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Bipolar Plus OCD: Which to Treat First?

Bipolar Plus OCD: Which to Treat First?

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A 30-year-old woman with subtle paranoia and a history of mood cycling and obsessive preoccupations is brought by her family for treatment. Only after she is given an antidepressant for her presumed obsessive-compulsive disorder (OCD) does she begin to have delusional thoughts.


Is there some sort of overlap between OCD and bipolar disorder? If so, how can one treat the OCD without worsening the bipolar? On the issue of overlap, a search of PubMed yields many articles describing a clear connection between the two, from genetics to prevalence to clinical occurrence. Are these just unlucky people with 2 problems? Or do these folks have bipolar disorder, with an OCD-like presentation?

Combination bipolar disorder–OCD patients are more likely to have a family history of mood disorders and less likely to have a family history of OCD, “supporting the view that the majority of cases of comorbid BD-OCD are, in fact, BD cases.”1 This is not just an academic issue: if in these overlap cases the OCD symptoms are somehow part of bipolar disorder, treatment can focus on bipolar and the “OCD” may resolve without adding an antidepressant that could worsen bipolar cycling, induce mixed states, or even cause psychosis.

Bipolar disorder–OCD overlap is common: between 15% and 20% of patients with bipolar disorders also meet criteria for OCD.2 When found together, the conditions interact: OCD symptoms worsen during depression and improve during mania (most but not all of the time).3 Importantly then, in the overlapping presentation, OCD symptoms often cycle. In one study, they worsened then remitted in 75% of the OCD-bipolar patients versus only 3% of pure OCD patients.3

Therefore, in a patient whose OCD symptoms clearly come and go and who also has episodes of depression, one should consider the possibility of a bipolar disorder before treating with antidepressants. (Oh, all right, yes, you should consider bipolar disorder in nearly every patient; very few conditions in the DSM do not warrant bipolar disorder in the differential.)

Can treating the bipolar make the “OCD” go away? The answer is clearly yes, though not in all such cases.4 Even a case of hoarding remitted when serotonin reuptake inhibitors were discontinued in favor of lamotrigine.5 Thus, when one sees bipolar disorder and OCD together, treat the bipolar first. The OCD symptoms might remit.

And if they don’t? Then first turn to the non-medication approach to OCD: the variation of cognitive- behavioral therapy (CBT) known as exposure and response prevention (ERP). Indeed, ERP is a good place to start for all OCD patients. ERP yields slightly more improvement than does antidepressant medication6; and it is obviously preferable as a long-term treatment, since its benefits last when treatment is stopped.7

But ERP is hard to access: very few CBT specialists also regard themselves as ERP specialists. This is ironic because “inexperienced master’s students with no postgraduate training can be as capable as experienced and certified behavior therapists in treating OCD patients, as long as therapists adhere to a standardized treatment manual and adequate training and supervision is provided.”8 So presumably an ex­perienced CBT therapist could follow the manual and do well the first time.


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