Clinical Significance of Lifetime Panic Spectrum Symptoms in the Treatment of Patients With Bipolar I Disorder
Frank E, Cyranowski JM, Rucci P, Shear MK, Fagiolini A, Thase ME, Cassano GB, et al.;
Commented by , 22 Nov 2002
Aim of the study
To evaluate the prevalence and the impact of panic symptoms on the clinical course and treatment outcome in patients with bipolar I disorder (BPI).
Method
Participants were 66 outpatients meeting Research Diagnostic Criteria for BPI disorder. Patients were included during an acute affective episode (33 depressive, 21 manic, 12 mixed-cycling) and followed up to remission. Treatment consisted in algorithm-based pharmacotherapy accompanied by either intensive clinical management or interpersonal and social rhythm therapy.
Patients were assessed weekly throughout treatment. Severity of depressive symptoms were rated on the 17-item version of the Hamilton Depression Rating Scale (HDRS). Severity of manic symptoms were rated on the 12-item Bech-Rafaelsen Mania Scale.
Full remission was defined by an average HDRS score of 7 or less and an average Bech-Rafaelsen Mania Scale score of 7 or less over a period of 4 consecutive weeks. Current status and life-time history of BPI disorder were assessed with the Structured Clinical Interview for DSM-IV (SCID-IV).
Patients were assessed for lifetime experience of panic-agoraphobic symptoms with the Panic-Agoraphobic Spectrum-Self-Report (PAS-SR), which comprises 114-items referring to typical and atypical manifestations of panic disorder as well as to other related, subtler, manifestations of the core condition.
Using a cut-off score of 35, half of the patients were categorized as low PAS-SR scorers (median score 19) and half as high PAS-SR scorers (median score 52.
Results
Patients with high PAS-SR scores:
1) were significantly more likely to be female,
2) reported significantly more lifetime depressive episodes,
3) had significantly higher baseline HDRS scores,
4) reported significantly more often suicidal ideation, and
5) had a significantly longer median time to remission.
Discussion
There is a high prevalence of current and/or lifetime panic disorder in patients with BPI disorder. In addition, as shown in the present study, many more patients with BPI disorder present with panic symptoms not meeting the full criteria for panic disorder (the prevalence of panic symptoms was 4 times as great as that of panic disorder).
The presence of panic symptoms has a major impact on the severity of depressive episodes in patients with BPI. Patients with panic symptoms have higher levels of depression, a greater risk of suicidality, and more depressive episodes during their life.
The most striking finding of the study concerns the impact of panic symptoms on the course of depressive episodes in patients with BPI disorder. Patients with panic symptoms had a much longer time to remission of depressive episodes, as shown by a delay of 6 months to remission with acute treatment in patients with high panic symptom scores vs only 4 months in patients with low panic symptom scores.
The study presents two important limitations: first, it relies on a small sample of patients and second, the assessments of panic symptoms was retrospective.
In spite of these limitations, this is an important study that should be taken into consideration in the acute as well as in the long-term treatment of patients with BPI disorder.