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Treatment of patients with both OCD and bipolar disorder should include measures to achieve mood stabilization before initiating treatment with agents, such as SRIs, that may induce or exacerbate hypomania or mania. Stabilizing the bipolar disorder may require a combination of medications, including lithium, anticonvulsants, and second-generation antipsychotic drugs (193). In bipolar OCD patients, SSRIs appear to be less likely than clomipramine to precipitate hypomania or mania (29). Potential drug interactions should be carefully considered when clomipramine, fluoxetine, fluvoxamine, paroxetine, or sertraline are considered for use in combination with these agents.

Episodic OCD, characterized by periods of markedly different symptom severity independent of OCD treatment, appears to be considerably more common in OCD patients with bipolar disorder (29). Thus, a history of episodic OCD should raise the psychiatrist's suspicion that co-occurring bipolar disorder may be present. Perhaps as a result of co-occurring bipolar disorder, patients with episodic OCD appear to be more likely to suffer from alcohol abuse or dependence, panic disorder, and agoraphobia (29), which will also require treatment.

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