From panic attacks to obsessive compulsive disorders, how COVID-19 has taken a toll on mental health

At the start of the pandemic in 2020, the National Institute of Mental Health and Neurosciences, Bengaluru, started a national helpline for COVID-related mental health issues. The nature of calls in the second wave is different from those in the first. From psycho-social issues in the first wave, callers are now trying to cope with hospitalisation, death, grief and the like.

Dr K Sekar heads the Centre for Psychosocial Support in Disaster Management, which runs the helpline (080-4611 0007). He reveals that calls had plateaued by March, but are peaking again. “When we started the helpline in March 2020, we got 1-2 lakh calls within the first month itself. The issue then was, how to adjust. During lockdowns, there were calls about lack of rations and jobs, migrants unable to go home, general depression, etc. …that is, the calls were more about social situations.”

Now, in the second wave, it is more about the loss of loved ones, not being able to perform their final rites, the helplessness of not finding oxygen or beds, about the elderly left back alone, etc. “There are more calls on mental health issues and severe psychosocial issues now,” he says.

An example is of an 87-year-old man who survived COVID-19 but lost his wife to it. He didn’t wish to live anymore.

“Apart from talking to him about the meaning of life, etc, we also arranged for a person who would visit him frequently. Now he awaits that person’s visits,” says Dr Sekar. The helpline is currently following up with around 58,000 such patients.

During such calamities, a large section of people would have abnormal reactions, Dr Sekar said. Eventually, however, only about 10 percent of the population would need long-term care by mental health professionals. “Initially, about 90 percent of the population would have abnormal psychosocial reactions as we saw in the first wave; thoughts like, ‘Who is the government to ask me to sit at home?’, ‘Why can’t I go to work?’, etc. Now it’s coming down to about 60 percent of the population who have mental health issues but can’t be diagnosed as having a mental illness per se,” he says.

“Within about a year, the affected population will come down to 30 percent, that is, people suffering prolonged grief over the severe trauma they suffered. In another year, there would be about 10 percent who need long-term mental healthcare. This timeline can vary depending on the intensity of the situation.”

Based on evolving evidence from COVID-19 as well as previous experience from SARS and MERS epidemics, this February, the Psychiatry Department at NIMHANS published a document on the possible mental health effects of COVID. The document says a mental health pandemic is looming and that our systems need to be prepared for this. Following are some key pointers from the document.

How COVID-19 has lead to widespread anxiety

The document says that, in the current scenario of COVID-19 deaths, lockdowns, job losses, etc, anxiety and depression are quite widespread. In most cases, anxiety may not interfere with daily functioning or would disappear once the stressor is gone. In some other cases though, the mental health problem could interfere with daily life, or cause suicidal thoughts, to the extent that the patient would need treatment by a mental health professional immediately.

Several types of anxiety disorders are expected to increase with COVID-19 . Cases of Generalised Anxiety Disorder (GAD, wherein the person suffers persistent nervousness, irritability, poor concentration, sleep disturbances, etc), panic disorders (characterised by panic attacks), phobia such as excessive fear of crowds, are expected to appear.

Cases of Obsessive-Compulsive Disorder (OCD) are expected to increase with COVID-19 , with distressing obsessions about contamination, and washing rituals that can last hours. Healthcare workers are more vulnerable to this in the current scenario.

Cases of Post Traumatic Stress Disorder (PTSD) are also expected to arise due to COVID-19 . The NIMHANS document cites a study that found a seven-nine percent prevalence of PTSD among those living in areas hit hard by COVID-19 .

The document points out that worldwide, increased suicide rates are also being reported during COVID-19 . Severe COVID-19 infection, losing family members, losing jobs and livelihood, having a mental illness, are among the risk factors for suicide. Substance use (mostly tobacco and alcohol) to deal with isolation and stress is also expected.

During COVID-19 , besides recognised mental health conditions, many new factors have emerged as ‘life events’ – that is, social experiences that have an impact on the individual’s mental health. These include COVID-19 diagnosis for oneself or family members, lockdown, migration, work-from-home, online education, etc, which have never been on any rating scale. These factors should be considered, says the document.

“Normally we may have 2-3 life events a year; for example, having fever for a week and recovering. But now, people are going through multiple life events in a short period. Also, their family, society, community are all being challenged at the same time,” says Dr Sekar.

Effects on COVID-19 patients

COVID-19 infection itself can affect the brain and lead to neurological effects like agitation and delirium, but severe dysfunctions are rare, says the document. COVID-19 ’s neurological effects are not completely clear yet. However, psychological effects are more common, due to traumatic memories of suffering from COVID-19 , isolation and stigma, etc. High rates of anxiety, depression and stress-related disorders are being reported from those who recovered from acute COVID-19 infection.

This is similar to what was reported during MERS and SARS outbreaks, with survivors having symptoms even a year after recovery. In the case of SARS, nearly half the survivors had PTSD symptoms, says the NIMHANS document. (However, SARS and MERS had much higher death rates compared to COVID-19 , hence the effects can’t be directly generalised). Brain fog – a state of reduced cognitive functioning – is also being increasingly recognised among COVID-19 survivors.

Mental health of some is more affected

While almost everyone is facing mental health effects of COVID, some already vulnerable groups are even more affected. These include:

Children and adolescents: According to various studies, lockdown restrictions are causing some children to be attention-seeking and have higher dependency on parents. Additions like gaming behaviour, uncertainty about the future due to exam postponement, etc are seen in teenagers.

The NIMHANS document quotes a study from China among 2,330 children, which found that around 22 percent reported depressive symptoms and 19 percent reported anxiety symptoms during COVID. Another study from China among over 8000 adolescents cited the prevalence as 43 percent and 37 percent respectively.

An Indian study which specifically focused on children in isolation/quarantine found that 30 percent of them met the criteria for PTSD. Children who lose their parents have a higher risk of developing mood disorders, psychosis, death by suicide in adulthood, says the NIMHANS report. Also, children with physical or mental disabilities are more affected during COVID since services to them have been almost cut off.

Elderly at higher risk: Awareness about higher COVID risk, further social isolation, difficulty accessing essential services, all increase the elderly’s risk of mental health issues. They may commonly face sleeplessness, feelings of emptiness and imprisonment, health anxieties, etc. And some may go on to develop disorders like depression, anxiety disorders, substance use and PTSD. Those living alone or in old age homes are more vulnerable.

People with pre-existing mental issues: In most parts of the world, COVID has led to worsening or relapse of pre-existing mental health conditions. People with disabilities may have fears about financial security, access to healthcare and provisions, about their caregiver falling sick, etc. Surveys show this group has been disproportionately affected by COVID in these aspects.

Frontline healthcare workers: A study in Karnataka found that 26.6% of frontline health workers suffered from anxiety disorders, and 23.8% suffered depression. Certain categories including nurses, those working in ICU, less experienced health workers, those with poor job security, were found to be more vulnerable. Anxiety related to COVID infection, sleep disturbances, burn-out, suicidal thoughts, etc may be present. While the majority would recover over time, some will need immediate psychiatric intervention, the report says.

People in quarantine/isolation: People under home quarantine may be affected by the fear of infection, depression, loneliness, stigma, loss of pay, etc. Studies show that those in hospital quarantine/isolation had more anxiety and depressive symptoms. In vulnerable people, hospital quarantine can lead to acute stress, and they have a higher risk of PTSD later.

Mental health support systems needed

Dr Pratima Murthy, who heads the Psychiatry Department at NIMHANS, says, “In addition to mental health impacts during the pandemic, it’s well-recognised that after the pandemic also, there will be ongoing stress for a lot of people. Also, the health difficulties because of ‘long COVID’ can create psychiatric issues like anxiety and depression. And we do expect other neuropsychiatric complications from COVID infection itself.” Hence, she says, proper support systems should be built in to help people recover quickly and get back to their lives.

This article was first published in Citizen Matters, a civic media website and is republished here with permission. (c) Oorvani Foundation/Open Media Initiative.

Howie Mandel ‘Living in a Nightmare’ With OCD

A photo of Howie Mandel

A photo of Howie Mandel

“America’s Got Talent” judge Howie Mandel has been open for many years about his struggles with anxiety and obsessive-compulsive disorder (OCD). However, in a recent interview with People magazine, the comedian discussed how painful that struggle could be: “If I’m not laughing, then I’m crying. And I still haven’t been that open about how dark and ugly it really gets.”

Mandel, 65, has suffered from OCD since childhood (although he wasn’t officially diagnosed until he was an adult). In an interview with Everyday Health in 2010, Mandel said: “I was always incredibly obsessed with germs and cleaning and taking shower after shower after shower. Even when I was very young, I wouldn’t tie my shoelaces because they had touched the ground. I had continuous repetitive thoughts that I couldn’t get past. As a child, my mind was a lot busier than I was.”

Although Mandel said he is “living in a nightmare,” he explained that he tries to anchor himself: “I have a beautiful family and I love what I do. But at the same time, I can fall into a dark depression I can’t get out of.” He has been married to his wife, Terry, since 1980 and has a son and two daughters. His eldest daughter, Jackie, 36, also suffers from anxiety and OCD.

The pandemic was an especially difficult time for Mandel. He told People: “There isn’t a waking moment of my life when ‘we could die’ doesn’t come into my psyche,” he said. “But the solace I would get would be the fact that everybody around me was okay. It’s good to latch onto okay. But [during the pandemic] the whole world was not okay. And it was absolute hell.”

Mandel said he is speaking up again at this time because “my life’s mission is to remove the stigma [of mental illness]. I’m broken. But this is my reality. I know there’s going to be darkness again — and I cherish every moment of light.”


OCD is a common, chronic, and long-lasting disorder in which a person has uncontrollable, reoccurring thoughts (obsessions) and/or behaviors (compulsions) that he or she feels the urge to repeat over and over.

Approximately 2.3% of the U.S. population has OCD, which is about one in 40 adults and one in 100 children. The average age of onset is 19.5 years. About 50% of those with OCD have onset of symptoms in childhood and adolescence.

Males present earlier, but in adulthood, more females are affected. In families with a history of OCD, there’s a 25% chance that another immediate family member will develop symptoms.

Half of adults with OCD (50.6%) have serious impairment, 34.8% have moderate impairment, and only 15% are mildly impaired.

The majority (90%) of adults who have OCD at some point in their lives also have at least one other mental disorder. Conditions that are often comorbid with OCD include:

  • Anxiety disorders, including panic disorder, phobias, and post-traumatic stress disorder (75.8%)
  • Mood disorders, including major depressive disorder and bipolar disorder (63.3%)
  • Impulse-control disorders, including attention deficit-hyperactivity disorder (55.9%)
  • Substance use disorders (38.6%)

Signs and Symptoms

People with OCD may have symptoms of obsessions, compulsions, or both. These symptoms can interfere with all aspects of life, such as work, school, and personal relationships.

Obsessions are repeated thoughts, urges, or mental images that cause anxiety. Common symptoms include:

  • Fear of germs or contamination
  • Unwanted forbidden or taboo thoughts involving sex, religion, or harm
  • Aggressive thoughts towards others or self
  • Having things symmetrical or in a perfect order

Compulsions are repetitive behaviors that a person with OCD feels the urge to do in response to an obsessive thought. Common compulsions include:

  • Excessive cleaning and/or handwashing
  • Ordering and arranging things in a particular, precise way
  • Repeatedly checking on things, such as to see if a door is locked or that the oven is off
  • Compulsive counting

Not all rituals or habits are compulsions. Everyone double checks things sometimes. But a person with OCD generally:

  • Can’t control his or her thoughts or behaviors, even when those thoughts or behaviors are recognized as excessive
  • Spends at least 1 hour a day on these thoughts or behaviors
  • Doesn’t get pleasure when performing the behaviors or rituals, but may feel brief relief from the anxiety the thoughts cause
  • Experiences significant problems in their daily life due to these thoughts or behaviors


The exact cause of OCD is still unknown, but it is believed to be multifactorial. Twin and family studies have shown that people with first-degree relatives (such as a parent, sibling, or child) who have OCD are at a higher risk for developing OCD themselves. The risk is higher if the first-degree relative developed OCD as a child or teen.

Imaging studies (functional MRIs, diffusion tensor imaging, and single-photon emission computerized tomography) have shown differences in the cortico-striatal-thalamo-cortical (CSTC) circuits of the brain in patients with OCD. These differences are most noticeable in the orbitofrontal cortex, the caudate, anterior cingulate cortex, and thalamus.

Environmental factors may also play a part in the development of OCD. Those implicated (but for which causal associations have not, as of yet, been established) include:

  • Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections, a group A streptococcal infection
  • Premenstrual and postpartum periods, which can be associated with new onset or exacerbation of OCD
  • Exposure to traumatic events
  • Neurologic lesions, such as stroke or traumatic brain injury that affect CSTC circuits


The mainstays of OCD treatment are serotonin reuptake inhibitors (SRIs) and cognitive behavioral therapy (CBT). Although most patients with OCD respond to treatment, some patients continue to experience symptoms.

It is important to consider any other mental disorders a patient may have when making decisions about treatment.


Two primary neurotransmitters are thought to contribute to OCD: serotonin and glutamate. The improvement of OCD symptoms with the use of serotonergic antidepressants led to the hypothesis that changes in serotonin play an important role in OCD. More recent studies support the idea that glutamate also plays a significant role.

SRIs, which include selective serotonin reuptake inhibitors (SSRIs), are used to help reduce OCD symptoms. SRIs often require higher daily doses in the treatment of OCD compared with depression and may take 8 to 12 weeks to start working.

If symptoms do not improve with these types of medications, research has shown that some patients may respond well to an antipsychotic medication, such as aripiprazole or haloperidol, as an adjunct.


Psychotherapy can be an effective treatment for adults and children with OCD. Research has shown that certain types of psychotherapy, including CBT and other related therapies (e.g., habit reversal training), can be as effective as medication for many individuals. Research also has shown that a type of CBT called exposure and response prevention — spending time in the very situation that triggers compulsions (e.g., touching dirty objects) but then being prevented from undertaking the usual resulting compulsion (e.g., handwashing) — is effective in reducing compulsive behaviors in patients with OCD, even in those who did not respond well to SRIs.

Other treatment options

In 2018, the FDA approved transcranial magnetic stimulation (TMS) as an adjunct in the treatment of OCD in adults. TMS is a procedure that uses magnetic fields to stimulate nerve cells in the brain. The FDA permitted the marketing of TMS as a treatment for major depression in 2008 and expanded the use to include pain associated with certain migraine headaches in 2013.

Clinical trials of new methods for treating OCD can be found at the National Institute of Mental Health clinical trials webpage.

Michele R. Berman, MD, is a pediatrician-turned-medical journalist. She trained at Johns Hopkins, Washington University in St. Louis, and St. Louis Children’s Hospital. Her mission is both journalistic and educational: to report on common diseases affecting uncommon people and summarize the evidence-based medicine behind the headlines.

Talk about it, carefully – The Spokesman

Talking about mental illnesses/struggles can be hard for almost anyone, but that doesn’t mean we shouldn’t talk about them.

I personally think it’s hard for some people to talk about their mental struggles because of how it makes them feel. Whether it’s depression, anxiety, panic, stress or anything of the sort, these things can make some people feel less of a person and/or insecure. They can make people feel weaker and more discouraged the more they talk about it.

To some, talking about it helps, but taking into account that everyone’s feelings are different and interpreted unlike others, some people do not like opening up about what goes on in their head and how everything around them makes them feel.

Talking about one’s mental state could also lead some people to anxiety/panic attacks and could also trigger an obsessive-compulsive disorder, generalized anxiety disorder, social anxiety disorder or any mental illness one might struggle with. Everyone handles these triggers differently — many worse than others, some better than most.

In conclusion, if you are a pushing a loved one, friend and/or family member to open up to you because you want to try and help, asking once and reassuring them that you will be there if they need it would be better than pressuring them into talking to you because of the things that could be attacking them neurotically.

Anna Hajjar


Exposure Therapy for Anxiety: What to Expect and Effectiveness

In exposure therapy, a person is exposed to a situation, event, or object that triggers anxiety, fear, or panic for them. Over a period of time, controlled exposure to a trigger by a trusted person in a safe space can lessen the anxiety or panic.

There are different kinds of exposure therapies. They can include:

  • In vivo exposure. This therapy involves directly facing the feared situation or activity in real life.
  • Imaginal exposure. It involves vividly imagining the trigger situation in detail.
  • Virtual reality exposure. This therapy can be used when in vivo exposure isn’t realistic, like if someone has a fear of flying.
  • Interoceptive exposure. This therapy involves purposefully triggering a physical sensation that is feared, but harmless.

A 2015 research review showed that within those kinds of exposure therapies there are different techniques like:

  • Prolonged exposure (PE). This includes a combination of in vivo and imaginal exposure. For example, someone might repeatedly revisit a traumatic event by visualizing it, and talking about it with a therapist simultaneously, and then discussing it to gain a new perspective about the event.
  • Exposure and response prevention (EX/RP, or ERP). Typically used for people with obsessive compulsive disorder (OCD), this involves doing exposure homework, such as touching something considered “dirty,” and then refraining from performing the compulsive behavior that is triggered from the exposure.

Generalized anxiety

Treatment for generalized anxiety disorder (GAD) can include imaginal exposure and in vivo, but in vivo exposure is not as common. The 2015 research review above showed that cognitive behavioral therapy (CBT) and imaginal exposure improved general functioning in people with GAD compared to relaxation and nondirective therapy.

There is not a lot of research with exposure therapy and GAD, and more is needed to further explore its effectiveness.

Social anxiety

In vivo exposure is typically used for people with social anxiety. This can include things like going to a social situation and not avoiding certain activities. The same 2015 research review above showed that exposure with or without cognitive therapy may be effective in reducing symptoms of social anxiety.

Driving anxiety

Virtual reality exposure therapy has been used to help people with a driving phobia. A small 2018 study found that it was effective in reducing driving anxiety, but more research still needs to be done with this specific phobia. Other therapies may need to be used alongside exposure therapy.

Public speaking

Virtual reality exposure therapy has been found to be effective and therapeutic to treat anxiety about public speaking for both adults and teens. One small 2020 study found that there was a significant decrease in self-rated anxiety about public speaking after a 3-hour session. These results were maintained 3 months later.

Separation anxiety

Separation anxiety disorder is one of the most common anxiety disorders in children. Exposure therapy is considered the top treatment for it. This involves exposing the child to feared situations and, at the same time, encouraging adaptive behavior and thinking. Over time, the anxiety lessens.

Obsessive compulsive disorder (OCD)

Exposure and response prevention (ERP) uses imaginal and in vivo exposure and is often used to help treat OCD. In vivo exposures are done in the therapy session as well as assigned for homework, and the response prevention (not engaging in compulsive behaviors) is part of that. An individual lets the anxiety decrease on its own instead of performing the behaviors that would get rid of the anxiety. When in vivo exposure is too hard or impractical, imaginal exposure is used.

While a 2015 research review showed that ERP was effective, ERP is comparable to cognitive restructuring alone and ERP with cognitive restructuring. Exposure therapy for OCD is most effective when guided by a therapist and not done independently. It’s also more effective when using both in vivo and imaginal exposure, as opposed to solely in vivo.

Panic disorder

Interoceptive exposure therapy is often used to treat panic disorder. According to a 2018 research review of 72 studies, interoceptive exposure and face-to-face settings, meaning working with a trained professional, were associated with better rates of effectiveness, and people were more accepting of the treatment.

Selective serotonin reuptake inhibitors, and serotonin and norepinephrine reuptake inhibitors for anxiety, obsessive-compulsive, and stress disorders: A 3-level network meta-analysis


In this study, we aimed to assess the efficacy and acceptability of SSRIs, SNRIs, and placebo for internalizing symptoms of children and adults diagnosed with anxiety, obsessive-compulsive, or stress-related disorders, accounting for clinical and methodological differences. Our results revealed higher efficacy of medications than placebo on the aggregate measure of internalizing symptoms. Effect sizes were small to moderate in overall psychopathology for all considered diagnoses and in all symptom domains. We also found significant results when restricting the analysis to the most used assessment instrument in each diagnosis; however, this restriction led to the exclusion of 72.71% of all available outcome measures. Moreover, estimates of efficacy were moderated by patient diagnosis, treatment duration, study funding, and study year of publication. Finally, concerning pairwise comparisons, we found small between-medication differences for paroxetine and escitalopram when compared to sertraline, considering efficacy. When evaluating acceptability through discontinuation rate due to any cause, no differences among medications were found; nevertheless, fluvoxamine was associated with a higher rate of discontinuation due to adverse events than all other medications, except fluoxetine.

8]. All included SSRIs and SNRIs showed greater reduction in overall psychopathology than placebo, with effect sizes comparable to those of other interventions in medicine [29]. Combined with data on major depression [30], this should address concerns on the benefit of SSRIs and SNRIs in global mental health, given that one of the main criticisms about previous studies is that they did not account for multiple domains of emotional distress [5]. Moreover, our findings provide support for transdiagnostic systems of psychopathology, which emphasize that psychosocial impairment is better explained and predicted by transdiagnostic dimensions than traditional diagnoses [31,32]. Studies assessing comorbidity in patients with anxiety, obsessive-compulsive, and stress-related disorders report rates above 50% [10]. Standard network meta-analyses are designed to evaluate symptom domains separately [14], which might not represent most patients in clinical settings; thus, current evidence may be potentially misleading. This suggests the need to evaluate efficacy of treatments in multiple symptom domains, given that patients seek help for overall improvement in symptoms and functioning rather than improvements in specific symptom domains. In addition, there is no gold standard for assessing symptom severity for anxiety disorders, and standard network meta-analyses often restrict outcome measures to specific scales [13,14]. We also found small to moderate effect sizes when restricting the analysis to the most used assessment instrument in each diagnosis in our sensitivity analysis; nevertheless, this restriction led to the exclusion of 72.71% of all available outcome measures. This may indicate that a great amount of the literature is not included in previous studies, which significantly constraints current evidence and limits power. Hence, multiple-endpoint design also addresses low item overlap between assessment instruments, ranging from 37% similarity for anxiety scales to 45% for post-traumatic stress disorder, and concerns about biases inherent to each scale, given the inconsistent and highly heterogeneous current assessment landscape [11,12].

8] as these analyses have been recognized as the highest level of evidence in treatment guidelines [33]. Nonetheless, unlike major depression and other narrowly defined psychiatric disorders, which allow a more “unidimensional” construct assessment, anxiety disorders are a group of highly correlated emotional disorders that require a distinct approach. The 3-level design addresses this important issue, at the same time allowing us to combine direct and indirect information in a network [34–36]. Although 3-level network meta-analyses, like standard meta-analyses, are susceptible to the quality of the primary studies, 3-level network meta-analyses may represent a significant methodological advancement to be used in this research field.


The most comprehensive network meta-analysis on medications for anxiety disorders before this analysis [14], which assessed only generalized anxiety disorder, found results consistent with our findings, indicating that SSRIs and SNRIs are effective for generalized anxiety disorder and that there are no significant differences among medications. Nevertheless, this previous work assessed only 89 outcome measures, which represents 18.98% of the 469 evaluated in our study. This significant difference is partially related to the exclusion of comorbidities. Given that anxiety disorders often co-occur, we understand that the inclusion of distinct disorders is a crucial aspect of this field. Bandelow and colleagues [38] also assessed the efficacy of antidepressants for anxiety disorders, including not only generalized anxiety disorder but also social anxiety disorder and panic disorder. Bandelow and colleagues’ work represents the largest meta-analysis in this field, evaluating 206 treatment arms related to the efficacy of medications. Without using a network meta-analysis approach, this work reported effect sizes of 2.09 for SSRIs and 2.25 for SNRIs and indicated substantial differences between medications, with effect sizes ranging from 1.06 for citalopram to 2.75 for escitalopram. These conflicting findings may be due to the use of pre–post effect sizes, which estimate the improvement within one group and not the difference between the intervention and the placebo group. This suggests a large variation in placebo response rates in trials assessing different medications for these disorders. Despite being commonly used, pre–post effect estimates have been criticized in the literature [17], given that it is impossible to disentangle which proportion of the effect size is caused by the intervention and which by other processes, such as natural recovery or the expectations of the patients.

9]. Sugarman and colleagues reported similar results, indicating an effect size of 0.34 based on 56 outcome measures [39]. These discrepancies compared to our findings and to our number of outcome measures reflect a major difference related to our 3-level approach. All previous meta-analyses included only 1 outcome measure for study. We took these dependencies into account with the 3-level meta-analytical model [21], including assessment instrument as a random variable, and also using a network meta-analysis approach, including medication as a random variable. Moreover, these 2 previous studies restricted assessment instruments to the scales most commonly used in each diagnosis, which can lead to biased estimates and not account for co-occurring symptoms of distinct domains. Furthermore, our larger quantity of data allowed us to explore different potential moderators, given the higher statistical power.

We found no age group moderation effect, indicating that SSRIs and SNRIs are also effective for anxiety symptoms in younger individuals. These findings contrast with previous evidence on the efficacy of antidepressants for depressive symptoms indicating that children and adolescents do not present good response to treatments with SSRIs or SNRIs compared with adults [13]. Given that the temporal relationship of comorbidity suggests that the onset of anxiety disorders often occurs earlier, aiming to reduce psychopathology and morbidity before the onset of depression may be an important prevention strategy in clinical practice to be further investigated. Also, children and adolescents do not respond as well to psychotherapy as adults do [40], so pharmacological interventions may be of great importance.

Strengths and limitations of the study

This study has some major strengths. To the best of our knowledge, this is the first 3-level network meta-analysis in the field of psychiatry and the largest meta-analysis to date to evaluate the efficacy of antidepressants on mental health symptoms of patients diagnosed with anxiety, obsessive-compulsive, or stress-related disorders, due to full inclusion of all available outcome measures in this field, and an extensive search for both published and unpublished trials, with no restriction regarding participant age, date of publication, or study language. This approach allows a well-powered comparison of efficacy and acceptability among these medications, exploring the multilevel structure of efficacy, avoiding exclusion of a great amount of available outcome measures, and avoiding biases related to specific symptoms or inherent to assessment instruments. Moreover, we extracted detailed clinical and methodological information for each included study, exploring potential moderators of efficacy estimates.

18], and the assumed correlation was based on previous reports concerning mental health [17]. Lastly, we identified moderate heterogeneity in our data analysis, as expected in meta-analyses with a 3-level design and with a large number of studies [41]. Accordingly, we explored and identified potential sources of heterogeneity through meta-regression and sensitivity analysis.


To our knowledge, our 3-level network meta-analysis represents the most comprehensive review of available evidence to date regarding the efficacy of SSRIs and SNRIs for the treatment of anxiety, obsessive-compulsive, and stress-related disorders, considering not only specific domains but all assessments of internalizing symptoms related to these disorders. Our findings, estimated using a 3-level approach, improve the evidence for the benefit of SSRIs and SNRIs for anxiety disorders, given that previous meta-analyses were restricted to specific scales or specific symptom domains, which reduces statistical power and does not reflect clinical practice. This method allowed us to properly estimate the efficacy of these medications on overall psychopathology, avoiding potential biases related to assessment instruments, and also to explore the multilevel structure of transdiagnostic efficacy. Our study might contribute to guiding psychiatrists, patients, clinicians, and policy makers on better evidence-based decisions for the initial treatment of these disorders.

Do I Have OCD or an Anxiety Disorder?

Though there are some overlaps between anxiety disorders and OCD, there are specific differences that set them apart.

Until recent years, the Diagnostic and Statistical Manual of Mental Disorders defined OCD as a type of anxiety disorder because of the anxiety levels in the condition. But the recent edition, published in 2013, lists OCD as a separate condition.

OCD is now listed in the “obsessive-compulsive disorders and related conditions” section, which includes body dysmorphic disorder, hoarding disorder, and trichotillomania (hair-pulling disorder).

Symptoms of anxiety disorders

There are many types of anxiety disorders, such as generalized anxiety disorder (GAD), agoraphobia, and panic disorder. The common trait among these conditions is persistent, excessive anxiety or fearful thoughts in one or more situations.

In other words, people with an anxiety disorder experience fear or anxiety that is disproportionate to the situation (thoughts that predict more severe harm will occur than the situation actually warrants). Many people with an anxiety disorder recognize this, but that alone doesn’t help to lessen the symptoms.

Depending on the type of anxiety disorder you have, you might experience anxiety when faced with a specific situation or object, or you might find that many things trigger your anxiety throughout the day.

Symptoms of OCD

Obsessive-compulsive disorder also involves persistent thoughts that cause excessive fear, doubt, and anxiety. Unlike anxiety disorders, OCD is characterized by obsessions and compulsions:

  • Obsessions are unwelcome thoughts, worries, doubts, urges, or images that occur repeatedly. They can make you feel very anxious or uncomfortable.
  • Compulsions are repeated behaviors that you use to temporarily relieve the stress that an obsession has caused. This might involve repeated hand-washing or checking the door multiple times.

Without another way to manage their obsession, people with OCD rely on their compulsive patterns. They might engage in patterns of obsession and compulsion several times a day, which can interfere with daily life, and it often becomes a difficult cycle to break.

According to the American Psychiatric Association, an OCD diagnosis requires “obsessions and/or compulsions that are time-consuming (more than one hour a day), cause significant distress, and impair work or social functioning.”

Similar to anxiety disorders, a person with OCD often recognizes their obsessions are unrealistic, but this alone doesn’t make them easier to manage.

How common are anxiety disorders and OCD?

Anxiety disorders affect 18.1% of the U.S. population each year, making it the most common mental health condition in the country. While its highly treatable, only 36.9% of people with an anxiety disorder are receiving treatment.

OCD is less common, affecting around 2% to 3% of people in the United States. The average age at which symptoms appear is 19 years.

Are the treatments different?

After diagnosis, you can get a treatment plan specific to your needs. Treatments for OCD and anxiety disorders can include one or a mix of the following:

  • Psychotherapy, also called talk therapy, such as cognitive behavioral therapy (CBT).
  • Medication to help reduce the symptoms. This might include anti-anxiety medications, such as beta-blockers and antidepressants. Selective serotonin reuptake inhibitors (SSRIs) can also help treat OCD, often in higher doses than used for depression.
  • Complementary health approaches, including relaxation techniques.

People with OCD and some types of anxiety disorder, such as specific phobias, can benefit from exposure and response prevention, a type of treatment for OCD.

What you should know about OCD

The World Health Organization (WHO) ranks obsessive compulsive disorder (OCD) as one of the top ten most disabling illnesses.

According to Yvonne Uwamahoro, a counsellor at Mental Health Hub, Kicukiro, OCD is an anxiety disorder characterised by uncontrollable, unwanted thoughts and ritualised, repetitive behaviour you feel compelled to perform.

If you have OCD, you probably recognise that your obsessive thoughts and compulsive behaviour are irrational but even so, you feel unable to resist them and break free, she says.

Causes and risk factors

Uwamahoro says that genetic factors could be the cause as genes may play a role in OCD for some. OCD tends to run in families. Having a relative with OCD increases the risk of having it.

“OCD often occurs in people who have other mental health illnesses. This can include, anxiety disorders, depression, attention deficit hyperactivity disorder, and substance abuse,” the counsellor notes.

She explains that pregnancy and postpartum period can lead to OCD, this is because hormones can trigger symptoms. OCD symptoms may worsen with pregnancy. OCD after giving birth can include intense worry over the baby’s well-being.

An example of common obsessions is fear of germs or dirt. Photo: Net

Uwamahoro says OCD is most common in older teens or young adults. It can begin as early as pre-school age and as late as age 40. Stress can make OCD symptoms appear. It is often linked to major life changes, such as the loss of a loved one, divorce, relationship issues, problems in school, or abuse, period of uncertainty, and pandemic. 

According to the Centers for Disease Control and Prevention, having OCD means having obsessions, compulsions, or both. Examples of obsessive or compulsive behaviours include, unwanted thoughts, impulses, or images that occur over and over and which cause anxiety or distress.

The National Institute of Mental Health (NIH) states that the symptoms may come and go, ease over time, or worsen. People with OCD may try to help themselves by avoiding situations that trigger their obsessions, or they may use alcohol or drugs to calm themselves.

“Although most adults with OCD recognise that what they are doing doesn’t make sense, some adults and most children may not realise that their behaviour is out of the ordinary. Parents or teachers typically recognise OCD symptoms in children,” Uwamahoro says.

She adds that teenagers and young adults with a mental health background in their families, or are living in a stressful environment, are at risk.


Uwamahoro says that OCD can affect one’s relationship with others, work or school effort, and general wellness. For example, poor concentration is common, usually as a result of being distracted by upsetting and intrusive thoughts (obsessions).

One can fail to do their tasks because they are dealing with non-stop thoughts, Uwamahoro adds.

OCD can also cause a child to become avoidant of situations that may provoke intrusive thoughts; for example, avoiding areas that they believe to be contaminated, like school toilets.

The mental health counsellor highlights that young people who fear being poisoned may avoid any contact with science laboratories given the potential for chemicals to be nearby. In severe cases, a person with OCD may struggle to leave the house and may be unable to attend school altogether or interact with others freely.

Prevention and treatment

 Mental health experts say that if you think you have OCD, see a Doctor, a psychiatrist, or mental health professional. The diagnosis process will likely include a physical exam to see if your symptoms are due to a health condition. Blood tests to check your blood count, how well your thyroid works, and any drugs or alcohol in your system. A psychological test or evaluation about your feelings, fears, obsessions, compulsions, and actions, can also be done.

Uwamahoro points out that OCD usually doesn’t happen all at once. Symptoms start small, and to someone, they can seem to be normal behaviours. They can be triggered by a personal crisis, abuse, or something negative that affects one a lot, like the death of a loved one. It’s more likely if people in one’s family have OCD or another mental health disorder, such as depression or anxiety.

She adds that examples of common obsessions often have a theme, such as, fear of germs or dirt, fear to touch things other people have touched, like doorknobs. Or fear to hug or shake hands with others.

Or, one may feel stressed when objects are out of place, one may find it hard to leave home until they’ve arranged things in a certain way, they may also have excessive doubt or fear of making a mistake. They may check repeatedly to make sure kitchen appliances are turned off or if doors are locked.

The International OCD Foundation states that OCD treatment can be difficult, and requires a lot of courage and determination. Having a support network to talk to during treatment can make all the difference, which is why accessing a support group in your area is necessary.

“Treatment for most OCD patients should involve Exposure and Response Prevention (ERP) and medication. About seven out of ten people with OCD will benefit from either medication or ERP,” The International OCD Foundation states.

My Life With OCD: I Fear Manifesting My Thoughts

So, if you have OCD and believe in the law of attraction, what should you do?

This is a difficult question because it might feel impossible to abandon your spiritual beliefs, even if it’s a trigger for you.

“If someone has OCD, I would generally encourage them to avoid the law of attraction. This isn’t because I think it is bad per se, but because there is so much potential to get confused with it,” Pizey explains. “If the law of attraction is tied up with your spirituality and you feel the call to apply it to your life, then just try to hold on to it lightly.”

Kress adds that it’s possible for people with OCD to have a healthy relationship with spirituality.

“When it comes to the law of attraction, it can be helpful to reinterpret the belief in a more balanced way,” she says. “For example, we can choose to believe that the Universe knows our true intentions despite our negative thoughts and that we attract our heart’s desire.”

Anyone who struggles with intrusive thoughts, whether they’ve received an OCD diagnosis or not, might benefit from therapy. With OCD, exposure and response therapy, as well as acceptance and commitment therapy, can be helpful.

Personally, I’ve found that many aspects of the law of attraction do work for me. For example, I enjoy visualizing positive things, and I’m able to engage in this without it becoming an obsession. However, I generally find that discussing manifestation or the law of attraction can be a trigger for me.

Beyond that, I’m now more focused on accepting my OCD than trying to control the world around me through manifestation.

I’d much rather direct my energy to therapy, self-care, and enjoying life instead of trying to “attract” anything into it.

As Pizey says, “In my experience, learning to overcome OCD is about gaining greater clarity and peace of mind by being in the moment, accepting life’s challenges, and living according to our values. These are things we should put our energies into.”

Sian Ferguson is a freelance health and cannabis writer based in Cape Town, South Africa. As someone with multiple anxiety disorders, she’s passionate about using her writing skills to educate and empower readers. She believes that words have the power to change minds, hearts, and lives.

Relationship OCD: What It Is and How to Get Help

Doubts, questions, and flaws: Virtually every relationship has them. But if you have relationship OCD, these issues could be continually on your mind.

Perhaps you have what most would consider an ideal relationship. Your partner is loving, attentive, and genuinely supportive. But for some reason, you have nagging doubts about them that won’t go away.

Maybe you’re in the middle of date night with your partner when someone you find attractive walks past, triggering questions in your mind like, “Am I really attracted to my partner?”

Or maybe you can’t stop finding flaws in your relationship, so you spend all of your spare time searching for answers on the internet. But no matter how much you research, you never find the certainty you need.

This constant quest to be sure may leave you feeling frustrated, full of anxiety, and exhausted. At the same time, your partner may feel confused and not know how to help.

If this scenario sounds familiar, you may be experiencing relationship obsessive-compulsive disorder (ROCD). You might feel encouraged to learn that many treatment options exist that can help reduce these thoughts and behaviors.

How Apps and VR Therapy Can Help OCD Patients

With OCD, as with phobias, there is often a ritual or safety behavior involved that the patient thinks is helping them cope with their fear and make them feel safer, but the rituals actually reinforce the fear. Michael Ambrose, licensed clinical psychologist at My OCD Care, says, “We’re not trying to habituate to the fear, but instead we’re trying to build a second learning pathway. It’s important to interact with things that can disconfirm your fear.”

Over-predicting negative outcomes is a hallmark of OCD, and avoidant behavior reinforces the fear. When people with OCD face their fears through exposure therapy they learn that they overvalued the thought. As they progress through increasingly challenging exposures, they become more functional and their lives open up.

Ambrose stressed how important it is for people with OCD to find a specialist. “There are many conditions in the DSM-V (the Diagnostic and Statistical Manual of Mental Disorders, 5th edition) that can be treated by a generalist, but OCD is not one of them. Spending too much time talking about the obsession and trying to get to the root of it isn’t helpful for someone with OCD. They need exposure to help them get comfortable with the uncertainty.”

The International OCD Foundation provides an extensive list of resources, but that doesn’t mean securing treatment for OCD is easy. Many therapists trained in ERP have waiting lists, and many don’t take insurance. ERP sessions can run $300 an hour or more, depending on location. After the first two barriers of time and money, one of the biggest obstacles to battling OCD is learning how to manage between therapy appointments.

Smith saw how technology could bridge the gap in between appointments and made it his mission to create an OCD treatment platform that would allow anyone, anywhere, to access support regardless of where they live or how much money they have. NOCD accepts many insurance plans and has cash payment options for noninsured members. The NOCD app is free and available to everyone. It provides access to community support groups as well as to self-help tools.

Another option for convenient, affordable OCD treatment is TalkSpace, where a patient can opt to meet with a therapist on live video, via text, or through video or audio messaging, and they pay for the services they want. Rachel O’Neill, a licensed professional clinical counselor at TalkSpace, said, “I’ve had moments with my clients where I’m able to be part of their home or office environment through a live video session or video message, in a way that’s so much more connected than I’ve been able to be in a traditional office setting.”

Seeing a patient in their space is helpful, especially if the fear exists in that space, but what about when the fear is associated with something a person is unlikely to encounter? Many obsessive, intrusive thoughts are also taboo, immoral, or illegal, so they can be challenging or impossible to simulate. If the point of treatment is exposure, how do you get it?

“In vivo approaches can also sometimes be prohibitively expensive, as in flight therapy for a flying phobia,” said Nadkarni, “And some patients may also be more willing to try virtual reality therapy, since it could be perceived as safer, because the patient knows it can be switched off.”

Mariaskin gets creative with real-life exposures for her clients, but she also uses the Oculus VR headset for some OCD subsets, such as claustrophobia. Clients wear an Oculus Go, and the therapist cues up a specific virtual environment where the walls progressively close in on them. “We control the point where the walls stop,” she said, “and we can be very fine-grained in creating exposures that meet the patients where they are.”

What to Know About OCD: Symptoms, Causes, Treatment

Symptoms of OCD fall into the categories of obsessions and compulsions. They can show up in a variety of ways from person to person.

These symptoms can get in the way of daily life, especially because they can take up time.

For example, someone with a ritual of knocking on their door three times before leaving will likely do it even when it’s impractical — like if they’re late for work or in an emergency.


Obsessions are often compared to intrusive thoughts, but they’re also different from day-to-day anxieties.

If you have OCD, you might often try to suppress these thoughts or relieve the anxiety they cause with a different thought or a compulsion.

These obsessions, or thoughts, could include:

  • images of hurting others
  • thoughts you consider immoral, bad, or shameful
  • urges to do something you don’t want to do

It’s common to have one specific thought (or type of thought) that comes to you over and over again. But the thought can also change over time.


Compulsions are repetitive behaviors that you might feel a strong need to do in order to soothe anxiety related to an obsession.

Some examples of compulsions include:

  • repeating words or phrases mentally
  • hand-washing
  • repeating an action
  • checking locks, windows, or other objects

These compulsions might not seem directly connected to the obsession. For example, somebody might have intrusive thoughts about hurting someone, feel upset by these thoughts, and then feel a compulsion to shake their hands to relieve that distress.

Here’s a deeper dive into the symptoms of OCD if you’d like to learn more.