Distress and functioning in mixed anxiety and depressive disorder

The aim of the present study was to evaluate the validity of mixed anxiety and depressive disorder (MADD) with reference to functional characteristics and symptomatic characteristics in comparison with anxiety disorders, depressive disorders, and groups showing subthreshold symptoms (exclusively depressive or anxiety related). The present study was carried out in the following three medical settings: two psychiatric and one primary care. Patients seeking care in psychiatric institutions due to anxiety and depressive symptoms and attending primary medical settings for any reason were taken into account. A total of 104 patients (65 women and 39 men, mean age 41.1 years) were given a General Health Questionnaire (GHQ-30), Global Assessment of Functioning (GAF) and Present State Examination questionnaire, a part of Schedules for Clinical Assessment in Neuropsychiatry, Version 2.0. There were no statistically relevant differences between MADD and anxiety disorders in median GHQ score (19 vs 16) and median GAF score (median 68.5 vs 65). When considering depressive disorders the median GHQ score (28) was higher, and median GAF score (59) was lower than that in MADD. In groups with separated subthreshold anxiety or depressive symptoms, median GHQ scores (12) were lower and median GAF scores (75) were higher than that in MADD. The most frequent symptoms of MADD are symptoms of generalized anxiety disorder (GAD) and depression. Mixed anxiety and depressive disorder differs significantly from GAD only in higher rates of depressed mood and lower rates of somatic anxiety symptoms. Distinction from depression was clearer; six of 10 depressive symptoms are more minor in severity in MADD than in the case of depression. Distress and interference with personal functions in MADD are similar to that of other anxiety disorders. A pattern of MADD symptoms locates this disorder between depression and GAD.     

Screening for and detection of depression, panic disorder, and PTSD in public-sector obstetric clinics

OBJECTIVE: This study assessed rates of detection and treatment of minor and major depressive disorder, panic disorder, and posttraumatic stress disorder among pregnant women receiving prenatal care at public-sector obstetric clinics. METHODS: Interviewers systematically screened 387 women attending prenatal visits. The screening process was initiated before each woman's examination. After the visit, patients were asked whether their clinician recognized a mood or anxiety disorder. Medical records were reviewed for documentation of psychiatric illness and treatment. RESULTS: Only 26 percent of patients who screened positive for a psychiatric illness were recognized as having a mood or anxiety disorder by their health care provider. Moreover, clinicians detected disorders among only 12 percent of patients who showed evidence of suicidal ideation. Women with panic disorder or a lifetime history of domestic violence were more likely to be identified as having a psychiatric illness by a health care provider at some point before or during pregnancy. All women who screened positive for panic disorder had received or were currently receiving mental health treatment outside the prenatal visit, whereas 26 percent of women who screened positive for major or minor depression had received or were currently receiving treatment outside the prenatal visit. CONCLUSIONS: Detection rates for depressive disorders in obstetric settings are lower than those for panic disorder and lower than those reported in other primary care settings. Consequently, a large proportion of pregnant women continue to suffer silently with depression throughout their pregnancy. Given that depressive disorders among perinatal women are highly prevalent and may have profound impact on infants and children, more work is needed to enhance detection and referral.     

Neurosis from the viewpoint of DIS (Diagnostic Interview Schedule)

We examined the relationship between clinical and DIS-Lifetime diagnoses given independently on 106 psychiatric patients clinically diagnosed as suffering from neurosis. They had many coexisting DIS diagnoses, and some of them had no DIS diagnosis. The key to the coexistence relationships in DIS diagnosis was a major depressive episode, and the subjects were classified into four types by the DIS coexistence relationships; Type I: 28 cases (26.4%) had coexisting diagnoses belonging to anxiety disorders or somatoform disorders, in addition to a major depressive episode. They were suffering from clinically severe neurosis accompanied by borderline personality disorder. Type II: 30 cases (28.3%) belonged to anxiety disorders or somatoform disorders without a major depressive episode without anxiety disorders or somatoform disorders, and had clinically depressive neurosis or depressive episode with less distortion of the personality. Type IV: 30 cases (28.3%) were other than Type I-III, and were clinically similar to symptomatic neurosis.     

Neurosis from the Viewpoint of DIS (Diagnostic Interview Schedule)

Abstract: We examined the relationship between clinical and DIS-Lifetime diagnoses given independently on 106 psychiatric patients clinically diagnosed as suffering from neurosis. They had many coexisting DIS diagnoses, and some of them had no DIS diagnosis. The key to the coexistence relationships in DIS diagnosis was a major depressive episode, and the subjects were classified into four types by the DIS coexistence relationships; Type I: 28 cases (26.4%) had coexisting diagnoses belonging to anxiety disorders or somatoform disorders, in addition to a major depressive episode. They were suffering from clinically severe neurosis accompanied by borderline personality disorder. Type II: 30 cases (28.3%) belonged to anxiety disorders or somatoform disorders without a major depressive episode, and had clinically symptomatic neurosis. Type III: 18 cases (17.0%) had a major depressive episode without anxiety disorders or somatoform disorders, and had clinically depressive neurosis or depressive episode with less distortion of the personality. Type IV: 30 cases (28.3%) were other than Type I-III, and were clinically similar to symptomatic neurosis.     

Recognition, management, and course of anxiety and depression in general practice

This article addresses the issues of recognition of psychiatric disorders by general physicians (GPs) and the effects of recognition on management and course. Among 1994 patients who were screened with the General Health Questionnaire and who were rated by their GP, 1450 (72.7%) had not been identified by the GP as having a psychiatric disorder in the year before the index visit. Among these "new" patients, 557 (38.4%) had positive General Health Questionnaire scores. Only 47% of the new patients who met Bedford College diagnostic criteria for anxiety, depression, or ill-defined disorder had their psychiatric disorder recognized by their GP. Among patients who met Bedford College criteria, mean episode durations were longer for anxiety disorders (20 to 22 months) than for depressive disorders (9 to 10 months). Among the new patients, those with psychiatric disorders recognized by the GP were more likely to receive mental health interventions. Recognition was associated with shorter episode duration among patients with an anxiety disorder, but not among patients with depressive or ill-defined disorders.     

Are anxiety and depression addressed in primary care patients with chronic obstructive pulmonary disease? A chart review

Objective: Screening for mental illness in primary care is widely recommended, but little is known about the evaluation, treatment, and long-term management processes that follow screening. The aim of this study was to examine and describe the quality of mental health care for persons with chronic obstructive pulmonary disease (COPD) and anxiety/depressive disorders, as measured by adherence to practice guidelines. Method: This retrospective chart review examined data for 102 primary care and mental health care patients with COPD who were diagnosed, using Structured Clinical Interview for DSM-IV criteria, with major depressive disorder, dysthymia, depression not otherwise specified, generalized anxiety disorder, or anxiety not otherwise specified. Data were gathered from primary care progress notes from the year prior to enrollment in a randomized controlled trial (enrollment was from July 2002 to April 2004). We compared the care received by these patients over 1 year with that recommended by practice guidelines. Charts were abstracted using a checklist of recommended practice guidelines for diagnostic evaluation, acute treatment, and long-term management of anxiety and depressive disorders. Results: Fifty (49%) of the 102 patients were recognized during the review year as having an anxiety or depressive disorder. Eighteen patients were newly assessed for depressive or anxiety disorders during the chart review year. Patients followed in primary care alone, compared with those who were comanaged by mental health care providers, were less likely to have guideline-adherent care. Conclusion: Depressive and anxiety disorders are recognized in about half of patients; however, guideline-supported diagnostic evaluation, acute treatment (except for medications), and long-term management rarely occur in the primary care setting. To improve the treatment of depressive and anxiety disorders in primary care, the process of care delivery must be understood and changed.     

Identification of psychiatric distress by primary care physicians

The aims of the present study were to evaluate the extent to which primary care physicians' (PCPs) identification of psychiatric distress is related to a number of nonpsychopathological factors, such as patient sociodemographic and health-related characteristics, and to assess the impact of depression on PCP identification of psychiatric distress, controlling for patient sociodemographic and health-related characteristics. Two patient samples were chosen to explore these issues: 1) patients not fulfilling any ICD-10-defined or subthreshold psychiatric diagnosis and, 2) patients with an ICD-10 diagnosis of current depression. Patients attending 46 primary care clinics during an index period were screened by the General Health Questionnaire (GHQ)-12 and selected for a second stage interview according to GHQ score. Among the 559 interviewed patients, 123 had no mental disorder and 66 had an ICD-10 current depressive disorder. Identification of psychiatric distress by the PCP was associated with retirement among subjects without mental disorders but not among depressed patients. Patient's negative overall health self-perception and severity of physical illness were significantly related to identification of psychiatric distress in the two groups, whereas neither disability nor reason for medical consultation had a significant effect. Patients with current depression, compared with those without, were 4.3 times more likely to be identified by PCPs as having psychiatric distress when adjusting for all the above nonpsychopathological variables. Patients with depression and comorbid anxiety disorders were more likely to be recognized by the PCP as compared with those with pure depression. Finally, among depressive symptoms, diurnal variation and symptoms related to suicidal tendencies were predictive of identification of psychiatric distress, whereas increase of appetite was negatively associated with PCP recognition.     

Anxiety and mood disorders in primary care practice

Anxiety and mood disorders are common conditions in primary health care service. Primary care physicians (PCPs) have a privileged role in the early recognition of these conditions. In this study, the prevalence rates of threshold and subthreshold mood and anxiety disorders were surveyed among 1815 primary care attendees in 12 PCPs’ offices in Budapest, using the Diagnostic Interview Schedule (DIS). The 1-year prevalence of DIS/DSM-III-R anxiety and/or mood disorders was 16.8%, and the 1-month prevalence was 12.5%. The occurrence rates of subthreshold anxiety and/or depression were 25.7 and 13.1%, respectively. The impact of threshold anxiety and mood disorders on work performance was considerably higher than the impact of subthreshold symptoms. At the time of the interview, 6.7% of the patients received mood and/or anxiety disorder diagnoses by their PCPs. The measure of agreement between the diagnoses generated by the DIS and the ones given by the PCPs was low. The presence of an acute or chronic physical illness made it more difficult for the PCPs to recognize a psychiatric disorder. Conversely, patients’ psychological complaints significantly improved the recognition of anxiety and/or mood disorders. The use of the Beck Depression Inventory (BDI) brief version would help the patients to reveal their psychological symptoms, and the physicians to recognize an underlying psychiatric disorder.     

Panic disorder. Spectrum of severity and somatization

One hundred++ ninety-five primary care patients were screened for panic disorder utilizing the National Institute of Mental Health Diagnostic Interview Schedule (DIS) as well as four additional questions that screened for core autonomic symptoms of panic disorder. A spectrum of severity of panic disorder was found. A subgroup of patients, labeled in the study as having simple panic, was found to have anxiety attacks associated with four or more autonomic symptoms, but they did not meet DSM-III recurrence criteria (three anxiety attacks within a 3-week period). Compared to primary care patients without panic attacks, patients with both simple panic and panic disorder exhibited multiple phobias, avoidance behavior, a high lifetime risk of major depression, and elevated scores on self-rating scales of anxiety and depression. The four autonomic screening questions that the authors added to the DIS interview increased the sensitivity of the DIS in identifying patients with panic disorder. Patients with panic disorder who selectively focus on their frightening autonomic symptoms may not be identified by screen questions that only focus on the cognitive awareness of anxiety.     

Psychiatric morbidity and illness experience of primary care patients with chronic fatigue in Hong Kong

OBJECTIVE: The authors' goal was to examine the prevalence and experience of psychiatric morbidity among primary care patients with chronic fatigue in Hong Kong. METHOD: One hundred adult patients with medically unexplained fatigue for 6 or more months were assessed with the Explanatory Model Interview Catalogue, psychopathological rating scales, and an enhanced version of the Structured Clinical Interview for DSM-III-R. RESULTS: The lifetime prevalence of DSM-III-R depressive and anxiety disorders was 54%. Current depressive and anxiety disorders were identified in 28 patients, who exhibited more psychopathology and functional impairment than other patients. Thirty-three patients had somatoform pain disorder, and 30 had undifferentiated somatoform disorder, but most of them could also be diagnosed as having shenjing shuairuo (weakness of nerves) and, to a lesser extent, ICD-10 neurasthenia. Chronic fatigue syndrome diagnosed according to the 1988 Centers for Disease Control criteria was rare (3%) and atypical. Generally, patients mentioned fatigue if asked, but pains (36%), insomnia (20%), and worries (13%) were the most troublesome symptoms. Most patients attributed illness onset to psychosocial sources. CONCLUSIONS: Psychiatric morbidity was common among primary care patients with chronic fatigue. Subthreshold psychiatric morbidity was very common and was more validly represented by the disease construct of shenjing shuairuo or neurasthenia than somatoform disorder.     

Depressive, anxiety, and somatoform disorders in primary care: prevalence and recognition

Recent studies emphasize the negative impact of comorbidity on the course of depression. If undiagnosed, depression and comorbidity contribute to high medical utilization. We aimed to assess (1) prevalences of depression alone and with comorbidity (anxiety/somatoform disorders) in primary care, (2) coexistence of anxiety/somatoform disorders in depressive patients, and (3) diagnostic validity of two screeners regarding depression with versus without comorbidity. We examined 394 primary care outpatients using the Composite International Diagnostic Interview (CIDI), the General Health Questionnaire (GHQ-12), and the Well-Being Index (WHO-5). We conducted configurational frequency analyses to identify nonrandom configurations of the disorders and receiver operating characteristic (ROC)-analyses to assess diagnostic validity of the screeners. Point prevalence of any depressive disorder was 22.8%; with at least one comorbid disorder, 15%; and with two comorbid conditions, 6.1%, which significantly exceeded expected percentage (0.9%, P< or =.0001). Depression without comorbidity occurred significantly less often than expected by chance (P< or =.0007). Comorbidity of depressive and anxiety or somatoform disorders was associated with a high odds ratio (6.25). The screeners were comparable regarding their diagnostic validity for depression with [GHQ-12: area under the curve (AUC)=0.86; WHO-5: AUC=0.88] and without comorbidity (GHQ-12: AUC=0.84; WHO-5: AUC=0.86). It can be concluded that comorbidity between depression and anxiety/somatoform disorders in primary care may occur much more frequently than expected. These results confirm assumptions that the current division between depression and anxiety might be debatable. Validity of screeners tested in our study was not affected by comorbid conditions (e.g., anxiety or somatoform disorders).     

Prevalence and rates of recognition of anxiety disorders in internal medicine outpatient departments of 23 general hospitals in Shenyang,China

ObjectiveAssess the prevalence, risk factors and treating clinicians' rates of recognition of anxiety disorders in internal medicine departments of different types of general hospitals in Shenyang, China.MethodA two-stage screening process using an expanded Chinese version of the 12-item General Health Questionnaire (GHQ) and the Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID) identified 457 persons 15 years of age or older with current anxiety disorders from among 5312 consecutive attendees at the outpatient internal medicine departments of 23 randomly selected general hospitals. Clinical charts were reviewed to determine whether or not the treating internist had made a diagnosis of anxiety or prescribed anxiolytic medications.ResultsThe 1-month prevalence of any type of anxiety disorder was 9.8% (95% CI=9.0–10.8%). The prevalences of the three most common disorders: anxiety disorder not otherwise specified, generalized anxiety disorder and anxiety disorder due to a general medical condition, were 6.3% (5.6–7.1%), 2.4% (2.0–2.9%), and 0.6% (0.4–0.8%), respectively. Multivariate logistic regression analysis identified the following independent predictors of having a current anxiety disorder: every being married (OR=3.5, 95% CI=2.3–5.4), prior treatment for psychological problems (3.3, 1.8–6.0), having religious beliefs (1.9, 1.3–2.9), low family income (1.5, 1.2–1.9) and never having attended college (1.3, 1.02–1.8). Among the 402 patients with anxiety disorders for whom the clinical chart was reviewed only 16 (4.0%, CI=2.3–6.3%) were diagnosed with an anxiety condition or treated with anxiolytic medications.ConclusionThe prevalence of anxiety in internal medicine outpatients in urban China is lower than that reported in most western countries and the profile of risk factors is somewhat different. The very low rate of recognition of these disorders by internists is related both to the low rates of care-seeking for psychological problems in the general population and to the high-volume collective model of care delivery in the outpatient departments of Chinese general hospitals. Steps to increase the recognition and treatment of anxiety disorders in Chinese general hospitals must focus both on changing attitudes of patients and clinicians and, more importantly, on altering the structure of care delivery.     

Screening instruments for depression and anxiety following stroke: experience in the Perth community stroke study

Evaluation of the relative efficacy of three screening instruments for depression and anxiety in a group of stroke patients was undertaken as part of the Perth community stroke study. Data are presented on the sensitivity and specificity of the Hospital Anxiety and Depression Scale (HAPS), the Geriatric Depression Scale and the General Health Questionnaire (GHQ) (28-item version) in screening patients 4 months after stroke for depressive and anxiety disorders diagnosed according to DSM-III criteria. The GHQ-28 and GDS but not the HADS depression, were shown to be satisfactory screening instruments for depression, with the GHQ-28 having an overall superiority. The performance of all 3 scales for screening post-stroke anxiety disorders was less satisfactory. The HADS anxiety had the best level of sensitivity, but the specificity and positive predictive values were low and the misclassification rate high.     

A comparison of methods of scoring the General Health Questionnaire

The General Health Questionnaire (GHQ) has been criticized for failing to detect individuals with chronic symptoms due to its focus on recent changes in one's usual state. Using data from a community survey in Edmonton, Canada, in which 3,258 subjects completed the 30-item GHQ and the Diagnostic Interview Schedule (DIS), the traditional method of scoring the GHQ was compared to a revised method proposed by Goodchild and Duncan-Jones. A case was defined to be someone with a history in the preceding month of one or more of the following DIS/DSM-III disorders: major depressive episode, phobia, panic disorder and obsessive-compulsive disorder. A receiver operating characteristic analysis demonstrated no difference in the two methods of scoring the GHQ.     

Screening for mental disorders in cancer patients – discriminant validity of HADS and GHQ‐12 assessed by standardized clinical interview

The detection and classification of comorbid mental disorders has major implications in cancer care. Valid screening instruments for different diagnostic specifications are therefore needed. This study investigated the discriminant validity of the German versions of the Hospital Anxiety and Depression Scale (HADS) and the General Health Questionnaire (GHQ‐12). A total of 188 cancer patients participated in the examination, consisting first of the assessment of psychological distress and, second, of the diagnosis of mental disorders according to DSM‐IV by clinical standardized interview (CIDI). Discriminant validity of the two instruments regarding the diagnosis of any mental disorder, anxiety, depression and multiple mental disorders was compared using ROC analysis. Overall, the total HADS scale shows a better screening performance than the GHQ‐12, especially for the detection of depressive and anxiety disorders. Best results are achieved for depressive disorders with an area under the curve (AUC) of 0.80, a sensitivity of 79% and a specificity of 76% (cut‐off point = 17). For the ability of the instruments to detect patients with mental disorders in general, the GHQ‐12 (AUC: 0.68) shows a similar overall accuracy to the HADS (AUC: 0.70). The screening performance of both scales for comorbid mental disorders is comparable. The HADS is a valid screening instrument for depressive and anxiety disorders in cancer care. The GHQ‐12 can be considered as an alternative to the HADS when diagnostic specifications are less detailed and the goal of screening procedures is to detect patients with single or multiple mental disorders in general. Limitations of conventional screening instruments are given through the differing methodological approaches of screening tests (dimensional approach) and diagnosis according to DSM‐IV (categorical approach). Copyright © 2001 Whurr Publishers Ltd.     

Knowledge About Recommended Treatment and Management of Major Depressive Disorder, Panic Disorder, and Generalized Anxiety Disorder Among Family Physicians

BACKGROUND: Concerns have been raised about whether primary care physicians appropriately manage mental disorders. We assessed family physicians' knowledge of appropriate management of major depressive disorder (MDD), panic disorder, and generalized anxiety disorder (GAD). METHOD: Active members of the Texas Academy of Family Physicians (N = 3553) were mailed a questionnaire in 2002 asking them to indicate which treatments they felt were effective for MDD, panic disorder, and GAD and also to indicate how they had treated their last patient with each disorder. Their treatment strategies were then compared with current guidelines. RESULTS: 574 physicians (16%) responded. The percentage of respondents scoring at or above 80% for knowledge of effective treatments was 88.3% for MDD, 16.8% for panic disorder, and 12.5% for GAD (p <.001 for MDD vs. panic disorder or GAD). Only 0.3% of MDD patients, 1.4% of panic disorder patients, and 4.0% of GAD patients were not prescribed at least 1 of the effective treatments. Referral rates to mental health providers were high for all 3 conditions. CONCLUSIONS: There were significant gaps in physician knowledge of current guidelines on treating panic disorder and GAD, but not MDD. However, most patients with one of the disorders were either referred to a mental health provider or treated with an effective modality.     

Anxiety, depression, and quality of life in primary care patients

Background: Anxiety and depressive disorders have a significant and negative impact on quality of life. However, less is known about the effects of anxiety and depressive symptoms on quality of life. The purpose of this study was to examine the impact of anxiety and depressive symptoms on emotional and physical functioning, the effects of anxiety symptoms on functioning independent of depressive symptoms, and the effects of depressive symptoms on functioning independent of anxiety symptoms.Method: Participants included 919 patients, recruited from 2 university-affiliated primary care clinics between May 2004 and September 2006, who completed self-report measures of anxiety symptoms, depressive symptoms, and quality of life.Results: Almost 40% of the sample reported anxiety symptoms and 30% reported depressive symptoms. In both unadjusted and adjusted models, anxiety and depressive symptoms were significantly associated with all domains of quality of life. When anxiety and depressive symptoms were added simultaneously, both remained significant. As the severity of anxiety or depressive symptoms increased, quality of life decreased. Furthermore, patients with moderate to severe anxiety or depressive symptoms had greater impairments in most quality of life domains than patients with acute myocardial infarction, congestive heart failure, or diabetes.Conclusion: Detection and treatment of anxiety and depressive symptoms in the primary care setting should be emphasized.     

Does a coexisting anxiety disorder predict persistence of depressive illness in primary care patients with major depression?

We assessed whether a coexisting anxiety disorder predicts risk for persistent depression in primary care patients with major depression at baseline. Patients with major depression were identified in a 12-month prospective cohort study at a University-based family practice clinic. Presence of an anxiety disorder and other potential prognostic factors were measured at baseline. Persistent depressive illness (major depression, minor depression, or dysthymia) was determined at 12 months. Of 85 patients with major depression at baseline, 43 had coexisting anxiety disorder (38 with social phobia). The risk for persistent depression at 12 months was 44% greater [Risk Ratio (RR) = 1.44, 95% confidence interval (CI) 1.02-2.04] in those with coexisting anxiety. This risk persisted in stratified analysis controlling for other prognostic factors. Patients with coexisting anxiety had greater mean depressive severity [repeated measures analysis of variance (ANOVA), p < 0.04] and total disability days (54.9 vs 19.8, p < 0.02) over the 12-month study. Patients with social phobia had similar increased risk for persistent depression (RR = 1.40, 95% CI 0.98-2.00). A coexisting anxiety disorder indicates risk for persistent depression in primary care patients with major depression. Social phobia may be important to recognize in these patients. Identifying anxiety disorders can help primary care clinicians target patients needing more aggressive treatment for depression.