The impact of depression and anxiety on well being, disability and use of health care services in nursing home patients

OBJECTIVE: To determine the impact of depression and anxiety on well being, disability and use of health care services among nursing patients. METHODS: The study-population consisted of 350 elderly nursing home patients from 14 nursing homes in the Netherlands. Well being, disability, use of health care services (i.e. assistance in ADL, paramedical care, number of medications) and depression and anxiety and other relevant characteristics (gender, age, education, marital status, urbanization, cognition, morbidity, social support) were measured cross-sectionally. Associations of well being, disability and use of health care services with independent baseline characteristics were assessed with bivariate and with multivariate analyses. RESULTS: Presence of depression and/or anxiety was associated with significantly less well being, but not with more disability. Presence of depression and/or anxiety was also significantly associated with four of the seven indicators of health care service use measured in this study: less assistance in ADL, more consultation of medical specialists, a higher mean number of medications and more use of antidepressants. CONCLUSION: Presence of depression and/or anxiety has a statistically and clinically significant negative impact on well being, but not on disability. Future studies should focus on interventions for improving the detection, diagnosis and treatment of depression and/or anxiety in the nursing home.     

Comorbidity and risk-patterns of depression, generalised anxiety disorder and mixed anxiety-depression in later life: results from the AMSTEL study

BACKGROUND: Depression and generalised anxiety disorder frequently overlap. The question remains unresolved whether these are specific disorders, or that they represent different dimensions of a single disorder. Although both are highly prevalent disorders in this age group, studies on this issue in the elderly are scarce. Research is needed that investigates patterns of comorbidity and possibly different risk profiles for pure depression, pure generalised anxiety and mixed anxiety-depression in older people. METHODS: GMS-AGECAT diagnoses were obtained from 4051 community living older persons. Comorbidity was studied along a severity gradient for men and women separately. Multivariate analysis of risk factors included demographic variables, environmental vulnerability, longstanding vulnerability, physical/functional stresses and gender. RESULTS: The prevalence of pure depression was 12.2%, pure generalised anxiety 2.9%, mixed anxiety-depression 1.8%. Comorbidity increased with higher severity levels of both depression and generalised anxiety. Comorbidity was twice as likely in women than in men. Different risk profiles for diagnostic categories were not demonstrated for concurrent risk factors. Longstanding vulnerability was associated significantly stronger with mixed anxiety-depression than with pure anxiety and pure depression. Mixed anxiety-depression was overrepresented in women. CONCLUSIONS: Both lines of investigation suggest that, in the elderly, a dimensional classification is more appropriate than a categorical classification of depression and generalised anxiety. Mixed anxiety-depression is a more severe form of psychopathology that is almost specific to women in this age group.     

Social anxiety disorder and depression in Saudi Arabia

The purpose of this study was to estimate the prevalence of depression in patients with social anxiety disorder (SAD) and to assess the relationship between the severity of SAD symptoms and depression. Ninety-eight consecutive patients with generalized SAD according to DSM-IV criteria were included in a cross-sectional case-control study. Patients were referred to a psychiatric outpatient clinic in a general hospital in Saudi Arabia. The Liebowitz Social Anxiety Scale was used to estimate the severity of SAD. Fifty-eight (59%) of the patients with SAD had another current psychiatric disorder. Forty (41%) patients had current depression, and 37 (92.5%) of them had it after SAD onset. Eleven of 16 patients with severe SAD (69%) had depression whereas only 29 of 82 of SAD patients with mild or moderate subtypes (35%) had depression. Patients with severe SAD were four times more likely to have depression than the patients with mild or moderate SAD even after controlling for confounding sociodemographic and clinical factors. Depression is common among patients with SAD, particularly the severe subtype. Early recognition and treatment of SAD, especially the severe subtype, may prevent the occurrence of depression. Prospective studies are needed to investigate the risk factors that may lead to depression in SAD.     

Comorbid depression, but not comorbid anxiety disorders, predicts poor outcome in anxiety disorders

Influence of type of comorbidity was studied over the course of 1 year in a sample of 141 outpatients with panic disorder with or without agoraphobia and generalized anxiety disorder, who were receiving different forms of cognitive behavior therapy. Influence of type of comorbidity was determined on the basis of change scores (linear regression analysis) and remission data (Kaplan-Meier survival analysis). Three categories, as assessed at baseline, were compared: no comorbidity, comorbidity among anxiety disorders, and comorbidity with mood disorders. Primary outcome variable: State-Trait Anxiety Inventory State subscale measured at four assessments (0, 12, 24, and 52 weeks). Analyses of change and remission indicated that comorbidity with mood disorders led to (i) less improvement and (ii) a lower remission rate than comorbidity among anxiety disorders and no comorbidity. Because comorbidity has a critical influence on prognosis, it seems to be important to make a reliable diagnosis of the disorders present.     

Comorbidity of anxiety disorders in patients with remitted bipolar disorder

Comorbidity between bipolar disorder and anxiety disorders has attracted considerable attention in recent years. However, a majority of the earlier studies examined anxiety disorders in acutely ill patients resulting in a possible confounding effect of the affective episodes. This study examines the prevalence of anxiety disorders in remitted bipolar subjects recruited from a psychiatric hospital in India and their effect on the severity of bipolar illness. A total of eighty remitted DSM-IV adult bipolar subjects and 50 non-psychiatric controls were recruited over a 10-month period. They were evaluated using a structured interview and various scales. The effect of anxiety disorders on bipolar severity was analyzed using multiple regression analyses. Anxiety disorders were highly prevalent in bipolar subjects compared to controls (49 [61%] vs. 7 [14%], χ² = 28.01, P < 0.001). Commonest lifetime anxiety disorder was obsessive-compulsive disorder (35%). Lifetime anxiety disorder had significant effect on all four indices of severity of illness, that included (1) percentage of time spent in episodes (Beta = 18.67, SE = 5.11, P < 0.001), (2) maximum period of continuous euthymia in the preceding 2 years (Beta = −5.26, SE = 1.71, P = 0.003), (3) presence of psychosis (Beta = 3.22, SE = 1.02, P = 0.002), and 4) response to mood stabilizers (Beta = −2.11, SE = 0.76, P = 0.006). The findings of this study confirm previous observations of the high prevalence and negative impact of comorbid anxiety disorders in bipolar disorder and also demonstrate that the findings are similar in culturally diverse settings. Future studies should systematically examine the various treatment options for anxiety disorders in bipolar patients. It is also necessary to examine the neurobiological and family/genetic correlates of anxious bipolar subjects to validate if they are a subgroup of bipolar disorders.     

小学生焦虑抑郁障碍共病调查

目的：探讨小学生焦虑抑郁障碍共病情况。方法：用儿童焦虑障碍筛查量表（SCRED）对县城2900名及农村1800名8～14岁小学生进行筛查,对筛查出的焦虑障碍儿童进行抑郁障碍诊断,对焦虑与抑郁障碍共病儿童实施相关量表及问卷测量。结果：儿童焦虑抑郁障碍共病率为12.7%,其中县城12.9%,农村12.3%,两地差异无统计学意义（χ2=0.011,P=0.915）。焦虑抑郁障碍共病儿童与仅有焦虑障碍儿童在焦虑量表及家庭功能评定量表上得分差异均无显著性（P均〉0.05）,抑郁量表分与焦虑量表的躯体焦虑、广泛焦虑及焦虑总分呈显著相关（P〈0.001）。结论：小学生焦虑与抑郁障碍共病率较高。     

Effects of a transdiagnostic group treatment for anxiety on secondary depression

Researchers have recently explored transdiagnostic anxiety treatments based on models of anxiety emphasizing a single common pathway across diagnostic categories. Results from a previous study [Norton and Hope, in press] indicated that a transdiagnostic approach was effective for both targeted and untargeted anxiety disorders. Consistent with the tripartite model, the transdiagnostic treatment should also influence symptoms of a broader pathology such as negative affectivity. This follow-up to Norton and Hope found significant decreases in depressed mood for clients undergoing transdiagnostic treatment for anxiety when compared to wait-list control participants. Although not statistically established, severity of depressive diagnoses seemed to generally decrease across treatment, whereas no change in severity occurred for those not receiving treatment.     

抑郁与焦虑共病障碍临床研究

目的:调查抑郁与焦虑共病障碍的发生率,探讨其特点及预后.方法:对150例抑郁障碍患者用汉密尔顿抑郁量表(HAMD)、汉密尔顿焦虑量表(HAMA)、社会功能缺陷筛选量表(SDSS)和临床疗效总评量表(CGI)评定,3个月后进行随访.结果:45.3%的抑郁障碍患者共病焦虑障碍,共病以广泛焦虑障碍与惊恐障碍为最多(分别为22.0%、13.3%);入组时及3个月末,共病组HAMD、HAMA、CGI及SDSS总分均显著高于抑郁组(P＜0.05),3个月末共病组HAMA减分率显著低于抑郁组(P＜0.05),HAMD减分率两组差异无显著性.结论:抑郁与焦虑共病障碍发生率高,具有抑郁及焦虑症状重、社会功能损害重,焦虑症状不易缓解等特征.     

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.     

Distinguishing generalized anxiety disorder from major depression: prevalence and impairment from current pure and comorbid disorders in the US and Ontario

Estimation of comparative disease burden in epidemiological surveys is complicated by the fact that high comorbidities exist among many chronic conditions. The easiest way to take comorbidity into consideration is to distinguish between pure and comorbid conditions and to evaluate the incremental effects of comorbid conditions in prediction equations. This approach is illustrated here in an analysis of the effects of pure and comorbid major depression (MD) and generalized anxiety disorder (GAD) on a number of different measures of role impairment in the US National Comorbidity Survey (NCS) and the Mental Health Supplement to the Ontario (Canada) Health Survey (the Supplement). Pure MD and pure GAD were found to have roughly equal independent associations with role impairments. The incremental effects of having comorbid MD and GAD were found to vary depending on the outcome under investigation. The paper closes with a discussion of the methodological complexities associated with generalizing to comorbidities that involve rare conditions or more than two disorders.     

Comorbidity in obsessive-compulsive disorder: focus on depression

The authors investigated the comorbidity between obsessive-compulsive disorder (OCD) and other psychiatric disorders in a group of 154 outpatients. The influence of an associate major depressive disorder (MDD) on the outcome of treatment with clomipramine was examined in a subgroup of 52 patients. The results showed that MDD was the most frequent disorder associated with OCD (almost 20% of the patients), followed by generalized anxiety and panic disorder. The co-presence of depression delayed the effect of clomipramine.     

Comorbidity of anxiety disorders in adolescents

We examined the comorbidity of anxiety disorders and their clinical consequences in adolescents. The 1,035 adolescents, aged 12 to 17 years old, were randomly selected from 36 schools in the province of Bremen, Germany. Anxiety disorders and other psychiatric disorders were coded based on DSM-IV criteria using the computerized Munich version of the Composite International Diagnostic Interview. The comorbidity rate within the anxiety disorders was relatively low (14.1%). However, the comorbidity of anxiety disorders with other psychiatric disorders was high. Approximately half (51%) of the anxious adolescents had other psychiatric disorders. The most common comorbid pattern was that of anxiety and depressive disorders. Among those with both anxiety and depressive disorders, a majority of them (72%) had anxiety before that of depression. Anxious adolescents with comorbid disorders were significantly more psychologically distressed, as assessed using the SCL-90-R, and used more mental health services than adolescents with anxiety disorders only. The effect of comorbidity on mental health services utilization was stronger in males than females. The findings suggest the need to design intervention strategies to deal with cases with multiple disorders.     

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.     

Parental representation in patients with major depression, anxiety disorder and mixed conditions

Differences in parental bonding between patients with pure major depression, mixed anxiety-depression and pure anxiety disorders were investigated in 272 consecutive outpatients. A low parental care score seemed to be the best discriminating variable between the mixed group and the 3 other groups. This study supports previous family and twin studies as well as clinical studies emphasizing the mixed group as a special disorder group, possibly with a different etiology. The role of the father in child development seems to be particularly important.     

Relation between depression and anxiety in dystonic patients: implications for clinical management

Past clinical research has identified depression as the most common psychiatric disorder associated with cervical dystonia (CD). The purpose of our study is to document different patterns of psychopathology, the frequency of psychiatric disorders, and possible correlation with the neurological disorder in patients with CD. Forty patients with CD were investigated to assess levels of psychopathology on two self-rated scales: the Beck Depression Inventory (BDI) and Symptom Check List (SCL-90). To determine the presence of psychiatric disorders, the patients were evaluated using the standard instrument in the DSM-III-R (Structured Clinical Interview Schedule, SCID). A small group of dystonic patients (12%) had higher levels of psychopathology, with significant amounts of concomitant anxiety and depression on the BDI and SCL-90. SCID criteria for at least one psychiatric disorder were fulfilled in 22 patients (55%), including both the lifetime and current diagnoses. The most frequent diagnostic categories were anxiety (40%) and major depressive disorders (37.5%). In 17 patients (42.5%), criteria for at least one lifetime diagnosis were fulfilled prior to the onset of CD. Psychiatric evaluation does not indicate one specific disorder associated with CD. The presence of anxiety and depression symptoms before and during the course of dystonia, without a possible causal relationship, could mean that the alteration of a chain of physiological events in the central nervous system may not lead to a single clinical picture. The relatively high overall lifetime prevalence of anxiety and depressive disorders may indicate the need for a broader diagnostic and therapeutic approach to patients with focal dystonia.     

The nosologic relationship between generalized anxiety disorder and major depression

Generalized anxiety disorder (GAD) has undergone a series of revisions in its diagnostic criteria that has moved it, nosologically, away from its original affiliation with panic disorder (PD) and closer to major depressive disorder (MDD). This, together with its high comorbidity and putative shared genetic risk with MDD, has brought into question its place in future psychiatric nosology, prompting the planners of Diagnostic and Statistical Manual-V (DSM-V) and International Classification of Diseases-11 (ICD-11) to set up a workgroup tasked to better understand the relationship between GAD and MDD. This review attempts to summarize the extant data to compare GAD and MDD on a series of research validators to explore this relationship. Although insufficient data currently exist for GAD in several key validator classes, tentative conclusions can be drawn on the diagnostic status of GAD in relation to MDD. Although GAD possesses substantial overlap with MDD in the areas of genetics, childhood environment, demographics, and personality traits, this tends to hold true for other anxiety disorders (ADs) as well, with the strongest evidence for PD. Data from life events, personality disorders, biology, comorbidity, and pharmacology are mixed, showing some areas of similarity between GAD and MDD but some clear differences, again with a moderate degree of nonspecificity. Thus, although the bulk of evidence supports a close underlying relationship between them, the relatively nonspecific nature of these findings provides little more reason to question the nosologic validity of GAD in relation to MDD than that of some other anxiety disorders.     

History of separation anxiety in patients with panic disorder and depression and normal controls

The frequency and severity of separation anxiety for subjects with panic disorder and major depression was compared with that for normal controls. The subjects were diagnosed according to DSM-III criteria. Each subject completed a questionnaire consisting of 9 items derived from DSM-III criteria for separation anxiety disorder. The incidence of separation anxiety and its severity were significantly higher for the panic disorder subjects than for normal controls but there was no significant difference between depressed and panic disorder subjects. Panic disorder subjects with a history of separation anxiety disorder had a significantly earlier onset of panic attacks.     

Comorbidity of the anxiety disorders in a community-based older population in The Netherlands

OBJECTIVE: The aim of the study was to investigate patterns of comorbidity among the anxiety disorders in a community-based older population, and the relationship of these disorders with major depression, use of alcohol and benzodiazepines, cognitive impairment and chronic somatic illnesses. METHOD: The data were derived from the Longitudinal Aging Study Amsterdam (LASA) study. A two-stage screening design was adopted to identify respondents with anxiety disorders. RESULTS: In total, 10% of the elderly with an anxiety diagnosis suffered from two or more anxiety disorders. Major depression (13% vs. 3%), benzodiazepine use (24% vs. 11%) and chronic somatic diseases (12% vs. 7%) were significantly more prevalent in respondents with an anxiety disorder than in respondents without anxiety disorders. Heavy or excessive alcohol intake (5% vs. 4%) and cognitive impairment (11% vs. 13%) were not significantly associated with any anxiety disorder. CONCLUSION: When anxiety disorders are diagnosed, in older people there is a relatively high probability of comorbid conditions being present.     

Meta-analysis on anxiety and depression in adult celiac disease

Smith DF, Gerdes LU. Meta‐analysis on anxiety and depression in adult celiac disease. Objective: We used meta‐analysis to test hypotheses concerning whether adult celiac disease is reliably linked with anxiety and/or depression. Method: We examined published reports on anxiety and depression in adult celiac disease. Results: Eighteen studies on depression and eleven studies on anxiety in adult celiac disease met selection criteria. They show that depression is reliably more common and/or more severe in adults with celiac disease than in healthy adults (overall meta‐analysis effect size: 0.97). The fail‐safe margin of unpublished reports that would be required to negate the finding exceeds 8000. Adults with celiac disease do not, however, differ reliably in terms of depression from adults with other physical illnesses, nor do they differ reliably from healthy adults or adults with other physical illnesses in terms of anxiety. Conclusion: Depression is common in adult celiac disease and resembles the condition in other physical illnesses. We view the findings as support for the notion that non‐specific mechanisms mediate emotional disorders in adult celiac disease.