The prevalence and predictors of comorbid bipolar disorder and obsessive-compulsive disorder: A systematic review and meta-analysis

Crocin (bioactive compound of Crocus sativus L.) potently restores REM sleep deprivation-induced manic- and obsessive-compulsive-like behaviors in female rats

Rapid-eye movement (REM) sleep deprivation (SD) can induce manic-like behaviors including hyperlocomotion. On the other hand, crocin (one of the main compounds of Crocus sativus L. or Saffron) may be beneficial in the improvement of mental and cognitive dysfunctions. Also, crocin can restore the deleterious effects of SD on mental and cognitive processes. In this study, we investigated the effect of REM SD on female rats' behaviors including depression- and anxiety-like behaviors, locomotion, pain perception, and obsessive-compulsive-like behavior, and also, the potential effect of crocin on REM SD effects. We used female rats because evidence on the role of REM SD in modulating psychological and behavioral functions of female (but not male) rats is limited. REM SD was induced for 14 days (6h/day), and crocin (25, 50, and 75 mg/kg) was injected intraperitoneally. Open field test, forced swim test, hot plate test, and marble burying test were used to assess rats' behaviors. The results showed REM SD-induced manic-like behavior (hyperlocomotion). Also, REM SD rats showed decreased anxiety- and depression-like behavior, pain subthreshold (the duration it takes for the rat to feel pain), and showed obsessive compulsive-like behavior. However, crocin at all doses partially or fully reversed REM SD-induced behavioral changes. In conclusion, our results suggested the possible comorbidity of OCD and REM SD-induced manic-like behavior in female rats or the potential role of REM SD in the etiology of OCD, although more studies are needed. In contrast, crocin can be a possible therapeutic choice for decreasing manic-like behaviors.

Clinical features in co-occuring obsessive-compulsive disorder and bipolar disorder: A systematic review and meta-analysis

Obsessive-compulsive disorder (OCD) frequently co-occurs with various psychiatric conditions and may impact as many as one-fifth of individuals diagnosed with bipolar disorder (BD). Despite the expanding body of literature on the coexistence of OCD and BD, there is a notable lack of comprehensive data pertaining to the distinct features of obsessive-compulsive symptoms that define this comorbidity. To bridge this knowledge gap, we conducted a systematic search of PubMed/MEDLINE, Scopus, EMBASE, and PsycINFO until August 7th, 2023. We performed random-effects meta-analyses to compare individuals with both OCD and BD to those with OCD in terms of OCD symptomatology as well as the specific categories of obsessions and compulsions. Out of the 10,393 records initially screened, 17 studies were ultimately incorporated into the qualitative assessment, with 15 of them being included in the quantitative analysis. Individuals with OCD and BD experienced fewer lifetime contamination obsessions (OR=0.71; 95 %CI=0.53, 0.95; p = 0.021) and more sexual obsessions (OR=1.77; 95 %CI=1.03, 3.04; p = 0.04) compared to individuals with OCD without BD. No significant difference was observed for other types of obsessions or compulsions or for the severity of OCD symptoms, although BD type may play a role according to meta-regression analyses. The detection of the presence of sexual or contamination obsessions through a detailed interview may be the focus of clinical attention when assessing OCD in the context of comorbid BD. Sub-phenotyping complex clinical presentation of comorbid psychiatric disorders can aid in making more informed decisions when choosing an appropriate treatment approach.

Obsessive-Compulsive Disorder as an Epiphenomenon of Comorbid Bipolar Disorder? An Updated Systematic Review

BACKGROUND

Bipolar disorder (BD) and obsessive-compulsive disorder (OCD) comorbidity is an emerging condition in psychiatry, with relevant nosological, clinical, and therapeutic implications.

METHODS

We updated our previous systematic review on epidemiology and standard diagnostic validators (including phenomenology, course of illness, heredity, biological markers, and treatment response) of BD-OCD. Relevant papers published until (and including) 15 October 2023 were identified by searching the electronic databases MEDLINE, Embase, PsychINFO, and Cochrane Library, according to the PRISMA statement (PROSPERO registration number, CRD42021267685).

RESULTS

We identified 38 new articles, which added to the previous 64 and raised the total to 102. The lifetime comorbidity prevalence ranged from 0.26 to 27.8% for BD and from 0.3 to 53.3% for OCD. The onset of the two disorders appears to be often overlapping, although the appearance of the primary disorder may influence the outcome. Compared to a single diagnosis, BD-OCD exhibited a distinct pattern of OC symptoms typically following an episodic course, occurring in up to 75% of cases (vs. 3%). Notably, these OC symptoms tended to worsen during depressive episodes (78%) and improve during manic or hypomanic episodes (64%). Similarly, a BD course appears to be chronic in individuals with BD-OCD in comparison to patients without. Additionally, individuals with BD-OCD comorbidity experienced more depressive episodes (mean of 8.9 ± 4.2) compared to those without comorbidity (mean of 4.1 ± 2.7).

CONCLUSIONS

We found a greater likelihood of antidepressant-induced manic/hypomanic episodes (60% vs. 4.1%), and mood stabilizers with antipsychotic add-ons emerging as a preferred treatment. In line with our previous work, BD-OCD comorbidity encompasses a condition of greater nosological and clinical complexity than individual disorders.

Status of Type II vs. Type I Bipolar Disorder: Systematic Review with Meta-Analyses

LEARNING OBJECTIVES AFTER PARTICIPATING IN THIS CME ACTIVITY, THE PSYCHIATRIST SHOULD BE BETTER ABLE TO

• Analyze and compare the different bipolar disorder (BD) types.• Identify markers that distinguish BD types and explain how the DSM-IV defines the disorder.

ABSTRACT

Since the status of type II bipolar disorder (BD2) as a separate and distinct form of bipolar disorder (BD) remains controversial, we reviewed studies that directly compare BD2 to type I bipolar disorder (BD1). Systematic literature searching yielded 36 reports with head-to-head comparisons involving 52,631 BD1 and 37,363 BD2 patients (total N = 89,994) observed for 14.6 years, regarding 21 factors (with 12 reports/factor). BD2 subjects had significantly more additional psychiatric diagnoses, depressions/year, rapid cycling, family psychiatric history, female sex, and antidepressant treatment, but less treatment with lithium or antipsychotics, fewer hospitalizations or psychotic features, and lower unemployment rates than BD1 subjects. However, the diagnostic groups did not differ significantly in education, onset age, marital status, [hypo]manias/year, risk of suicide attempts, substance use disorders, medical comorbidities, or access to psychotherapy. Heterogeneity in reported comparisons of BD2 and BD1 limits the firmness of some observations, but study findings indicate that the BD types differ substantially by several descriptive and clinical measures and that BD2 remains diagnostically stable over many years. We conclude that BD2 requires better clinical recognition and significantly more research aimed at optimizing its treatment.

Treatment-resistant OCD: Pharmacotherapies in adults

Serotonin reuptake inhibitor (SRI) medications are well established as first-line pharmacotherapeutic treatment for Obsessive-Compulsive Disorder (OCD). However, despite the excellent safety profile and demonstrated efficacy of these medications, a substantial proportion of individuals with OCD fail to attain sufficient benefit from SRIs. In this narrative review, we discuss clinical features of OCD that have been associated with poorer response to SRIs, and we present pharmacotherapeutic interventions that have been explored as augmenting or alternative treatments for treatment-resistant OCD. We additionally highlight non-SRI interventions for OCD that are currently under investigation. Pharmacotherapeutic interventions were identified via expert consensus. To assess the evidence base for individual pharmacotherapies, targeted searches for relevant English-language publications were performed on standard biomedical research databases, including MEDLINE. Information relevant to ongoing registered clinical trials in OCD was obtained by search of ClinicalTrials.gov. Pharmacotherapies are grouped for review in accordance with the general principles of Neuroscience-based Nomenclature (NbN). Clinical features of OCD that may suggest poorer response to SRI treatment include early age of onset, severity of illness, duration of untreated illness, and the presence of symmetry/ordering or hoarding-related symptoms. Based on evolving pathophysiologic models of OCD, diverse agents engaging serotonin, dopamine, norepinephrine, glutamate, and anti-inflammatory pathways have been explored as alternative or adjunctive therapies for treatment-resistant OCD and have at least preliminary evidence of efficacy. Medications with dopamine antagonist activity remain the most robustly evidence-based of augmenting interventions, yet dopamine antagonists benefit only a minority of those who try them and carry elevated risks of adverse effects. Interventions targeting glutamatergic and anti-inflammatory pathways are less well evidenced, but may offer more favorable benefit to risk profiles. Ongoing research should explore whether specific interventions may benefit individuals with particular features of treatment-resistant OCD.

Comorbidities in Youth with Bipolar Disorder: Clinical Features and Pharmacological Management

BACKGROUND

Bipolar Disorder (BD) is a highly comorbid condition, and rates of cooccurring disorders are even higher in youth. Comorbid disorders strongly affect clinical presentation, natural course, prognosis, and treatment.

METHODS

This review focuses on the clinical and treatment implications of the comorbidity between BD and Attention-Deficit/Hyperactivity Disorder, disruptive behavior disorders (Oppositional Defiant Disorder and/or Conduct Disorder), alcohol and substance use disorders, Autism Spectrum Disorder, anxiety disorders, Obsessive-Compulsive Disorder, and eating disorders.

RESULTS

These associations define specific conditions which are not simply a sum of different clinical pictures, but occur as distinct and complex combinations with specific developmental pathways over time and selective therapeutic requirements. Pharmacological treatments can improve these clinical pictures by addressing the comorbid conditions, though the same treatments may also worsen BD by inducing manic or depressive switches.

CONCLUSION

The timely identification of BD comorbidities may have relevant clinical implications in terms of symptomatology, course, treatment and outcome. Specific studies addressing the pharmacological management of BD and comorbidities are still scarce, and information is particularly lacking in children and adolescents; for this reason, the present review also included studies conducted on adult samples. Developmentally-sensitive controlled clinical trials are thus warranted to improve the prognosis of these highly complex patients, requiring timely and finely personalized therapies.

The global assessment of OCD

Obsessive Compulsive Disorder (OCD) is a common mental disorder that often causes great sufferance, with substantial impairment in social functioning and quality of life and affects family and significant relationships. Notwithstanding its severity, OCD is often not adequately diagnosed, or it is diagnosed with delay, leading often to a long latency between onset of the OCD symptoms and the start of adequate treatments. Several factors contribute to the complexity of OCD's clinical picture: early age of onset, chronic course, heterogeneity of symptoms, high rate of comorbidity with other psychiatric disorders, slow or partial response to therapy. Therefore, it is of primary importance for clinicians involved in diagnosing OCD, to assess all aspects of the disorder. This narrative review focuses on the global assessment of OCD, highlighting crucial areas to explore, pointing out the clinical features which are relevant for the treatment of the disorder, and giving an overview of the psychometric tools that can be useful during the screening procedure.

Influence of childhood maltreatment on prevalence, onset and persistence of psychiatric comorbidities and suicide attempts in bipolar disorders

Background

Methods

Results

Conclusions

Through the prism of comorbidity: A strategic rethinking of early intervention in obsessive-compulsive disorder

The diagnostic criteria for obsessive-compulsive disorder (OCD) have undergone minor changes in DSM-5 yet a major turnaround intervened in the overarching categorical allocation. OCD indeed has been separated from the anxiety disorders and included in an autonomous class of OCD-related disorders. Converging factors, i.e., the specificity of the clinical phenotype, the robust evidence for familial aggregation, the availability of effective treatments, and the increasing awareness of the role of environmental factors in its onset and course make OCD a suited target for tailored early intervention programs. However, studies on the topic are still scarce and OCD remains marginally conceptualized within an overdue early detection/intervention framework. Starting from the consolidated clinical evidence of OCD extensive comorbidity with schizophrenia-spectrum and bipolar disorders, we articulate a strategic proposal for a more integral incorporation of OCD within early detection and intervention paradigm.

Research Status in Clinical Practice Regarding Pediatric and Adolescent Bipolar Disorders

Bipolar disorders (BDs) have high morbidity. The first onset of 27.7% of BDs occurs in children under 13 years and of 37.6% occurs in adolescents between 13 and 18 years. However, not all of the pediatric and adolescent patients with BD receive therapy in time. Therefore, studies about pediatric and adolescent patients with disorders have aroused increased attention in the scientific community. Pediatric and adolescent patients with BD present with a high prevalence rate (0.9-3.9%), and the pathogenic factors are mostly due to genetics and the environment; however, the pathological mechanisms remain unclear. Pediatric and adolescent patients with BD manifest differently from adults with BDs and the use of scales can be helpful for diagnosis and treatment evaluation. Pediatric and adolescent patients with BDs have been confirmed to have a high comorbidity rate with many other kinds of disorders. Both medication and psychological therapies have been shown to be safe and efficient methods for the treatment of BD. This review summarizes the research status related to the epidemiology, pathogenic factors, clinical manifestations, comorbidities, diagnostic and treatment scales, medications, and psychological therapies associated with BDs.

Psychiatric comorbidities of obsessive-compulsive disorder: A series of systematic reviews and meta-analyses

OBJECTIVE

Although there is a growing number of studies on psychiatric comorbidities of obsessive-compulsive disorder (OCD), controversy remains about the strength of associations between some disorders. We present a series of systematic reviews and meta-analyses examining four psychiatric disorders frequently associated with OCD-depression, bipolar disorder, substance abuse disorder and psychosis.

METHODS

Three electronic databases were searched up to May 2017; PsycINFO, Medline, and Web of Science. Meta-analyses using random effects models were conducted.

RESULTS

The meta-analyses found strong associations between all comorbidities and OCD, particularly for depression. In addition, a series of systematic reviews were conducted giving information about the characteristics of these psychiatric associations.

CONCLUSION

It is probable that these disorders share common etiological factors, and thus trans-diagnostic processes must be addressed when offering treatment. Clinical implications of these findings are discussed with suggestions for further research in the area.

Rate of OCD and sub-threshold OCD in bipolar disorder patients with first depressive episode

Evidence indicates that obsessive-compulsive disorder (OCD) co-occurs with bipolar disorder (BD) at a higher rate than in the general population. Although there is a preliminary indication of a predominant aggregation of OCD in BD patients with bipolar depression (BP-D), no explicit evaluation has previously been undertaken. Using the Structured Clinical Interview for DSM-5 Axis-I disorders and appropriate rating scales, seventy-three BD patients experiencing their first depressive episode were screened for OCD and subthreshold OCD. Nineteen (26%) of the 73 participants in addition to BP-D also met DSM-5 criteria for OCD and 17 (23.2%) patients met criteria for sub-threshold OCD. No differences in demographic and clinical variables evaluated in the study were found between the BP-D patients with and without OCD. Limitations of the study included a relatively small sample size, cross-sectional design and inclusion of only hospitalized BP-D patients. Additional studies are warranted to better define the longitudinal course of comorbid BP-D/OCD, treatment approaches and outcomes of this challenging patient population. Explicit prospective comparison of the rate of DSM-5 OCD and subthreshold OCD in depressive versus manic episodes of bipolar disorder within the same patient is justified.

Specialty knowledge and competency standards for pharmacotherapy for adult obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) affects approximately one person in 40 and causes substantial suffering. Evidence-based treatments can benefit many; however, optimal treatment can be difficult to access. Diagnosis is frequently delayed, and pharmacological and psychotherapeutic interventions often fail to follow evidence-based guidelines. To ameliorate this distressing situation, the International OCD Accreditation Task Force of the Canadian Institute for Obsessive-Compulsive Disorders has developed knowledge and competency standards for specialized treatments for OCD through the lifespan. These are foundational to evidence-based practice and will form the basis for upcoming ATF development of certification/accreditation programs. Here, we present specialty standards for the pharmacological treatment of adult OCD. We emphasize the importance of integrating pharmacotherapy with clear diagnosis, appreciation of complicating factors, and evidence-based cognitive behavioral therapy. Clear evidence exists to inform first- and second-line pharmacological treatments. In disease refractory to these initial efforts, multiple strategies have been investigated, but the evidence is more equivocal. These standards summarize this limited evidence to give the specialist practitioner a solid basis on which to make difficult decisions in complex cases. It is hoped that further research will lead to development of a clear, multi-step treatment algorithm to support each step in clinical decision-making.

First manic/hypomanic episode in obsessive-compulsive disorder patients treated with antidepressants: A systematic review

High doses of antidepressants, particularly clomipramine and selective serotonin reuptake inhibitors (SSRIs), are the well-established treatment for obsessive-compulsive disorder (OCD), but manic/hypomanic episodes are potential adverse events associated with this treatment. A systematic literature review was performed on manic/hypomanic episodes in non-bipolar OCD patients. Clinical, sociodemographic and antidepressant characteristics during the manic/hypomanic switch were extracted using descriptive statistics. Data were obtained from 20 case reports and case series. Switching episodes mostly appeared in the first 12 weeks after antidepressant initiation and took place more frequently during SSRI use (mostly fluoxetine) in 64.3% of cases. Clomipramine and SSRI use differed non-significantly between the switching episodes that appeared during the first 12 weeks of antidepressant treatment and the episodes that appeared beyond 12 weeks. Switching episodes emerging before 12 weeks were associated with a lower defined daily dose of antidepressants than episodes emerging after 12 weeks. These findings suggest that there are two independent characteristics involved in manic/hypomanic switch in OCD: a) they appeared most frequently with SSRI use (fluoxetine) regardless of the time of it use, and b) episodes appeared in the first 12 weeks after SSRI or clomipramine initiation had a lower dose of antidepressant than episodes appeared after 12 weeks.

Transvestic Disorder, Obsessive Compulsive Disorder, and Bipolar Disorder in an Adolescent Male: Diagnostic Conundrums and Management Difficulties

Transvestic disorder with comorbid obsessive-compulsive disorder and bipolar disorder (BD) is a rare presentation, with only 1 case report in available literature. It may be an arduous task to differentiate between the phenomenology of transvestic disorder and obsessive-compulsive disorder. We, herein, report the case of a 17-year-old boy who presented with complaints of cross-dressing which was difficult to be differentiated from sexual obsessions. He also suffered from BD that complicated the management.

Classification of comorbidity in obsessive-compulsive disorder: A latent class analysis

OBJECTIVE

Patients with OCD differ markedly from one another in both number and kind of comorbid disorders. In this study, we set out to identify and characterize homogeneous subgroups of OCD patients based on their comorbidity profile.

METHODS

In a cohort of 419 adult subjects with OCD, the lifetime presence of fifteen comorbid disorders was assessed. Latent class analysis was used to identify comorbidity-based subgroups. Groups were compared with regard to core clinical characteristics: familiality, childhood trauma, age at onset, illness severity, OCD symptom dimensions, personality characteristics, and course of illness.

RESULTS

The study sample could be divided in a large group (n = 311) with a low amount of comorbidity that could be further subdivided into two subgroups: OCD simplex (n = 147) and OCD with lifetime major depressive disorder (n = 186), and a group (n = 108) with a high amount of comorbidity that could be further subdivided into a general anxiety-related subgroup (n = 49), an autism/social phobia-related subgroup (n = 27), and a psychosis/bipolar-related subgroup (n = 10). Membership of the high-comorbid subgroup was associated with higher scores on childhood trauma, illness severity, and the aggression/checking symptom dimension and lower scores on several personality characteristics.

CONCLUSION

Grouping OCD patients based on their comorbidity profile might provide more homogeneous, and therefore, more suitable categories for future studies aimed at unraveling the etiological mechanisms underlying this debilitating disorder.

Lifetime bipolar disorder comorbidity and related clinical characteristics in patients with primary obsessive compulsive disorder: a report from the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS)

INTRODUCTION

Bipolar disorder (BD) and obsessive compulsive disorder (OCD) are prevalent, comorbid, and disabling conditions, often characterized by early onset and chronic course. When comorbid, OCD and BD can determine a more pernicious course of illness, posing therapeutic challenges for clinicians. Available reports on prevalence and clinical characteristics of comorbidity between BD and OCD showed mixed results, likely depending on the primary diagnosis of analyzed samples.

METHODS

We assessed prevalence and clinical characteristics of BD comorbidity in a large international sample of patients with primary OCD (n = 401), through the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS) snapshot database, by comparing OCD subjects with vs without BD comorbidity.

RESULTS

Among primary OCD patients, 6.2% showed comorbidity with BD. OCD patients with vs without BD comorbidity more frequently had a previous hospitalization (p < 0.001) and current augmentation therapies (p < 0.001). They also showed greater severity of OCD (p < 0.001), as measured by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS).

CONCLUSION

These findings from a large international sample indicate that approximately 1 out of 16 patients with primary OCD may additionally have BD comorbidity along with other specific clinical characteristics, including more frequent previous hospitalizations, more complex therapeutic regimens, and a greater severity of OCD. Prospective international studies are needed to confirm our findings.

Psychiatric comorbidities in bipolar disorders: An examination of the prevalence and chronology of onset according to sex and bipolar subtype

OBJECTIVES

Bipolar Disorder (BD) is frequently comorbid with other psychiatric disorders. However, few studies systematically examine which disorders are more likely to occur pre- or post-BD onset. We examine the prevalence and Age At Onset (AAO) of psychiatric conditions in adults with BD.

METHODS

A structured clinical interview was used to assess lifetime history and AAO of alcohol and cannabis misuse, suicide attempts, anxiety and eating disorders in a French sample of euthymic patients with BD (n = 739). Regression analyses were used to test for statistically significant associations between rates and AAO of comorbidities in BD groups stratified by sex or subtype.

RESULTS

Prevalence of alcohol and cannabis misuse was associated with male sex and BD-I subtype; whilst most anxiety and eating disorders were associated with female sex. The AAO of most comorbid conditions preceded that of BD, except for panic disorder, agoraphobia and alcohol misuse. Few variations were observed in AAO of comorbidities according to groups.

LIMITATIONS

All assessments were retrospective, so estimates of prevalence rates and especially exact AAO of some comorbidities are at risk of recall bias.

CONCLUSIONS

Sex and BD subtype are associated with different rates of comorbid disorders. However, there were minimal between group differences in median AAO of comorbidities. By describing the chronological sequence of comorbidities in BD we were able to demonstrate that a minority of comorbidities typically occurred post-onset of BD. This is noteworthy as these disorders might be amenable to interventions aimed at early secondary prevention.

Is deep brain stimulation effective and safe for patients with obsessive compulsive disorder and comorbid bipolar disorder?

BACKGROUND

Deep brain stimulation (DBS) is an effective treatment for refractory obsessive-compulsive disorder (OCD). Bipolar disorder (BD) is generally considered a contra-indication for DBS due to frequently reported transient impulsivity or (hypo)mania.

OBJECTIVE

The present study is the first study to examine effectiveness and safety of DBS for patients with OCD and BD.

METHODS

Five consecutive patients suffering from treatment-refractory OCD with comorbid BD (I or II) underwent DBS of the ventral anterior limb of the internal capsule (vALIC). We examined effectiveness of DBS on symptoms of OCD and depression, using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and Hamilton Depression Rating Scale (HAM-D). We monitored side-effects, in particular DBS-induced (hypo)manic symptoms, using the Young mania rating scale (YMRS).

RESULTS

Follow-up time ranged between 15 and 68 months. vALIC-DBS led to a significant improvement of OCD and depressive symptoms. Mean Y-BOCS score decreased from 36.8 (SD 2.4) to 22.4 (SD 9.4). Mean HAM-D score dropped from 24.2 (SD 8.6) to 16.5 (SD 11.3). Transient hypomanic symptoms were observed in 4 out of 5 patients and in 1 patient, hypomanic symptoms resolved by adjusting stimulation and medication. Changes in YMRS scores were not significant. Hypomanic symptoms did not result in admission or lasting adverse consequences.

CONCLUSION

DBS effectively alleviates symptoms of OCD and depression in patients with OCD and BD but there is a large risk of developing transient hypomanic symptoms. Altogether, comorbid BD should not be considered as an absolute contra-indication for DBS in OCD patients with comorbid BD, but patients should be monitored carefully during optimization and follow-up of DBS.

Comorbidity of obsessive-compulsive disorder in bipolar spectrum disorders: Systematic review and meta-analysis of its prevalence

BACKGROUND

Obsessive-compulsive disorder (OCD) is often comorbid with Bipolar Disorder (BD), complicating its presentation and management. OCD prevalence rates in BD vary widely across studies and recent meta-analyses.

OBJECTIVE

We performed a comprehensive systematic review and meta-analysis of studies reporting cross-sectional or lifetime OCD prevalence in BD, assessed by meta-regression various determinants of estimated prevalence and compared it with major depressive disorder (MDD) patients and general population subjects included in extracted studies.

METHODS

Relevant articles published up to January 2019 in PubMed/MEDLINE were retrieved. Prevalence rates underwent Freeman-Tukey double arcsine transformation before meta-analysis.

RESULTS

We included 29 studies reporting cross-sectional prevalence (N = 6109) and 39 studies reporting lifetime prevalence (N = 8205); eight studies reported both. The pooled lifetime and cross-sectional prevalence of comorbid OCD in BD was estimated at 10.9% (95% CI: 7.8-14.4%) and 11.2% (7.6-15.3%), respectively, in the random-effects model. Respective estimates in the general population were 2.5% and 1.6%. Study setting (epidemiological or clinical), diagnostic criteria and procedures, gender, BD subtype and remission status could not explain heterogeneity of prevalence estimates in meta-regressions. Age had a small yet significant negative correlation with lifetime prevalence. OCD prevalence in BD was not significantly different than in MDD.

LIMITATIONS

Search was limited to English-language literature.

CONCLUSIONS

Lifetime OCD prevalence in BD was 4.4 times higher than in the general population. Cross-sectional prevalence was as high as lifetime, suggesting that OCD in BD is more chronic/ persistent than in the general population, where cross-sectional stands at about two thirds the lifetime prevalence.

Obsessive-compulsive Disorder with Comorbid Bipolar Disorders: Clinical Features and Treatment Implications

BACKGROUND

Obsessive-compulsive disorder (OCD) symptoms within the context of a bipolar disorder (BD) have been described since the 19th century. Interestingly, the existence of a relevant overlap between the aforementioned psychiatric syndromes has been confirmed by a number of recent epidemiological and family studies.

AIMS

The aim of the present paper is to review the clinical features and the therapeutic implications of the OCD-BD comorbidity.

DISCUSSION

In the last two decades, the frequent association between OCD and BD has been earning a growing interest given its relevant nosological and therapeutic implications. Usually patients suffering from OCD-BD comorbidity show a peculiar clinical course, characterized by a larger number of concomitant depressive episodes and episodic course. In these cases, the treatment with antidepressants is more likely to elicit hypomanic or manic switches, while mood stabilizers significantly improve the overall clinical picture. Moreover, OCD-BD patients are frequently comorbid with a number of other psychiatric disorders, in particular anxiety disorders, social phobia, and different substance abuses, such as alcohol, nicotine, caffeine and sedatives.

CONCLUSIONS

BD-OCD comorbidity needs further investigations in order to provide more solid evidences to give patients a more precise clinical diagnosis and a more targeted therapeutic approach.

Bipolar disorder comorbidity in patients with obsessive-compulsive disorder: Prevalence and predictors

BACKGROUND

Patients with obsessive-compulsive disorder (OCD) often present with comorbidities, mainly anxiety and affective disorders, which may influence OCD course, help-seeking and treatment response. Some authors have studied bipolar disorder (BD) comorbidity in patients with OCD, but usually in small samples. The objective was to estimate the lifetime prevalence of BD in a large clinical sample of OCD patients, and to compare demographic and clinical features of patients with and without BD comorbidity.

METHOD

This cross-sectional study with 955 adult OCD patients from the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders (C-TOC) used several assessment instruments, including the Yale-Brown Obsessive-Compulsive Scale, the Dimensional Yale-Brown Obsessive-Compulsive Scale, the Beck Depression and Anxiety Inventories, and the Structured Clinical Interview for DSM-IV Axis I Disorders. Descriptive and bivariate analyses were followed by logistic regression.

RESULTS

The lifetime prevalence of BD was 7.75% (N = 74). The variables that were independently associated with BD comorbidity were: panic disorder with agoraphobia, impulse control disorders, and suicide attempts.

LIMITATIONS

The cross-sectional design does not permit causal inferences; the external validity may be limited, as the participants were from tertiary services. Despite the large sample size, some analyses may have been underpowered due to the relatively low prevalence of the outcome and of some explanatory variables.

CONCLUSIONS

Patients with OCD comorbid with BD have some clinical features indicative of greater severity, including higher suicide risk, and require a careful therapeutic approach for the appropriate treatment of both disorders.

Lamotrigine-induced obsessive-compulsive disorder in patients with bipolar disorder

IntroductionLamotrigine is a commonly used drug in the treatment of bipolar disorder. Although there are reports of its effectiveness in the management of bipolar disorder and comorbid obsessive-compulsive disorder (OCD), lamotrigine has also been associated with obsessionality in patients with bipolar disorder.

METHODS

Charts of 8 patients with bipolar disorder who had de novo onset of obsessions and compulsions after the use of lamotrigine were reviewed. The Naranjo scale was used to assess the likelihood of patients developing OCD due to lamotrigine use.

RESULTS

Two to 8 months after the initiation of lamotrigine, patients with no such prior history developed obsessions and compulsions meeting the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnostic criteria for medication-induced OCD. In all except 1 patient, the symptoms resolved within a month of lamotrigine discontinuation.

CONCLUSIONS

Some patients with bipolar disorder may develop OCD after initiation of lamotrigine. Due to the inherent limitations of a case series, the findings should be interpreted with caution.

Personalized Pharmacotherapy for Bipolar Disorder: How to Tailor Findings From Randomized Trials to Individual Patient-Level Outcomes

The quest for "personalized medicine" in psychiatry has focused mainly on pursuing potential biomarkers such as pharmacogenetic predictors of drug response. However, the collective randomized trial database across phases of bipolar disorder allows one to identify clinical characteristics that inform the likelihood of desired treatment outcomes. In turn, those characteristics, termed moderators and mediators of drug response, enable those who administer treatment to construct clinical profiles that can help them tailor pharmacotherapies to the features of a given patient rather than simply to an overall diagnosis. Bipolar disorder typically involves more heterogeneous than uniform clinical presentations, partly because of its highly prevalent psychiatric and medical comorbid conditions. Further clinical diversity arises from characteristics such as bipolar I versus II disorder subtype, rapid cycling, mixed versus pure affective episodes, psychosis, anxiety, chronicity, cognitive dysfunction, and suicidality, among other distinguishing features. By coupling such profiles with an awareness of the psychotropic breadth of spectrum held by particular medications, clinicians can devise strategic combination therapy regimens, capitalizing on synergies and using drugs that exert multiple relevant effects, addressing comorbid conditions, incorporating medications that could offset adverse effects of other agents, and avoiding or deprescribing medication options that lack known evidence to target symptoms within the clinical profile of a given patient.

Aripiprazole augmentation in treating comorbid bipolar disorder and obsessive-compulsive disorder: A systematic review

BACKGROUND

Apparent comorbidity between bipolar disorder (BD) and obsessive-compulsive disorder (OCD) is a common condition in psychiatry, but treatment of BD-OCD remains 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.

METHODS

A systematic review was conducted on aripiprazole augmentation in treating comorbid BD-OCD patients. Relevant papers published through August 31st 2018 were identified searching the electronic databases MEDLINE, Embase, PsycINFO and the Cochrane Library.

RESULTS

Aripiprazole augmentation to mood stabilizers (lithium carbonate, valproate), even at low doses (10-15 mg/day), helped to achieve significant remission in affective and obsessive-compulsive symptoms. Aripiprazole was generally safe and well tolerated.

LIMITATIONS

Most studies are case reports. Enrolment of subjects mainly from outpatient specialty units might have introduced selection bias and limited community-wide generalizability.

CONCLUSIONS

Keeping in mind scantiness and heterogeneity of the available literature, the best interpretation of the available evidence appears to be that aripiprazole augmentation to mood stabilizers, even at low doses, is effective in BD-OCD patients.

Suicide Risk in Comorbid Bipolar Disorder and Obsessive-Compulsive Disorder: A Systematic Review

INTRODUCTION

The co-occurrence of bipolar disorder (BD) and obsessive-compulsive disorder (OCD) seemed to be a poor prognostic factor associated with greater disability, lower social and occupational functioning, poorer treatment response, and higher suicidal ideas and attempts compared to BD patients.

MATERIALS AND METHODS

A systematic review was conducted on the risk of suicide in BD-OCD patients compared to BD patients. Relevant papers published through August 2018 were identified searching the electronic databases MEDLINE, EMBASE, PsycINFO, and the Cochrane Library.

RESULTS

In all cases, diagnoses were according to the standard Diagnostic and Statistical Manual criteria and were established using validated assessment scales. More than 80% of the selected studies presented higher rates of history of suicide attempts and lifetime depressive episodes in BD-OCD patients compared to non-comorbid patients.

CONCLUSIONS

Osler's view that medicine should be a treatment of diseases, not of symptoms, is consistent with the approach of mood stabilization as the first objective in apparent BD-OCD patients, as opposed to immediate treatment with antidepressants. In line with that, especially in comorbid patients, lithium may be preferred because of its proven anti-suicidal effect.

Comorbidity of bipolar and anxiety disorders: An overview of trends in research

Over the last three decades burgeoning research has shown that anxiety disorder comorbidity is not only highly prevalent in bipolar disorder (BD), but it also adversely impacts the course, outcome, and treatment of BD. The present review provides an overview of the current trends in research on comorbid anxiety and BDs based on prior reviews and meta-analyses (n = 103), epidemiological surveys, and large-scale clinical studies. The results reiterated the fact that at least half of those with BD are likely to develop an anxiety disorder in their lifetimes and a third of them will manifest an anxiety disorder at any point of time. All types of anxiety disorders were equally common in BD. However, there was a wide variation in rates across different sources, with most of this discrepancy being accounted for by methodological differences between reports. Comorbid anxiety disorders negatively impacted the presentation and course of BD. This unfavourable clinical profile led to poorer outcome and functioning and impeded treatment of BD. Despite the extensive body of research there was paucity of data on aetiology and treatment of anxiety disorder comorbidity in BD. Nevertheless, the substantial burden and unique characteristics of this comorbidity has important clinical and research implications.

Obsessive-compulsive disorder comorbid with schizophrenia and bipolar disorder

Obsessive Compulsive Disorder (OCD) and Obsessive Compulsive Symptoms (OCS) are known to be highly comorbid with bipolar disorder and schizophrenia. Comorbid OCD/OCS influences the course of schizophrenia and bipolar disorder. There is also some evidence to suggest that a diagnosis of OCD may be associated with elevated risk for later development of psychosis and bipolar disorder. Comorbid OCD/OCS is associated with a greater severity of schizophrenia phenotype and poorer prognosis. In addition, certain atypical antipsychotics, clozapine in particular are known to induce or worsen OCS in schizophrenia. OCD when comorbid with bipolar disorder mostly runs an episodic course with worsening and improvement of OCD/OCS in depressive and in manic/hypomanic phases respectively. There is limited systematic data on the treatment of OCD in schizophrenia and bipolar disorder. When OCD presents in the context of schizophrenia, management may include treatment with atypical antipsychotics with limited serotonergic properties, changing the antipsychotic, reduction in the dose of the antipsychotic, addition of cognitive-behavior therapy (CBT), or a specific serotonin reuptake inhibitor (SSRI). When OCD is comorbid with bipolar disorder, mood stabilization is the priority. CBT may be preferred over SSRIs to treat OCD/OCS that persist in between the mood episodes because SSRIs may induce a switch or worsen the course of bipolar disorder. SSRIs when indicated have to be used judiciously under the cover of adequate mood stabilization.

Aripiprazole augmentation in treating comorbid bipolar disorder and obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is one of the most difficult additional diagnoses to manage in patients with bipolar disorder (BD) since the gold standard treatment for one disease (antidepressants for OCD) can worsen the other. This case report describes the efficacy of aripiprazole augmentation as maintenance therapy in a young patient with comorbid BD-OCD. Our patient presented complete remission of affective and obsessive-compulsive symptoms with remarkable improvement in social and occupational functioning for 24 months. Adverse drug reactions were not severe enough to result in drug discontinuation. In consideration of the important nosological, clinical and therapeutic implications, future research efforts may lead to more grounded guidelines, which are greatly needed in patients with comorbid BD-OCD.

Treatment of anxiety disorders in patients with comorbid bipolar disorder

Anxiety disorders are the most prevalent comorbid diagnoses in patients with bipolar disorder (BD). A comorbid anxiety diagnosis can significantly impact the severity of bipolar symptoms, increase the risk of suicidality, and decrease psychosocial functioning and quality of life. The Canadian Network for Mood and Anxiety Treatments (CANMAT) task force published recommendations for treatment in 2012 suggesting that specific anticonvulsant mood stabilizers and second-generation antipsychotics are the medications of choice to treat these comorbidities. Serotonergic antidepressant medications are first-line medications for the treatment of most anxiety disorders; however, this can be problematic for a patient with BD. Antidepressant use in BD has been associated with a risk of manic switch as well as potential destabilization of mood. Mood stabilizer therapy should be established for patients with comorbid BD and an anxiety disorder before other medications are added to address the anxiety disorder. While benzodiazepine medications are recommended as third-line therapy in the CANMAT task force recommendations, their use should be avoided in patients with comorbid BD, posttraumatic stress disorder, and substance use disorders. The use of benzodiazepines should in general be avoided for all patients if possible, based upon current clinical research. Interpersonal, cognitive behavioral, and relaxation therapy are effective for the treatment of anxiety symptoms, especially emotional experiences, in patients who are euthymic.

Bipolar disorder and obsessive compulsive disorder: The comorbidity does not further impair the neurocognitive profile

BACKGROUND

The comorbidity of bipolar disorder (BD) and obsessive-compulsive disorder (OCD) has been widely described. Several studies have investigated the cognitive profiles of BD and OCD patients, but studies that compare BD, BD-OCD, and OCD patients in neuropsychological domains do not exist. The purpose of this study was to compare set-shifting, decision making, and central coherence among BD, BD-OCD, and OCD patients.

METHODS

A battery of neuropsychological tests was administered to 68 patients (22 BD, 26 BD-OCD, 20 OCD). The Young Mania Rating Scale and Hamilton Depression Rating Scale were used to evaluate manic and depressive symptoms, and OCD severity was assessed with the Yale Brown Obsessive Compulsive Scale.

RESULTS

No significant differences emerged in decision-making and cognitive flexibility, whereas BD patients had lower scores in the Accuracy Index on Rey-Osterrieth Complex Figure Test and poor response speed on Hayling Sentence Completion Test Part A than OCD patients.

LIMITATIONS

The small sample size with different BD patients, the cross-sectional design, and the study clinical nature.

CONCLUSIONS

The most striking result is that, contrary to our hypothesis, comorbidity does not further impair the neurocognitive profile. The clinical relevance of our work could be a shift from the current cognitive rehabilitation model focusing on individualized pathways towards a new overlapping model for all three patient groups. This could make the cognitive rehabilitation faster and less costly. Notwithstanding, these disorders do not only need cognitive training but also various psycho-educative approaches and treatment according to their different clinical profile.

Bipolar disorder, comorbid anxiety disorders, gynecomastia and dental pain: case analysis with literature review

Bipolar disorder with comorbid anxiety disorders frequently requires rational polypharmacy, including use of serotonergic psychotropics. These may result in adverse effects, influencing adherence, complicating treatment and confounding diagnoses. Serotonergic non-adherence is associated with discontinuation syndromes. In this complex case with an on/off/on/off design, both dose-dependent buspirone-induced gynecomastia and buspirone discontinuation syndrome with dental pain are reported. Clinicians and patients should consider these findings to maximise treatment adherence, minimise any unnecessary interventions and address unusual adverse effects. Since patients may not voluntarily disclose specific adverse effects and often do not acknowledge non-adherence, clinician-directed questions are required. This case further emphasises the importance of medication and symptom timelines to guide determination of causation for adverse effects. Although findings from this case cannot be generalised, they suggest the need for continued clinician and patient education, as well as the benefit from detailed case reports.

DECLARATION OF INTEREST

None.

A NATURALISTIC EXPLORATORY STUDY OF OBSESSIVE-COMPULSIVE BIPOLAR COMORBIDITY IN YOUTH

BACKGROUND

Growing evidence supports the comorbidity between bipolar disorder (BD) and obsessive-compulsive disorder (OCD) in children and adolescents. Our aim is to further explore clinical and treatment implications of this comorbidity, as it appears in clinical practice.

METHOD

The sample included 429 consecutive patients with BD and/or OCD as primary diagnoses, followed for a mean period of 6 months (range 4-9 months), 172 with BD (102 males, mean age 13.7±2.9 years), 169 with OCD (118 males, mean age of 13.2±2.7 years) and 88 with comorbid BD+OCD (56 males, mean age 14.2±2.6 years, 52 with BD as the primary diagnosis), followed for a mean period of 6 months (range 4-9 months). The comorbid group was compared to pure BD and OCD groups, to explore differential clinical and treatment features.

RESULTS

The BD-OCD comorbidity was found in 33.8% of the BD patients and in 34.2% of the OCD patients. Age at onset of BD and OCD were not different in pure and "comorbid" groups. The comorbid group presented a higher occurrence of BD type II and hoarding symptoms, and more frequently received a psychotherapy and second generation antipsychotics, but it presented the poorest outcome in terms of response to treatments. Severity at baseline (clinical severity and functional impairment), hoarding obsessions and compulsions, and conduct disorder comorbidity were associated with a treatment non-response.

LIMITATIONS

A selection bias may have increased the rate of comorbidity, as most of the patients were referred to our tertiary hospital for severe BD and/or OCD and pharmacological treatment. We have used CGI-I as an outcome measure, not a specific measure of BD or OCD symptoms' severity and improvement. The short duration of the follow-up may limit our conclusions.

CONCLUSIONS

The timely identification of BD-OCD comorbidity may have relevant clinical implications in terms of symptomatology, course, treatment and outcome.

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder

The Canadian Network for Mood and Anxiety Treatments (CANMAT) previously published treatment guidelines for bipolar disorder in 2005, along with international commentaries and subsequent updates in 2007, 2009, and 2013. The last two updates were published in collaboration with the International Society for Bipolar Disorders (ISBD). These 2018 CANMAT and ISBD Bipolar Treatment Guidelines represent the significant advances in the field since the last full edition was published in 2005, including updates to diagnosis and management as well as new research into pharmacological and psychological treatments. These advances have been translated into clear and easy to use recommendations for first, second, and third- line treatments, with consideration given to levels of evidence for efficacy, clinical support based on experience, and consensus ratings of safety, tolerability, and treatment-emergent switch risk. New to these guidelines, hierarchical rankings were created for first and second- line treatments recommended for acute mania, acute depression, and maintenance treatment in bipolar I disorder. Created by considering the impact of each treatment across all phases of illness, this hierarchy will further assist clinicians in making evidence-based treatment decisions. Lithium, quetiapine, divalproex, asenapine, aripiprazole, paliperidone, risperidone, and cariprazine alone or in combination are recommended as first-line treatments for acute mania. First-line options for bipolar I depression include quetiapine, lurasidone plus lithium or divalproex, lithium, lamotrigine, lurasidone, or adjunctive lamotrigine. While medications that have been shown to be effective for the acute phase should generally be continued for the maintenance phase in bipolar I disorder, there are some exceptions (such as with antidepressants); and available data suggest that lithium, quetiapine, divalproex, lamotrigine, asenapine, and aripiprazole monotherapy or combination treatments should be considered first-line for those initiating or switching treatment during the maintenance phase. In addition to addressing issues in bipolar I disorder, these guidelines also provide an overview of, and recommendations for, clinical management of bipolar II disorder, as well as advice on specific populations, such as women at various stages of the reproductive cycle, children and adolescents, and older adults. There are also discussions on the impact of specific psychiatric and medical comorbidities such as substance use, anxiety, and metabolic disorders. Finally, an overview of issues related to safety and monitoring is provided. The CANMAT and ISBD groups hope that these guidelines become a valuable tool for practitioners across the globe.

Exploration of comorbid obsessive-compulsive disorder in patients with bipolar disorder: The clinic-based prevalence rate, symptoms nature and clinical correlates

BACKGROUND

Comorbidity of bipolar disorder (BD) and obsessive-compulsive disorder (OCD) has received clinical attention. However, the detailed nature and nolosogic validity of the comorbidity have not been fully explored. This study investigated the comorbidity rate, clinical nature, and correlates of OCD in patients with BD.

METHODS

Patients (n = 314) with BD were recruited and lifetime clinical characteristics were evaluated comprehensively. The comorbid OCD ('OCD-BD') group and the 'non-OC BD' group were compared in terms of the clinical variables of BD.

RESULTS

OCD was found in 15.9% of patients. Earlier age at onset, more frequent pharmacological (hypo)manic switch and a higher rate of comorbid panic disorder were associated with comorbid OCD. In two-thirds (65.4%) of the OCD-BD subjects, obsessive-compulsive symptoms worsened or were confined to depressive episodes. Contamination obsession and checking compulsion were the most common types of obsessive-compulsive symptoms. Drug-induced (hypo)manic switch was observed in more than 60% of the OCD-BD subjects who were previously exposed to antidepressants. None of the OCD-BD subjects were taking antidepressants for OCD in the current specialty clinics.

LIMITATIONS

Subject recruitment from specialty clinics, retrospective and cross-sectional evaluation, and difficulties in clarifying the causal relationships.

CONCLUSIONS

The comorbidity rate of OCD in Korean BD patients was comparable to that of Caucasian patients. Even though OCD seems to be more often linked to depressive episodes, a heterogeneous nosologic relationship including a possibility of drug-mediated induction is suggested.

Clinical and familial profile of bipolar disorder with and without obsessive-compulsive disorder: an Indian study

Abstract Introduction Comorbid obsessive-compulsive disorder (OCD) is common in bipolar disorder (BD). Clinical characteristics, functionality and familial pattern of this comorbidity are largely understudied. Objective To assess clinical profile, familial loading of psychiatric disorders and level of functioning in remitted BD patients who have comorbid OCD and to compare results with those of remitted BD patients without OCD. Methods Remitted BD-I subjects were assessed using the Structured Clinical Interview for DSM-IV Axis I Disorders, Global Assessment of Functioning Scale (GAF), Hamilton Depression Rating Scale (HDRS), Young Mania Rating Scale (YMRS), Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and Family Interview for Genetic Studies (FIGS). BD patients with and without OCD were compared. Group differences were analyzed using the chi-square test and the independent samples t test. Values <0.05 were considered statistically significant. Results Of the 90 remitted BD-I patients, 35.5% (n=32) had obsessive-compulsive symptoms/OCD. The BD-OCD group showed significantly lower GAF scores, higher rates of suicidal attempts, hospitalizations, manic and depressive episodes compared to the group with BD only (p<0.05). In addition, first and second-degree relatives had higher rates of BD-OCD and OCD, but not of BD. Conclusions BD-OCD is characterized by more severe BD, more dysfunction and higher familial loading of BD-OCD and OCD. Larger studies involving relatives of probands will help to confirm our findings and to delineate nosological status of BD-OCD comorbidity.

Bipolar disorder comorbidity in patients with a primary diagnosis of OCD

OBJECTIVE

Bipolar disorder (BD) is considered to be a common comorbid condition in subjects with obsessive-compulsive disorder (OCD), but there is limited literature on the prevalence of BD and its clinical correlates in those with a primary diagnosis of OCD.

METHODS

We studied the prevalence of BD in a sample of consecutively registered outpatients attending a specialty OCD clinic in India over a period of 13 months. One hundred and seventy-one patients with a primary diagnosis of OCD were assessed systematically using structured and semi-structured instruments.

RESULTS

The prevalence of lifetime BD in OCD was 4%. The OCD + BD group had an episodic course of OCD and higher rate of lifetime suicide attempts.

CONCLUSIONS

BD may not be as highly prevalent in OCD as reported in literature. Those with OCD seem to have only a marginally higher risk for developing BD than the general population. A diagnosis of BD seems to have a pathoplastic effect on the course of OCD. Patients with OCD-BD comorbidity have to be specifically assessed for suicide risk.

Sleep and circadian alterations in people at risk for bipolar disorder: A systematic review

BACKGROUND

Sleep and circadian abnormalities have been mostly demonstrated in bipolar patients. However, it is not clear whether these alterations are present in population at high risk for bipolar disorder (BD), indicating a possible risk factor for this condition.

OBJECTIVE

This systematic review aims to define current evidence about sleep and rhythm alterations in people at risk for BD and to evaluate sleep and circadian disorders as risk factor for BD.

METHODS

The systematic review included all articles about the topic until February 2016. Two researchers performed an electronic search of PubMed and Cochrane Library. Keywords used were 'sleep' or 'rhythm' or 'circadian' AND 'bipolar disorder' or 'mania' or 'bipolar depression' AND 'high-risk' or 'risk'.

RESULTS

Thirty articles were analyzed (7451 participants at risk for BD). Sleep disturbances are frequent in studies using both subjective measures and actigraphy. High-risk individuals reported irregularity of sleep/wake times, poor sleep and circadian rhythm disruption. Poor sleep quality, nighttime awakenings, and inadequate sleep are possible predictive factors for BD. A unique study suggested that irregular rhythms increase risk of conversion. People at risk for BD showed high cortisol levels in different times of day. Studies about anatomopathology, melatonin levels, inflammatory cytokines and oxidative stress were not identified. The most important limitations were differences in sleep and rhythm measures, heterogeneity of study designs, and lack of consistency in the definition of population at risk.

CONCLUSION

Sleep and circadian disturbances are common in people at risk for BD. However, the pathophysiology of these alterations and the impact on BD onset are still unclear.

Comorbidity between bipolar disorder and borderline personality disorder: Prevalence, explanatory theories, and clinical impact

BACKGROUND

The relationship between bipolar disorder (BD) and borderline personality disorder (BPD) has been controversial and widely debated. Specifically, the comorbidity between both disorders has yielded a plethora of research, but there are no comprehensive reviews on this issue.

OBJECTIVE

To determine the empirical evidence regarding the comorbidity between BD and BPD based on prevalence data, explanatory theories for their co-occurrence, and clinical impact of one disorder in the other.

METHOD

A comprehensive search of databases (PubMed and PsycINFO) was performed. Published manuscripts between January 1985 and August 2015 were identified. Overall, 70 studies fulfilled inclusion criteria.

RESULTS

Over a fifth of subjects showed comorbidity between BPD and BD. Empirical evidence from common underlying factors was inconclusive, but BPD appears to be a risk factor for BD. Data also indicated that the negative impact of BPD in BD (e.g., suicidality, worse mood course) was greater than vice verse.

CONCLUSIONS

Given the high prevalence of comorbidity between BD and BPD and the negative effects of BPD in subjects with BD, further studies are needed to clarify the factor associated with the comorbidity between these two disorders. This information is important to develop appropriate treatments for subjects with both disorders, improve their clinical course, and prevent the increased risk of suicidality commonly found in these subjects.

Bipolar I and II Disorders; A Systematic Review and Meta-Analysis on Differences in Comorbid Obsessive-Compulsive Disorder

CONTEXT

More than half of the bipolar disorder (BD) cases have an additional diagnosis; one of the most difficult to manage is obsessive-compulsive disorder (OCD). Although some authors recently investigated the co-occurrence of anxiety and BD, the topic remains insufficiently studied. The current study aimed to investigate differences in comorbid OCD between BD-I and BD-II.

EVIDENCE ACQUISITION

A systematic review and meta-analysis was conducted on the prevalence and predictors of comorbid BD-I/BD-II and OCD. Relevant papers published until June 30, 2015 were identified searching the electronic databases MEDLINE, Embase, PsycINFO and the Cochrane Library.

RESULTS

Fourteen articles met the inclusion criteria. The pooled prevalence of BD-I in OCD was 3.9% (95% confidence interval (CI), 2.4 to 6.4, I2 = 83%, Q = 56) while that of BD-II in OCD was 13.5% (95% CI, 9.3 to 19.3, I2 = 89%, Q = 91). The pooled prevalence of OCD in BD-I was 21.7 (95% CI, 4.8 to 60.3, I2 = 84%, Q = 95). With regard to OCD-BD predictors, mean age and rate of males did not predict the prevalence of BD-I (β = 0.0731, 95% CI, -0.1097 to 0.256, z = 0.78; β = 0.035, 95% CI, -0.2356 to 0.1656, z = 0.34) and BD-II (β = 0.0577, 95% CI, -0.1942 to 0.0788, z = 0.83; β = -0.0317, 95% CI, -0.1483 to 0.085, z = 0.53) in OCD. The mean age explained some of the observed heterogeneity (R2 = 0.13; R2 = 0.08).

CONCLUSIONS

This first systematic review and meta-analysis of the prevalence and predictors of comorbid BD-I/BD-II and OCD suggests that BD-OCD comorbidity is a common condition in psychiatry. However, the available evidence does not allow to assess whether BD-I or BD-II are more common in patients with OCD.

Management of obsessive-compulsive disorder comorbid with bipolar disorder

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.

Utilizing a medical questionnaire to predict anxiety and depression in outpatients

Introduction

Anxiety and depressive symptoms are seen in patients with anxiety and mood disorders but are also common in those with organic disorders. However, since physical symptoms are predominant complaints from patients who visit nonpsychiatric outpatient clinics, anxiety and depressive symptoms are often unrecognized. It is important for physicians to be aware of these issues concurrent with the physical symptoms. We therefore examined whether a self-administered medical questionnaire could identify anxiety and depressive symptoms.

Patients and methods

A total of 453 patients on their first visit to the Department of General Medicine, Chiba University Hospital, Chiba, Japan, participated in this study. They were asked to complete a medical questionnaire and the Hospital Anxiety and Depression Scale questionnaire before examination. Data on age, sex, number of complaints, symptom duration, and number of previous physicians were extracted from the medical questionnaire. These data were used as independent variables in logistic regression analysis to develop a predictive model for the presence of anxiety and depressive symptoms.

Results

Data from 358 (79.0%) patients were included in the analyses. Logistic regression analysis identified the following predictors: “three or more complaints” (odds ratio [OR] 2.39; 95% confidence interval [CI] 1.48–3.88) and “four or more previous physicians” (OR 1.72; 95% CI 1.10–2.69). In the predictive model for the presence of symptoms of anxiety and depression, the likelihood ratio was 2.40 (95% CI 1.33–4.34) in patients reporting both conditions and 1.35 (95% CI 1.04–1.77) in those reporting either condition.

Conclusion

The presence of anxiety and depressive symptoms can be predicted from the items of a medical questionnaire in outpatients visiting a general medicine department of a university hospital. When patients report three or more complaints or four or more previous physicians on a medical questionnaire, physicians should consider the presence of anxiety or depression or both in differential diagnosis.

Comorbid bipolar disorder and obsessive-compulsive disorder:state of the art in pediatric patients

A full-text Chinese translation of this article will be available at http://dx.doi.org/10.11919/j.issn.1002-0829.215128 on April 25, 2016.

Course of illness in comorbid bipolar disorder and obsessive-compulsive disorder patients

Psychiatric comorbidity is extremely common. One of the most common and difficult to manage comorbid conditions is the co-occurrence of bipolar disorder (BD) and obsessive compulsive disorder (OCD). We updated our recent systematic review searching the electronic databases MEDLINE, Embase, and PsycINFO to investigate course of illness in BD-OCD patients. We identified a total of 13 relevant papers which found that the majority of comorbid OCD cases appeared to be related to mood episodes. OC symptoms in comorbid patients appeared more often during depressive episodes, and comorbid BD and OCD cycled together, with OC symptoms often remitting during manic/hypomanic episodes.