Q:  Behavioral Therapies & Meds for OCD & BP

Dr. Phelps,

I am an undergraduate student in a very demanding academic program (I am hoping to apply to medical school in a few years). I have a  diagnosis of Bipolar I Disorder with  mixed states and rapid cycling in addition to comorbid Obsessive Compulsive Disorder. I also have some significant prementrual difficulties. I have had several hospitalizations since  the beginning of college and have had to take time off at two points to stabilize. Much of my difficulties at the time stemmed from the fact  that I was unwilling to comply with my bipolar medications (I wanted to  stay up all night, write novels, etc.) I had a manic episode last September  that took many months for me to recover from and I am terrified of having another episode. I have been in a good, stable remission for several months and would now like to focus on the OCD symptoms which also  really interfere with my functioning as a student. I am aware of CBT and antidepressants as  possible treatment options. I have tried many a antidepressants (when I was in high school and had not been properly diagnosed). I got much, much worse on Prozac, Paxil, Zoloft, and uvox. My former psychiatrist says that being on lithium and depakote would  possibly revent induction of mania. I'm still scared. I'm switching  universities right now because I didn't get enough financial aid, so I'm not sure  if  this is even the right time to play around with my medications. I am willing to learn more about CBT but I have A LOT of different  symptoms and am not sure if I will be able to find a CBT therapist in my area. Stability is KEY during this time (and the rest) of my life.  What should someone with comorbid OCD and bipolar disorder do as far as medications  go? Do you have any suggestions? Also, I'm very "journal-friendly" and  like to read about all the research that is  going on surrounding the issues I'm interested in. If you have any  articles in mind, please let me know. Thank you so much for reading this request  for help and considering it for inclusion in your page on this site. I  have been reading your other website for years and am a big fan!

 

Dear Ms. E' -- 
Sorry about the delay in getting back to you. I presume things may have changed somewhat in the interim. But the reply I began two weeks ago, before getting derailed, probably still applies. Here goes: You summarize a complicated situation well.  And you've learned that the behavioral therapies (how much the cognitive piece actually adds, in the treatment of OCD, is still somewhat debated) are an important tool in the treatment of OCD, thus presenting an alternative to antidepressants -- the usual medication approach for OCD, as you know well -- which might destabilize the bipolar part of things. Your experience with that very problem is of course very relevant. And, your doctor is also correct, in general it appears that mood stabilizers can reduce the risk of antidepressants inducing hypomania/mania.  For example, in several studies, the risk was close to zero; these studies were recently combined in a "meta-analysis" which concluded that the "switch risk" was about 3-4%. ^Gijsman But there are other concerns about antidepressants, other possible risks, summarized on my Antidepressant Controversies page. 

So, first you maximize non-antidepressant options: you've considered re: CBT and how to find it (you've read Brain Lock; and Drs. Foa and Wilson,  more difficult but more thorough -- Stop Obsessing, yes?).  As you go, you try to make sure you've got very good control of the bipolar side: no evidence of cycling. Then you examine, at that point, how much the OCD symptoms are still really interfering with your life. Is it worth taking a risk destabilizing the bipolar side trying to go after those symptoms? (for some people, I believe the answer would be "definitely no", but for others, "definitely yes"). At that point, if you've really maximized the behavioral treatments, then to my knowledge the primary option (other than exploring treatments with little evidence for their efficacy, and often no data on their safety) is to cautiously add a serotonergic antidepressant, perhaps increasing your mood stabilizers as necessary if the antidepressant appears to be destabilizing things. 

Good luck with all that. 

Dr. Phelps

Published November, 2005