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Journal of Affective Disorders

Volume 249, 15 April 2019, Pages 15-19
Journal of Affective Disorders

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

https://doi.org/10.1016/j.jad.2019.02.024Get rights and content

Highlights

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    Apparent BD-OCD comorbidity is a common condition in psychiatry, but treatment of BD-OCD remains a clinical challenge.

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    Aripiprazole augmentation to mood stabilizers, even at low doses, helped to achieve significant remission in affective and obsessive-compulsive symptoms.

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    Addition of SRIs may be needed only in a minority of BD patients with refractory OCD.

Abstract

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.

Introduction

Apparent comorbidity between bipolar disorder (BD) and obsessive-compulsive disorder (OCD) is a common condition in psychiatry (Amerio et al., 2015a).

Results from our meta-analysis showed higher comorbidity rates in youths compared to adults, with the majority of patients that experienced the onset of OCD prior to the onset of BD (Tonna et al., 2016). BD-OCD patients presented higher prevalence of family history for mood disorders and lower prevalence of family history for OCD versus non-BD-OCD patients (Amerio et al., 2015b). Moreover, obsessive-compulsive symptoms in comorbid patients appeared more often - and sometimes exclusively - during depressive episodes, and comorbid BD and OCD cycled together, with OC symptoms often remitting during manic/hypomanic episodes (Amerio et al., 2016).

From a clinical perspective, the treatment of BD-OCD patients remains a great challenge. Though serotonin reuptake inhibitors (SRIs) are the first line treatment for OCD, they can induce mood instability in BD, especially if administered at high doses and maintained for a long time (Amerio et al., 2014).

The present paper is the first systematic review on aripiprazole augmentation in treating BD-OCD comorbidity.

Section snippets

Methods

This review was conducted according to methods recommended by the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Higgins and Green, 2011, Liberati et al., 2009).

Results

Twenty-seven potential studies were identified from searching the selected databases and listing references of relevant articles. After removing duplicates, twenty-four articles were retrieved. Studies were screened and selected as described in Fig. 1. The search identified six articles that were included in the systematic review.

Discussion

Aripiprazole is a psychotropic agent belonging to the chemical class of benzisoxazole derivatives. It is the first approved atypical antipsychotic with a mechanism of action that exerts a partial agonism with high affinity at Dopamin D2 and Serotonin-5-HT1A receptors as well as an antagonism at Serotonin-5-HT2A receptors. Aripiprazole provides good clinical effectiveness in a range of mental disorders and a favorable safety profile with low potential for metabolic and sexual side effects and

Limitations

The main strength of this study is that it is the first systematic review of this topic, and thus includes the entire available scientific evidence. Further, all included original studies used methodologically similar and psychometrically-validated diagnostic and outcome measures: DSM-based criteria, Y-BOCS and Young Mania Rating Scale (YMRS).

The main limitation of included studies is sample size, as documented by the quality assessment scores. Only one study was assigned a score greater than

Competing interests

Dr. Amerio and Dr. Odone report no conflicts of interest. Dr. Ghaemi is employed by Novartis Institutes for Biomedical Research, and holds equity in Novartis.

Fundings

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Contributors

Authors AA, AO and SNG designed the study and wrote the protocol. Studies were identified and independently reviewed for eligibility by two authors (AA, AO) in a two-step based process. Data were extracted by one author (AA) and supervised by a second author (SNG) using an ad-hoc developed data extraction spreadsheet. Authors AA and AO wrote the first draft of the manuscript. Our manuscript has been approved by all authors.

Acknowledgment

The authors thank Prof. Giuseppe Maina for his careful critique and his helpful comments.

References (18)

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