Comorbidity in bipolar disorders: Introduction - Simple and Practical Mental Health

By Joseph F. Goldberg, MD (bio)

Patients with a bipolar disorder often present with one or more additional psychiatric, substance use, or other medically comorbid conditions.

How common are comorbid diagnoses in bipolar disorders?

Two-thirds to three-quarters of bipolar disorder patients assessed in large naturalistic studies have at least one comorbid diagnosis, while one-quarter to one-third have three or more comorbidities (McElroy et al., 2001; Simon et al., 2004).

Which comorbid diagnoses are most common?

Such complex presentations often involve obsessive-compulsive disorder (OCD), alcohol and substance use disorders, anxiety disorders, attention deficit-hyperactivity disorder (ADHD), eating disorders, and posttraumatic stress disorder (PTSD).

There are several reasons why these comorbid diagnoses are important.

Diagnostic confusion

Comorbid diagnoses likely contribute to diagnostic confusion and delays (often of many years) until an “accurate” diagnosis of bipolar disorder is made (Hirschfeld et al., 2003). Sometimes, “inaccurate” diagnoses are simply due to diagnosing only the comorbid disorder but not the bipolar disorder. Symptoms of the comorbid disorder may vie for an evaluator’s attention, especially if symptoms of the comorbid condition seem more prominent than those of past manias or hypomanias. Overlapping, non-pathognomonic symptoms across disorders (e.g., inattention, anxious distress, impulsivity, affective instability) makes accurate diagnoses all the more difficult in the world of comorbidity, following the DSM-5 dictum that symptoms of one disorder should not be better accounted for by another.

Course, outcome, and treatment implications

In a series of short articles on other pages on this website (see Related Pages below) I will discuss the prevalence and extent of identifiable psychiatric comorbidities in adults with bipolar disorder, the ramifications of specific comorbidities on course and outcome, and most importantly, the implications of comorbidities for psychopharmacological and psychosocial treatment and management. The presence of another diagnosis with a bipolar disorder often changes the recommended treatment of the bipolar disorder, the comorbid diagnosis, or both.

Editor: Let’s make sure that we specifically SCREEN all patients with bipolar disorders for comorbid diagnoses AND specifically LIST these comorbid conditions in the official diagnoses so that we and others keep them in mind in planning treatment in both the short-term and the long-term.

Bipolar disorder with comorbid obsessive-compulsive disorder

Bipolar disorder with comorbid attention-deficit/ hyperactivity disorder (Coming soon)

The Manic-Panic Connection: Comorbid Bipolar Disorder and Panic Disorder

Bipolar disorder with comorbid panic disorder: Treatment

YOU ask the Expert: Bipolar disorders (Joseph Goldberg, MD)

Pearls in treating bipolar depression: Interview with Joseph Goldberg, MD

References

Hirschfeld RM, Lewis L, Vornik LA. Perceptions and impact of bipolar disorder: how far have we really come? Results of the national depressive and manic-depressive association 2000 survey of individuals with bipolar disorder. J Clin Psychiatry. 2003 Feb;64(2):161-74. PubMed PMID: 12633125.

McElroy SL, Altshuler LL, Suppes T, Keck PE Jr, Frye MA, Denicoff KD, Nolen WA, Kupka RW, Leverich GS, Rochussen JR, Rush AJ, Post RM. Axis I psychiatric comorbidity and its relationship to historical illness variables in 288 patients with bipolar disorder. Am J Psychiatry. 2001 Mar;158(3):420-6. PubMed PMID: 11229983.

Simon NM, Otto MW, Weiss RD, Bauer MS, Miyahara S, Wisniewski SR, Thase ME, Kogan J, Frank E, Nierenberg AA, Calabrese JR, Sachs GS, Pollack MH; STEP-BD Investigators. Pharmacotherapy for bipolar disorder and comorbid conditions: baseline data from STEP-BD. J Clin Psychopharmacol. 2004 Oct;24(5):512-20. PubMed PMID: 15349007.

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