Effectiveness of a meditation-based stress management program as an adjunct to pharmacotherapy in patients with anxiety disorder

OBJECTIVE: The objective of this study was to examine the effectiveness of a meditation-based stress management program in patients with anxiety disorder. METHODS: Patients with anxiety disorder were randomly assigned to an 8-week clinical trial of either a meditation-based stress management program or an anxiety disorder education program. The Hamilton Anxiety Rating Scale (HAM-A), the Hamilton Depression Rating Scale (HAM-D), the State-Trait Anxiety Inventory (STAI), the Beck Depression Inventory, and the Symptom Checklist--90-Revised (SCL-90-R) were used to measure outcome at 0, 2, 4, and 8 weeks of the program. RESULTS: Compared to the education group, the meditation-based stress management group showed significant improvement in scores on all anxiety scales (HAM-A, P=.00; STAI state, P=.00; STAI trait, P=.00; anxiety subscale of SCL-90-R, P=.00) and in the SCL-90-R hostility subscale (P=.01). Findings on depression measures were inconsistent, with no significant improvement shown by subjects in the meditation-based stress management group compared to those in the education group. The meditation-based stress management group did not show significant improvement in somatization, obsessive-compulsive symptoms, and interpersonal sensitivity scores, or in the SCL-90-R phobic anxiety subscale compared to the education group. CONCLUSIONS: A meditation-based stress management program can be effective in relieving anxiety symptoms in patients with anxiety disorder. However, well-designed, randomized, and controlled trials are needed to scientifically prove the worth of this intervention prior to treatment.     

Pharmacologic treatment of anxiety disorders in 1989 versus 1996: results from the Harvard/Brown anxiety disorders research program

OBJECTIVE: This article reports on the pharmacologic treatment of patients diagnosed with generalized anxiety disorder (GAD) enrolled in a naturalistic long-term study of anxiety disorders, with enrollment in 1989 through 1991 and follow-up in 1996. METHOD: 711 patients were enrolled in the study during 1989-1991. At intake, 167 patients met DSM-III-R criteria for GAD; at 1996 follow-up, 103 patients met these criteria. The patients were divided into 3 groups by diagnosis: GAD alone (N = 18 at intake, N =11 at follow-up), GAD comorbid with another anxiety disorder (N = 84 at intake, N = 52 at follow-up), and GAD comorbid with Research Diagnostic Criteria-defined major depressive disorder, with or without another anxiety disorder (N = 65 at intake, N = 40 at follow-up). The groups were evaluated at intake and follow-up on whether they received medication and the types of medication they received. RESULTS: Nearly one third of patients in the 1989-1991 sample were not receiving any medication for treatment of their anxiety disorder; in 1996, 27% of patients still were receiving no medication. There was a decrease in benzodiazepine treatment and an increase in antidepressant treatment in 1996 for GAD patients who did not have comorbid depression or another anxiety disorder. CONCLUSION: The finding of one quarter to one third of patients with GAD receiving no medication is consistent with previous observations of undertreatment of depression. The findings on medication type suggest a shift in the type of medications being prescribed for treatment of GAD from exclusive benzodiazepine treatment to the combination of benzodiazepine and antidepressant treatment.     

Fluvoxamine in the treatment of anxiety disorders

Fluvoxamine is a selective-serotonin reuptake inhibitor (SSRI) that has proved effective in large double-blind, randomized, controlled trials involving patients with social anxiety disorder (SAD), obsessive-compulsive disorder (OCD), and panic disorder. Improvements have also been demonstrated in patients with post-traumatic stress disorder, as well as those with a range of obsessive-compulsive spectrum disorders including binge eating disorder, bulimia nervosa, pathological gambling, and body dysmorphic disorder. Several well controlled studies have confirmed the efficacy of fluvoxamine in children and adolescents with OCD, SAD, and other anxiety disorders, and it was the first SSRI to be registered for the treatment of OCD in children. Fluvoxamine is well tolerated. In common with other SSRIs, the most frequently reported adverse event is nausea. Fluvoxamine does not cause sedation or cognitive impairment and is associated with a low risk of sexual dysfunction, suicidality, and withdrawal reactions. It is safe in overdose and has no significant effect on body weight or cardiovascular parameters.     

Sertraline in the treatment of anxiety disorders

Sertraline was first developed and approved for the treatment of depression. However, considerable research has been conducted on its use in anxiety disorders. This paper reviews the data emerging from controlled and open trials of the use of sertraline in anxiety disorders. Sertraline has been tested extensively in the treatment of panic and obsessive-compulsive disorders. Less extensive testing has been completed on social phobia and post-traumatic stress disorder. The reviewed studies show that sertraline is an effective and well-tolerated treatment of all of these disorders. A comparison of sertraline with other pharmacotherapeutic options shows it to be at least equivalent to other medications for anxiety disorders.     

Venlafaxine in the treatment of anxiety disorders

Venlafaxine extended-release (Effexor XR, Wyeth-Ayerst Co.) is a novel, dual acting serotonin-norepinephrine reuptake inhibitor antidepressant, which inhibits the synaptic reuptake of both serotonin and norepinephrine. Controlled trials have demonstrated the efficacy and safety of venlafaxine in the treatment of anxiety disorders including social anxiety disorder, generalized anxiety disorder, post-traumatic stress disorder, panic disorder and obsessive-compulsive disorder. Generally well-tolerated with side effects that usually abate with continued treatment, venlafaxine is an important alternative to the selective serotonin reuptake inhibitors for patients with anxiety disorders.     

Selective reduction in amygdala volume in pediatric anxiety disorders: a voxel-based morphometry investigation.

BACKGROUND: Significant controversy has emerged concerning pediatric anxiety disorders. Some researchers question the justification for diagnosing and treating pediatric anxiety disorders, owing to concerns about the inappropriate medicalization of social problems. Others note the importance of diagnosis and treatment, given that pediatric anxiety disorders represent a strong risk factor for serious adult mental disorders. We examine the neural correlates of pediatric anxiety disorders, to consider the validity of the categorization scheme used in recent treatment studies. METHODS: Using inclusion criteria derived from recent treatment trials, we compared gray matter volume throughout the brain in children with and without anxiety. Morphometric analyses used optimized voxel-based morphometry, an automated method for examining structural changes throughout the brain. RESULTS: Reductions in left amygdala gray matter volume were noted for patients with anxiety disorders relative to comparison subjects. CONCLUSIONS: We discuss implications of these findings for current controversies.     

Clinical effectiveness of a cognitive behavioral group treatment program for anxiety disorders: A benchmarking study

Previous research has established efficacy of cognitive behavioral therapy (CBT) for anxiety disorders, yet it has not been widely assessed in routine community clinic practices. Efficacy research sacrifices external validity to achieve maximum internal validity. Recently, effectiveness research has been advocated as more ecologically valid for assessing routine clinical work in community clinics. Furthermore, there is a lack of effectiveness research in group CBT. This study aims to extend existing research on the effectiveness of CBT from individual therapy into group therapy delivery. It aimed also to examine outcome using not only symptom measures, but also measures of related symptoms, cognitions, and life quality and satisfaction. Results from a cohort of patients with various anxiety disorders demonstrated that treatment was effective in reducing anxiety symptoms to an extent comparable with other effectiveness studies. Despite this, only 43% of individuals showed reliable change, and 17% were ‘recovered’ from their anxiety symptoms, and the post-treatment measures were still significantly different from the level of anxiety symptoms observed in the general population.     

Pharmacologic treatment of anxiety disorders

The benzodiazepines and the beta-adrenergic blockers are effective in the treatment of anxiety neurosis (generalized anxiety disorder and panic disorder) but offer little help in the treatment of agoraphobia and obsessive-compulsive disorders. The antidepressants are often effective in agoraphobia and obsessive-compulsive disorders, and the evidence suggests that their antipanic and antiobsessional effects may be independent of their antidepressant properties. There is suggestive evidence linking the antiobsessional effect to a specific neurotransmitter (serotonin) system.     

Comorbidity in childhood anxiety disorders and treatment outcome.

OBJECTIVE: Psychiatric comorbidity is common in anxious children. The purpose of this study was to investigate the impact of comorbidity on treatment outcome in anxious children. METHOD: Participants were 173 children between the ages of 8 and 13 years who met primary DSM-III-R/DSM-IV diagnoses of separation anxiety disorder, overanxious disorder/generalized anxiety disorder, or avoidant disorder/social phobia assessed by the Anxiety Disorders Interview Schedule for Children (ADIS-C). The majority (79%) had at least one comorbid diagnosis. Participants were randomly assigned to cognitive-behavioral therapy or waitlist. Group differences in ADIS-C diagnoses were compared after treatment. Multiple parent and child self-report measures were used to measure symptoms as well. RESULTS: Pretreatment comorbidity was not associated with differences in treatment outcome: 68.4% of noncomorbid participants and 70.6% of comorbid participants were free of their primary diagnosis after treatment. Regarding parent and child self-report symptoms, multivariate analyses of variance revealed significant time (treatment) main effects, but no significant main effect for group (comorbid status) or time/group interaction. CONCLUSIONS: The cognitive-behavioral treatment program was similarly effective in anxious children with and without comorbid disorders; both groups showed clinically significant reductions in pretreatment diagnoses and symptoms.     

The treatment of anxiety disorders in children and adolescents.

Anxiety disorders are the most common psychiatric conditions in the pediatric population, with prevalence estimates ranging from 5-18%. Children and adolescents with excessive anxiety often meet diagnostic criteria for a number of disorders within the DSM-IV. Unfortunately, the current diagnostic system is controversial because of high rates of symptom overlap, comorbidity with other psychiatric disorders, and lack of biological markers that would support a more empirical anxiety nosology. Treatment strategies for pediatric anxiety disorders have important historical roots. Several controlled studies of cognitive-behavioral therapy (CBT) demonstrate efficacy for pediatric anxiety disorders. In contrast, no controlled psychopharmacology studies have demonstrated efficacy in children and adolescents with anxiety disorders, except obsessive-compulsive disorder; however, several large, methodologically sound psychopharmacotherapy trials are underway for pediatric anxiety disorders. This update will review the current status of psychosocial and psychopharmacologic treatment of pediatric anxiety disorders. In addition, a brief discussion of nosology, epidemiology, and developmental course of anxiety is included. Preliminary psychopharmacology treatment and CBT treatment algorithms are presented for pediatric anxiety disorders, based on the best available data. Recommendations for future research directions are also discussed.     

Oxprenolol in the treatment of anxiety due to environmental stress.

The author conducted two trial studies to evaluate the use of oxprenolol in the treatment of symptoms resulting from environmental stress. Results indicated that on a three-times-a-day regimen, 80 mg of oxprenolol was superior to 20 mg of oxprenolol and equally as effective as 5 mg of diazepam. The author discusses the benefit of beta-blocking drugs and points to the need for further studies.     

Perceived stress in anxiety disorders and the general population: a study of the Sheehan stress vulnerability scale

The objectives of this study were to (1) validate and establish normative values for a single-item, self-rated measure of perceived stress, the Stress Vulnerability Scale (SVS); and (2) compare levels of perceived stress in patients with anxiety disorders with the general population. The sample was drawn from the general population (n=630) and from participants in pharmacotherapy trials of anxiety disorders (social phobia, n=127; posttraumatic stress disorder, n=116). The SVS was administered at baseline in all groups and following treatment in the placebo-controlled clinical trial samples. The SVS demonstrated good reliability and validity. Pretreatment scores in the anxiety disorders were significantly greater than in the general population. Perceptions of vulnerability to the effects of daily stress are considerably greater in anxiety disorders compared to the general population and also differ within the anxiety disorders.     

National trends in the outpatient treatment of anxiety disorders

BACKGROUND: Recent advances in psychotherapy and pharmacotherapy have increased the number of treatment options for anxiety disorders. This article examines changes in outpatient treatment of anxiety disorders in the United States between 1987 and 1999. METHOD: Analyses are presented of service utilization data from 2 nationally representative surveys of the general population: the 1987 National Medical Expenditure Survey and the 1999 Medical Expenditure Panel Survey. Respondents were selected who made 1 or more outpatient visits for the treatment of an anxiety disorder (ICD-9/DSM-IV: 300.0, 300.2, 300.3, or 308.3). The rates of treatment, psychotropic medication use, psychotherapy, number of outpatient treatment visits, type of provider, and source of payment were determined. RESULTS: The rate of outpatient treatment for anxiety disorders increased from 0.43 per 100 persons in 1987 to 0.83 in 1999 (p <.001). Among those treated for an anxiety disorder, the proportion that received psychotropic medications increased from 52.1% to 69.9% (p =.008). Among treated patients, antidepressant use increased from 18.3% to 44.9% (p <.0001), while use of benzodiazepines (42.3% to 31.7%, p =.09) and psychotherapy (60.5% to 48.0%, p =.07) tended to decline. A decreasing proportion of mean treatment expenditures was covered by self-payment (53.2% to 31.5%, p <.0001). CONCLUSION: Between 1987 and 1999, there was an increase in the proportion of the population who received outpatient treatment for anxiety disorders. Among patients receiving care, treatment became characterized by greater use of psychotropic medications, especially antidepressant medications, with nonsignificant trends toward less common use of psychotherapy.     

Recent advances in the psychopharmacological treatment of anxiety disorders

The authors review recent progress in the pharmacological treatment of anxiety disorders. Most research within the last five years has focused on panic disorder; the findings include support for the usefulness of imipramine and clomipramine and probably other agents; evidence that the benzodiazepines alprazolam, diazepam, lorazepam, and clonazepam are approximately equally effective as antipanic agents; and high variability in relapse rates after discontinuation of drug treatment. Further work is required to determine whether buspirone and other forthcoming serotonin agonist drugs have a role in treating panic disorder and other anxiety disorders. For generalized anxiety disorder, scientific studies do not support the effectiveness of beta blocker; tricyclics may be potentially useful. Psychopharmacological treatments for social phobia, obsessive-compulsive disorder, and posttraumatic stress disorder are also reviewed.     

Non-adherence and non-response in the treatment of anxiety disorders

Among the best established treatments for anxiety disorders are cognitive-behavioral interventions and serotonin reuptake inhibitors. Although clinically useful, these therapies are far from universally efficacious; some patients are unable to complete treatment, and many treatment completers fail to achieve clinically significant improvement. A review of meta-analyses on the treatment of anxiety disorders reveals that about a fifth of patients drop out prematurely and a third of treatment completers are classified as non-responders. In this article we examine the predictors of, and potential solutions for, the problems of treatment non-adherence and non-response to cognitive-behavioral and serotonergic treatments of adult anxiety disorders. Despite decades of research, few reliable predictors have been identified, and no predictor has been consistently supported in the literature. However, there is suggestive evidence that risk of premature dropout is associated with low treatment motivation, side effects, and practical barriers to attending sessions. There is also suggestive evidence that poor response is associated with severe pretreatment psychopathology and comorbidity, as well as high expressed emotion in the patient's family environment. Methods for better estimating treatment prognosis are proposed and possible directions for improving treatment outcome are discussed.     

Effectiveness of a computer-based interactive eating disorders prevention program at long-term follow-up

Computer-based delivery of health-related psychoeducational programming is increasingly popular. In the present study, 72 non-symptomatic undergraduate women were randomized to an Internet-based prevention program for eating disorders with or without accompanying discussion groups, or a control group. Sixty-one of the women (84%) completed the Student Bodies program, and were assessed at short and eight-nine month follow-up. Participation in the program resulted in better outcomes across all groups compared to controls, and women in the unmoderated discussion group appeared to have the most reduction in risk. Benefits of the program continued at follow-up. Decrease in risk also was associated with time spent using the Internet-based program. The present study suggests that the use of Student Bodies may reduce risk of eating and body image concerns over the long term, and that moderation of discussion groups may not be essential for successful outcomes. Further research on larger samples will help determine the degree to which discussion groups or the Student Bodies program alone are effective.     

Family-based treatment of childhood anxiety disorders

Recently attention has turned to family involvement in the treatment of childhood anxiety disorders. Theoretical models and research on parenting behaviour have identified specific targets for family intervention. A growing number of family-based treatment studies targeting these parenting behaviours and interactions suggest that this approach is effective. A review of the targets of treatment and intervention strategies are described in detail.