From the Guidelines
The most effective treatment approach for patients with bipolar disorder experiencing anxiety is a combination of mood stabilizers and targeted anxiety interventions, prioritizing mood stability to prevent exacerbation of anxiety symptoms. This approach is supported by the most recent and highest quality studies, although the provided evidence does not directly address anxiety management in bipolar disorder, it emphasizes the importance of mood stabilizers in managing bipolar disorder 1.
Pharmacological Interventions
- Mood stabilizers such as lithium or valproate are recommended for the maintenance treatment of bipolar disorder 1, and their use can indirectly benefit anxiety symptoms by stabilizing mood.
- Selective serotonin reuptake inhibitors (SSRIs) may be considered for anxiety symptoms, but with caution due to the risk of triggering mania.
- Atypical antipsychotics can address both mood and anxiety symptoms but should be used judiciously considering their side effect profile.
Non-Pharmacological Interventions
- Cognitive behavioral therapy (CBT) is crucial for addressing anxiety symptoms directly, helping patients identify and challenge anxious thoughts and develop coping strategies.
- Psychoeducational therapy, family-focused therapy, and interpersonal therapy can support psychological development, skill building, and family relationships, which are often impacted by bipolar disorder 1.
Monitoring and Follow-Up
Regular monitoring is essential to assess medication response, side effects, and the emergence of new symptoms, with follow-up appointments initially every 2-4 weeks. This comprehensive approach is necessary to manage anxiety in the context of bipolar disorder effectively, reducing the risk of worsening mood instability, treatment non-adherence, and suicide 1.
Given the complexity of managing bipolar disorder with comorbid anxiety, a multidisciplinary approach that includes psychiatry, psychology, and social work is ideal for providing the necessary pharmacological and non-pharmacological interventions tailored to the individual's needs.
From the FDA Drug Label
Lithium is indicated in the treatment of manic episodes of Bipolar Disorder. Maintenance therapy reduces the frequency of manic episodes and diminishes the intensity of those episodes which may occur.
The FDA drug label does not answer the question.
From the Research
Treatment Approach for Bipolar Disorder with Anxiety
The treatment approach for patients with bipolar disorder experiencing anxiety involves a combination of medications and psychotherapy.
- Mood stabilizers, such as lithium, valproate, and lamotrigine, are recommended as first-line treatments for bipolar disorder 2.
- Antipsychotic agents, such as quetiapine, aripiprazole, asenapine, lurasidone, and cariprazine, are also recommended, but some are associated with weight gain 2.
- For patients with comorbid bipolar disorder and an anxiety disorder, specific anticonvulsant mood stabilizers and second-generation antipsychotics are the medications of choice 3.
- Serotonergic antidepressant medications are not recommended as monotherapy for patients with bipolar disorder, as they can increase the risk of manic switch and destabilization of mood 3.
Psychotherapy for Anxiety in Bipolar Disorder
Psychotherapy is an effective treatment for anxiety symptoms in patients with bipolar disorder, especially when used in conjunction with medication.
- Interpersonal, cognitive behavioral, and relaxation therapy are effective for the treatment of anxiety symptoms, especially emotional experiences, in patients who are euthymic 3.
- Mindfulness-Based Cognitive Therapy may also be beneficial for patients with bipolar disorder and anxiety 4.
Avoiding Certain Medications
Certain medications, such as benzodiazepines, should be avoided in patients with comorbid bipolar disorder, posttraumatic stress disorder, and substance use disorders due to the risk of dependence and other adverse effects 3, 4.
- Benzodiazepines should be used with caution and only as a last resort, as they can have negative consequences for patients with bipolar disorder 3.