The role of comorbidity in the detection of psychiatric disorders with checklists for mental and physical symptoms in primary care

Objective  To examine the contribution of a mental and physical symptom count to the detection of single or comorbid anxiety, depressive and somatoform disorders. Method  In primary care 1,046 consulting patients completed the Hospital Anxiety and Depression Scale (HADS) and the Physical Symptom Checklist (PSC-51). In a stratified sample of 473 patients DSM-IV psychiatric disorders were assessed using the WHO-SCAN interview. The diagnostic value of the HADS total score and the PSC-51 symptom count was examined with ROC-analyses. Results  The discriminative power of PSC-51 and HADS was highest for patients with both a somatoform disorder and an anxiety or depressive disorder, with an AUC of 0.86 (95% CI: 0.81–0.91) and 0.91 (95% CI: 0.87–0.94) respectively. Using both symptom counts together did not increase the diagnostic value for the detection of the psychiatric disorders. Conclusion  Both symptom counts preferentially detected patients with comorbid disorders. When interpreting diagnostic values of screening questionnaires one should keep in mind that the validity of these values can be dependent of the presence of comorbid disorders.     

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.     

Discriminant validity of the 12-item version of the general health questionnaire in a Swedish case-control study

Background: The 12-item version of the General Health Questionnaire (GHQ-12) is widely used as a proxy for Affective Disorders in public health surveys, although the cut-off points for distress vary considerably between studies. The agreement between the GHQ-12 score and having a clinical disorder in the study population is usually unknown.

Aims: This study aimed to assess the criterion validity and to determine the sensitivity and specificity of the GHQ-12 in the Swedish population.

Methods: This study used 556 patient cases surveyed in specialized psychiatric care outpatient age- and sex-matched with 556 controls from the Stockholm Health Survey. Criterion validity for two scoring methods of GHQ-12 was tested using Receiver Operating Characteristics (ROC) analyses with Area Under the Curve (AUC) as a measure of agreement. Reference standard was (1) specialized psychiatric care and (2) current depression, anxiety or adjustment disorder.

Results: Both the Likert and Standard GHQ-12 scoring method discriminated excellently between individuals using specialized psychiatric services and healthy controls (Likert index AUC?=?0.86, GHQ index AUC?=?0.83), and between individuals with current disorder from healthy controls (Likert index AUC?=?0.90, GHQ index AUC?=?0.88). The best cut-off point for the GHQ index was ≥4 (sensitivity?=?81.7 and specificity?=?85.4), and for the Likert index ≥14 (sensitivity?=?85.5 and specificity?=?83.2).

Conclusions: The GHQ-12 has excellent discriminant validity and is well suited as a non-specific measure of affective disorders in public mental health surveys.     

The Comorbidity of Major Depression and Anxiety Disorders: Recognition and Management in Primary Care

BACKGROUND: Depressive and anxiety disorders commonly occur together in patients presenting in the primary care setting. Although recognition of individual depressive and anxiety disorders has increased substantially in the past decade, recognition of comorbidity still lags. The current report reviews the epidemiology, clinical implications, and management of comorbidity in the primary care setting. METHOD: Literature was reviewed by 2 methods: (1) a MEDLINE search (1980-2001) using the key words depression, depressivedisorders, and anxietydisorders; comorbidity was also searched with individual anxiety diagnoses; and (2) direct search of psychiatry, primary care, and internal medicine journals over the past 5 years. RESULTS: Between 10% and 20% of adults in any given 12-month period will visit their primary care physician during an anxiety or depressive disorder episode (although typically for a nonpsychiatric complaint); more than 50% of these patients suffer from a comorbid second depressive or anxiety disorder. The presence of depressive/anxiety comorbidity substantially increases medical utilization and is associated with greater chronicity, slower recovery, increased rates of recurrence, and greater psychosocial disability. Typically, long-term treatment is indicated, although far less research is available to guide treatment decisions. Selective serotonin reuptake inhibitor antidepressants are the preferred treatment based on efficacy, safety, and tolerability criteria. Knowledge of their differential clinical and pharmacokinetic profiles can assist in optimizing treatment. CONCLUSION: Increased recognition of the high prevalence and negative psychosocial impact of depression and anxiety disorder comorbidity will lead to more effective treatment. While it is hoped that early and effective intervention will yield long-term benefits, research is needed to confirm this.     

Axis-I comorbidity in female patients with dissociative identity disorder and dissociative identity disorder not otherwise specified

The aim of this study was to investigate axis-I comorbidity in patients with dissociative identity disorder (DID) and dissociative disorder not otherwise specified (DDNOS). Using the Diagnostic Interview for Psychiatric Disorders, results from patients with DID (n = 44) and DDNOS (n = 22) were compared with those of patients with posttraumatic stress disorder (PTSD) (n = 13), other anxiety disorders (n = 14), depression (n = 17), and nonclinical controls (n = 30). No comorbid disorders were found in nonclinical controls. The average number of comorbid disorders in patients with depression or anxiety was 0 to 2. Patients with dissociative disorders averagely suffered from 5 comorbid disorders. The most prevalent comorbidity in DDNOS and DID was PTSD. Comorbidity profiles of patients with DID and DDNOS were very similar to those in PTSD (high prevalence of anxiety, somatoform disorders, and depression), but differed significantly from those of patients with depression and anxiety disorders. These findings confirm the hypothesis that PTSD, DID, and DDNOS are phenomenologically related syndromes that should be summarized within a new diagnostic category.     

Screening for mental health: validity of the MHI-5 using DSM-IV Axis I psychiatric disorders as gold standard

Short screening questionnaires for mental health are useful tools for research and clinical practice, e.g. they could play a major role in detecting patients with psychiatric disorders in primary care. The present study tests the validity of the five-item Mental Health Inventory (MHI-5) screening test using DSM-IV Axis I diagnoses as a gold standard and analyzes its performance in different diagnostic groups. A random sample was drawn from the resident registration office files in northern Germany. Personal interviews with a response rate of 70% were conducted. Of the sample, 4036 respondents filled in the MHI-5. DSM-IV diagnoses were assessed using the Munich Composite International Diagnostic Interview (M-CIDI). The area under the receiver operating characteristics curve (AUC) of 0.72 in identifying any DSM-IV Axis I disorder (except substance use) is not satisfying. The MHI-5 revealed best performance for mood (AUC: 0.88) followed by anxiety disorders (AUC: 0.71). Sensitivity and specificity were poor for somatoform and substance use disorders, especially in cases without comorbid mood or anxiety disorder. The power to detect mood and anxiety disorders of the MHI-5 was better for the 4-week compared with the 12-month diagnoses. The MHI-5 can be recommended to screen for mood disorders. Data have to be confirmed for primary care settings.     

Comorbidity of anxiety and depressive disorders: issues in conceptualization, assessment, and treatment

OBJECTIVES: The purpose of this review is to provide a clinically relevant analysis of issues concerning comorbidity among anxiety and depressive disorders. The co-occurrence of social anxiety disorder (SAD) and generalized anxiety disorder (GAD) with depressive disorders is highlighted as an illustration. Data on prevalence, rates of comorbidity, order of onset, course, and functional impairment associated with these disorders, in both the general population and clinical samples, are examined. The second half of the review focuses on discussion of practical issues concerning assessment and treatment of comorbid anxiety and depressive syndromes. CONCLUSIONS: Available evidence suggests that comorbidity among SAD, GAD, and the depressive disorders is substantial and pervasive. Co-occurrence of these syndromes is typically characterized by a chronic course with clinically significant impairment in social and occupational functioning. SAD and GAD precede the onset of major depression in a majority of cases and appear to be risk factors for developing major depression. Clinicians encountering patients with primary complaints of anxiety or depression should carefully assess for the presence of comorbid symptoms and syndromes. Treatment outcome research suggests that pharmacotherapy and psychosocial therapy (cognitive-behavior therapy in particular) both represent viable first-line treatment alternatives. However, with increasing severity of depression, pharmacotherapy is indicated as a primary intervention. The authors recommend increased efforts in screening and detection, more clinical trials that include patients with comorbid syndromes and symptoms, and continued research on the integration of pharmacological and psychotherapeutic treatments.     

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.     

Postnatal psychiatric morbidity: a validation study of the GHQ-12 and the EPDS as screening tools

OBJECTIVE: To assess the validity of the 12-Item General Health Questionnaire (GHQ-12) and the Edinburgh Postnatal Depression Scale (EPDS) in screening for the most common postnatal psychiatric morbidities (mood, anxiety and adjustment disorders). METHOD: A two-phase cross-sectional study was designed. First, a sample of 1453 women visiting at 6 weeks postpartum completed the GHQ-12 and the EPDS questionnaires. Second, based upon EPDS outcomes, participants were stratified and randomly selected within each stratum for clinical evaluation [Structured Clinical Interview for DSM-IV (SCID)]. Receiver operating characteristic (ROC) analysis was used. RESULTS: The concurrent validity was satisfactory (0.80). At optimum cut-off scores, both GHQ-12 and EPDS yielded very good sensitivity (80; 85.5) and specificity (80.4; 85.3), respectively. ROC curves showed that the performance of the EPDS (AUC=0.933) is slightly superior to that of GHQ-12 (AUC=0.904). CONCLUSION: Both GHQ-12 and EPDS are valid instruments to detect postnatal depression as well as postnatal anxiety and adjustment disorders.     

Affective and anxiety comorbidity in post-traumatic stress disorder treatment trials of sertraline

Comorbidity of mood and anxiety disorders is common in patients suffering from post-traumatic stress disorder (PTSD). The current study evaluated the efficacy and tolerability of sertraline in a subgroup of PTSD patients suffering from anxiety or depression comorbidity. Two multicenter, 12-week, double-blind, flexible-dose US studies of adult outpatients from the general population with a DSM-III-R diagnosis of PTSD evaluated the safety and efficacy of sertraline (50 to 200 mg/d) compared to placebo in the treatment of PTSD. The total severity score of the Clinician-Administered PTSD Scale (CAPS-2) and the Davidson Trauma Scale (DTS) were used to examine the effect of comorbidity on treatment outcome. Among the combined 395 subjects enrolled in the two trials, 32.9% had a comorbid depressive diagnosis (no anxiety diagnosis), 6.3% had a comorbid anxiety disorder diagnosis (no depression), 11.4% had both a depression and anxiety disorder diagnosis, and 49.4% had no comorbidity. The correlation, at baseline, between Hamilton Depression Rating Scale (HAM-D) total score and the three CAPS-2 clusters was 0.37 for the re-experiencing/intrusion cluster, 0.52 for the avoidance/numbing cluster, and 0.45 for the hyperarousal cluster. Patients suffering from PTSD complicated by a current diagnosis of both depression and an anxiety disorder showed the highest baseline CAPS-2 cluster score severity. Patients treated with sertraline improved significantly (P <.05) compared to placebo on both the CAPS-2 and DTS whether or not they had a comorbid depressive or anxiety disorder. Sertraline was well tolerated. The presence of comorbidity was associated with a modest and mostly nonspecific increase in the side effect burden of approximately 10% to 20% on both study treatments. Patients suffering from dual depression and anxiety disorder comorbidity benefited from somewhat higher doses (147 mg v 125 mg; P =.08). Similarly, the presence of dual comorbidity resulted in a modest but nonsignificant increase in the mean time to response from 4.5 weeks to 5.5 weeks.We conclude that sertraline (50 to 200 mg/d) is effective and well tolerated in the treatment of PTSD for patients suffering from a current, comorbid depressive or anxiety disorders.     

Validation of diagnoses of distress disorders in the US National Comorbidity Survey Replication Adolescent Supplement (NCS-A)

Research diagnostic interviews need to discriminate between closely related disorders in order to allow comorbidity among mental disorders to be studied reliably. Yet conventional studies of diagnostic validity generally focus on single disorders and do not examine discriminant validity. The current study examines the validity of fully-structured diagnoses of closely-related distress disorders (generalized anxiety disorder, post-traumatic stress disorder, major depressive episode, and dysthymic disorder) in the lay-administered Composite International Diagnostic Interview Version 3.0 (CIDI) with independent clinical diagnoses based on the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS) in the US National Comorbidity Survey Replication Adolescent Supplement (NCS-A). The NCS-A is a national survey of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) among 10,148 adolescents. A probability sub-sample of 347 of these adolescents and their parents were administered blinded follow-up K-SADS interviews. Good concordance [area under the receiver operating characteristic curve (AUC)] was found between diagnoses based on the CIDI and the K-SADS for generalized anxiety disorder (AUC = 0.78), post-traumatic stress disorder (AUC = 0.79), and major depressive episode/dysthymic disorder (AUC = 0.86). Further, the CIDI was able to effectively discriminate among different types of distress disorders in the sub-sample of respondents with any distress disorder.     

Missed bipolarity and psychiatric comorbidity in women with postpartum depression

Objective:  To investigate the diagnostic profile of women referred for postpartum depression.
Methods:  Fifty-six women seen consecutively with the referral diagnosis of postpartum depression were administered structured instruments to gather information about their DSM-IV Axis I diagnoses.
Results:  In terms of frequency of occurrence, the primary diagnoses in this sample were: major depressive disorder (46%), bipolar disorder not otherwise specified (29%), bipolar II disorder (23%), and bipolar I disorder (2%). A current comorbid disorder, with no lifetime comorbidity, occurred among 32% of the sample; by contrast, lifetime comorbidity alone (i.e., with no currently comorbid disorder) was found among 27%. Both a lifetime and a current comorbidity were found among 18% of the women, and 23% had no comorbid disorder. The most frequently occurring current comorbid disorder was an anxiety disorder (46%), with obsessive-compulsive disorder (62%) being the most common type of anxiety disorder. For lifetime comorbidity, substance use (20%) and anxiety disorders (12%) were the two most common. Over 80% of patients who scored positive on either the Highs Scale or the Mood Disorder Questionnaire met the diagnostic criteria for a bipolar disorder.
Conclusion:  The results suggest that postpartum depression is a heterogeneous entity and that misdiagnosis of bipolar disorder in the postpartum period may be quite common. The findings have important clinical implications, which include the need for early detection of bipolarity through the use of reliable and valid assessment instruments, and implementation of appropriate prevention and treatment strategies.     

Validity of the 12-item General Health Questionnaire (GHQ-12) in detecting depressive and anxiety disorders among high school students

Despite the common use of the 12-item General Health Questionnaire (GHQ-12) with adolescents, there is limited data supporting its validity with this population. The aims of the study were to investigate the psychometric properties of the GHQ-12 among high school students, to validate the GHQ-12 against the gold standard of a diagnostic interview, and to suggest a threshold score for detecting depressive and anxiety disorders. Six hundred and fifty-four high school students from years 10 to 12 (ages 15-18) completed the GHQ-12 (Likert scored) and the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-IV-Test Revision (DSM-IV-TR). Receiver operating characteristic (ROC) curves were plotted. The mean GHQ-12 score for the total sample was 9.9 (S.D.=5.4). Results from the ROC curve indicated that the GHQ-12 performed better than chance at identifying depressive and anxiety disorders (area under the curve (AUC)=0.781). A GHQ-12 threshold score of 9/10 for males and 10/11 for females was found to be optimal. Given the significant proportion of mental illness among high school students, there may be a need to introduce screening for mental illnesses as part of the school curriculum. This can assist with the early identification and enable low stigma preventive intervention within the school environment.     

Comorbid Depressive Disorders in Anxiety-disordered Youth: Demographic,Clinical, and Family Characteristics

Research indicates that depression and anxiety are highly comorbid in youth. Little is known, however, about the clinical and family characteristics of youth with principal anxiety disorders and comorbid depressive diagnoses. The present study examined the demographic, clinical, and family characteristics of 200 anxiety-disordered children and adolescents (aged 7–17) with and without comorbid depressive disorders (major depressive disorder or dysthymic disorder), seeking treatment at a university-based anxiety clinic. All participants met DSM-IV diagnostic criteria for a principal anxiety disorder (generalized anxiety disorder, separation anxiety disorder, or social phobia). Of these, twelve percent (n = 24) also met criteria for a comorbid depressive disorder. Results suggest that anxiety-disordered youth with comorbid depressive disorders (AD-DD) were older at intake, had more severe anxious and depressive symptomotology, and were more impaired than anxiety-disordered youth without comorbid depressive disorders (AD-NDD). AD-DD youth also reported significantly more family dysfunction than AD-NDD youth. Future research should examine how this diagnostic and family profile may impact treatment for AD-DD youth.     

Depression, anxiety, and somatoform disorders: Vague or distinct categories in primary care? Results from a large cross-sectional study

Objective

Depression, anxiety, and somatization are the most frequently observed mental disorders in primary health care. Our main objective was to draw on the often neglected general practitioners' (GPs) perspective to investigate what characterizes these three common mental diagnoses with regard to creating more suitable categories in the DSM-V and ICD-11.

Methods

We collected independent data from 1751 primary care patients (participation rate=77%) and their 32 treating GPs in Germany. Patients filled out validated patient self-report measures for depression (PHQ-9), somatic symptom severity (PHQ-15), and illness anxiety (Whiteley-7), and questions regarding coping and attribution of illness. GPs' clinical diagnoses and associated features were assessed.

Results

Patients diagnosed by their GPs with depression, anxiety, and/or somatoform disorders were significantly older, less educated, and more often female than the reference group not diagnosed with a mental disorder. They had visited the GP more often, had a longer duration of symptoms, and were more often under social or financial stress. Among the mental disorders diagnosed by the GPs, depression (OR=4.4; 95% CI=2.6 to 7.5) and comorbidity of somatoform, depressive, and anxiety disorders (OR=9.5; 95% CI=4.6 to 19.4) were associated with the largest degrees of impairment compared to the reference group. Patients diagnosed as having a somatoform/functional disorder only had mildly elevated impairment on all dimensions (OR=2.0; 95% CI=1.4 to 2.7). Similar results were found for the physicians' attribution of psychosocial factors for cause and maintenance of the disease, difficult patient-doctor relationship, and self-assessed mental disorder.

Conclusion

In order to make the DSM-V and ICD-11 more suitable for primary care, we propose providing appropriate diagnostic categories for (1) the many mild forms of mental syndromes typically seen in primary care; and (2) the severe forms of comorbidity between somatoform, depressive, and/or anxiety disorder, e.g., with a dimensional approach.     

Diagnosing mental disorders in primary care: the General Health Questionnaire (GHQ) and the Symptom Check List (SCL-90-R) as screening instruments

Background: The treatment of mental disorders in Germany is mainly done by primary care physicians. Several studies have shown that primary care physicians have difficulty in diagnosing these disorders. Recently, several self-report questionnaires have been developed that can be used as screening instruments to identify psychopathology in primary care settings and in the community. The aim of this paper was to investigate the screening properties of the General Health Questionnaire (GHQ-12) and the Symptom Check-List (SCL-90-R) in a primary care setting in Germany. Method: A randomly selected sample (n = 408) of adult outpatients from 18 primary care offices in Düsseldorf was screened using the German versions of the GHQ-12 and the SCL-90-R. A structured diagnostic interview (SCID) and an impairment rating (IS) were used as a gold standard to which both questionnaires were compared. Test performance was evaluated by receiver operating characteristic (ROC) analysis. Results: We found no difference in the performance of the general scores of the two questionnaires. Both instruments were able to detect cases. Complex scoring methods offered no advantages over simpler ones for the GHQ-12. ROC analysis confirmed that the SCL-90-R subscales “anxiety” and “depression” showed acceptable concurrent validity for the diagnostic groups anxiety and depression (according to DSM-III-R). Conclusions: GHQ-12 and SCL-90-R appeared to be useful tools for identifying mental disorders in primary care practice and research. The use of GHQ-12 or SCL-90-R, employed as a first step, supplemented by a second-stage interview, may enhance the detection rate of mental disorder in primary care settings. Accepted: 16 February 1999     

Frequency and patterns of psychiatric comorbidity in a sample of primary care patients with anxiety disorders

The current report examines the rates of psychiatric comorbidity in a sample of 539 primary care patients diagnosed with anxiety disorders using the Structured Clinical Interview for DSM-IV (SCID-IV). Though not a typical psychiatric sample, rates of comorbidity were found to be as high or higher than those reported in studies conducted in traditional mental health settings. Multiple anxiety disorders were diagnosed in over 60% of participants and over 70% of participants had more than one current axis I diagnosis. Rates of current and lifetime comorbid major depression were also very high. Patterns of diagnostic comorbidity were also examined, with significantly elevated risks for the co-occurrence of several specific pairings of disorders being found. The study results are discussed in context of a recently published, large-scale study of anxiety disorder comorbidity in psychiatric patients (Brown et al., 2001). Implications of these results for both the mental health and primary care fields are also discussed.     

The effect of comorbid anxiety and depressive disorders on health care utilization and costs among adolescents with asthma

OBJECTIVE: To assess whether youth with asthma and comorbid anxiety and depressive disorders have higher health care utilization and costs than youth with asthma alone. METHODS: A telephone survey was conducted among 767 adolescents (aged 11 to 17 years) with asthma. Diagnostic and Statistical Manual-4th Version (DSM-IV) anxiety and depressive disorders were assessed via the Diagnostic Interview Schedule for Children. Health care utilization and costs in the 12 months pre- and 6 months post-interview were obtained from computerized health plan records. Multivariate analyses were used to determine the impact of comorbid depression and anxiety on medical utilization and costs. RESULTS: Unadjusted analyses showed that compared to youth with asthma alone, youth with comorbid anxiety/depressive disorders had more primary care visits, emergency department visits, outpatient mental health specialty visits, other outpatient visits and pharmacy fills. After controlling for asthma severity and covariates, total health care costs were approximately 51% higher for youth with depression with or without an anxiety disorder but not for youth with an anxiety disorder alone. Most of the increase in health care costs was attributable to nonasthma and non-mental health-related increases in primary care and laboratory/radiology expenditures. CONCLUSIONS: Youth with asthma and comorbid depressive disorders have significantly higher health care utilization and costs. Most of these costs are due to increases in non-mental health and nonasthma expenses. Further study is warranted to evaluate whether improved mental health treatment and resulting increases in mental health costs would be balanced by savings in medical costs.     

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.