Treatment of anxiety disorders in the Finnish general population

BACKGROUND: Treatments for anxiety disorders in the general population are not widely investigated. We determined the proportion, type and determinants of treatment in the Finnish general population. METHODS: Within the Health 2000 Study, a representative sample (n = 6005) of adults (age > 30 years) were interviewed in 2000-2001 with the Composite International Diagnostic Interview (M-CIDI) to assess the presence of DSM-IV mental disorders during the preceding 12 months. Logistic regression models were used to examine factors influencing the type of treatment (pharmacotherapy and/or psychological treatment) and also the types of pharmacotherapy (antidepressants, anxiolytics, or sedatives and hypnotics) used for anxiety disorders. RESULTS: For individuals with an anxiety disorder, 40% (95/229) currently used psychotropic medication, 23% (55/229) used antidepressants, 19% (44/229) anxiolytics and 17% (41/229) sedatives or hypnotics. Of those using health care services for mental health reasons (34%, 76/229), 80% (61/76) received pharmacotherapy. Only 45% (34/76) reported having psychological treatment, with few having more than 4 visits (27%, 20/76). Living in a semi-urban environment, retirement and high perceived disability increased the likelihood of pharmacotherapy-only treatment; higher education and comorbidity with mood disorders increased the likelihood of psychological treatment. General practitioners more often than psychiatrists provided pharmacotherapy treatment alone (67% vs. 34%, p < 0.05), particularly anxiolytics or sedatives. LIMITATIONS: Use of mental health services and psychological treatment were based on self-reports. No data on duration of pharmacotherapy was available. CONCLUSIONS: Anxiety disorders remain largely untreated in the general population. Among those seeking treatment, pharmacotherapy predominates, whereas even brief psychotherapies are rare. Contrary to clinical guidelines, anxiolytics and sedatives are commonly used instead of antidepressants.     

Memory biases in the anxiety disorders: current status

Information-processing models of emotional disorders suggest that anxious individuals may be characterized by a memory bias for threat-relevant information. This paper reviews and synthesizes evidence for explicit (conscious) and implicit (unconscious) memory biases in the anxiety disorders. Our review suggests variations among the anxiety disorders for explicit memory biases. Specifically, there is support for explicit memory biases for threat-relevant information in panic disorder (PD), particularly when information has been deeply encoded, but not in social phobia (SP) or generalized anxiety disorder (GAD). The few available studies suggest the presence of explicit memory biases in posttraumatic stress disorder (PTSD) and obsessive-compulsive disorder (OCD), but further research is needed. In contrast, some degree of support for implicit memory biases has been demonstrated for each of the anxiety disorders. Inconsistencies in the existing literature, topics worthy of future research attention, and directions for revising existing information-processing models of anxiety are discussed.     

Biofeedback in the treatment of anxiety disorders

Studies which have used various forms of biofeedback in the treatment of anxiety disorders are summarized and examined in regard to whether biofeedback-mediated physiological changes are responsible for reductions in subjective reports of anxiety. The evidence suggests that frontal EMG biofeedback training to reduce muscle tension is the most promising biofeedback training technique to date. Studies of heart rate and EEG alpha biofeedback offer only minimal support for the use of these methods to facilitate anxiety reduction. The limited literature on the application of skin resistance level, finger pulse volume, and temperature biofeedback in the treatment of anxiety disorders suggests that these may be viable treatment techniques. The role of factors other than physiological change that may render biofeedback a successful treatment are discussed.     

Preliminary investigation of intolerance of uncertainty treatment for anxiety disorders

Intolerance of uncertainty (IU) is the tendency to react negatively to uncertain situations or events, and it has been found to be an important maintaining factor in a number of different anxiety disorders. It is often included as a part of cognitive behavioural interventions for anxiety disorders but its specific contribution to treatment outcome has not been examined. The aim of the present study was to examine the effectiveness of a brief treatment specifically targeting IU in a 25‐year‐old man with comorbid diagnoses of social phobia, panic disorder, generalised anxiety disorder, major depressive disorder and dysthymia. A single case design series was utilised. Six sessions of individual therapy were provided with symptom measures administered weekly throughout the 3‐week baseline, treatment and 1‐month post‐treatment phase. Clinically significant improvement occurred on measures of IU and social anxiety but not on a general measure of anxiety. The clinical implications of this finding and directions for future research are discussed.     

Computer-supported cognitive behavioral treatment of anxiety disorders

This article reviews the empirical literature pertaining to the use of computer-supported cognitive-behavioral treatment of anxiety disorders, including palmtop computers, virtual reality exposure therapy, and personal computer software programs. The advantages and disadvantages unique to each type of technology are described. The review concludes with a discussion of ethical issues, barriers to the use of technology by clinicians, and suggestions for a process by which scientists and practitioners can conceptualize how technology can advance our understanding of anxiety and our dissemination of effective treatments.     

L-5-hydroxytryptophan in the treatment of anxiety disorders

Ten outpatients suffering from anxiety states (Anxiety Disorders: DSM-III) were treated with L-5-hydroxytryptophan and carbidopa. A significant reduction in anxiety was observed on three different anxiety scales. It is suggested that 5-HT systems may be involved in the mediation of anxiety.     

Comorbidity among anxiety disorders: implications for treatment and DSM-IV.

Research on comorbidity among psychological disorders is relatively new. Yet, comorbidity data have fundamental significance for classification and treatment. This significance is particularly apparent in the anxiety disorders, which, prior to DSM-III-R, were subsumed under disorders considered more significant (e.g., psychotic and depressive disorders). After considering definitional, methodological, and theoretical issues of comorbidity, data on comorbidity among the anxiety disorders are reviewed as well as data on comorbidity of anxiety disorders with the depressive, personality, and substance use disorders. Treatment implications are presented with preliminary data on the effects of psychosocial treatment of panic disorder on co-morbid generalized anxiety disorder. Implications of comorbidity for research on the nature of psychopathology and the ultimate integration of dimensional and categorical features in our nosology are considered.     

The clinical and cost-effectiveness of self-help treatments for anxiety and depressive disorders in primary care: a systematic review.

Anxiety and depression are prevalent in primary care; however, current treatments differ in their availability, cost-effectiveness, and acceptability to patients. Self-help treatments (such as manual-based bibliotherapy) may be an appropriate intervention for some patients. The aim of this research was to determine the clinical and cost-effectiveness of self-help treatments for anxiety and depression in primary care by conducting a systematic review of randomised and non-randomised trials of self-help interventions for patients with anxiety and depression in primary care, from electronic database searches, correspondence with authors, and limited handsearching. Eight studies were identified, examining written interventions based mostly on behavioural principles. Although the majority of trials reported some significant advantages in outcome associated with self-help treatments, the number of included studies was limited and a number of methodological limitations were identified. There were no data concerning long-term clinical benefits or cost-effectiveness. In conclusion, self-help treatments may have the potential to improve the overall cost-effectiveness of mental health service provision. However, the available evidence is limited in quantity and quality and more rigorous trials are required to provide more reliable estimates of the clinical and cost-effectiveness of these treatments.     

Enduring effects of evidence-based psychotherapies in acute depression and anxiety disorders versus treatment as usual at follow-up — A longitudinal meta-analysis

Objective

This meta-analysis examined the enduring efficacy of evidence-based psychotherapies (EBP) in comparison to treatment as usual (TAU) by examining effects from termination to follow-up for acute anxiety and depression in an adult outpatient population. It was hypothesized that EBPs might extend their efficacy at follow-up assessment (Tolin, 2010).

Method

Longitudinal multilevel meta-analyses were conducted that examined the magnitude of difference between EBP and TAU. Targeted (disorder-specific) outcomes were examined, along with dropout rates at follow-up assessments.

Results

A total of 15 comparisons (including 30 repeated effect sizes [ES]) were included in this meta-analysis (average of 8.9 month follow-up). Small to moderate ES differences were found to be in favor of EBPs at 0–4 month assessments (Hedges' g = 0.40) and up to 12–18 month assessments (g = 0.20), indicating no extended efficacy at follow-up. However, the TAU-conditions were heterogeneous, ranging from absence of minimal mental health treatment to legitimate psychotherapeutic interventions provided by trained professionals, the latter of which resulted in smaller ES differences. Furthermore, samples where substance use comorbidities were not actively excluded indicated smaller ES differences. TAU-conditions produced slightly higher dropout rates than EBP-conditions.

Conclusion

Findings indicate small and no extended superiority of EBP for acute depression and anxiety disorders in comparison to TAU at follow-up assessment. There are a limited number of studies investigating the transportability and lasting efficacy of EBP compared to TAU, especially to TAU with equivalent conditions between treatment groups.     

Whole-body cryotherapy as adjunct treatment of depressive and anxiety disorders

Introduction: Rheumatism has been treated using whole-body cryotherapy (WBCT) since the 1970s. The aim of this study was to assess the efficacy of WBCT as an experimental, adjunctive method of treating depressive and anxiety disorders. Materials and Methods: A control (n=34) and a study group (n=26), both consisting of outpatients 18–65 years old with depressive and anxiety disorders (ICD-10), received standard psychopharmacotherapy. The study group was additionally treated with a series of 15 daily visits to a cryogenic chamber (2–3 min, from –160°C to –110°C). The Hamilton’s depression rating scale (HDRS) and Hamilton’s anxiety rating scale (HARS) were used as the outcome measures. Results: After three weeks, a decrease of at least 50% from the baseline HDRS-17 scores in 34.6% of the study group and 2.9% of the control group and a decrease of at least 50% from the baseline HARS score in 46.2% of the study group and in none of the control group were noted. Conclusions: These findings, despite such limitations as a small sample size, suggest a possible role for WBCT as a short-term adjuvant treatment for mood and anxiety disorders.     

Parental styles and long‐term outcome following treatment for anxiety disorders

Poor parenting has long been associated with the diagnosis of anxiety and mood disorders, but it is not clear whether perceived parenting can predict long‐term outcome following treatment. The shortened Parental Bonding Instrument (PBI) was examined in respect to outcome, 3–14 years after initial treatment, in a group of patients having an original diagnosis of generalized anxiety, panic or post‐traumatic stress disorder. All patients had been entered into one of six controlled clinical treatment trials between 1985 and 1999, which had compared cognitive behavioural therapy with other forms of treatment including psychotherapy, medication and placebo. Significantly lower levels of paternal care and higher levels of parental control were reported by patients still having a clinical diagnosis at long‐term follow‐up compared with those with no diagnosis. In addition, the parental style of ‘affectionless control’ (i.e. low care/high control) from either parent was over‐represented in those with a diagnosis at long‐term follow‐up. However, only maternal control was significant for male patients, whilst only paternal care and control were significant for females. Findings on a subgroup of patients, who completed the PBI both pre‐treatment and at long‐term follow‐up, suggest the results are not due to changes in clinical status affecting recall in the recovered patients. Copyright © 2004 John Wiley & Sons, Ltd.     

Shared genetic contributions to anxiety disorders and pathological gambling in a male population

Background

Pathological gambling (PG) frequently co-occurs with anxiety disorders. However, the extent to which the co-occurrence is related to genetic or environmental factors across PG and anxiety disorders is not known.

Method

Data from the Vietnam Era Twin Registry (n = 7869, male twins) were examined in bivariate models to estimate genetic and shared and unique environmental contributions to PG and generalized anxiety disorder (GAD) and PG and panic disorder (PD).

Results

While both genetic and unique environmental factors contributed individually to PG, GAD, and PD, the best fitting model indicated that the relationship between PG and GAD was attributable predominantly to shared genetic contributions (r_A = 0.53). In contrast, substantial correlations were observed between both the genetic (r_A = 0.34) and unique environmental (r_E = 0.31) contributions to PG and PD.

Limitations

Results may be limited to middle aged males.

Conclusions

The existence of shared genetic contributions between PG and both GAD and PD suggests that specific genes, perhaps those involved in affect regulation or stress responsiveness, contribute to PG and anxiety disorders. Overlapping environmental contributions to the co-occurrence of PG and PD suggest that common life experiences (e.g., early life trauma) contribute to both PG and PD. Conversely, the data suggest that distinct environmental factors contribute to PG and GAD (e.g., early onset of gambling in PG). Future studies should examine the relationship between PG and anxiety disorders amongst other populations (women and adolescents) to identify specific genetic and environmental influences that account for the manifestation of these disorders and their co-occurrences.     

Specificity of treatment effects: cognitive therapy and relaxation for generalized anxiety and panic disorders

The aim of this study was to address claims that among bona fide treatments no one is more efficacious than another by comparing the relative efficacy of cognitive therapy (CT) and relaxation therapy (RT) in the treatment of generalized anxiety disorder (GAD) and panic disorder without agoraphobia (PD). Two fixed-effects meta-analyses were conducted, for GAD and PD separately, to review the treatment outcome literature directly comparing CT with RT in the treatment of those disorders. For GAD, CT and RT were equivalent. For PD, CT, which included interoceptive exposure, outperformed RT on all panic-related measures, as well as on indices of clinically significant change. There is ample evidence that both CT and RT qualify as bona fide treatments for GAD and PD, for which they are efficacious and intended to be so. Therefore, the finding that CT and RT do not differ in the treatment of GAD, but do for PD, is evidence for the specificity of treatment to disorder, even for 2 treatments within a CBT class, and 2 disorders within an anxiety class.     

Anxiety in a neglected population: prevalence of anxiety disorders in pre-adolescent children

It is widely believed that anxiety is a common disorder of childhood and adolescence, but epidemiological studies have varied substantially in the prevalence rates that they report. In addition, less attention has been paid to the prevalence of anxiety in pre-adolescent children. For these reasons, a review of epidemiological studies reporting on the prevalence of anxiety disorders in this younger population is described. A comprehensive literature search, encompassing electronic searches of databases and hand searches of journals, returned 11 studies that reported on the prevalence of DSM-III-R or DSM-IV anxiety, specifically in children aged below 12 years of age, which had employed certain minimum standards of epidemiological practice, and had some degree of generalisability to wider populations. The rates of diagnosis of 'any anxiety disorder' varied widely between the studies. The minimum figure reported was 2.6%, and the maximum was 41.2%. Separation Anxiety Disorder appeared to be the most common individual anxiety diagnosis in this age group. Anxiety disorders appear to be more common than depressive disorders, and probably also more common than disorders of behaviour. Anxiety disorders are, at the very least, fairly common in pre-adolescent children. This is concerning when the limited current treatment options for this age group are considered. Reasons for the varied prevalence rates reported by the studies, focussing on the differences in methods employed, are suggested. Implications for treatment are discussed.     

Biopsychosocial determinants of treatment outcome for mood and anxiety disorders up to 8 months postpartum

Little is known about the biopsychosocial determinants that predict postpartum treatment outcome for mood and anxiety disorders. Postpartum mood and anxiety symptoms and psychosocial/biological variables were recorded for 8 months of 22 women treated with antidepressants during pregnancy. Depression scores decreased by 58%, whereas anxiety scores decreased by 35%. Family history of psychiatric illness and prior psychiatric illness unrelated to pregnancy predicted depressive treatment outcome, and sexual abuse history and prior psychiatric illness unrelated to pregnancy predicted anxiety outcome. Biological and psychosocial variables predicted pharmacological treatment outcome in postpartum-depressed and anxious women.