Anxiety disorders in 318 bipolar patients: prevalence and impact on illness severity and response to mood stabilizer

OBJECTIVE: The aim of this study was to assess the frequency and impact of anxiety disorders on illness severity and response to mood stabilizers in bipolar disorders. METHOD: 318 bipolar patients consecutively admitted to the psychiatric wards of 2 centers as inpatients were recruited. Patients were interviewed with a French version of the Diagnostic Interview for Genetic Studies providing DSM-IV Axis I diagnoses and demographic and historical illness characteristics. Logistic and linear regressions to adjust for age and sex were performed. RESULTS: In a population with mostly bipolar type I patients (75%), 24% had at least 1 lifetime anxiety disorder (47% of these patients had more than 1 such disorder), 16% of patients had panic disorder (with and without agoraphobia, and panic attacks), 11% had phobia (agoraphobia without panic disorder, social phobia, and other specific phobias), and 3% had obsessive-compulsive disorder. Comorbidity with anxiety disorders was not correlated with severity of bipolar illness as assessed by the number of hospitalizations, psychotic characteristics, misuse of alcohol and drugs, and suicide attempts (violent and nonviolent). Bipolar patients with an early onset of illness had more comorbidity with panic disorder (p <.05). Anxiety disorders were detected more frequently in bipolar II patients than in other patients, but this difference was not significant (p =.09). Bipolar patients with anxiety responded less well to anticonvulsant drugs than did bipolar subjects without anxiety disorder (p <.05), whereas the efficacy of lithium was similar in the 2 groups. There was also a strong correlation between comorbid anxiety disorders and depressive temperament in bipolar patients (p =.004). CONCLUSION: Patients with bipolar disorders often have comorbid anxiety disorders, particularly patients with depressive temperament, and the level of comorbidity seems to decrease the response to anticonvulsant drugs.     

Panic disorder versus panic disorder with major depression: Defining and understanding differences in psychiatric morbidity

The present study examined the impact of comorbid major depressive disorder (MDD) on psychiatric morbidity, panic symptomatology and frequency of other comorbid psychiatric conditions in subjects with panic disorder (PD). Four hundred thirty-seven patients with PD were evaluated at intake as part of a multicenter longitudinal study of anxiety disorders; 113 of these patients were also in an episode of MDD. Patients were diagnosed by DSM-III-R criteria utilizing structured clinical interviews. The 113 PD/MDD patients were compared with the 324 remaining PD subjects regarding panic symptoms at intake, sociodemographic, quality of life and psychiatric morbidity variables. Differences in frequency of other comorbid Axis I psychiatric disorders were assessed at intake; personality disorders were evaluated twelve months after intake. The results revealed that PD/MDD patients exhibit increased morbidity and decreased psychosocial functioning as compared to PD patients. Personality disorders were more prevalent in the PD/MDD group at six month follow-up assessment; the PD/MDD group also had an increased frequency of posttraumatic stress disorder (PTSD) and more comorbid Axis I anxiety disorders as compared to the PD group. The total number and frequency of panic symptoms was highly consistent between the two patient groups. Depression and Anxiety 5:12–20, 1997. © 1997 Wiley-Liss, Inc.     

Cross‐prevalence of migraine and bipolar disorder

Ortiz A, Cervantes P, Zlotnik G, van de Velde C, Slaney C, Garnham J, Turecki G, O’Donovan C, Alda M. Cross‐prevalence of migraine and bipolar disorder.
Bipolar Disord 2010: 12: 397–403. © 2010 The Authors. Journal compilation © 2010 John Wiley & Sons A/S. Objective: In two related studies, we explored the prevalence of migraine and its associated clinical characteristics in patients with bipolar disorder (BD) as well as psychiatric morbidity in patients treated for migraine. Method: The first study included 323 subjects with BD type I (BD I) or BD type II (BD II), diagnosed using the Schedule for Affective Disorders and Schizophrenia, Lifetime version (SADS‐L) format, or the Structured Clinical Interview for DSM‐IV Axis I Disorders (SCID). Migraine history was assessed by means of a structured questionnaire. In a second sample of 102 migraine patients, we investigated current and lifetime psychiatric morbidity using the SADS‐L. Statistical analyses were conducted using nonparametric analysis and log‐linear models. Results: A total of 24.5% of BD patients had comorbid migraine; those with BD II had a higher prevalence (34.8%) compared to BD I (19.1%) (p < 0.005). BD patients with comorbid migraine had significantly higher rates of suicidal behaviour, social phobia, panic disorder, generalized anxiety disorder, and obsessive‐compulsive disorder (all p < 0.05). In the sample of migraine patients, 34.3% had a current psychiatric diagnosis, and 73.5% had a lifetime psychiatric diagnosis. The prevalence of BD I was 4.9%, and 7.8% for BD II. Discussion: Migraine is prevalent within the BD population, particularly among BD II subjects. It is associated with an increased risk of suicidal behaviour and comorbid anxiety disorders. Conversely, migraine sufferers have high rates of current and lifetime psychopathology. A greater understanding of this comorbidity may contribute to our knowledge of the underlying mechanisms of BD.     

Phenomenology of panic disorder in youth

We compared the demographic and clinical characteristics of youth with panic disorder (PD) (n=42), non-panic anxiety (n=407), and non-anxiety psychiatric disorders (n=1,576). Subjects were recruited from a mood and anxiety disorders clinic and assessed with the KSADS-P. In this large clinical sample, approximately 2% of the patients had PD. Most of these patients were adolescent, female, and Caucasian. PD was associated frequently with comorbid bipolar disorder, MDD, and other anxiety conditions, in particular general anxiety and separation anxiety disorders. Palpitations, chest pain, faintness, and trembling/shaking were the most frequent PD symptoms. In comparison with the other groups, youths with PD were significantly slightly older, Caucasian, and have more comorbid bipolar disorder. Subjects with both panic and non-panic anxiety disorders were more likely to have comorbid major depression and conduct disorders than those with other non-anxiety disorders.     

Psychiatric diagnosis and quality of life: the additional burden of psychiatric comorbidity

Objectives

To compare quality of life (QoL) in mental health outpatients to non-clinical norms, and examine the associations between QoL and principal diagnosis, number of comorbid Axis I diagnoses, and type of comorbidity.

Methods

Consecutively referred and assessed patients (n = 2024) formed the study sample pool. Of these, 1486 individuals who had completed a QoL instrument at intake and had a principal diagnosis amenable to comparison by group analysis were included in the study. Principal diagnoses were unipolar mood disorder (n = 687), eating disorder (n = 226), bipolar disorder (n = 165), social anxiety disorder (n = 165), generalized anxiety disorder (n = 125), and panic disorder (n = 118). QoL for psychiatric groups was compared to non-clinical norms using a valid and reliable measure.

Results

QoL was significantly impaired in all psychiatric groups compared to nonclinical norms. There was a significant interaction between principal diagnosis and number of comorbid Axis I disorders, controlling for age, sex, marital status, employment, and years of school. The addition of one comorbidity significantly attenuated QoL in social anxiety disorder, panic disorder, and bipolar disorder. For all other conditions, a significant loss in QoL occurred with two or more comorbidities. Axis I depressive and anxiety comorbidity significantly attenuated QoL across all diagnostic groups.

Conclusions

QoL is significantly impaired in psychiatric outpatients and diagnostic groups vary in the extent to which they experience additional QoL burden with increasing comorbidities.     

Differences in Axis I and II comorbidity between bipolar I and II disorders and major depressive disorder

OBJECTIVE: To obtain a comprehensive view of differences in current comorbidity between bipolar I and II disorders (BD) and (unipolar) major depressive disorder (MDD), and Axis I and II comorbidity in BD in secondary-care psychiatric settings. METHOD: The psychiatric comorbidity of 90 bipolar I and 101 bipolar II patients from the Jorvi Bipolar Study and 269 MDD patients from the Vantaa Depression Study were compared. We used DSM-IV criteria assessed by semistructured interviews. Patients were inpatients and outpatients from secondary-care psychiatric units. Comparable information was collected on clinical history, index episode, symptom status, and patient characteristics. RESULTS: Bipolar disorder and MDD differed in prevalences of current comorbid disorders, MDD patients having significantly more Axis I comorbidity (69.1% vs. 57.1%), specifically anxiety disorders (56.5% vs. 44.5%) and cluster A (19.0% vs. 9.9%) and C (31.6% vs. 23.0%) personality disorders. In contrast, BD had more single cluster B personality disorders (30.9% vs. 24.6%). Bipolar I and bipolar II were similar in current overall comorbidity, but the prevalence of comorbidity was strongly associated with the current illness phase. CONCLUSIONS: Major depressive disorder and BD have somewhat different patterns in the prevalences of comorbid disorders at the time of an illness episode, with differences particularly in the prevalences of anxiety and personality disorders. Current illness phase explains differences in psychiatric comorbidity of BD patients better than type of disorder.     

Panic disorder, comorbidity, and suicide attempts

In a previous report, we demonstrated a strong association between panic disorder and suicide attempts based on data from the Epidemiologic Catchment Area study (a probability sample of more than 18,000 adults living in five US communities). In these analyses, although we controlled statistically for comorbidity of panic disorder with other psychiatric disorders, we did not directly estimate the risk of suicide attempts in persons with uncomplicated panic disorder (ie, without any other Axis I disorders) compared with those with comorbid conditions. Persons with uncomplicated panic disorder represent fewer than a third of persons with panic disorder. However, the lifetime rates of suicide attempts in persons with uncomplicated panic disorder (7%) were consistently higher than for persons with no psychiatric disorder (1%). Similar findings on the rate of suicide attempts in persons with uncomplicated major depression (7.9%) emerged. We conclude that suicide attempts are associated with panic disorder in its uncomplicated or its comorbid form and that the risks are comparable with those of major depression, comorbid and uncomplicated. These epidemiologic findings are discussed within a clinical perspective to explain why these associations may not appear obvious in clinical practice.     

Clinical and subthreshold panic disorder

Background: Panic disorder (PD) is a highly prevalent and disabling condition, and subthreshold cases may be even more prevalent. This study examined psychiatric comorbidities, work functioning, and health‐care utilization of individuals with subthreshold panic. The purpose of this study was to add to the accumulating evidence of significant comorbidity and disability associated with subthreshold PD. Methods: Data are drawn from the Health Care for Communities study, a national household survey of the United States' adult, civilian, noninstitutionalized population (N=9585). Data assessing psychiatric disorders, employment and work productivity, and health‐care utilization were collected. Seven categories of panic and subthreshold panic were created. Results: The prevalence of clinical and subthreshold panic in the general population was 40%. Subthreshold panic was associated with increased odds of several comorbid disorders, including depression, dysthymia, psychosis, generalized anxiety disorder, bipolar disorder, and alcohol and drug use disorders. Subthreshold panic was also associated with greater likelihood of health‐care service utilization but not with the intensity of mental health services. Conclusion: Psychiatric comorbidities and health‐care utilization are common among patients with subthreshold panic. The relationship between varying degrees of panic symptomology and other mental health problems and indices of functioning impairment warrants further investigation. These results inform further research focusing on the course of subthreshold PD and its impact on quality of life. Depression and Anxiety, 2010. © 2009 Wiley‐Liss, Inc.     

Comorbidity in bipolar disorder among the elderly: results from an epidemiological community sample

OBJECTIVE: This study sought to determine psychiatric comorbidity among elderly individuals with bipolar disorder. METHOD: An epidemiological community survey identified 84 elderly (ages >/=65) respondents with bipolar disorder, 1,327 younger adults with bipolar disorder, and 8,121 elderly respondents without bipolar disorder. RESULTS: Elderly respondents with bipolar disorder reported lifetime and 12-month rates of comorbid alcohol use disorders (38.1%, 38.1%, respectively), dysthymia (15.5%, 7.1%), generalized anxiety disorder (20.5%, 9.5%), and panic disorder (19.0%, 11.9%) that were significantly higher than among elderly respondents without bipolar disorder. They had lower lifetime and 12-month rates of alcohol use disorders and lower 12-month rates of dysthymia and panic disorder than younger adults with bipolar disorder. Elderly men with bipolar disorder reported a greater prevalence of alcoholism; women reported a greater prevalence of panic disorder. CONCLUSIONS: Comorbid axis I disorders, including panic disorder, are common among elderly individuals with bipolar disorder.     

Quality of life and impulsivity in bipolar disorder

Victor SE, Johnson SL, Gotlib IH. Quality of life and impulsivity in bipolar disorder.
Bipolar Disord 2011: 13: 303–309. © 2011 The Authors.
Journal compilation © 2011 John Wiley & Sons A/S. Objectives: Bipolar disorder (BD) is a chronic psychiatric illness that impairs quality of life (QoL) in numerous life domains even when mood symptoms are not present and is characterized by elevated impulsivity. Many of the comorbid conditions that are associated with diminished QoL in BD also involve impulsivity. The objective of this project was to investigate whether impulsivity might mediate the effects of these comorbid conditions on poor QoL. Methods: A total of 76 participants diagnosed with bipolar I disorder by the Structured Clinical Interview for DSM‐IV Axis I disorders completed the Quality of Life in Bipolar Disorder (QoL‐BD) scale, the Barratt Impulsivity Scale (BIS‐11), and the Positive Urgency Measure (PUM). Participants were also assessed for comorbid DSM‐IV diagnoses of anxiety, substance use, and impulse control disorders. Results: Several subscales of the BIS‐11 as well as the PUM total score were significantly negatively correlated with overall QoL. PUM total score remained a significant predictor of QoL after controlling for comorbid anxiety, substance use, and impulse control disorders. After controlling for impulsivity, comorbid disorders were no longer significantly related to overall QoL. Conclusions: The data support the hypothesis that impulsivity, specifically positive urgency, is highly correlated with QoL in BD. Impulsivity was found to mediate the relation between QoL and several comorbidities in BD. Interventions targeting impulsivity might help to improve QoL in BD.     

Valproate Adjuvant Cognitive Behavioral Therapy in Panic Disorder Patients With Comorbid Bipolar Disorder: Case Series and Review of the Literature

Anxiety disorders are the most common comorbid psychiatric disorders in patients with bipolar disorder. Managing anxiety symptoms in comorbid conditions is challenging and has received little research interest. The findings from preclinical research on fear conditioning, an animal model of anxiety disorder, have suggested that memory reconsolidation updating (exposure-based therapy) combined with valproate might facilitate the amelioration of fear memories. Here, three cases of successful amelioration of agoraphobia and panic symptoms through valproate adjuvant therapy for cognitive behavioral therapy in patients who failed to respond to two to three consecutive standard pharmacotherapy trials over several years are described. To the best of the author’s knowledge, this is the first attempt to combine CBT with valproate in patients with panic disorder, agoraphobia, and comorbid bipolar disorder. Additionally, the background preclinical research on this combination therapy based on the reconsolidation-updating mechanism, the inhibition of histone deacetylase 2, and critical period reopening, off-label use of valproate in panic disorder, plasticity-augmented psychotherapy, and how to combine valproate with CBT is discussed.     

Psychopathology in the young offspring of parents with bipolar disorder: a controlled pilot study

Studies have suggested that the offspring of parents with bipolar disorder are at risk for a spectrum of psychopathology, but few have focused on children in the youngest age ranges or examined the impact of comorbid parental disorders. We utilized a pre-existing sample of young (mean age: 6.8 years) offspring of parents with bipolar disorder (n=34), of parents with panic or major depression (n=179), and of parents with neither mood or anxiety disorder (n=95). Children were assessed blindly to parental diagnoses using the Schedule for Affective Disorders and Schizophrenia-Epidemiologic version (K-SADS-E). Offspring of bipolar parents had significantly higher rates of disruptive behavior and anxiety disorders than offspring from both of the comparison groups, accounted for by elevated rates of ADHD and overanxious disorder. These comparisons were significant even when lifetime histories of the corresponding categories of comorbid disorders in the parents (disruptive behavior disorders and anxiety disorders) were covaried. In addition, offspring of bipolar parents had increased rates of bipolar I disorder, compared with psychiatric controls. Results support the hypotheses of elevated behavior, anxiety, and mood disorders among offspring at risk for bipolar disorder, and suggest that this psychopathology is already evident in early childhood.     

Catechol o-methyltransferase, serotonin transporter, and tryptophan hydroxylase gene polymorphisms in bipolar disorder patients with and without comorbid panic disorder.

OBJECTIVE: Genetic epidemiologic and clinical data suggest that comorbid panic disorder may define a subtype of bipolar disorder. Comorbid panic disorder might thereby influence the strength of association between bipolar disorder and genes that have been implicated in bipolar disorder on the basis of their function in monoamine neurotransmission and previously reported linkage results. Polymorphic markers at catechol O-methyltransferase (COMT), serotonin transporter (5-HTT), and tryptophan hydroxylase (TPH) genes were analyzed in a case-control association study of bipolar disorder patients with or without lifetime panic disorder. METHOD: Unrelated subjects of Italian descent meeting DSM-III-R criteria for lifetime bipolar disorder (N=111), with (N=49) or without (N=62) comorbid lifetime panic disorder, were compared to 127 healthy subjects. DNA was extracted from blood leukocytes. The frequencies of COMT Val158Met, 5-HTTLPR, and TPH IVS7+218C>A polymorphisms were determined. Genotype and allele frequency comparisons between affected (bipolar disorder, bipolar disorder without panic disorder, or bipolar disorder with panic disorder) and unaffected individuals were carried out with chi-square tests or Fisher's exact tests. RESULTS: Relative to the comparison subjects, subjects with bipolar disorder without panic disorder, but not those with comorbid bipolar disorder and panic disorder, showed significantly higher frequencies of the COMT Met158 and the short 5-HTTLPR alleles and genotypes. The differences in the frequencies of the TPH IVS7+218A alleles and genotypes approached statistical significance. CONCLUSIONS: The findings support the hypothesis that comorbid panic disorder identifies a genetic subtype of bipolar disorder and suggest a role for COMT and 5-HTT in vulnerability to these disorders.     

Comorbid personality disorders in subjects with panic disorder: do personality disorders increase clinical severity?

Personality disorders are common in subjects with panic disorder. Personality disorders have been shown to affect the course of panic disorder. The purpose of this study was to examine which personality disorders affect clinical severity in subjects with panic disorder. This study included 122 adults (71 women, 41 men) who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition ( DSM-IV ) criteria for panic disorder (with or without agoraphobia). Clinical assessment was conducted by using the Structured Clinical Interview for DSM-IV Axis I Disorders, the Structured Clinical Interview for DSM-IV Axis II Personality Disorders, and the Panic and Agoraphobia Scale, Global Assessment Functioning Scale, Beck Depression Inventory, and State-Trait Anxiety Inventory. Patients who had a history of sexual abuse were assessed with Sexual Abuse Severity Scale. Logistic regressions were used to identify predictors of suicide attempts, suicidal ideation, sexual abuse, and early onset of disorder. The rates of comorbid Axes I and II psychiatric disorders were 80.3% and 33.9%, respectively, in patients with panic disorder. Patients with panic disorder with comorbid personality disorders had more severe anxiety, depression, and agoraphobia symptoms, had earlier ages at onset, and had lower levels of functioning. The rates of suicidal ideation and suicide attempts were 34.8% and 9.8%, respectively, in subjects with panic disorder. The rate of patients with panic disorder and a history of childhood sexual abuse was 12.5%. The predictor of sexual abuse was borderline personality disorder. The predictors of suicide attempt were comorbid paranoid and borderline personality disorders, and the predictors of suicidal ideation were comorbid major depression and avoidant personality disorder in subjects with panic disorder. In conclusion, this study documents that comorbid personality disorders increase the clinical severity of panic disorder. Borderline personality disorder may be the predictor of a history of sexual abuse and early onset in patients with panic disorder. Paranoid and borderline personality disorders may be associated with a high frequency of suicide attempts in patients with panic disorder.     

Neuropsychiatric aspects of migraine

Migraine is a common chronic disorder that presents with recurrent attacks of headache and associated symptoms. Various somatic and psychiatric conditions have been reported as comorbid conditions with migraine. Among the psychiatric disorders that have been reported as comorbid with migraine are major depression, anxiety, panic disorder, and bipolar disorder. Recent studies discussing the comorbidity of headache and psychiatric disorders are reviewed here.     

Distinguishing illness severity from tic severity in children and adolescents with Tourette's disorder

OBJECTIVE: To examine whether tic severity, comorbid disorders, or both are associated with illness morbidity in youths with Tourette's disorder (TD). METHOD: Subjects were 156 consecutively referred youths (aged 5-20 years) who met DSM-III-R criteria for Tourette's disorder at a major academic medical center. All subjects were evaluated with a clinical interview by a child and adolescent psychiatrist and an assessment battery that included the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Epidemiologic version. Statistical analysis used chi 2 and multivariate logistic regression. RESULTS: Nineteen (12%) of the 156 youths with TD required psychiatric hospitalization. Current age, TD severity, TD duration, obsessive-compulsive disorder, psychosis, major depression, bipolar disorder, panic disorder, and overanxious disorder were significant univariate predictors of psychiatric hospitalization (p < .01). While tic severity was marginally significant as a predictor of psychiatric hospitalization (p < .05), major depression (p < .016) and bipolar disorder (p < .001) were robust predictors of psychiatric hospitalization, even after statistical adjustment for collinearity and correction for all other variables assessed. CONCLUSION: The findings indicate that comorbid mood disorders are strongly associated with illness morbidity in youths with TD, highlighting the importance of attention to comorbidity in patients with TD.     

Current comorbidity of psychiatric disorders among DSM-IV major depressive disorder patients in psychiatric care in the Vantaa Depression Study

BACKGROUND: While numerous studies have documented the high comorbidity of major depressive disorder (MDD) with individual mental disorders, no published study has reported overall current comorbidity with all Axis I and II disorders among psychiatric patients with MDD, nor systematically investigated variations in current comorbidity by sociodemographic factors, inpatient versus outpatient status, and number of lifetime depressive episodes. METHOD: Psychiatric outpatients and inpatients in Vantaa, Finland, were prospectively screened for an episode of DSM-IV MDD, and 269 patients with a new episode of MDD were enrolled in the Vantaa Depression MDD Cohort Study. Axis I and II comorbidity was assessed via semistructured Schedules for Clinical Assessment in Neuropsychiatry, version 2.0, and Structured Clinical Interview for DSM-II-R personality disorders interviews. RESULTS: The great majority (79%) of patients with MDD suffered from 1 or more current comorbid mental disorders, including anxiety disorder (57%), alcohol use disorder (25%), and personality disorder (44%). Several anxiety disorders were associated with specific Axis II clusters, and panic disorder with agoraphobia was associated with inpatient status. The prevalence of personality disorders varied with inpatient versus outpatient status, number of lifetime depressive episodes, and type of residential area, and the prevalence of substance use disorders varied with gender and inpatient versus outpatient status. CONCLUSION: Most psychiatric patients with MDD have at least 1 current comorbid disorder. Comorbid disorders are associated not only with other comorbid disorders, but also with sociodemographic factors, inpatient versus outpatient status, and lifetime number of depressive episodes. The influence of these variations on current comorbidity patterns among MDD patients needs to be taken account of in treatment facilities.     

The implications of medical and psychiatric comorbidity with panic disorder

The frequent presentation of patients with panic disorder in medical settings may, in part, be explained by the physical symptoms inherent in panic disorder. However, a number of medical disorders have symptoms that overlap with panic disorder symptoms, and elevated panic disorder prevalence is comorbid with a number of medical illnesses, including respiratory disorders, vestibular dysfunction, and hyperthyroidism and hypothyroidism. The presence of medical comorbidity complicates the identification, presentation, and treatment of panic disorder. In addition, comorbid mood disorders occur commonly and result in greater severity, poorer quality of life, and greater impairment. Recent work suggests that panic disorder occurs more commonly with bipolar disorder than major depressive disorder, resulting in substantial impairment, as well as poorer response to treatment. The implications of mood disorder and its medical comorbidity for the identification and treatment of panic disorder are discussed.     

Health service use among persons with comorbid bipolar and substance use disorders

OBJECTIVE: This study tested the hypothesis that patients with comorbid bipolar and substance use disorders use health services to a greater extent than patients with either bipolar or substance use disorder alone. METHODS: A retrospective chart review was conducted among patients who used health services at the Ralph H. Johnson Department of Veterans Affairs medical center in Charleston, South Carolina, and had bipolar disorder alone, substance use disorder alone, and comorbid bipolar and substance use disorders. Patients with a psychiatric admission between 1999 and 2003 were included in the study. Information was collected on the use of health services one year before and including the index admission. RESULTS: The records of 106 eligible patients were examined for this study: 18 had bipolar disorder alone, 39 had substance use disorder alone, and 49 had both bipolar and substance use disorders. Compared with the other two groups, the group with comorbid bipolar and substance use disorders was significantly more likely to be suicidal. Compared with the group with bipolar disorder alone, the group with comorbid disorders had significantly fewer outpatient psychiatric visits and tended to have shorter psychiatric hospitalizations. Among patients with an alcohol use disorder, those who also had bipolar disorder were significantly less likely than those with an alcohol use disorder alone to have had an alcohol-related seizure. Patients with comorbid bipolar and substance use disorders were significantly less likely than those with substance use disorder alone to be referred for intensive substance abuse treatment, even though both groups were equally likely to enter and complete treatment when they were referred. CONCLUSIONS: Despite significant functional impairment among patients with comorbid bipolar and substance use disorders, they had significantly fewer psychiatric outpatient visits than those with bipolar disorder alone and were referred for intensive substance abuse treatment significantly less often than those with substance use disorder alone.     

Axis I and axis II comorbidity in panic/agoraphobic patients with and without suicidal ideation

In view of the controversial relationship between certain aspects of panic disorder with agoraphobia (PDA), suicidal ideation and comorbidity, the purposes of this study were to compare severity of PDA and Axis I and Axis II comorbidity in PDA patients with and without suicidal ideation, and to examine predictors of suicidal ideation in these patients. Eighty-eight consecutive outpatients with PDA were administered structured diagnostic interviews for the DSM-IV Axis I and Axis II disorders (SCID-I and SCID-II), while the severity of PDA was assessed by means of the Panic Disorder Severity Scale. Of the patients, 25 (28.4%) reported suicidal ideation in past years ('ideators'). The severity of PDA was greater among ideators, and they were significantly more likely to have a personality disorder and more than one comorbid Axis I and Axis II disorder. There were no ideators without either Axis I or Axis II comorbidity. Univariate logistic regression identified several predictors of suicidal ideation: any DSM-IV Cluster C personality disorder, any DSM-IV Cluster B personality disorder, any comorbid mood disorder, and severity of PDA. With multivariate logistic regression, a combination of any Cluster C personality disorder and severity of PDA emerged as the most significant predictor of suicidal ideation. These findings have implications for clinical practice in that PDA patients should be carefully assessed for the severity of their illness and presence of certain personality disorders and comorbid mood disorders, because they may all increase the risk for suicidal ideation.