Zyprexa & OCD
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Q:  Zyprexa & OCD

Hello. Our 25 year old son takes 15 mg. zyprexa and 450 mg lithium for bipolar with psychosis. While the zyprexa has controlled the mania and psychosis, he has now developed OCD very badly. He might have had a slight tendency toward OCD earlier, but that's hard to say for sure. His psychiatrist does not believe that zyprexa can cause OCD and does not want to add an SSRI for treatment of OCD for fear of inducing mania again. He has been stable for a year, since this all began 4 years ago. Can you point me toward evidence that backing off the zyprexa can alleviate the OCD? Or would another antipsychotic like abilify be worth the try? Stuck with OCD and no treatment options from psychiatrist.

Dear George -
Unfortunately, the good news here for me it is bad news for you: I find myself agreeing with his psychiatrist.  But that is just the standard way of thinking.

A broader way of thinking is as follows: "medications are guilty until proven innocent", regarding nearly anything that happens after they are started. By this logic, even an increase in OCD symptoms has to be considered as possibly induced by Zyprexa.

The logic here is the same one we use when a very unusual side effect comes on right after a medication is started.  Even if that side effect has hardly ever been recorded in association with that medication, is the temporal association is very tight, the medications still has to be considered "probably guilty" until proven otherwise.

How does one do that?  Unfortunately, there is really only one way: you start to taper it downward and watch what happens to the problem. So for your son's case, the idea would be to gradually lower Zyprexa and watch what happens to the OCD symptoms (obviously).

Of course, the problem is that when Zyprexa is the mainstay medication for the prevention of the return of mania, such reductions will make everyone nervous -- or should.  Particularly if the mania was extreme, or dangerous.

Further, it is also possible that OCD symptoms are a manic manifestation and that they will actually get worse if Zyprexa is lowered.

Nevertheless, and here perhaps is the evidence you are asking me for, it is recognized that Zyprexa has an effect on serotonin.  The precise effect is not very clear.  It is plausible that in some particular cases -- probably rare, if at all -- the serotonin effect of Zyprexa would have a paradoxical impact, worsening OCD.

Good luck getting this figured out.  Be gentle with the psychiatrist.

Dr. Phelps

Published January, 2009


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