Comorbid anxiety in bipolar CHOICE: Insights from the bipolar inventory of symptoms scale

J Affect Disord. 2019 Mar 1:246:126-131. doi: 10.1016/j.jad.2018.12.039. Epub 2018 Dec 18.


Background: Approximately 86-89% of patients with BD have a comorbid anxiety disorder associated with poor quality of life and reduced likelihood of recovery from an acute mood episode. The purpose of this study is to assess the prevalence and impact of comorbid anxiety using the Bipolar Inventory of Symptoms Scale (BISS) in patients with BD who participated in a 6-month pragmatic trial.

Methods: Participants (N = 482) in the Bipolar Clinical Health Outcomes Initiative in Comparative Effectiveness (CHOICE) study were adults with BD I or II. Anxiety diagnoses were assessed with the MINI. Global illness severity was assessed using the Clinical Global Impression-Bipolar Version. Mood symptoms and anxiety severity were assessed using the BISS.

Results: 61% of the study sample met criteria for a current anxiety disorder. Patients with a higher BISS anxiety score at baseline had a higher overall BD illness severity, depressive severity, and manic episode severity (p < 0.001). A single cutoff value of BISS anxiety had great sensitivity, yet poor specificity for determining a comorbid anxiety diagnosis. There were no significant differences in outcomes for individuals treated for anxiety disorders with anxiolytics compared with those who were not treated with anxiolytics.

Limitations: Sample size limitations prevented an analysis of whether the BISS cutoff score of 10 performed differently across varied anxiety disorders.

Conclusions: Given its ability to identify patients with co-occurring anxiety, the BISS anxiety subscale shows clinical utility as a screening measure though its application as a clinical assessment measure may not be advisable.

Keywords: Anxiety disorders; Bipolar disorder; Bipolar inventory of symptoms scale; Comparative effectiveness research; Mood disorders.

Publication types

  • Multicenter Study
  • Pragmatic Clinical Trial
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adult
  • Anti-Anxiety Agents / therapeutic use
  • Antipsychotic Agents / therapeutic use
  • Anxiety Disorders / diagnosis*
  • Anxiety Disorders / drug therapy
  • Anxiety Disorders / epidemiology*
  • Bipolar Disorder / diagnosis*
  • Bipolar Disorder / drug therapy
  • Bipolar Disorder / epidemiology*
  • Comorbidity
  • Comparative Effectiveness Research
  • Female
  • Humans
  • Lithium / therapeutic use
  • Male
  • Middle Aged
  • Prevalence
  • Psychiatric Status Rating Scales*
  • Quality of Life
  • Quetiapine Fumarate / therapeutic use
  • Sensitivity and Specificity
  • Severity of Illness Index
  • Treatment Outcome
  • United States / epidemiology


  • Anti-Anxiety Agents
  • Antipsychotic Agents
  • Quetiapine Fumarate
  • Lithium