Comorbid bipolar disorder and obsessive-compulsive disorder in children and adolescents: Treatment implications.

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Apparent comorbidity between bipolar disorder (BD) and obsessive–compulsive disorder (OCD) is a common condition in psychiatry with higher prevalence rates in youths (23.2%, 95% confidence interval [CI] = [11.5%, 41.3%]) compared to adults (13.56%, 95% CI = [10.4%, 16.25%]) (Amerio et al., 2015). The meaning of this comorbidity has not been clarified yet. The treatment of BD-OCD patients remains a great challenge since the gold standard for one disease (serotonin reuptake inhibitors [SRIs] for OCD) can worsen the other (antidepressants can cause mania and/or more mood episodes in BD; Amerio et al., 2014a). The literature on pharmacologic or psychotherapeutic approaches especially in pediatric BD-OCD patients is limited. Therefore, we updated our recent systematic review (Amerio et al., 2014b) and focused specifically on the treatment of BD-OCD comorbidity in children and adolescents. 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 Obsessivecompulsive) OR Obsessive-compulsive disorder))). Studies published in English through 31 August 2015 were included. Further studies were retrieved from reference listing of relevant articles and consultation with experts in the field. Seven studies were selected (Table 1). In all selected studies, BD-OCD patients received mood stabilizers (lithium, divalproex sodium). 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 (quetiapine, risperidone, aripiprazole). Addition of antidepressant (clomipramine) to mood stabilizers led to clinical remission of both conditions in only one study. In other cases, antidepressants (escitalopram) seemed prone to cause more manic/hypomanic episodes in BD-OCD than in non-comorbid patients. The evidence so far on BD-OCD nosology supports the view that the majority of cases of comorbid BD-OCD are in fact BD cases (Amerio et al., 2014a). Osler’s view that medicine should be treatment of diseases, not of symptoms, is consistent with the approach of mood stabilization as a first objective in apparent BD-OCD patients, as opposed to immediate treatment with SRIs.