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.     

Moderating effects of major depression on patterns of comorbidity in patients with panic disorder

Given the high rate of co-occurring major depression in patients with panic disorder, it is unclear whether patterns of comorbidity in individuals with panic disorder reported in the literature are associated with panic disorder or with the presence of major depression. Subjects were 231 adult subjects with panic disorder and major depression (n=102), panic disorder without comorbid major depression (n=29), major depression without comorbid panic disorder (n=39), and neither panic disorder nor major depression (n=61). Subjects were comprehensively assessed with structured diagnostic interviews that examined psychopathology across the life cycle. Panic disorder, independently of comorbidity with major depression, was significantly associated with comorbid separation anxiety disorder, simple phobia, obsessive-compulsive disorder, generalized anxiety disorder, and agoraphobia. Major depression, independently of comorbidity with panic disorder, was significantly associated with comorbidity with psychoactive substance use disorders and childhood disruptive behavior disorders. Overanxious disorder was associated with both panic disorder and major depression. Major depression has important moderating effects on patterns of comorbidity of panic disorder in referred adults.     

The relationship between anxiety and substance use disorders among individuals with severe affective disorders

We sought to determine the association between anxiety disorders and substance use disorders among patients with severe affective disorders in a community-based outpatient treatment program. Two hundred sixty participants in a supported socialization program were assessed using the Structured Clinical Interview for DSM-III-R (SCID). Multivariate logistic regression analyses were used to determine the relationship between anxiety disorders and alcohol and substance use disorders among patients with severe and persistent affective disorders (i.e., major depression and bipolar disorder). Among patients with severe and persistent affective disorders, cocaine (odds ratio [OR] = 5.9 [1.4, 24.6]), stimulant (OR = 5.1 [1.2, 20.9]), sedative (OR = 5.4 [1.2, 24.7]), and opioid use disorders (OR = 13.9 [1.4, 138.7]) were significantly more common among those with, compared with those without, anxiety disorders. This association persisted after adjusting for differences in sociodemographic characteristics and comorbid psychotic disorders. Significant associations between panic attacks, social phobia, specific phobia, and obsessive-compulsive disorder (OCD) and specific substance use disorders were also evident. These findings are consistent with and extend previous results by documenting an association between anxiety disorders and substance use disorders, independent of comorbid psychotic disorders among patients in a outpatient psychiatric rehabilitation program. These data highlight the prevalence of comorbid anxiety disorders, a potentially undetected and therefore undertreated problem, among patients with severe affective disorders and substance use comorbidity. Future work is needed to determine the nature of this association and to determine whether treatment of one prevents onset of the other.     

Understanding alcohol misuse and comorbid psychiatric disorders

PURPOSE OF REVIEW: This review examines the relationship between alcohol misuse and comorbid psychiatric disorders, and the treatment of these comorbid disorders. In the past, the literature was dominated by papers describing prevalence, clinical services and comorbidity with schizophrenia. It is now advancing into areas such as the relationship between alcohol misuse and the anxiety disorders, affective disorders and eating disorders, and considering the diagnostic paradigm. Knowledge is also emerging about the influences of genetics and adverse effects over different stages of the life cycle in the development of these disorders. RECENT FINDINGS: Recent studies have examined the relationships between alcohol dependence and psychiatric illness, particularly anxiety and depression, but also subthreshold conditions. Childhood trauma, having parents with substance dependence and genetic factors influence the development of alcohol and comorbid psychiatric disorders. There is a genetic contribution to suicidal behaviour in alcohol-dependent patients. Early diagnosis is important. Alcohol Use Disorders Identification Test scores on admission to psychiatric hospital were found to correlate with suicidal ideation and behaviour. In patients with alcohol use disorders, treatment for depression works better after a period of abstinence. Abstinence alone can help for anxiety disorders. High-intensity services had better outcomes for this comorbid population than less intensive services. SUMMARY: Depression in patients with alcohol use disorders cannot be ignored. Treatment of depression alone will not help the alcohol use problems. All psychiatric inpatients should be screened for alcohol use disorders as part of their risk assessment. Research is focusing more on examining the complexities of these disorders, but there are no specific pharmacotherapies to treat particular comorbid conditions.     

Detection and management of comorbidity in patients with schizophrenia.

Approximately half of patients with schizophrenia have at least one comorbid psychiatric or medical condition, worsening prognosis and contributing to the high rate of morbidity and mortality. Depression is associated with suicide, the leading cause of premature death in patients with schizophrenia; obsessive-compulsive symptoms may worsen prognosis; alcohol and substance use disorders are associated with a poor outcome; and comorbid medical conditions, including cardiac and pulmonary disease, infectious diseases, diabetes, hyperlipidemia, hypogonadism, and osteoporosis, are often underrecognized and undertreated. The new generation of antipsychotic medications has improved the potential outcome of patients with schizophrenia. Providing optimal treatment for patients and fully realizing the potential of these new agents require focused attention on detection, recognition, and treatment of comorbid psychiatric and medical conditions in patients with schizophrenia.     

Anxiety disorders in major depression

The prevalence and clinical impact of anxiety disorder comorbidity in major depression were studied in 255 depressed adult outpatients consecutively enrolled in our Depression Research Program. Comorbid anxiety disorder diagnoses were present in 50.6% of these patients and included social phobia (27.0%), simple phobia (16.9%), panic disorder (14.5%), generalized anxiety disorder ([GAD] 10.6%), obsessive-compulsive disorder ([OCD] 6.3%), and agoraphobia (5.5%). While both social phobia and generalized anxiety preceded the first episode of major depression in 65% and 63% of cases, respectively, panic disorder (21.6%) and agoraphobia (14.3%) were much less likely to precede the first episode of major depression than to emerge subsequently. Although comorbid groups were not distinguished by depression, anxiety, hostility, or somatic symptom scores at the time of study presentation, patients with comorbid anxiety disorders tended to be younger during the index episode and to have an earlier onset of the major depressive disorder (MDD) than patients with major depression alone. Our results support the distinction between anxiety symptoms secondary to depression and anxiety disorders comorbid with major depression, and provide further evidence for different temporal relationships with major depression among the several comorbid anxiety disorders.     

Diagnosis and management of bipolar disorder with comorbid anxiety in the elderly

Currently, in individuals over 65 year of age, prevalence rates of bipolar disorder range from 0.1% to 0.4%. As is the case for bipolar disorder in younger individuals, bipolar disorder may be unrecognized or underrecognized among older adults. While anxiety disorders are frequently comorbid among younger individuals with bipolar illness, the prevalence and impact of comorbid anxiety is far less understood among geriatric individuals with bipolar disorder, in whom anxiety disorders may be underreported. This comorbidity may have serious consequences, since in older adult populations with depression, the presence of comorbid anxiety is associated with more severe depressive symptoms, more chronic medical illness, greater functional impairment, and lower quality of life; the same associations may prove to be true in older patients with bipolar disorder. As with younger individuals with bipolar disorder, effective treatment of the underlying mood disorder is critically important before treating comorbid symptoms. Unfortunately, few evidence-based studies are available to guide the treating clinician in the management of these vulnerable patients, many of whom have additional psychiatric or medical comorbidity.     

Influence of psychiatric comorbidity on recovery and recurrence in generalized anxiety disorder, social phobia, and panic disorder: a 12-year prospective study

OBJECTIVE: The authors sought to observe the long-term clinical course of anxiety disorders over 12 years and to examine the influence of comorbid psychiatric disorders on recovery from or recurrence of panic disorder, generalized anxiety disorder, and social phobia. METHOD: Data were drawn from the Harvard/Brown Anxiety Disorders Research Program, a prospective, naturalistic, longitudinal, multicenter study of adults with a current or past history of anxiety disorders. Probabilities of recovery and recurrence were calculated by using standard survival analysis methods. Proportional hazards regression analyses with time-varying covariates were conducted to determine risk ratios for possible comorbid psychiatric predictors of recovery and recurrence. RESULTS: Survival analyses revealed an overall chronic course for the majority of the anxiety disorders. Social phobia had the smallest probability of recovery after 12 years of follow-up. Moreover, patients who had prospectively observed recovery from their intake anxiety disorder had a high probability of recurrence over the follow-up period. The overall clinical course was worsened by several comorbid psychiatric conditions, including major depression and alcohol and other substance use disorders, and by comorbidity of generalized anxiety disorder and panic disorder with agoraphobia. CONCLUSIONS: These data depict the anxiety disorders as insidious, with a chronic clinical course, low rates of recovery, and relatively high probabilities of recurrence. The presence of particular comorbid psychiatric disorders significantly lowered the likelihood of recovery from anxiety disorders and increased the likelihood of their recurrence. The findings add to the understanding of the nosology and treatment of these disorders.     

Cognitive-Behavioral Therapy for the Management of Insomnia Comorbid with Mental Disorders

Insomnia is frequently comorbid with psychiatric conditions, mostly depression and anxiety disorders. Because disturbed sleep is a symptom of most major mental disorders, it has been traditionally assumed that effective treatment of the psychiatric condition will resolve the coincident insomnia also. However, insomnia often persists after successful treatment of the comorbid mental disorder, suggesting that insomnia often warrants separate treatment attention. Cognitive-behavioral therapy (CBT) is a well established and efficacious treatment for insomnia. Most evidence supporting the efficacy of CBT comes from studies conducted with patients suffering from primary insomnia, yet over the past 20 years there has been growing support for the use of cognitive-behavioral insomnia intervention for patients with comorbid psychiatric conditions. Overall, promising results have been obtained from these studies, not only with regard to insomnia improvement but also concurrent improvements in comorbid psychiatric conditions. In this article we review recent studies in this area with particular focus on treatment of insomnia in the context of depression, post-traumatic stress disorder, and alcohol dependence.     

Asthma and mental disorders in primary care

This study examines relationships between asthma and likelihood of current mental disorders and suicidal ideation in an urban primary care population. A systematic waiting room sample of 998 adult patients was screened for mental disorders using the PRIME-MD PHQ. Asthma diagnoses were provided by primary care physicians. Multivariate logistic regression analyses were used to determine the odds of current major depression, panic attacks, generalized anxiety disorder, alcohol and drug use disorder, and suicidal ideation among patients with a diagnosis of asthma, as compared to those without asthma. After controlling for differences in sociodemographic characteristics and comorbid mental disorders, asthma was associated with increased likelihood of panic attack (OR=1.7 (1.1, 2.6)) and suicidal ideation (OR=1.9 (1.03, 3.4)). There was no statistically significant association between asthma and major depression, generalized anxiety disorder, alcohol, or drug use disorders after adjustment. Results suggest that physician-diagnosed asthma is associated with self-reported panic attacks and suicidal ideation in a systematic sample of primary care patients. Physicians who treat patients with asthma should remain vigilant for the presence of comorbid psychiatric problems and carefully evaluate whether there is a clinical need to treat each condition.     

Personality disorders and psychiatric comorbidity in obsessive-compulsive disorder and anorexia nervosa

The aim of this prospective longitudinal study was to examine the course of adolescent anorexia nervosa and obsessive-compulsive disorder (OCD) (fulfilling DSM-III-R criteria) to compare psychiatric comorbidity and personality disorders of both groups. Because anorexia nervosa patients are mainly female, we compared them only with female OCD patients. Ten years after discharge the whole sample (32 female patients; 100%) of a group of 39 (32 female; 7 male) anorexia nervosa patients could be reexamined personally. 25 (61%) female patients of a group of 116 patients (41 female; 75 male) with obsessive-compulsive disorder were also reexamined. The anorexia nervosa patients were interviewed using the Structured Interview for Anorexia and Bulimia nervosa (SIAB [39]) to assess eating disorder symptomatology. To examine comorbid psychiatric disorders we used the Composite International Diagnostic Interview, WHO [44] and SCID-II [45] for personality disorders. One fourth of the patients with anorexia nervosa (AN) and 20% of the patients with obsessive-compulsive disorder had a personality disorder according to DSM-III-R. Most of them were "Cluster C"-personality disorders (AN: 28%; OCD: 20%). In the group of the female OCD patients 8% schizoid, 4% schizotype and 12% paranoid personality disorders were observed. The most prevalent psychiatric disorders were anxiety (AN: 28%; OCD: 20%) and affective disorders (AN: 16%; OCD: 16%). Our results support the view that in the course of anorexia nervosa and in obsessive-compulsive disorder there is a high prevalence of psychiatric comorbidity and "Cluster C"-personality disorders according to DSM-III-R. These results might confirm a model of a high vulnerability of the serotonergic neurotransmitter system in patients with anorexia nervosa or OCD.     

Anxiety disorders and comorbid depression in community dwelling older adults

Anxiety disorder is a common psychiatric problem during late‐life, and frequently co‐occurs with depression. High comorbidity between anxiety and depression may partly be explained by the definition of the disorders and the assessment of both disorders with one instrument at the same time. The current study investigates the relation of current and past depression with anxiety disorders in the Rotterdam Study, a large population‐based cohort study of older adults in the Netherlands (n study population = 5565). DSM‐IV anxiety disorder was ascertained with the Munich version of the Composite International Diagnostic Interview. DSM‐IV depression was diagnosed with the Schedules for Clinical Assessment of Neuropsychiatry (SCAN) on a different day. Past depression was assessed from general practitioners' records, self‐report, and a prior SCAN interview. Of the 457 persons with an anxiety disorder, 11.6% had a comorbid major depression, and another 6.3% had other depressive syndromes. However, 49.3% of persons with an anxiety disorder experienced or had in the past experienced a depressive episode. Our study suggests that comorbid depression in older adults with anxiety disorders may be less prevalent than previously suggested. However, the relation of current anxiety disorders with past depression is substantial. Copyright © 2011 John Wiley & Sons, Ltd.     

Lifetime comorbidity of antisocial personality disorder and anxiety disorders among adults in the community

The association between lifetime anxiety disorders, conduct disorder (CD), and antisocial personality disorder (ASPD) among adults in the community was explored. Data were drawn from the National Comorbidity Survey (n = 5,877), a representative community sample of adults aged 15-54 in the 48 contiguous US states. Multiple logistic regression analyses were used to determine the association between anxiety disorders, CD and ASPD, and between the co-occurrence of anxiety disorders and ASPD in the likelihood of comorbid substance use and affective disorders, suicidal ideation (SI) and suicide attempt (SA). Out of the 3.3% of adults with ASPD, over half (54.33%) had a comorbid anxiety disorder (lifetime). Similarly, 42.31% of adults with a history of CD (9.4%) who did not meet criteria for ASPD had a lifetime anxiety disorder. Social phobia [OR = 1.65 (1.01, 2.7)] and post-traumatic stress disorder [OR = 2.28 (1.3, 4.0)] were associated with significantly increased odds of ASPD, after adjusting for differences in sociodemographic characteristics and other psychiatric comorbidity. Major depression was no longer significantly associated with ASPD after adjusting for anxiety disorders. The comorbidity of anxiety disorders and ASPD was associated with significantly higher odds of major depression, substance use disorders, and SI and SA compared with odds among those without both disorders. These data provide initial evidence of an association between PTSD and social phobia and an increased likelihood of ASPD among adults in the community, after adjustment for comorbid affective and substance use disorders. Adults with ASPD and comorbid anxiety had significantly higher levels of comorbid major depression, alcohol dependence, and substance dependence and substantially higher rates of lifetime suicidal ideation and suicide attempts compared to adults with ASPD or anxiety disorders alone or with neither disorder. Future studies are needed to replicate this finding using longitudinal data and to investigate the possible mechanisms of the observed links between anxiety disorders and ASPD.     

Relationships between major depressive disorder and comorbid anxiety and personality disorders

OBJECTIVE: The aim of the study was to examine whether comorbid anxiety disorders influence depressed patients' likelihood of meeting criteria for a personality disorder (PD) and whether comorbid anxiety disorders influence the stability of the PDs in patients with remitted depression. METHODS: The initial sample consisted of 373 outpatients who met criteria for major depressive disorder (MDD) (by Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition-Patient Edition) and who were enrolled in the 8-week acute treatment phase of a study of fluoxetine for MDD. Sixty-four subjects who responded to fluoxetine treatment in the acute phase met criteria for remission throughout a 26-week continuation phase during which they remained on fluoxetine with or without cognitive behavioral therapy. Stability of PDs was defined as meeting criteria for a PD at both beginning and end point of the continuation treatment phase. RESULTS: Before fluoxetine treatment, anxious depressed patients (defined as meeting criteria for MDD as well as at least one comorbid anxiety disorder) were significantly more likely to meet criteria for any comorbid PD diagnosis compared with depressed patients without comorbid anxiety disorders. In particular, there was a significant relationship between the presence of Cluster A and C PDs and the presence of anxious depression at baseline before antidepressant treatment. After successful treatment of MDD, we found a significant relationship between anxious depression diagnosed at baseline and the stability of a Cluster C PD diagnosis. CONCLUSION: Anxious depression may place patients at greater risk of having a PD diagnosis, especially one from Cluster A or C. Once the depression remits, patients who initially met criteria for anxious depression may be more likely to maintain a Cluster C PD diagnosis compared with patients initially diagnosed with MDD alone.     

Lamotrigine in the Treatment of Unipolar Depression with and Without Comorbidities: A Literature Review

To review the available data behind the use of lamotrigine in unipolar depression and common comorbid conditions. A PubMed based literature review was conducted using keywords related to lamotrigine, depression, anxiety, post traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), and personality disorders. A large number of trials using lamotrigine for unipolar depression and various comorbid conditions were reviewed. A major limitation behind the majority of studies was a limited course of the treatment phase. The most robust data was found among studies that followed patients for over 8?weeks, and used higher dosages. Patients with comorbid anxiety states appeared to benefit. Patients with borderline personality disorder also appeared to benefit. The benefits of lamotrigine in unipolar depression have been inconsistently noted in a number of studies. This is due in part to short treatment phases, atypical domains of benefit and different patient populations across studies. Patients with more treatment-resistance, comorbid anxiety and borderline personality disorder may be more able to benefit from lamotrigine.     

Psychopathology and comorbidity of psychiatric disorders in patients with kleptomania

OBJECTIVE: This study compared patients with kleptomania, patients with alcohol abuse or dependence, and psychiatric patients without impulse-control disorders or substance-related disorders on several key psychopathological dimensions. In addition, the comorbidity of kleptomania with other psychiatric disorders was examined. METHOD: Eleven patients with kleptomania recruited over a cumulative 2-year period and 60 patients with alcohol abuse or dependence and 29 psychiatric comparison patients recruited over a consecutive 6-month period participated in structured clinical interviews to determine the presence of impulse-control and substance-related disorders and of other psychiatric disorders that were comorbid with kleptomania. Psychopathological dimensions were measured with the Barratt Impulsiveness Scale, the Sensation Seeking Scale, the Montgomery-Asberg Depression Rating Scale, and the anxiety and depression subscales of the Hospital Anxiety and Depression Scale. RESULTS: Significant group effects were found for the Barratt Impulsiveness Scale total and cognitive impulsivity scores, with the patients with kleptomania having higher impulsivity scores than the other groups. Significant group differences were found on the Sensation Seeking Scale total and disinhibition scores. No significant group effects were found for the mood and anxiety measures. Patients with kleptomania had high rates of comorbid psychiatric disorders, particularly mood disorders, other impulse-control disorders, and substance abuse or dependence (mainly nicotine dependence). CONCLUSIONS: Kleptomania presented a specific psychopathological profile that distinguished patients with this disorder from patients with alcohol abuse or dependence and other psychiatric comparison patients. Impulsivity was the major psychopathological feature of kleptomania. A link between kleptomania and affective disorder was supported by the high rate of comorbid affective disorders in patients with kleptomania and a specific pattern of variation in the two conditions over time. Further prospective studies are needed to confirm this pattern. Because kleptomania is characterized by a low rate of comorbid substance-related disorders other than nicotine dependence and by severe psychopathology, it could be an appropriate disorder in which to study the information processes and psychobiology underlying impulsivity.     

Management of anxiety in late life

Epidemiologic data are used as a framework to discuss the pharmacologic and cognitive-behavioral management of anxiety disorders in late life. Generalized anxiety disorder (GAD) and phobias account for most cases of anxiety in late life. The high level of comorbidity between GAD and major depression, and the observation that the anxiety usually arises secondarily to the depression, suggests that antidepressant medication should be the primary pharmacologic treatment for many older people with GAD. Most individuals with late-onset agoraphobia do not have a history of panic attacks and the illness often starts after a traumatic event. Exposure therapy is the treatment of choice for agoraphobia without panic. It is uncommon for obsessive-compulsive disorder (OCD) and panic disorder to start for the first time in old age, but these disorders can persist from younger years into late life. Case reports and uncontrolled case series suggest that elderly people with OCD or panic disorder can benefit from pharmacologic and cognitive-behavioral treatments that are known to be effective in younger patients. However, it is not known whether the rate of response among elderly patients is adversely affected by the chronicity of these disorders. The prevalence and incidence of post-traumatic stress disorder in late life are not known. Uncontrolled data support the use of selective serotonin reuptake inhibitors in war veterans with chronic symptoms of post-traumatic stress disorder; other treatments for this condition await evaluation in the elderly.     

Quality of life in anxiety disorders: a comparison of obsessive-compulsive disorder, social anxiety disorder, and panic disorder

BACKGROUND: There is growing recognition that the anxiety disorders are disabling disorders associated with substantial morbidity and impaired quality of life (QOL). Nevertheless, there have been few studies comparing QOL across these conditions. SAMPLING AND METHODS: 337 outpatients with obsessive-compulsive disorder (OCD; n = 220), panic disorder (PD; n = 53), or social anxiety disorder (SAD; n = 64) were compared using a number of assessment scales to compare objective and subjective impairment in QOL. The association of QOL with symptom severity and comorbid depression was also assessed. RESULTS: The extent of impairment due to OCD, PD or SAD appears to be similar across the QOL scales. However, various domains are differentially affected in each of the disorders; OCD patients had more impairment in family life and activities of daily living; SAD patients had more impairment in social life and leisure activities, and PD patients were less able to avoid the use of nonprescribed drugs. QOL was lower in patients with increased symptom severity as well as in those with comorbid depression. CONCLUSIONS: While the extent of impairment appears similar across a number of different anxiety disorders, characteristic symptoms of each disorder may be associated with differential impairment of various domains of function, and may require specifically tailored interventions.     

Gender differences in the rate of comorbid axis I disorders in depressed outpatients

We examined gender differences in comorbid Axis I disorders in 236 outpatients with major depression. Axis I comorbidity, age of onset of depression and comorbid disorder were assessed with the SCID-P. Depression severity was assessed with the HAM-17. The results indicated that males had a higher rate of comorbid substance abuse/dependence, while females had a higher rate of comorbid bulimia nervosa. These results are consistent with previous research, with the marked exception that females did not have higher rates of anxiety disorders in general, and in particular, panic disorder, simple and social phobia, obsessive-compulsive disorder and agoraphobia. It is concluded that the female predominance in anxiety disorders found in general population studies may be due to comorbidity with depression.     

Patterns of comorbidity in panic disorder and major depression: findings from a nonreferred sample

Previous findings in referred adult samples document major depression as having important moderating effects on the patterns of comorbidity for panic disorder and major depression. This study evaluated whether these patterns of comorbidity are moderated by referral bias. Panic disorder (PD) and major depression (MD) were used to predict the risk for comorbid psychiatric disorders and functional outcomes using data from a large sample of adults who had not been ascertained on the basis of clinical referral (N=1,031). Participants were comprehensively assessed with structured diagnostic interview methodology to evaluate childhood and adult comorbid psychiatric disorders. PD increased the risk for anxiety disorders, independently of MD. MD increased the risk for mania, antisocial personality disorder, psychoactive substance use disorder, disruptive behavior disorders, overanxious disorder, social phobia, and generalized anxiety disorder, independently of PD. These results extend to nonreferred samples' previously reported findings documenting that MD has important moderating effects on patterns of comorbidity for PD and indicate that patterns of comorbidity for PD are not due to referral bias.