Treatment of anxiety disorders in patients with comorbid bipolar disorder

Valproate Adjuvant Cognitive Behavioral Therapy in Panic Disorder Patients With Comorbid Bipolar Disorder: Case Series and Review of the Literature

Anxiety disorders are the most common comorbid psychiatric disorders in patients with bipolar disorder. Managing anxiety symptoms in comorbid conditions is challenging and has received little research interest. The findings from preclinical research on fear conditioning, an animal model of anxiety disorder, have suggested that memory reconsolidation updating (exposure-based therapy) combined with valproate might facilitate the amelioration of fear memories. Here, three cases of successful amelioration of agoraphobia and panic symptoms through valproate adjuvant therapy for cognitive behavioral therapy in patients who failed to respond to two to three consecutive standard pharmacotherapy trials over several years are described. To the best of the author's knowledge, this is the first attempt to combine CBT with valproate in patients with panic disorder, agoraphobia, and comorbid bipolar disorder. Additionally, the background preclinical research on this combination therapy based on the reconsolidation-updating mechanism, the inhibition of histone deacetylase 2, and critical period reopening, off-label use of valproate in panic disorder, plasticity-augmented psychotherapy, and how to combine valproate with CBT is discussed.

Characterization of depressed bipolar patients with current suicidal ideation

OBJECTIVE

Bipolar disorder is one of the most frequent psychiatric disorders among suicidal patients. A large part of patients with bipolar disorder (30-50%) will attempt suicide. Suicidal ideation being a major risk factor of suicidal act, it is crucial to better characterize patients with suicidal bipolar depression (i.e. depression with current suicidal ideation). The aim of this study was to characterize suicidal bipolar depressed patients in comparison with non-suicidal depressed patients in terms of clinical characteristics, evolution of depression and suicidal ideation course over time, and risk of suicide attempt during follow-up.

METHODS

Among patients with bipolar disorder recruited from the network of FondaMental expert centres for bipolar disorder between 2009 and 2017, we selected patients with at least mild depression (Montgomery-Åsberg Depression Rating Scale total score >11) and without current manic symptomatology (Young Mania Rating Scale total score <7) at baseline (N = 938). Suicidal depression was defined by a baseline score ⩾2 for item 12 of the Quick Inventory of Depressive Symptomatology-Self Report (N = 271, 28.9%). Non-suicidal depression was defined by a baseline item 12 of the Quick Inventory of Depressive Symptomatology-Self Report score <2 (N = 667, 71.1%). A subsample of about 300 patients (with or without suicidal ideation at baseline) was followed up for 2 years.

RESULTS

Baseline clinical features (e.g. depression severity, childhood trauma, global functioning) were more severe in patients with than without suicidal depression. Suicidal patients tended to remain more suicidal throughout the follow-up than patients without suicidal ideation at baseline (3.4-fold higher risk of persistent suicidal ideation at the 2-year visit despite an improvement in depressive symptomatology).

CONCLUSIONS

Depressed bipolar disorder patients reporting suicidal ideation had more severe clinical features at baseline and were more prone to report persistent suicidal ideation during the follow-up, independently of thymic state. Clinicians should closely monitor this subgroup of patients.

Effects of psychological and pharmacological interventions on anxiety symptoms in patients with bipolar disorder in full or partial remission: A systematic review

BACKGROUND

Anxiety symptoms are prevalent in bipolar disorder (BD) even during periods of remission and impede treatment efficacy, prognosis and functional capacity. This highlights a pressing clinical need to identify novel effective anxiety treatments. This systematic review aimed to evaluate the evidence within the field.

METHODS

Following PRISMA guidelines, we conducted a systematic search on PubMed, PsycInfo, EMBASE and Cochrane Library for randomised controlled trials (RCTs) targeting anxiety in remitted BD patients.

RESULTS

We identified 10 RCTs investigating the effects of psychological or pharmacological treatments on anxiety in remitted BD patients. Two studies of transdiagnostic personalised cognitive behavioural therapy (CBT) found a treatment-related reduction in anxiety. This evidence was preliminary given small sample size and use of self-report measures in a single-blind trial design, respectively. The remaining six psychological intervention trials provided more preliminary evidence due to several methodological challenges. The two pharmacological studies found anxiolytic effects of add-on olanzapine or methylene blue to lithium treatment, respectively. Nevertheless, this evidence should be interpreted with caution given high drop-out rates and substantial side-effects that may have impeded blinding.

LIMITATIONS

We did not conduct a quantitative meta-analysis.

CONCLUSIONS

There is preliminary evidence for beneficial effects of modified CBT and add-on pharmacotherapy on residual anxiety in BD. Future trials should pre-screen participants for anxiety, define one clinician-rated anxiety measurement as a primary outcome, and employ intention-to-treat analysis to assess treatment effect. This will advance treatment development and enable personalised approaches to address residual anxiety in BD, which has great clinical relevance.

The prevalence of anxiety and its association with the quality of life and illness severity among bipolar affective disorder patients in a developing country

The objective of the study was to determine the prevalence of anxiety symptoms and describe the association with illness severity, quality of life (QOL) and current medications among patients with BPAD who are currently in remission. A descriptive cross-sectional study conducted among outpatient clinic patients at the University Professorial Unit of University of Ruhuna, Sri Lanka. The study population consisted of patients diagnosed with BPAD and who are currently in remission. Anxiety symptoms among BPAD patients were assessed using the DASS-21 anxiety subscale and QOL was assessed using WHOQoL-BREF. Medications and severity of illness related information were gathered from both the patent and from their medical records. The study population consisted of 145 patients. The prevalence of anxiety among patients with BPAD who are currently in remission was 48.3 % (95 %CI 40.0-56.6). Multiple logistic regression revealed that being anxious was independently associated with currently not being married (aOR 2.92) and currently not being employed (aOR 2.1). Presence of anxiety significantly reduced the QOL in all the domains. Having anxiety was significantly associated with having one or more relapses within the past three years (aOR 4.1), one or more hospital admissions within the past three years (aOR 6.1), needing more psychoactive medications to maintain a euthymic state (aOR 7.7), and one or more suicidal attempts in the past (aOR 6.5). Anxiety was highly prevalent among patients with BPAD. Those with anxiety experienced significantly lower QOL and were found to be having significantly high adverse outcomes from the disease.