Bipolar disorder does not occur in isolation but instead is associated with numerous co-occurring conditions that strongly impact the course of the illness, including risk of relapse and even suicidal behavior, and functional outcomes. Anxiety, impulsivity and substance use occur in the majority of patients with bipolar disorder and do not necessarily resolve when mood symptoms improve. The issue of comorbidity between bipolar anxiety, impulse control, substance use and personality disorders is very complex and prone to different pathogenetic interpretations. It is likely that the affective dysregulation of bipolar disorder extends beyond elation and depression to include, among others, such negative affective arousal states as anxiety, panic, irritability, impulsivity and mood lability.
The identification of differential patterns of comorbidity may provide important information in distinguishing more homogeneous clinical subtypes of affective disorders from the genetic and therapeutic point of view. As concern treatment perspective, anxiety disorders are highly prevalent in bipolar disorder and confer poor outcomes. Treatment challenges, particularly the use of antidepressants in this population, will be highlighted. Lithium and atypical antipsychotics seems to be not effective in controlling panic anxiety. On the contrary, Valproate seems to provide benefit in treating both mood instability and anxiety in patients with co-morbid bipolar and panic disorder. Bipolar disorder is associated with the highest rates of substance use disorders of any Axis I illness. However, until recently minimal research has focused on the treatment of this important subgroup and patients with substance use are still generally excluded from bipolar disorder clinical trials. Recent placebo-controlled clinical trials in patients with bipolar disorder and comorbid alcohol and substance abuse indicate a possible efficacy of valproate. In conclusion, in patients with bipolar disorder psychiatric comorbidity, other than clinical presentation and course of the illness, strongly influences treatment response to different mood stabilizers.
This post was submitted by Dr Giulio Perugi.
