Do Obsessive-Compulsive Symptoms Increase the Risk of Developing Psychosis? A Systematic Review and Meta-analysis

There is a phenomenological overlap of obsessive-compulsive symptoms (OCSs) and psychosis, leading to discussion about whether OCSs increase the risk of developing psychosis. Previous reviews have focused on clinical high-risk (CHR) cohorts, which may misestimate risk due to sampling biases. The current systematic review and meta-analyses aimed to determine the risk of OCSs on developing psychosis in individuals classified at CHR and at the population level.

A total of 2081 articles were screened, with 11 studies meeting the criteria for inclusion. Two separate meta-analyses were conducted for CHR cohorts and for register-based cohorts to estimate the risk ratio (RR) of OCSs for developing psychosis.

In CHR cohorts, the meta-analysis found no significant difference in the risk of developing psychosis between individuals with and without OCSs (RR = 0.99, 95% CI, 0.71-1.38, P = .95) across 8 studies with low heterogeneity (I ² < 0.000%, 95% CI, 0-67.03). In register-based cohorts, OCSs were associated with a 15-fold increase in the risk of developing psychosis (RR = 15.01, 95% CI, 8.36-26.93, P < .001), although this estimate was derived from 3 studies with significant heterogeneity (I ² = 85.1%, 95% CI, 37.14-99.67).

The limited number of studies and high heterogeneity in the population-level cohort limit any firm conclusions. However, the findings indicate that OCSs may increase the risk of developing psychosis in the register-based cohorts, but not in CHR cohorts. The discrepancy may reflect shared underlying vulnerabilities present in both OCSs and psychosis that are obscured by samples enriched for psychosis risk.