The way to treat bipolar disorder anxiety is to treat bipolar disorder. Anxiety is a synonym for pain, and almost all mental illnesses cause pain, except for the classic euphoric mania that brings the patient to a carefree state of bliss.
Some mood episodes provoke more anxiety than others, with a mixed state at the top of the list. Anxiety does not appear in the criteria for mixed conditions, but it often occurs in the following cases: Depression and mania are mixed.1 The International Society for Bipolar Disorder has even calculated the exact ratio of this nasty recipe. To cause anxiety, you need one mania symptom during depression or two mania symptoms during mania.1
Mixed states tend to respond better to anticonvulsants and atypical antipsychotics than lithium. This may be the reason why anxiety predicts resistance to lithium. Bipolar disorder..2 However, there are two exceptions to this rule. Suicide and panic disorder.Both mixed states and anxiety increase the risk of suicide in bipolar disorder, lithium Reduce that risk to one-sixth..3 This protective effect is independent of the mood benefits of lithium, so it is worth considering lithium in suicidal-prone patients, even if it is unlikely to alleviate core symptoms.
Patients with classical lithium responsiveness tend to suffer from pure mania and hypomania and have no comorbidities of anxiety disorders, but recent studies have shown that panic disorder Predictor of lithium response..Four Although less anxious with pure mania and hypomania, these patients are highly alert to the threat that is the essence of panic disorder. One study found that panic phobia was more common than patients. Bipolar depression or mixed state..Five
The next step in treating a mixed condition is to reduce antidepressants and other things that contribute to the symptoms of mania (substance abuse, steroids, irregular circadian rhythms, etc.). Most patients in a mixed state have been taking antidepressants for a long time, and it can be difficult to determine if the drug exacerbates the mixed symptoms. Given these uncertainties, it is best to taper slowly. Over weeks or months..6 Rapid discontinuation can cause mania and other mood symptoms. This task is like tapering benzodiazepines. If symptoms worsen, increase the dose and slow down the taper.
Anxiolytic mood stabilizer
In bipolar disorder, anxiety is a non-specific symptom, Multiple causes, Mood episodes, stress, and coexisting anxiety disorders. Can we say that mood stabilizers are really anxiolytics because there are so many different causes? Probably not, there are several trials that may provide a path in choosing mood stabilizers for patients with significant anxiety.
Among the anticonvulsants, valproic acid and lamotridin Anxious bipolar disorder..7-9 The evidence for valproic acid here is stronger, and the drug also improved anxiety in patients without bipolar disorder, probably due to something like benzodiazepines. Gabber operability..10,11 Lamotrigin may also treat obsessive-compulsive disorder through glutamatergic effects, based on small placebo-controlled trials and several uncontrolled trials.12
Atypical antipsychotics can also improve anxiety. Quetiapine and olanzapine reduced anxiety in a large randomized placebo-controlled trial in patients with bipolar depression and nonspecific anxiety (both were secondary analyzes). The effect size was large enough to stand out to casual observers (0.35 for olanzapine, 0.56 for quetiapine).13,14 Quetiapine showed similar anxiolytic effects at doses of 300 mg and 600 mg, and olanzapine showed similar anxiolytic effects when combined with monotherapy or fluoxetine.
The properties of these anxiolytics appear to be inferior to other atypical antipsychotics. Both ziprasidone and risperidone failed a placebo-controlled trial of bipolar disorder with anxiety, and risperidone actually exacerbated anxiety in studies of bipolar disorder with coexisting bipolar disorder.7
The unanswered question here is whether these drugs directly targeted anxiety or treated mild mixed conditions.Most patients show 1-2 manic symptoms with depression, judging by the average Young Mania Rating Scale 5, and anxiety Manic symptoms went up..13,14 Quetiapine, on the other hand, has shown a large effect size in generalized anxiety disorder (GAD). More direct effect.15 Quetiapine approached FDA approval in the GAD, but was withheld because the FDA did not consider the disorder serious enough to justify all the risks of antipsychotics. The lesson also applies to bipolar disorder. Quetiapine may be very effective in anxiety, but it should not be used in mild cases.
Anxiety may not provide a direct path to medication for bipolar disorder, but it tells us something about patient care. These patients are at increased risk of withdrawal of treatment, side effects of medication, substance abuse, and suicide. In these cases, supportive psychotherapy, fast-acting treatments, and additional phone calls to make sure you can tolerate new medications can be of great help.
Dr. Aiken Mood Disorders Section Editor Age of psychiatryTM,Editor-in-chief Carla Psychiatry Report, Director of the Mood Treatment Center.He has written several books on mood disorders, but these days Workbook on depression and bipolar disorder. The author does not accept rewards from pharmaceutical companies, but receives royalties from PESI. Workbook on depression and bipolar disorder From WW Norton and Companyr Bipolar, not so many.
1. Swann AC, Lafer B, Perugi G, etc. Bipolar mixed state: Report of symptom structure, disease course, and diagnosis by the International Community Task Force for Bipolar Disorder. J is a psychic medicine. 2013; 170 (1): 31-42.
2. Swann AC, Sekunda SK, Katz MM, etc. Lithium treatment for mania: clinical features, symptom change specificity, and outcome. Psychiatric resolution. 1986; 18 (2): 127-141.
3. Tondo L, Baldessarini RJ. Suicidal behavior in mood disorders: response to pharmacological treatment. Curr Psychiatry Rep. 2016; 18 (9): 88.
4. Nunes A, Ardau R, Berghöfer A, etc. Prediction of lithium reaction using clinical data. Acta Psychiatr Scand. 2020; 141 (2): 131-141.
5. Simon NM, Otto MW, Fischmann D, etc. Panic Disorder and Bipolar Disorder: Anxiety susceptibility as a potential mediator of panic during mania. J Emotional discord. 2005; 87 (1): 101-105.
6. Phelps J, Manipod V. Treatment of Anxiety by Discontinuing Antidepressants: Case Series. Med hypothesis. 2012; 79 (3): 338-341.
7. Rakofsky JJ, Dunlop BW Treatment of nonspecific anxiety and anxiety disorders in patients with bipolar disorder: Review. J Clean Psychiatry. 2011; 72 (1): 81-90.
8. Davis LL, Bartolucci A, Petty F. Divalproex in the treatment of bipolar depression: a placebo-controlled trial. J Emotional discord. 2005; 85 (3): 259-266.
9. Sheehan DV, Harnett-Sheehan K, Hidalgo RB, etc. A randomized, placebo-controlled trial of quetiapine XR and divalproexER monotherapy in the treatment of patients with anxious bipolar disorder. J Emotional discord. 2013; 145 (1): 83-94.
10. Bach DR, Corn CW, Vander J, Vantel A. Effect of valproic acid and pregabalin on human anxiety-like behavior in randomized controlled trials. Transl Psychiatry. 2018; 8 (1): 157.
11. Aliyev NA, Aliyev ZN. Valproic acid (depacaine chrono) in the acute treatment of outpatients with generalized anxiety disorder without psychiatric comorbidities: a randomized, double-blind, placebo-controlled trial. Our psychiatry. 2008; 23 (2): 109-114.
12. Bruno A, Micò U, Pandolfo G, etc. Lamotridin enhancement of serotonin reuptake inhibitor in treatment-resistant obsessive-compulsive disorder: double-blind, placebo-controlled trial.. J Psycho Pharma Call. 2012; 26 (11): 1456-1462
13. Lydiard RB, Culpepper L, Schiöler H, etc. Quetiapine monotherapy as a treatment for anxiety in patients with bipolar depression: A pooled analysis of the results of two double-blind, randomized, placebo-controlled trials. Primcare Companion J Clean Psychiatry. 2009; 11 (5): 215-225.
14. Tohen M, Calabrese J, Vieta E, etc. The effect of coexisting anxiety on the therapeutic response of bipolar depression. J Emotional discord. 2007; 104 (1-3): 137-146.
15. Slee A, Nazareth I, Bondoronek P, Liu Y, Cheng Z, Freemantle N. Pharmacological treatment of generalized anxiety disorder: systematic review and network meta-analysis. Lancet.. 2019; 393 (10173): 768-777.
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