Somatic complaints among pregnant women cared for in obstetrics: normal pregnancy or depressive and anxiety symptom amplification revisited?

Despite the extensive research documenting the significance of medically unexplained somatic symptoms in primary care patients, few studies have examined somatic symptoms as a predictor of depressive and anxiety disorders among pregnant women cared for in Obstetrics. We utilized the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PHQ) to assess current depressive and anxiety disorders and self-reported somatic symptoms among 186 women receiving prenatal care. We examined the bivariate relationships between depressive and anxiety disorders and mean number of somatic symptoms. Linear regression analyses assessed the unique association between maternal depression, anxiety and somatic symptoms, while controlling for selected demographics and maternal medical risk. Twenty three percent (N=43) of women met screening criteria for depressive and/or anxiety disorders. Women with depression and/or anxiety were significantly more likely to report somatic symptoms (mean=7.1, SD=2.6) compared to women without depression or anxiety (mean=5.0, SD=2.6) [t(df)=4.54(184), P<.001]. This association persisted in multivariate models. Our findings suggest that antenatal depressive and anxiety disorders are associated with an amplification of physical symptoms of pregnancy. Eliciting and tracking somatic symptoms during prenatal visits could potentially improve detection of depressive and anxiety disorders in the obstetrical sector.     

Child temperament,ADHD, and caregiver strain: exploring relationships in an epidemiological sample

OBJECTIVE: To investigate the relationship between child-reported dimensions of temperament and attention-deficit/ hyperactivity disorder (ADHD), as well as other indicators of child psychopathology, including disruptive disorders, depression, and anxiety. It also examined whether difficult child temperament scores independently predicted caregiver strain. METHOD: A school-district-wide, two-phase screening design (response rate 70% for phase 2) identified elementary school children at high risk for ADHD. Two hundred high-risk children and their parents completed standardized instruments to assess child temperament, diagnoses of disruptive disorders, children's symptoms of anxiety and depression, and caregiver strain. Relationships were examined using analysis of variance, correlations, and multivariate prediction models, adjusting for child sociodemographic characteristics and psychopathology. All estimates were weighted for sampling design and differential participation. RESULTS: Combined subtype ADHD was associated with lower scores on task orientation and higher scores on general activity level. Depressive symptoms correlated significantly with all but one difficult temperament dimension, in a pattern consistent with clinical symptoms of depression. Child temperament did not vary by ADHD treatment status. Among these high-risk children, maternal caregiver strain experiences were increased by male gender, inattention symptoms, and oppositional defiant disorder, but not by difficult temperament scores. CONCLUSION: This study provides support for Graham and Stevenson's hypothesis of continuity between specific temperament traits and certain child psychiatric disorders, namely ADHD and depressive disorders.     

Child and parent reports of childhood anxiety: Differences in coping styles

This study compares children anxious only on parent report (PR) with those anxious on self-report (SR) and self- and parent report (SPR) to examine the reasons for the reporting differences. Sixty-five children aged 7–12 years who met criteria for one or more Axis I anxiety disorders (25% with comorbid nonanxiety diagnoses) completed standardized measures of anxiety, depression, and coping style. Parents completed measures of child psychopathology and adult coping style. Assessing clinicians completed the Global Assessment of Functioning. All parents endorsed anxiety in their children. Based on their responses on standardized self-report measures of anxiety, children were classified as endorsing anxiety (SPR group) or not endorsing anxiety (PR group). Multivariate analysis of variance revealed that children in the SPR group endorsed more depression and employed a greater variety of coping strategies than children in the PR group. The two groups did not differ on parent or clinician measures. These findings suggest that reporting differences may be related to differences in coping styles in anxious children. SPR children may overreport anxiety symptoms due to feelings of decreased self-worth associated with depressive thinking, whereas PR children may be able to distract themselves from their anxieties. The lack of difference in functioning between the two groups suggests that self-report anxiety questionnaire scores are not necessarily indicative of severity. Depression and Anxiety 6:62–69, 1997. © 1997 Wiley-Liss, Inc.     

Relationships among pain, anxiety, and depression in primary care

Pain, anxiety, and depression are commonly seen in primary care patients and there is considerable evidence that these experiences are related. This study examined associations between symptoms of pain and symptoms and diagnoses of anxiety and depression in primary care patients. Results indicate that primary care patients who endorse symptoms of muscle pain, headache, or stomach pain are approximately 2.5-10 times more likely to screen positively for panic disorder, generalized anxiety disorder, or major depressive disorder. Endorsement of pain symptoms was also significantly associated with confirmed diagnoses of several of the anxiety disorders and/or major depression, with odds ratios ranging from approximately 3 to 9 for the diagnoses. Patients with an anxiety or depressive disorder also reported greater interference from pain. Similarly, patients endorsing pain symptoms reported lower mental health functioning and higher scores on severity measures of depression, social anxiety, and posttraumatic stress disorder. Mediation analyses indicated that depression mediated some, but not all of the relationships between anxiety and pain. Overall, these results reveal an association between reports of pain symptoms and not only depression, but also anxiety. An awareness of these relationships may be particularly important in primary care settings where a patient who presents with reports of pain may have an undiagnosed anxiety or depressive disorder.     

Treatment and Prevention of Depression and Anxiety in Youth: Test of Cross-Over Effects

Anxiety and depression are highly comorbid and share several common etiological processes. Therefore, it may be more efficient to develop interventions that treat or prevent these problems together rather than as separate entities. The present meta-analytic review examined whether interventions for children and adolescents that explicitly targeted either anxiety or depression showed treatment specificity or also impacted the other outcome (i.e. cross-over effects). We addressed this question both within the same type of study (i.e. treatment, prevention) and across study types. Only randomized controlled trials (RCTs) that assessed both constructs with dimensional measures were included in this review. For treatment studies, RCTs targeting anxiety (n = 18) showed significant effects on both anxious and depressive symptoms, although more strongly on anxiety than depression; similarly, RCTs treating depression (n = 9) yielded significant effects on both depressive and anxious symptoms, but stronger effects on depression than anxiety. Thus, there were cross-over effects in treatments purportedly targeting either anxiety or depression, and also treatment specificity, such that larger effects were seen for the target problem at which the treatment was aimed. Anxiety prevention studies (n = 14) significantly affected anxious, but not depressive symptoms, indicating no cross-over effect of anxiety prevention trials on depression. For depression prevention studies (n = 15), the effects were not significant for either depressive or anxiety symptoms, although the effect was significantly larger for depressive than for anxious symptoms. Post-hoc analyses revealed that the effect on depressive symptoms was significant in depression preventions trials of targeted but not universal samples. Implications for transdiagnostic interventions are discussed.     

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.     

抑郁障碍共患焦虑:诊断与评估之挑战(英文)

抑郁障碍共患焦虑是常见的精神病理现象。该现象使抑郁障碍临床表现复杂化,并导致治疗困难。通过评定符合抑郁症诊断标准患者的焦虑症状严重程度或者通过确定抑郁症患者是否同时符合焦虑症诊断标准,临床医生评估抑郁症状和焦虑症状之间的重叠程度。然而,中国临床医疗中存在很多因素,往往难以准确评估患者的共患情况。在中国对于这种最常见的精神病理共患现象——抑郁障碍共患焦虑——的诊断缺乏严重削弱了国内对常见精神障碍治疗的有效性。我们认为,中国临床广泛使用有效可靠的评估工具将有助于对许多同时存在抑郁症状和焦虑症状的患者的诊断与治疗。     

A Multi-Informant Examination of Maternal Symptoms and Autonomy Granting in Youth Anxiety

Evidence suggests the important role of (a) parenting behaviors and (b) parental psychopathology in the development and maintenance of youth anxiety. Using a multi-informant approach, the current study examined the association of maternal autonomy granting and maternal symptoms (i.e., anxiety and depression) with youth anxiety among mothers and 88 youth (ages of 6–17) diagnosed with a principal anxiety disorder. Results from the generalized estimating equations (GEE) analyses indicated that mothers reported higher youth anxiety symptoms compared to youth self-reports. Youth-perceived maternal autonomy granting was inversely associated with youth anxiety, and maternal self-reported anxiety and depressive symptoms significantly moderated this relationship: As mothers reported higher anxiety and depressive symptoms, the inverse association between parental autonomy granting and youth anxiety weakened. The interaction between parenting behavior and parental psychopathology significantly influenced youth anxiety symptoms, which presents important clinical implications to integrate into parenting work in the treatment of youth anxiety disorders.     

Sex differences in the use of coping strategies: predictors of anxiety and depressive symptoms

This study examined sex differences in the use of coping strategies and their relationship to depression and anxiety-related psychopathology. Responses on measures of coping strategies, depression, and anxiety were obtained from a carefully screened nonclinical sample (N = 107). The results demonstrated that women who used less positive reframing had higher levels of depressive symptoms compared with women who used more positive reframing and to men irrespective of their use of more or less positive reframing. In addition, women who reported the use of more self-blame had elevated levels of trait anxiety, although a similar effect was not found for men. The observed sex differences in the use of coping strategies and their association with depression and anxiety-related problems underscores differences in the clinical presentation of anxiety and depression between women and men.     

Low-income depressed older adults with psychiatric comorbidity: secondary analyses of response to psychotherapy and case management

OBJECTIVE: This study examined the influence of comorbid anxiety and personality disorders on depression treatment response in 67 low-income older adults. METHODS: Participants were randomized to clinical case management, cognitive-behavioral group therapy, or both for 6 months. Outcomes were assessed at baseline, post-treatment, and 6 and 12 months after treatment. RESULTS: Dropout and depression diagnoses were similar across groups. Participants with comorbidity had more depressive and anxiety symptoms at most time points; degree of improvement did not differ significantly. Of participants with personality disorder, none met criteria at post-treatment (three relapsed by 12-month follow-up). CONCLUSIONS: Findings suggest depressed low-income elders with anxiety or personality disorders can be retained and benefit from depression treatment, but may require additional interventions to achieve similar levels of depressive symptoms.     

Follow-up and family study of anxious depression

OBJECTIVE: The failure of the concept of anxious depression to find its way into DSM-III-R led the authors to conclude that a further report on the occurrence of anxiety symptoms in depressed subjects is indicated. METHOD: The subjects were 327 consecutively evaluated inpatients and outpatients with primary unipolar depressive disorder at five university medical centers participating in the National Institute of Mental Health Collaborative Program on the Psychobiology of Depression--Clinical Studies. The authors restricted their sample selection to patients with primary depressive disorder so that patients with other preexisting psychiatric disorders, especially anxiety disorders, would not contaminate the symptom picture, family studies, or follow-up. The examined six anxiety symptoms and derived a new anxiety summary score to show the effect of anxiety in depression on family data and 5-year outcome. RESULTS: Depressed subjects with higher ratings for anxiety took longer to recover. There was also a significant relationship between anxiety in depressed probands and the risk for primary unipolar depressive disorder, but not anxiety disorders or alcoholism, among 832 blindly interviewed first-degree relatives. CONCLUSIONS: These data confirm the usefulness of subdividing depressed patients according to anxiety symptoms: psychic and somatic symptoms of anxiety, taken together, significantly predict family illness and course. The data also emphasize the wisdom of requiring that generalized anxiety disorder not be diagnosed in the presence of a mood disorder. Clearly, symptoms of anxiety coexist with depression and need to be recognized for the effective treatment of the underlying depressive disorder.     

The association of depression and anxiety with medical symptom burden in patients with chronic medical illness

BACKGROUND: Primary care patients with anxiety and depression often describe multiple physical symptoms, but no systematic review has studied the effect of anxiety and depressive comorbidity in patients with chronic medical illnesses. METHODS: MEDLINE databases were searched from 1966 through 2006 using the combined search terms diabetes, coronary artery disease (CAD), congestive heart failure (CHF), asthma, COPD, osteoarthritis (OA), rheumatoid arthritis (RA), with depression, anxiety and symptoms. Cross-sectional and longitudinal studies with >100 patients were included as were all randomized controlled trials that measure the impact of improving anxiety and depressive symptoms on medical symptom outcomes. RESULTS: Thirty-one studies involving 16,922 patients met our inclusion criteria. Patients with chronic medical illness and comorbid depression or anxiety compared to those with chronic medical illness alone reported significantly higher numbers of medical symptoms when controlling for severity of medical disorder. Across the four categories of common medical disorders examined (diabetes, pulmonary disease, heart disease, arthritis), somatic symptoms were at least as strongly associated with depression and anxiety as were objective physiologic measures. Two treatment studies also showed that improvement in depression outcome was associated with decreased somatic symptoms without improvement in physiologic measures. CONCLUSIONS: Accurate diagnosis of comorbid depressive and anxiety disorders in patients with chronic medical illness is essential in understanding the cause and in optimizing the management of somatic symptom burden.     

Symptoms of anxiety and depression in the course of cognitive decline

BACKGROUND/AIMS: Anxiety and depression are common inpatients with cognitive decline and Alzheimer's disease (AD), and recognition and treatment of these symptoms can improve their quality of life. The present study investigates anxiety and depression in different phases of cognitive decline. METHODS: The sample consisted of five groups of elderly people in different phases of cognitive decline; four from a community-based sample (Longitudinal Aging Study Amsterdam), and one group of elderly people diagnosed with AD. ANOVAs were performed to investigate group differences in the severity and prevalence of anxiety and depression, and comorbid anxiety and depressive symptoms. RESULTS: The prevalence rates of anxiety, comorbid anxiety and depressive symptoms and depressive symptoms follow a pattern of an increasing prevalence as cognitive performance declines and a decrease in the prevalence when cognitive functioning is severely impaired. AD patients report fewest anxiety symptoms. CONCLUSION: We found that the prevalence of anxiety symptoms, depressive symptoms and comorbid anxiety and depressive symptoms seems to increase in the early phase of cognitive decline, and decreases as cognitive functioning further declines. Elderly diagnosed with AD report less anxiety as expected, probably due to lack of insight caused by AD.     

Common and Specific Emotion-related Predictors of Anxious and Depressive Symptoms in Youth

This study examined whether specific emotion-related constructs may be uniquely related to anxious or depressive symptoms in youth. Although anxiety and depression are comorbid in both youth and adult populations, delineation of these disorders is a worthwhile endeavor given that such differentiation may lead to a clearer conceptualization of the disorders that in turn may facilitate more efficient diagnosis and effective treatment. Children in the 4th and 5th grades (N = 187; M age = 10 years, 3 months) completed measures to assess symptoms of anxiety and depression and emotion-related functioning. Using structural equation modeling, emotion-related variables were identified that were common to both anxiety and depression (poor emotion awareness, emotion dysregulation, poor emotion regulation coping, high frequency of negative affect), most strongly related to depression (low frequency of positive affect), and most distinctly associated with anxiety (frequency of emotion experience, somatic response to emotion activation). The findings suggest that comprehensive theoretical formulations of anxiety and depression in youth should consider emotion-related variables. The results also suggest potential avenues that may facilitate more efficient assessment and treatment of such youth.     

Depression in youth with obsessive-compulsive disorder: clinical phenomenology and correlates

This study examined differences in clinical presentation and functional impairment in youth with obsessive-compulsive disorder (OCD) with or without comorbid depressive disorders and sought to determine the predictors of youth-reported depressive symptoms. One-hundred and sixty youth were reliably diagnosed with OCD and comorbid disorders using the Anxiety Disorders Interview Schedule for DSM-IV: Parent version (Silverman and Albano, 1996) and confirmed by an experienced clinician. Sixteen percent (n = 25) had a comorbid diagnosis of a current depressive disorder (DD). Significantly more females than males had a DD. Those with a DD showed increased OCD symptom severity, OCD-related functional impairment, and family accommodation relative to those without a comorbid DD. Depressive symptoms were significantly positively correlated with years of age, degree of OCD symptom severity, measures of OCD-related functional impairment, and non-OCD anxiety symptoms. Hierarchical regression analyses showed that age, gender, functional impairment, and non-OCD anxiety were significant predictors of depressive symptoms, even when OCD symptom severity was controlled. Notably, functional impairment was a partial mediator of the relationship between OCD symptom severity and depression levels, suggesting depression levels are the product of both degree of symptoms and amount of day-to-day impairment. Results are discussed in terms of implications for assessment and treatment.     

Symptomatic and syndromal anxiety in chronic forms of major depression: effect of nefazodone,cognitive behavioral analysis system of psychotherapy,and their combination

BACKGROUND: Limited information is available on treatment response of anxiety symptoms in chronic forms of major depression. Concurrent anxiety disorders are prevalent in chronic depression, but the responsiveness of patients with such comorbidity to different treatments is largely unknown. This study investigated the comparative efficacy of nefazodone, Cognitive Behavioral Analysis System of Psychotherapy (CBASP), and their combination in improving anxiety symptoms in patients with chronic forms of major depression, including those with a concurrent anxiety disorder. METHOD: 681 patients with chronic major depressive disorder (DSM-IV criteria) participated in a multicenter study of 12 weeks of acute treatment with nefazodone (N = 226), CBASP (N = 228), or the combination (N = 227). The Hamilton Rating Scale for Anxiety (HAM-A), the HAM-A psychic anxiety factor, and the anxiety/arousal subscale of the 30-item Inventory for Depressive Symptomatology-Self Report (IDS-SR-30) were used to assess anxiety symptoms. RESULTS: In the full sample. without controlling for change in depressive symptoms, combination therapy was superior to both monotherapies on all 3 anxiety measures both in the rate of change and at endpoint. When change in depressive symptoms was controlled for, there were no treatment differences in rate of change from baseline to week 12 on any of the 3 anxiety measures. In those patients with a concurrent anxiety disorder, however, the combination was superior to CBASP on the HAM-A and the IDS-SR-30. Nefazodone alone and combination therapy were both superior to CBASP on the HAM-A psychic anxiety factor. CONCLUSION: For patients with chronic depression, combination therapy is superior to CBASP or nefazodone alone. Among patients with a concurrent anxiety disorder, nefazodone. either alone or in combination with CBASP, improves anxiety symptoms faster than CBASP alone, independent of depressive symptom reduction.     

Depressive symptoms and depressive diagnoses in a community population. Use of a new procedure for analysis of psychiatric classification

A multivariate classification technique was used to examine whether depressive symptoms and symptoms frequently associated with depressive disorders would cluster into recognizable syndromes that parallel traditional DSM-III psychiatric diagnoses. An analysis was made of all respondents in the Epidemiologic Catchment Area (ECA) project of the Piedmont region of North Carolina who reported suffering from depressive symptoms (n = 406) at the second wave of the ECA study. The analysis identified five profiles of symptoms that adequately described the interrelationships of the symptoms as reported in the population. One profile included a set of symptoms nearly identical to the symptoms associated with the DSM-III classification of major depression. Other depressive syndromes emerged and included a premenstrual syndrome among younger women and a mixed anxiety/depression syndrome. The existence of these other depressive syndromes may explain the present discrepancy in the epidemiologic literature between a high prevalence of depressive symptoms and a low prevalence of traditional depressive diagnoses in community populations.     

Anxiety disorder comobidity in Bipolar I Disorder: relationship to depression severity and treatment outcome

The present study investigated the greater symptom severity and poorer treatment response found in patients with bipolar illness and anxiety comorbidity, and examined depression as a potential mediator of this relationship. The sample consisted of 92 patients in an acute episode of Bipolar I Disorder with a current or past history of an anxiety disorder. Diagnoses were based on structured clinical interview, and participants were assessed at pre-treatment and then randomly assigned to pharmacotherapy alone or pharmacotherapy plus family intervention. Patients were assessed on a monthly basis by blind assessors over 28 months. Compared to patients without anxiety comorbidity, individuals with bipolar disorder and an anxiety disorder possessed greater current symptom severity, even after controlling for depression severity. Logistic regression analysis identified that being female and having higher current depression but not manic severity predicted comorbid anxiety. Comorbid anxiety was associated with poorer treatment response in the sample regardless of treatment type, particularly in subsequent depressive symptoms. Multiple regression analyses indicated that current depression but not manic severity partially mediated the relationship between comorbid anxiety and treatment outcome. Results from the current study investigating comorbid anxiety disorders are consistent with past research limited to anxiety symptoms. Depression only partially accounted for the link between comorbid anxiety and greater symptom severity and poorer treatment response, and examination of other factors is warranted. Because of the clinical relevance of comorbid anxiety in severe affective disorders, treatments designed to specifically address both concerns are needed.     

The use of paroxetine and cognitive-behavioral therapy in postpartum depression and anxiety: a randomized controlled trial

BACKGROUND: Approximately 10% to 16% of women experience a major depressive episode after childbirth. A significant proportion of these women also suffer from comorbid anxiety disorders. The purpose of this study was to evaluate whether the addition of cognitive-behavioral therapy (CBT) to standard antidepressant therapy offers additional benefits in the treatment of post-partum depression with comorbid anxiety disorders. METHOD: Thirty-five women referred to a tertiary care hospital outpatient program with a DSM-IV diagnosis of postpartum depression with comorbid anxiety disorder were randomly assigned to 1 of 2 treatment groups-paroxetine-only monotherapy group (N = 16) or paroxetine plus 12 sessions of CBT combination therapy group (N = 19)-for a 12-week trial. Progress was monitored by a psychiatrist blinded to treatment group, using the Hamilton Rating Scale for Depression, Hamilton Rating Scale for Anxiety, Yale-Brown Obsessive Compulsive Scale, Clinical Global Impressions scale, and Edinburgh Postnatal Depression Scale. Data were analyzed using 2-tailed statistical tests at an alpha level of.05. The study was conducted from April 1, 2002, to June 30, 2003. RESULTS: Both treatment groups showed a highly significant improvement (p <.01) in mood and anxiety symptoms. Groups did not differ significantly in week of recovery, dose of paroxetine at remission, or measures of depression, anxiety, and obsessive-compulsive symptoms at outcome. CONCLUSION: Antidepressant monotherapy and combination therapy with antidepressants and CBT were both efficacious in reducing depression and anxiety symptoms. However, in this sample of acutely depressed/anxious postpartum women, there were no additional benefits from combining the 2 treatment modalities. Further research into the efficacy of combination therapy in the treatment of moderate-to-severe depression with comorbid disorders in postpartum women is recommended.     

Liaison psychiatry and HIV infection (I): Avoidance coping responses associated with depressive symptoms accompanying somatic complaints

Abstract We examined the relationship of somatic complaints to coping behaviors and mood states among 50 HIV-positive patients without AIDS. Although no patients fulfilled the DSM-III-R criteria for mood disorders including major depression, scores for depressive symptoms were significantly higher in the HIV-positive patients than in healthy persons. Although depressive symptoms in HIV patients may not be strong enough to warrant a psychiatric diagnosis of mood disorders, these patients may be prone to depressive symptoms. The HIV patients indicated a tendency toward somatic complaints more frequently than their healthy counterparts. The scores for depressive symptoms were significantly and positively correlated with scores for avoidance coping responses. The presence or absence of six complaints (i.e., general fatigue, abdominal distress, chest pain or discomfort, and numbness or chills) could be discriminated based on the score of avoidance coping responses. The results of this study suggest that avoidance coping responses associated with depressive symptoms accompany several somatic complaints in HIV patients without AIDS.