Bipolar comorbidity: from diagnostic dilemmas to therapeutic challenge

Abstract

Comorbidity in bipolar disorder is the rule rather than the exception more than 60% of bipolar patients have a comorbid diagnosis and is associated with a mixed affective or dysphoric state; high rates of suicidality; less favourable response to lithium and poorer overall outcome. There is convincing evidence that rates of substance use and anxiety disorders are higher among patients with bipolar disorder compared to their rates in the general population. The interaction between anxiety disorders and substance use goes both ways: patients with bipolar disorder have a higher rate of substance use and anxiety disorder, and vice versa. Bipolar disorder is also associated with borderline personality disorder and ADHD, and to a lesser extent with weight gain. As more than 40% of bipolar patients have anxiety disorder, it is indicated that while diagnosing bipolar patients, systematic enquiry about different anxiety disorders is called for. This also presents a therapeutic challenge, since agents that effectively treat anxiety disorders are associated with the risk of induced mania. Therefore, the treating psychiatrist needs to carefully evaluate the potential benefit of treating the anxiety against the potential cost of inducing a manic episode. A possible solution would be to use, when possible, a non-pharmacological intervention, such as a cognitivebehavioural approach. Alternately, it is suggested that the clinician attempts to ensure that the patient receives adequate treatment with mood stabilizers before slowly and carefully attempting the addition of anti-anxiety compounds with a relatively lower risk of mania induction (e.g. SSRIs compared to TCAs).

Clinical Features and Management of Bipolar Disorder and Obsessive Compulsive Disorder Comorbidity

“…bipolar hastalarda manik kaymaya ya da hızlı döngüye neden olabilirler. [39] Bu unsurların tedavi eden hekimler tarafından dikkate alınıp, yarar-zarar dengesine göre, farmakoterapide hangi ilaçların kullanılacağına karar verilmesi zorunludur.…”

“…[30] Diğer bazı yazarlar, bu hastalarda bilişsel davranışçı terapiler (BDT) gibi farmakoterapi dışı seçeneklerin göz önünde tutulmasını istemişlerdir. [39] Manik hastalarda bu seçeneğin kullanımının sınırlı olduğuna da dikkat çekilerek, en doğru yaklaşımın, hastaların duygudurum dü-zenleyicileri ve atipik antipsikotiklerle düzelmelerinin ardından, anksiyete tedavisinde kullanılan ilaçlardan (TSA'lar yerine SSRI'ler gibi) manik kaymaya yol açma riski daha az olanların eklenmesi olduğu belirtilmiştir.…”

“…[42] Sasson ve arkadaşları olumlu olgu sunumlarına atıfta bulunarak, lamotrijin ve topiramatın OKB-BPB hastalarında etkinliğinin ayrıntılı olarak araştırılmasını önermişlerdir. [39] www.cappsy.org Atipik antipsikotiklerinin çoğunun (amisulpirid, olanzapin, risperidon, ketiapin, aripiprazol) tedaviye dirençli OKB olgularında etkin olduğunu bildiren araştırmalar bulunmaktadır (43)(44)(45)(46)(47). Küçük hasta grupları üzerinde yapılan bu çalışmalarda ortalama risperidon 3mg/gün, olanzapin 11.2mg/gün ve amisülpirid 200-600mg/gün, aripiprazol 10-30mg/gün dozlarında kullanılmış ve bu ilaçların tedaviye dirençli OKB olgularında etkin olduğu bildirilmiştir.…”

Comorbidade com transtornos de ansiedade em transtorno bipolar

“…However, the latter are associated with a lower rate of manic inducement, being preferentially used when there is BD comorbidity. 65 Preliminary studies showed some efficacy of sodium divalproate. [66][67][68] especially when there is rapid cycling; 65 and gabapentine [69][70] in the control of panic symptoms, what may represent an alternative to the use of antidepressants in these cases.…”

“…65 Preliminary studies showed some efficacy of sodium divalproate. [66][67][68] especially when there is rapid cycling; 65 and gabapentine [69][70] in the control of panic symptoms, what may represent an alternative to the use of antidepressants in these cases. It is remarkable, in face of these difficulties, the importance of the association of cognitive-behavioral therapy for the treatment of these patients.…”