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Treating Bipolar Disorder with Comorbid Anxiety Disorders

The following treatment guidelines are meant as a reference tool, but are not intended as treatment advice or to replace the clinical decision-making process of psychiatrists or other health professionals who administer these treatments. In clinical practice there are often good reasons why treatment approaches differ from what is described here.

 

The majority of individuals with Bipolar Disorder also experience Anxiety Disorders, which increase their suffering and disability [ref]. However, there has not been much research dedicated to understanding how to treat Anxiety Disorders that co-occur with Bipolar Disorder. This poses some problems, because the SSRI antidepressants, which are the main class of medications used to treat Anxiety Disorders, can in some cases worsen the course of Bipolar Disorder; they should be avoided when manic symptoms are present, and should not be used for extended periods of time (see here for more information).

Current recommendations are to treat these cases with the standard treatments for Bipolar Disorder, with the idea that as the manic and depressive symptoms improve, so too will the anxiety symptoms [ref, ref]. Antidepressants should be used only in accordance with the guidelines for Bipolar Depression, and not added specifically for the anxiety symptoms.

Options for Treating Anxiety Disorders that will not Worsen Bipolar Disorder

Psychotherapy, especially Cognitive Behavioral Therapy (CBT), is well known for being very effective in treating all of the Anxiety Disorders. CBT can be combined with the standard treatments for Bipolar Disorder, though if the individual is in the midst of a severe mood episode (Manic, Depressive or Mixed) they may not be able to participate fully in the psychotherapy.

Quetiapine XR, which is a first-line treatment for Bipolar Disorder, has also been found to be effective for Generalized Anxiety Disorder [ref] as well as other anxiety symptoms occurring in Bipolar Disorder [ref], and should thus be considered for use early-on in these cases.

There is some evidence that combining either Lamotrigine or Olanzapine with Lithium can help to reduce anxiety symptoms in people whose Bipolar Disorder is stable and in remission, but who are experiencing an Anxiety Disorder [ref].

There is evidence that benzodiazepines are effective for treating Panic Disorder [ref], Social Phobia [ref] and Generalized Anxiety Disorder [ref], that Pregabalin may help to alleviate symptoms of Social Phobia [ref] and Generalized Anxiety Disorder [ref], and that Gabapentin may be useful for Social Phobia [ref] and Panic Disorder [ref]. None of these medications are particularly effective for treating Bipolar Disorder, but at least they are unlikely to worsen Bipolar Disorder by causing any mood instability.

A Treatment Approach for Anxiety Disorders in Bipolar Disorder

A common-sense approach to treating Anxiety Disorders occurring in individuals with Bipolar Disorder is to divide the cases into those where the Bipolar Disorder is active, and those where it is in remission:

If an individual is experiencing an Anxiety Disorder at the same time as they are enduring an active Bipolar mood episode (Hypomanic, Manic, Depressive or Mixed), it would make sense to focus mainly on treating the Bipolar episode with the expectation that the Anxiety Disorder would improve along with the Bipolar episode. In these cases, Quetiapine XR should be considered as a first option, especially when Generalized Anxiety Disorder is present.

If the Anxiety Disorder occurs at a time when there person is not having any active Bipolar episodes, then psychotherapy would be the preferred option. A combination of either Lamotrigine or Olanzapine with Lithium could also be considered.

In either situation, a long-acting benzodiazepine like Clonazepam or Diazepam could be added in cases of Panic Disorder, Social Phobia and Generalized Anxiety Disorder. Gabapentin could be used for Social Phobia and Panic Disorder, and Pregabalin could be tried for Social Phobia and Generalized Anxiety Disorder.

 

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