How Do Obsessive-Compulsive Symptoms Affect Wellbeing in People Taking Clozapine?

What you need to know

• Obsessive-compulsive symptoms (OCS) are common side effects of clozapine, an antipsychotic medication used to treat schizophrenia.
• This study found that OCS negatively impact wellbeing in people taking clozapine, even when accounting for depression and psychotic symptoms.
• Obsessional thinking and hoarding behaviors had the most significant negative effects on wellbeing.
• OCS did not appear to impair overall functioning, which may contribute to underrecognition of these symptoms by clinicians.
• The researchers recommend that clinicians routinely assess and treat OCS in patients taking clozapine to improve wellbeing.

Understanding obsessive-compulsive symptoms

Obsessive-compulsive symptoms (OCS) involve unwanted, intrusive thoughts (obsessions) and/or repetitive behaviors or mental acts (compulsions) that a person feels driven to perform. Some examples include:

• Obsessive thoughts about contamination and compulsive hand washing
• Obsessive doubts about locking doors and compulsively checking locks
• Obsessive fears of harming others and mental rituals to neutralize the thoughts
• Obsessive need for symmetry and compulsively arranging objects

While many people experience occasional obsessive thoughts or compulsive urges, OCS become problematic when they are frequent, distressing, time-consuming, or interfere with daily life.

Clozapine and OCS

Clozapine is an antipsychotic medication used to treat schizophrenia in people who have not responded well to other medications. It can be very effective at reducing psychotic symptoms and improving functioning. However, clozapine can also cause or worsen OCS as a side effect in some people.

Previous research has found that up to 47% of people taking clozapine may develop significant OCS. This is much higher than rates of OCS in the general population or in people with schizophrenia not taking clozapine. The risk of developing OCS appears to increase the longer a person takes clozapine.

The impact on wellbeing

While the benefits of clozapine often outweigh the risks for many patients, it’s important to understand how side effects like OCS may impact quality of life. This study aimed to examine how OCS affect wellbeing in people taking clozapine, independent of other factors like depression or psychotic symptoms that can also influence wellbeing.

The researchers analyzed data from 184 patients who were taking clozapine and assessed annually as part of their routine clinical care. At each visit, patients completed questionnaires measuring:

• OCS severity (using the Obsessive-Compulsive Inventory-Revised)
• Mental wellbeing (using the Short Warwick-Edinburgh Mental Wellbeing Scale)
• Depression and psychotic symptoms (rated by clinicians)
• Overall functioning (rated by clinicians)

By looking at how these measures changed over time for each patient, the researchers could examine the relationship between OCS and wellbeing.

Key findings

The study found that higher OCS severity was significantly associated with lower wellbeing scores, even when accounting for depression and psychotic symptoms. For each 1-point increase in OCS severity (on a scale of 0-72), there was an associated 0.09-point decrease in wellbeing scores.

This may seem small, but the researchers note that for patients with clinically significant OCS (scoring 21 or higher), this would represent a decrease in wellbeing that is likely meaningful in terms of quality of life.

When looking at specific types of OCS, obsessional thinking and hoarding behaviors had the strongest negative impact on wellbeing. Interestingly, compulsive checking behaviors did not significantly affect wellbeing scores. The researchers suggest this may be because checking behaviors feel more aligned with a person’s goals or values (termed “ego-syntonic”) and thus cause less subjective distress.

Implications for treatment

An important finding was that while OCS negatively impacted subjective wellbeing, they did not appear to significantly affect clinician ratings of overall functioning. This discrepancy highlights how OCS may be an “invisible” problem - patients may not spontaneously report these symptoms, and clinicians may not notice their impact during brief appointments focused on psychosis symptoms.

The researchers emphasize that quality of life and subjective wellbeing are important treatment goals for people with schizophrenia, beyond just managing psychotic symptoms. They recommend that clinicians caring for patients on clozapine should:

1. Routinely screen for and assess OCS, even if patients don’t bring them up
2. Pay particular attention to obsessional thinking and hoarding symptoms
3. Consider OCS treatment options like cognitive-behavioral therapy or medication adjustments when appropriate
4. Monitor subjective wellbeing as an important outcome, not just functional measures

Strengths and limitations

This study had several strengths, including its large sample size, long-term follow-up (patients were followed for an average of 26.5 months), and “real world” clinical setting. By using data from routine care rather than a controlled research environment, the findings are likely to reflect the actual experiences of patients.

However, there were also some limitations to consider:

• The study relied on brief self-report measures of OCS and wellbeing rather than more comprehensive clinical interviews.
• As an observational study, it can show associations between OCS and wellbeing but cannot prove that OCS directly cause lower wellbeing.
• The study did not have a control group of patients not taking clozapine for comparison.
• Patients received routine clinical care during the study period, which may have included treatments for OCS that could impact the results.

Future research directions

The researchers suggest several areas for future study:

1. Evaluating which treatments are most effective for clozapine-related OCS
2. Exploring patients’ qualitative experiences of OCS and their impact on quality of life
3. Investigating potential differences in how patients vs. clinicians perceive and report OCS
4. Examining whether early detection and treatment of OCS can prevent negative impacts on wellbeing

Conclusions

• Obsessive-compulsive symptoms are common in people taking clozapine and can significantly impact wellbeing.
• Clinicians should routinely assess for OCS in patients on clozapine, even if not reported spontaneously.
• Treating OCS may be an important way to improve quality of life for people with schizophrenia, beyond just managing psychotic symptoms.
• More research is needed on effective treatments for clozapine-related OCS and their impact on long-term outcomes.