Obsessive–compulsive disorder (OCD) has been traditionally described as a chronic disorder. However, with the availability and accessibility of effective interventions, there has been a significant improvement in clinical outcomes. Recent meta-analyses of studies reporting on long-term course and outcome have shown that approximately half achieve clinical remission (Sharma et al. 2014; Liu et al. 2021). There is also evidence to suggest that rates of recurrence after achieving full remission in OCD could be relatively low, with 75% maintaining improvement at 5 years (Marcks et al. 2011). Thus, a significant proportion of those with OCD are likely to experience sustained clinical remission and recovery. Despite this, little is known about the functional outcomes among those who achieve clinical remission/recovery in OCD.

Recovery from severe mental illness involves much more than recovery from most physical illnesses. Results from longitudinal studies in schizophrenia suggest that symptomatic improvement may not fully translate to functional improvement (Jablensky 2000). Those with severe mental illness may need to overcome stigma, impaired personal, social and family relationships, and achieve gainful employment (Ralph 2000). Functional outcomes may also be influenced by cognitive functioning which are significantly impaired during the symptomatic phase (Leucht 2014). Additionally, subjective perception of functioning and well-being are critical to recovery.

DSM-5 has described the goal of recovery as a “complete return to full functioning”, without actually operationalising what constitutes ‘full functioning’. Similarly, most diagnostic instruments have operationalised clinical remission in psychiatric disorders without outlining the concept of recovery. Outside the realm of these structured instruments and classificatory systems, definitions of recovery have commonly incorporated the concept that “Recovery should be consistent with normative behaviour, dimensions that are within the range of what most people would consider as “within normal limits” (Noordys et al. 2002).

Like in most major mental illnesses, the major conceptual and methodological issue has been the lack of consensus on what constitutes recovery in OCD. The recent International Expert Consensus for defining treatment response, remission, recovery and relapse in obsessive–compulsive disorder (Delphi Survey) has attempted to address this and has proposed that those subjects may be considered to be clinically recovered from OCD if they have “a score of ≤ 12 on the Yale-Brown Obsessive Compulsive Scale (YBOCS) and Clinical global impression–Severity (CGI -S) rating of 1 (normal, not all ill) or 2 (border line mentally ill) for a period of one year” (Mataix-cols et al. 2016). The post-treatment YBOCS score of ≤ 12 represents the clinical cut-off for recovery which is correlated with positive quality of life (QOL), enjoyment, satisfaction and social adjustment measured by Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) and Social Adjustment Scale. The major drawback of this consensus statement was the non-inclusion of other aspects of functioning especially subjective measures. This was partly addressed by Burchi et al., as they have proposed inclusion of a self-assessment of functionality using simple structured instruments like Work & Social Adjustment Scale (< 10 cut-off indicating low impairment) (2018).

While it is possible that symptomatic improvement in OCD will lead to functional improvement, the existing evidence suggest that it may not be always the case. A study by Huppert and colleagues (2009), reported that individuals in remission had level of functioning intermediate between healthy controls and those symptomatic. Thus, it appears that functioning does not recover fully even when patients are in symptomatic remission suggesting that the chronicity of OCD perhaps has a significant long-term impact. There were similar trends when subjective measures of well-being and functioning like QOL assessments were used. There is consistent evidence that OCD is associated with significant impairments in multiple domains of QOL, with impairments increasing with severity of illness. Symptom severity, however, does not fully explain the decrease in the QOL. Though there was a positive significant association between OCD and global QOL scores, there was wider difference in scores between OCD subjects and healthy controls (HC) when severity was milder, compared to a narrower difference in severe cases (Pozzo et al. 2018). Additionally, co-morbid depression in those with OCD has been associated with a worse QOL (Stengler-Wenze et al. 2006). It needs to understood whether depression in those remitted have an influence on functionality.

Consensus eludes on whether assessment of cognitive functioning is required for those who have clinically recovered from OCD (Burchi et al. 2018). The relationship between neuropsychological deficits and functional outcome in those recovered is still to be understood in OCD. While cognitive deficits reported in the symptomatic phase may improve with symptom reduction and treatment (Bannon et al. 2006), deficits in set-shifting, response inhibition, alternation, and nonverbal memory may actually persist even after achieving full clinical remission (Rao et al. 2008). In a study of recovered bipolar patients, subtle neuropsychological deficits were reported including decision making difficulties, which may significantly affect medication compliance or involve faulty decisions (Martinez-Aran et al. 2007). Additionally, it has been shown that neuropsychological deficits in OCD can improve with cognitive training (Kashyap et al. 2019). However, whether the persistent neuropsychological deficits in recovered OCD patients actually impair functioning or whether improvement in neuropsychological deficits translates to improved functioning is yet to be understood.

Though achieving functional recovery in OCD has critical public health implications, this remains sparsely studied. The paucity of studies limits any definitive assumptions; however, given the chronicity of OCD, it is highly likely that even after achieving clinical recovery, significant impairments will remain following loss of opportunities in education, employment and socialisation. This being the case, it is necessary to develop recovery-oriented services/programs for those with OCD.

Recovery oriented treatment approaches should incorporate an early diagnosis, a stepped-care approach and provide personalised treatments. OCD has possibly the longest duration of untreated illness. Patients are often secretive and embarrassed of their symptoms, while others fail to recognise symptoms as a disorder, resulting in delay in seeking help or in some cases, not seeking help at all. Improving awareness among public, general practitioners, teachers, parents and students is a priority. There evidence that early diagnosis and interventions improve outcomes and reduce chronicity in OCD (Burchi and Pallanti 2019).

The inclusion of recovery as one of the expected outcomes of treatment of OCD may ensure that those with symptom remission are continued to be provided support to achieve functional recovery. Developing a stepped-care treatment approach to achieve functional recovery in OCD could ensure rationale use of available services. Simple measures of functionality, disability and quality of life need to be incorporated in routine clinical assessments for patients who have achieved clinical recovery in OCD. Comprehensive assessments can be reserved for the sub-group who report difficulties in functioning after clinical recovery in OCD. Multi-dimensional assessments in the dysfunctional group need to incorporate assessment of functional and cognitive domains, in addition to exploring for persisting psychopathology, especially depression. Those with deficits need to be provided a personalized recovery-oriented package targeting persisting difficulties. Research on functional recovery in OCD needs to be an immediate clinical priority. This will improve conceptual clarity and ensure the criteria for recovery in OCD is more evidence based.

To conclude, effective interventions in OCD has improved clinical outcomes. However, functional recovery among those who achieved clinical remission in OCD remains sparsely studied. Given that OCD is a chronic disorder, it is possible that even after achieving clinical remission, patients may experience personal, social and occupational impairments. Those who do not achieve adequate functional recovery need to be assessed comprehensively and provided personalized input to target persisting deficits for better outcomes.