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Original Research

Comorbid Anxiety in Children and Adolescents With Bipolar Spectrum Disorders: Prevalence and Clinical Correlates

Regina Sala, MD; David A. Axelson, MD; Josefina Castro-Fornieles, MD, PhD; Tina R. Goldstein, PhD; Wonho Ha, PhD; Fangzi Liao, MS; Mary Kay Gill, MSN; Satish Iyengar, PhD; Michael A. Strober, PhD; Benjamin I. Goldstein, MD, PhD; Shirley Yen, PhD; Heather Hower, MSW; Jeffrey Hunt, MD; Neal D. Ryan, MD; Daniel Dickstein, MD; Martin B. Keller, MD; and Boris Birmaher, MD

Published: September 7, 2010

Article Abstract

Objective: Anxiety disorders are among the most common comorbid conditions in youth with bipolar disorder. We aimed to examine the prevalence and correlates of comorbid anxiety disorders among youth with bipolar disorder.

Method: As part of the Course and Outcome of Bipolar Youth study, 446 youth, ages 7 to 17 years, who met DSM-IV criteria for bipolar I disorder (n = 260) or bipolar II disorder (n = 32) or met operationalized criteria for bipolar disorder not otherwise specified (n = 154) were included. Subjects were evaluated for current and lifetime Axis I psychiatric disorders at intake using the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Aged Children-Present and Lifetime version, and standardized instruments were used to assess functioning and family history.

Results: Forty-four percent (n = 194) of the sample met DSM-IV criteria for at least 1 lifetime anxiety disorder, most commonly separation anxiety (24%) and generalized anxiety disorders (16%). Nearly 20% met criteria for 2 or more anxiety disorders. Overall, anxiety disorders predated the onset of bipolar disorder. Subjects with bipolar II disorder were more likely than subjects with bipolar I disorder or bipolar disorder not otherwise specified to have a comorbid anxiety disorder. After adjusting for confounding factors, youth with bipolar disorder with anxiety were more likely to have bipolar II disorder; longer duration of mood symptoms; more severe ratings of depression; and family history of depression, hopelessness, and somatic complaints during their worst lifetime depressive episode than those without anxiety.

Conclusions: Comorbid anxiety disorders are common in youth with bipolar disorder, and they most often predate bipolar disorder onset. Bipolar II disorder, a family history of depression, and more severe lifetime depressive episodes distinguish youth with bipolar disorder with comorbid anxiety disorders from those without. Careful consideration should be given to the assessment of comorbid anxiety in youth with bipolar disorder.

J Clin Psychiatry

Submitted: November 20, 2009; accepted April 13, 2010.

Online ahead of print: September 7, 2010 (doi:10.4088/JCP.09m05845gre).

Corresponding author: Regina Sala, MD, University of Pittsburgh, Western Psychiatric Institute and Clinic, 100 N Bellefield Ave, No. 542, Pittsburgh, PA 15213 (

Volume: 71

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