Clinical Practice & Epidemiology in Mental Health




ISSN: 1745-0179 ― Volume 15, 2019
SYSTEMATIC REVIEW

The Perception of Physical Health Status in Obsessive-Compulsive Disorder: A Systematic Review and Meta-Analysis



Andrea Pozza1, Fabio Ferretti1, *, Anna Coluccia1
1 Department of Medical Sciences, Surgery and Neurosciences, Santa Maria alle Scotte University Hospital of Siena, viale Bracci 16, 53100 Siena, Italy

Abstract

Background:

Physical Health Status is a neglected outcome in clinical practice with Obsessive-Compulsive Disorder (OCD) and a systematic review is lacking.

Objective:

The current study presents the first systematic review and meta-analysis summarizing the evidence on (a) perceived Physical Health Status, Bodily Pain and Role Limitations due to Physical Problems in patients with OCD compared with controls, (b) age, gender, severity of OCD symptoms, study publication date, study methodological quality as moderators of perceived Physical Health Status.

Methods:

Case-control studies were included if they (a) compared OCD patients with healthy/general population participants as controls, and (b) used validated self-report instruments. Two reviewers searched electronic databases, contacted corresponding authors, and examined reference lists/conference proceedings/theses.

Results:

Fourteen studies were included. A large significant negative effect size without publication bias showed that controls reported higher perceived Physical Health Status than patients with OCD. Medium and small effect sizes favouring controls emerged for Role Limitations due to Physical Problems and Bodily Pain, respectively. Higher age, females percentage, and publication date were associated with larger effect sizes; higher OCD severity and methodological quality were associated with smaller effect sizes.

Conclusion:

Perceived Physical Health should be evaluated and addressed by clinicians during treatment, particularly with older, female and less severe patients. Lifestyle interventions might be implemented.

Keywords: Obsessive-Compulsive Disorder, Functioning, Physical Health, Systematic Review, Well-being, Pain, Lifestyle, Meta-analysis.


Article Information


Identifiers and Pagination:

Year: 2019
Volume: 15
First Page: 75
Last Page: 93
Publisher Id: CPEMH-15-75
DOI: 10.2174/1745017901915010075

Article History:

Received Date: 06/03/2019
Revision Received Date: 01/07/2019
Acceptance Date: 01/07/2019
Electronic publication date: 31/07/2019
Collection year: 2019

Article Metrics:

CrossRef Citations:
0

Total Statistics:

Full-Text HTML Views: 225
Abstract HTML Views: 171
PDF Downloads: 82
ePub Downloads: 79
Total Views/Downloads: 557

Unique Statistics:

Full-Text HTML Views: 167
Abstract HTML Views: 107
PDF Downloads: 65
ePub Downloads: 57
Total Views/Downloads: 396
Geographical View

© 2019 Pozza et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: (https://creativecommons.org/licenses/by/4.0/legalcode). This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Department of Medical Sciences, Surgery and Neurosciences, Santa Maria alle Scotte University Hospital Viale Bracci 16, 53100 Siena, Italy; Tel: +39 0577 586409; Fax: +39 0577 233222;
E-mail: ferrefa@unisi.it





1. INTRODUCTION

Obsessive-Compulsive Disorder (OCD) is a chronic mental health condition consisting of distressing thoughts, mental images or impulses, called obsessions, and recurrent overt/ mental behaviours, called compulsions [1American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM5) 5th ed. 5th ed.2013.]. Considerable evidence indicates that OCD produces a significant impairment in various health-related domains, such as interpersonal relation ships, intimate bonds, and work functioning [2Coluccia A, Fagiolini A, Ferretti F, et al. Obsessive-Compulsive Disorder and quality of life outcomes: Protocol for a systematic review and meta-analysis of cross-sectional case-control studies. Epidemiol Biostat Public Health 2015; 12: 2.-7Remmerswaal KCP, Batelaan NM, Smit JH, et al. Quality of life and relationship satisfaction of patients with Obsessive Compulsive Disorder. J Obsessive Compuls Relat Disord 2016; 11: 56-62.[http://dx.doi.org/10.1016/j.jocrd.2016.08.005] ]. Impairment in psychological quality of life is particularly severe for female patients and among those patients with less intense symptoms, as an inverse correlation between the intensity of OCD symptoms and quality of life there has been found [8Pozza A, Lochner C, Ferretti F, Cuomo A, Coluccia A. Does higher severity really correlate with a worse quality of life in obsessive-compulsive disorder? A meta-regression. Neuropsychiatr Dis Treat 2018; 14: 1013-23.[http://dx.doi.org/10.2147/NDT.S157125] [PMID: 29713171] ].

While there is a long tradition of literature on the psychological quality of life in OCD, there is a paucity of evidence about perceived Physical Health Status, which is under-recognized by researchers and practitioners, as the focus of the intervention is often on the mental health dimension of the condition, such as obsessions and compulsions [9Aguglia A, Signorelli MS, Albert U, Maina G. The impact of general medical conditions in obsessive-compulsive disorder. Psychiatry Investig 2018; 15(3): 246-53.[http://dx.doi.org/10.30773/pi.2017.06.17.2] [PMID: 29475243] ]. The rationale for investigating perceived physical health in OCD is related to various clinical aspects.

First, approximately 50% of patients suffer from concurrent general medical diseases [9Aguglia A, Signorelli MS, Albert U, Maina G. The impact of general medical conditions in obsessive-compulsive disorder. Psychiatry Investig 2018; 15(3): 246-53.[http://dx.doi.org/10.30773/pi.2017.06.17.2] [PMID: 29475243] ]. Female and older patients with OCD are at a higher risk of developing general medical diseases [9Aguglia A, Signorelli MS, Albert U, Maina G. The impact of general medical conditions in obsessive-compulsive disorder. Psychiatry Investig 2018; 15(3): 246-53.[http://dx.doi.org/10.30773/pi.2017.06.17.2] [PMID: 29475243] ]. Therefore, practitioners treating this clinical subgroup should be aware of this aspect and also evaluate and address this potential perceived impairment of physical health. Secondly, longitudinal research shows that OCD is associated with an increased physical health burden and double the risk of mortality compared with the general population [10Meier SM, Mattheisen M, Mors O, Schendel DE, Mortensen PB, Plessen KJ. Mortality among persons with obsessive-compulsive disorder in Denmark. JAMA Psychiatry 2016; 73(3): 268-74.[http://dx.doi.org/10.1001/jamapsychiatry.2015.3105] [PMID: 2681 8216] ] which remains elevated even after controlling for other concurrent mental health conditions [10Meier SM, Mattheisen M, Mors O, Schendel DE, Mortensen PB, Plessen KJ. Mortality among persons with obsessive-compulsive disorder in Denmark. JAMA Psychiatry 2016; 73(3): 268-74.[http://dx.doi.org/10.1001/jamapsychiatry.2015.3105] [PMID: 2681 8216] ]. Thirdly, specific OCD subtypes, such as contagion obsessions and doubts related to the possibility of causing harm, may have a physical health focus [11Fergus TA. The Cyberchondria Severity Scale (CSS): An examination of structure and relations with health anxiety in a community sample. J Anxiety Disord 2014; 28(6): 504-10.[http://dx.doi.org/10.1016/j.janxdis.2014.05.006] [PMID: 24956357] , 12Pozza A, Mazzoni GP, Berardi D, et al. Studio preliminare sulle proprietà psicometriche della versione italiana della Disgust Propensity and Sensitivity Scale-Revised (DPSS-R) in campioni non-clinici e campioni clinici con Disturbo Ossessivo-Compulsivo e Disturbi d’ansia. Psicoter Cogn Comport 2016; 22: 271-96.]. For instance, contamination fears and engagement in repetitive washing behaviours can lead the patient to avoid social contacts or sports or to follow unhealthy eating habits. Moreover, there is an overlap in the cognitive and behavioural maintenance mechanisms of OCD and health anxiety, such as anxiety sensitivity and reassurance seeking [13Raines AM, Oglesby ME, Capron DW, et al. Obsessive compulsive disorder and anxiety sensitivity: Identification of specific relations among symptom dimensions. J Obsessive Compuls Relat Disord 2014; 3: 71-6.[http://dx.doi.org/10.1016/j.jocrd.2014.01.001] , 14Solem S, Borgejordet S, Haseth S, Hansen B, Håland Å, Bailey R. Symptoms of health anxiety in obsessive-compulsive disorder: Relationship with treatment outcome and metacognition. J Obsessive Compuls Relat Disord 2015; 5: 76-81.[http://dx.doi.org/10.1016/j.jocrd.2015.03.002] ].

Fourthly, investigating physical health in OCD may suggest some clinical implications useful for practice. Physical health could be a target of treatment. The detrimental effects of OCD on perceived physical health might be due to the lack of a healthy lifestyle produced by the symptoms [9Aguglia A, Signorelli MS, Albert U, Maina G. The impact of general medical conditions in obsessive-compulsive disorder. Psychiatry Investig 2018; 15(3): 246-53.[http://dx.doi.org/10.30773/pi.2017.06.17.2] [PMID: 29475243] ]. Some studies showed that interventions aimed at improving bodily health such as aerobic exercise in addition to standard treatment produce an improvement also in the OCD clinical picture and the related symptomatology, such as anxious symptoms and negative mood [15Abrantes AM, Brown RA, Strong DR, et al. A pilot randomized controlled trial of aerobic exercise as an adjunct to OCD treatment. Gen Hosp Psychiatry 2017; 49: 51-5.[http://dx.doi.org/10.1016/j.genhosppsych.2017.06.010] [PMID: 2912 2148] , 16Sarris J, Camfield D, Berk M. Complementary medicine, self-help, and lifestyle interventions for obsessive compulsive disorder (OCD) and the OCD spectrum: A systematic review. J Affect Disord 2012; 138(3): 213-21.[http://dx.doi.org/10.1016/j.jad.2011.04.051] [PMID: 21620478] ]. OCD may be expected to benefit also from mindfulness-based interventions [17Mathur S, Sharma MP, Reddy JY. Preliminary findings of efficacy of Mindfulness Integrated Cognitive Therapy (MICT) for Obsessive-Compulsive Disorder (OCD). Archives of Mental Health 2016; 17: 65-9.], which help the person decentering from intrusive thoughts and developing a not-judgemental attitude towards the body [18Barcaccia B, Baiocco R, Pozza A, et al. The more you judge the worse you feel. A judgemental attitude towards one’s inner experience predicts depression and anxiety. Pers Individ Dif 2019; 138: 33-9.[http://dx.doi.org/10.1016/j.paid.2018.09.012] , 19Kumar A, Sharma MP, Narayanaswamy JC, Kandavel T, Janardhan Reddy YC. Efficacy of mindfulness-integrated cognitive behavior therapy in patients with predominant obsessions. Indian J Psychiatry 2016; 58(4): 366-71.[http://dx.doi.org/10.4103/0019-5545.196723] [PMID: 28196991] ].

Therefore, we may expect that OCD patients report poorer perceived physical health than controls without a psychiatric disorder or recruited from the general population. Certain sociodemographic variables, including age and gender, might act as moderators of a lower perceived physical health in OCD. The moderator role of age may be supported by previous research suggesting that the risk of general medical diseases among OCD patients is higher in older individuals than in younger ones [9Aguglia A, Signorelli MS, Albert U, Maina G. The impact of general medical conditions in obsessive-compulsive disorder. Psychiatry Investig 2018; 15(3): 246-53.[http://dx.doi.org/10.30773/pi.2017.06.17.2] [PMID: 29475243] ]. Additionally, empirical evidence demonstrated gender-based clinical differences in OCD: female patients with OCD might experience worse physical health since they more frequently suffer from concurrent medical diseases, depressed mood, contamination fears, suicidality, and eating disorders, which potentially produce impairment in perceived physical health [20Jaisoorya TS, Reddy YC, Srinath S, Thennarasu K. Sex differences in Indian patients with obsessive-compulsive disorder. Compr Psychiatry 2009; 50(1): 70-5.[http://dx.doi.org/10.1016/j.comppsych.2008.05.003] [PMID: 19059 517] ]. The severity of OCD symptoms might be expected to moderate the negative effect of the condition on physical health in the same manner as for psychological quality of life since lower severity is associated with impaired psychological quality of life [8Pozza A, Lochner C, Ferretti F, Cuomo A, Coluccia A. Does higher severity really correlate with a worse quality of life in obsessive-compulsive disorder? A meta-regression. Neuropsychiatr Dis Treat 2018; 14: 1013-23.[http://dx.doi.org/10.2147/NDT.S157125] [PMID: 29713171] ].

In light of all these aspects, an insight into perceived physical health in OCD appears necessary and identifying which variables are associated with lower physical health in OCD can suggest some directions for clinical practice. In the present literature, there is no quantitative summary of perceived physical health in OCD patients. This study presents the first systematic review and meta-analysis aimed at summarizing the existing data on perceived physical health in OCD, specifically: (a) perceived Physical Health Status in OCD patients compared with controls (screened healthy individuals or individuals recruited from the general population), (b) socio-demographic, clinical, and study-related moderator variables of perceived Physical Health Status (age, gender, level of severity of OCD symptomatology, publication date, methodological quality), (c) additional outcomes related to perceived Physical Health Status, including Bodily Pain and Role Limitations due to Physical Problems.

2. METHODS

2.1. Eligibility Criteria

A systematic review was conducted following the PRISMA guidelines [21Shamseer L, Moher D, Clarke M, et al. PRISMA-P Group. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: Elaboration and explanation. BMJ 2015; 350: g7647.[http://dx.doi.org/10.1136/bmj.g7647] [PMID: 25555855] ]. The protocol of the review was regisStered on PROSPERO (2018 CRD42018106194). Eligibility criteria involved (a) Characteristics of participants, (b) ChaSracteristics of outcomes, (c) Characteristics of comparators, (d) Characteristics of design:

(a) Studies were included if they used a clinical group with a current primary OCD diagnosis. Diagnosis had to be established by a semi-structured clinical interview based on the criteria of a standardized diagnostic system such as the Structured Clinical Interview according to DSM-IV [SCID-I; 22] or by an unstructured clinical interview conducted by a mental health professional based on the criteria of a standardized diagnostic system such as the DSM-5 [1American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM5) 5th ed. 5th ed.2013.] or the ICD-10 [23World Health Organization. The ICD-10 classification of mental and behavioural disorders: Diagnostic criteria for research 1993.]. Studies including patients with a lifetime diagnosis of OCD or including participants with subthreshold OCD were not included. Studies were included only if they used adolescent/adult participants, as the clinical characteristics of the disorder in children are significantly different than those of adolescent/adult OCD [24Geller DA, Biederman J, Faraone S, et al. Developmental aspects of obsessive compulsive disorder: Findings in children, adolescents, and adults. J Nerv Ment Dis 2001; 189(7): 471-7.[http://dx.doi.org/10.1097/00005053-200107000-00009] [PMID: 115 04325] ]. Studies using participants with primary hoarding were excluded since it is conceptualized as a distinct diagnosis in the DSM-5. Studies were included if they had recruited patients from primary, secondary or tertiary care settings. Concurrent psychological or pharmacological treatment was not a reason for exclusion. Studies were not considered to be excluded if the patients had concurrent general medical diseases. Studies conducted on OCD in the elderly where patients included individuals aged over 70 years old, were excluded.

(b) Studies were included if they evaluated perceived Physical Health Status by validated, internationally recognized self-report instruments, such as the Medical Outcomes Survey 36-Item Short-Form Health Survey [36; 25] or the World Health Organization Quality of Life-Brief Form [WHOQOL-BREF; 26].

(c) Studies were included if using control groups of screened participants not meeting the criteria for any of the mental disorders included in a standardized classification system and this condition was checked by a clinical interview by a mental health practitioner. In addition, studies were also included if they used control groups of unscreened participants drawn from the general population.

(d) Studies were included if they used a case-control design, where a group of patients with a current primary OCD diagnosis was compared with a healthy or a general population control group on perceived physical health. Any other type of research was allowed if the study provided the data necessary to compute an effect size estimate (for the data requested to compute the effect sizes, see paragraph “Meta-analysis and summary measures”). No publication data or language restriction was applied.

2.2. Search Procedure

Studies were identified by carrying out an online systematic search of electronic databases and by using each of the keywords “Obsessive Compulsive Disorder”, “Obsessions”, “Compulsions” combined through the Boolean operator AND with the keywords “Physical Health”, “Physical Health Status”, “Physical Quality of Life”. The search procedure was conducted during the last week of November 2018 by using the electronic databases Scopus, PubMed, PsycINFO, EMBASE, Cochrane Library.

Subsequently, the corresponding authors of the included studies were contacted to request further data/to discover if they had further data. An inspection of all the references of the studies included in the review was also performed. An hand-search of conference proceedings was carried out in order to locate potential abstracts, papers, or posters relevant to OCD research presented at the following scientific associations: American Psychiatry Association, American Psychological Association, European Psychiatry Association, European Association of Psychology, British Psychological Society, Royal College of Psychiatrists. Theses and doctoral dissertations were hand-searched to identify additional unpublished eligible data.

2.3. Study Selection Process

Studies were assessed on eligibility criteria by two reviewers (AP, FF) independently during three different stages. During the first and the second stages, studies were assessed with regard to eligibility criteria after the reading of the title and of the abstract, respectively. During these stages, studies were retained when there was no agreement on inclusion between the reviewers. Finally, the studies remaining were assessed on eligibility criteria after the reading of the full text. In this selection stage, the reviewers discussed reasons for inclusion and any disagreements in judgement were addressed during meetings with another independent reviewer (AC) to obtain consensus on which studies to include in the pool.

2.4. Data Extraction and Coding

All the information was extracted from each of the included studies by two reviewers (AP, FF) independently and inserted into an excel worksheet which was firstly piloted on 2 included studies. The following information was extracted and coded from each of the studies: (a) Title of the paper, (b) First author, (c) Publication date, (d) Country where the study was conducted, (e) Inclusion and exclusion criteria, (f) Total sample size, (g) Number of patients with OCD, (h) Number of controls, (i) Types of controls (screened participants without psychiatric disorders or unscreened participants from general population), (j) Mean and standard deviation of the OCD group on the perceived Physical Health Status outcome, (k) Mean and standard deviation of the control group on the perceived Physical Health Status outcome, (l) Mean and standard deviation of the OCD group on the measure of role limitations due to physical problems, (m) Mean and standard deviation of the control group on the measure of role limitations due to physical problems, (n) Mean and standard deviation of the OCD group on the measure of bodily pain, (o) Mean and standard deviation of the control group on the measure of bodily pain, (p) Total mean age and age range, (q) Total percentage of females, (r) Measure(s) used to assess perceived Physical Health Status, (s) Measure(s) adopted to evaluate role limitations due to physical problems, (t) Measure(s) to assess bodily pain, (u) OCD symptom severity (measured in terms of the Y-BOCS scores), (v) Research design, (w) Instrument(s) used to establish the OCD diagnosis, (x) Percentage of patients on concurrent medication, (y) Patients’ recruitment strategies, (z) Strategies used to recruit the controls, (aa) Comorbid personality disorders, (ab) Comorbid depression symptoms, (ac) Percentage of patients with concurrent general medical diseases.

The third independent reviewer (AC) not involved in the extraction procedure checked the correctness of the data inserted in the worksheet by the other two reviewers. After the insertion of the data was completed, discrepancies in the data extracted by the two reviewers were discussed and resolved in a final meeting between the reviewers who conducted the data extraction and the third independent reviewer.

2.5. Moderator Coding

When inconsistency analyses showed significant and high heterogeneity between the effect sizes, the role of moderators was investigated. Two independent reviewers (FF and AP) coded the moderators independently. Subsequently, during meetings between the two reviewers, data insertion in the worksheet was checked for accuracy and potential discrepancies were resolved with a third reviewer (AC). The following variables were coded as moderators: (a) mean sample age; (b) sample gender (coded as the percentage of females); (c) OCD symptom severity, coded as a continuous variable based on Yale-Brown Obsessive Compulsive Scale scores [Y-BOCS; 27], which is the gold standard symptom measure; (d) study publication date; (e) study methodological quality according to the Newcastle-Ottawa Scale scores [NOS; 28] (see Quality Assessment paragraph below).

2.6. Quality Assessment

The NOS was used to judge the methodological quality of the studies. This tool has recently been recommended by systematic review practice guidelines as the most reliable instrument for conducting a quality assessment of cross-sectional/cohort studies [29Zeng X, Zhang Y, Kwong JS, et al. The methodological quality assessment tools for preclinical and clinical studies, systematic review and meta-analysis, and clinical practice guideline: A systematic review. J Evid Based Med 2015; 8(1): 2-10.[http://dx.doi.org/10.1111/jebm.12141] [PMID: 25594108] ]. The NOS includes eight items grouped into three domains: (a) Selection, (b) Comparability, (c) Outcome (cohort studies) or exposure (case-control studies) according to the study design. For each item, a series of response options are provided. A star system is adopted to allow a semi-quantitative quality assessment. The highest quality studies are assigned a maximum of one star for each item, excepting the item related to comparability where two stars are allowed. The scores on the NOS range from zero to nine stars. Two reviewers (AP, FF) performed the quality assessment independently. Discrepancies in the assignment of the scores were resolved in a consensus meeting with an independent third reviewer (AC).

2.7. Meta-Analysis and Summary Measures

The meta-analysis was calculated using random-effect models, which assume that the included studies are drawn from populations of studies that systematically differ from each other [30Borenstein M, Cooper H, Hedges L, et al. Effect sizes for continuous data The handbook of research synthesis and meta-analysis 2009.]. Effect sizes were calculated as standardized mean differences (SMD) by computing the following formula reported in Cohen [31Cohen J. Statistical power analysis for the behavioral sciences 1988.]: (MOCD-MCONTROL)/SDPOOLED, where MOCD is the mean of the OCD groups on the perceived Physical Health Status instruments (or the measure of role limitations due to physical problems or the measure of bodily pain), MCONTROL indicates the mean of the controls on that measure and SDPOOLED is the pooled standard deviation. The effect sizes were estimated with a 95% confidence interval and interpreted according to the criteria described by Cohen [31Cohen J. Statistical power analysis for the behavioral sciences 1988.]: values equal to 0.80 or higher were judged as large, values up to 0.50 as medium, and values up to 0.20 as small. When a study reported the data on more than one instrument to assess Physical Health Status, such as on both the SF-36 Physical Health Status scale and the WHOQOL-BREF Physical Health Status scale, a mean effect size was calculated by combining the effect sizes related to the scores on all the instruments. A standardized mean difference was calculated separately also for the data obtained from the SF-36 Role Limitations due to Physical Problems scale to summarize the evidence about the perceived negative interference of physical health-related problems. Finally, a standardized mean difference was calculated separately also for the data obtained from the SF-36 Bodily Pain scale to summarize the data related to perceived physical pain in OCD.

To verify publication bias, three different procedures were adopted including the Duval and Tweedie's trim and fill procedure [32Duval S, Tweedie R. Trim and fill: A simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics 2000; 56(2): 455-63.[http://dx.doi.org/10.1111/j.0006-341X.2000.00455.x] [PMID: 1087 7304] ], the visual inspection of the funnel plot and the Egger test.

Sensitivity analyses were performed by computing the effect sizes only in the studies (a) using the SF-36 Physical Health Status scale, (b) using adults, (c) using healthy screened controls, (d) using OCD patients without general medical disorders.

To assess between-studies heterogeneity, two indices were used, the I2 [33Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ 2003; 327(7414): 557-60.[http://dx.doi.org/10.1136/bmj.327.7414.557] [PMID: 12958120] ] and the Q statistic [34Lipsey MW, Wilson D. Practical meta-analysis 2001.], respectively. The I2 is expressed as a percentage attributable to variability rather than chance [33Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ 2003; 327(7414): 557-60.[http://dx.doi.org/10.1136/bmj.327.7414.557] [PMID: 12958120] ]. A value close to zero indicates homogeneity, whereas values of 25%-50%, 50%-75%, and 75%-100% indicate low, moderate, and high heterogeneity, respectively. The Q statistic is computed by summing the squared deviations of each study’s effect estimate from the overall effect estimate while weighting the contribution of each study by its inverse variance [35Hedges LV. Distribution theory for Glass’s estimator of effect size and related estimators. J Educ Stat 1981; 6: 107-28.[http://dx.doi.org/10.3102/10769986006002107] ]. In the hypothesis of homogeneity among the effect sizes, the Q statistic follows a chi-square distribution with k − 1 degrees of freedom, k being the number of studies. The moderators' analysis was conducted by performing weighted least squares meta-regressions. The meta-analysis was carried out using the Comprehensive Meta-analysis software version 2.00.

3. RESULTS

3.1. Study Selection

The electronic search and the search through additional sources produced 2512 records after removing duplicates. Of these, 2467 were excluded by the title or abstract as being on irrelevant constructs. Thus, 45 studies were full-text screened for inclusion. Sixteen studies were excluded for not using Physical Health Status measures or not assessing Physical Health Status/Role Limitations due to Physical Problems/Pain. Nine studies were excluded as they did not include a control group. Six studies were excluded since they were conducted on child samples. After this selection, fourteen studies were included by the consensus of the three independent assessors in the systematic review and meta-analysis (n= 20,223, 15 effect sizes). The Flow Chart is shown in Fig. (1).

3.2. Study Characteristics

All included studies were in English and published in peer-reviewed journals. Publication date ranged from 1996 to 2018. Three studies were conducted in Europe [36Albert U, Maina G, Bogetto F, Chiarle A, Mataix-Cols D. Clinical predictors of health-related quality of life in obsessive-compulsive disorder. Compr Psychiatry 2010; 51(2): 193-200.[http://dx.doi.org/10.1016/j.comppsych.2009.03.004] [PMID: 2015 2302] -38Stengler-Wenzke K, Kroll M, Matschinger H, Angermeyer MC. Quality of life of relatives of patients with obsessive-compulsive disorder. Compr Psychiatry 2006; 47(6): 523-7.[http://dx.doi.org/10.1016/j.comppsych.2006.02.002] [PMID: 17067 878] ], three in North America [39Eisen JL, Mancebo MA, Pinto A, et al. Impact of obsessive-compulsive disorder on quality of life. Compr Psychiatry 2006; 47(4): 270-5.[http://dx.doi.org/10.1016/j.comppsych.2005.11.006] [PMID: 16769 301] -41Koran LM, Thienemann ML, Davenport R. Quality of life for patients with obsessive-compulsive disorder. Am J Psychiatry 1996; 153(6): 783-8.[http://dx.doi.org/10.1176/ajp.153.6.783] [PMID: 8633690] ], three in South America [5Fontenelle IS, Fontenelle LF, Borges MC, et al. Quality of life and symptom dimensions of patients with obsessive-compulsive disorder. Psychiatry Res 2010; 179(2): 198-203.[http://dx.doi.org/10.1016/j.psychres.2009.04.005] [PMID: 20483484] , 42Vivan AdeS, Rodrigues L, Wendt G, Bicca MG, Cordioli AV. Quality of life in adolescents with obsessive-compulsive disorder. Br J Psychiatry 2013; 35(4): 369-74.[http://dx.doi.org/10.1590/1516-4446-2013-1135] [PMID: 24402211] , 43Trettim AJ, Pires JP, Matos MB, et al. Quality of Life among Young Adults with Obsessive Compulsive Disorder: A Population-Based Study. Int J Fam Comm Med 2017; 1: 1-7.[http://dx.doi.org/10.15406/ijfcm.2017.01.00007] ], three in Asia [44Hou SY, Yen CF, Huang MF, Wang PW, Yeh YC. Quality of life and its correlates in patients with obsessive-compulsive disorder. Kaohsiung J Med Sci 2010; 26(8): 397-407.[http://dx.doi.org/10.1016/S1607-551X(10)70065-6] [PMID: 20705 250] -46Srivastava S, Bhatia MS, Thawani R, Jhanjee A. Quality of life in patients with obsessive compulsive disorder: A longitudinal study from India. Asian J Psychiatr 2011; 4(3): 178-82.[http://dx.doi.org/10.1016/j.ajp.2011.05.008] [PMID: 23051114] ], two in the Middle East [47Kivircik Akdede BB, Alptekin K, Akvardar Y, Kitiş A. [Quality of life in patients with obsessive-compulsive disorder: Relations with cognitive functions and clinical symptoms]. Turk Psikiyatr Derg 2005; 16(1): 13-9.[PMID: 15793694] , 48Jahangard L, Fadaei V, Sajadi A, et al. Patients with OCD report lower quality of life after controlling for expert-rated symptoms of depression and anxiety. Psychiatry Res 2018; 260: 318-23.[http://dx.doi.org/10.1016/j.psychres.2017.11.080] [PMID: 29227895] ]. All studies used adults, except for one [44Hou SY, Yen CF, Huang MF, Wang PW, Yeh YC. Quality of life and its correlates in patients with obsessive-compulsive disorder. Kaohsiung J Med Sci 2010; 26(8): 397-407.[http://dx.doi.org/10.1016/S1607-551X(10)70065-6] [PMID: 20705 250] ] using adolescents/ adults (age range = 16 -70 years) and one using adolescents [42Vivan AdeS, Rodrigues L, Wendt G, Bicca MG, Cordioli AV. Quality of life in adolescents with obsessive-compulsive disorder. Br J Psychiatry 2013; 35(4): 369-74.[http://dx.doi.org/10.1590/1516-4446-2013-1135] [PMID: 24402211] ]. Six studies compared OCD patients with screened healthy controls [40Gros DF, Magruder KM, Frueh BC. Obsessive compulsive disorder in veterans in primary care: Prevalence and impairment. Gen Hosp Psychiatry 2013; 35(1): 71-3.[http://dx.doi.org/10.1016/j.genhosppsych.2012.09.004] [PMID: 230 44243] , 42Vivan AdeS, Rodrigues L, Wendt G, Bicca MG, Cordioli AV. Quality of life in adolescents with obsessive-compulsive disorder. Br J Psychiatry 2013; 35(4): 369-74.[http://dx.doi.org/10.1590/1516-4446-2013-1135] [PMID: 24402211] , 44Hou SY, Yen CF, Huang MF, Wang PW, Yeh YC. Quality of life and its correlates in patients with obsessive-compulsive disorder. Kaohsiung J Med Sci 2010; 26(8): 397-407.[http://dx.doi.org/10.1016/S1607-551X(10)70065-6] [PMID: 20705 250] , 46Srivastava S, Bhatia MS, Thawani R, Jhanjee A. Quality of life in patients with obsessive compulsive disorder: A longitudinal study from India. Asian J Psychiatr 2011; 4(3): 178-82.[http://dx.doi.org/10.1016/j.ajp.2011.05.008] [PMID: 23051114] -48Jahangard L, Fadaei V, Sajadi A, et al. Patients with OCD report lower quality of life after controlling for expert-rated symptoms of depression and anxiety. Psychiatry Res 2018; 260: 318-23.[http://dx.doi.org/10.1016/j.psychres.2017.11.080] [PMID: 29227895] ], eight compared OCD patients with controls recruited from the general population [5Fontenelle IS, Fontenelle LF, Borges MC, et al. Quality of life and symptom dimensions of patients with obsessive-compulsive disorder. Psychiatry Res 2010; 179(2): 198-203.[http://dx.doi.org/10.1016/j.psychres.2009.04.005] [PMID: 20483484] , 36Albert U, Maina G, Bogetto F, Chiarle A, Mataix-Cols D. Clinical predictors of health-related quality of life in obsessive-compulsive disorder. Compr Psychiatry 2010; 51(2): 193-200.[http://dx.doi.org/10.1016/j.comppsych.2009.03.004] [PMID: 2015 2302] -39Eisen JL, Mancebo MA, Pinto A, et al. Impact of obsessive-compulsive disorder on quality of life. Compr Psychiatry 2006; 47(4): 270-5.[http://dx.doi.org/10.1016/j.comppsych.2005.11.006] [PMID: 16769 301] , 41Koran LM, Thienemann ML, Davenport R. Quality of life for patients with obsessive-compulsive disorder. Am J Psychiatry 1996; 153(6): 783-8.[http://dx.doi.org/10.1176/ajp.153.6.783] [PMID: 8633690] , 43Trettim AJ, Pires JP, Matos MB, et al. Quality of Life among Young Adults with Obsessive Compulsive Disorder: A Population-Based Study. Int J Fam Comm Med 2017; 1: 1-7.[http://dx.doi.org/10.15406/ijfcm.2017.01.00007] , 45Kumar A, Sharma MP, Kandavel T, Reddy YJ. Cognitive appraisals and quality of life in patients with obsessive compulsive disorder. J Obsessive Compuls Relat Disord 2012; 1: 301-5.[http://dx.doi.org/10.1016/j.jocrd.2012.08.003] ]. Eight studies used the SF-36 Physical Health Status scale [5Fontenelle IS, Fontenelle LF, Borges MC, et al. Quality of life and symptom dimensions of patients with obsessive-compulsive disorder. Psychiatry Res 2010; 179(2): 198-203.[http://dx.doi.org/10.1016/j.psychres.2009.04.005] [PMID: 20483484] , 36Albert U, Maina G, Bogetto F, Chiarle A, Mataix-Cols D. Clinical predictors of health-related quality of life in obsessive-compulsive disorder. Compr Psychiatry 2010; 51(2): 193-200.[http://dx.doi.org/10.1016/j.comppsych.2009.03.004] [PMID: 2015 2302] , 37Rodriguez-Salgado B, Dolengevich-Segal H, Arrojo-Romero M, et al. Perceived quality of life in obsessive-compulsive disorder: Related factors. BMC Psychiatry 2006; 6: 20.[http://dx.doi.org/10.1186/1471-244X-6-20] [PMID: 16684346] , 39Eisen JL, Mancebo MA, Pinto A, et al. Impact of obsessive-compulsive disorder on quality of life. Compr Psychiatry 2006; 47(4): 270-5.[http://dx.doi.org/10.1016/j.comppsych.2005.11.006] [PMID: 16769 301] -41Koran LM, Thienemann ML, Davenport R. Quality of life for patients with obsessive-compulsive disorder. Am J Psychiatry 1996; 153(6): 783-8.[http://dx.doi.org/10.1176/ajp.153.6.783] [PMID: 8633690] , 43Trettim AJ, Pires JP, Matos MB, et al. Quality of Life among Young Adults with Obsessive Compulsive Disorder: A Population-Based Study. Int J Fam Comm Med 2017; 1: 1-7.[http://dx.doi.org/10.15406/ijfcm.2017.01.00007] , 48Jahangard L, Fadaei V, Sajadi A, et al. Patients with OCD report lower quality of life after controlling for expert-rated symptoms of depression and anxiety. Psychiatry Res 2018; 260: 318-23.[http://dx.doi.org/10.1016/j.psychres.2017.11.080] [PMID: 29227895] ]; seven studies used the WHOQOL-BREF Physical Health Status scale [38Stengler-Wenzke K, Kroll M, Matschinger H, Angermeyer MC. Quality of life of relatives of patients with obsessive-compulsive disorder. Compr Psychiatry 2006; 47(6): 523-7.[http://dx.doi.org/10.1016/j.comppsych.2006.02.002] [PMID: 17067 878] , 39Eisen JL, Mancebo MA, Pinto A, et al. Impact of obsessive-compulsive disorder on quality of life. Compr Psychiatry 2006; 47(4): 270-5.[http://dx.doi.org/10.1016/j.comppsych.2005.11.006] [PMID: 16769 301] , 42Vivan AdeS, Rodrigues L, Wendt G, Bicca MG, Cordioli AV. Quality of life in adolescents with obsessive-compulsive disorder. Br J Psychiatry 2013; 35(4): 369-74.[http://dx.doi.org/10.1590/1516-4446-2013-1135] [PMID: 24402211] , 44Hou SY, Yen CF, Huang MF, Wang PW, Yeh YC. Quality of life and its correlates in patients with obsessive-compulsive disorder. Kaohsiung J Med Sci 2010; 26(8): 397-407.[http://dx.doi.org/10.1016/S1607-551X(10)70065-6] [PMID: 20705 250] -47Kivircik Akdede BB, Alptekin K, Akvardar Y, Kitiş A. [Quality of life in patients with obsessive-compulsive disorder: Relations with cognitive functions and clinical symptoms]. Turk Psikiyatr Derg 2005; 16(1): 13-9.[PMID: 15793694] ]. The included studies used different measures of depression: four studies [36Albert U, Maina G, Bogetto F, Chiarle A, Mataix-Cols D. Clinical predictors of health-related quality of life in obsessive-compulsive disorder. Compr Psychiatry 2010; 51(2): 193-200.[http://dx.doi.org/10.1016/j.comppsych.2009.03.004] [PMID: 2015 2302] , 37Rodriguez-Salgado B, Dolengevich-Segal H, Arrojo-Romero M, et al. Perceived quality of life in obsessive-compulsive disorder: Related factors. BMC Psychiatry 2006; 6: 20.[http://dx.doi.org/10.1186/1471-244X-6-20] [PMID: 16684346] , 39Eisen JL, Mancebo MA, Pinto A, et al. Impact of obsessive-compulsive disorder on quality of life. Compr Psychiatry 2006; 47(4): 270-5.[http://dx.doi.org/10.1016/j.comppsych.2005.11.006] [PMID: 16769 301] , 48Jahangard L, Fadaei V, Sajadi A, et al. Patients with OCD report lower quality of life after controlling for expert-rated symptoms of depression and anxiety. Psychiatry Res 2018; 260: 318-23.[http://dx.doi.org/10.1016/j.psychres.2017.11.080] [PMID: 29227895] ] used the HAM-D, three [5Fontenelle IS, Fontenelle LF, Borges MC, et al. Quality of life and symptom dimensions of patients with obsessive-compulsive disorder. Psychiatry Res 2010; 179(2): 198-203.[http://dx.doi.org/10.1016/j.psychres.2009.04.005] [PMID: 20483484] , 42Vivan AdeS, Rodrigues L, Wendt G, Bicca MG, Cordioli AV. Quality of life in adolescents with obsessive-compulsive disorder. Br J Psychiatry 2013; 35(4): 369-74.[http://dx.doi.org/10.1590/1516-4446-2013-1135] [PMID: 24402211] , 44Hou SY, Yen CF, Huang MF, Wang PW, Yeh YC. Quality of life and its correlates in patients with obsessive-compulsive disorder. Kaohsiung J Med Sci 2010; 26(8): 397-407.[http://dx.doi.org/10.1016/S1607-551X(10)70065-6] [PMID: 20705 250] ] used the BDI or the BDI-II, one [45Kumar A, Sharma MP, Kandavel T, Reddy YJ. Cognitive appraisals and quality of life in patients with obsessive compulsive disorder. J Obsessive Compuls Relat Disord 2012; 1: 301-5.[http://dx.doi.org/10.1016/j.jocrd.2012.08.003] ] used the DASS-21, whereas the other studies did not assess depression.

Three studies [36Albert U, Maina G, Bogetto F, Chiarle A, Mataix-Cols D. Clinical predictors of health-related quality of life in obsessive-compulsive disorder. Compr Psychiatry 2010; 51(2): 193-200.[http://dx.doi.org/10.1016/j.comppsych.2009.03.004] [PMID: 2015 2302] , 38Stengler-Wenzke K, Kroll M, Matschinger H, Angermeyer MC. Quality of life of relatives of patients with obsessive-compulsive disorder. Compr Psychiatry 2006; 47(6): 523-7.[http://dx.doi.org/10.1016/j.comppsych.2006.02.002] [PMID: 17067 878] , 46Srivastava S, Bhatia MS, Thawani R, Jhanjee A. Quality of life in patients with obsessive compulsive disorder: A longitudinal study from India. Asian J Psychiatr 2011; 4(3): 178-82.[http://dx.doi.org/10.1016/j.ajp.2011.05.008] [PMID: 23051114] ] reported the proportion of the patients with personality disorders (51%, 0%, and 0%, respectively). Three studies [41Koran LM, Thienemann ML, Davenport R. Quality of life for patients with obsessive-compulsive disorder. Am J Psychiatry 1996; 153(6): 783-8.[http://dx.doi.org/10.1176/ajp.153.6.783] [PMID: 8633690] , 44Hou SY, Yen CF, Huang MF, Wang PW, Yeh YC. Quality of life and its correlates in patients with obsessive-compulsive disorder. Kaohsiung J Med Sci 2010; 26(8): 397-407.[http://dx.doi.org/10.1016/S1607-551X(10)70065-6] [PMID: 20705 250] , 48Jahangard L, Fadaei V, Sajadi A, et al. Patients with OCD report lower quality of life after controlling for expert-rated symptoms of depression and anxiety. Psychiatry Res 2018; 260: 318-23.[http://dx.doi.org/10.1016/j.psychres.2017.11.080] [PMID: 29227895] ] reported the proportion of the patients on concurrent pharmacotherapy (100%, 54%, and 100%, respectively). Five studies excluded patients with general medical disorders [5Fontenelle IS, Fontenelle LF, Borges MC, et al. Quality of life and symptom dimensions of patients with obsessive-compulsive disorder. Psychiatry Res 2010; 179(2): 198-203.[http://dx.doi.org/10.1016/j.psychres.2009.04.005] [PMID: 20483484] , 45Kumar A, Sharma MP, Kandavel T, Reddy YJ. Cognitive appraisals and quality of life in patients with obsessive compulsive disorder. J Obsessive Compuls Relat Disord 2012; 1: 301-5.[http://dx.doi.org/10.1016/j.jocrd.2012.08.003] -48Jahangard L, Fadaei V, Sajadi A, et al. Patients with OCD report lower quality of life after controlling for expert-rated symptoms of depression and anxiety. Psychiatry Res 2018; 260: 318-23.[http://dx.doi.org/10.1016/j.psychres.2017.11.080] [PMID: 29227895] ], seven did not report information on comorbidity with general medical disorders [36Albert U, Maina G, Bogetto F, Chiarle A, Mataix-Cols D. Clinical predictors of health-related quality of life in obsessive-compulsive disorder. Compr Psychiatry 2010; 51(2): 193-200.[http://dx.doi.org/10.1016/j.comppsych.2009.03.004] [PMID: 2015 2302] , 38Stengler-Wenzke K, Kroll M, Matschinger H, Angermeyer MC. Quality of life of relatives of patients with obsessive-compulsive disorder. Compr Psychiatry 2006; 47(6): 523-7.[http://dx.doi.org/10.1016/j.comppsych.2006.02.002] [PMID: 17067 878] -40Gros DF, Magruder KM, Frueh BC. Obsessive compulsive disorder in veterans in primary care: Prevalence and impairment. Gen Hosp Psychiatry 2013; 35(1): 71-3.[http://dx.doi.org/10.1016/j.genhosppsych.2012.09.004] [PMID: 230 44243] , 42Vivan AdeS, Rodrigues L, Wendt G, Bicca MG, Cordioli AV. Quality of life in adolescents with obsessive-compulsive disorder. Br J Psychiatry 2013; 35(4): 369-74.[http://dx.doi.org/10.1590/1516-4446-2013-1135] [PMID: 24402211] -44Hou SY, Yen CF, Huang MF, Wang PW, Yeh YC. Quality of life and its correlates in patients with obsessive-compulsive disorder. Kaohsiung J Med Sci 2010; 26(8): 397-407.[http://dx.doi.org/10.1016/S1607-551X(10)70065-6] [PMID: 20705 250] ], one reported that 74.60% of the group had comorbid medical disorders [37Rodriguez-Salgado B, Dolengevich-Segal H, Arrojo-Romero M, et al. Perceived quality of life in obsessive-compulsive disorder: Related factors. BMC Psychiatry 2006; 6: 20.[http://dx.doi.org/10.1186/1471-244X-6-20] [PMID: 16684346] ] and one reported 61.66% [41Koran LM, Thienemann ML, Davenport R. Quality of life for patients with obsessive-compulsive disorder. Am J Psychiatry 1996; 153(6): 783-8.[http://dx.doi.org/10.1176/ajp.153.6.783] [PMID: 8633690] ]. The supplementary file presents an overview of study characteristics.

Fig. (1)
PRISMA flowchart.


3.3. Quality Assessment

Six studies received 5 points on the NOS [5Fontenelle IS, Fontenelle LF, Borges MC, et al. Quality of life and symptom dimensions of patients with obsessive-compulsive disorder. Psychiatry Res 2010; 179(2): 198-203.[http://dx.doi.org/10.1016/j.psychres.2009.04.005] [PMID: 20483484] , 38Stengler-Wenzke K, Kroll M, Matschinger H, Angermeyer MC. Quality of life of relatives of patients with obsessive-compulsive disorder. Compr Psychiatry 2006; 47(6): 523-7.[http://dx.doi.org/10.1016/j.comppsych.2006.02.002] [PMID: 17067 878] , 39Eisen JL, Mancebo MA, Pinto A, et al. Impact of obsessive-compulsive disorder on quality of life. Compr Psychiatry 2006; 47(4): 270-5.[http://dx.doi.org/10.1016/j.comppsych.2005.11.006] [PMID: 16769 301] , 41Koran LM, Thienemann ML, Davenport R. Quality of life for patients with obsessive-compulsive disorder. Am J Psychiatry 1996; 153(6): 783-8.[http://dx.doi.org/10.1176/ajp.153.6.783] [PMID: 8633690] , 45Kumar A, Sharma MP, Kandavel T, Reddy YJ. Cognitive appraisals and quality of life in patients with obsessive compulsive disorder. J Obsessive Compuls Relat Disord 2012; 1: 301-5.[http://dx.doi.org/10.1016/j.jocrd.2012.08.003] ], three received 6 points [36Albert U, Maina G, Bogetto F, Chiarle A, Mataix-Cols D. Clinical predictors of health-related quality of life in obsessive-compulsive disorder. Compr Psychiatry 2010; 51(2): 193-200.[http://dx.doi.org/10.1016/j.comppsych.2009.03.004] [PMID: 2015 2302] , 37Rodriguez-Salgado B, Dolengevich-Segal H, Arrojo-Romero M, et al. Perceived quality of life in obsessive-compulsive disorder: Related factors. BMC Psychiatry 2006; 6: 20.[http://dx.doi.org/10.1186/1471-244X-6-20] [PMID: 16684346] , 47Kivircik Akdede BB, Alptekin K, Akvardar Y, Kitiş A. [Quality of life in patients with obsessive-compulsive disorder: Relations with cognitive functions and clinical symptoms]. Turk Psikiyatr Derg 2005; 16(1): 13-9.[PMID: 15793694] ], four 7 points [40Gros DF, Magruder KM, Frueh BC. Obsessive compulsive disorder in veterans in primary care: Prevalence and impairment. Gen Hosp Psychiatry 2013; 35(1): 71-3.[http://dx.doi.org/10.1016/j.genhosppsych.2012.09.004] [PMID: 230 44243] , 42Vivan AdeS, Rodrigues L, Wendt G, Bicca MG, Cordioli AV. Quality of life in adolescents with obsessive-compulsive disorder. Br J Psychiatry 2013; 35(4): 369-74.[http://dx.doi.org/10.1590/1516-4446-2013-1135] [PMID: 24402211] , 44Hou SY, Yen CF, Huang MF, Wang PW, Yeh YC. Quality of life and its correlates in patients with obsessive-compulsive disorder. Kaohsiung J Med Sci 2010; 26(8): 397-407.[http://dx.doi.org/10.1016/S1607-551X(10)70065-6] [PMID: 20705 250] , 48Jahangard L, Fadaei V, Sajadi A, et al. Patients with OCD report lower quality of life after controlling for expert-rated symptoms of depression and anxiety. Psychiatry Res 2018; 260: 318-23.[http://dx.doi.org/10.1016/j.psychres.2017.11.080] [PMID: 29227895] ] and one study [46Srivastava S, Bhatia MS, Thawani R, Jhanjee A. Quality of life in patients with obsessive compulsive disorder: A longitudinal study from India. Asian J Psychiatr 2011; 4(3): 178-82.[http://dx.doi.org/10.1016/j.ajp.2011.05.008] [PMID: 23051114] ] 9 points.

The definition of cases was judged as adequate for all the studies. All the studies were considered to have reported some independent validation. Representativeness of cases was judged as adequate for all the studies. Selection and definition of controls were judged as adequate for all the studies. Comparability of the subjects across the included studies was judged as adequate only in one study [46Srivastava S, Bhatia MS, Thawani R, Jhanjee A. Quality of life in patients with obsessive compulsive disorder: A longitudinal study from India. Asian J Psychiatr 2011; 4(3): 178-82.[http://dx.doi.org/10.1016/j.ajp.2011.05.008] [PMID: 23051114] ]. Ascertainment of exposure was judged as adequate for all the studies. Six studies did not use the same method of ascertainment of exposure for cases and controls and this item of the NOS was not judged as adequate for this subgroup of studies [5Fontenelle IS, Fontenelle LF, Borges MC, et al. Quality of life and symptom dimensions of patients with obsessive-compulsive disorder. Psychiatry Res 2010; 179(2): 198-203.[http://dx.doi.org/10.1016/j.psychres.2009.04.005] [PMID: 20483484] , 36Albert U, Maina G, Bogetto F, Chiarle A, Mataix-Cols D. Clinical predictors of health-related quality of life in obsessive-compulsive disorder. Compr Psychiatry 2010; 51(2): 193-200.[http://dx.doi.org/10.1016/j.comppsych.2009.03.004] [PMID: 2015 2302] -39Eisen JL, Mancebo MA, Pinto A, et al. Impact of obsessive-compulsive disorder on quality of life. Compr Psychiatry 2006; 47(4): 270-5.[http://dx.doi.org/10.1016/j.comppsych.2005.11.006] [PMID: 16769 301] , 41Koran LM, Thienemann ML, Davenport R. Quality of life for patients with obsessive-compulsive disorder. Am J Psychiatry 1996; 153(6): 783-8.[http://dx.doi.org/10.1176/ajp.153.6.783] [PMID: 8633690] ]. For six studies the provision of the information about the non-response rate was not judged as adequate [5Fontenelle IS, Fontenelle LF, Borges MC, et al. Quality of life and symptom dimensions of patients with obsessive-compulsive disorder. Psychiatry Res 2010; 179(2): 198-203.[http://dx.doi.org/10.1016/j.psychres.2009.04.005] [PMID: 20483484] , 38Stengler-Wenzke K, Kroll M, Matschinger H, Angermeyer MC. Quality of life of relatives of patients with obsessive-compulsive disorder. Compr Psychiatry 2006; 47(6): 523-7.[http://dx.doi.org/10.1016/j.comppsych.2006.02.002] [PMID: 17067 878] , 39Eisen JL, Mancebo MA, Pinto A, et al. Impact of obsessive-compulsive disorder on quality of life. Compr Psychiatry 2006; 47(4): 270-5.[http://dx.doi.org/10.1016/j.comppsych.2005.11.006] [PMID: 16769 301] , 47Kivircik Akdede BB, Alptekin K, Akvardar Y, Kitiş A. [Quality of life in patients with obsessive-compulsive disorder: Relations with cognitive functions and clinical symptoms]. Turk Psikiyatr Derg 2005; 16(1): 13-9.[PMID: 15793694] , 41Koran LM, Thienemann ML, Davenport R. Quality of life for patients with obsessive-compulsive disorder. Am J Psychiatry 1996; 153(6): 783-8.[http://dx.doi.org/10.1176/ajp.153.6.783] [PMID: 8633690] , 45Kumar A, Sharma MP, Kandavel T, Reddy YJ. Cognitive appraisals and quality of life in patients with obsessive compulsive disorder. J Obsessive Compuls Relat Disord 2012; 1: 301-5.[http://dx.doi.org/10.1016/j.jocrd.2012.08.003] ]. The quality assessment according to the criteria of the NOS is in Table 1.

3.4. Comparison of Perceived Physical Health Status between Patients with OCD and Controls

An overview of all the analyses is in Table 2. The comparison of perceived Physical Health Status showed a large significant-negative-effect size favouring controls over patients with OCD (SMD = -0.97, SE = 0.25, 95% CI: -1.46 - 0.45, p < 0.001). Controls reported significantly higher levels of perceived Physical Health Status than patients with OCD (Fig. 2). Evidence of publication bias was not observed as the values of the Egger test were not significant [B = -6.12, SE = 4.00, 95% CI: -14.86 - 2.60, t(12) = 1.52, p = 0.15] and the funnel plot did not appear asymmetrical (Fig. 3). Absence of publication bias was also supported by the trim and fill procedure showing that the mean effect size did not change when it was adjusted for publication bias (SMD = -0.95, 95% CI: -1.46 - 0.45; number of trimmed studies =0]. A significant heterogeneity was observed since the result of the Q test was significant [Q(13) = 560.80, p <0.001], and the value of the I2 was higher than 75 (I2 = 97.68).

Table 1
Quality assessment according to the Newcastle-Ottawa Scale (NOS): one star indicates one point.


Fig. (2)
Forest plot of perceived Physical Health Status between OCD patients and controls.


Fig. (3)
Funnel plot.


Table 2
Overview of analyses.


3.5. Sensitivity Analysis

In a sensitivity analysis, the mean effect size was calculated by including only the studies (k = 8) using the SF-36 Physical Health Status scale [5Fontenelle IS, Fontenelle LF, Borges MC, et al. Quality of life and symptom dimensions of patients with obsessive-compulsive disorder. Psychiatry Res 2010; 179(2): 198-203.[http://dx.doi.org/10.1016/j.psychres.2009.04.005] [PMID: 20483484] , 36Albert U, Maina G, Bogetto F, Chiarle A, Mataix-Cols D. Clinical predictors of health-related quality of life in obsessive-compulsive disorder. Compr Psychiatry 2010; 51(2): 193-200.[http://dx.doi.org/10.1016/j.comppsych.2009.03.004] [PMID: 2015 2302] , 37Rodriguez-Salgado B, Dolengevich-Segal H, Arrojo-Romero M, et al. Perceived quality of life in obsessive-compulsive disorder: Related factors. BMC Psychiatry 2006; 6: 20.[http://dx.doi.org/10.1186/1471-244X-6-20] [PMID: 16684346] , 39Eisen JL, Mancebo MA, Pinto A, et al. Impact of obsessive-compulsive disorder on quality of life. Compr Psychiatry 2006; 47(4): 270-5.[http://dx.doi.org/10.1016/j.comppsych.2005.11.006] [PMID: 16769 301] -41Koran LM, Thienemann ML, Davenport R. Quality of life for patients with obsessive-compulsive disorder. Am J Psychiatry 1996; 153(6): 783-8.[http://dx.doi.org/10.1176/ajp.153.6.783] [PMID: 8633690] , 43Trettim AJ, Pires JP, Matos MB, et al. Quality of Life among Young Adults with Obsessive Compulsive Disorder: A Population-Based Study. Int J Fam Comm Med 2017; 1: 1-7.[http://dx.doi.org/10.15406/ijfcm.2017.01.00007] , 48Jahangard L, Fadaei V, Sajadi A, et al. Patients with OCD report lower quality of life after controlling for expert-rated symptoms of depression and anxiety. Psychiatry Res 2018; 260: 318-23.[http://dx.doi.org/10.1016/j.psychres.2017.11.080] [PMID: 29227895] ]. The results showed a medium significant effect size favouring controls over patients with OCD (SMD = -0.63, SE = 0.26, 95% CI: -1.15 - 0.10, p < 0.05). Evidence of publication bias was not observed as the result of the Egger test was not significant [B = -8.88, SE = 4.75, 95% CI: -20.851 - 2.74, t(6) = 1.86, p = 0.11]. Absence of publication bias was also supported by the trim and fill procedure which showed that the mean effect size did not change when it was corrected for publication bias (SMD = -0.63, 95% CI: -1.15 - 0.10; number of trimmed studies =0].

Another sensitivity analysis included only the studies using adults (k = 12) [5Fontenelle IS, Fontenelle LF, Borges MC, et al. Quality of life and symptom dimensions of patients with obsessive-compulsive disorder. Psychiatry Res 2010; 179(2): 198-203.[http://dx.doi.org/10.1016/j.psychres.2009.04.005] [PMID: 20483484] , 36Albert U, Maina G, Bogetto F, Chiarle A, Mataix-Cols D. Clinical predictors of health-related quality of life in obsessive-compulsive disorder. Compr Psychiatry 2010; 51(2): 193-200.[http://dx.doi.org/10.1016/j.comppsych.2009.03.004] [PMID: 2015 2302] -41Koran LM, Thienemann ML, Davenport R. Quality of life for patients with obsessive-compulsive disorder. Am J Psychiatry 1996; 153(6): 783-8.[http://dx.doi.org/10.1176/ajp.153.6.783] [PMID: 8633690] , 43Trettim AJ, Pires JP, Matos MB, et al. Quality of Life among Young Adults with Obsessive Compulsive Disorder: A Population-Based Study. Int J Fam Comm Med 2017; 1: 1-7.[http://dx.doi.org/10.15406/ijfcm.2017.01.00007] , 45Kumar A, Sharma MP, Kandavel T, Reddy YJ. Cognitive appraisals and quality of life in patients with obsessive compulsive disorder. J Obsessive Compuls Relat Disord 2012; 1: 301-5.[http://dx.doi.org/10.1016/j.jocrd.2012.08.003] -48Jahangard L, Fadaei V, Sajadi A, et al. Patients with OCD report lower quality of life after controlling for expert-rated symptoms of depression and anxiety. Psychiatry Res 2018; 260: 318-23.[http://dx.doi.org/10.1016/j.psychres.2017.11.080] [PMID: 29227895] ]. A medium significant effect size emerged favouring controls over patients with OCD (SMD = -0.60, SE = 0.22, 95% CI: -1.05 - 0.16, p < 0.01). Evidence of publication bias was not observed as the Egger test was not significant [B = -2.52, SE = 4.06, 95% CI: -11.58 - 6.53, t(10) = 0.10, p = 0.54]. Absence of publication bias was also supported by the trim and fill procedure showing that the mean effect size did not change when corrected for publication bias (SMD = -0.60, 95% CI: -1.05 - 0.15; number of trimmed studies =0).

The mean effect size was calculated also by including only the studies using screened controls (k = 6) [40Gros DF, Magruder KM, Frueh BC. Obsessive compulsive disorder in veterans in primary care: Prevalence and impairment. Gen Hosp Psychiatry 2013; 35(1): 71-3.[http://dx.doi.org/10.1016/j.genhosppsych.2012.09.004] [PMID: 230 44243] , 42Vivan AdeS, Rodrigues L, Wendt G, Bicca MG, Cordioli AV. Quality of life in adolescents with obsessive-compulsive disorder. Br J Psychiatry 2013; 35(4): 369-74.[http://dx.doi.org/10.1590/1516-4446-2013-1135] [PMID: 24402211] , 44Hou SY, Yen CF, Huang MF, Wang PW, Yeh YC. Quality of life and its correlates in patients with obsessive-compulsive disorder. Kaohsiung J Med Sci 2010; 26(8): 397-407.[http://dx.doi.org/10.1016/S1607-551X(10)70065-6] [PMID: 20705 250] , 46Srivastava S, Bhatia MS, Thawani R, Jhanjee A. Quality of life in patients with obsessive compulsive disorder: A longitudinal study from India. Asian J Psychiatr 2011; 4(3): 178-82.[http://dx.doi.org/10.1016/j.ajp.2011.05.008] [PMID: 23051114] -48Jahangard L, Fadaei V, Sajadi A, et al. Patients with OCD report lower quality of life after controlling for expert-rated symptoms of depression and anxiety. Psychiatry Res 2018; 260: 318-23.[http://dx.doi.org/10.1016/j.psychres.2017.11.080] [PMID: 29227895] ]. The findings showed a large significant effect size favouring controls over patients with OCD (SMD = -1.53, SE = 0.83, 95% CI: -3.16 - 0.09, p < 0.001). Evidence of publication bias was not found as the Egger test was not significant [B = -14.65, SE = 12.23, 95% CI: -48.62 - 19.31, t(4) = 1.19, p = 0.29]. Absence of publication bias was supported by the trim and fill procedure which showed that the mean effect size did not change when it was corrected for publication bias (SMD = -1.53, 95% CI: -3.16 - 0.09; number of trimmed studies = 0).

A further sensitivity analysis included only the studies using patients without comorbid medical conditions (k = 6) [5Fontenelle IS, Fontenelle LF, Borges MC, et al. Quality of life and symptom dimensions of patients with obsessive-compulsive disorder. Psychiatry Res 2010; 179(2): 198-203.[http://dx.doi.org/10.1016/j.psychres.2009.04.005] [PMID: 20483484] , 39Eisen JL, Mancebo MA, Pinto A, et al. Impact of obsessive-compulsive disorder on quality of life. Compr Psychiatry 2006; 47(4): 270-5.[http://dx.doi.org/10.1016/j.comppsych.2005.11.006] [PMID: 16769 301] , 45Kumar A, Sharma MP, Kandavel T, Reddy YJ. Cognitive appraisals and quality of life in patients with obsessive compulsive disorder. J Obsessive Compuls Relat Disord 2012; 1: 301-5.[http://dx.doi.org/10.1016/j.jocrd.2012.08.003] -48Jahangard L, Fadaei V, Sajadi A, et al. Patients with OCD report lower quality of life after controlling for expert-rated symptoms of depression and anxiety. Psychiatry Res 2018; 260: 318-23.[http://dx.doi.org/10.1016/j.psychres.2017.11.080] [PMID: 29227895] ]. The results showed a large yet non-significant effect size favouring controls over patients with OCD (SMD = -0.91, SE = 0.51, 95% CI: -1.90 - 0.08, p = 0.08). Evidence of publication bias was not found by the Egger test, which was non-significant [B = -1.45, SE = 6.35, 95% CI: -48.62 - 19.31, t(4) = 0.22, p = 0.82] but it was supported by the trim and fill procedure showing that the mean effect size changed when corrected for publication bias (SMD = -1.57, SE = 0.51, 95% CI: -1.90 - 0.08; number of trimmed studies = 2).

3.6. Comparison on SF-36 Bodily Pain between Patients with OCD and Controls

The comparison on bodily pain showed a significant, yet small, positive effect size favouring patients with OCD over controls (SMD = 0.22, SE = 0.05, 95% CI: 0.11 - 0.33, p < 0.001, k = 6): patients reported significantly higher levels of bodily pain than controls. No evidence of heterogeneity emerged [Q(5) = 6.50, p = 0.26, I2 = 23.09]. Absence of publication bias was supported by the trim and fill procedure showing that the mean effect size did not change when corrected for publication bias (SMD = -0.22, 95% CI: 0.11 - 0.33; number of trimmed studies =0) and confirmed also by the Egger test, which was not significant [B = 2.01, SE = 0.97, 95% CI: -0.70 - 4.73, t(4) = 2.06, p = 0.10].

3.7. Comparison on SF-36 Role Limitations due to Physical Problems between OCD Patients and Controls

The comparison of SF-36 Role Limitations due to Physical Problems showed a medium significant positive effect size favouring patients with OCD over controls (SMD = 0.55, SE = 0.14, 95% CI: 0.83 - 0.26, p < 0.001, k = 6): patients reported significantly higher levels of role limitations due to physical problems than controls. Significant heterogeneity emerged [Q(5) = 41.59, p < 0.001, I2= 87.98]. Absence of publication bias was supported by the trim and fill procedure showing that the mean effect size did not change when corrected for publication bias (SMD = 0.55, 95% CI: 0.83 - 0.26; number of trimmed studies =0). Absence of publication bias was confirmed also by the Egger test which was not significant [B = -1.60, SE = 3.45, 95% CI: -11.19 - 7.98, t(4) = 0.46, p = 0.65].

3.8. Moderator Analysis

Age was negatively associated with the effect sizes: higher age was associated with larger standardized mean differences in effect sizes on perceived Physical Health Status between patients with OCD and controls (B = -0.01, SE = 0.01, 95% CI: -0.02 - 0.01, p < 0.001, k = 13). Female gender was negatively associated with the effect sizes: higher percentage of females was associated with larger standardized mean differences in effect sizes on perceived Physical Health Status between patients with OCD and controls (B = -0.03, SE = 0.01, 95% CI: -0.04 - 0.02, p < 0.001, k = 14). OCD severity was positively associated with the effect sizes: higher OCD severity was associated with narrower standardized mean differences in effect sizes on perceived Physical Health Status between patients with OCD and controls (B = 0.21, SE = 0.01, 95% CI: 0.18 - 0.23, p < 0.001, k = 11).

Publication date was negatively associated with the effect sizes: more recent publication dates were associated with larger standardized mean differences in effect sizes on perceived Physical Health Status between patients with OCD and controls (B = -0.05, SE = 0.01, 95% CI: -0.06 - 0.03, p < 0.001, k = 14).

Methodological quality, coded through the scores on the NOS, was positively associated with effect sizes. Studies with higher methodological quality were associated with lower standardized mean differences in effect sizes on perceived Physical Health Status between patients with OCD and controls (B = 0.10, SE = 0.03, 95% CI: 0.02-0.16, p = 0.008, k = 14).

4. DISCUSSION

While there are numerous literature studies on the psychological quality of life in OCD [2Coluccia A, Fagiolini A, Ferretti F, et al. Obsessive-Compulsive Disorder and quality of life outcomes: Protocol for a systematic review and meta-analysis of cross-sectional case-control studies. Epidemiol Biostat Public Health 2015; 12: 2., 3Coluccia A, Fagiolini A, Ferretti F, et al. Adult obsessive-compulsive disorder and quality of life outcomes: A systematic review and meta-analysis. Asian J Psychiatr 2016; 22: 41-52.[http://dx.doi.org/10.1016/j.ajp.2016.02.001] [PMID: 27520893] ], perceived physical health is under-recognized as research and practice focus on the mental health component of the condition [9Aguglia A, Signorelli MS, Albert U, Maina G. The impact of general medical conditions in obsessive-compulsive disorder. Psychiatry Investig 2018; 15(3): 246-53.[http://dx.doi.org/10.30773/pi.2017.06.17.2] [PMID: 29475243] ]. This investigation is the first systematic review and meta-analysis studying perceived Physical Health Status in patients with OCD. Fourteen studies were included. According to a range of NOS methodological quality points from 0 to 9, six studies received 5 points, three received 6 points, four studies 7 points and one study nine points. Perceived Physical Health Status was significantly lower in patients with OCD than in controls, as indicated by a large effect size without evidence of publication bias. This result was similar to the large effect size (SMD = - 1.22, p < 0.001) reported in a recent meta-analysis on patients with schizophrenia [49Dong M, Lu L, Zhang L, et al. Quality of Life in Schizophrenia: A Meta-Analysis of Comparative Studies. Psychiatr Q 2019; •••: 1-14.[http://dx.doi.org/10.1007/s11126-019-09633-4] [PMID: 31119453] ] where the clinical groups reported significantly lower perceived Physical Health Status than the control groups, as measured by the WHOQOL-BREF [26The WHOQOL Group. Development of the World Health Organization WHOQOL-BREF quality of life assessment. Psychol Med 1998; 28(3): 551-8.[http://dx.doi.org/10.1017/S0033291798006667] [PMID: 9626712] ]. Although this has the limitation of indirect comparison, this result suggests that perceived physical health in OCD may be impaired to the same extent as in other severe psychiatric conditions such as psychoses.

In the studies using the SF-36 Physical Health Status scale, the effect size was medium without publication bias. A medium effect size without publication bias was also found when the analysis was conducted only on adults. A non-significant effect size emerged in those studies reporting that patients had not comorbid medical disorders, but this analysis included only 6 studies and appeared at risk of publication bias. Patients with OCD reported significantly higher Bodily Pain than controls without publication bias and heterogeneity. However, it should be noted that for Bodily Pain the effect size was small. Patients with OCD reported significantly higher levels of Role limitations due to physical problems than controls, with a medium effect size without publication bias. Overall, the present results suggest that in OCD, perceived Physical Health Status and Role Limitations due to Physical Problems are lower than among controls and should be considered as an important problem associated with this disease. The smaller difference between patients and controls on Bodily Pain suggests that this physical outcome may be less relevant to OCD. It might be hypothesized that OCD is associated with worse Physical Health Status due to an unhealthy lifestyle, including sedentary lifestyle, social isolation, unhealthy eating habits caused by contamination fears [11Fergus TA. The Cyberchondria Severity Scale (CSS): An examination of structure and relations with health anxiety in a community sample. J Anxiety Disord 2014; 28(6): 504-10.[http://dx.doi.org/10.1016/j.janxdis.2014.05.006] [PMID: 24956357] ] or the use of maladaptive behaviours to regulate negative emotion, such as cigarette smoking. This point may have the implication of suggesting that clinicians also address physical health literacy during their psychiatric encounters with OCD patients. As these variables were not controlled for, future research should assess whether Physical Health status is worsened by an unhealthy lifestyle. Alternatively, it may be that patients with OCD have health anxiety and selective attention mechanisms on bodily signs leading to misinterpretations of them, and then to a worse perception of Health Status [14Solem S, Borgejordet S, Haseth S, Hansen B, Håland Å, Bailey R. Symptoms of health anxiety in obsessive-compulsive disorder: Relationship with treatment outcome and metacognition. J Obsessive Compuls Relat Disord 2015; 5: 76-81.[http://dx.doi.org/10.1016/j.jocrd.2015.03.002] ]. A clinical implication of this may be the use of interventions targeting anxiety sensitivity in OCD, which can reduce OCD symptoms by decreasing hypervigilance on body signs and misinterpretations of them [50Timpano KR, Raines AM, Shaw AM, Keough ME, Schmidt NB. Effects of a brief anxiety sensitivity reduction intervention on obsessive compulsive spectrum symptoms in a young adult sample. J Psychiatr Res 2016; 83: 8-15.[http://dx.doi.org/10.1016/j.jpsychires.2016.07.022] [PMID: 27522 321] ]. Perceived Physical Health Status should be a target of treatment; the implication of these results may be that health-focused interventions may be included as adjuncts to standard treatment [15Abrantes AM, Brown RA, Strong DR, et al. A pilot randomized controlled trial of aerobic exercise as an adjunct to OCD treatment. Gen Hosp Psychiatry 2017; 49: 51-5.[http://dx.doi.org/10.1016/j.genhosppsych.2017.06.010] [PMID: 2912 2148] , 51Solem S, Borgejordet S, Haseth S, et al. Symptoms of health anxiety in obsessive-compulsive disorder: Relationship with treatment outcome and metacognition. J Obsessive Compuls Relat Disord 2015; 5: 76-81.[http://dx.doi.org/10.1016/j.jocrd.2015.03.002] , 52Sarris J, Camfield D, Berk M. Complementary medicine, self-help, and lifestyle interventions for obsessive compulsive disorder (OCD) and the OCD spectrum: A systematic review. J Affect Disord 2012; 138(3): 213-21.[http://dx.doi.org/10.1016/j.jad.2011.04.051] [PMID: 21620478] ]. Also, mindfulness-based therapy may be useful for Physical Health in OCD as it enables the person to decenter from intrusive thoughts and have a non-judgemental attitude towards the body [17Mathur S, Sharma MP, Reddy JY. Preliminary findings of efficacy of Mindfulness Integrated Cognitive Therapy (MICT) for Obsessive-Compulsive Disorder (OCD). Archives of Mental Health 2016; 17: 65-9.].

Higher age was associated with larger effect sizes on perceived Physical Health Status between patients with OCD and controls. This result may be attributed to the fact that perceived Physical Health tends to decrease over time and it may be lower for older patients. In addition, the effect of age may be a consequence of longer illness duration: symptoms persisting over time can reduce perceived Physical Health due to the cumulative effect of the above-mentioned variables associated with OCD interfering with Physical Health, such as social isolation and a sedentary lifestyle.

Female gender was negatively associated with effect sizes. A higher females percentage was associated with larger effect sizes on perceived Physical Health Status between OCD patients and controls. This result suggested that females had worse perceived Physical Health than males, consistent with the evidence found on psychological quality of life [3Coluccia A, Fagiolini A, Ferretti F, et al. Adult obsessive-compulsive disorder and quality of life outcomes: A systematic review and meta-analysis. Asian J Psychiatr 2016; 22: 41-52.[http://dx.doi.org/10.1016/j.ajp.2016.02.001] [PMID: 27520893] ]. This result may be in line with a general trend in the scientific literature related to the so-called “Gender and health paradox” [53Rieker PP, Bird CE. Rethinking gender differences in health: Why we need to integrate social and biological perspectives. J Gerontol B Psychol Sci Soc Sci 2005; 60(Spec No 2): 40-7.[http://dx.doi.org/10.1093/geronb/60.Special_Issue_2.S40] [PMID: 16251589] ], indicating that women report worse health than men (despite living longer). Gender-based differences in the clinical picture of OCD may also explain the result that females tend to experience a worse physical health status. Females with OCD more frequently report medical diseases, negative mood, contamination fears, suicidal ideation, and comorbid eating disorders, which appear to impact the perception of physical health [20Jaisoorya TS, Reddy YC, Srinath S, Thennarasu K. Sex differences in Indian patients with obsessive-compulsive disorder. Compr Psychiatry 2009; 50(1): 70-5.[http://dx.doi.org/10.1016/j.comppsych.2008.05.003] [PMID: 19059 517] ].

OCD severity was positively associated with effect sizes: higher OCD severity was associated with smaller differences in effect sizes on perceived Physical Health Status between OCD patients and controls. This result seemed to be consistent with the evidence found for psychological quality of life in OCD, which tends to be lower for patients with less severe symptoms than for those with higher severity [8Pozza A, Lochner C, Ferretti F, Cuomo A, Coluccia A. Does higher severity really correlate with a worse quality of life in obsessive-compulsive disorder? A meta-regression. Neuropsychiatr Dis Treat 2018; 14: 1013-23.[http://dx.doi.org/10.2147/NDT.S157125] [PMID: 29713171] ]. An explanation may be that patients with less severe symptoms have higher health expectancies, that would make them have a worse perception of Physical Health Status. The clinical implication of this may be that clinicians should pay attention to perceived Physical Health of less severe patients. Publication date was negatively associated with the effect sizes: more recent publication dates were associated with larger differences in effect sizes on perceived Physical Health Status between patients with OCD and controls.

4.1. Limitations and Conclusion

Some shortcomings should be pointed out. Firstly, the cross-sectional design of the studies does not allow conclusions to be drawn about the causal effect of OCD symptoms on perceived physical health but can only suggest an association. It might be argued that a poorer perception of Physical Health Status can induce obsessive fears or exacerbate to some extent pre-existing fears or compulsive behaviours. Thus, the investigation of perceived physical health needs for prospective designs. Secondly, seven of the studies did not report information about comorbid medical conditions. This lack of information prevented the adjustment of the analyses, and the sensitivity analysis was conducted on a small subgroup.

Only three out of the studies provided information about the number of patients on concurrent psychopharmacological treatment: 100% of the samples in two studies [41Koran LM, Thienemann ML, Davenport R. Quality of life for patients with obsessive-compulsive disorder. Am J Psychiatry 1996; 153(6): 783-8.[http://dx.doi.org/10.1176/ajp.153.6.783] [PMID: 8633690] , 44Hou SY, Yen CF, Huang MF, Wang PW, Yeh YC. Quality of life and its correlates in patients with obsessive-compulsive disorder. Kaohsiung J Med Sci 2010; 26(8): 397-407.[http://dx.doi.org/10.1016/S1607-551X(10)70065-6] [PMID: 20705 250] ] and 54% in one [48Jahangard L, Fadaei V, Sajadi A, et al. Patients with OCD report lower quality of life after controlling for expert-rated symptoms of depression and anxiety. Psychiatry Res 2018; 260: 318-23.[http://dx.doi.org/10.1016/j.psychres.2017.11.080] [PMID: 29227895] ]. The lack of this information does not allow the effects of psychopharmacotherapy on perceived physical health to be accounted for. It may be argued that medication routinely prescribed for OCD at higher dosages than for anxiety or depressive disorders, such as Selective Serotonin Reuptake Inhibitors (SSRIs), may be associated with side-effects that impact physical health such as nausea, dizziness sedation, insomnia, and sexual dysfunction [54Jenike MA. Clinical practice. Obsessive-compulsive disorder. N Engl J Med 2004; 350(3): 259-65.[http://dx.doi.org/10.1056/NEJMcp031002] [PMID: 14724305] ]. In addition, since OCD is typically a resistant disorder, it is often necessary to associate different classes of drugs in addition to the SSRIs such as Atypical Antipsychotics, as evidenced also by a recent review [55Albert U, Carmassi C, Cosci F, et al. Role and clinical implications of atypical antipsychotics in anxiety disorders, obsessive-compulsive disorder, trauma-related, and somatic symptom disorders: A systematized review. Int Clin Psychopharmacol 2016; 31(5): 249-58.[http://dx.doi.org/10.1097/YIC.0000000000000127] [PMID: 26974 213] ], with the risk of greater side effects and less perception of one's health. Another variable potentially moderating the association between OCD and physical health might be depression [56Masellis M, Rector NA, Richter MA. Quality of life in OCD: Differential impact of obsessions, compulsions, and depression comorbidity. Can J Psychiatry 2003; 48(2): 72-7.[http://dx.doi.org/10.1177/070674370304800202] [PMID: 12655903] , 57Pozza A, Coradeschi D, Dèttore D. Do dysfunctional beliefs moderate the negative influence of comorbid severe depression on outcome of residential treatment for refractory OCD? A pilot study. Clin Neuropsychiatry 2013; 10: 72-83.]. However, in the present studies there was a large heterogeneity in the instruments used to measure it and this did not allow depression to be investigated as a moderator. As previously mentioned, future research should compare perceived physical health in OCD with other severe mental disorders such as psychosis or potentially with other conditions belonging to the so-called OCD spectrum, such as body dysmorphic disorder or skin picking disorder which typically involve a negative body experience [58Schneider SC, Turner CM, Storch EA, Hudson JL. Body dysmorphic disorder symptoms and quality of life: The role of clinical and demographic variables. J Obsessive Compuls Relat Disord 2019; 21: 1-5.[http://dx.doi.org/10.1016/j.jocrd.2018.11.002] , 59Pozza A, Giaquinta N, Dèttore D. Borderline, avoidant, sadistic personality traits and emotion dysregulation predict different pathological skin picking subtypes in a community sample. Neuropsychiatr Dis Treat 2016; 12: 1861-7.[http://dx.doi.org/10.2147/NDT.S109162] [PMID: 27536108] ].

In conclusion, this is the first systematic review on Perceived Physical health in OCD: this quality of life domain should be considered more carefully by researchers in future investigations and by clinicians as a target of treatment, particularly with older, female and less severe patients. New interventions for Physical Health status in OCD may be evaluated.

CONSENT FOR PUBLICATION

Written of informed consents were obtained from all the participants prior of the study.

FUNDING

None.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

AP designed the study, wrote the protocol, searched the literature, participated in the selection of the studies, performed the statistical analysis, and wrote the paper.

FF designed the study, wrote the protocol, searched the literature, participated in the selection of the studies, performed the statistical analysis, and wrote the paper.

AC designed the study, participated in the selection of the studies, and reviewed and approved the final version of the paper.

SUPPLEMENTARY MATERIAL

Supplementary material is available on the publishers website along with the published article.

REFERENCES

[1] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM5) 5th ed. 5th ed.2013.
[2] Coluccia A, Fagiolini A, Ferretti F, et al. Obsessive-Compulsive Disorder and quality of life outcomes: Protocol for a systematic review and meta-analysis of cross-sectional case-control studies. Epidemiol Biostat Public Health 2015; 12: 2.
[3] Coluccia A, Fagiolini A, Ferretti F, et al. Adult obsessive-compulsive disorder and quality of life outcomes: A systematic review and meta-analysis. Asian J Psychiatr 2016; 22: 41-52.[http://dx.doi.org/10.1016/j.ajp.2016.02.001] [PMID: 27520893]
[4] Coluccia A, Ferretti F, Fagiolini A, Pozza A. Quality of life in children and adolescents with obsessive-compulsive disorder: A systematic review and meta-analysis. Neuropsychiatr Dis Treat 2017; 13: 597-608.[http://dx.doi.org/10.2147/NDT.S122306] [PMID: 28280342]
[5] Fontenelle IS, Fontenelle LF, Borges MC, et al. Quality of life and symptom dimensions of patients with obsessive-compulsive disorder. Psychiatry Res 2010; 179(2): 198-203.[http://dx.doi.org/10.1016/j.psychres.2009.04.005] [PMID: 20483484]
[6] Lochner C, Mogotsi M, du Toit PL, Kaminer D, Niehaus DJ, Stein DJ. Quality of life in anxiety disorders: A comparison of obsessive-compulsive disorder, social anxiety disorder, and panic disorder. Psychopathology 2003; 36(5): 255-62.[http://dx.doi.org/10.1159/000073451] [PMID: 14571055]
[7] Remmerswaal KCP, Batelaan NM, Smit JH, et al. Quality of life and relationship satisfaction of patients with Obsessive Compulsive Disorder. J Obsessive Compuls Relat Disord 2016; 11: 56-62.[http://dx.doi.org/10.1016/j.jocrd.2016.08.005]
[8] Pozza A, Lochner C, Ferretti F, Cuomo A, Coluccia A. Does higher severity really correlate with a worse quality of life in obsessive-compulsive disorder? A meta-regression. Neuropsychiatr Dis Treat 2018; 14: 1013-23.[http://dx.doi.org/10.2147/NDT.S157125] [PMID: 29713171]
[9] Aguglia A, Signorelli MS, Albert U, Maina G. The impact of general medical conditions in obsessive-compulsive disorder. Psychiatry Investig 2018; 15(3): 246-53.[http://dx.doi.org/10.30773/pi.2017.06.17.2] [PMID: 29475243]
[10] Meier SM, Mattheisen M, Mors O, Schendel DE, Mortensen PB, Plessen KJ. Mortality among persons with obsessive-compulsive disorder in Denmark. JAMA Psychiatry 2016; 73(3): 268-74.[http://dx.doi.org/10.1001/jamapsychiatry.2015.3105] [PMID: 2681 8216]
[11] Fergus TA. The Cyberchondria Severity Scale (CSS): An examination of structure and relations with health anxiety in a community sample. J Anxiety Disord 2014; 28(6): 504-10.[http://dx.doi.org/10.1016/j.janxdis.2014.05.006] [PMID: 24956357]
[12] Pozza A, Mazzoni GP, Berardi D, et al. Studio preliminare sulle proprietà psicometriche della versione italiana della Disgust Propensity and Sensitivity Scale-Revised (DPSS-R) in campioni non-clinici e campioni clinici con Disturbo Ossessivo-Compulsivo e Disturbi d’ansia. Psicoter Cogn Comport 2016; 22: 271-96.
[13] Raines AM, Oglesby ME, Capron DW, et al. Obsessive compulsive disorder and anxiety sensitivity: Identification of specific relations among symptom dimensions. J Obsessive Compuls Relat Disord 2014; 3: 71-6.[http://dx.doi.org/10.1016/j.jocrd.2014.01.001]
[14] Solem S, Borgejordet S, Haseth S, Hansen B, Håland Å, Bailey R. Symptoms of health anxiety in obsessive-compulsive disorder: Relationship with treatment outcome and metacognition. J Obsessive Compuls Relat Disord 2015; 5: 76-81.[http://dx.doi.org/10.1016/j.jocrd.2015.03.002]
[15] Abrantes AM, Brown RA, Strong DR, et al. A pilot randomized controlled trial of aerobic exercise as an adjunct to OCD treatment. Gen Hosp Psychiatry 2017; 49: 51-5.[http://dx.doi.org/10.1016/j.genhosppsych.2017.06.010] [PMID: 2912 2148]
[16] Sarris J, Camfield D, Berk M. Complementary medicine, self-help, and lifestyle interventions for obsessive compulsive disorder (OCD) and the OCD spectrum: A systematic review. J Affect Disord 2012; 138(3): 213-21.[http://dx.doi.org/10.1016/j.jad.2011.04.051] [PMID: 21620478]
[17] Mathur S, Sharma MP, Reddy JY. Preliminary findings of efficacy of Mindfulness Integrated Cognitive Therapy (MICT) for Obsessive-Compulsive Disorder (OCD). Archives of Mental Health 2016; 17: 65-9.
[18] Barcaccia B, Baiocco R, Pozza A, et al. The more you judge the worse you feel. A judgemental attitude towards one’s inner experience predicts depression and anxiety. Pers Individ Dif 2019; 138: 33-9.[http://dx.doi.org/10.1016/j.paid.2018.09.012]
[19] Kumar A, Sharma MP, Narayanaswamy JC, Kandavel T, Janardhan Reddy YC. Efficacy of mindfulness-integrated cognitive behavior therapy in patients with predominant obsessions. Indian J Psychiatry 2016; 58(4): 366-71.[http://dx.doi.org/10.4103/0019-5545.196723] [PMID: 28196991]
[20] Jaisoorya TS, Reddy YC, Srinath S, Thennarasu K. Sex differences in Indian patients with obsessive-compulsive disorder. Compr Psychiatry 2009; 50(1): 70-5.[http://dx.doi.org/10.1016/j.comppsych.2008.05.003] [PMID: 19059 517]
[21] Shamseer L, Moher D, Clarke M, et al. PRISMA-P Group. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: Elaboration and explanation. BMJ 2015; 350: g7647.[http://dx.doi.org/10.1136/bmj.g7647] [PMID: 25555855]
[22] First MB, Spitzer RL, Gibbon M, et al. User’s guide for the Structured clinical interview for DSM-IV axis I disorders SCID-I: Clinician version 1997.
[23] World Health Organization. The ICD-10 classification of mental and behavioural disorders: Diagnostic criteria for research 1993.
[24] Geller DA, Biederman J, Faraone S, et al. Developmental aspects of obsessive compulsive disorder: Findings in children, adolescents, and adults. J Nerv Ment Dis 2001; 189(7): 471-7.[http://dx.doi.org/10.1097/00005053-200107000-00009] [PMID: 115 04325]
[25] Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 1992; 30(6): 473-83.[http://dx.doi.org/10.1097/00005650-199206000-00002] [PMID: 159 3914]
[26] The WHOQOL Group. Development of the World Health Organization WHOQOL-BREF quality of life assessment. Psychol Med 1998; 28(3): 551-8.[http://dx.doi.org/10.1017/S0033291798006667] [PMID: 9626712]
[27] Goodman WK, Price LH, Rasmussen SA, et al. The Yale-Brown obsessive compulsive scale: I. Development, use, and reliability. Arch Gen Psychiatry 1989; 46(11): 1006-11.[http://dx.doi.org/10.1001/archpsyc.1989.01810110048007] [PMID: 2684084]
[28] Wells G, Shea B, O’Connell D, et al. Newcastle-Ottawa quality assessment scale cohort studies. http://www.ohri.ca/programs/ clinical_epidemiology/oxford.asp (accessed 5th December 2018).
[29] Zeng X, Zhang Y, Kwong JS, et al. The methodological quality assessment tools for preclinical and clinical studies, systematic review and meta-analysis, and clinical practice guideline: A systematic review. J Evid Based Med 2015; 8(1): 2-10.[http://dx.doi.org/10.1111/jebm.12141] [PMID: 25594108]
[30] Borenstein M, Cooper H, Hedges L, et al. Effect sizes for continuous data The handbook of research synthesis and meta-analysis 2009.
[31] Cohen J. Statistical power analysis for the behavioral sciences 1988.
[32] Duval S, Tweedie R. Trim and fill: A simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics 2000; 56(2): 455-63.[http://dx.doi.org/10.1111/j.0006-341X.2000.00455.x] [PMID: 1087 7304]
[33] Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ 2003; 327(7414): 557-60.[http://dx.doi.org/10.1136/bmj.327.7414.557] [PMID: 12958120]
[34] Lipsey MW, Wilson D. Practical meta-analysis 2001.
[35] Hedges LV. Distribution theory for Glass’s estimator of effect size and related estimators. J Educ Stat 1981; 6: 107-28.[http://dx.doi.org/10.3102/10769986006002107]
[36] Albert U, Maina G, Bogetto F, Chiarle A, Mataix-Cols D. Clinical predictors of health-related quality of life in obsessive-compulsive disorder. Compr Psychiatry 2010; 51(2): 193-200.[http://dx.doi.org/10.1016/j.comppsych.2009.03.004] [PMID: 2015 2302]
[37] Rodriguez-Salgado B, Dolengevich-Segal H, Arrojo-Romero M, et al. Perceived quality of life in obsessive-compulsive disorder: Related factors. BMC Psychiatry 2006; 6: 20.[http://dx.doi.org/10.1186/1471-244X-6-20] [PMID: 16684346]
[38] Stengler-Wenzke K, Kroll M, Matschinger H, Angermeyer MC. Quality of life of relatives of patients with obsessive-compulsive disorder. Compr Psychiatry 2006; 47(6): 523-7.[http://dx.doi.org/10.1016/j.comppsych.2006.02.002] [PMID: 17067 878]
[39] Eisen JL, Mancebo MA, Pinto A, et al. Impact of obsessive-compulsive disorder on quality of life. Compr Psychiatry 2006; 47(4): 270-5.[http://dx.doi.org/10.1016/j.comppsych.2005.11.006] [PMID: 16769 301]
[40] Gros DF, Magruder KM, Frueh BC. Obsessive compulsive disorder in veterans in primary care: Prevalence and impairment. Gen Hosp Psychiatry 2013; 35(1): 71-3.[http://dx.doi.org/10.1016/j.genhosppsych.2012.09.004] [PMID: 230 44243]
[41] Koran LM, Thienemann ML, Davenport R. Quality of life for patients with obsessive-compulsive disorder. Am J Psychiatry 1996; 153(6): 783-8.[http://dx.doi.org/10.1176/ajp.153.6.783] [PMID: 8633690]
[42] Vivan AdeS, Rodrigues L, Wendt G, Bicca MG, Cordioli AV. Quality of life in adolescents with obsessive-compulsive disorder. Br J Psychiatry 2013; 35(4): 369-74.[http://dx.doi.org/10.1590/1516-4446-2013-1135] [PMID: 24402211]
[43] Trettim AJ, Pires JP, Matos MB, et al. Quality of Life among Young Adults with Obsessive Compulsive Disorder: A Population-Based Study. Int J Fam Comm Med 2017; 1: 1-7.[http://dx.doi.org/10.15406/ijfcm.2017.01.00007]
[44] Hou SY, Yen CF, Huang MF, Wang PW, Yeh YC. Quality of life and its correlates in patients with obsessive-compulsive disorder. Kaohsiung J Med Sci 2010; 26(8): 397-407.[http://dx.doi.org/10.1016/S1607-551X(10)70065-6] [PMID: 20705 250]
[45] Kumar A, Sharma MP, Kandavel T, Reddy YJ. Cognitive appraisals and quality of life in patients with obsessive compulsive disorder. J Obsessive Compuls Relat Disord 2012; 1: 301-5.[http://dx.doi.org/10.1016/j.jocrd.2012.08.003]
[46] Srivastava S, Bhatia MS, Thawani R, Jhanjee A. Quality of life in patients with obsessive compulsive disorder: A longitudinal study from India. Asian J Psychiatr 2011; 4(3): 178-82.[http://dx.doi.org/10.1016/j.ajp.2011.05.008] [PMID: 23051114]
[47] Kivircik Akdede BB, Alptekin K, Akvardar Y, Kitiş A. [Quality of life in patients with obsessive-compulsive disorder: Relations with cognitive functions and clinical symptoms]. Turk Psikiyatr Derg 2005; 16(1): 13-9.[PMID: 15793694]
[48] Jahangard L, Fadaei V, Sajadi A, et al. Patients with OCD report lower quality of life after controlling for expert-rated symptoms of depression and anxiety. Psychiatry Res 2018; 260: 318-23.[http://dx.doi.org/10.1016/j.psychres.2017.11.080] [PMID: 29227895]
[49] Dong M, Lu L, Zhang L, et al. Quality of Life in Schizophrenia: A Meta-Analysis of Comparative Studies. Psychiatr Q 2019; •••: 1-14.[http://dx.doi.org/10.1007/s11126-019-09633-4] [PMID: 31119453]
[50] Timpano KR, Raines AM, Shaw AM, Keough ME, Schmidt NB. Effects of a brief anxiety sensitivity reduction intervention on obsessive compulsive spectrum symptoms in a young adult sample. J Psychiatr Res 2016; 83: 8-15.[http://dx.doi.org/10.1016/j.jpsychires.2016.07.022] [PMID: 27522 321]
[51] Solem S, Borgejordet S, Haseth S, et al. Symptoms of health anxiety in obsessive-compulsive disorder: Relationship with treatment outcome and metacognition. J Obsessive Compuls Relat Disord 2015; 5: 76-81.[http://dx.doi.org/10.1016/j.jocrd.2015.03.002]
[52] Sarris J, Camfield D, Berk M. Complementary medicine, self-help, and lifestyle interventions for obsessive compulsive disorder (OCD) and the OCD spectrum: A systematic review. J Affect Disord 2012; 138(3): 213-21.[http://dx.doi.org/10.1016/j.jad.2011.04.051] [PMID: 21620478]
[53] Rieker PP, Bird CE. Rethinking gender differences in health: Why we need to integrate social and biological perspectives. J Gerontol B Psychol Sci Soc Sci 2005; 60(Spec No 2): 40-7.[http://dx.doi.org/10.1093/geronb/60.Special_Issue_2.S40] [PMID: 16251589]
[54] Jenike MA. Clinical practice. Obsessive-compulsive disorder. N Engl J Med 2004; 350(3): 259-65.[http://dx.doi.org/10.1056/NEJMcp031002] [PMID: 14724305]
[55] Albert U, Carmassi C, Cosci F, et al. Role and clinical implications of atypical antipsychotics in anxiety disorders, obsessive-compulsive disorder, trauma-related, and somatic symptom disorders: A systematized review. Int Clin Psychopharmacol 2016; 31(5): 249-58.[http://dx.doi.org/10.1097/YIC.0000000000000127] [PMID: 26974 213]
[56] Masellis M, Rector NA, Richter MA. Quality of life in OCD: Differential impact of obsessions, compulsions, and depression comorbidity. Can J Psychiatry 2003; 48(2): 72-7.[http://dx.doi.org/10.1177/070674370304800202] [PMID: 12655903]
[57] Pozza A, Coradeschi D, Dèttore D. Do dysfunctional beliefs moderate the negative influence of comorbid severe depression on outcome of residential treatment for refractory OCD? A pilot study. Clin Neuropsychiatry 2013; 10: 72-83.
[58] Schneider SC, Turner CM, Storch EA, Hudson JL. Body dysmorphic disorder symptoms and quality of life: The role of clinical and demographic variables. J Obsessive Compuls Relat Disord 2019; 21: 1-5.[http://dx.doi.org/10.1016/j.jocrd.2018.11.002]
[59] Pozza A, Giaquinta N, Dèttore D. Borderline, avoidant, sadistic personality traits and emotion dysregulation predict different pathological skin picking subtypes in a community sample. Neuropsychiatr Dis Treat 2016; 12: 1861-7.[http://dx.doi.org/10.2147/NDT.S109162] [PMID: 27536108]

Endorsements



"Open access will revolutionize 21st century knowledge work and accelerate the diffusion of ideas and evidence that support just in time learning and the evolution of thinking in a number of disciplines."


Daniel Pesut
(Indiana University School of Nursing, USA)

"It is important that students and researchers from all over the world can have easy access to relevant, high-standard and timely scientific information. This is exactly what Open Access Journals provide and this is the reason why I support this endeavor."


Jacques Descotes
(Centre Antipoison-Centre de Pharmacovigilance, France)

"Publishing research articles is the key for future scientific progress. Open Access publishing is therefore of utmost importance for wider dissemination of information, and will help serving the best interest of the scientific community."


Patrice Talaga
(UCB S.A., Belgium)

"Open access journals are a novel concept in the medical literature. They offer accessible information to a wide variety of individuals, including physicians, medical students, clinical investigators, and the general public. They are an outstanding source of medical and scientific information."


Jeffrey M. Weinberg
(St. Luke's-Roosevelt Hospital Center, USA)

"Open access journals are extremely useful for graduate students, investigators and all other interested persons to read important scientific articles and subscribe scientific journals. Indeed, the research articles span a wide range of area and of high quality. This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals."


Debomoy K. Lahiri
(Indiana University School of Medicine, USA)

"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


Browse Contents



Webmaster Contact: info@benthamopen.net
Copyright © 2019 Bentham Open