OCD and Bipolar Disorder: What Is the Connection? Comorbidity, Diagnosis, Medication, and Treatment
Obsessive-compulsive disorder (OCD) and bipolar disorder can occur in the same person. When they do, the central clinical problem is not simply the presence of two diagnostic labels. Obsessions and compulsions may change across depressive, hypomanic, manic, mixed, and euthymic periods, while medications that are standard for OCD can affect mood stability in bipolar disorder. The most useful assessment therefore follows symptoms over time and treats current mood state as part of the OCD treatment decision. For a direct comparison of obsessions, mood episodes, repetition, sleep, and insight, see OCD vs Bipolar Disorder: What Is the Difference?.
The best-supported overall principle is to establish or protect mood stability first, then treat persistent OCD with an approach matched to the person's phase of bipolar illness. The 2025 CANMAT–ICOCS international OCD guideline specifically addresses bipolar comorbidity, and bipolar guidelines likewise emphasize the risk of treatment-emergent mood switching with antidepressants. Current OCD guidance and the CANMAT/ISBD bipolar guidance support a coordinated strategy rather than an automatic application of the usual OCD medication sequence.
Can You Have OCD and Bipolar Disorder at the Same Time?
Yes. A person can meet diagnostic criteria for both OCD and bipolar disorder. The diagnoses describe different symptom domains: OCD centers on obsessions, compulsions, or both, while bipolar disorders are defined by episodes involving marked changes in mood, energy, activity, and associated behavior. A diagnosis of one does not exclude the other.
At the same time, the apparent overlap is clinically complicated. Some people have enduring OCD that remains recognizable between mood episodes. In others, obsessive-compulsive symptoms are strongly tied to depressive or elevated mood states. A large updated systematic review found that obsessive-compulsive symptoms in bipolar disorder often follow an episodic course and may worsen during depression while improving during mania or hypomania. The authors also stressed that the nature of the relationship remains scientifically unsettled rather than proving that every case represents two fully independent disorders. The 2024 updated systematic review is especially useful for understanding this longitudinal question.
What OCD Means in This Context
OCD involves recurrent intrusive thoughts, urges, or mental images that are experienced as unwanted or difficult to control, and/or repetitive behaviors or mental acts performed in response to distress, feared consequences, or a felt need for certainty or completeness. Compulsions can be visible, such as checking or washing, or mental, such as reviewing, counting, neutralizing, praying, comparing, or repeatedly trying to become certain.
The presence of intrusive thoughts alone does not establish OCD. Diagnosis depends on the broader pattern: the relationship between obsessions and compulsions, time consumption, distress or impairment, and whether the symptoms are better explained by another condition or substance. The National Institute of Mental Health overview of OCD summarizes the core syndrome and its established treatments.
What Bipolar Disorder Means in This Context
Bipolar disorder involves distinct mood episodes characterized by changes in mood together with changes in energy, activity, sleep, thinking, and behavior. Mania can include unusually elevated or irritable mood, markedly increased activity or energy, reduced need for sleep, faster speech and thought, inflated self-confidence or grandiosity, distractibility, and impulsive or risky behavior. Hypomania involves a similar change but is less severe than mania and does not by itself produce the same degree of marked impairment or need for hospitalization. Bipolar depression includes a depressive episode in a person with a bipolar course.
The longitudinal history matters because a person may seek care during depression and not recognize earlier hypomania. The NIMH bipolar disorder resource emphasizes that diagnosis is based on severity, duration, frequency, and lifetime course, not on a single mood snapshot.
How Common Is OCD in Bipolar Disorder?
Estimates vary substantially across studies because samples, diagnostic methods, bipolar subtypes, age groups, and whether participants are currently symptomatic all differ. A systematic review and meta-analysis of bipolar-spectrum samples estimated lifetime OCD prevalence at about 10.9% and cross-sectional prevalence at about 11.2%. The confidence intervals were broad enough to reinforce that these figures are population estimates, not an individual prediction. The prevalence meta-analysis also found substantial heterogeneity across the literature.
Older clinical reviews and guidelines have often quoted higher ranges, including approximately 10% to 20%. The more useful conclusion is that OCD occurs often enough in bipolar populations to require routine attention, while there is no single prevalence percentage that applies to every setting.
Why the Combination Can Be Hard to Diagnose
The diagnostic challenge comes from overlapping surface features that may arise from different processes. Repetitive thinking can be an obsession, depressive rumination, anxious worry, racing thought, perseveration, or a mood-congruent preoccupation. Repetitive behavior can be a compulsion, ordinary habit, agitation, goal-directed overactivity, or behavior driven by mania. Correct classification depends on what the thought or behavior means to the person, what triggers it, what function it serves, and how it changes across mood states.
Obsessions Versus Racing Thoughts
Obsessions are typically recurrent and intrusive and are often accompanied by distress, doubt, disgust, guilt, fear, or a need to neutralize uncertainty. Racing thoughts in hypomania or mania are more often part of an accelerated stream of ideas occurring with increased energy, decreased need for sleep, rapid speech, distractibility, and other signs of an elevated or irritable mood episode. A person can experience both, so clinicians look for the complete syndrome rather than classifying a thought only by its speed or repetitiveness.
Compulsions Versus Manic Goal-Directed Activity
A compulsion is performed according to an internal rule or urge, commonly to reduce distress, prevent a feared outcome, obtain certainty, or correct a not-right feeling. Manic goal-directed activity is usually embedded in a broader episode of increased energy and drive. Spending hours checking a door because of feared responsibility has a different functional pattern from staying awake all night launching multiple projects during an episode of expansive mood, even though both behaviors may look repetitive from the outside.
Intrusive Thoughts Versus Grandiose or Psychotic Beliefs
OCD can include disturbing intrusive thoughts and, in some people, limited insight about the reasonableness of obsessive fears. Mania can also include grandiosity and, when severe, psychotic symptoms. The key questions include whether the thought is experienced as intrusive and unwanted, whether compulsions are used to manage it, whether it rises and falls with a mood episode, and whether there are broader features of mania or psychosis. Insight alone is therefore not a sufficient differential marker.
Obsessions Versus Depressive Rumination
Depressive rumination commonly circles around loss, worthlessness, failure, hopelessness, or past events. OCD may also involve guilt, responsibility, morality, memory, or fear of harm, which can sound similar in conversation. OCD becomes more likely when the thinking has an intrusive obsessional quality and is linked to neutralizing, checking, reassurance seeking, reviewing, avoidance, or other compulsions. Both processes can coexist and can intensify one another during bipolar depression.
The Most Important Diagnostic Tool Is the Timeline
A careful assessment maps obsessive-compulsive symptoms and mood episodes on the same timeline. Clinicians ask when obsessions first appeared, when compulsions began, whether they continue during euthymia, what happens to them during depression, whether they diminish or change during hypomania or mania, and whether medication changes preceded a mood shift. This approach is especially important because the updated systematic review found frequent mood-related fluctuation in obsessive-compulsive symptoms.
A timeline also reduces the risk of diagnosing bipolar disorder from ordinary emotional variation or diagnosing OCD from any repetitive thought. Bipolar diagnosis requires a syndromal pattern of mood and energy change. OCD diagnosis requires a syndromal pattern of obsessions and/or compulsions with clinically meaningful burden. Screening questionnaires can help organize symptoms, but a score is not a diagnosis and cannot establish the relationship between two disorders.
Does OCD Usually Get Worse During Bipolar Depression?
Often, but not universally. Across the literature, obsessive-compulsive symptoms have frequently been reported as more severe during depressive episodes and less prominent during manic or hypomanic periods. The 2024 systematic review reported this pattern across a substantial share of the studies it synthesized. That finding describes a group-level tendency and should not be turned into a rule for an individual patient. Some people have persistent OCD across mood states, and others have a different pattern.
This matters clinically because an apparent surge in OCD during bipolar depression may partly improve as the mood episode is treated. Persistent obsessions and compulsions during a stable mood period provide stronger evidence that OCD itself needs targeted intervention rather than being approached only as a feature of the current mood episode.
Does OCD Get Better During Mania or Hypomania?
Some studies report improvement or temporary remission of obsessive-compulsive symptoms during elevated mood states, but improvement in OCD during mania is not recovery. Mania can produce severe impairment, unsafe decisions, psychosis, hospitalization, relationship disruption, financial harm, and medical risk. Any reduction in compulsions during mania therefore has no therapeutic meaning by itself. The active mood episode requires treatment on its own terms.
What Is the Clinical Impact of Having Both Disorders?
Recent evidence suggests that the combination is associated with a more complicated clinical course. A 2025 systematic review and meta-analysis comparing bipolar disorder with and without OCD found higher odds of chronic mood episodes, rapid cycling, panic disorder, eating disorders, substance use disorders, and lifetime suicide attempts, together with earlier bipolar onset and poorer functioning in the comorbid group. The meta-analysis included 26 studies qualitatively and 22 in quantitative synthesis.
These associations do not prove that OCD causes a more severe bipolar course or that every person with both diagnoses will experience these outcomes. They do justify more deliberate assessment of mood cycling, substance use, functioning, treatment adherence, and suicide risk when both conditions are present.
Suicide Risk Requires Direct Assessment
Both bipolar disorder and OCD can be associated with suicidal thoughts or behavior, and the 2025 meta-analysis found a higher prevalence of lifetime suicide attempts in adults with bipolar disorder plus OCD than in bipolar disorder alone. That is a population-level association, not a prediction of what one person will do. Clinical assessment should distinguish intrusive self-harm obsessions from suicidal intent while also recognizing that the two can coexist.
An intrusive fear such as ‘What if I lose control and hurt myself?’ can function as an OCD obsession, especially when it leads to avoidance, checking, reassurance seeking, or mental neutralizing. Suicidal thinking linked to hopelessness, desire to die, planning, preparation, or intent requires a different and urgent response. If there is imminent danger, inability to stay safe, severe mania, psychosis, or rapidly escalating suicidal intent, emergency evaluation should not be delayed.
How Is OCD With Bipolar Disorder Treated?
Treatment is usually organized around one principle: stabilize the bipolar illness and then target clinically significant OCD that remains. The reason is pharmacological as well as diagnostic. Serotonin reuptake inhibitors are established treatments for OCD, but antidepressants can precipitate mania, hypomania, mixed symptoms, or mood destabilization in susceptible people with bipolar disorder. The risk changes the order and monitoring of treatment decisions.
The newest CANMAT–ICOCS international OCD guideline recommends mood stabilization as a foundational goal in bipolar-OCD comorbidity. The earlier CANMAT/ISBD bipolar guideline likewise notes that OCD symptoms may improve with effective bipolar treatment and that antidepressants, when used, require attention to antimanic protection and switch risk.
Treatment During Mania or a Mixed State
During an acute manic or mixed presentation, the immediate treatment target is the mood episode. Trying to intensify antidepressant treatment for OCD while mania is active can work against that goal. Current bipolar guidance prioritizes evidence-based treatment for mania or mixed states, and antidepressant use is generally approached with particular caution when there are signs of mood elevation or mixed features.
OCD-specific psychotherapy may also need to be timed realistically. A person who is severely sleep-deprived, psychotic, highly agitated, unable to sustain attention, or making dangerous decisions may not be able to engage effectively in structured exposure work. Once the acute episode is controlled, clinicians can reassess which obsessions and compulsions remain and what level of OCD treatment is still needed.
Treatment During Bipolar Depression
Bipolar depression creates a different problem because OCD symptoms may become more prominent at the same time that the person is depressed. Standard unipolar-depression logic cannot simply be imported. The 2023 CANMAT/ISBD evidence update summarizes bipolar-depression treatments and notes that antidepressants, when considered, are adjunctive options for selected patients rather than universal monotherapy.
If obsessive-compulsive symptoms rise during depression, treatment planning asks two questions at once: what is the best evidence-based treatment for the bipolar depressive episode, and which OCD symptoms persist beyond mood-state improvement? This sequencing can prevent an escalating antidepressant strategy from being driven by symptoms that may partly track the mood episode.
Treatment When Mood Is Stable but OCD Persists
Persistent OCD during euthymia is the clearest setting for targeted OCD treatment. Psychological treatment can be especially valuable because it does not carry antidepressant switch risk. Exposure and response prevention (ERP) is a core evidence-based behavioral treatment for OCD. It helps a person approach obsession-triggering situations or internal experiences while reducing rituals, reassurance, avoidance, checking, neutralizing, and other compulsive responses.
Broader cognitive behavioral therapy for OCD can include ERP alongside cognitive and behavioral strategies. In bipolar-OCD comorbidity, therapy planning still considers current sleep, energy, concentration, impulsivity, and mood stability so that exposures are deliberate therapeutic exercises rather than behavior occurring in an unstable mood state.
Is ERP Safe for Someone With Bipolar Disorder?
A bipolar diagnosis does not by itself exclude ERP. The clinically relevant question is whether the person is sufficiently stable to participate in structured treatment and whether the exposure plan is appropriate to the obsessional problem. Direct randomized evidence specifically for ERP in bipolar-OCD populations is limited, so clinicians largely combine the strong general OCD evidence for ERP with bipolar-specific monitoring and phase-sensitive judgment.
ERP should target compulsions and avoidance rather than sleep deprivation, reckless activity, medication changes, or other behaviors that could destabilize bipolar illness. When a mood episode is active, treatment may need to prioritize stabilization before intensive exposure work.
Why OCD Medication Is More Complicated in Bipolar Disorder
For OCD without bipolar disorder, SSRIs and the serotonin reuptake inhibitor clomipramine are established pharmacologic treatments. In bipolar disorder, the same serotonergic strategy introduces a clinically important problem: antidepressant treatment can be associated with a switch into hypomania or mania or with other forms of mood destabilization. The NIMH bipolar resource and bipolar treatment guidelines both caution against antidepressant monotherapy in bipolar illness.
The risk is not a reason to conclude that no person with bipolar disorder can ever receive an antidepressant for OCD. It means the decision belongs inside an individualized bipolar treatment plan with mood stabilization, selection of agent and dose, review of past antidepressant reactions, and active monitoring for emerging activation. People should not start, stop, increase, or abruptly discontinue psychiatric medication on the basis of an online article.
SSRIs
SSRIs are among the most effective medication classes for OCD in the general population. Bipolar-OCD comorbidity changes how they are introduced and monitored. The 2019 systematic treatment review found that the evidence base for the comorbid condition was small and heterogeneous and supported mood stabilization as the primary goal. The current CANMAT–ICOCS OCD guideline allows consideration of an SSRI for persistent OCD after mood stabilization rather than treating it as the automatic first step.
Because OCD often requires sustained serotonergic treatment and sometimes higher SSRI doses than depression, monitoring for activation is not a one-time task. New decreased need for sleep, unusual energy, pressured speech, escalating irritability, impulsive spending, grandiosity, rapidly increasing goal-directed behavior, or a marked departure from baseline warrants prompt clinical review.
Clomipramine
Clomipramine is an effective OCD medication but is also an antidepressant and therefore does not escape the bipolar switch problem. It has additional tolerability, cardiac, anticholinergic, interaction, and overdose considerations that can make prescribing more complex. Our detailed guide to clomipramine for OCD covers its general OCD evidence and safety profile; in bipolar-OCD comorbidity, those issues sit on top of the need to protect mood stability.
Mood Stabilizers
Mood stabilizers are used to treat bipolar disorder, not because they have a broadly established direct anti-obsessional effect comparable with standard OCD treatments. Their role in bipolar-OCD care is foundational: they treat and prevent mood episodes and may reduce obsessive-compulsive symptoms when those symptoms are tightly linked to the bipolar course. Medication choice depends on bipolar subtype, current phase, previous response, medical history, pregnancy considerations when relevant, interactions, and adverse-effect profile.
Antipsychotic Medications
Second-generation antipsychotics can have two very different roles in this clinical picture. Some are evidence-based treatments for bipolar mania, bipolar depression, or maintenance, depending on the agent. Separately, certain antipsychotics are used as augmentation in treatment-resistant OCD. These evidence bases should not be treated as interchangeable. A medication chosen to control mania is not automatically an OCD treatment, and an OCD augmentation study does not establish the best bipolar regimen.
The small bipolar-OCD literature includes signals for combinations involving second-generation antipsychotics, especially aripiprazole in older studies, but the evidence is limited and includes many case reports and small trials. The systematic treatment review explicitly describes this limitation. Our article on antipsychotic augmentation for OCD explains the broader OCD augmentation evidence and safety issues.
What About Lithium and OCD?
Lithium is a major treatment for bipolar disorder and can be highly important for mood stabilization and long-term relapse prevention. It is not a standard stand-alone treatment for primary OCD. In a person with both disorders, successful bipolar treatment with lithium may indirectly reduce obsessive-compulsive symptoms that track mood episodes, while persistent OCD may still require ERP or another OCD-specific strategy. The treatment target should therefore be explicit: mood stabilization and anti-obsessional treatment are related goals but not identical ones.
What Does the Evidence Say About Medication Combinations?
The evidence is much thinner than the confident lists of drug combinations found on many consumer pages. The 2019 systematic review identified only 15 eligible studies, and almost half were case reports. All included patients received mood stabilizers, alone or with second-generation antipsychotics, and evidence for adding antidepressants was sparse. That literature supports a treatment hierarchy and careful monitoring more strongly than it supports a single ‘best’ combination for everyone.
Newer guidelines preserve the same broad principle while integrating contemporary OCD and bipolar evidence: stabilize the bipolar disorder, reassess the obsessive-compulsive syndrome, use psychotherapy where appropriate, and consider serotonergic medication selectively when clinically necessary. This is one of the clearest areas where evidence quality should be stated openly rather than turning low-level signals into prescription rules.
How Clinicians Monitor for Antidepressant-Related Mood Switching
Monitoring is most useful when it is based on the person's own early warning signs. Before starting or changing an antidepressant, clinicians may document baseline sleep, energy, activity, irritability, speech rate, impulsivity, confidence, concentration, and usual daily rhythm. A previous antidepressant-associated hypomanic or manic episode, mixed features, rapid cycling, recent mania, or unstable sleep can materially affect risk assessment.
Follow-up then looks for change from baseline rather than waiting for a fully developed manic episode. Family members or trusted people may notice decreased sleep, unusual talkativeness, escalating plans, increased spending, irritability, or risk-taking before the person recognizes these changes. Monitoring does not replace clinical judgment, and medication decisions should remain with the treating clinician.
Can Bipolar Medication Make OCD Worse?
There is no single answer for the entire class of bipolar medications. Individual agents have different mechanisms and different psychiatric adverse-effect profiles. Some antipsychotic medications have been associated in parts of the literature with new or worsened obsessive-compulsive symptoms, while other antipsychotics have evidence as OCD augmentation agents. The effect depends on the specific drug, dose, indication, individual vulnerability, and concurrent treatment. A new onset or clear worsening of obsessions or compulsions after a medication change deserves review rather than automatic attribution to the underlying disorder.
Can OCD Medication Trigger Bipolar Disorder?
An antidepressant can precipitate mania or hypomania in a person with bipolar vulnerability, but that is not the same as saying that an OCD medication creates bipolar disorder from nothing. A treatment-emergent mood episode can reveal an underlying bipolar diathesis or occur in the context of an established bipolar diagnosis. Diagnostic interpretation requires the full history, timing, duration, and persistence of symptoms after medication changes.
The 2024 systematic review reported a high frequency of antidepressant-associated manic or hypomanic episodes in selected bipolar-OCD studies, but those figures come from a heterogeneous literature and should not be used as an individual's probability of switching. The clinically sound message is simpler: the risk is meaningful enough to change prescribing and monitoring practice.
What a Comprehensive Assessment Should Include
A strong evaluation covers lifetime mood history; current and past obsessions and compulsions; age at onset of each symptom cluster; periods of euthymia; sleep and circadian change; family history of bipolar disorder and OCD; substance use; previous psychiatric medications; any activation or switching after antidepressants; psychotic symptoms; suicide risk; medical conditions; and the functional effects on work, school, relationships, and self-care.
Collateral history can be particularly valuable when hypomanic periods felt productive or pleasant and were not recognized as symptoms. At the same time, clinicians should avoid treating every energetic period as hypomania. The threshold depends on a distinct change from baseline with the required associated symptoms, duration, and clinical context.
What Treatment Success Looks Like
Success is broader than reducing one symptom score. In bipolar-OCD comorbidity, treatment aims for sustained mood stability, fewer and less impairing obsessions and compulsions, reduced avoidance and reassurance seeking, more regular sleep, better functioning, lower relapse risk, and a treatment plan the person can realistically maintain. Improvement in one condition should not be purchased through destabilization of the other.
Because the course can change over time, a plan that was appropriate during acute bipolar depression may need revision once mood is stable. Likewise, an OCD intervention that works during euthymia may need temporary modification during a manic episode. Longitudinal care is therefore part of the treatment itself, not merely follow-up after treatment.
When to Seek Urgent Help
Urgent assessment is appropriate when there are signs of severe mania, rapidly escalating agitation, psychosis, inability to sleep for a prolonged period with increasing activation, dangerous impulsivity, inability to care for basic needs, medication toxicity, or suicidal intent or planning. If immediate safety is at risk, use local emergency services or an available crisis service in your country.
For non-emergency changes, contact the treating clinician promptly if a new medication or dose increase is followed by a clear decrease in need for sleep, unusual acceleration, grandiosity, markedly increased goal-directed activity, severe irritability, or other symptoms suggesting hypomania, mania, or a mixed state.
Frequently Asked Questions
Can someone have both OCD and bipolar disorder?
Yes. Both diagnoses can occur in the same person. The assessment should establish that each syndrome meets its own criteria and should examine how obsessive-compulsive symptoms relate to mood episodes over time.
Is OCD part of bipolar disorder?
OCD is a distinct diagnostic disorder. In some people with bipolar disorder, however, obsessive-compulsive symptoms are strongly mood-dependent, and researchers continue to study whether certain presentations represent independent comorbidity, a particular bipolar phenotype, or another longitudinal relationship. The evidence does not support one explanation for every patient.
Can bipolar disorder look like OCD?
Some features can look similar on the surface, especially repetitive thinking, agitation, checking-like behavior, or intense preoccupation. Function, subjective experience, associated symptoms, and course distinguish an obsession-compulsion cycle from mood-driven thought and behavior.
Can OCD look like bipolar disorder?
Severe anxiety, insomnia caused by obsessions, rapidly shifting distress, and intense intrusive thoughts can be mistaken for mood instability. Bipolar diagnosis requires a distinct episode involving mood together with characteristic changes in energy, activity, sleep, and other features. OCD distress by itself does not establish hypomania or mania.
Do OCD symptoms get worse during bipolar depression?
They often do in published studies, but individual courses vary. Some people have OCD that persists independently of mood state, while others show marked worsening during depressive episodes and improvement during elevated mood states.
Can SSRIs trigger mania in someone with OCD and bipolar disorder?
Yes, antidepressant-associated hypomania or mania is a recognized concern in bipolar disorder. That is why an SSRI for persistent OCD is generally considered within a mood-stabilized treatment plan and with monitoring rather than as routine antidepressant monotherapy.
Should a person with bipolar disorder stop an SSRI if they develop activation?
Medication changes should be made with the prescribing clinician whenever possible. New symptoms such as sharply reduced need for sleep, rapidly increasing energy, grandiosity, risky behavior, or severe agitation deserve prompt clinical contact. Severe or dangerous symptoms require urgent evaluation.
Is ERP better than medication when OCD and bipolar disorder occur together?
ERP has the advantage of not carrying antidepressant switch risk, so it can be particularly attractive when mood is stable. Direct comparative trials in bipolar-OCD populations are limited, however, and treatment choice depends on OCD severity, current mood phase, access to skilled ERP, previous treatment response, and the broader bipolar plan.
Does lithium treat OCD?
Lithium is an established bipolar treatment, not a standard primary OCD medication. It may reduce obsessive-compulsive symptoms when those symptoms improve with mood stabilization, while persistent OCD may still need ERP or another OCD-specific treatment.
Are antipsychotics used for OCD and bipolar disorder?
Yes, but for different reasons. Several antipsychotics are used to treat specific phases of bipolar disorder, and some also have evidence as augmentation for treatment-resistant OCD. The dose, agent, treatment target, evidence base, and monitoring requirements are not interchangeable.
Can both conditions be treated successfully?
Yes. Effective care is possible, but it usually requires a coordinated strategy that protects mood stability while directly treating persistent obsessions and compulsions. The treatment plan may change across mood phases and should be reviewed longitudinally.
The Bottom Line
OCD and bipolar disorder can coexist, and the combination deserves a treatment model built around time, mood state, and treatment interaction. The core diagnostic task is to determine which obsessive-compulsive symptoms persist independently, which fluctuate with mood episodes, and whether repetitive thoughts or behaviors are actually obsessions and compulsions. The core treatment task is to establish mood stability without leaving clinically significant OCD untreated.
Current guidelines and systematic reviews converge on a practical sequence: stabilize bipolar illness, reassess OCD across mood states, use ERP or CBT when appropriate, and consider serotonergic medication selectively with bipolar-specific safeguards and monitoring. This approach is more faithful to the evidence than either ignoring OCD because bipolar disorder is present or treating OCD with an ordinary antidepressant algorithm while overlooking mood-switch risk.