Dr. Michael J. Ostacher wrote:

I think all the branded atypicals are approved for the treatment of mania in bipolar disorder, either monotherapy or as adjunctive treatment. Only aripiprazole and ziprasidone are not approved for adjunctive treatment at this point. Those are drugs that are routinely used in bipolar disorder, specifically for anxiety. It’s quite difficult to recommend those drugs directly for the treatment of anxiety in people with bipolar disorder in the absence of data.

There are some data from the quetiapine depression study that suggests that anxiety scores drop considerably, but there are other studies that are ongoing. We are doing a study at Mass General, an investigator-initiated trial that Naomi Simon is the principal investigator of and for which I’m the co-principal investigator, of ziprasidone added to adequate mood stabilizers for the treatment of generalized anxiety disorder in people with bipolar disorder, and that is the only current study that I’m aware of that’s looking specifically at that issue.

Tardive dyskinesia is not my biggest concern when using these drugs with people with bipolar disorder. My major concerns are metabolic effects of the drug. All of these drugs have warnings in them about diabetes and cholesterol problems, even though clearly there are some drugs that are more problematic when it comes to that than others. If people have patients who are being treated, who have persistent anxiety, who are not being treated with atypicals, I think given the approval of those drugs for use in bipolar disorder, it’s probably reasonable to try them. At this point, though, because of the absence of data, I could not make a recommendation as to which one might be better than others, because none is specifically studied in a way that is designed to answer the question directly. There’s some quetiapine data available, but beyond that it’s not completely clear to me that one would be better than the other.

So I don’t think it’s unreasonable to use those to treat anxiety and to do it empirically. I think that we need to share with the patients the potential risks of using those drugs, especially when it’s for a use for which we don’t have very much data, but at the same time I think it’s perfectly reasonable to do so.

-Michael J. Ostacher, MD, MPH
Associate Medical Director,
Bipolar and Research Program,
Massachusetts General Hospital;
Instructor in Psychiatry, Harvard Medical School