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Bipolar disorder frequently co-occurs with OCD and complicates treatment of OCD symptoms. Special considerations are discussed.
“Robert,” a 20-year-old male has struggled with worsening obsessions for the past 2 years. He obsesses about contamination and the possibility of spreading illness to others. In response, he performs multiple cleaning rituals throughout the day, often washing his hands for hours. These symptoms currently interfere with his ability to attend university classes, and he reports no quality of life as he cannot socialize with friends. Robert went to his primary care physician, who started him on fluoxetine 20mg/day. Within 2 weeks, Robert reported he was uncomfortably energized with the thought that he had superpowers. He was unable to sleep, began to spend money recklessly, and felt his mind was racing a mile per minute. This resulted in an emergency department visit where a psychiatrist made a diagnosis of bipolar disorder and discontinued the fluoxetine. Instead, he started him on valproic acid. Now, several weeks later, Robert denies any mood symptoms but continued to complain about his obsessive thoughts.
Obsessive–compulsive disorder (OCD) is characterized by obsessions or compulsions (or both) that are distressing, time-consuming, and oftentimes impairing. OCD has a lifetime prevalence of 1% to 3 % and thus ranks as one of the most common mental health illnesses.1 By contrast, the prevalence of current and lifetime comorbid OCD in bipolar disorder is estimated at 10.9% and 11.2% respectively. Conversely, bipolar disorder has been reported in approximately 10% to 20% of patients with OCD.2,3 This comorbidity is not only fairly common but also associated with greater psychosocial dysfunction and higher suicide attempts when compared with individuals with bipolar disorder without OCD4 and associated with more severe OCD symptoms than individuals with OCD without bipolar disorder.5 (Table)
Consistent with the case of Robert, research suggests that a majority of individuals with this comorbidity experience the onset of OCD prior to the onset of bipolar disorder6, with even some suggesting that OCD symptoms in childhood/adolescence may foreshadow a vulnerability to a later diagnosis of bipolar disorder.7
After establishing the comorbidity, what should a clinician do in the case of a patient like Robert? Clearly, Robert’s bipolar disorder needs to be treated as untreated illness, or delayed treatment, may result in high rates of suicide, alcohol and drug problems, and psychosocial impairment.8 Similarly, if left untreated, OCD remission rates are low (approximately 20%) and suicide ideation and attempts are elevated.9 Fortunately, with appropriate treatment, patients report substantially higher rates of symptom response and remission and shorter durations of illness.1
In general, the standard of care in terms of pharmacotherapy for OCD, and the medications FDA-approved for OCD, are the SSRIs and the SRI clomipramine, often used in high doses.1 This treatment approach, however, may have the unintended consequence of triggering a manic episode, as in Robert’s case. If antidepressants are used, clinical experience suggests that clinicians need to optimize prophylactic anti-manic agents before initiation. In Robert’s case, he was started on valproic acid. After mood stabilization, Robert’s clinician could then consider beginning OCD treatment with an SSRI, with careful monitoring of his mood.
Interestingly, some evidence suggests that in the case of comorbid bipolar disorder and OCD, that OCD symptoms may remit during effective treatment of the bipolar disorder. In fact, mood stabilizers alone or with atypical antipsychotics may be adequate to resolve comorbid symptoms of OCD and therefore SSRIs might not be necessary for many patients.10 Although the evidence is still preliminary, one could for example add aripiprazole (10 mg to 15 mg/d) to Robert’s antiepileptic (valproic acid) as both maintenance therapy for bipolar disorder and for treating his OCD symptoms.11
Of course, if one is concerned about destabilizing Robert’s mood by adding medication to the antiepileptic he is taking, one could instead maximize exposure response prevent (ERP) therapy. Using ERP for OCD, 60% to 85% of patients report a considerable reduction in symptoms and improvement is often maintained for several years.1 ERP is usually delivered weekly or twice weekly, for approximately 20 to 30 total hours of therapy.
In summary, bipolar disorder frequently co-occurs with OCD and complicates the treatment of OCD. Having said that, if mood is stabilized before addressing the OCD, and the use of ERP is also entertained, people such as Robert can be hopeful of finding relief for both conditions.
Dr Grant is professor, Department of Psychiatry & Behavioral Neuroscience, University of Chicago. He spoke at PsychCongress in a presentation titled When Trouble Strikes Twice: Addressing the Complex Needs of Patients with Both OCD and Mood Disorders.
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