Major depression: the importance of clinical characteristics and treatment response to prognosis

Background: This article analyzed data from the intervention arm of a large treatment trial to demonstrate the importance of clinical severity, course, comorbidity, and treatment response in patient prognosis. Methods: This is a secondary analysis of data from a large primary care‐based geriatric depression treatment trial that analyzes outcomes from the measurement‐based stepped‐care intervention arm ( N =871 patients) to determine: whether increasing severity levels of depression at baseline were linked with other factors associated with poor depression outcomes such as double depression, anxiety, medical disorders, and high levels of neuroticism and pain; and whether patients with increasing levels of depressive severity would have more intervention visits and treatment trials based on a stepped‐care algorithm, but would be less likely to reach remission and have a greater likelihood of re‐emerging depression in the year after intervention. Results: Increasing levels of depression severity were a robust predictor of lack of remission and were associated with other clinical variables that have been associated with lack of remission in earlier studies such as double depression, anxiety, medical comorbidity, high neuroticism levels, and chronic pain. Patients with higher levels of severity received significantly more intervention visits, more months of antidepressant treatment and more antidepressant trials, but had fewer depression‐free days during the 12‐month intervention and in the postintervention year. Conclusion: Patients with higher levels of depression severity had worse clinical outcomes despite receiving greater intensity of treatment. A new classification of depression is proposed based on clinical severity, course of illness and treatment experience. Depression and Anxiety, 2010. © 2009 Wiley‐Liss, Inc.     

A systematic review of intervention studies about anxiety in caregivers of people with dementia

BACKGROUND: There is considerable literature on managing depression, burden and psychological morbidity in caregivers of people with dementia (CG). Anxiety has been a relatively neglected outcome measure but may require specific interventions. OBJECTIVE: To synthesise evidence regarding interventions that reduce anxiety in CGs. METHODS: Twenty-four studies met our inclusion criteria. We rated the methodology of studies, and awarded grades of recommendation (GR) for each type of intervention according to Centre for Evidence Based Medicine guidelines, from A (highest level of evidence) to D. RESULTS: Anxiety level was the primary outcome measure in only one study and no studies were predicated on a power calculation for anxiety level. There was little evidence of efficacy for any intervention. The only RCT to report significantly reduced anxiety involved a CBT and relaxation-based intervention specifically devised to treat anxiety, and there was preliminary evidence (no randomised controlled trials) that caregiver groups involving yoga and relaxation without CBT were effective. There was grade B evidence that behavioural management, exercise therapies and respite were ineffective. LIMITATIONS: Many interventions were heterogeneous, so there is some overlap between groups. Lack of evidence of efficacy is not evidence of lack of efficacy. CONCLUSIONS: CBT and other therapies developed primarily to target depression did not effectively treat anxiety. Good RCTs are needed to specifically target anxiety which might include relaxation techniques. Some of the interventions focussed on reducing contact with the care recipients but caregivers may want to cope with caring and preliminary evidence suggests strategies to help CGs manage caring demands may be more effective.     

Comorbidity of depression and anxiety disorders in later life.

Since psychiatric disorders differ throughout the lifespan in phenomenology, course, and treatment, there is need for study of comorbidity of such disorders in geriatric populations. Prior findings of low prevalence of comorbid late-life anxiety disorders in depressed elderly are now disputed by recent studies. Risk factors for comorbid late-life depression and anxiety may be different from those for depression without anxiety. Similar to adults, elderly depressives with comorbid anxiety symptoms present with more severe pathology and have a more difficult course of illness, including decreased or delayed treatment response. In this paper, we review the literature on anxiety and depression comorbidity in late life, and we make recommendations for the assessment and treatment of comorbid late-life anxiety and depression. We also recommend directions for future research in the area of psychiatric comorbidity in late life.     

Comorbid depression and anxiety spectrum disorders

The relationship between depression and anxiety disorders has long been a matter of controversy. The overlap of symptoms associated with these disorders makes diagnosis, research, and treatment particularly difficult. Recent evidence suggests genetic and neurobiologic similarities between depressive and anxiety disorders. Comorbid depression and anxiety are highly prevalent conditions. Patients with panic disorder, generalized anxiety disorder, social phobia, and other anxiety disorders are also frequently clinically depressed. Approximately 85% of patients with depression also experience significant symptoms of anxiety. Similarly, comorbid depression occurs in up to 90% of patients with anxiety disorders. Patients with comorbid disorders do not respond as well to therapy, have a more protracted course of illness, and experience less positive treatment outcomes. One key to successful treatment of patients with mixed depressive and anxiety disorders is early recognition of comorbid conditions. Antidepressant medications, including the selective serotonin reuptake inhibitors, tricyclic antidepressants, and monoamine oxidase inhibitors, are highly effective in the management of comorbid depression and anxiety. The high rates of comorbid depression and anxiety argue for well-designed treatment studies in these populations. Depression and Anxiety 4:160–168, 1996/1997. © 1997 Wiley-Liss, Inc.     

Examination of the decline in symptoms of anxiety and depression in generalized anxiety disorder: impact of anxiety sensitivity on response to pharmacotherapy

Pharmacotherapy is an effective treatment for generalized anxiety disorder (GAD), but few studies have examined the nature of decline of anxiety and depression during pharmacotherapy for GAD and even fewer studies have examined predictors of symptom decline. This study examined the decline in symptoms of anxiety and depression in patients with GAD during a 6-week open trial of fluoxetine. Growth curve analyses indicated that pharmacotherapy with fluoxetine led to significant declines in symptoms of anxiety and depression over the 6 weeks of treatment. However, the decay slope observed for anxiety symptoms was significantly greater than that for depressive symptoms. Further analyses revealed that the decline in anxiety remained significant after accounting for the changes in symptoms of depression. However, the effect of treatment on depression was no longer significant after controlling for the reduction in anxiety symptoms. Overall anxiety sensitivity (AS) did not moderate the level of reduction in symptoms of anxiety or depression during pharmacotherapy. However, AS specific to physical concerns demonstated a marginal negative association with decline in anxiety and depression. AS specific to social concerns also demonstrated a marginal negative association with decline in anxiety symptoms. These findings suggest that the decline in anxiety symptoms is independent of the decline in symptoms of depression during pharmacotherapy for GAD and specific AS dimensions may predict symptom change in GAD.     

ANXIOUS FORMS OF DEPRESSION

Previous research has described distinctive features for anxious and nonanxious forms of major depression. The concept of “mixed anxiety depression disorder” (MADD) refers to a milder degree of the anxious form of depression, since the depressive symptoms fall short of the number required for a diagnosis of major depression. It is argued that this can be thought of as a subclinical form of anxious depression, rather than a separate disorder in its own right. In view of its substantial prevalence in general medical settings, its associated disability and its public health importance, it deserves to be recognized, and seen as being continuous with the more severe forms of anxious depression. It will therefore be included in the Field Trials of the version of the ICD‐11 (where ICD is the International Classification of Disease) intended for primary care. It is argued that current anxiety, depression (without anxiety), and anxious depression would cover most of the psychologically distressed patients seen in general medical settings, using a pseudodimensional system.     

Yoga for anxiety: A systematic review and meta-analysis of randomized controlled trials

Yoga has become a popular approach to improve emotional health. The aim of this review was to systematically assess and meta-analyze the effectiveness and safety of yoga for anxiety. Medline/PubMed, Scopus, the Cochrane Library, PsycINFO, and IndMED were searched through October 2016 for randomized controlled trials (RCTs) of yoga for individuals with anxiety disorders or elevated levels of anxiety. The primary outcomes were anxiety and remission rates, and secondary outcomes were depression, quality of life, and safety. Risk of bias was assessed using the Cochrane tool. Eight RCTs with 319 participants (mean age: 30.0–38.5 years) were included. Risk of selection bias was unclear for most RCTs. Meta-analyses revealed evidence for small short-term effects of yoga on anxiety compared to no treatment (standardized mean difference [SMD] = −0.43; 95% confidence interval [CI] = −0.74, −0.11; P = .008), and large effects compared to active comparators (SMD = −0.86; 95% CI = −1.56, −0.15; P = .02). Small effects on depression were found compared to no treatment (SMD = −0.35; 95% CI = −0.66, −0.04; P = .03). Effects were robust against potential methodological bias. No effects were found for patients with anxiety disorders diagnosed by Diagnostic and Statistical Manual criteria, only for patients diagnosed by other methods, and for individuals with elevated levels of anxiety without a formal diagnosis. Only three RCTs reported safety-related data but these indicated that yoga was not associated with increased injuries. In conclusion, yoga might be an effective and safe intervention for individuals with elevated levels of anxiety. There was inconclusive evidence for effects of yoga in anxiety disorders. More high-quality studies are needed and are warranted given these preliminary findings and plausible mechanisms of action.     

The role of atypical antipsychotics in bipolar depression and anxiety disorders

Abstract:  Bipolar disorder is a complex condition that includes symptoms of mania, depression, and often anxiety. Diagnosing and treating bipolar depression is challenging, with the disorder often being diagnosed as unipolar depression. In addition, comorbid anxiety can be a significant detractor to successful outcomes, increasing symptom severity, frequency of episodes and suicide rates, and decreasing response to antidepressant therapy. Anxiety often precedes and hastens the onset of bipolar disorder, and a shared genetic etiology has been suggested. Studies have demonstrated the efficacy of atypical antipsychotics for the acute and maintenance treatment of mania. Evidence from studies in patients with treatment-resistant major depressive disorder and bipolar depression indicate that these agents may also have antidepressant effects. In open trials in patients with bipolar mania, risperidone therapy has led to significant reductions in depression scores compared with baseline. Reductions in depression scores in patients with bipolar mania have been significantly greater with olanzapine compared with placebo. In patients with bipolar depression, the combination of olanzapine and fluoxetine resulted in significant improvement in depression compared with olanzapine alone or placebo. Although little data are available on the effects of these agents on comorbid anxiety in patients with bipolar disorder, some atypical antipsychotics have demonstrated efficacy in patients with anxiety disorders, including obsessive-compulsive disorder, post-traumatic stress disorder, and generalized anxiety disorder. Thus, atypical antipsychotics represent an important therapeutic option for the treatment of bipolar disorder, providing improvements in manic, depressive, and anxiety symptoms.     

The relationship between generalized anxiety disorder, depression and mortality in old age

BACKGROUND: The association between depression and an increased risk of death in elderly persons has been established in both clinical and community studies. Co-occurrence of depression and generalized anxiety has been shown to represent more severe and more chronic psychopathology. However, little is known about the relation between generalized anxiety disorder, mixed anxiety-depression (generalized anxiety disorder and depression) and excess mortality in the elderly. OBJECTIVE: To investigate whether generalized anxiety and mixed anxiety-depression are associated with mortality. METHOD: Generalized anxiety disorder, mixed anxiety-depression and depression were assessed in 4051 older persons with a ten-year follow-up of community death registers. The mortality risk of generalized anxiety, depression and mixed anxiety-depression was calculated after adjustment for demographic variables, physical illness, functional disabilities and social vulnerability. RESULTS: In generalized anxiety disorder and mixed anxiety-depression no significant excess mortality was found. In depression a significant excess mortality was found in men [HR 1.44 (1.09-1.89)] but not in women [HR 1.04 (0.87-1.24)] after adjustment for the different variables. CONCLUSIONS: In elderly persons depression increases the risk of death in men. Neither generalized anxiety nor mixed anxiety-depression are associated with excess mortality. Generalized anxiety disorder may even predict less mortality in depressive elderly people. The relation between generalized anxiety disorder and its possibly protective effect on mortality has to be further explored.     

Impact of ethnicity on mood disorders in Parkinson's disease

Anxiety and depression are common in Parkinson's disease (PD) patients, yet their prevalence and severity compared to individuals without PD requires more research. Moreover, it has never been compared across different ethnic groups. The objective of this study was to close that gap in the literature by exploring the caseness and severity of anxiety and depression in PD patients of different ethnicities compared to controls without PD. It was found that caseness and severity of anxiety and depression are higher in individuals with PD compared to controls. Furthermore, the caseness and severity of anxiety and depression do not vary significantly among ethnic groups. Finally, depression caseness was not predicted by age, gender, disease duration, restless legs syndrome prevalence, Hoehn and Yahr (H&Y) score nor Unified Parkinson's disease rating scale part III (UPDRS-III) score. Anxiety caseness was predicted by gender, with females 2.7 times more likely to have anxiety caseness than males. Overall, our study suggests that treatment plans should be individualized based on prevalence and severity of the two conditions in individuals with PD rather than generalize treatment for specific ethnic groups.     

心理干预对癫患者焦虑抑郁情绪的影响

目的:探讨心理干预对癫患者焦虑抑郁情绪的影响。方法:对163例成人癫患者在抗癫治疗的同时实施为期3个月的心理干预;采用中文版Zung焦虑自评量表(SAS)及抑郁自评量表(SDS)分别于干预前、干预后1个月和3个月进行评定。结果:163例癫患者实施心理干预后焦虑和抑郁情绪改善显著,并随干预时间延长而显著下降。与干预前比较,干预1周,SAS及SDS评分与干预前差异无统计学意义(P=0.469、0.272);干预1个月和3个月,SAS及SDS评分与干预前比较差异有显著统计学意义(F=15.196、16.207,P均<0.001)。结论:癫患者焦虑抑郁情绪明显;心理干预能够显著改善患者焦虑抑郁情绪;干预时间越长,效果越好。     

Citalopram treatment of social anxiety disorder with comorbid major depression

Treatment of patients with both social anxiety disorder and major depression has been little studied although social anxiety disorder and depression frequently co-occur. Each disorder has been shown to respond to serotonin reuptake inhibitor treatment. Objectives of this study were to characterize a sample of these comorbid patients and to assess response to treatment with citalopram. Patients with primary DSM-IV generalized subtype of social anxiety disorder and comorbid major depression (N = 21) were assessed for symptoms of each disorder, including atypical depressive features, and functional impairment. Patients were treated with a flexible dose of open label citalopram for 12 weeks. Response rates for the intention-to-treat sample at week 12 were 14/21 (66.7%) for social anxiety disorder and 16/21 (76.2%) for depression. All continuous measures of social anxiety, depression, and functional impairment improved significantly with treatment, but depression symptoms responded more rapidly and more completely than social anxiety symptoms. Mean dose of citalopram at study endpoint was 37.6 mg/day. Only three patients (14.3%) fulfilled DSM-IV criteria for atypical features of depression, although 18 (85.7%) fulfilled the criterion for interpersonal rejection sensitivity. Citalopram treatment may benefit patients with primary social anxiety disorder and comorbid major depression, and it should be further studied in controlled trials. Improvement in social anxiety disorder symptoms lagged behind improvement in depression, and greater than 12 weeks of treatment may be required to assess full social anxiety response in patients with comorbid depression. The overlap of social anxiety disorder with atypical features of depression may primarily be due to the shared feature of rejection sensitivity.     

玉树地震后罹患创伤后应激障碍、焦虑症和抑郁症调查

目的:调查玉树地震后不同人群创伤后应激障碍(PTSD)、焦虑症、抑郁症的发生情况。方法:抽取震后灾区人群、其非灾区的亲属人群、灾区救援人群及非灾区人群为对象,每一人群进行随机分成两组,第1组每周进行1次集体心理干预;第2组每周进行3次集体心理干预。采用PTSD检查量表平民版(PCL-C)、焦虑自评量表(SAS)、抑郁自评量表(SDS)对不同人群在3个月、6个月进行问卷调查。结果:各人群在干预3个月和6个月均检出PTSD、焦虑症、抑郁症。各人群中第2组干预6个月时PTSD、焦虑症、抑郁症检出率明显低于干预3个月时(P均0.05)。结论:震后不同人群均存有PTSD、焦虑症、抑郁症发生;随着时间推移及积极干预可明显降低其发生。     

社工员干预对住院精神分裂症患者情绪的影响

目的：探讨医务社会工作人员（社工员）干预对住院精神分裂症患者焦虑、抑郁情绪的影响。方法：将79例伴有焦虑、抑郁情绪的恢复期精神分裂症患者随机分成研究组（服用抗精神病药联合社工员干预治疗）40例和对照组（单用抗精神病药治疗）39例。每周干预5次,每次2h,共2个月。以汉密尔顿抑郁量表（HAMD）、汉密尔顿焦虑量表（HAMA）及自知力和治疗态度问卷（ITAQ）在干预前、后进行评定比较。结果：干预后研究组HAMD、HAMA评分均较干预前显著降低（P均〈0.01）,ITAQ评分较干预前显著增高（P〈0.01）;两组间比较差异有统计学意义（P〈0.05或P〈0.01）。结论：社工员的干预对住院精神分裂症患者焦虑抑郁情绪的改善及治疗态度的好转有明显作用。     

Genetics of anxiety disorders: the complex road from DSM to DNA

Anxiety disorders are among the most common psychiatric disorders, affecting one in four individuals over a lifetime. Although our understanding of the etiology of these disorders is incomplete, familial and genetic factors are established risk factors. However, identifying the specific casual genes has been difficult. Within the past several years, advances in molecular and statistical genetic methods have made the genetic dissection of complex disorders a feasible project. Here we provide an overview of these developments, with a focus on their implications for genetic studies of anxiety disorders. Although the genetic and phenotypic complexity of the anxiety disorders present formidable challenges, advances in neuroimaging and experimental animal models of anxiety and fear offer important opportunities for discovery. Real progress in identifying the genetic basis of anxiety disorders will require integrative approaches that make use of these biologic tools as well as larger‐scale genomic studies. If successful, such efforts may yield novel and more effective approaches for the prevention and treatment of these common and costly disorders. Depression and Anxiety, 2009. © 2009 Wiley‐Liss, Inc.     

Symptomatic and syndromal anxiety and depression.

The diagnosis of anxiety disorders and major depression can be reliably made based on signs and symptoms. However there are significant limitations to the current system of classification including overlapping criteria, high comorbidity, and the issue of subthreshold syndromes. The literature on treatment response documents that selective serotonin reuptake inhibitors are effective in the treatment of the various anxiety disorders, including when comorbid major depression is present. The literature also suggests that tricyclic antidepressant medications have superior benefits over selective serotonin reuptake inhibitors in major depression. Examination of the functional anatomy of the fear and reward systems may shed light on the underlying processes in the anxiety and depressive disorders. Such an approach points out the importance of addressing avoidance behaviors, which may be more responsive to cognitive behavioral treatments than pharmacological agents.     

癫(疒间)患者焦虑抑郁情绪研究

目的:探讨癫(疒间)患者焦虑抑郁情绪的有关因素. 方法:80例成年癫疒间患者,前期诊疗不规范,采用焦虑自评量表(SAS)和抑郁自评量表(SDS)评估. 结果:癫疒间合并焦虑情绪者25%,合并抑郁情绪者45%.多因素回归分析结果显示,病程越长,发作程度越严重,男性患者更易产生焦虑情绪,而居住在农村的癫疒间患者更易产生抑郁情绪. 结论:癫疒间患者焦虑抑郁情绪明显高于正常人群,性别、病程、发作严重程度和生活居住地是影响癫疒间患者焦虑抑郁情绪的独立危险因素.     

Optimizing exposure‐based CBT for anxiety disorders via enhanced extinction: Design and methods of a multicentre randomized clinical trial

Exposure‐based psychological interventions currently represent the empirically best established first line form of cognitive‐behavioural therapy for all types of anxiety disorders. Although shown to be highly effective in both randomized clinical and other studies, there are important deficits: (1) the core mechanisms of action are still under debate, (2) it is not known whether such treatments work equally well in all forms of anxiety disorders, including comorbid diagnoses like depression, (3) it is not known whether an intensified treatment with more frequent sessions in a shorter period of time provides better outcome than distributed sessions over longer time intervals. This paper reports the methods and design of a large‐scale multicentre randomized clinical trial (RCT) involving up to 700 patients designed to answer these questions. Based on substantial advances in basic research we regard extinction as the putative core candidate model to explain the mechanism of action of exposure‐based treatments. The RCT is flanked by four add‐on projects that apply experimental neurophysiological and psychophysiological, (epi)genetic and ecological momentary assessment methods to examine extinction and its potential moderators. Beyond the focus on extinction we also involve stakeholders and routine psychotherapists in preparation for more effective dissemination into clinical practice.     

癫患者焦虑抑郁情绪研究

目的：探讨癫癎患者焦虑抑郁情绪的有关因素。方法：80例成年癫癎患者，前期诊疗不规范，采用焦虑自评量表（SAS）和抑郁自评量表（SDS）评估。结果：癫癎合并焦虑情绪者25％，合并抑郁情绪者45％。多因素回归分析结果显示，病程越长，发作程度越严重，男性患者更易产生焦虑情绪，而居住在农村的癫癎患者更易产生抑郁情绪。结论：癫癎患者焦虑抑郁情绪明显高于正常人群，性别、病程、发作严重程度和生活居住地是影响癫癎患者焦虑抑郁情绪的独立危险因素。