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Anxiety Disorders TECHNICAL COMMENTARY Anxiety disorders Introduction excluded from the library. The PRISMA flow diagram is a suggested way of providing Anxiety disorders are a group of mental information about studies included and disorders characterised by excessive fear or excluded with reasons for exclusion. Where no worrying. It is important to recognise comorbid flow diagram has been presented by individual anxiety as it may influence treatment strategies reviews, but identified studies have been and outcomes. described in the text, reviews have been Anxiety disorders include generalised anxiety checked for this item. Note that early reviews disorder, which is characterised by continuous may have been guided by less stringent and excessive worrying for six months or more. reporting checklists than the PRISMA, and that Specific phobias are characterised by anxiety some reviews may have been limited by journal provoked by a feared object/situation, resulting guidelines. in avoidance. Social phobia is anxiety provoked Evidence was graded using the Grading of by social or performance situations. Recommendations Assessment, Development Agoraphobia is anxiety about situations where and Evaluation (GRADE) Working Group escape may be difficult or help might not be approach where high quality evidence such as available. Panic disorder is characterised by a that gained from randomised controlled trials panic attack, which is a distinct episode where (RCTs) may be downgraded to moderate or low a person experiences sudden apprehension if review and study quality is limited, if there is and fearfulness, where they may present with inconsistency in results, indirect comparisons, shortness of breath, palpitations, chest pain or imprecise or sparse data and high probability of choking. reporting bias. It may also be downgraded if Method risks associated with the intervention or other matter under review are high. Conversely, low We have included only systematic reviews quality evidence such as that gained from (systematic literature search, detailed observational studies may be upgraded if effect methodology with inclusion/exclusion criteria) sizes are large or if there is a dose dependent published in full text, in English, from the year response. We have also taken into account 2010 that report results separately for people sample size and whether results are consistent, with a diagnosis of bipolar or related disorders. precise and direct with low associated risks Reviews were identified by searching the (see end of table for an explanation of these databases MEDLINE, EMBASE, and terms)2. The resulting table represents an PsycINFO. Hand searching reference lists of objective summary of the available evidence, identified reviews was also conducted. When although the conclusions are solely the opinion multiple copies of review topics were found, of staff of NeuRA (Neuroscience Research only the most recent and/or comprehensive Australia). review was included. Reviews with pooled data were prioritised for inclusion. Review reporting assessment was guided by the Preferred Reporting Items for Systematic Results Reviews and Meta-Analyses (PRISMA) We found six systematic reviews that met our checklist that describes a preferred way to inclusion criteria3-8. present a meta-analysis1. Reviews with less than 50% of items checked have been NeuRA Anxiety disorders October 2018 Margarete Ainsworth Building, Barker Street, Randwick NSW 2031. Phone: 02 9399 1000. Email: [email protected] Page 1 To donate, phone 1800 888 019 or visit www.neura.edu.au TECHNICAL COMMENTARY Anxiety disorders • Moderate quality evidence suggests the lifetime prevalence of anxiety disorders in people with bipolar disorder is around 45%, and the current prevalence in people in the euthymic phase is around 35%. These rates are significantly higher than in people without bipolar disorder. The most common anxiety disorders were; generalised, social anxiety, specific phobias, and panic disorders. • Moderate to low quality evidence suggests the prevalence of anxiety disorders in children or youth with bipolar disorder is around 54%. The most common anxiety disorders were; generalised and separation anxiety disorders. • Moderate quality evidence suggests an early age of onset of bipolar disorder is associated with an increased risk of comorbid anxiety disorders. • Moderate to low quality evidence suggests cognitive behavioural therapy is effective for improving anxiety symptoms in people with bipolar disorder. NeuRA Anxiety disorders October 2018 Margarete Ainsworth Building, Barker Street, Randwick NSW 2031. Phone: 02 9399 1000. Email: [email protected] Page 2 To donate, phone 1800 888 019 or visit www.neura.edu.au TECHNICAL COMMENTARY Anxiety disorders Frias A, Palma C, Farriols N Comorbidity in pediatric bipolar disorder: prevalence, clinical impact, etiology and treatment Journal of Affective Disorders 2015; 174: 378-89 View review abstract online Comparison Anxiety disorders in children and youth with bipolar disorder. Summary of evidence Moderate to low quality evidence (unclear sample size, inconsistent, imprecise, direct) suggests the overall prevalence of anxiety disorders, particularly generalised or separation anxiety, in children or youth with bipolar disorder is around 54%. Anxiety disorders 7 studies, N = not reported, overall mean prevalence rate = 54%, range 41% to 80% Rates were higher in prospective studies than in cross-sectional studies, and most studies found higher rates of generalized anxiety disorder and/or separation anxiety disorder than other anxiety disorders. Consistency in results Authors report the data are inconsistent. Precision in results Appears imprecise Directness of results Direct Joslyn C, Hawes DJ, Hunt C, Mitchell PB Is age of onset associated with severity, prognosis, and clinical features in bipolar disorder? A meta-analytic review Bipolar Disorders 2016; 18: 389-403 View review abstract online Comparison Association between an early age of onset of bipolar disorder and comorbid anxiety disorders. Summary of evidence Moderate quality evidence (large samples, inconsistent and imprecise, direct) suggests an early age of onset of bipolar NeuRA Anxiety disorders October 2018 Margarete Ainsworth Building, Barker Street, Randwick NSW 2031. Phone: 02 9399 1000. Email: [email protected] Page 3 To donate, phone 1800 888 019 or visit www.neura.edu.au TECHNICAL COMMENTARY Anxiety disorders disorder is associated with an increased risk of comorbid anxiety disorders. Anxiety disorders Significant, small effect of increased risk of anxiety disorders in people with an early age of onset of bipolar disorder; 10 studies, N = 4,841, OR = 1.72, 95%CI 1.34 to 2.19, p < 0.001, I2 = 64% Consistency in results Inconsistent Precision in results Imprecise Directness of results Direct Pavlova B, Perlis RH, Alda M, Uher R Lifetime prevalence of anxiety disorders in people with bipolar disorder: a systematic review and meta-analysis The Lancet Psychiatry 2015; 2: 710-7 View review abstract online Comparison Prevalence of anxiety disorders in people with bipolar disorder. Summary of evidence Moderate quality evidence (large samples, inconsistent, imprecise, direct) suggests the lifetime prevalence of anxiety disorders in people with bipolar disorder is around 45%, which is significantly higher than in people without bipolar disorder. The most common anxiety disorders were; generalised, social phobia, and panic disorders. Anxiety disorders Lifetime prevalence: 40 studies, N = 14,914, 45%, 95%CI 40% to 51%, I2 = 98% The most common lifetime anxiety disorders were generalised anxiety disorder (20%), social phobia (20%), and panic disorder (19%). Significant, medium-sized increased risk of anxiety disorders in people with bipolar disorder than in people without bipolar disorder; 5 studies, N = 58,190, RR = 3.22, 95%CI 2.41 to 4.29, p < 0.0001, I2 = 98% No significant differences in anxiety disorders in people with bipolar I or bipolar II disorders; NeuRA Anxiety disorders October 2018 Margarete Ainsworth Building, Barker Street, Randwick NSW 2031. Phone: 02 9399 1000. Email: [email protected] Page 4 To donate, phone 1800 888 019 or visit www.neura.edu.au TECHNICAL COMMENTARY Anxiety disorders 13 studies, N = 6,209, RR = 1.07, 95%CI 0.96 to 1.20, p = 0.223, I2 = 71% Consistency in results Inconsistent Precision in results Imprecise for vs. control comparison, precise for bipolar I vs. II comparison. Directness of results Direct Pavlova B, Perlis RH, Mantere O, Sellgren CM, Isometsa E, Mitchell PB, Alda M, Uher R Prevalence of current anxiety disorders in people with bipolar disorder during euthymia: a meta-analysis Psychological Medicine 2017; 47: 1107-15 View review abstract online Comparison Prevalence of anxiety disorders in people with bipolar disorder during euthymia. Summary of evidence Moderate quality evidence (large samples, inconsistent, imprecise, direct) suggests the current prevalence of anxiety disorders in people with bipolar disorder during euthymia is around 35%, which is significantly higher than in people without bipolar disorder. The most common anxiety disorders were; generalised, social anxiety, and specific phobia disorders. Anxiety disorders Current prevalence: 10 studies, N = 2,120, 34.7%, 95%CI 23.9% to 45.5%, I2 = 96% The most common lifetime anxiety disorders were generalised anxiety disorder (11.6%), social anxiety disorder (9.7%), and specific phobia (9.7%). Significant, medium to large increased risk of anxiety disorders in people with bipolar disorder
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