Untreated anxiety among adult primary care patients in a Health Maintenance Organization

BACKGROUND: Untreated anxiety may be particularly difficult for primary care physicians to recognize and diagnose because there are no reliable demographic or medical profiles for patients with this condition and because these patients present with a high rate of comorbid psychological conditions that complicate selection of treatment. METHOD: A prospective assessment of untreated anxiety symptoms and disorders among primary care patients. RESULTS: Approximately 10% of eligible patients screened in clinic waiting rooms of a mixed-model health maintenance organization reported elevated symptoms and/or disorders of anxiety that were unrecognized and untreated. These patients with untreated anxiety reported significantly worse functioning on both physical and emotional measures than "not anxious" comparison patients; in fact these patients reported reduced functioning levels within ranges that would be expected for patients with chronic physical diseases, such as diabetes and congestive heart failure. The most severe reductions in functioning were reported by untreated patients whose anxiety was mixed with depression symptoms or disorders. CONCLUSION: Primary care physicians may benefit from screening tools and consultations by mental health specialists to assist in recognition and diagnosis of anxiety symptoms and disorders alone and mixed with depression.     

Psychiatric disorder in a birth cohort of young adults: Prevalence, comorbidity, clinical significance, and new case incidence from ages 11–21.

Mental health data were gathered at ages 11, 13, 15, 18, and 21 in an epidemiological sample using standardized diagnostic assessments. Prevalence of Diagnostic and Statistical Manual of Mental Disorders-III-Revised (DSM-III-R) mental disorders increased longitudinally from late childhood (18%) through mid- (22%) to late-adolescence (41%) and young adulthood (40%). Nearly half of age-21 cases had comorbid diagnoses; and comorbidity was associated with severity of impairment. The incidence of cases with adult onset was only 10.6%: 73.8% of adults diagnosed at age 21 had a developmental history of mental disorder. Relative to new cases, those with developmental histories were more severely impaired and more likely to have comorbid diagnoses. The high prevalence rate and significant impairment associated with a diagnosis of mental disorder suggests that treatment resources need to target the young adult sector of the population. The low new-case incidence in young adulthood, however, suggests that primary prevention and etiological research efforts need to target children and adolescents. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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 over report 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.     

Transmission intergénérationnelle des troubles intériorisés: Modèles théoriques et recherches empiriques.

It is well recognised that mental health disorders in parents are associated with internalizing disorders in their children. For better understanding of the nature of this association, this article presents a critical analysis of 5 theoretical models and of major findings from empirical studies conducted on this question in the past 15 years. Several psychosocial characteristics are found to be more frequent in families of depressed or anxious parents and are associated to a higher prevalence of internalizing disorders in their children. Two hypotheses are drawn from these findings : (a) The presence of internalizing disorders in a parent may contribute to the emergence of other at-risk conditions associated with internalizing disorders in children; and (b) the presence of some psychosocial characteristics may exacerbate the influence of being exposed to parental anxiety or depression. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Peer social status of children with anxiety disorders.

The peer social status of 6–13-year-old children with anxiety disorders was investigated. Sixteen children who met Diagnostic and Statistical Manual of Mental Disorders (DSM-III) criteria for anxiety disorders were compared with 26 children with conduct disorders and 45 nonreferred children. Anxiety-disorder children were liked significantly less than normal children, but anxious and conduct-disorder children did not differ from one another. The conduct-disorder group received more "like-least"" and "fight-most"" nominations than the anxious and nonreferred groups, which did not differ. Furthermore, the anxious group received the lowest social-impact scores (total like-most and like-least nominations) of any group and were most likely to fall in the socially neglected category of peer status. The lack of popularity of children with anxiety disorders may be limited to those with concurrent depression. Overall, these findings indicate that childhood anxiety disorders, at least when they coexist with depression, are associated with diminished peer popularity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comorbidity of anxiety and depression in children and adolescents.

Anxiety and depression in children and adolescents are reviewed, including differential diagnosis, assessment of symptoms, family history data, developmental features, and clinical correlates. Findings indicate that 15.9% to 61.9% of children identified as anxious or depressed have comorbid anxiety and depressive disorders and that measures of anxiety and depression are highly correlated. Family history data are inconclusive. Differences emerged among children with anxiety, depression, or both disorders. Anxious children were distinguishable from the other 2 groups in that they showed less depressive symptomatology and tended to be younger. The concurrently depressed and anxious group tended to be older and more symptomatic. In this group, the anxiety symptoms tended to predate the depressive symptoms. Findings are discussed in the context of a proposed developmental sequence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Racial distinctions in the psychosocial histories of incarcerated youth.

This study examined the psychosocial histories of 134 male, juvenile offenders, focusing on race and the probability of being diagnosed with internalizing and/or externalizing psychological disorders at the time of their sentencing to a correctional institution for committing serious and violent crimes as minors. In addition, based on case file information, the author investigated offenders' histories with child maltreatment, court-ordered probation, and counseling services received as part of the child welfare and/or juvenile justice system. Results from logistic regression analyses indicated the probability for White youth to be diagnosed with internalizing disorders was over 19 times that of Black youth; however, rates of externalizing disorders were similar across groups. Although maltreatment histories were comparable based on race, White youth received more counseling services, were significantly older at the time of diagnosis, and were more likely to be diagnosed with internalizing and comorbid disorders. Issues regarding multicultural assessment in the child welfare and juvenile justice system are discussed, specifically highlighting the potential for attributional bias in the diagnostic and treatment recommendation process. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Patients who somatize in primary care: a longitudinal study of cognitive and social characteristics

We examined the cognitive and sociodemographic characteristics of patients making somatic presentations of depression and anxiety in primary care. Only 15% of patients with depressive symptomatology on self-report, and only 21% of patients with current major depression or anxiety disorders on diagnostic interview, presented psychosocial symptoms to their GP. The remainder of patients with psychiatric distress presented exclusively somatic symptoms and were divided into three groups-initial, facultative and true somatizers-based on their willingness to offer or endorse a psychosocial cause for their symptoms. Somatizers did not differ markedly from psychologizers in sociodemographic characteristics except for a greater proportion of men among the true somatizers. Compared to psychologizers, somatizers reported lower levels of psychological distress, less introspectiveness and less worry about having an emotional problem. Somatizers were also less likely to attribute common somatic symptoms to psychological causes and more likely to endorse normalizing causes. In the 12 months following their initial visit, somatizers made less use of speciality mental health care and were less likely to present emotional problems to their GP. Somatizers were markedly less likely to talk about personal problems to their GP and reported themselves less likely to seek help for anxiety or sadness. Somatization represents a persistent pattern of illness behaviour in which mental health care is not sought despite easily elicited evidence of emotional distress. Somatization is not, however, associated with higher levels of medical health care utilization than that found among patients with frank depression or anxiety.     

Relationship of cocaine and other substance dependence to well-being of high-risk psychiatric patients

OBJECTIVE: The co-occurrence of substance dependence disorders was determined in a sample of 160 frequently hospitalized adults with severe mental illness, and the relationship between substance dependence and psychosocial functioning and well-being was examined. METHODS: A structured interview was used to assess subjects for co-occurring current DSM-III-R substance dependence disorders during an acute psychiatric hospitalization. They were administered a structed interview that included the subscales of the Addiction Severity Index, the Center for Epidemiological Studies-Depression Scale, Lehman's Quality of Life Interview, Rosenberg's Self-Esteem Scale, the Mastery Scale, and questions about service needs. RESULTS: Seventy-eight of the subjects (48.8 percent) were diagnosed as having at least one current substance dependence disorder. Most subjects with comorbid substance dependence were polysubstance dependent (55.1 percent), and almost half (44.9 percent) met criteria for cocaine dependence. Subjects who were substance dependent were significantly overrepresented among those diagnosed with bipolar disorder, psychotic disorder not otherwise specified, and major depression. When the analysis controlled for demographic characteristics and primary diagnosis, comorbidity was related to depressive symptoms, adverse life conditions, and diminished life satisfaction in several domains. Substance-dependent subjects were significantly more likely to have been arrested and jailed than nondependent subjects. Cocaine-dependent subjects were significantly less satisfied than all other subjects with their living situation and personal safety and more likely to request assistance for their drug and alcohol use problems. CONCLUSIONS: The findings corroborate high rates of co-occurring substance dependence disorders among frequently hospitalized patients with severe mental illness. They also reveal a high prevalence of cocaine dependence and a dramatic pattern of negative correlates of cocaine dependence. The findings suggest that successful interventions for substance dependence may improve these patients' life circumstances and that psychiatric patients may be particularly receptive to such interventions during hospitalization.     

Comorbid anxiety disorders and treatment of depression in people with multiple sclerosis.

Objective: Anxiety is highly comorbid with depression, but little is known about the impact of anxiety disorders on the effectiveness of empirically supported psychotherapies for depression. We examined such outcomes for people with Multiple Sclerosis (MS) and depression, with versus without comorbid anxiety disorders. Design: Participants with MS (N = 102) received 16 weeks of telephone-administered psychotherapy for depression and were followed for one year post-treatment. Results: Participants with comorbid anxiety disorders improved to a similar degree during treatment as those without anxiety disorders. Outcomes during follow-up were mixed, and thus we divided the anxiety diagnoses into distress and fear disorders. The distress disorder (GAD) was associated with elevated anxiety symptoms during and after treatment. In contrast, fear disorders (i.e., panic disorder, agoraphobia, social phobia, specific phobia) were linked to depression, specifically during follow-up, across 3 different measures. Conclusions: People with GAD receiving treatment for depression may benefit from additional services targeting anxiety more specifically, while those with comorbid fear disorders may benefit from services targeting maintenance of gains after treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Association of Parental Depression With Psychiatric Course From Adolescence to Young Adulthood Among Formerly Depressed Individuals.

The authors examined whether parental major depressive disorder (MDD) is associated with course of depression and other psychopathology among formerly depressed adolescents as they enter adulthood. The sample consisted of 244 individuals (age 24) in a longitudinal study who had experienced MDD by 19. Maternal MDD was associated with MDD recurrence, chronicity and severity, anxiety disorders, and (among sons only) lower psychosocial functioning in offspring between the ages of 19 and 24. Paternal MDD was associated with lower functioning. Sons of depressed fathers had elevated suicidal ideation and attempt rates in young adulthood. Recurrent paternal MDD was associated with depression recurrence in daughters but not sons. The impact of parental MDD on offspring could not be attributed to characteristics of the offspring's depression prior to age 19. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A controlled study of food behavior and emotional manifestation in a population of obese female adolescents

BACKGROUND: Obesity is a major Public Health problem in developed countries. It is frequently associated with psychological difficulties that may interfere with treatment. PATIENTS AND METHODS: 22 obese female adolescents, aged 13 to 19 years, and 24 age-matched female controls, were compared with regard to emotional pathology (anxiety, depression), eating behaviors, self-esteem, body image and parental history of depression. The evaluation was both categorical (DSM III-R criteria) and dimensional for depression and anxiety. It also included a self-esteem scale and questionnaires. RESULTS: The obese adolescents had more depressive symptoms, more prevalent anxiety disorders, more frequent histories of parental depression, eating behaviors characterized by over-eating and/or restricted intake, lower self-esteem and dissatisfaction with their body image, leading to avoidance behaviors in some of them. CONCLUSIONS: Psychological manifestations, although they are still insufficiently documented, especially in adolescents, may aggravate obesity and interfere with treatment.     

Psychosocial adjustment and educational outcome in adolescents with a childhood diagnosis of attention deficit disorder

OBJECTIVE: To conduct a retrospective follow-up study of psychosocial adjustment and educational outcome in adolescents with a childhood diagnosis of attention deficit disorder (ADD) and a group of clinical controls. METHODS: Groups included male and female subjects aged 14 to 18 years at time of follow-up with childhood diagnosis of ADD (cases; n = 48) versus other neurodevelopmental disorders (clinical controls; n = 37). Cases were also subdivided based on the presence of conduct disorder (CD) at follow-up. All groups were compared on measures of academic performance, self-esteem, behavior, alcohol and substance use, and adaptive functioning. RESULTS: Cases had significantly lower academic performance and poorer social, emotional, and adaptive functioning than clinical controls. Cases with CD had significantly lower academic performance, greater externalizing behaviors and emotional difficulties, and lower adaptive functioning than cases without CD. Cases with CD fared worse than clinical controls on self-report measures of behavior, socialization skills, and alcohol and substance use. CONCLUSIONS: These academic and psychosocial problems in adolescents with a childhood diagnosis of ADD suggest potential long-term ramifications for vocational and psychological functioning into adulthood. In addition, the presence of CD in some of these cases during adolescence appears to further increase the risk for maladaptive outcome.     

Adolescent psychosocial risk factors for severe intimate partner violence in young adulthood.

The authors examined prospective measures of psychosocial risk factors as predictors of severe intimate partner violence among a community sample of 610 young adults at risk for intergenerational transmission of depression. The hypothesized risk factors were youth history of depression by age 15 and maternal history of depression. Youth social functioning at age 15 was tested as a mediator of these associations. Results showed that youth history of depression by age 15 predicted victimization at age 20. Severe violence perpetration was predicted by maternal depressive history among women but not men. Youth social functioning was a partial mediator of both associations. In sum, the findings suggest that psychosocial factors observed in adolescence may contribute to the risk of experiencing severe intimate partner violence during young adulthood. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Gender differences in homeless persons with schizophrenia and substance abuse

The purpose of this study was to test the generalizability of previous research on gender differences between men and women with co-occurring schizophrenia and substance abuse. One hundred eight patients with schizophrenia or schizo-affective disorder involved in a study of treatment for homeless persons were interviewed for information regarding substance use, social functioning and support, comorbid disorders, victimization, medical illness, and legal troubles. We found that women had more children and were more socially connected than men. Women also had higher rates of sexual and physical victimization, comorbid anxiety and depression, and medical illness than men. We conclude that homeless women with dual disorders, like women with substance use disorders in the general population, have distinct characteristics, vulnerabilities, and treatment needs compared with men. In addition to comprehensive treatment of psychiatric and substance use disorders, gender-specific services should be developed, including prevention and treatment of victimization and related problems as well as help with accessing medical services.     

Anxiety disorders in plastic surgery

Surgery is a stressful event, with the potential for profound disturbance to the patient's psychological and physiologic homeostasis. Cosmetic surgery is a particularly intense psychological experience because, in addition to the usual concerns about surgical side effects, cosmetic patients bring their hopes and expectations for improved self-image, putting them at risk for the added anxiety of disappointment. High levels of anxiety coupled with the perception of vulnerability or threat to self can cause significant psychological reactions complicating care for the plastic surgical patient. This paper outlines the diagnostic features of the common types of anxiety disorders seen in plastic surgical patients, and it offers treatment strategies for the practitioner, delineating when referral to a mental health expert is advised. Specific clinical case studies of panic attack, posttraumatic stress disorder, and acute stress disorder are presented to illustrate the variety of abnormal anxiety responses that may be encountered in the perioperative setting. Interventions for the anxious patient are part science and part art. Careful questioning and psychosocial assessment can identify those patients who are at greater risk for psychological problems after surgery. However, some patients may mask or keep secret their concerns, which can be manifested with resulting anger and hostility. Plastic surgeons must use appropriate indicators of psychological anxiety and measure a specific patient's reactions to surgery to make the diagnosis of abnormal anxiety. Close follow-up by the plastic surgical team is an essential part of the anxiety disorder patient's psychological treatment, but it is imperative that these problematic patients be referred promptly to a qualified mental health professional to limit their adverse experience and promote their well-being. Patients who are less anxious during the perioperative period report less emotional distress and fewer defensive behaviors and are likely to be more satisfied with the outcome of their surgery.     

Major depressive subtypes and treatment response

The purpose of this study was to investigate the relationships between depressive subtypes and response to fluoxetine treatment in a large cohort of outpatients. We studied 294 outpatients with major depressive disorder who were then treated with fluoxetine 20 mg/day for 8 weeks. Treatment outcome was evaluated with the Hamilton Depression Rating Scale (HDRS)-17, the Clinical Global Impressions-Severity, and with the HDRS-8; the latter is proposed to be a relatively more specific measure of depression severity than the HDRS-17. We assessed the relationships between degree of treatment response and several depressive subtypes (melancholic, atypical, hostile, and anxious depression, double depression, and depression with comorbid personality disorders), after adjusting for baseline depression severity. We found that nonanxious depressives (patients without any comorbid anxiety disorder) improved slightly but significantly more during treatment than anxious depressives on all outcome measures. Melancholic depression was associated with slightly less improvement on the HDRS-17 only, whereas the other subtypes of depression were not associated with differences in treatment outcome.     

Childhood history of anxiety in adults with panic disorder: association with anxiety sensitivity and comorbidity

Converging lines of evidence indicate a nonspecific link between childhood anxiety disorders and adult panic disorder. Anxiety sensitivity, defined as the fear of anxiety symptoms, was hypothesized to be a potential mediating variable in this link. This study examined the association among childhood history of anxiety disorders, current anxiety symptoms, and anxiety sensitivity in a sample of 100 patients with panic disorder undergoing treatment. Fifty-five percent of the patients had histories of one or more childhood anxiety disorders. Despite the heterogeneity of symptoms and treatment interventions among these patients, a childhood history of anxiety was associated with comorbid anxiety conditions, agoraphobic avoidance, and anxiety sensitivity scores. Anxiety sensitivity was itself a significant predictor of current severity of illness, but a childhood history of anxiety was not. These findings are consistent with the hypothesis that having an anxiety disorder during childhood is linked with patterns of anxiety and phobic avoidance in adulthood, including the level of anxiety sensitivity in patients with panic disorder.     

Minor depression in a cohort of young adults in Israel

BACKGROUND: A diagnosis of minor depression was considered for DSM-IV. Mild depression is thought to be common in primary care settings and the community, but studies of the validity of minor depression as a separate diagnostic category are few. METHODS: Minor depression as defined by Research Diagnostic Criteria was assessed by psychiatrists using a modified Schedule for Affective Disorders and Schizophrenia-Lifetime version in a cohort of 5200 young adults in Israel. Subjects with year-prevalent minor depression were compared with subjects with major depression or generalized anxiety disorder and with controls on aspects of psychopathologic condition, psychosocial functioning, help-seeking behaviors, and demographic correlates. RESULTS: Symptomatically, minor depression appeared to be a mild version of major depression. Minor depression was associated with good teenage and general social functioning, but also with absence from work, separation or divorce, recent impairment in overall functioning, and help-seeking. CONCLUSIONS: The results lend support for including minor depression or expanding severity modifiers in future classifications to better capture the phenomenon of subthreshold depression.     

Comorbidity of unipolar depression: II. Comorbidity with other mental disorders in adolescents and adults.

The current and lifetime comorbidity of depressive (i.e., major depressive disorder and dysthymia) with other common mental disorders was examined in community samples of older adolescents (n?=?1,710) and adults (n?=?2,060). Current and lifetime histories of depression in the adolescents were highly comorbid with several other mental disorders. The adults had a lower but statistically significant degree of comorbidity, primarily with substance use disorder. Depression in both groups was more likely to occur after the other disorder rather than to precede it. Comorbidity did not affect the duration or severity of depression. Comorbidity in the adolescents was associated with greater frequency of suicidal behavior and treatment seeking. The findings suggest that early-onset depression is associated with a greater degree of comorbidity and may represent a more serious form of the disorder. (PsycINFO Database Record (c) 2010 APA, all rights reserved)