Obsessions and suicidality in youth suffering from bipolar I disorder
Middle East Current Psychiatry volume 30, Article number: 82 (2023)
Obsessive compulsive disorder (OCD) is a common comorbidity with bipolar disorder, a comorbidity that is known to increase suicide risk. This study aimed to assess the presence of OCD in youth diagnosed with bipolar I disorder and to evaluate the association between OCD and suicide in the same cohort.
Eighty subjects diagnosed with bipolar I disorder were enrolled in this study; subjects were divided according to the presence or absence of OCD to group A: bipolar disorder patients with OCD (n = 26) and group B: bipolar disorder patients without OCD (n = 54).
The following scales were applied: Dimensional Yale-Brown Obsessive-Compulsive Scale (DYBOCS)–Beck Scale for Suicidal Ideations (BSSI)–Hamilton Depression Rating Scale (HDRS), and Young Mania Rating Scale (YMRS).
DYBOCS score of group A was 30.23 ± 0.43, and that of group, B was 18.50 ± 1.88 with a significant difference (p < 0.01). There was a significant positive correlation between BSSI and age, age of onset and YMRS in group A (p < 0.01).
The study demonstrated that OCD is a common comorbidity in youth with bipolar I disorder and may be associated with a greater risk of suicide than in youth with bipolar I disorder without comorbid OCD. Furthermore, comorbidity of OCD with bipolar I disorder in youth may be associated with younger age of onset and more severe symptoms profile.
Bipolar disorder is a persistent, incapacitating mental disorder that can have a significant negative influence on a patient’s life. Whether it is bipolar II disorder (BD), which is distinguished by the existence of a hypomanic phase and a severe depressive episode, or bipolar I disorder (BD), which is characterized by the presence of a manic episode. The signs of a manic episode include irritability, a diminished need for sleep, grandiosity, and an exceedingly elevated mood . Up to 75% of manic episodes can also involve psychotic symptoms including delusions, pertaining to varying degrees of poor psychosocial functioning .
Obsessive compulsive disorder (OCD) has a lifetime prevalence of 2–3% and a first-degree relative prevalence of up to 11% . OCD is the core component in a set of conditions known as obsessive compulsive and related disorders in DSM-5 (OCRD).
The presence of obsessions and compulsions is what defines it. Obsessions are ego- dystonic, persistent, and repeatedly occurring ideas or images that are typically accompanied by extremely high levels of anxiety. Compulsions are compulsive rituals that a patient feels forced to engage in to get rid of the associated distress and anxiety [4, 5].
Given its important nosological and therapeutic consequences, the re-occurring link between OCD and BD has been receiving more attention for several decades.
Patients presenting with OCD and BD show an atypical clinical course, characterized by a higher number of associated depressive episodes, a more episodic course and higher treatment resistance [6,7,8]. OCD has been debated as a separate disorder comorbidity with bipolar disorder or a manifestation of bipolar disorder sharing the same psycho-pathology [9, 10].
According to Zutshi et al. around 80% of BD with OCD patients only had OCD during depressive episodes or reported worsening OCD symptoms while depressed.
Perugi et al. found that half of their sample had a main diagnosis of OCD and continued to have obsessive-compulsive symptoms throughout hypomanic episodes. The greater part of patients in the BD I and OCD group, however, exhibited OCD symptoms during the manic phase or when in remission, while a minority had OCD symptoms throughout the depressed phase , according to Ul ain Khan et al.
OCD has been considered to be linked to comparatively low suicide risk . Most recent investigations, on the opposite, demonstrated a substantial relationship between OCD and suicidal behavior . Nevertheless, a vast variation in prevalence rates occurs .
Nevertheless, most studies discovered that OCD raised the risk of suicide in BD patients .
When Di Salvo et al. looked into how OCD comorbidity affected suicidality in BD, they found a strong link between the two. Despite to some extent higher rates in BD and comorbid OCD patients, Di Salvo et al. observed no appreciable differences in lifetime suicidal attempts between individuals with and without comorbidity of OCD .
In this work, we hypothesized that youth with bipolar disorder type I comorbid with OCD are at a greater risk of suicide than youth with bipolar I disorder without comorbid OCD.
This was a cross-sectional observational study where 80 subjects with bipolar I disorder were enrolled consecutively (convenient sample) from the Psychiatry Hospital, Cairo University. “The 80 subjects were divided into two groups according to the presence or absence of obsessions. Sample size calculation was achieved using PS: Power and Sample Size Calculation software Version 3.1.2 (Vanderbilt University, Nashville, TN, USA)”.
Both sexes were included, and the age of patients ranged between 15 and 24 years. All of the individuals met the DSM-5 bipolar I disorder diagnostic criteria (in partial remission). Thus neither admission nor medication adjustment were necessary at the time of administration. They could successfully complete the self-rated psychometric exams since they were cooperative, had clinically average IQ, and could read and write.
Urine drug screening tests for recent substance use and comorbid neurological or severe medical illnesses were used as exclusion criteria.
Patients were then separated into 2 groups using DSM-5 criteria: group A, which comprised subjects with obsessive-compulsive disorder (n = 26), and group B, which included subjects without OCD (n = 54).
We asked the participants about DSM-5 criteria to diagnose OCD. The diagnosis was then verified by two senior consultant psychiatrists.
The following scales were used once the diagnoses were established: Hamilton depression rating scale (HDRS), Beck Scale for Suicidal Ideations (BSSI), Young Mania Rating Scale (YMRS), and Dimensional Yale-Brown Obsessive-Compulsive Scale (DY-BOCS). Thorough medical and neurological testing was performed.
Dimensional Yale-Brown Obsessive-Compulsive Scale 
The Arabic version of the scale was used ; dimensions of OCD symptoms were rated according to their severity. The scale assesses the prevalence of obsessive-compulsive symptoms across five categories that group obsessions and compulsions according to a common theme.
Beck Scale for suicidal ideation BSSI . The Arabic version was used  was created to assess the seriousness, prevalence, and features of suicidal ideation in adult individuals. It evaluated the possibility of subsequent suicide attempts in those who had suicidal thoughts, or plans.
It assesses mood, guilt sentiments, suicidal thoughts, insomnia, agitation or retardation, etc. to determine the severity of the depression.
The 11-item Young Mania Rating Scale  is a diagnostic multiple- choice test designed to assess the presence and severity of mania and related symptoms.
We used IBM Corp.’s (Armonk, NY, USA) SPSS version 28 statistical program for the social sciences. Mean and standard deviation plus SD were used for quantitative variables, whereas frequencies and percentages were utilized for categorical variables. For quantitative variables with regularly distributed distributions, unpaired t tests were used to compare groups, whereas Mann-Whitney tests were used for those with non-normally distributed distributions. The chi-square (c2) test was performed to compare categorical data. The Spearman correlation coefficient was employed to determine correlations between quantitative variables. Statistics defined significance as P values 0.05. Epi info (Epi info statistical package: CDC.GA 30329-4027, USA) was used to calculate the sample size under the assumptions that = 0.1, power = 0.8, precision = 5, and effect size = 1 .
The demographic information for the two study groups is shown in Table 1.
Data comparison revealed no apparent disparities in gender, socioeconomic status, educational attainment, or occupation between groups A and B.
On the other hand, group As mean age is considerably lower than group Bs and p value < 0.001.
The results of Table 2’s comparison of the two groups’ scores on various psychometric tests regarding the age of onset of illness and scores of different psychometric tools such as DY-BOCS, HDRS, YMRS, and BSSI; results showed that patients of group A had a statistically significant younger age of onset of illness, statistically significant higher scores of DY-BOCS, HDRS, YMRS, BSSI as p value < 0.001
In Table 3, the correlations between the mean age of onset with the mean scores of DYBOCS (r = 0.157), HDRS (r = 0.052), YMRS (r = 0.486), and BSSI (r = 1) were all positive which reflects a direct relationship between variables.
There was a statistically significant positive correlation (r = 1) between the mean age of onset with the mean scores of BSSI (p < 0.001), i.e., the older the age of onset, the higher the suicidality in bipolar disorder patients with OCD.
In Table 4, the correlations between the mean score of BSSI with the mean scores of the age of onset (r = 1), DYBOCS (r = 0.157), HDRS (r = 0.052), and YMRS (r = 0.486) were all positive which reflects a direct relationship between variables.
The current study sought to examine the prevalence of obsessive-compulsive disorder among young people with bipolar I disorder as well as the relationship between the disorder and suicide in this cohort.
The age of the sample chosen was between 15 and 24 years. The mean age of group A was 19.92 ± 1.8, and group B was 22.02 ± .1.1with a statistically significant difference (p < 0.001). Masi et al. identified a mean age of 14 years, which is younger than the mean age in our research .
While our research categorized youth as being between the ages of 15 and 24, the study included patients between the ages of 7 and 18 years old, which may account for the discrepancy.
Masi et al. showed that the difference in mean age between the bipolar disorder-obsessive compulsive disorder group and the bipolar-only group was statistically significant in the same study , which is consistent with our findings.
In group A, there were roughly 46% males and 54% females, but in group B, there were roughly 60% males and 40% females. Among both groups studied, there was no significant gender mismatch (p = 0.07).
Contrary to our findings, Di Salvo et al. discovered that men were likelier to have OCD comorbidity . There was no statistically significant difference between the two groups when it comes to education (p = 0.143), which is consistent with other research [7, 14, 18].
Regarding employment, there was also no statistical difference between groups studied (p = 0.21), which is consistent with Ul ain Khan et al. .
According to the study, 32.5% of patients with bipolar I disorder also have comorbid OCD.
A thorough examination of 64 papers that included data from three studies performed in Italy and the US revealed that lifetime prevalence rates of comorbid OCD in BD subjects ranged between 10 and 20% [28,29,30].
Another study carried out at various hospitals found that the lifetime prevalence of comorbid OCD in subjects with BD was about 2% up to 35% [31, 32]. Pre-occupational and/or compulsive symptoms were reportedly present in 22% of BD subjects.
Comorbidity prevalence rates (OCD-BD patients) were 35% when patients who had remitted from their condition were included. OCD and BD co-occur more frequently than previously believed, according to these data .
One study, which contradicted these conclusions, claimed that BD-I patients during their first episode did not have higher rates of OCD than the general population and that OCD was a low comorbidity among them. These findings are probably a result of the small sample size and inclusion of individuals with only BD I .
Age of onset differed significantly between groups B and A, with group B’s difference being statistically significant (p 0.001). Jeon et al. and Di Salvo et al research discovered a similar statistically significant correlation with a notable variation in the age of onset between both groups studied [7, 18].
Bipolar disorder patients in group A who also had obsessive-compulsive disorder had a mean YMRS score that was higher (5.08 ± 0.74) than the mean age in group B (1.59 ± 0.77). The difference was significant between both groups (p < 0.001).
The mean HDRS score in group A was higher (9.19 ± 2.56) than the mean age in group B (5.50 ± 2.51). The difference was statistically significant between the two groups (p < 0.001).
According to Zutshi et al., the majority of BD with OCD patients (78%) either had OCD that was only present during depressive episodes or claimed that their OCD got worse while they were depressed .
Up to two-thirds of patients had an improvement in their OCD during manic or hypomanic episodes, and other studies found no incidences of OCD during manic episodes .
In the study by Perugi et al., it was found that during hypomanic episodes, around 50% of the sample with an OCD main diagnosis continued to exhibit OCD symptoms . Specifically among patients with mixed moods, Keck et al. found concurrent OCD in inpatient manic bipolar patients .
Ul ain Khan et al.  found that the greater part of patients in the BD I with OCD had OCD symptoms during mania or in remission and a minority had OC symptoms during the depressive episode, which is contrary to what is commonly claimed in the literature, such as in Magalhes et al.’s study.
In contrast, Koyuncu et al. observed no significant difference between the two groups when comparing the severity of manic episodes .
Obsessive-compulsive symptoms only manifested during depressive episodes in 50–75% of patients with comorbid OCD and BD, according to Amerio et al.’s review article . Amerio et al. hypothesized that, in light of these findings, “the course of illness is a crucial diagnostic validator of OCD in BD patients” .
Yet, most OCD with BD individuals in a prior study of BD-I by Shashidhara et al. indicated that their OCD got worse during manic phases . It is advised that more research be done to interpret this discrepancy in relation to problems in various clinical circumstances.
In group A, the mean BSSI score was higher (10.85 ± 0.88)) than the mean score in group B (4.56 ± 0.50). The difference was statistically significant between the two groups (p < 0.001).
Despite the rates being somewhat higher in BD with OCD patients; Di Salvo et al. did not observe a significant difference in lifetime suicide attempts between patients with and without comorbidity of OCD .
However, Chen and Dilsaver discovered that bipolar patients with OCD comorbidity had significantly more lifetime suicidal thoughts and attempts than those without .
In group A there was a statistically positive association between the mean age of onset and the mean scores of the BSSI, i.e., the higher the suicidality, the older the age of onset.
Our findings disagree with those of prior research projects that found that suicidality rises with earlier onset age .
One of the problems that can account for the inconsistency is the diversity of onset definitions. In earlier research, the age of the patient’s first hospitalization or initial course of treatment was a popular criterion of age at onset . However, this was not consistently applied in our study, making it challenging to compare the various results as we defined the age of onset as the age at which the first symptom or indication manifested itself. This study, according to the researchers, is the first to examine the link between OCD and suicidality in young Egyptians.
Nevertheless, our findings have several drawbacks. The study did not evaluate all components of suicidality; nevertheless, looking into non-suicidal self-injury in the same patient population will provide more data that will aid in future management strategies and a relatively small sample size.
This study concludes that obsessive-compulsive disorder is found to be common in youth with bipolar disorder and may be associated with a greater risk for suicide than bipolar I without obsessive-compulsive disorder.
Furthermore, comorbidity of obsessive-compulsive disorder with bipolar I in youth was associated with a younger age at onset and a more severe symptom profile. In contrast, suicidality in youth with bipolar I disorder and comorbid obsessive- compulsive disorder was associated with older age and onset.
This research highlights the clinical importance of clinical assessment of OCD and suicidality in youth with bipolar I disorder, which are often neglected in the presence of other mood symptoms that take the upper hand in management and care.
It also emphasizes how crucial it is to test adolescents and young adults with bipolar I disorder for OCD since it affects the treatment strategy, including the choice of medication.
Availability of data and materials
Materials are available upon justifiable request.
Dimensional Yale-Brown Obsessive Compulsive Scale
Beck Scale For Suicidal Ideations
Hamilton Depression Rating Scale
Young Mania Rating Scale
McIntyre RS, Berk M, Brietzke E, Goldstein BI, López-Jaramillo C, Kessing LV, Malhi GS, Nierenberg AA, Rosenblat JD, Majeed A, Vieta E, Vinberg M, Young AH, Mansur RB (2020) Bipolar disorders. Lancet (London, England) 396(10265):1841–1856. https://doi.org/10.1016/S0140-6736(20)31544-0
American Psychiatric Association (2022) Diagnostic and statistical manual of mental disorders (5th ed., text rev.)
Carmi L, Brakoulias V, Arush OB, Cohen H, Zohar J (2022) A prospective clinical cohort-based study of the prevalence of OCD, obsessive compulsive and related disorders, and tics in families of patients with OCD. BMC Psychiatry 22(1):1–7
Robbins TW, Vaghi MM, Banca P (2019) Obsessive-compulsive disorder: puzzles & prospects. Neuron 102(1):27–47
Stein DJ, Costa DLC, Lochner C, Miguel EC, Reddy YCJ, Shavitt RG, van den Heuvel OA, Simpson HB (2019) Obsessive-compulsive disorder. Nat Rev Dis Primers 5(1):52. https://doi.org/10.1038/s41572-019-0102-3
Domingues-Castro MS, Torresan RC, Shavitt RG, Fontenelle LF, Ferrão YA, Rosário MC, Torres AR (2019) Bipolar disorder comorbidity in patients with obsessive-compulsive disorder: prevalence and predictors. J Affect Disord 256:324–330
Jeon S, Baek JH, Yang SY, Choi Y, Ahn SW, Ha K, Hong KS (2018) Exploration of co-morbid obsessive-compulsive disorder in patients with bipolar disorder: the clinic-based prevalence rate, symptoms nature and clinical correlates. J Affect Disord 225(336):227–233. https://doi.org/10.1016/j.jad.2017.08.012
Mucci F, Toni C, Favaretto E, Vannucchi G, Marazziti D, Perugi G (2018) Obsessive- compulsive disorder with comorbid bipolar disorders: clinical features and treatment implications. Curr Med Chem 25(41):5722–5730. https://doi.org/10.2174/0929867324666171108145127
Kazhungil F, Cholakottil A, Kattukulathil S, Kottelassal A, Vazhakalayil R (2017) Clinical and familial profile of bipolar disorder with and without obsessive-compulsive disorder: an Indian study. Trends Psychiatry Psychother 39:270–275
Tonna M, Trinchieri M, Lucarini V, Ferrari M, Ballerini M, Ossola P, Marchesi C (2021) Pattern of occurrence of obsessive-compulsive symptoms in bipolar disorder. Psychiatry Res 297:113715
Zutshi A, Reddy YC, Thennarasu K, Chandrashekhar CR (2006) Comorbidity of anxiety disorders in patients with remitted bipolar disorder. Eur Arch Psychiatry Clin Neurosci 256(7):428-436.400
Magalhães PVS, Kapczinski NS, FlávioKapczinski F (2010) Correlates and impact of obsessive-compulsive comorbidity in bipolar disorder. Compr Psychiatry 51(4):353–356
Perugi G, Akiskal HS, Pfanner C, Presta S, Gemignani A, Milanfranchi A, Cassano GB (1997) The clinical impact of bipolar and unipolar affective comorbidity on obsessive–compulsive disorder. J Affect Disord 46(1):15–23
Ulain Khan Q, Younus S, Hasan H, Khan MZ (2020) Association of bipolar I disorder with obsessive-compulsive disorder: a clinical study from Pakistan. Neurol Psychiatry Brain Res 33:89–92
Afifi DY, Shahin MO, Alaa Y, Ayoub DR (2022) Investigation of symptom severity, self-esteem, & suicidality in anxiety disorders and obsessive compulsive disorder. Rev Iberoam Psicol Ejerc Deporte 17(6):28,380-386
Albert U, De Ronchi D, Maina G, Pompili M (2019) Suicide risk in obsessive-compulsive disorder and exploration of risk factors: a systematic review. Curr Neuropharmacol 17(8):681-696.2. https://doi.org/10.2174/1570159X16666180620155941
Amerio A (2019) Suicide risk in comorbid bipolar disorder and obsessive-compulsive disorder: a systematic review. Indian J Psychol Med 41(2):133–137
Di Salvo G, Pessina E, Aragno E, Martini A, Albert U, Maina G, Rosso G (2020) Impact of comorbid obsessive-compulsive disorder on suicidality in patients with bipolar disorder. Psychiatry Res 290:113088
Rosario-Campos MC, Miguel EC, Quatrano S, Chacon P, Ferrao Y, Findley D, Leckman JF (2006) The Dimensional Yale-Brown Obsessive–Compulsive Scale (DY-BOCS): an instrument for assessing obsessive–compulsive symptom dimensions. Mol Psychiatry 11(5):495–504
Abdel Hamid AAL, Nasreldin M, Gohar SM, Saleh AA, Tarek M (2019) Sexual and religious obsessions in relation to suicidal ideation in bipolar disorder. All Wiley Journals FF. Wiley Online Library. https://doi.org/10.1111/sltb.12540
Beck AT, Kovacs M, Weissman A (1979) Assessment of suicidal intention: the Scale for Suicide Ideation. J Consult Clin Psychol 47(2):343
Aly N, Abdel Latief S, Abdel Latief A, El Naggar A (2012) Assessment of suicidality risk factors and its management at Poison Control Center Cairo University (adolescence suicidality). J Am Sci 8:724–7286
Hamilton M (1960) A rating scale for depression. J Neurol Neurosurg Psychiatry 23:56–62. https://doi.org/10.1136/jnnp.23.1.56
Alhadi AN, Alarabi MA, Alshomrani AT, Shuqdar RM, Alsuwaidan MT, McIntyre RS (2018) Arabic translation, validation and cultural adaptation of the 7-item Hamilton depression rating scale in two community samples. Sultan Qaboos Univ Med J 18(2):289:e167-e172
Young RC, Biggs JT, Ziegler VE, Meyer DA (1978) A rating scale for mania: reliability, validity and sensitivity. Br J Psychiatry 133(5):429–435
Masi G, Berloffa S, Mucci M, Pfanner C, D’Acunto G, Lenzi F, Milone A (2018) A naturalistic exploratory study of obsessive-compulsive bipolar comorbidity in youth. J Affect Disord 231:21–26
Ferentinos P, Preti A, Veroniki A, Pitsalidis KG, Theofilidis AT, Antoniou A, Fountoulakis KN (2020) Comorbidity of obsessive-compulsive disorder in bipolar spectrum disorders: systematic review and meta-analysis of its prevalence. J Affect Disord 263:193–208
Amerio A, Odone A, Liapis CC, Ghaemi SN (2014) Diagnostic validity of comorbid bipolar disorder and obsessive-compulsive disorder: a systematic review. Acta Psychiatr Scand 129(5):343–358
Carta MG, Fineberg N, Moro MF, Preti A, Romano F, Balestrieri M, Caraci F, Dell’Osso L, Disciascio G, Drago F, Hardoy MC, Roncone R, Minerba L, Faravelli C, Angst J (2020) The burden of comorbidity between bipolar spectrum and obsessive-compulsive disorder in an Italian community survey frontier psychiatry. Sec Mood Disord 11. https://doi.org/10.3389/fpsyt.2020.00188
Merikangas KR, Akiskal HS, Angst J et al (2007) Lifetime and 12-month prevalence of bipolar spectrum disorder in the national comorbidity survey replication. Arch Gen Psychiatry 64(5):543–552. https://doi.org/10.1001/archpsyc.64.5.543
Koyuncu A, Tükel R, Özyıldırım I, Meteris H, Yazıcı O (2010) Impact of obsessive-compulsive disorder comorbidity on the socio-demographic and clinical features of patients with bipolar disorder. Compr Psychiatry 51(3):0–297
Saunders EFH, Fitzgerald KD, Zhang P, Melvin G, McInnis MG (2012) Clinical Features of Bipolar Disorder comorbid with anxiety disorders differ between men and women. Special products. All Wiley Journals FF. Wiley Online Library. https://doi.org/10.1002/da.21932. Citations: 39
Pashinian A, Faragian S, Levi A, Yeghiyan M, Gasparyan K, Weizman R, Weizman A, Fuchs C, Poyurovsky M (2006) Obsessive–compulsive disorder in bipolar disorder patients with first manic episode. J Affect Disord 94(1–3):151–156
Keck PE Jr, McElRoy SL, Strakowski SM, West SA, Hawkins JM, Huber TJ, Mark NR, Michael D (1995) Outcome and comorbidity in first- compared with multiple-episode mania. J Nerv Ment Dis 183(5):320–324
Amerio A, Tonna M, Odone A, Stubbs B, Ghaemi SN (2016) Course of illness in comorbid bipolar disorder and obsessive–compulsive disorder patients. Asian J Psychiatr 20:12–14
Shashidhara M, Sushma BR, Viswanath B, Math SB, Reddy YJ (2015) Comorbid obsessive-compulsive disorder in patients with bipolar-I disorder. J Affect Disord 174:367–371
Chen YW, Dilsaver SC (1995) Comorbidity for obsessive-compulsive disorder in bipolar and unipolar disorders. Psychiatry Res 59(1–2, 29):57-64§
Carter TDC, EmanuelaMundo E, Parikh SV, James L, Kennedy JL (2003) Early age at onset as a risk factor for poor outcome of bipolar disorder. J Psychiatr Res 37(4):297–303
Egeland JA, Blumenthal RL, Nee J, Sharpe L, Jean Endicott J (1987) Reliability and relationship of various ages of onset criteria for major affective disorder. J Affect Disord 12(2):159–165
We appreciate everyone who took part in the study for their time and great cooperation.
Ethics approval and consent to participate
The plan was approved in June 2021 by the Scientific Committee of Kasr Al-Ainy’s Department of Psychiatry. Then, in January 2022 (Registration number: MS-545-2021) the Ethical Committee of Cairo University accepted this research. The participants received a clear explanation of the study.
Consent for publication
Consent from the research participants was obtained for publication.
The authors declare that they have no conflict of interest.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Ezzat, M., Younis, M.A., Khalil, M.A. et al. Obsessions and suicidality in youth suffering from bipolar I disorder. Middle East Curr Psychiatry 30, 82 (2023). https://doi.org/10.1186/s43045-023-00354-w