Are Anxiety Disorders Associated with a More Severe Form of Bipolar Disorder in Adolescents?

Article excerpt

Byline: Aswin. Ratheesh, Shoba. Srinath, Y. Janardhan Reddy, Satish. Girimaji, Shekhar. Seshadri, K. Thennarasu, Yvan. Hutin

Background: Anxiety disorders are common among children and adolescents with bipolar disorder. Among adults, anxiety disorder comorbidity is associated with a more severe form of bipolar disorder and a poorer outcome. There is limited data on the effect of comorbid anxiety disorder on bipolar disorder among children and adolescents. Aim: To study the prevalence of anxiety disorders among adolescents with remitted bipolar disorder and examine their association with the course and severity of illness, global functioning, and quality of life. Materials and Methods: We evaluated 46 adolescents with DSM IV bipolar disorder (I and II) who were in remission, using the Schedule for Affective Disorders and Schizophrenia for School-Age Children. We measured quality of life using the Pediatric Quality of Life Inventory and global functioning using the Children's Global Assessment Scale, and then compared these parameters between adolescents with and without current anxiety disorders. We also compared the two groups on other indicators of severity such as number of episodes, suicidal ideation, presence of psychotic symptoms, and response to treatment. Results: Among the 46 subjects, the prevalence of current and lifetime anxiety disorders were 28% (n=13) and 41% (n=19), respectively. Compared with others, adolescents with anxiety had more lifetime suicidal ideation, more number of episodes, lower physical, psychosocial, and total subjective quality of life, and lower global functioning. Conclusions: Among adolescents with bipolar disorder, anxiety disorders are associated with a poorer course, lower quality of life, and global functioning. In these subjects, anxiety disorders should be promptly recognized and treated.


Anxiety disorders are common among adults with bipolar disorder and influence their clinical and functional outcome. [sup][1],[2] In adults, they are associated with greater severity, earlier age-at-onset, mixed state presentations, poor symptomatic and functional recovery, suicidal behavior, diminished acute response to pharmacological treatment, decreased quality of life, and unfavorable course and outcome. [sup][3],[4]

Although the consequences of anxiety disorders comorbidity among adults are well elucidated, the data are inconclusive among children and adolescents. [sup][5],[6],[7],[8],[9] Drug-induced hypomania was more common among children with anxiety disorders (30-36%), than those without comorbid anxiety disorders (22%). [sup][8] In one study, those adolescents with anxiety had a lower age at onset and more hospitalizations than those without. [sup][5] A later study has suggested that adolescents with post-traumatic stress disorder (PTSD) and comorbid bipolar disorder are more likely to have a substance use disorder compared with those who did not have PTSD. [sup][9] Studies that have compared the illness severity among children and adolescents with or without anxiety disorders using the Clinical Global Impression severity scale have been inconsistent in their findings. [sup][6],[8] In two studies, presence of anxiety disorders had no influence on global functioning. [sup][5],[6] The studies that have determined the association of anxiety with outcomes among children and adolescents with bipolar disorder have two main limitations. First, they do not provide enough information regarding illness severity and quality of life of these children and adolescents. Second, they assessed study subjects during affective episodes. Anxiety symptoms may occur exclusively during mood episodes [sup][10],[11],[12],[13] and hence, the assessment of anxiety during mood episodes may result in overestimation of the prevalence of anxiety disorders. Only one study estimated the prevalence of anxiety disorders in remission. [sup][14] However, remission from mood episodes was determined historically without a clear assessment of the same. …