Do antidepressant-induced manic episodes in obsessive-compulsive disorder patients represent the clinical expression of an underlying bipolarity?

To the Editor,

According to the American Psychiatric Association, serotonin reuptake inhibitors (SRIs) are the first-line treatment for obsessive-compulsive disorder (OCD) (Fineberg et al., 2013). Several published case reports describe OCD patients who have developed manic episodes induced by different SRIs (Raja and Azzoni, 2004), which raises the question of comorbidity between bipolar disorder (BD) and OCD. We present the case of a patient with severe OCD who developed a manic episode during treatment with sertraline.

The patient is a 56-year-old Caucasian unmarried woman with positive family history for major depressive disorder. From the age of 20, she had presented fear of contamination, leading to elaborate washing and cleaning rituals that had partially impaired her functional capacity. These symptoms met DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fouth Edition) criteria for OCD and were untreated for 34 years. No history of manic or depressive episodes was reported.

At the age of 54, a few months after leaving her parents’ home, the obsessions and compulsions increased and she presented with depressed mood and feelings of worthlessness. She was admitted to the inpatient service and treated with sertraline 200 mg/day; her obsessive-compulsive and affective symptoms were well controlled and a satisfactory quality of life was regained.

After 8 months on sertraline 250 mg/day, she developed a manic episode. Her therapy was modified to valproate 1000 mg/day and olanzapine 10 mg/day. Olanzapine was gradually decreased and valproate was continued for the next 5 months with remission of obsessive-compulsive symptoms and mood stabilization.

After her father’s death, compulsive rituals increased prominently. Sertraline 75 mg/day was added to valproate and again complete remission of bipolar and obsessive-compulsive symptoms for the following months was reported.

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., 2014).

In our case, three features support the hypothesis of an underlying bipolarity unmasked by the antidepressant used to treat OCD: positive family history for affective disorders; manic switch induced by antidepressant; and improvement of affective and obsessive-compulsive symptoms with mood stabilizers and atypical antipsychotics.

Osler’s view that medicine should be the treatment of diseases, not of symptoms (Ghaemi, 2006), is consistent with the approach of mood stabilization as a first objective in apparent BD-OCD patients, as opposed to immediate treatment with SRIs (Raja and Azzoni, 2004).

This case highlights why only a minority of patients with persistent OCD comorbid with BD should be prescribed antidepressants in as low a dose as feasible.