Abstract
To the Editor
In a standard 1969 psychiatry textbook, Mayer-Gross and colleagues included patients with comorbid bipolar disorder (BD) and obsessive-compulsive disorders (OCD) in the manic-depressive disorders. Considering course of illness as a key diagnostic validator, 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). However, an optimal treatment approach remains to be defined.
We present the case of a patient with severe OCD who developed a manic episode during treatment with clomipramine.
The patient is a 24-year-old Caucasian woman with positive family history for recurrent depression. At 19 years of age, 2 weeks after delivery, she presented a major depressive episode that improved in the next few weeks with fluvoxamine 100 mg/day.
From the age of 22, she had gradually presented fear of contamination with hand washing more than 10 times per day, pathological doubts about daily events, and compulsive checking of light switches. These symptoms met Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, criteria for OCD. No history of manic episodes was reported.
She was admitted to the inpatient service and initially treated with fluvoxamine 200 mg/day without satisfactory control of obsessive-compulsive symptoms. Her therapy was modified to clomipramine 150 mg/day.
After 4 weeks, she developed a manic episode. Her therapy was modified to lithium 900 mg/day and aripiprazole 30 mg/day. Aripiprazole was gradually decreased and lithium was continued with mood stabilization and remission of obsessive-compulsive symptoms.
After 3 months, washing and checking rituals increased prominently. Aripiprazole 10 mg/day was added to lithium and affective and obsessive-compulsive symptoms were well controlled for the following 12 months.
Positive family history for recurrent depression, postpartum onset of depressive episode, manic switch induced by antidepressant and improvement of affective and obsessive-compulsive symptoms with mood stabilizers and atypical antipsychotics, support the hypothesis of an underlying bipolarity (Tonna et al., 2015).
Osler’s view that medicine should be treatment of diseases, not of symptoms, is consistent with the approach of mood stabilization as the primary goal in treating apparent BD-OCD patients (Patra, 2016), as opposed to immediate treatment with antidepressants that seemed to be less effective and more harmful in BD-OCD than in non-comorbid patients (Amerio et al., 2014).
Footnotes
Acknowledgements
A.A. and M.T. have contributed to data acquisition and data interpretation. A.A. and A.O. 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.
Consent
Written informed consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Declaration of Conflicting Interests
Dr. Amerio, Dr. Tonna, and Dr. Odone 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.