Letters to the Editor
Effective Use of Olanzapine for Obsessive–Compulsive Symptoms in a Patient With Bipolar Disorder
Dear Editor:
A connection between bipolar disorder (BD) and obsessive–compulsive disorder (OCD) has recently been suggested and is supported by epidemiologic and clinical data that report comorbidity rates too high to be explained by chance (1–4).
The comorbidity of BD with OCD has important prognostic and therapeutic implications. The less favourable functional outcome (4) and the observed higher rates of suicidality (2) are major concerns in these patients. Further, comorbidity poses significant problems with respect to treatment choice, since the use of antidepressants to control obsessive–compulsive symptoms can precipitate mania or rapid cycling (1). We present the case of a patient with BD I and comorbid OCD whose obsessive–compulsive symptoms were successfully treated with olanzapine.
Case Report
Mr AB, aged 30 years, had been diagnosed 5 years previously with BD I and was being treated with topiramate 400 mg daily. Only recently did he report that he also suffered from recurrent, intrusive thoughts having sexual and aggressive content that led him to compulsive mental acts (specifically, praying). The obsessive–compulsive symptoms first appeared after the remission of his first manic episode; however, embarrassment and feelings of guilt prevented him from reporting them.
He received a diagnosis of OCD according to DSM-IV criteria. His original score on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) was 20. Olanzapine 15 mg daily was added to his therapeutic regimen to treat the obsessive–compulsive symptoms. This medication was preferred over antidepressants because the latter may precipitate manic episodes. The addition of olanzapine led to clear improvement in the obsessive–compulsive symptoms over a period of 6 weeks, at the end of which time his Y-BOCS score was 6.
Discussion
The treatment of patients with comorbid BD and OCD appears rather problematic. It seems that mood stabilizers alone do not suffice to control obsessive–compulsive symptoms (5), although there have been some positive experiences with lithium (6), as well as with topiramate and lamotrigine (1). The use of antidepressants risks inducing mania or rapid cycling (1), and treatment of mania with classic neuroleptic drugs may lead to worsened obsessive–compulsive symptoms (3). However, there seems to be some hope in the use of the newer, atypical antipsychotic agents. The role of these drugs in treating BD is now well established (7), and there is some evidence that such agents are efficacious in treating OCD. Most reports concern cases of refractory OCD (8–10), but it has been suggested that such cases could imply bipolarity (5).
Owing to the prognostic and therapeutic implications mentioned, it is most important to carefully assess BD patients for the existence of obsessive–compulsive symptoms. It should be borne in mind that specifically oriented questioning is necessary to disclose such symptoms, given that patients often conceal them out of ignorance or embarrassment (4), as in the case we report. Atypical antipsychotics such as olanzapine act favourably on obsessive–compulsive symptoms, as well as on BD, and could thus be of use in patients with comorbid BD and OCD.
References
1. Cassano GB, McElroy SL, Brady K, Nolen WA, Placidi GF. Current issues in the identification and management of bipolar spectrum disorders in ‘special populations.’ J Affect Disord 2000;59:S69–S79.
2. Krüger S, Bräunig P, Cooke RG. Comorbidity of obsessive-compulsive disorder in recovered inpatients with bipolar disorder. Bipolar Disord 2000;2:71–4.
3. Perugi G, Akiskal HS, Toni C, Simonini E, Gemignani A. The temporal relationship between anxiety disorders and (hypo)mania : a retrospective examination of 63 panic, social phobic and obsessive-compulsive patients with comorbid bipolar disorder. J Affect Disord 2001;67:199–206.
4. Chen YW, Dilsaver SC. Comorbidity for obsessive-compulsive disorder in bipolar and unipolar disorders. Psychiatry Res 1995;59:57–64.
5. Hantouche EG, Angst J, Demonfaucon C, Perugi G, Lancrenon S, Akiskal HS. Cyclothymic OCD: a distinct form? J Affect Disord 2003;75:1–10.
6. Swartz CM, Shen WW. Is episodic obsessive compulsive disorder bipolar? A report of four cases. J Affect Disord 1999;56:61–6.
7. Cookson J. Use of antipsychotic drugs and lithium in mania. Br J Psychiatry Suppl 2001;41:148–56.
8. Ramasubbu R, Ravindran A, Lapierre Y. Serotonin and dopamine antagonism in obsessive-compulsive disorder: effect of atypical antipsychotic drugs. Pharmacopsychiatry 2000; 33:236–8.
9. Weiss EL, Potenza MN, McDougle CJ, Epperson CN. Olanzapine addition in obsessive-compulsive disorder refractory to selective serotonin reuptake inhibitors: an open-label case series. J Clin Psychiatry 1999;60:524–7.
10. Jacobsen FM. Risperidone in the treatment of affective illness and obsessive-compulsive disorder. J Clin Psychiatry 1995;56:423–9.
Petros Petrikis, MD; Christina Andreou, MD
Vasilis P Bozikas, MD PhD; Athanasios Karavatos, MD, PhD
Thessaloniki, Greece
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