Abstract
Apparent comorbidity between bipolar disorder (BD) and obsessive–compulsive disorder (OCD) is a common condition in psychiatry with higher prevalence rates in youths (23.2%, 95% confidence interval [CI] = [11.5%, 41.3%]) compared to adults (13.56%, 95% CI = [10.4%, 16.25%]) (Amerioet al., 2015).
The meaning of this comorbidity has not been clarified yet. The treatment of BD-OCD patients remains a great challenge since the gold standard for one disease (serotonin reuptake inhibitors [SRIs] for OCD) can worsen the other (antidepressants can cause mania and/or more mood episodes in BD; Amerio et al., 2014a).
The literature on pharmacologic or psychotherapeutic approaches especially in pediatric BD-OCD patients is limited. Therefore, we updated our recent systematic review (Amerio et al., 2014b) and focused specifically on the treatment of BD-OCD comorbidity in children and adolescents.
Studies were identified by searching the electronic databases MEDLINE, EMBASE and PsycINFO. We combined the search strategy of free text terms and exploded MeSH headings for the topics of BD, OCD and treatment combined as follows: ((((((‘Therapeutics’[Mesh]) OR treatment*) OR therap*) OR pharmacotherap*) OR psychotherap*)) AND (((((((((‘Bipolar Disorder’[Mesh]) OR Bipolar disorder) OR BD) OR Bipolar) OR Manic depressive disorder) OR Manic depressive) OR Manic)) AND ((((‘Obsessive-Compulsive Disorder’[Mesh]) OR OCD) OR Obsessive-compulsive) OR Obsessive-compulsive disorder))). Studies published in English through 31 August 2015 were included. Further studies were retrieved from reference listing of relevant articles and consultation with experts in the field.
Seven studies were selected (Table 1). In all selected studies, BD-OCD patients received mood stabilizers (lithium, divalproex sodium). In the largest study, 42.1% of comorbid patients required a combination of multiple mood stabilizers and 10.5% a combination of mood stabilizers with atypical antipsychotics (quetiapine, risperidone, aripiprazole). Addition of antidepressant (clomipramine) to mood stabilizers led to clinical remission of both conditions in only one study. In other cases, antidepressants (escitalopram) seemed prone to cause more manic/hypomanic episodes in BD-OCD than in non-comorbid patients.
Studies that met inclusion/exclusion criteria for systematic review.
BD: bipolar disorder; OCD: obsessive–compulsive disorder; OC: obsessive–compulsive; Pt.: patients; DSM: Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition; DICA-R: Diagnostic Interview for Children and Adolescents–Revised; K-SADS-E: Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children–Epidemiologic Version; K-SADS-PL: Schedule for Affective Disorders and Schizophrenia for School-Age Children–Present and Lifetime Version. Y-BOCS: Yale–Brown Obsessive–Compulsive Scale; YMRS: Young Mania Rating Scale; CGI: Clinical Global Impression; C-GAS: Children’s Global Assessment Scale; HAM-D: The Hamilton Rating Scale for Depression; NS: Not specified; SRIs: serotonin reuptake inhibitors; CBT: cognitive behavioral therapy; ↓: decrease.
Differences statistically significant (p < 0.05).
Checklist for measuring study quality developed by Downs and Black.
Annigeri B, Raman R and Appaji R (2011) Obsessivecompulsive disorder with bipolar mood disorder: A rare comorbidity in India. Indian Journal of Psychological Medicine 33: 83–85.
Cop E (2014) An adolescent with obsessive-compulsive disorder and bipolar disorder: A case report. Bulletin of Clinical Psychopharmacology 24: S46.
Fuchs DC (1994) Clozapine treatment of bipolar disorder in a young adolescent. Journal of the American Academy of Child & Adolescent Psychiatry 33: 1299–302.
Jana AK, Praharaj SK and Sinha VK (2012) Comorbid bipolar affective disorder and obsessive-compulsive disorder in childhood: A case study and brief review. Indian Journal of Psychological Medicine 34: 279–282.
Joshi G, Mick E, Wozniak J, et al. (2010) Impact of obsessive-compulsive disorder on the antimanic response to olanzapine therapy in youth with bipolar disorder. Bipolar Disorders 12: 196–204.
Masi G, Millepiedi S, Perugi G, et al. (2009) Pharmacotherapy in pediatric obsessivecompulsive disorder: a naturalistic, retrospective study. CNS Drugs 23: 241–52.
Masi G, Perugi G, Millepiedi S, et al. (2007) Bipolar comorbidity in pediatric obsessivecompulsive disorder: clinical and treatment implications. Journal of Child and Adolescent Psychopharmacology 17: 475–86.
The evidence so far on BD-OCD nosology supports the view that the majority of cases of comorbid BD-OCD are in fact BD cases (Amerio et al., 2014a). Osler’s view that medicine should be treatment of diseases, not of symptoms, is consistent with the approach of mood stabilization as a first objective in apparent BD-OCD patients, as opposed to immediate treatment with SRIs.
Footnotes
Authors’ contributions
Authors A.A., M.T., A.O. and B.S. designed the study and wrote the protocol. Studies were identified and independently reviewed for eligibility by two authors (A.A., A.O.) in a two-step based process. Data were extracted by one author (A.A.) and supervised by a second author (S.N.G.) using an ad hoc developed data extraction spreadsheet. The same authors who performed data extraction (A.A., S.N.G.) independently assessed the quality of selected studies using the checklist developed by Downs and Black for both randomized and non-randomized studies. A.A., M.T., A.O. and B.S. have been involved in drafting the manuscript, and S.N.G. revised it critically. S.N.G. has given final approval of the version to be published. All authors read and approved the final manuscript.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Amerio, Dr Tonna, Dr Odone and Dr Stubbs report no conflicts of interest. Dr Ghaemi has provided research consulting to Sunovion and Pfizer and has obtained a research grant from Takeda Pharmaceuticals. Neither he nor his family holds equity positions in pharmaceutical corporations.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.