Pharmacologic treatment considerations in co-occurring bipolar and anxiety disorders

Background: Anxiety disorders are among the most commonly co-occurring psychiatric syndromes with bipolar disorder. The presence of co-occurring anxiety disorders has important prognostic and treatment implications. Method: Using the PaperChase database augmented by a manual search of the literature, we identified 122 publications that consisted of reports regarding pharmacologic agents used in the treatment of bipolar disorder also assessing the efficacy of these agents in anxiety disorders, treatment studies of patients with comorbid bipolar disorder and specific anxiety disorders, and studies of novel antiepileptic agents in the treatment of anxiety symptoms or disorders. Results: No randomized controlled trials have been conducted in patients with bipolar disorder and any co-occurring anxiety disorder. Among agents with antimanic or mood-stabilizing effects, evidence of efficacy from placebo-controlled trials exists for valproate in the treatment of panic disorder; lamotrigine, risperidone, and olanzapine in posttraumatic stress disorder; and risperidone, olanzapine, and quetiapine as adjunctive treatment in selective serotonin reuptake inhibitor-refractory obsessive-compulsive disorder. Antidepressants from virtually every class have efficacy in the treatment of most anxiety disorders but present the challenge of minimizing switch risk when used in conjunction with a moodstabilizer. Among novel antiepileptic agents without proven thymoleptic properties studied in randomized controlled trials in anxiety disorders, gabapentin and pregabalin had efficacy in the treatment of social anxiety disorder, and pregabalin in the treatment of generalized anxiety disorder. Conclusion: In the absence of controlled trials in patients with comorbid bipolar and anxiety disorders, the initial goals of treatment include mood stabilization and selection of thymoleptic agents with efficacy in the co-occurring anxiety disorder.