What medications are used to treat Obsessive-Compulsive Disorder (OCD) and Bipolar Disorder?

Treatment of Comorbid OCD and Bipolar Disorder

Mood stabilization must be achieved first before addressing OCD symptoms in patients with comorbid bipolar disorder and OCD, using lithium or valproate as primary agents, with aripiprazole augmentation as the preferred strategy for persistent obsessive-compulsive symptoms. 1, 2

Primary Treatment Algorithm

Step 1: Establish Mood Stability

• Initiate mood stabilizers as the foundation of treatment, specifically lithium (FDA-approved for bipolar disorder in patients ≥12 years) or valproate 1
• Lithium is approved for both acute mania and maintenance therapy in adolescents and adults 1
• Alternative mood stabilizers include aripiprazole, olanzapine, risperidone, quetiapine, or ziprasidone for acute mania 1
• Multiple mood stabilizers may be necessary in 42% of comorbid OCD-bipolar patients to achieve adequate mood control 3

Step 2: Address Persistent OCD Symptoms After Mood Stabilization

• Aripiprazole augmentation to lithium carbonate is the best-evidenced option for treatment-resistant comorbid patients, effective both as maintenance therapy and for treating obsessive-compulsive symptoms during manic episodes 2
• Aripiprazole has the strongest evidence for efficacy in SSRI-resistant OCD according to multiple controlled trials 4
• Combination of atypical antipsychotics with mood stabilizers was required in 10.5% of comorbid patients in tertiary care settings 3

Step 3: Consider Cognitive-Behavioral Therapy

• CBT with exposure and response prevention should be preferred over SSRIs for OCD symptoms that persist between mood episodes 5, 6
• CBT has larger effect sizes compared to antipsychotic augmentation for OCD treatment 4
• Psychotherapy avoids the risk of mood destabilization associated with serotonergic agents 5

Critical Warnings About SSRI Use in This Population

High Risk of Mood Destabilization

• SSRIs can induce hypomanic switches, worsen bipolar course, or precipitate mixed episodes in bipolar patients 5, 3
• Clomipramine and SSRIs were associated with hypomanic switches in comorbid patients, especially those not concomitantly treated with mood stabilizers 3
• A manic episode precipitated by an antidepressant is characterized as substance-induced per DSM-IV-TR 1

When SSRIs Are Absolutely Necessary

• Use SSRIs only judiciously under the cover of adequate mood stabilization if OCD remains severely impairing despite mood stabilizers, aripiprazole augmentation, and CBT 5
• Addition of SSRIs to mood stabilizers led to clinical remission in only isolated case reports 2
• Higher doses are required for OCD (fluoxetine 60-80 mg daily, paroxetine 60 mg daily, sertraline up to maximum doses) compared to depression treatment 7, 8
• Clomipramine should be reserved as second or third-line after SSRI failure in OCD, but carries even higher risk of mood switches 4, 9, 3

Alternative Pharmacological Strategies

Adjuvant Topiramate or Olanzapine

• Topiramate or olanzapine-SSRI/clomipramine combination along with mood stabilizer has shown effectiveness for treating OCD in bipolar disorder 6
• Olanzapine is FDA-approved for maintenance therapy in adults with bipolar disorder and approved in combination with fluoxetine for bipolar depression 1

Glutamatergic Agents

• N-acetylcysteine has the strongest evidence among glutamatergic agents for treatment-resistant OCD, with three out of five RCTs showing superiority to placebo 4
• Memantine has demonstrated efficacy in several trials for OCD 4

Clinical Course Considerations

Expected Pattern

• OCD in bipolar disorder typically runs an episodic course with worsening during depressive phases and improvement during manic/hypomanic phases 5
• Comorbid patients show more episodic OCD course with greater number of concurrent major depressive episodes compared to non-bipolar OCD patients 3
• Higher rates of sexual obsessions and concurrent panic disorder-agoraphobia are seen in bipolar-OCD patients 3

Treatment Duration

• Maintain treatment for at least 12-24 months after achieving remission due to high relapse rates after discontinuation 4, 7

Common Pitfalls to Avoid

• Never start with SSRIs as first-line treatment in comorbid bipolar-OCD patients without established mood stability 5, 2
• Do not mistake behavioral reactions to psychosocial stressors as symptoms requiring medication changes 1
• Avoid unnecessary polypharmacy, though multiple agents are often required 1
• When using antipsychotics, monitor for metabolic side effects including weight gain, blood glucose, and lipid profiles 4
• Assess for serotonin syndrome if changing or combining serotonergic medications 4