Therapists' professional and personal characteristics as predictors of outcome in long-term psychodynamic psychotherapy and psychoanalysis

BACKGROUND

Whether long-term psychodynamic therapy (LPP) and psychoanalysis (PA) differ from each other and require different therapist qualities has been debated extensively, but rarely investigated empirically.

METHODS

In a quasi-experimental design, LPP was provided for 128 and PA for 41 outpatients, aged 20-46 years and suffering from mood or anxiety disorder, with a 5-year follow-up from start of treatment. Therapies were provided by 58 experienced therapists. Therapist characteristics, measured pre-treatment, were assessed with the Development of Psychotherapists Common Core Questionnaire (DPCCQ). General psychiatric symptoms were assessed as the main outcome measure at baseline and yearly after start of treatment with the Symptom Check List, Global Severity Index (SCL-90-GSI).

RESULTS

Professionally less affirming and personally more forceful and less aloof therapists predicted less symptoms in PA than in LPP at the end of the follow-up. A faster symptom reduction in LPP was predicted by a more moderate relational style and work experiences of both skillfulness and difficulties, indicating differences between PA and LPP in the therapy process.

CONCLUSIONS

Results challenge the benefit of a classically "neutral" psychoanalyst in PA. They also indicate closer examinations of therapy processes within and between the two treatments, which may benefit training and supervision of therapists.

Bipolar disorder with comorbid anxiety disorders: impact of comorbidity on treatment outcome in cognitive-behavioral therapy and psychoeducation

BACKGROUND

Comorbid anxiety disorders are extremely prevalent in bipolar disorder (BD) and have substantial impact on the course of illness. Limited evidence regarding treatment factors has led to a renewal of research efforts examining both the impact of treatments on comorbid anxiety and the impact of comorbid anxiety on treatments. The current study examines the impact of comorbid anxiety disorders on response to two psychosocial interventions for BD.

METHODS

A sample of 204 patients with BD took part in the study. Of them, 41.7% had a comorbid anxiety disorder. All participants received either individual cognitive-behavioral therapy or group psychoeducation for BD. Evaluations included complete pretreatment and 18-month follow-up assessments of mood and anxiety symptoms, functioning, medication compliance, dysfunctional attitudes, and coping style. Outcome was compared based on the presence or absence of a comorbid anxiety disorder.

RESULTS AND DISCUSSION

The participants with comorbid anxiety disorders ranked more severe than those without on several measures. Despite more severe illness characteristics, the magnitude of their treatment gains was equivalent or superior to that of the participants without anxiety disorders on a variety of outcome measures. Although the treatments did not specifically target the anxiety disorder, the participants made significant improvements in anxiety symptoms. Despite greater illness severity, patients with comorbid anxiety disorders can make substantial gains from psychosocial interventions targeting BD. Even in the presence of an anxiety disorder, they are able to attend to the content of the psychosocial treatments and apply it to better manage their condition. The presence of a comorbid anxiety disorder should not be considered a deterrent to offering BD-focused psychosocial treatments.

Axis I psychiatric diagnoses in adolescents and young adults with 22q11 deletion syndrome

BACKGROUND

22q11.2 deletion syndrome (22q11DS) associates with schizophrenia spectrum disorders (SSDs), autism spectrum disorders (ASDs), and other psychiatric disorders, but co-occurrence of diagnoses are not well described.

METHODS

We evaluated the co-occurrence of SSDs, ASDs and other axis I psychiatric diagnoses in 31 adolescents and adults with 22q11DS, assessing ASDs using either stringent Collaborative Program for Excellence in Autism (ASD-CPEA) criteria, or less stringent DSM-IV criteria alone (ASD-DSM-IV).

RESULTS

Ten (32%) individuals met criteria for an SSD, five (16%) for ASD-CPEA, and five others (16%) for ASD-DSM-IV. Of those with ASD-CPEA, one (20%) met SSD criteria. Of those with ASD-DSM-IV, four (80%) met SSD criteria. Depressive disorders (8 individuals; 26%) and anxiety disorders (7; 23%) sometimes co-occurred with SSDs and ASDs. SSDs, ASDs, and anxiety occurred predominantly among males and depression predominantly among females.

CONCLUSIONS

Individuals with 22q11DS can manifest SSDs in the presence or absence of ASDs and other axis I diagnoses. The results suggest that standard clinical care should include childhood screening for ASDs, and later periodic screening for all axis I diagnoses.

Beliefs of Australian health professionals about the helpfulness of interventions for mental disorders: differences between professions and change over time

OBJECTIVE

To assess the beliefs of general practitioners (GPs), psychiatrists and clinical psychologists about the helpfulness of different interventions for mental disorders, and to examine change in beliefs over time.

METHODS

A questionnaire was mailed to 6848 GPs, psychiatrists and clinical psychologists registered with Medicare Australia. The questionnaire was based around one of six vignettes describing a person with a mental disorder: depression, depression with suicidal thoughts, early schizophrenia, chronic schizophrenia, social phobia and post-traumatic stress disorder. The depression and early schizophrenia vignettes were identical to those used in a similar survey of health professionals conducted in 1996. A range of interventions were rated for their likely helpfulness for each disorder, and consensus was defined as at least 66% of each profession rating an intervention as helpful.

RESULTS

Responses were received from 1536 health professionals. A broader array of interventions were endorsed for depression than in 1996, including GPs, psychiatrists, psychologists, becoming more physically active, reading about people with similar problems and how they have dealt with them, psychotherapy, and cognitive behaviour therapy. For the schizophrenia vignettes, GPs, psychiatrists and antipsychotics were thought to be helpful by a majority of professionals. A variety of professionals, psychological treatments and lifestyle activities were endorsed for the anxiety disorders. Differences between professions were noted in beliefs about the helpfulness of antidepressants and counsellors for anxiety disorders and depression, as well as cognitive behaviour therapy for schizophrenia.

CONCLUSION

Consensus across professions was reached on the helpfulness of a variety of interventions for each mental disorder, although there were some notable differences in beliefs. The study gives an updated overview of treatment beliefs for mental disorders by Australian health professionals, which can be used as a benchmark with which to compare the beliefs of the Australian public.

Integration of mental health resources in a primary care setting leads to increased provider satisfaction and patient access

OBJECTIVE

This evaluation assessed the opinions and experiences of primary care providers and their support staff before and after implementation of expanded on-site mental health services and related system changes in a primary care clinic.

METHOD

Individual semistructured interviews, which contained a combination of open-ended questions and rating scales, were used to elicit opinions about mental health services before on-site system and resource changes occurred and repeated following changes that were intended to improve access to on-site mental health care.

RESULTS

In the first set of interviews, prior to expanding mental health services, primary care providers and support staff were generally dissatisfied with the availability and scheduling of on-site mental health care. Patients were often referred outside the primary care clinic for mental health treatment, to the detriment of communication and coordinated care. Follow-up interviews conducted after expansion of mental health services, scheduling refinements and other system changes revealed improved provider satisfaction in treatment access and coordination of care. Providers appreciated immediate and on-site social worker availability to triage mental health needs and help access care, and on-site treatment was viewed as important for remaining informed about patient care the primary care providers are not delivering directly.

CONCLUSIONS

Expanding integrated mental health services resulted in increased staff and provider satisfaction. Our evaluation identified key components of satisfaction, including on-site collaboration and assistance triaging patient needs. The sustainability of integrated models of care requires additional study.

Associations between DSM-IV mental disorders and subsequent heart disease onset: beyond depression

BACKGROUND

Prior studies on the depression-heart disease association have not usually used diagnostic measures of depression, or taken other mental disorders into consideration. As a result, it is not clear whether the association between depression and heart disease onset reflects a specific association, or the comorbidity between depression and other mental disorders. Additionally, the relative magnitude of associations of a range of mental disorders with heart disease onset is unknown.

METHODS

Face-to-face household surveys were conducted in 19 countries (n=52,095; person years=2,141,194). The Composite International Diagnostic Interview retrospectively assessed lifetime prevalence and age at onset of 16 DSM-IV mental disorders. Heart disease was indicated by self-report of physician's diagnosis, or self-report of heart attack, together with their timing (year). Survival analyses estimated associations between first onset of mental disorders and subsequent heart disease onset.

RESULTS

After comorbidity adjustment, depression, panic disorder, specific phobia, post-traumatic stress disorder and alcohol use disorders were associated with heart disease onset (ORs 1.3-1.6). Increasing number of mental disorders was associated with heart disease in a dose-response fashion. Mood disorders and alcohol abuse were more strongly associated with earlier onset than later onset heart disease. Associations did not vary by gender.

CONCLUSIONS

Depression, anxiety and alcohol use disorders were significantly associated with heart disease onset; depression was the weakest predictor. If confirmed in future prospective studies, the breadth of psychopathology's links with heart disease onset has substantial clinical and public health implications.

Impulsivity, anxiety, and alcohol misuse in bipolar disorder comorbid with eating disorders

Background

Eating disorders (ED) are noted to occur with bipolar disorder (BD), but relationships between additional comorbidities, clinical correlates, and personality factors common to both remain largely unknown.

Methods

Using data from the Prechter Longitudinal Study of Bipolar Disorder, we measured the prevalence and demographic factors of comorbid ED with BD, presence of additional comorbidity of anxiety and substance use disorders, psychosis, suicide attempts, mixed symptoms, childhood abuse, impact of NEO-Personality Inventory (NEO-PI) personality factors, and mood outcome in 354 patients with BD. We analyzed the prevalence of ED using both broad and narrow criteria.

Results and discussion

ED was more common in the Prechter BD sample than the general population, with the majority of those with ED being female. Anxiety disorders, alcohol abuse/dependence, and NEO-PI N5 impulsiveness were independently associated with ED in a multivariable linear regression analysis. BD age at onset was earlier in the ED group than that in the non-ED group and was earlier than the average onset of ED. Anxiety occurred before ED and alcohol use disorders after both BD and ED. Childhood trauma was associated with ED. Impulsivity and anxiety associated with BD may fuel ED and put patients at risk for other impulsivity-related disorders such as alcohol use disorders. ED was associated with more severe and variable moods and more frequent depression. Patients with BD should be regularly screened for ED, anxiety disorders, and alcohol use disorders, and comorbidity should be promptly addressed.

The relationship between excessive daytime sleepiness and depressive and anxiety disorders in women

OBJECTIVE

Excessive daytime sleepiness (EDS) is a common clinical symptom that affects women more than men. However, the association of excessive sleepiness with depressive and anxiety disorders in the broader population is unclear. The aim of this study was, therefore, to examine the association between excessive daytime sleepiness as measured by the Epworth Sleepiness Scale, and depressive and anxiety disorders in a population-based sample of women.

METHODS

Using the Structured Clinical Interview for DSM-IV Disorders (Non-Patient) (SCID-I/NP), 944 women aged 20-97 years (median 49 years, IQR 33-65 years) were assessed for depressive and anxiety disorders as part of the Geelong Osteoporosis Study. EDS was assessed using the Epworth Sleepiness Scale (ESS, cut-off > 10). Lifestyle factors were documented by self-report, height and weight were measured, and socioeconomic status categorised according to the Index of Relative Socio-Economic Advantage and Disadvantage.

RESULTS

Overall, 125 (13.2%) of the women were identified with EDS. EDS was associated with an increased likelihood for both current (OR = 2.11, 95% CI 1.10-4.06) and lifetime history (OR = 1.95, 95% CI 1.28-2.97) of depressive disorders, but not anxiety disorders, independent of age and alcohol consumption. These findings were not explained by antidepressant or sedative use, body mass index, physical activity, smoking, or socioeconomic status.

CONCLUSIONS

These results suggest that excessive daytime sleepiness is associated with current and lifetime depressive, but not anxiety disorders. Clinically, this highlights the need to take into account the possible bidirectional relationship between depressive disorders and excessive sleepiness when assessing mental health issues in patients with EDS.

Effectiveness of compassionate mind training on depression, anxiety, and self-criticism in a group of Iranian depressed patients

OBJECTIVE

The purpose of this study was to examine the effectiveness of compassionate mind training (CMT) on symptoms of depression and anxiety in Iranian depressed sufferers.

METHOD

Nineteen depressed patients aged 20 to 40 (Beck Depression Inventory value ≥ 20) were randomly assigned into two groups. The experimental group participated in 12 sessions of group therapy based on Paul Gilbert's manual of CMT. The control group was given no intervention. The participants were assessed by Beck Depression Inventory-II (BDI-II), Anxiety Scale (AS), and Levels of Self-Criticism (LSCS) questionnaires at the beginning and immediately after the intervention. To follow-up the therapeutic effect of CMT, the three questionnaires were answered again by participants two months after the end of the intervention. Data were analyzed by independent samples t-test.

RESULTS

The results revealed that CMT significantly decreases depression (P < 0.05) and anxiety score (P < 0.05) in the follow-up study, but not immediately after the intervention. Although CMT decreased self-criticism, this effect was marginally insignificant.

CONCLUSION

The findings indicated that CMT could alleviatedepression and anxiety in a group of Iranian depressed patients.

Sex differences and estrous cycle in female rats interact with the effects of fluoxetine treatment on fear extinction

A common treatment for anxiety disorders is chronic administration of selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine. Recent data suggest that SSRIs modulate fear responses after conditioned fear extinction and that gonadal hormones influence fear extinction. In this study we investigated the influence of sex and the estrous cycle on the effects of acute (experiment 1) and chronic (experiment 2) fluoxetine treatment on fear extinction. In experiment 1, rats received tone-footshock pairings during day 1. On day 2, rats received either fluoxetine (10mg/kg in 0.5mL) or vehicle prior to extinction learning. On day 3, extinction memory was assessed during extinction recall. In experiment 2, rats were exposed to a similar behavioral protocol, except that fluoxetine and vehicle were administered for 14 consecutives days after conditioning (days 2-15). Extinction learning and extinction recall occurred on days 15 and 16, respectively. Acute administration of fluoxetine increased fear responses equally in males and females during extinction learning and extinction recall. Chronic administration of fluoxetine reduced fear responses during extinction learning and extinction recall in female but not in male rats and this effect seems to be modulated by the estrous cycle. The SSRI-induced reduction of freezing during extinction learning and recall suggest a general anxiolytic effect of the drug treatment rather than a specific effect on extinction learning per se. Our data show evidence of sex-specific anxiolytic effects of 14-day treatment of fluoxetine while the acute anxiogenic effect of SSRI seems independent of sex effects.

Enhancing recovery rates: lessons from year one of IAPT

BACKGROUND

The English Improving Access to Psychological Therapies (IAPT) initiative aims to make evidence-based psychological therapies for depression and anxiety disorder more widely available in the National Health Service (NHS). 32 IAPT services based on a stepped care model were established in the first year of the programme. We report on the reliable recovery rates achieved by patients treated in the services and identify predictors of recovery at patient level, service level, and as a function of compliance with National Institute of Health and Care Excellence (NICE) Treatment Guidelines.

METHOD

Data from 19,395 patients who were clinical cases at intake, attended at least two sessions, had at least two outcomes scores and had completed their treatment during the period were analysed. Outcome was assessed with the patient health questionnaire depression scale (PHQ-9) and the anxiety scale (GAD-7).

RESULTS

Data completeness was high for a routine cohort study. Over 91% of treated patients had paired (pre-post) outcome scores. Overall, 40.3% of patients were reliably recovered at post-treatment, 63.7% showed reliable improvement and 6.6% showed reliable deterioration. Most patients received treatments that were recommended by NICE. When a treatment not recommended by NICE was provided, recovery rates were reduced. Service characteristics that predicted higher reliable recovery rates were: high average number of therapy sessions; higher step-up rates among individuals who started with low intensity treatment; larger services; and a larger proportion of experienced staff.

CONCLUSIONS

Compliance with the IAPT clinical model is associated with enhanced rates of reliable recovery.

[Benzodiazepine dependence and the risk of depression and anxiety disorders: seniors' health study]

AIM OF THE STUDY

The objective of this study is to examine the relationship between benzodiazepine dependence and anxiety disorders and depression in people aged 65 years and over. We referred to the data from the study on the health of seniors, a survey of a representative sample of 707 benzodiazepine users living in the community in Quebec, Canada. Benzodiazepine dependence, anxiety disorders and depression were measured using self-reported questionnaires based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth revised edition.

RESULTS

Seniors have consumed an average daily dose of 6.1±7.6mg diazepam equivalent to an average of 205±130 days. The prevalence of benzodiazepine dependence has been estimated at 9.5%. This dependence increases the risk of minor depression for females (relative risk [RR]=4.36, confidence interval 95% [95% CI]=1.19 to 15.99).

CONCLUSION

The results of this study suggest that the use of benzodiazepines is far from being optimal among seniors in Quebec. The proportion of seniors who develop an addiction is important. The results illustrate the need to develop and implement programs to improve the quality of benzodiazepine use among this population.

An Examination of the Association of Distress Intolerance and Emotion Regulation with Avoidance

Distress intolerance is an important motivator of maladaptive avoidance-based coping strategies. The selection of such avoidance behaviors is also influenced by one's access to alternative emotion regulatory strategies. However, little research has examined the relative contributions of these vulnerability factors to avoidance. This study examined whether distress intolerance and access to emotion regulation strategies were uniquely (additively or interactively) associated with self-reported avoidance. Two samples-an unselected sample (n = 300) and a clinical sample (n = 100)-comprised of patients seeking treatment for unipolar mood and/or anxiety disorders were administered measures of distress intolerance, emotion regulation, and avoidance. Results of linear regression analyses indicated that distress intolerance and access to emotion regulation strategies were uniquely and additively associated with avoidance. Implications for the prevention and treatment of psychological disorders are discussed.

Exploring the Relationship Between Social Anxiety and Bulimic Symptoms: Mediational Effects of Perfectionism Among Females

Previous findings indicate that social anxiety and bulimia co-occur at high rates; one mechanism that has been proposed to link these symptom clusters is perfectionism. We tested meditational models among 167 female undergraduates in which maladaptive evaluative perfectionism concerns (MEPC; i.e., critical self-evaluative perfectionism) mediated the relationship between social anxiety and bulimic symptoms. Results from a first model indicated that MEPC mediated the relationship between fear of public scrutiny and bulimia symptoms. This indirect effect was significant above and beyond the indirect effects of maladaptive body-image cognitions and perfectionism specific to pure personal standards. A second model was tested with MEPC mediating the relationship between social interaction anxiety and bulimia symptoms. Similar results were obtained; however, in this model, a significant direct effect remained after partialing out the indirect effect of the mediators. Theoretical implications are discussed.

Psychosocial aspects of Hansen's disease (leprosy)

In general, the prevalence of psychiatric disorders among people with Hansen's disease has greatly increased to date. However, inadequate psychiatric care of people with Hansen's disease is an area of increasing concern. Many studies have been conducted in India and abroad to find out the prevalence of comorbid psychiatric disorders in patients suffering from Hansen's disease. Although efforts have been made by the government and international organizations to solve the medical problems among this group of patients, this disease still carries a number of psychosocial issues. The social stigma connected to these patients makes this disease completely different from others. Even nowadays people affected by Hansen's disease have to leave their village and are socially isolated. Depression is the most common psychiatric disorder found in these patients. Early detection and treatment of psychiatric disorders among Hansen's disease patients is a powerful psychotherapeutic measure. Integrated healthcare strategy will be beneficial to these patients. A comprehensive MEDLINE search and review of relevant literature was carried out and the data extracted and studied with particular reference to psychosocial issues in Hansen's disease. The focus of this research work is related to psychiatric and social aspects vis-à-vis stigma in these patients with Hansen's disease.

Fear bradycardia and activation of the human periaqueductal grey

Animal models of predator defense distinguish qualitatively different behavioral modes that are activated at increasing levels of predation threat. A defense mode observed at intermediate threat levels is freezing: a cessation of locomotion that is characterized by a parasympathetically dominated autonomic nervous system response that causes heart rate deceleration, or fear bradycardia. Studies in rodents have shown that freezing depends on amygdalar projections to the periaqueductal grey (PAG). In humans, freezing-like behaviors are implicated in development and maintenance of psychopathology, but neural mechanisms underlying freezing or its characteristic autonomic response profile have not been identified. Here, we combined event-related blood oxygenation level-dependent functional MRI (BOLD-fMRI) with autonomic response measures in a picture viewing paradigm to probe activity and interconnectivity within the amygdala-PAG pathway and test for an association with parasympathetic as opposed to sympathetic activation. In response to negatively arousing pictures, we observed parasympathetic (bradycardia) and sympathetic (pupil dilation) autonomic responses, BOLD responses in the amygdala and PAG, and effective connectivity between these regions. Critically, BOLD responses in the PAG to negative pictures correlated on a trial-by-trial basis with bradycardia but not pupil dilation. This correlation with bradycardia remained significant when partialling out pupil dilation. Additionally, activity in regions associated with motor planning and inhibition mirrored the PAG response. Thus, our findings implicate the human PAG in a parasympathetically dominated defense mode that subserves a state of attentive immobility. Mechanistic insight into this qualitatively distinct defense mode may importantly advance translational models of anxiety disorders.

Psychiatric, somatic and other functional gastrointestinal disorders in patients with irritable bowel syndrome at a tertiary care center

Background/Aims

To study the prevalence of somatic and psychiatric co-morbidities in the patients of irritable bowel syndrome (IBS) and to assess the quality of life (QOL) of these patients.

Methods

One hundred and eighty-four IBS patients and 198 controls were included. Diagnosis of IBS, its sub-classification and assessment of other functional gastrointestinal disorders (FGIDs) was made on basis of Rome III criteria. Severity of IBS was assessed using IBS severity scoring system. Psychiatric evaluation was done using Patient Heath Questionnaire. QOL was evaluated using WHO QOL-BREF.

Results

One hundred and forty-seven (79.9%) and 158 (85.9%) patients with IBS had at least one other FGID or at least one somatic co-morbidity, respectively. Higher number of patients had at least one psychiatric co-morbidity compared to controls (79.9% vs 34.3%; P < 0.001). Major depressive syndrome (47.3% vs 5.1%; P < 0.001), somatoform disorder (50% vs 14.6%; P < 0.001) and panic syndrome (44% vs 11.6%; P < 0.001) were more common in IBS than controls. Only 14 (7.6%) patients were receiving drug treatment for their psychiatric illness. Severe IBS symptoms were present in significantly higher number of patients with constipation predominant IBS than diarrhea predominant IBS. Those with severe disease had higher prevalence of psychiatric (95.1%) and somatic (96.7%) co-morbidities compared with mild disease. QOL of IBS patients was significantly lower in all four domains compared to controls. Presence of at least one other FGID was significantly associated with presence of one or more psychiatric co-morbidity (P < 0.001).

Conclusions

Majority of IBS patients presenting to a tertiary care center had associated psychiatric, somatic co-morbidities and reduced QOL. Very few of them received specific psychiatric treatment.

Childhood stressful events, HPA axis and anxiety disorders

Anxiety disorders are among the most common of all mental disorders and their pathogenesis is a major topic in psychiatry, both for prevention and treatment. Early stressful life events and alterations of hypothalamic pituitary adrenal (HPA) axis function seem to have a significant role in the onset of anxiety. Existing data appear to support the mediating effect of the HPA axis between childhood traumata and posttraumatic stress disorder. Findings on the HPA axis activity at baseline and after stimuli in panic disordered patients are inconclusive, even if stressful life events may have a triggering function in the development of this disorder. Data on the relationship between stress, HPA axis functioning and obsessive-compulsive disorder (OCD) are scarce and discordant, but an increased activity of the HPA axis is reported in OCD patients. Moreover, normal basal cortisol levels and hyper-responsiveness of the adrenal cortex during a psychosocial stressor are observed in social phobics. Finally, abnormal HPA axis activity has also been observed in generalized anxiety disordered patients. While several hypothesis have attempted to explain these findings over time, currently the most widely accepted theory is that early stressful life events may provoke alterations of the stress response and thus of the HPA axis, that can endure during adulthood, predisposing individuals to develop psychopathology. All theories are reviewed and the authors conclude that childhood life events and HPA abnormalities may be specifically and transnosographically related to all anxiety disorders, as well as, more broadly, to all psychiatric disorders.

Psychiatric diseases: Need for an increased awareness among the anesthesiologists

Psychological disorders and psychiatric diseases have been on the rise since the last three decades. An increasing number of such patients are encountered nowadays for elective or emergency surgery. A multi-array of challenges are faced while anesthetizing these patients or treating them in an intensive care unit. The problems include the deteriorated mental physiology, altered cognition and the possible drug interactions with psychotropic medications. The challenge starts from the preoperative assessment stage. Knowledge of the pharmacological profile of the various anti-psychotic drugs, their side-effects and drug interactions are of prime importance for an anesthesiologist to facilitate smooth delivery of anesthesia in such patients. It is important to formulate a clear plan to deal with any challenge in the perioperative or postoperative period. All the clinical aspects and various definitions of mental disorders in the present article have been used as per the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). We reviewed the advances in psychiatric diseases, their treatment and their implications on delivery of anesthesia.

Anxiety and mood disorders in children and adolescents: A practice update

Anxiety and mood disorders are among the most common disorders in children and adolescents. They presage later emotional difficulties and disabilities. An understanding of the disorders' presentation, common contributing factors and methods of intervention will enable paediatricians and family doctors to provide optimal support to these children and their families. The present paper briefly reviews the epidemiology of anxiety and mood disorders in children and adolescents. Phenomenology is referred to according to the major diagnostic categories for anxiety and depression. Contributing factors, including genetic and environmental components and their possible interaction, are discussed. The management of the disorders, including common strategies for encouraging coping responses, stress reduction and medication, is also described.

Post-traumatic Stress Disorder and Cardiovascular Disease

This review provides an up-to-date summary of the evidence from clinical and epidemiologic studies indicating that persons with post-traumatic stress disorder (PTSD) may have an increased risk of coronary heart disease and possibly thromboembolic stroke. Persons with PTSD, a common anxiety disorder in both veteran and nonveteran populations, have been reported to have an increased risk of hypertension, hyperlipidemia, obesity, and cardiovascular disease. Increased activity of the sympathoadrenal axis may contribute to cardiovascular disease through the effects of catecholamines on the heart, vasculature, and platelet function. Reported links between PTSD and hypertension and other cardiovascular risk factors may partly account for reported associations between PTSD and heart disease. The associations observed between PTSD and cardiovascular diseases have implications for cardiology practice and research.

The importance of serotonin and noradrenaline in anxiety

The therapeutics of obsessive-compulsive disorder (OCD) involves the serotonergic system in the brain; the selective serotonin reuptake inhibitors (SSRIs) are the only class of drugs to be consistently effective for this disorder. Preclinical studies in the orbito-frontal cortex - a brain area known to be involved in mediation of OCD symptoms - show that sustained administration of SSRI for 2 months leads to enhanced 5-HT release. Initially, raised 5-HT levels, resulting from serotonin (5-HT) reuptake inhibition, over-activates the cell body 5-HT1A autoreceptor, which has an inhibitory effect on the neuronal firing rate. However, after long-term administration of SSRIs, these 5-HT1A autoreceptors become desensitized to the raised extracellular 5-HT levels, and increase 5-HT transmission. The recovery of neuronal firing rate is faster with escitalopram (the active S-enantiomer of citalopram) than with citalopram, which may be due to different mechanisms of action. The 5-HT system has reciprocal interactions with the noradrenaline (NA) system. Although not a major mediator in the treatment of OCD symptomatology, patients with anxiety disorders such as panic disorder have increased NA reactivity and/or tone. Long-term SSRI administration reduces the firing rate of NA neurones, unlike 5-HT neurones. Evidence indicates that accrued 5-HT levels have an inhibitory modulatory effect on NA transmission, thus indicating the clinical relevance of SSRI treatment for anxiety disorders. The different effectiveness of the SSRIs escitalopram and citalopram in enhancing synaptic 5-HT levels may be due to the inhibitory action of the R-enantiomer in racemic citalopram on S-enantiomer binding to the 5-HT transporter. This allows escitalopram to produce higher extracellular 5-HT levels than can be achieved by the equivalent S-enantiomer dose of citalopram. Escitalopram is therefore a viable front-line treatment option for people with anxiety disorders, and possibly for those who have failed to respond to conventional SSRI therapies.

Anxiety and OC spectrum disorders over life cycle

The developmental trajectory of anxiety disorders over the life span is an area of increasing interest. Obsessive-compulsive disorder (OCD), traditionally considered an anxiety disorder, is a disabling and chronic condition that is associated with considerable negative impact on numerous aspects of daily functioning. Lifetime prevalence has been estimated at 1.6%. OCD, like other anxiety disorders, is frequently associated with comorbid depression. Unlike depression, anxiety disorders begin early in life, often early in the teenage years. Thus, the total duration of symptoms may be nearly lifelong. Although a variety of pharmacological and behavioral treatments have proven effective, many patients fail to respond, and for some of those who do respond, response may be incomplete. Patients with these disorders deserve early and rigorous treatment, but the best way of achieving this goal is unclear. The Cape Town Consensus Statement reflects the opinions of an international expert working group who convened to review what is known about OCD and to suggest directions for future research. In their view, phenomenonological, clinical, and neurobiological features of OCD do not justify continued placement in the category of anxiety disorders. It has been suggested that OCD might better be placed in a separate category of obsessive-compulsive related disorders (OCRDs). Phenomenology, demographics, epidemiology, course of illness, comorbidity, endophenotyping and treatment response are factors that may influence the definition of the boundaries and relationships between these disorders. Endophenotyping characteristics include brain circuitry, neurocognitive factors, genetics, and immune function. Incorporation of a dimensional approach to the existing categorical approach to diagnosis may help to enrich the diagnostic specificity of the approach to OC behaviors.

Generalized anxiety disorder: how to treat, and for how long?

Generalized anxiety disorder (GAD) is a common, chronic and disabling anxiety disorder with considerable comorbidity with depression as well as with other anxiety disorders. Although tricyclic antidepressants and benzodiazepines have been found to be efficacious in patients with GAD, tolerability problems and other risks limit their use in clinical practice. In placebo-controlled, acute (<8 weeks) trials, several medications, including the selective serotonin reuptake inhibitors ([SSRIs] escitalopram, paroxetine, and sertraline) and others (venlafaxine, buspirone, pregabalin), have demonstrated efficacy in patients with GAD. Indeed, current guidelines for the treatment of GAD recommend SSRIs as first-line pharmacological therapy because of their efficacy and tolerability profiles. Although GAD is a chronic condition that is usually present for years, with symptoms typically fluctuating in intensity over time, there have been few randomized, controlled trials of pharmacotherapy beyond the acute phase of treatment. However, data from recent relapse-prevention studies and longer-term maintenance studies with paroxetine, venlafaxine and escitalopram strongly support the value of continued treatment for at least a further 6 months. This article focuses on pharmacological treatment, and reviews recently available data from acute, long-term and relapse-prevention trials in patients with GAD. In addition, issues relating to the natural course of GAD are highlighted as important considerations to guide selection of pharmacotherapy.

Challenges in the treatment of anxiety disorders: beyond guidelines

Anxiety disorders are highly prevalent, come in many forms and are often chronic, with many patients requiring long-term maintenance therapy. Anxiety and depression may also be comorbid in up to 50% of patients, leading to problems during diagnosis and treatment. Despite their frequency, the recognition and treatment of anxiety disorders is frequently suboptimal, with as few as 15% of patients obtaining treatment consistent with evidence-based care recommendations. Current treatment guidelines for anxiety disorders include a range of pharmacological and non-pharmacological approaches. However, the use of these guidelines alone may not be sufficient to improve patient outcomes. Optimal treatments for anxiety should be based on chronic disease management and balance efficacy with long-term tolerability. Current first-line therapies should include broad-spectrum agents that have proven efficacy in treating both anxiety and depression and are effective across all treatment phases. The allosteric serotonin reuptake inhibitor (ASRI), escitalopram, is a particularly effective treatment, offering high rates of remission combined with relatively low rates of discontinuation due to adverse events. Combination therapy involving medication and psychological approaches, e.g., cognitive behavioral therapy, may also be helpful. Novel approaches to delivering psychotherapy and self-management via the Internet may address accessibility issues for evidence-based psychological treatments.

[Not Available]

Anxiety disorders show a tendency to become chronic. Behavioral treatment and pharmacotherapeutic measures must frequently be applied over a lengthy period of time. The most suitable drugs for long-term treatment are the selective serotonin reuptake inhibitors (SSRI) and the serotonin norepinephrine reuptake inhibitor (SNRI), venlafaxine. With regard to side effects, the specific characteristics of the anti-anxiety drugs used for long-term therapy must be taken into account.