Older OCD patients at increased risk for ischemic stroke, but not hemorrhagic

Adult patients with obsessive-compulsive disorder (OCD) are at higher risk for new-onset ischemic stroke, but not hemorrhagic stroke, compared to patients without OCD, according to an analysis from Taiwan.

Evidence has mounted in recent years linking OCD to a number of metabolic disorders, including obesity and diabetes, Ya-Mei Bai, MD, PhD, of the Department of Psychiatry at Taipei Veterans General Hospital in Taipei, Taiwan, and colleagues wrote in Stroke. For example, a study by Albert et al assessing metabolic syndrome among OCD patients found high rates of abdominal obesity, hypertension, high triglycerides, and fasting hyperglycemia. Moreover, they added, OCD has been commonly reported following a cerebrovascular accident such as a stroke.

However, whether or not the reverse association also holds true—subsequent stroke following OCD diagnosis—has not been thoroughly investigated.

For their own analysis, Bai and colleagues pulled data from Taiwan’s National Health Insurance Research Database (NHIRD), to investigate the temporal association between OCD and stroke, hypothesizing that patients with OCD, especially elderly adults, would be at increased risk for new-onset stroke.

“[P]atients with OCD had an increased risk of developing new-onset ischemic stroke later in life compared with the non-OCD controls,” they found. “OCD was an independent risk factor for ischemic stroke after adjustment for stroke-related comorbidities, including metabolic disorders and other severe mental diseases. Clinicians should closely monitor cerebrovascular disease and related risks in patients with OCD.”

In light of these results, they added, the pathomechanism of OCD with an increased risk of ischemic stroke warrants additional investigation in future studies.

Bai and colleagues recruited patients who were 20 years of age or older with OCD diagnosed by a certified psychiatrist from Jan. 1, 2001 through Dec. 31, 2010 from Taiwan’s NHIRD—enrolled patients had no prior history of stroke before OCD diagnosis. After enrolling the OCD cohort, the age-, sex-, residence-, income-, and comorbidities-matched (1:1) control group was randomly selected. Follow-up was from the time of enrollment (defined as the time of OCD diagnosis) through Dec. 31, 2011 or until death. Diagnoses of ischemic and hemorrhagic stroke “made by board-certified neurologists, neurosurgeons, emergency room physicians, and internal medicine physicians” following brain imaging with computer tomography or magnetic resonance imaging were recorded during the follow-up period.

Data on all-cause clinical visits and Charlson Comorbidity Index (CCI) were collected to determine the systemic health conditions and health care usage in both cohorts, and the study authors also evaluated antidepressant use among OCD patients during follow-up; antidepressants included selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and norepinephrine-dopamine reuptake inhibitors.

The study cohort included 56,128 patients—28,064 patients each in the OCD and control groups—with an average age of 37 years. Participants were predominantly female (51.8%); age at enrollment was approximately 63 years for both groups.

“Patients with OCD had an increased incidence of new-onset ischemic stroke (0.29% versus 0.09%, P<0.001), but not hemorrhagic stroke (0.08% versus 0.05%, P=0.188), compared with the non-OCD controls,” the study authors found. “In addition, patients with OCD had higher CCI scores (P<0.001) and all-cause clinical visits (P<0.001) than the non-OCD controls.”

Cox regression analyses adjusting for demographic data, comorbidities, CCI scores, and all-cause clinical visits showed that patients with OCD (hazard ratio [HR] 3.02; 95% CI, 1.91-4.77)—particularly middle-aged (HR, 2.66; 95% CI, 1.34– 5.29) and elderly adults (HR, 3.46; 95% CI, 1.70–7.05)—had a higher risk of developing ischemic stroke during follow-up compared with the non-OCD controls. The HR for hemorrhagic stroke was identical between the two groups (HR, 0.87; 95% CI, 0.42-1.80).

Among patients with OCD, “both short-term use (HR, 1.69; 95% CI, 0.74–3.88; HR, 0.31; 95% CI, 0.05–1.95) and long-term use (HR, 1.37; 95% CI, 0.60–3.16; HR, 0.90; 95% CI, 0.22–3.76) of OCD medications were not related to the ischemic and hemorrhagic stroke compared with the nonuse,” they added. However, they also noted that the association between serotonin reuptake inhibitors and stroke risk is a controversial topic—for example, an analysis by Biffi et al found that patients taking serotonin reuptake inhibitors were at increased risk of cerebrovascular events, while another study by Douros et al found that the drugs were associated with a decreased rate of ischemic stroke.

“Further studies on the effect of antidepressants on the risk of cerebrocardiovascular disease, especially stroke, are warranted,” they wrote.

As for the temporal association between OCD and ischemic stroke, Bai and colleagues proposed several possible pathomechanisms that could explain the link:

  • The presence of psychiatric comorbidities, particularly schizophrenia, bipolar disorder, and major depressive disorder—as well as the stroke-related risk factors associated with these conditions, including obesity, smoking, and metabolic disorders—may increase stroke risk.
  • There is mounting evidence that OCD is a systemic inflammatory disease, and that systemic inflammation, including elevated levels of C-reactive protein (CRP) and interleukin-6 (IL-6) increases the risk of cerebrocardiovascular events later in life. “Sekeryapan Gediz et al reported a higher neutrophil-to-lymphocyte ratio and choroidal vascularity index, which are 2 biomarkers of systemic inflammation, in patients with OCD compared with healthy controls,” Bai and colleagues noted. “Turna et al revealed that CRP level was elevated in patients with OCD compared with controls and that CRP had a moderate to strong association with psychiatric symptomatology. The Reasons for Geographical and Racial Differences in Stroke study used a large sample size of 30,239 community-dwelling participants to determine that low high-sensitivity CRP (<2mg/L) is associated with a reduced risk of incident stroke and coronary heart disease.”

Study limitations included a potential underestimation of stroke incidence, as only those who sought medical attention would be identified in the database; data on disease severity, family history, and environmental factors were not available through the NHIRD; and the study could only identify a correlation between OCD and subsequent ischemic stroke, not a causal relationship.

  1. Adult patients with obsessive-compulsive disorder (OCD)—particularly middle-aged and elderly patients—are at higher risk for new-onset ischemic stroke, but not hemorrhagic stroke, compared to patients without OCD, according to an analysis from Taiwan.

  2. Note that this study established corrolation, not causation, and further studies are needed to establish the pathomechanism of OCD with an increased risk of ischemic stroke.

John McKenna, Associate Editor, BreakingMED™

The study authors had no relevant relationships to disclose.

Cat ID: 146

Topic ID: 87,146,730,8,38,192,146,925