title: The comorbidity of bipolar and anxiety disorders: prevalence, psychobiology, and treatment issues.
abstract: BACKGROUND
  Although symptoms of anxiety as well as anxiety disorders commonly occur in patients with bipolar disorder, the pathophysiologic, theoretical, and clinical significance of their co-occurrence has not been well studied.
  
  
  METHODS
  The epidemiological and clinical studies that have assessed the overlap of bipolar and anxiety disorders are reviewed, with focus on panic disorder and obsessive-compulsive disorder (OCD), and to a lesser extent, social phobia and post-traumatic stress disorder. Potential neural mechanism and treatment response data are also reviewed.
  
  
  RESULTS
  A growing number of epidemiological studies have found that bipolar disorder significantly co-occurs with anxiety disorders at rates that are higher than those in the general population. Clinical studies have also demonstrated high comorbidity between bipolar disorder and panic disorder, OCD, social phobia, and post-traumatic stress disorder. Psychobiological mechanisms that may account for these high comorbidity rates likely involve a complicated interplay among various neurotransmitter systems, particularly norepinephrine, dopamine, gamma-aminobutyric acid (GABA), and serotonin. The second-messenger system constituent, inositol, may also be involved. Little controlled data are available regarding the treatment of bipolar disorder complicated by an anxiety disorder. However, adequate mood stabilization should be achieved before antidepressants are used to treat residual anxiety symptoms so as to minimize antidepressant-induced mania or cycling. Moreover, preliminary data suggesting that certain antimanic agents may have anxiolytic properties (e.g. valproate and possibly antipsychotics), and that some anxiolytics may not induce mania (e.g. gabapentin and benzodiazepines other than alprazolam) indicate that these agents may be particularly useful for anxious bipolar patients.
  
  
  CONCLUSIONS
  Comorbid anxiety symptoms and disorders must be considered when diagnosing and treating patients with bipolar disorder. Conversely, patients presenting with anxiety disorders must be assessed for comorbid mood disorders, including bipolar disorder. Pathophysiological, theoretical, and clinical implications of the overlap of bipolar and anxiety disorders are discussed.
authors.affiliation: University of Cincinnati College of Medicine, Biological Psychiatry Program, Department of Psychiatry, P.O. Box 670559, 231 Bethesda Avenue, Cincinnati, OH 45267-0559, USA. marlenef@email.arizona.edu
authors.forename: Marlene P
authors.initials: MP
authors.lastname: Freeman
authors.forename: Scott A
authors.initials: SA
authors.lastname: Freeman
authors.forename: Susan L
authors.initials: SL
authors.lastname: McElroy
mesh_terms: D000928:Antidepressive Agents / Q000494:pharmacology / Q000627:therapeutic use; D018692:Antimanic Agents / Q000494:pharmacology / Q000627:therapeutic use; D001008:Anxiety Disorders / Q000150:complications / Q000523:psychology* / Q000628:therapy; D001714:Bipolar Disorder / Q000150:complications / Q000523:psychology* / Q000628:therapy; D015897:Comorbidity; D003937:Diagnosis, Differential; D006801:Humans; D015995:Prevalence; D011379:Prognosis
chemical_list: D000928:Antidepressive Agents; D018692:Antimanic Agents