Burton J. Tabaac, MD
@burtontabaac
The World Health Organization has categorized obsessive compulsive disorder (OCD) as one of the top ten disabling conditions worldwide, noting a lifetime prevalence of 1-3%. The authors of this comprehensive study cite mounting evidence supporting an association between OCD and stroke-related risk factors inclusive of obesity and diabetes. Using data collected between 2001 and 2010 by Taiwan’s National Health Insurance Research Database, it was demonstrated that patients with OCD have an elevated risk of suffering an acute ischemic stroke compared to non-OCD controls, with no difference in hazard ratio for hemorrhagic stroke.
Obsessive compulsive disorder secondary to cerebral infarction has been reported in the medical literature, yet the relationship between OCD and subsequent stroke has been minimally investigated. This study included patients aged 20 years and older diagnosed with OCD by psychiatrist expertise between January 2001 and December 2010, and who had no history of stroke prior to enrollment. In a follow up analysis (up to 11 years), the use of OCD medications was assessed, with study cohorts separated into subgroups: nonusers, short-term users (1 month to 1 year), and long-term users (more than 1 year). Medication use included SSRIs, SNRIs, and norepinephrine-dopamine reuptake inhibitors, e.g., bupropion.
Results underscored by the authors are as follows: Patients with OCD have an increased incidence of acute ischemic stroke, but not hemorrhagic stroke, compared with the non-OCD controls (see Figure below for graphical representation). The article further highlights that midlife adults and the elderly demonstrate a more profound elevated risk of developing ischemic stroke during the follow-up period (HR 2.66 and 3.46 respectively). In patients with OCD, both short- and long-term use of OCD medications were not correlated with ischemic or hemorrhagic stroke compared with nonuse.
A corroborating study cited in the paper revealed that patients with OCD are 45% more likely to have at least one metabolic or cardiovascular complication compared with non-OCD controls.1 The authors eloquently propose a myriad of potential pathophysiologic mechanisms to explain the association between OCD and ischemic stroke. One postulation is that the presence of psychiatric comorbidities, especially schizophrenia, bipolar disorder, and major depressive disorder, in patients with OCD have been reported to be associated with stroke risk. The comorbidities of severe mental health disorders further increase the likelihood of stroke-related risk factors, including obesity, smoking, and metabolic disorders. A second association posited that OCD is a systemic inflammatory disease, with systemic inflammation and elevated levels of C-reactive protein and interleukin-6 contributing to the increased risk of cerebrovascular disease.
Limitations of this study relate to the nature of registry-based analysis; the incidence of stroke may be underestimated as only subjects who seek medical attention are identified by the database. A separate but astute critique of the study is that the paper emphasizes the strong unidirectional association between OCD and subsequent ischemic stroke, but no causal relationship was able to be established. The authors conclude that OCD is an independent risk factor for ischemic stroke after adjusting for stroke-related comorbidities, including metabolic disorders, and other severe mental diseases. The pathophysiologic mechanism between OCD and increasing risk for ischemic stroke warrants additional investigation.
References:
1. Isomura K, Brander G, Chang Z, Kuja-Halkola R, Ruck C, Hellner C, Lichtenstein P, Larsson H, Mataix-Cols D, Fernandez de la Cruz L. Metabolic and cardiovascular complications in obsessive-compulsive disorder: A total population, sibling comparison study with long-term follow-up. Biological psychiatry. 2018;84:324-331.
