extremely true') with the highest possible total score of 100; higher scores reflected greater resilience.

The scale assessed the three factors of tenacity, strength and optimism based on exploratory factor analysis among the Chinese population. Tenacity describes an individual's perseverance under situations of hardship and challenge. The strength represents becoming strong after a setback. Optimism measures one's positive thinking with regard to resisting adverse events.

The data were analyzed in SPSS 22.0 (IBM Corp). Frequencies and percentages are presented for categorical variables. Continuous variables are presented as the mean (standard deviation). Intergroup comparisons were performed by using Student's t-tests or Kruskal-Wallis tests for continuous variables and chi-square tests for categorical variables. Comparisons used a two-sided significance level of 0.05.

Linear mixed-effects models (LMM) were used to compare the severity of OCD, depressive and anxiety symptoms at three time points. Symptom scores were treated as the dependent variables, the three levels of time were treated as fixed factors, and the subject was treated as a random factor. Akaike Information Criterion (AIC) was used to evaluate the LMM (Shek and Ma, 2011). Associations between total OCD severity scores and possible predictor variables were analyzed by univariate linear regression models. Variables entered into the model included demographic and clinical characteristics, information about COVID-19, and SAS, SDS and OCI-R scores at BASELINE. Second, multivariate linear regression analyses were used to explore the potential risk factors that were independently predictive of OCD symptoms at EARLY COVID-19 pandemic and the one-year FOLLOW-UP, and variables were selected based on univariate analyses. Variables with a p-value <0.05 were included in the analysis.

In total, 127 participants completed the questionnaires. Seventeen participants were excluded: 4 did not participate in a phone interview, 12 did not meet the diagnostic criteria of OCD, and 1 was younger than 18 years old. Finally, 110 OCD patients were recruited in the study. At the one-year FOLLOW-UP, 64 patients responded to the survey.

Demographic and clinical data are shown in Table 1 We found no significant differences in age, gender, education level, age of onset, duration, comorbidities, or treatment of participants between the two time points, i.e., during EARLY COVID-19 and at the one-year FOLLOW-UP.

By using LMM, we found that the OCD symptom total scores and depressive and anxiety symptoms were significantly different across the three time points (p=0.005; p<0.001; p<0.001). The patients with OCD experienced aggravated OCD, depressive and anxiety symptoms during EARLY COVID-19 compared to BASELINE (p=0.028; p<0.001; p<0.001). The total scores for OCD, depressive and anxiety symptoms at the one-year FOLLOW-UP were significantly higher than the scores at BASELINE (p=0.002; p=0.001; p=0.012). The results are shown in Table 2 and Figure 1 .

By using univariate linear regression analyses, we defined the OCD symptom total scores during EARLY COVID-19 as the dependent variable, and the predictor factors included age, gender, education level, age of onset, duration, comorbidities, treatment, concern about COVID-19 score, living alone, SAS, SDS and OCI-R scores at BASELINE, and CD-RISC and its three factors scores. We found that female gender, concern about COVID-19 score, SAS, SDS and OCI-R scores at BASELINE, and CD-RISC score and scores for its three factors had significant associations with OCD scores during EARLY COVID-19 ( p=0.034), and concern about COVID-19 (β=0.281; CI=0.127, 0.437; p<0.001) as risk factors for the exacerbation of OCD symptoms during EARLY COVID-19. Optimism, one of the composite factors of resilience, was a protective factor and decreased the odds of the exacerbation of OCD symptoms (β=-0.250; CI=-0.494, -0.005; p=0.045).

The R 2 of the multivariate linear regression was 0.921.

At the one-year FOLLOW-UP, by using univariate linear regression analyses, the SAS, SDS and OCI-R scores at BASELINE and the CD-RISC total, strength and optimism scores were chosen as candidate predictors (Table S2 ). Multivariate linear regression analyses showed that OCD symptoms severity at BASELINE were a risk factor for (β=0.662; CI=0.401, 0.923; p<0.001) and optimism was a protective factor against (β=-1.470, CI=-2.367; -0.574, p=0.002) exacerbation OCD symptoms at the one-year FOLLOW-UP (Table 4 ). The R 2 of the multivariate linear regression was 0.399.

This study evaluated OCD, depressive, and anxiety symptom profiles and related risk factors at three time points, namely, BASELINE, during EARLY COVID-19 and at a one-year FOLLOW-UP in OCD patients. The findings of our study revealed that the severity of OCD, depressive and anxiety symptoms increased during EARLY COVID-19, and the effect persisted one year later. The data further indicated that female gender, concern about COVID-19, and higher OCD symptom scores at BASELINE were risk factors for the exacerbation of OCD symptoms during EARLY COVID-19, and high optimism was a protective factor in the short and long term, allowing OCD patients to cope with the COVID-19 pandemic.

During EARLY COVID-19, the OCD patients experienced worsening OCD symptoms in our study, and the immediate impact was consistent with previous studies ( Moreover, our study further investigated the long-term effects on OCD patients at one-year FOLLOW-UP. We found that the total OCD symptom scores were still significantly higher than that at BASELINE, which showed that the negative impact al., 2020). We found that female gender, concern about COVID-19, and OCD symptoms severity at BASELINE increased the odds of OCD symptoms worsening during EARLY COVID-19. Previous studies have found that females had higher levels of anxiety and depression during the COVID-19 pandemic (Fancourt et al., 2021; Song et al., 2020) . In our study, female gender was a risk factor among OCD patients during EARLY COVID-19. In addition, excessive concern about COVID-19 may have caused anxiety and resulted in worsening OCD symptoms. Wheaton et al.(2021) found that concern about COVID-19 was moderately and positively correlated with both OCD and health anxiety symptoms in a large sample of community adults (n=738) in the United States.

Furthermore, the results in this study showed that optimism, one factor of resilience, was a protective factor for OCD patients against the exacerbation of OCD symptoms during EARLY COVID-19 and at the one year FOLLOW-UP. However, studies on resilience in OCD patients are limited. In this study, we found that resilience levels in the OCD patients were lower than those in the general population (Yu et al., 2007) , which was consistent with a previous study (Holm et al., 2019) . Studies have found a negative association between resilience and negative emotion, and this correlation is mainly driven by optimism (Chen et al., 2018) . Optimism was shown to be one of the protective factors against the development of depression and anxiety during COVID-19 (Song et al., 2020) . Individuals with high optimism feel that good things will happen to them, hard times are controllable and difficult times will certainly pass.

In contrast, OCD patients tend to overstate the threat and take the thought of danger as a fact, and thus feel worried, anxious and out of control and use compulsions to ease the worry. To face COVID-19, OCD patients may exaggerate the likelihood of infection for themselves or their family members, feel pessimistic about the future with regard to COVID-19, and even experience suicidal ideation more frequently (Benatti et al., 2020) . Some strong evidence suggests that resilience can be increased by mindfulness-based training. A randomized controlled trial (RCT) showed that the provision of mindfulness training could be an effective intervention to increase resilience to stress in university students (Galante et al., 2018) . Another RCT performed in active-duty marines also revealed that marines who received 8 weeks of mindfulness-based mind fitness training showed greater reactivity and enhanced recovery after stressful training (Johnson et al., 2014) . Therefore, mindfulness-based interventions that primarily focus on increasing the resilience to cope with COVID-19

for OCD patients should be tried.

Our study also has several limitations. First, the baseline survey relied on online questionnaires and clinical interviews. Although we attempted to reduce recall bias by collecting information based on previous medical records and/or through reminders from family members, our approach might not have completely eliminated this bias.

Considering that the outbreak of COVID-19 was a sudden, explosive, and unexpected event, it was unrealistic for us to prospectively collect potentially useful information before the pandemic, and yet, our findings can still provide beneficial knowledge for In summary, the results of our study revealed that OCD symptoms and depressive and anxiety symptoms were exacerbated in OCD patients during early COVID-19, and the impact was sustained at the one-year follow-up. Additionally, OCD symptoms severity at baseline, female gender, and concern about COVID-19 were risk factors 13 for the exacerbation of OCD symptoms in the short term, while optimism was a protective factor in both the short and long term. These results might provide beneficial knowledge to understand the psychological changes in OCD patients during the COVID-19 pandemic and identified targets for psychological interventions. Moulding, R., Doron, G., Kyrios, M., and Nedeljkovic, M. (2008) . Desire for control, sense of control and obsessive-compulsive checking: an extension to clinical samples. Journal of anxiety disorders 22, 1472 -1479 . https://doi.org/10.1016 /j.janxdis.2008 .03.001 Nissen, J.B., Højgaard, D., and Thomsen, P.H. (2020 . The immediate effect of COVID-19 pandemic on children and adolescents with obsessive compulsive disorder. BMC psychiatry 20, 511.https://doi.org/10.1186/s12888-020-02905-5 Pan, K.Y., Kok, A.A.L., Eikelenboom, M., Horsfall, M., Jörg, F., Luteijn, R.A., Rhebergen, D., Oppen, P.V., Giltay, E.J., and Penninx, B. (2021) Connor-Davidson Resilience Scale; β=coefficient; S.E.= standard error of estimated coefficient. C.I.=confidence interval. R 2 =0.399 Figure 1 . Comparison of the severity of OCD and depressive and anxiety symptoms at three time points by linear mixed-effects models.

Notes: OCI-R: Obsessive Compulsive Inventory Revised version; SAS: Self-Rating Anxiety Scale; SDS: Self-Rating Depression Scale.

Intolerance of uncertainty as a factor linking obsessive-compulsive symptoms, health anxiety and concerns about the spread of the novel coronavirus (COVID-19) in the United States

Factor structure and psychometric evaluation of the Connor-Davidson resilience scale in a new employee population of China

Factor analysis and psychometric evaluation of the Connor-Davidson resilience scale(CD-RISC) with Chinese people

A SELF-RATING DEPRESSION SCALE

A rating instrument for anxiety disorders

We thank our patients for participating in this study.