Abstract
More than half of patients with bipolar disorder (BD) also have an additional psychiatric diagnosis, one of the most difficult to manage being obsessive-compulsive disorder (OCD) (Amerio et al., 2014a, 2014b) with higher prevalence rates in youths (23.2%; compared to adults, 13.56%) (Amerio et al., 2015).
In 1970, the famous epidemiologist Alvan R. Feinstein defined comorbidity in relation to a specific index condition, as ‘any distinct additional entity that has existed or may occur during the clinical course of a patient who has the index disease under study’ (Maj, 2005). However, the question of which condition should be designated the index and which the comorbid condition is not always self-evident.
In order to address this unanswered question, we updated our recent systematic review (Amerio et al., 2015) to establish the onset of BD and OCD in comorbid patients.
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 30 September 2015were included.
Eleven studies were selected (Table 1). More than 60% of selected studies reported that BD-OCD patients experienced the onset of OCD prior to the onset of BD. In the minority of cases (25%), the onset of OCD usually was concomitant with the first mood episode, rather than preceding or following it. In contrast, only one study from United States reported an earlier mean age of onset of BD compared to OCD in comorbid patients. Some investigators also reported an earlier onset of obsessive-compulsive (OC) symptoms in comorbid patients compared to non-comorbid patients.
Studies that met inclusion/exclusion criteria for systematic review.
BD: bipolar disorder; OCD: obsessive-compulsive disorder; DIS: Diagnostic Interview Schedule; DSM-III: Diagnostic and Statistical Manual of Mental Disorders–Third Edition; DSM-IV: Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition; SCID: Structured Clinical Interview; 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; WASH-U-K-SADS: Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia; DAWBA: Development and Well-Being Assessment; NS: Not specified.
Checklist for measuring study quality developed by Downs and Black.
Amerio A, Odone A, Marchesi C, et al. (2014) Do antidepressant-induced manic episodes in obsessive-compulsive disorder patients represent the clinical expression of an underlying bipolarity? Australian and New Zealand Journal of Psychiatry 48: 957.
Annigeri B, Raman R and Appaji R (2011) Obsessive-compulsive disorder with bipolar mood disorder: A rare comorbidity in India. Indian Journal of Psychological Medicine 33: 83–85.
Chen YW and Dilsaver SC (1995) Comorbidity for obsessive-compulsive disorder in bipolar and unipolar disorders. Psychiatry Research 59(1–2): 57–64.
Cop E (2014) An adolescent with obsessive-compulsive disorder and bipolar disorder: A case report. Bulletin of Clinical Psychopharmacology 24: S46.
Diniz JB, Rosario-Campos MC, Shavitt RG, et al. (2004) Impact of age at onset and duration of illness on the expression of comorbidities in obsessive-compulsive disorder. The Journal of Clinical Psychiatry 65(1): 22–27.
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.
Mahasuar R, Janardhan Reddy YC and Math SB (2011) Obsessive-compulsive disorder with and without bipolar disorder. Psychiatry and Clinical Neurosciences 65(5): 423–33.
Masi G, Perugi G, Millepiedi S, et al. (2007) Bipolar comorbidity in pediatric obsessive-compulsive disorder: clinical and treatment implications. Journal of Child and Adolescent Psychopharmacology 17: 475–86.
Tillman R, Geller B, Bolhofner K, et al. (2003) Ages of onset and rates of syndromal and subsyndromal comorbid DSM-IV diagnoses in a prepubertal and early adolescent bipolar disorder phenotype. Journal of the American Academy of Child & Adolescent Psychiatry 42(12): 1486–93.
Taken together, the evidence so far on BD-OCD nosology supports the view that the majority of comorbid OCD cases appeared to be related to mood episodes (Tonna et al., 2015). As confirmed by this review, OC symptoms may be expression of vulnerability to BD increasing the risk of a later BD diagnosis. OC symptoms would initially coexist with BD symptoms even cycling together and they would gradually tend to decrease in the adulthood.
See Letter by Amerio et al., 48(10): 957; See also Letter by Tonna et al., 49(6): 578–579.
Footnotes
Acknowledgements
M.T. and A.A. have contributed equally to this work. Authors M.T., A.A., 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 both for randomized and non-randomized studies. M.T., A.A., 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 Tonna, Dr Amerio, 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 hold equity positions in pharmaceutical corporations.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.