From Kimberly Read & Marcia Purse,
Your Guide to Bipolar Disorder.
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About.com Health's Disease and Condition content is reviewed by Steven Gans, MD

Two studies published in January 2007 offer significant insights into the relationship between bipolar disorder and anxiety disorders, and the connection between these and substance abuse. These studies have important implications for bipolar patients, their families and friends, and for mental health care providers.

These two studies sought to identify the effects of comorbid anxiety disorders on patients with bipolar disorder, and to identify the types of comorbid anxiety disorders associated with cocaine and alcohol use.

The studies were not related to each other, but we found their combined results to be of even more interest than their results taken separately.

Study 1: "The Effect of Anxiety Disorder Comorbidity on Treatment Resistant Bipolar Disorders"
These researchers examined 44 treatment-resistant patients who were currently depressed. About half of them had one or more anxiety disorders: panic disorder, post-traumatic stress disorder (PTSD) and/or obsessive-compulsive disorder (OCD), along with bipolar disorder. The other half did not. Statistics on these patients pointed up a couple of significant differences:

• The mean age of onset of bipolar symptoms for those with comorbid anxiety disorders was about 13 years of age, while for those without anxiety disorders it was 22.
• More than 56 percent of those with anxiety disorders had a history of prior suicide attempts, while in the other group just under 24 percent had attempted suicide.
• The rate of substance abuse (other than alcohol) for the group with anxiety disorders was significantly higher than in the second group.

These patients were rated on four standard tests for severity of depression as well as a test for how well they functioned.

On every test, the group with comorbid anxiety disorder had higher scores on the depression scales (more severe) as well as scoring lower on the functionality scale (more impaired). The researchers summarized these findings by saying, "On several measures, bipolar patients with comorbid anxiety disorders were more significantly ill than bipolar patients without comorbid anxiety disorders."

Study 2: "Comorbid Disorders in Patients with Bipolar Disorder and Concomitant Substance Dependence."
This study's aim was to compare the rates of anxiety disorders and antisocial personality disorder with specific types of substance dependence - cocaine, alcohol, and cocaine plus alcohol.

In this study, statistics revealed some interesting points:

• The groups of cocaine users were more likely to be diagnosed bipolar I than bipolar II, while the patients that were alcohol-dependent were more evenly split between the two diagnoses.
• The alcohol-dependent patients were far more likely to be in a current mood of depression; more patients in the cocaine-dependent group were in a hypo/manic or mixed state.
• In all three groups, about 80 percent of patients had at least one comorbid anxiety disorder.

Next they looked at individual anxiety disorders and antisocial personality disorder. They found:

• Generalized anxiety disorder was most common in the alcohol-dependent group.
• PTSD was most common in the two groups of cocaine users, less so in the alcohol-only group.
• Antisocial personality disorder was most common in the group that used both cocaine and alcohol.
• Panic disorder, OCD and social phobia (social anxiety disorder) were fairly even over the three groups.
• Overall, the rates of comorbid anxiety disorders in these substance-dependent patients was nearly three times the rate reported in the general bipolar population.

Taken together, these two studies point to some serious issues for bipolar disorder patients, their families and friends, and their doctors and therapists.

Where an anxiety disorder is present, substance abuse is more likely to occur, and conversely, substance abuse makes it more likely that there is also a comorbid anxiety disorder. Since a person with bipolar disorder plus an anxiety disorder and/or substance abuse is likely to have more severe bipolar symptoms and more likely to attempt suicide, it becomes very important for:

• Patients to be completely open with their mental health care providers about alcohol or drug use, and take note of and report any anxiety symptoms;
• Family members/friends to inform the providers of alcohol/drug use and/or anxiety symptoms on the part of the patient;
• Family members/friends to seek emergency help when necessary for patients with multiple conditions, especially if the patient is in denial, does not comply with treatment, or has no regular mental health provider;
• Providers to be aware of the added risks associated with substance use and dependence, and with comorbid anxiety disorders, and to be sensitive to signs and symptoms of either in patients who do not report these issues.

Learn about these disorders:

• What is Generalized Anxiety Disorder?
• What is Post-Traumatic Stress Disorder?
• What is Panic Disorder?
• What is Social Anxiety Disorder?
• What is Obsessive-Compulsive Disorder?
• What is Antisocial Personality Disorder?
• What is Alcoholism?
• What is Substance Abuse?
• Self-Medicating: When the Cure IS the Disease

References:
Lee, J.H., and Dunner, D.L. The effect of anxiety disorder comorbidity on treatment resistant bipolar disorders. Depression and Anxiety 0:1-7 (2007)

Mitchell, J.D. et al. Comorbid disorders in patients with bipolar disorder and concomitant substance dependence. J. Affect. Disord. (2007), doi:10.1016/j.jad.2007.01.005