Treatment of comorbid bipolar disorder and obsessive-compulsive disorder: a systematic review

More than 20% of patients with bipolar disorder (BD) show lifetime comorbidity for obsessive-compulsive disorder (OCD), but treatment of BD-OCD is a clinical challenge. Although serotonin reuptake inhibitors (SRIs) are the first line treatment for OCD, they can induce mood instability in BD. An optimal treatment approach remains to be defined.

We systematically reviewed MEDLINE, Embase, PsychINFO and the Cochrane Library and retrieved data on clinical management of comorbid BD-OCD patients. Pharmacologic, psychotherapeutic and others alternative approaches were included.

Fourteen studies were selected. In all selected studies BD-OCD patients received mood stabilizers. 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. Addition of antidepressants to mood stabilizers led to clinical remission of both conditions in only one study. Some BD-OCD patients on mood stabilizer therapy benefitted from adjunctive psychotherapy.

Most studies are case reports or cross-sectional studies based on retrospective assessments. Enrollment of subjects mainly from outpatient specialty units might have introduced selection bias and limited community-wide generalizability.

Keeping in mind scantiness and heterogeneity of the available literature, the best interpretation of the available evidence appears to be that mood stabilization should be the primary goal in treating BD-OCD patients. Addition of SRI agents seems unnecessary in most cases, although it may be needed in a minority of BD patients with refractory OCD.