Academic journal article Indian Journal of Psychiatry

Management of Obsessive-Compulsive Disorder Comorbid with Bipolar Disorder

Academic journal article Indian Journal of Psychiatry

Management of Obsessive-Compulsive Disorder Comorbid with Bipolar Disorder

Article excerpt

Byline: Firoz. Kazhungil, E. Mohandas

Obsessive-compulsive disorder (OCD) is one of the most common comorbidities in bipolar disorder (BD). Clinicians often get perplexed in making treatment decisions when encountering comorbid OCD and BD as treatment of OCD by pharmacotherapy may induce or exacerbate mood instability and psychotherapeutic approaches for OCD may not be feasible in acute manic or depressive state of BD. In this study, we reviewed literature, whether existing guideline-based treatments of BD may be effective in OCD and whether newer agents will be of use for treating this comorbidity. We could find that treatment of such comorbid disorder is largely understudied. Adjuvant topiramate or olanzapine- selective serotonin reuptake inhibitor/clomipramine combination along with mood stabilizer is found to be effective for treating OCD in BD. Use of other conventional pharmacological agents and psychotherapy for treating comorbid OCD in BD lacks evidence and is limited to case reports. Our review also highlights the need for further studies regarding the treatment strategies in this highly prevalent comorbid disorder.


Obsessive-compulsive disorder (OCD) is one of the most frequently associated comorbidities in bipolar disorder (BD).[sup][1],[2],[3] Although the prevalence and impact of OCD in BD are much researched, the neurobiological and treatment aspects are less studied systematically.[sup][3],[4] For clinicians, it is a real challenge to manage patients with BD-OCD comorbidity because both mood stabilizing and management of OCD should go hand in hand. However, the serotonin reuptake inhibitors (SRIs) which are the first-line treatment for OCD can induce manic/mixed mood states in BD. Effects of combined pharmacological treatments and psychotherapeutic treatments are less studied, and no convincing upper hand for a specific modality is observed in OCD comorbid with BD.[sup][3],[5],[6],[7],[8],[9]

A recent systematic review has described treatment aspects of BD-OCD comorbidity.[sup][4] However, no consensus regarding the best available evidence-based treatment for OCD in manic, depressed, or remitted phases of BD exists. Here, we discuss the current evidence-based treatment of OCD in BD and promising pharmacological methods to manage this complex comorbidity.


Population-based studies have reported lifetime prevalence rates of comorbid OCD in BD patients ranging between 11.1% and 21%.[sup][1],[2],[10] In large sample hospital-based studies, the lifetime prevalence of comorbid OCD in BD patients ranged between 3% and 16.3%.[sup][3],[11],[12],[13] The prevalence of OCD may be masked by the presence of manic or depressive symptoms in BD which is evident from data in remitted patients where the reported prevalence of comorbid OCD is quite high (35–38.6%).[sup][14],[15],[16] Lifetime prevalence of BD in OCD is also much higher than that of either OCD or BD and studies show a lifetime prevalence ranging from 6% to 55.8%.[sup][3] Considering all these, we could observe that a significant proportion of BD patients suffer from OCD. The high prevalence of such association is even argued for a specific subtype of BD or OCD or one disorder increasing the propensity to develop the other.

Impact of OCD in BD

The presence of OCD poses a huge impact on morbidity of patients with BD. BD when comorbid with OCD has been associated with greater disability and poorer quality of life,[sup][3],[17] poor functioning,[sup][3],[13],[18] and higher unemployment [sup][3],[13] in comparison to “pure” OCD or “pure” BD. It is also associated with episodic course,[sup][19] rapid cycling,[sup][17] and more frequent hospitalizations.[sup][3] The presence of OCD positively correlates with time in episode.[sup][16] OCD may add to the high mortality in BD because OCD increasing suicidal ideas and attempts is consistently reported across many studies. …

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