Health-related Quality of Life across the anxiety disorders: findings from a sample of primary care patients

The relationship of race, ethnicity, gender identity, sex assigned at birth, sexual orientation, parental education, financial hardship and comorbid mental disorders with quality of life in college students with anxiety, depression or eating disorders

BACKGROUND

Previous studies showed that comorbidity and demographic factors added to burden on health-related quality of life (HRQoL). Only one study explored the relationship between HRQoL and comorbidity in college students with mental disorders, leaving generalizability of findings uncertain. Less is known about the association of demographics on HRQoL. This study investigated HRQoL based on demographics and comorbidity among college students with mental disorders.

METHODS

Participants were students (N = 5535) across 26 U.S. colleges and universities who met criteria for depression, generalized anxiety, panic, social anxiety, post-traumatic stress, or eating disorders based on self-report measures. ANOVA and linear regressions were conducted.

RESULTS

Overall, female, minoritized (gender, sexual orientation, race, or ethnicity), and lower socioeconomic status students reported lower HRQoL than male, heterosexual, White, non-Hispanic, and higher socioeconomic status peers. After accounting for comorbidity, differences in physical HRQoL based on sex assigned at birth and gender were no longer significant. For mental HRQoL, only gender and sexual orientation remained significant. A greater number of comorbidities was associated with lower HRQoL regardless of demographic group.

LIMITATIONS

The non-experimental design limits causal inference. The study focused on univariable associations without examining potential interactions between demographic factors. Future research should explore structural factors like discrimination.

CONCLUSION

Results suggested that increased comorbidities placed an additional burden on HRQoL and that certain demographic groups were more vulnerable to HRQoL impairment among students with mental disorders. Findings suggest the need for prevention of disorders and their comorbidity and implementing tailored interventions for specific student subgroups with increased vulnerability.

Health-related quality of life in psychiatric outpatients: a cross-sectional study of associations with symptoms, diagnoses, and employment status

BACKGROUND

This cross-sectional study aimed to explore health-related quality of life (HRQoL) in a large heterogeneous patient sample seeking outpatient treatment at a specialist mental health clinic.

METHOD

A sample of 1947 patients with common mental disorders, including depressive-, anxiety-, personality-, hyperkinetic- and trauma-related disorders, completed the EuroQoL 5-Dimension 5-Level (EQ-5D-5L) to assess HRQoL. We investigated clinical and sociodemographic factors associated with the EQ-5D index and the EQ Visual Analogue Scale (VAS) using regression analyses.

RESULTS

The sample reported lower HRQoL compared with the general population and primary mental health care patients. Sick leave, disability pension, work assessment allowance, and more symptoms of anxiety and depression were associated with lower EQ-5D index and EQ VAS scores. Furthermore, being male, use of pain medication and having disorders related to trauma were associated with reduced EQ-5D index scores, while hyperkinetic disorders were associated with higher EQ-5D index scores.

CONCLUSION

HRQoL of psychiatric outpatients is clearly impaired. This study indicated a significant association between employment status, symptom severity, and HRQoL in treatment-seeking outpatients. The findings highlight the importance of assessing HRQoL as part of routine clinical assessment.

Sociodemographic factors and use of pain medication are associated with health-related quality of life: results from an adult community mental health service in Norway

PURPOSE

Health-related quality of life (HRQoL) is an important aspect of mental health outcomes. There are few studies on HRQoL in heterogeneous patient populations seeking help at community mental health services. The aims of the study were to compare how HRQoL, measured by the EuroQol five dimensions with five levels (EQ-5D-5L), was distributed compared to other samples from national and international studies, and to explore what factors are associated with HRQoL.

METHODS

In a cross-sectional study, 1379 Norwegian outpatients reported their HRQoL before starting treatment. Associations with demographic variables, job status, socio-economic status, and use of pain medication were examined using multiple regression analysis.

RESULTS

Most of the sample, 70% to 90%, reported problems with usual activities, pain/discomfort, and anxiety/depression; 30% to 65% reported that these problems were of a moderate to extreme degree. Forty percent reported problems with mobility, and about 20% reported problems with self-care. The sample's HRQoL was considerably lower than the general population, and comparable to patient-groups from specialist mental health services. Originating from a developing country, lower level of education, lower yearly household income, being on sick leave or unemployed, and using pain medication were associated with lower HRQoL. Age, gender, and relationship status were not associated with HRQoL. This is the first study to simultaneously examine the unique contribution of these variables in one study.

CONCLUSION

The most impacted domains of HRQoL were pain/discomfort, anxiety/depression, and usual activities. Lower HRQoL was associated with several socio-demographic factors and use of pain medication. These findings might have clinical implications and suggest that mental health professionals should routinely measure HRQoL in addition to symptom severity, to identify areas that should be targeted to improve HRQoL.

The occurrence and extent of anxiety and distress among Dutch travellers after encountering an animal associated injury

BACKGROUND

Prompt administration of post-exposure prophylaxis (PEP) is crucial to prevent a fatal rabies infection after an animal associated injury (AAI), preferably within 24 h. PEP, especially in case of a type III injury for which rabies immune globulin (RIG) is needed, is difficult to obtain abroad. This, along with the fear of potentially having contracted a lethal disease, might be an important source for anxiety and distress. We investigated the occurrence and extent of self-reported anxiety and distress at different timepoints among Dutch travellers after encountering an AAI, and the involved factors.

METHODS

A retrospective quantitative observational study was conducted including insured Dutch travellers who actively contacted Eurocross Assistance after encountering an AAI abroad. An online questionnaire was designed to measure anxiety and distress levels, using the HADS (Hospital Anxiety and Depression Scale) and distress thermometer at three time points: departure from home (T1), post-AAI (T2), and treatment administration (T3). Statistical analyses included T-tests, Chi-square tests, and ANCOVA analyses.

RESULTS

We showed a significant increase in mean anxiety and distress scores at T2, and a significant decrease at T3. Women were more often anxious and distressed. Between T1 and T2, PrEP, and being aware of the risks were positively associated with anxiety levels, and PrEP and WHO region Africa with distress levels. Between T2 and T3, anxiety levels remained higher for monkey-induced injury, thoracic injuries, and WHO region Southeast Asia. PEP-delay between 24-48 h resulted in decreased distress levels at this time period, while type II injury elevated distress levels.

CONCLUSIONS

This study showed significant anxiety and distress levels after an AAI among the vast majority of travellers, which is detrimental to their health-related quality of life (HR-QOL). This highlights the importance of proper pre-travel information. In the context of rabies prevention, these results suggest that pre-travel advice and policy makers should also take aspects of HR-QOL into consideration.

Trajectories of generalized anxiety disorder, major depression and change in quality of life in adults aged 50 + : findings from a longitudinal analysis using representative, population-based data from Ireland

PURPOSE

To investigate the longitudinal association between trajectories (incidence, remission) of generalized anxiety disorder (GAD), major depression (MD) and change in quality of life (QoL) in adults aged 50 + , and to assess the symmetry in these relationships using observational study data.

METHODS

Data were derived from two waves of The Irish Longitudinal Study on Aging (2014-2015, wave 3: n = 6400; 2016, wave 4: n = 5715), a nationally representative cohort of community-dwelling adults aged 50 +. GAD and MD were assessed by means of the short form of the Composite International Diagnostic Interview. QoL outcomes were assessed using the Control, Autonomy, Self-realization, and Pleasure scale (CASP-12 with two domains control/autonomy and self-realization/pleasure). Covariate-adjusted, asymmetric fixed effects panel regressions and post-estimation Wald tests were used for statistical analysis.

RESULTS

Regarding incident disorders, only incident MD was significantly associated with a reduction in QoL over time (control/autonomy domain: b = - 0.74, SE: 0.30). Regarding remission, both remission of MD (b = 0.61, SE: 0.20) and remission of GAD (b = 0.61, 0.26) were significantly associated with an increase in the self-realization/pleasure domain over time. Subsequent Wald tests of the estimates were not significant, indicating symmetric effects.

CONCLUSION

Particularly the remission of GAD and MD was associated with a significant improvement in one of the QoL domains, indicating domain- and trajectory-specific differences. However, symmetric effects observed in this study indicate that gains and losses in QoL associated with remission and incidence of GAD and MD are of similar magnitude in adults aged 50 +.

Investigating the relationship between the five-factor model of distress tolerance, anxiety and anxiety sensitivity

BACKGROUND

Distress tolerance (DT) has been conceptualized as a vulnerability factor for several psychopathologies. A five factor model of DT has been suggested, but its associations with anxiety and anxiety sensitivity have yet to be explored.

OBJECTIVES

This study aimed to further validate the five-factor model of DT, identify the associations between its factors and elevated anxiety, and assess if anxiety sensitivity mediates the association between DT and anxiety.

DESIGN AND METHODS

This observational study included 330 students and university workers (women = 82.7%; mean age = 27.7 years, SD = 9.4). They completed online questionnaires assessing DT, anxiety sensitivity and anxiety levels.

RESULTS

The five-factor model was a good fit to the data (RMSEA = .04). Two factors, and the sex of the participants, contributed to the variance in anxiety (r2 = .418, p < .001). Tolerance of negative emotion was directly (β = -1.98, 95% CI = [-2.53, -1.42]) and indirectly (β = -1.10, 95% CI = [-1.55, -.78]) associated with lower anxiety through anxiety sensitivity. Tolerance of uncertainty was also directly (β = -.08, 95% CI = [-.10, -.06]) and indirectly (β = -.04, 95% CI = [-.05, -.02]) associated with lower anxiety through anxiety sensitivity.

CONCLUSIONS

Tolerance of negative emotion and uncertainty were associated with anxiety independently of the other factors of DT. These associations seem partially explained by the effect of anxiety sensitivity.

Awareness of Vaccination against Respiratory Tract Diseases, Including Pneumonia, Influenza, and COVID-19 in Patients with Diabetes Mellitus

Patients with diabetes have an increased risk of severe acute respiratory infections, and vaccination is their life-saving option. This study aimed to investigate the interest and knowledge of patients about influenza, pneumonia, and COVID-19(coronavirus disease 2019) vaccines. Materials. We handed out a questionnaire to patients with diabetes who were admitted to the endocrinology clinic between April and August 2021. The questionnaire collected information on demographic data, knowledge about respiratory tract disease vaccines, and hesitancy about vaccines. Results. Four hundred twenty-four patients (female = 256, male = 168) enrolled in the study. In this study, 148 (34.9%) participants were vaccinated against pneumonia, 155 (36.6%) against flu, and 312 (73.6%) against COVID-19. In addition, antivaccination sentiment was recorded in 8.7% of patients with diabetes. We found that participants in the study primarily rely on doctors as the source of information about vaccines (doctor (46.7%), nurse (1.2%), television (8.7%), friend/neighbour (8.7%), and others (2.6%)). The rate of vaccination was statistically higher than the presence of comorbid diseases. Conclusions. We examined the vaccine awareness of patients with diabetes and investigated factors affecting it. İt was determined that vaccination awareness is affected by many factors, especially comorbid diseases and educational status. The study showed that patients primarily relied on doctors as their source of information for vaccination. Doctor-centered vaccination promotion programmes can increase the rate of vaccination.

The burden of psoriasis in patients with early psoriatic arthritis

Objectives

Psoriasis impacts health-related quality of life (HRQoL) in PsA patients. However, this is not adequately measured with a general HRQoL questionnaire. The aim of this study was to quantify the degree of psoriasis evolution in PsA patients over the first year of follow-up and to evaluate whether the impact of psoriasis on HRQoL can be adequately measured with a dermatology-specific HRQoL questionnaire.

Methods

Data were used from PsA patients in the Dutch south west Early Psoriatic Arthritis cohort. Psoriasis severity was measured with the Psoriasis Area and Severity Index (PASI). Dermatology-specific HRQoL was assessed with the Skindex-17 questionnaire. We used a Sankey diagram to illustrate the evolution of psoriasis severity during the first year of follow-up. To assess the association between psoriasis severity and the symptoms and psychosocial subscale of the Skindex-17, a linear regression analysis with hierarchical variable selection and zero-inflated negative binominal regression analysis were performed, respectively.

Results

We included 644 patients; 109 (17%) patients had no psoriasis (PASI = 0), 456 (71%) had mild psoriasis (PASI < 7), 56 (9%) had moderate psoriasis (PASI 7–12) and 23 (4%) had severe psoriasis (PASI > 12). Psoriasis severity did not fluctuate much during the first year. PASI was significantly associated with both subscales of the Skindex-17 at baseline and 12 months.

Conclusion

Psoriasis severity in PsA patients is mostly mild but impacts HRQoL when measured using a dermatology-specific HRQoL questionnaire. For optimal management of PsA patients, we recommend rheumatologists acquire information on skin burden by using a dermatology-specific HRQoL questionnaire.

Quality of Life and Its Predictive Factors Among Healthcare Workers After the End of a Movement Lockdown: The Salient Roles of COVID-19 Stressors, Psychological Experience, and Social Support

Although healthcare workers play a crucial role in helping curb the hazardous health impact of coronavirus disease 2019 (COVID-19), their lives and major functioning have been greatly affected by the pandemic. This study examined the effects of the COVID-19 pandemic on the quality of life (QoL) of Malaysian healthcare workers and its predictive factors. An online sample of 389 university-based healthcare workers completed questionnaires on demographics, clinical features, COVID-19-related stressors, psychological experiences, and perceived social support after the movement lockdown was lifted. All domains of QoL were within the norms of the general population except for social relationship QoL, which was lower than the norm. Multiple linear regression analysis indicated that COVID-19-related stressors (e.g., stress due to annual leave being frozen, loss of daily routine, and frequent exposure to COVID-19 patients) and psychological sequelae (e.g., greater severity of depression, anxiety, and stress) predicted lower QoL. Conversely, greater perceived social support from friends and significant others predicted higher QoL. Clinical and demographic characteristics predicted QoL to a lesser extent: A history of pre-existing medical illness was associated only with lower physical health QoL, whereas older age and being single, divorced, or widowed were only predictive of higher environmental QoL. Efforts to enhance QoL among healthcare workers in response to the pandemic should focus on mitigating COVID-19-related stressors and psychological sequelae and facilitating social support.

Does cognitive behavioral therapy for anxiety disorders assist the discontinuation of benzodiazepines among patients with anxiety disorders? A systematic review and meta-analysis

Long-term use of benzodiazepines (BZD) is not recommended for the treatment of anxiety disorders. Cognitive behavioral therapy (CBT) is an effective treatment option for discontinuation of BZD in patients with anxiety disorders. This systematic review and meta-analysis sought to clarify whether CBT is effective for discontinuing BZD anxiolytics in patients with anxiety disorders. This study was preregistered with PROSPERO (registration number: CRD42019125263). A literature search of major electronic databases was conducted in December 2018. Three randomized controlled trials were included in this review, and meta-analyses were performed. The proportion of discontinuing BZD anxiolytics was significantly higher in the CBT plus gradual tapering group than in the gradual tapering alone group, both in the short term (3 months after allocation; number needed to treat: 3.2, 95% confidence interval [CI]: 2.1 to 7.1; risk ratio: 1.96, 95%CI: 1.29 to 2.98, P = 0.002, three studies) and long term (6 to 12 months after allocation; number needed to treat: 2.8, 95%CI: 1.9 to 5.3; risk ratio: 2.16, 95%CI: 1.41 to 3.32, P = 0.0004, three studies). CBT may be effective for discontinuing BZD anxiolytics, both in the short term and in the long term after the allocation. Further studies with larger sample sizes are necessary to draw definitive conclusions regarding the efficacy and safety of CBT for discontinuing BZD anxiolytics in patients with anxiety disorders.

Therapeutic effects of Silexan on somatic symptoms and physical health in patients with anxiety disorders: A meta-analysis

A meta-analysis was performed to examine therapeutic effects of Silexan on somatic symptoms, including insomnia/fatigue, and physical health in patients with anxiety disorders. Five randomized, placebo-controlled trials were included in this analysis: The efficacy of Silexan (80 mg/day) was investigated in patients with subthreshold anxiety disorders (three trials) and in patients with generalized anxiety disorder (two trials). Silexan was superior to placebo in terms of the mean change from baseline in the Hamilton Anxiety Rating Scale (HAMA) subscore somatic anxiety at week 10 with a standardized mean difference of -0.31 [95% Cl: -0.52 to -0.10, p = .004]. Treatment effects of silexan on somatic anxiety were independent of gender and age. Statistically significant differences were also shown for single HAMA items somatic muscular, cardiovascular, respiratory, and genitourinary symptoms, indicating clinical relevance with small to medium effects of Silexan. Similar clinically meaningful effects of Silexan on SF-36 physical health, including reduced bodily pain and improved general health, and on insomnia complaints and fatigue, were demonstrated. In this meta-analysis including all placebo-controlled clinical trials in patients with anxiety disorders to date, statistically significant and clinically meaningful advantages of Silexan over placebo treatment were found in improving somatic symptoms and physical health.

Functional impairment in Posttraumatic Stress Disorder: A systematic review and meta-analysis

Posttraumatic Stress Disorder (PTSD) is a serious and debilitating condition often associated with significant impairments in daily functioning. To date, research on the complexity of functional impairment in individuals with PTSD is scarce and only limited. Yet, a quantitative synthesis and comprehensive review of existing evidence is needed to better characterize the magnitude of functional impairment in PTSD in distinct domains. We conducted a systematic literature search including observational studies comparing functioning of individuals with and without PTSD. Random effects meta-analyses were performed for the different functional domains according to the WHO International Classification of Functioning, Disability and Health (ICF). The protocol followed the MOOSE guidelines for systematic reviews. A total of thirty-four studies comprising 14 206 participants were included in the study. Compared to healthy individuals, subjects with PTSD showed significant (ps < 0.001) impairments with large to very large effect sizes (ds > 1) in all domains. Subjects with, compared to without, PTSD showed significant (ps < 0.001) impairments with medium to large effect sizes (ds > 0.5) in the domains General Tasks and Demands, Mobility, Self Care, Domestic Life, Interpersonal Interactions and Relationships, Major Life Areas and Community, Social and Civic Life. Significant impairments with small to medium effect sizes in the same domains were observed comparing PTSD to other mental disorders. In conclusion, PTSD has a significant impact on most areas of daily functioning as conceptualized in the International Classification of Functioning, Disability and Health (ICF) of the WHO. Early detection and targeted treatment of functional deficits is warranted in this patient population.

Reported quality of life in countries with cases of COVID19: a systematic review

INTRODUCTION

Considering the relevance of the quality of life (QoL) and the consequences of the 2019 new coronavirus disease (COVID-19) due to the social distancing, this systematic review aimed to summarize effects of the COVID-19 in the QoL of the studied populations.

AREAS COVERED

Four databases, the methodological quality and the risk of bias in selected publications were investigated. Seven thousand and fifty-one individuals from Italy, Saudi Arabia, China, and Vietnam. Online system and printed questionnaires were used to assess the QoL, as patients affected by primary antibody deficiencies, residents, people from endemic and no endemic regions, and individuals with COVID-19. Different types of questionnaires are utilized to evaluate health-related quality of life (HRQOL). The methodological quality of three papers was good with low risk of bias and a decrease in the QoL.

EXPERT OPINION

The QoL of studies populations where COVID-19 was reported, worsened. Nevertheless, considering some indicators (infant mortality, average income, life expectancy, health coverage, and average schooling years), the standard of life and subsequently the quality of life among the presented countries (China, Vietnam, Italy, and Saudi Arabia) are different. Therefore, the simple comparison of these populations and the conclusions from this comparison must be done carefully.

Cost-effectiveness of Practice Team-Supported Exposure Training for Panic Disorder and Agoraphobia in Primary Care: a Cluster-Randomized Trial

BACKGROUND

Primary care is the main treatment setting for panic disorder and should be supplemented by collaborative care programs. However, shortage of mental health professionals prevents collaborative care programs from being effectively implemented. The PARADISE study showed the efficacy of a self-managed, cognitive-behavioural therapy (CBT)-oriented exposure training for patients with panic disorder with or without agoraphobia in primary care delivered by the family practice team.

OBJECTIVE

To assess the cost-effectiveness of the PARADISE intervention.

DESIGN

Cost-effectiveness analysis from the societal perspective based on data from a cluster-randomized controlled trial over a time horizon of 12 months.

PARTICIPANTS

Four hundred nineteen adult panic disorder patients with or without agoraphobia.

INTERVENTIONS

A self-managed, CBT-oriented exposure training for patients with panic disorder with or without agoraphobia in primary care delivered by the primary care practice team in comparison to routine care.

MAIN MEASURES

Total costs from the societal perspective. Direct costs and disease-specific costs. Quality-adjusted life years based on the EQ-5D-3L. Incremental cost-effectiveness ratios and cost-effectiveness acceptability curves.

KEY RESULTS

Patients in the intervention group caused lower costs (mean, €1017; 95% confidence interval [-€3306; €1272]; p = 0.38) and gained on average more QALY (mean, 0.034 QALY (95% confidence interval [0.005; 0.062]; p = 0.02). Therefore, the intervention dominated the control treatment. The probability of cost-effectiveness of the intervention at a willingness-to-pay margin of €50,000 per QALY was 96%. Results from supplementary analyses considering direct or disease-specific costs instead of total costs showed comparable results.

CONCLUSION

The PARADISE intervention is cost effective. This conclusion is valid for total costs, generic health care (direct) costs, disease-specific health care costs.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00004386 Current Controlled Trials: ISRCTN64669297.

Interaction between anxiety and depression on suicidal ideation, quality of life, and work productivity impairment: Results from a representative sample of the Lebanese population

PURPOSE

To assess the association between the interaction of anxiety and depression on the suicidal ideation, quality of life (QOL), and work productivity/impairment in Lebanon.

DESIGN

Cross-sectional.

METHODS

1487 participants were enrolled between November 2017 and March 2018.

RESULTS

The interaction of anxiety and depression (β = .101), higher depression alone (β = .021), higher anxiety traits (STAI-B) (β = .007) were associated with higher suicidal ideation. Higher depression (β = 1.177), having more anxiety traits (STAI-B) (β = .485) and higher anxiety (STAI-A) (β = .298) were associated with higher activity impairment. Higher depression, higher anxiety traits and state, were associated with lower mental and physical QOL.

PRACTICE IMPLICATIONS

Screening for anxiety and depression can help clinicians improve patients' QOL and work productivity and decrease the suicidal ideation risk.

Gender differences in health-related quality of life in people with severe mental illness

INTRODUCTION AND PURPOSE

The purpose was to analyze socioeconomic and clinical factors of psychosocial functioning and self-perception in relation to health-related quality of life (HRQOL) in people with severe mental health illness (SMI) by gender.

MATERIALS AND METHOD

A cross-sectional study was conducted on a sample of 133 women and 90 men. Recorded variables: HRQOL, SF-36 Physical Component Scores (PCS) and Mental Component Scores (MCS); sociodemographic and clinical data on psychosocial and self-perception functioning. Correlational studies using raw and adjusted linear regression models to evaluate the factors associated with HRQOL by obtaining coefficients, p-values and respective confidence intervals.

RESULTS

The mean PCS for women and men was 44.6 and 49.0 (p = 0.004) and 36.4 and 37.5 (p = 0.575), respectively for MCS. The factors associated with PCS in women were age, -0.2(-0.4:0); in work, 4.2(0.3:8.2); with an income higher than 700 euros/month, 4.4(1:7.7). In men, these factors were education level, 6.1(0.4:11.7); belief that they would not need help in the future, 4.6(0.1:9.2) and a higher need for psychosocial services, -6.6(-11.1:-2). Factors associated with MCS in women were, in work, 6.1(1.5:10.7); and having a high number of friends, 6.6(2.1:11.1). In men, these factors were, living alone, -7.1(-12.7:-1.4); lack of economic benefits, 8.5(3.2:13.8); and a higher need for psychosocial and social services, -3.6(-7.1:-0.2) and -7.7(-13.4:-2).

CONCLUSIONS

The dimensions affected and the factors that are associated with HRQOL for people with SMI differ by gender. Therefore, these differences should to be taken into account when designing interventions for improving HRQOL.

Emotional problems and health-related quality of life: population-based study

PURPOSE

The aim of the present study was to evaluate the influence of emotional problems on health-related quality of life (HRQoL) according to the type of emotional problem, degree of limitation, and perceived control of the problem with treatment.

METHOD

A population-based cross-sectional study with probabilistic stratified cluster sampling was conducted in 2014 and 2015 in the city of Campinas, Brazil. A total of 2145 individuals aged 18 years or older participated in the study. HRQoL was evaluated using the SF-36^® questionnaire. The dependent variables were the score of the eight scales of the SF-36^®. The independent variables were self-perceived emotional problems, type of emotional problem (according to ICD 10), degree of limitation, and perceived control of the problem with treatment. Mean scores were calculated and regression coefficients were adjusted for sex, age, number of health problems, and chronic diseases using multiple linear regression analysis.

RESULTS

The prevalence of emotional problems was 32.7%. Among the individuals with a problem, the mean SF-36^® scores were lower on all domains. Regarding the type of emotional problem, a complaint of depression exerted a stronger negative impact on HRQoL scores than anxiety. Moreover, a greater degree of limitation caused by the problem led to lower mean SF-36^® scores. The negative impact on HRQoL was substantially greater among those who did not have the problem under control.

CONCLUSION

In conclusion, the findings underscore the importance of the prevention and control of emotional problems with the aim of reducing the impact on HRQoL.

The allocation of resources in the care for patients with panic disorder in Germany: an excess cost analysis informing policy and science

Background

Panic disorder is a mental disorder of high prevalence, which frequently co-occurs with agoraphobia. There is a lack of studies measuring excess costs of panic disorder patients with and without agoraphobia. We compared costs of panic disorder patients with or without agoraphobia with costs of the anxiety-free population in Germany.

Methods

Primary data from a cluster-randomized trial of adults suffering from panic disorder (n = 419) and from a representative survey of the German general population (N = 5005) were collected between 2012 and 2014. Missing data from the cluster-randomized trial were first imputed by multiple imputation using chained equations and subsequently balanced with the data from the survey by Entropy Balancing. The societal perspective was chosen. Excess costs were calculated by generalized linear models and two-part-models.

Results

Entropy Balancing led to an exact match between the groups. We found 6-month total excess costs of 3220€ (95% CI 1917€–4522€) for panic disorder patients without agoraphobia and of 3943€ (95% CI 2950€–4936€) for patient with agoraphobia. Panic disorder patients with or without agoraphobia had significantly higher costs for psychotherapy, general practitioners, general hospital stays and informal care Indirect costs accounted for approximately 60% of the total excess costs.

Conclusions

Panic disorder with or without agoraphobia is associated with significant excess costs. Agoraphobia changes the pattern of resource utilization. Especially indirect costs are relevant. Agoraphobia influences resource utilization in the inpatient sector.

Trial registration ISRCTN64669297

Guided Digital Cognitive Behavioral Program for Anxiety in Primary Care: Propensity-Matched Controlled Trial

BACKGROUND

Cognitive behavioral therapy (CBT) is the gold standard treatment for adult anxiety disorders but is often not readily available in a scalable manner in many clinical settings.

OBJECTIVE

This study examines the feasibility, acceptability, and effectiveness of a coach-facilitated digital cognitive behavioral program for anxious adults in primary care.

METHODS

In an open trial, patients who screened positive for anxiety (General Anxiety Disorder-7 [GAD7] score ≥5) were offered the digital cognitive behavioral program (active group, n=593). Primary outcomes included anxiety, quality of life (QoL), and ambulatory medical use over 6 months. Intent-to-treat (ITT) and modified intent-to-treat (mITT) analyses were completed. Subsequently, we compared the outcomes of participants with those of a matched control group receiving primary care as usual (CAU; n=316).

RESULTS

More than half of the patients downloaded the cognitive behavioral mobile app program and about 60% of these were considered engaged, which was defined as completion of ≥3 techniques. The active group demonstrated medium size effects on reducing anxiety symptoms (effect size d=0.44; P<.001) and improving mental health QoL (d=0.49; P<.001) and showed significantly improved physical health QoL (d=0.39; P=.002) and a decreased likelihood of high utilization of outpatient medical care (odds ratio=0.49; P<.001). The active group did not significantly outperform the CAU group in anxiety reduction or QoL improvement (d=0.20; P=.07). However, intent-to-treat analysis showed that the active group had a significantly lower likelihood of high utilization of outpatient medical care than the enhanced CAU group (P<.0001; odds ratio=0.09).

CONCLUSIONS

A coach-facilitated digital cognitive behavioral program prescribed in primary care is feasible and acceptable. Primary care patients prescribed a digital cognitive behavioral program for anxiety experienced significant improvements in anxiety symptoms, QoL, and reduced medical utilization. This effect was observed even among patients with chronic medical conditions and behavioral health comorbidities. Although the primary outcomes in the active group did not improve significantly more than the CAU group, health care utilization declined, and some secondary outcomes improved in participants who engaged in the program compared to the CAU group.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03186872; https://clinicaltrials.gov/ct2/show/NCT03186872.

Health-economic benefits of treating trauma in psychosis

Background: Co-occurrence of posttraumatic stress disorder (PTSD) in psychosis (estimated as 12%) raises personal suffering and societal costs. Health-economic studies on PTSD treatments in patients with a diagnosis of a psychotic disorder have not yet been conducted, but are needed for guideline development and implementation. This study aims to analyse the cost-effectiveness of guideline PTSD therapies in patients with a psychotic disorder. Methods: This health-economic evaluation alongside a randomized controlled trial included 155 patients with a psychotic disorder in care as usual (CAU), with comorbid PTSD. Participants received eye movement desensitization and reprocessing (EMDR) (n = 55), prolonged exposure (PE) (n = 53) or waiting list (WL) (n = 47) with masked assessments at baseline (T0) and at the two-month (post-treatment, T2) and six-month follow-up (T6). Costs were calculated using the TiC-P interview for assessing healthcare consumption and productivity losses. Incremental cost-effectiveness ratios and economic acceptability were calculated for quality-adjusted life years (EQ-5D-3L-based QALYs) and PTSD 'Loss of diagnosis' (LoD, CAPS). Results: Compared to WL, costs were lower in EMDR (-€1410) and PE (-€501) per patient per six months. In addition, EMDR (robust SE 0.024, t = 2.14, p = .035) and PE (robust SE 0.024, t = 2.14, p = .035) yielded a 0.052 and 0.051 incremental QALY gain, respectively, as well as 26% greater probability for LoD following EMDR (robust SE = 0.096, z = 2.66, p = .008) and 22% following PE (robust SE 0.098, z = 2.28, p = .023). Acceptability curves indicate high probabilities of PTSD treatments being the better economic choice. Sensitivity analyses corroborated these outcomes. Conclusion: Adding PTSD treatment to CAU for individuals with psychosis and PTSD seem to yield better health and less PTSD at lower costs, which argues for implementation.

Preliminary study of effects on paranoia ideation and jumping to conclusions in the context of group treatment of anxiety disorders in young people

BACKGROUND

People with anxiety disorders tend to focus on unpleasant and threatening stimuli. Our aims were to evaluate: (1) the presence of paranoid ideation, and the jumping to conclusions (JTC) bias in young suffering from an anxiety disorder and (2) the effectiveness of a cognitive-behavioural intervention (CBT) to manage anxiety combined with 2 modules to reduce the JTC bias.

METHODS

Psychopathology, social functioning, metacognition and the JTC bias were investigated in 60 subjects, randomly assigned to the experimental CBT group + treatment-as-usual (TAU) (n = 35) or to a wait-list group (n = 25) receiving only TAU. Each group was divided into 2 subgroups based on the score of the SCL-90 subscale paranoid ideation (high paranoid ideation, HP; low paranoid ideation, LP). The experimental group received a weekly session of a CBT for a 3-month period.

RESULTS

At baseline, 46.7% of our sample showed a HP and 38% showed a JTC biasAt the end of the intervention, greater effectiveness in improving anxious symptoms, paranoid ideation, interpersonal sensitivity and interpersonal relationship was reported in the experimental CBT + TAU group, with a statistically significant reduction of the JTC bias, displayed by 14.3% of the experimental group versus the 36% of the TAU group. In the same variables, greater benefits were reported for the HP experimental subgroup.

CONCLUSIONS

Our study suggests the gains to integrate an anxiety CBT with modules to reduce the JTC bias in subjects with paranoid ideation, which may negatively impact the course of the disease.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder

Objective:

To provide practical clinical guidance for the treatment of adults with panic disorder, social anxiety disorder and generalised anxiety disorder in Australia and New Zealand.

Method:

Relevant systematic reviews and meta-analyses of clinical trials were identified by searching PsycINFO, Medline, Embase and Cochrane databases. Additional relevant studies were identified from reference lists of identified articles, grey literature and literature known to the working group. Evidence-based and consensus-based recommendations were formulated by synthesising the evidence from efficacy studies, considering effectiveness in routine practice, accessibility and availability of treatment options in Australia and New Zealand, fidelity, acceptability to patients, safety and costs. The draft guidelines were reviewed by expert and clinical advisors, key stakeholders, professional bodies, and specialist groups with interest and expertise in anxiety disorders.

Results:

The guidelines recommend a pragmatic approach beginning with psychoeducation and advice on lifestyle factors, followed by initial treatment selected in collaboration with the patient from evidence-based options, taking into account symptom severity, patient preference, accessibility and cost. Recommended initial treatment options for all three anxiety disorders are cognitive–behavioural therapy (face-to-face or delivered by computer, tablet or smartphone application), pharmacotherapy (a selective serotonin reuptake inhibitor or serotonin and noradrenaline reuptake inhibitor together with advice about graded exposure to anxiety triggers), or the combination of cognitive–behavioural therapy and pharmacotherapy.

Conclusion:

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder provide up-to-date guidance and advice on the management of these disorders for use by health professionals in Australia and New Zealand.

Quality of Life across Mental Disorders in Psychiatric Outpatients

Introduction: Literature has shown that individuals with various psychiatric disorders experience a lower quality of life (QoL). However, few have examined QoL across disorders. The current study explored differences in QoL and symptom severity across 4 psychiatric diagnostic groups: anxiety disorders (including obsessive compulsive disorder [OCD]), depressive disorders, schizophrenia, and pathological gambling. Materials and Methods: Data analysed was from a previous study that examined the prevalence of hoarding symptoms among outpatients (n = 500) in a tertiary psychiatric hospital in Singapore. Measures utilised included the Beck Anxiety Inventory (BAI), Beck Depression Inventory-II (BDI-II) and Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF). Sociodemographic information and details on type and number of comorbidities were also collected. Results: The depressive disorder group had the highest level of depressive and anxiety symptoms and the lowest QoL whereas; the schizophrenia group had the lowest level of depressive symptoms and the highest QoL. Age and employment status were the only sociodemographic correlates which were significantly associated with QoL. After controlling for sociodemographic factors, only the type of mental disorder was found to have a significant effect in explaining BAI, BDI-II and Q-LES-Q-SF. Conclusion: Findings offer insight in terms of the burden associated with the various disorders. Key words: Anxiety, Comorbid, Depression, Symptom severity

Psychological interventions for anxiety in adult primary care patients: A review and recommendations for future research

Anxiety symptoms are prevalent in primary care, yet treatment rates are low. The integration of behavioral health providers into primary care via the Primary Care Behavioral Health (PCBH) model offers a promising way to improve treatment options by adding a team member with the necessary skillset to deliver evidence-based psychological interventions for anxiety. We conducted a narrative review of psychological interventions for anxiety applied within adult primary care settings (k = 44) to update the literature and evaluate the fit of existing interventions with the PCBH model. The majority of studies were randomized controlled trials (RCTs; 70.5%). Most interventions utilized cognitive-behavioral therapy (68.2%) and were delivered individually, face-to-face (52.3%). Overall, 65.9% of interventions (58.6% of RCTs, 91.7% of pre-post) were effective in reducing anxiety symptoms, and 83.3% maintained the gains at follow-up. Although it is encouraging that most interventions significantly reduced anxiety, their longer formats (i.e., number and duration of sessions) and narrow symptom targets make translation into practice difficult. Methodological limitations of the research included homogenous samples, failure to report key procedural details, pre-post designs, and restrictive eligibility criteria. We offer recommendations to guide future research to improve the likelihood of successful translation of anxiety interventions into clinical practice.

The effect of technology assisted therapy for intellectually and visually impaired adults suffering from separation anxiety: Conquering the fear

Persons with an intellectual disability (ID) are at risk of developing separation anxiety (SA) and, if left untreated, this can be a risk factor for the development of psychopathology. The effects of an intervention, namely technology assisted therapy for SA (TTSA), were examined on the SA, challenging behavior, psychosocial functioning, and quality of life (QOL) experienced by moderate to mild intellectually and visually disabled adults. This study aimed to determine whether TTSA reduces SA and challenging behavior in persons with ID and visual impairment, and if this results in increased psychosocial functioning and QOL. A pre-experimental within-group design with randomized multiple baselines and staggered intervention start-points was used (n = 6). The variables were monitored with standardized instruments. The frequencies of each participant's use of the technology and the frequency and intensity of their behavior were recorded over time. Results indicate that the SA and challenging behavior experienced by the participants decreased significantly and their psychosocial functioning and QOL increased significantly. The conclusions are that TTSA has the potential to be a valid intervention to address SA in adults with visual and moderate to mild IDs.

Longitudinal impact of anxiety on depressive outcomes in patients with acute coronary syndrome: Findings from the K-DEPACS study

This study investigated the impact of anxiety evaluated within 2 weeks of an acute coronary syndrome (ACS) episode on depressive outcomes at a 1-year follow-up assessment. In 828 ACS patients, anxiety was determined by Hospital Anxiety and Depression Scale-anxiety subscale at baseline, and DSM-IV depressive disorders and depressive symptoms were evaluated both at baseline and follow-up. Anxiety at baseline was significantly associated with depressive disorder at the follow-up and less improvement in depressive symptoms over 1-year. Anxiety had negative longitudinal impacts on depressive outcomes of ACS, and therefore evaluation of anxiety could be recommended in recently developed ACS patients.

Initial and Follow-Up Evaluations of Integrated Psychological Services for Anxiety and Depression in a Safety Net Primary Care Clinic

OBJECTIVE

Despite the recognized importance of integrated behavioral health, particularly in safety net primary care, its effectiveness in real world settings has not been extensively evaluated. This article presents 2 successive studies examining the effectiveness of integrated behavioral care in a safety net setting.

METHOD

Study 1 compared the depression and anxiety scores of predominately low-income and minority patients who underwent brief interventions (N = 147) to those of patients from a demographically similar comparison clinic without integrated psychological services, matched on baseline levels of anxiety and depression and length of time between assessments (N = 139). Study 2 did not include a control group but served as a long-term follow-up assessment of anxiety and depression for a subset of 47 patients who finished treatment and could be reached by telephone within 6-18 months of their last session.

RESULTS

Study 1 found that patients from the clinic with integrated psychology services experienced greater decreases in depression and anxiety scores than patients in the control clinic. These effects did not differ as a function of age, gender, or race. Study 2 found that patients continued to decline in depression and anxiety over time, with lower scores at the last session and even lower scores after longer-term follow-up ranging from 6 to18 months. These improvements remained significant when controlling for other interim mental health treatments.

CONCLUSION

These results support the short- and long-term treatment effects of brief primary care behavioral interventions, further strengthening the case for integrated behavioral healthcare in safety net settings.

Post-traumatic stress syndrome in a large sample of older adults: determinants and quality of life

OBJECTIVES

The aims of this study are to assess in a sample of older adults consulting in primary care practices the determinants and quality of life associated with post-traumatic stress syndrome (PTSS).

METHOD

Data used came from a large sample of 1765 community-dwelling older adults who were waiting to receive health services in primary care clinics in the province of Quebec. PTSS was measured with the PTSS scale. Socio-demographic and clinical characteristics were used as potential determinants of PTSS. Quality of life was measured with the EuroQol-5D-3L (EQ-5D-3L) EQ-Visual Analog Scale and the Satisfaction With Your Life Scale. Multivariate logistic and linear regression models were used to study the presence of PTSS and different measures of health-related quality of life and quality of life as a function of study variables.

RESULTS

The six-month prevalence of PTSS was 11.0%. PTSS was associated with age, marital status, number of chronic disorders and the presence of an anxiety disorder. PTSS was also associated with the EQ-5D-3L and the Satisfaction with Your Life Scale.

CONCLUSION

PTSS is prevalent in patients consulting in primary care practices. Primary care physicians should be aware that PTSS is also associated with a decrease in quality of life, which can further negatively impact health status.

Association of Childhood Anxiety Disorders and Quality of Life in a Primary Care Sample

Anxiety disorders are associated with measurable deficits in quality of life (QOL) in adult samples. However, this association has largely been unexplored in pediatric samples. In this study, we examined relationships between child anxiety-including number of anxiety disorders (comorbidity), symptom severity, and subtypes of anxiety-and QOL in a pediatric primary care sample.

RESULTS

Anxiety comorbidity was common in the current sample (n = 73), with 3-quarters being diagnosed with more than one anxiety disorder. QOL in the current sample did not vary significantly by age, gender, or race/ethnicity. Both greater comorbidity and higher total anxiety symptom severity were inversely associated with QOL across multiple domains, although anxiety comorbidity did not reach significance in multivariate models adjusted for gender, income, and externalizing symptoms. On the anxiety severity subscales, both physical symptoms and social anxiety had independent associations with QOL.

CONCLUSIONS

Anxiety-related outcomes, as measured by anxiety comorbidity, symptom severity, and type of anxiety, are associated with significantly worse QOL in a pediatric sample. Providers should be aware that QOL is impacted by both severity and type of anxiety-related conditions, particularly social anxiety and somatic-related anxiety.

Family functioning, social support, and quality of life for patients with anxiety disorder

BACKGROUND

Few studies have examined the relationship between family functioning, social support and quality of life in patients with anxiety disorder. There is a paucity of research on anxiety disorders and their predictors in China.

AIMS

This study aimed to explore family functioning, social support and quality of life for patients with anxiety disorder and examine the relationship between these elements.

METHODS

A total of 107 patients who met Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) criteria for anxiety disorder and 80 healthy controls completed the McMaster Family Assessment Device, the Perceived Social Support Scale and the short form of the Quality of Life Enjoyment and Satisfaction Questionnaire.

RESULTS

The findings indicate that patients with anxiety disorder in China tend to have poor family functioning and quality of life, as well as a higher subjective perception of social support. There were strong correlations between family functioning, social support and quality of life. Affective involvement and not living with parents were identified as risk factors for anxiety disorders, while a high family income was a protective factor.

CONCLUSION

Anxiety disorder is associated with reduced family functioning and poorer quality of life for Chinese patients. In addition, the Family Assessment Device is a suitable instrument for evaluating family functioning in Chinese patients with anxiety disorder.

The health status of a village population, 7 years after a major Q fever outbreak

From 2007 to 2010, The Netherlands experienced a major Q fever outbreak with more than 4000 notifications. Previous studies suggested that Q fever patients could suffer long-term post-infection health impairments, especially fatigue. Our objective was to assess the Coxiella burnetii antibody prevalence and health status including fatigue, and assess their interrelationship in Herpen, a high-incidence village, 7 years after the outbreak began. In 2014, we invited all 2161 adult inhabitants for a questionnaire and a C. burnetii indirect fluorescence antibody assay (IFA). The health status was measured with the Nijmegen Clinical Screening Instrument (NCSI), consisting of eight subdomains including fatigue. Of the 70·1% (1517/2161) participants, 33·8% (513/1517) were IFA positive. Of 147 participants who were IFA positive in 2007, 25 (17%) seroreverted and were now IFA negative. Not positive IFA status, but age <50 years, smoking and co-morbidity, were independent risk factors for fatigue. Notified participants reported significantly more often fatigue (31/49, 63%) than non-notified IFA-positive participants (150/451, 33%). Although fatigue is a common sequel after acute Q fever, in this community-based survey we found no difference in fatigue levels between participants with and without C. burnetii antibodies.

Course of symptom change during anxiety treatment: Reductions in anxiety and depression in patients completing the Coordinated Anxiety Learning and Management program

When treating anxious patients with co-occurring depression, research demonstrates that both types of symptoms independently improve. The current analyses examined how reductions in anxiety and depression may be interrelated both during treatment, as well as over time following treatment. Participants were 503 individuals with one or more DSM-IV anxiety disorders who completed a collaborative care anxiety management program. Anxiety and depression were assessed at each treatment session (i.e., session by session data) and also at 6, 12, and 18-month post-baseline assessments (i.e., long-term outcomes data). Mediation analyses examined changes in symptoms in session by session data and long-term outcomes data. Anxiety and depression changed reciprocally in session by session data; change in anxiety mediated change in depression to a greater extent than vice versa. In the long-term outcomes data, change in anxiety mediated change in depression. However, the reverse mediation model of the long-term outcomes period revealed that accounting for changes in depression altered the effect of time on anxiety. Thus, temporal change during active treatment may share similarities with those related to maintaining gains after treatment, although differences arose in the reverse mediation models. Limitations of the methodology and implications of anxiety treatment for depression outcomes are discussed.

The impact of posttraumatic symptoms and comorbid mental disorders on the health-related quality of life in treatment-seeking PTSD patients

BACKGROUND

There is a dearth of literature dealing with the impact of the severity of posttraumatic symptoms and of comorbid mental disorders on the health-related quality of life (HRQOL) of victims of civilian violence with a primary diagnosis of PTSD.

OBJECTIVES

To investigate the influence of the severity of posttraumatic symptoms and of presence of comorbid mental disorders on the HRQOL of treatment-seeking outpatients with PTSD.

METHODS

A sample of 65 PTSD patients was recruited in a specialized outpatient clinic. The volunteers had the diagnoses of PTSD and of comorbid mental disorders established with the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I). The severity of posttraumatic, depression and anxiety symptoms was measured with the PCL-C, BDI and BAI, respectively. HRQOL was assessed by means of the SF-36, a 36-item self-administered scale that measures eight domains of quality of life: vitality, physical functioning, bodily pain, general health perceptions, physical role functioning, emotional role functioning, social role functioning, and mental health. Multiple linear regression models were fitted to investigate the relationship between the severity of posttraumatic, mood, and anxiety symptoms; the presence of specific current comorbid disorders and of psychotic symptoms, and the number of current comorbid conditions for each of the eight domains of HRQOL, after adjusting for the effect of sociodemographic characteristics.

RESULTS

The severity of PTSD symptoms predicted worse HRQOL in all eight domains of SF-36, even after controlling for the severity of depression and anxiety symptoms, the presence of panic disorder, OCD, specific and social phobia, psychotic symptoms, and the number of comorbid disorders. The strongest negative association between PTSD symptoms severity and HRQOL was found in the Social Functioning domain. Although the inclusion of the depressive symptoms in the models led to a reduction of the magnitude of the negative association between the severity of PTSD symptoms and the HRQOL domain scores, the former still accounted for most of the explained variance of the latter.

CONCLUSIONS

We found that even in the presence of comorbid mental disorders, the severity of posttraumatic symptoms remained the strongest predictor for impaired HRQOL in PTSD outpatients. Our results suggest that improvement of HRQOL should be considered a therapeutic objective and an essential outcome measure in the treatment of PTSD.

Loss and psychosocial factors as determinants of quality of life in a cohort of earthquake survivors

BACKGROUND

Despite the existing evidence of a long lasting effect of disaster related experiences on physical and psychological health, few studies have evaluated long-term quality of life (QOL) outcomes of disaster survivors and the factors associated with such outcomes.

METHODS

23 years after the 1988 Spitak earthquake in Armenia, the associations of demographic characteristics, trauma exposure and psychosocial variables on QOL were explored among a cohort of 725 exposed individuals. The EQ-5D-5 L instrument was applied to measure QOL of participants. Multivariate linear and ordinal logistic regressions were applied to evaluate the determinants of QOL and its underlying five domains (mobility, self-care, usual activity, pain/discomfort, and anxiety/depression).

RESULTS

Older age, current depression, post-traumatic stress disorder and anxiety symptoms were negatively associated with QOL. Additionally, those with severe losses (who did not receive any financial/material aid) had significantly poorer QOL outcomes, with higher odds of mobility difficulties (OR = 1.86, p < 0.05), self-care difficulties (OR = 2.85, p < 0.05), and mood problems (OR = 2.69, p < 0.05). However, those with severe earthquake related losses who received financial/material aid reported less self-care difficulties (OR = 0.21, p < 0.05) usual activity difficulties (OR = 0.40, p < 0.05), and mood problems (OR = 0.44, p < 0.05). Finally, each unit increase in current social support score was found to be significantly associated with a better QOL outcome and better self-reported outcomes across all underlying domains of QOL.

CONCLUSIONS

These findings suggest that earthquake related loss and concurrent psychopathology symptoms can have adverse impact on the QOL of survivors. They also indicate that well-targeted post-disaster financial/material aid and social support should be considered as means for improving the long-term QOL outcomes of disaster survivors.

Changes in comorbid conditions after prolonged exposure for PTSD: a literature review

Prolonged exposure (PE) is an effective psychological treatment for patients who suffer from PTSD. The majority of PTSD patients have comorbid psychiatric disorders, and some clinicians are hesitant to use PE with comorbid patients because they believe that comorbid conditions may worsen during PE. In this article, we reviewed the evidence for this question: what are the effects of PE on comorbid symptoms and associated symptomatic features? We reviewed findings from 18 randomized controlled trials of PE that assessed the most common comorbid conditions (major depression, anxiety disorders, substance use disorders, personality disorders, and psychotic disorders) and additional symptomatic features (suicidality, dissociation, negative cognitions, negative emotions, and general health and work/social functioning). Although systematic research is not available for all comorbid populations, the existing research indicates that comorbid disorders and additional symptomatic features either decline along with the PTSD symptoms or do not change as a result of PE. Therefore, among the populations that have been studied to date, there is no empirical basis for excluding PTSD patients from PE due to fear of increases in comorbid conditions or additional symptomatic features. Limitations of the existing research and recommendations for future research are also discussed.

A comparison of inpatients with anxious depression to those with nonanxious depression

Anxiety symptoms are common for patients with major depressive disorder (MDD). Anxious depression has been considered MDD with high levels of anxiety symptoms. The objective of this study was to investigate the factors associated with anxious depression for Chinese inpatients with MDD. A total of 174 acutely ill patients were enrolled. Baseline demographic variables, suicide risk, depression severity, quality of life (QOL), and daily functional impairment were assessed. Those MDD patients with a 17-item Hamilton Depression Rating Scale (HAMD-17) anxiety/somatization factor score≥7 were defined as anxious depression. Logistic regression was employed to examine the factors associated with anxious depression. One hundred and forty-one (81.0%) of the subjects reported anxious depression. Patients with anxious depression were more likely to have melancholic features, to be older, to experience more severe depression, to be at greater risk of suicide, to have more pain, poorer quality of life, and more severe functional impairment. Anxious depression is common in inpatients with MDD. These findings suggest that anxious depression significantly differs from nonanxious depression on several clinically relevant variables. These data add to a growing body of evidence that anxious depression is a more complex presentation of depression.

A longitudinal examination of anxiety disorders and physical health conditions in a nationally representative sample of U.S. older adults

BACKGROUND

There has been growing interest in the relation between anxiety disorders and physical conditions in the general adult population. However, little is known about the nature of this association in older adults. Understanding the complex relationship between these disorders can help to inform prevention and treatment strategies unique to this rapidly growing segment of the population.

METHODS

A total of 10,409 U.S. adults aged 55+ participated in Wave 1 (2001-2002) and Wave 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Lifetime and past-year DSM-IV anxiety, mood, and substance use disorders, and lifetime personality disorders, were assessed in both waves. Participants self-reported on whether they had been diagnosed by a healthcare professional with a broad range of physical health conditions; this study focuses on cardiovascular disease, gastrointestinal disease, and arthritis. Multivariable logistic regressions adjusted for sociodemographics, comorbid mental disorders, and number of physical health conditions assessed: (1) the relation between past-year physical conditions at Wave 1 and incident past-year anxiety disorders at Wave 2 and; (2) the relation between individual lifetime anxiety disorders at Wave 1 and incident physical conditions at Wave 2. A second set of adjusted multinomial logistic regressions examined Wave 1 sociodemographic and physical and mental health risk factors associated with incident physical condition alone, anxiety disorder alone, and comorbid anxiety and physical condition at Wave 2.

RESULTS

Past-year arthritis at Wave 1 was significantly associated with increased odds of incident generalized anxiety disorder at Wave 2. Further, any lifetime anxiety disorder and posttraumatic stress disorder at Wave 1 were significantly associated with increased odds of incident gastrointestinal disease at Wave 2. Differential sociodemographic and physical and mental health predictors were significantly associated with increased odds of incident comorbid anxiety disorder and physical conditions.

CONCLUSION

Results of the current study elucidate the longitudinal bidirectional relationships between anxiety disorders and physical health conditions in a large, nationally representative sample of older adults. These results have important implications for identifying at risk older adults, which will not only impact this growing segment of the population directly, but will also potentially lessen burden on the healthcare system as a whole.

Beyond generalized anxiety disorder: psychometric properties of the GAD-7 in a heterogeneous psychiatric sample

BACKGROUND

Although developed as a screener for Generalized Anxiety Disorder (GAD) in primary care, the GAD-7 is now commonly used as a measure of general anxiety symptoms across various settings and populations. However, little is known about its psychometric properties when used in such heterogeneous samples. We examined the internal consistency, convergent validity, sensitivity and specificity, sensitivity to change, and structure of the GAD-7 in patients receiving brief, intensive CBT treatment in a partial hospital setting. We also examined the properties of a modified version that assessed symptoms over the past 24-h.

METHODS

Participants (n=1082) completed the GAD-7 upon admission and discharge from a partial hospital program. They also completed measures of worry, depression, and well being and a structured diagnostic interview. We examined psychometric properties in the total sample and separately for patients with GAD, post-traumatic stress disorder, Social Anxiety Disorder (SAD), and panic disorder.

RESULTS

Internal consistency and convergent validity were good for the total sample and each anxiety disorder group. The GAD-7 demonstrated poor specificity and a high false positive rate for all anxiety disorders. Sensitivity to change was generally good. Factor analysis revealed that a one-factor structure did not fit the data well. The 24-h version performed similarly to the original version.

CONCLUSIONS

The GAD-7 performed well as a measure of anxiety symptom severity, but not as a screener in this psychiatric sample. It is a useful outcome measure for hetereogenous samples, but it may not perform as well specifically for individuals with SAD. A modified version of the GAD-7 that assessed anxiety symptoms over the past 24-h appears to be a reliable and valid modification.

Cost utility analysis of a collaborative stepped care intervention for panic and generalized anxiety disorders in primary care

OBJECTIVE

Generalized anxiety and panic disorders are a burden on the society because they are costly and have a significant adverse effect on quality of life. The aim of this study was to evaluate the cost-utility of a collaborative stepped care intervention for panic disorder and generalized anxiety disorder in primary care compared to care as usual from a societal perspective.

METHODS

The design of the study was a two armed cluster randomized controlled trial. In total 43 primary care practices in the Netherlands participated in the study. Eventually, 180 patients were included (114 collaborative stepped care, 66 care as usual). Baseline measures and follow-up measures (3, 6, 9 and 12 months) were assessed using questionnaires. We applied the TiC-P, the SF-HQL and the EQ-5D respectively measuring health care utilization, production losses and health related quality of life.

RESULTS

The average annual direct medical costs in the collaborative stepped care group were 1854 Euro (95% C.I., 1726 to 1986) compared to €1503 (95% C.I., 1374 to 1664) in the care as usual group. The average quality of life years (QALYs) gained was 0.05 higher in the collaborative stepped care group, leading to an incremental cost effectiveness ratio (ICER) of 6965 Euro per QALY. Inclusion of the productivity costs, consequently reflecting the full societal costs, decreased the ratio even more.

CONCLUSION

The study showed that collaborative stepped care was a cost effective intervention for panic disorder and generalized anxiety disorder and was even dominant when a societal perspective was taken.

TRIAL REGISTRATION

trialregister.nl, Netherlands Trial Register NTR107.

Improving access to psychological therapies and older people: findings from the Eastern Region

BACKGROUND

Evaluations of the Improving Access to Psychological Therapies (IAPT) scheme have not yet focused on minority subgroups. This paper aims to evaluate accessibility, waiting times and clinical outcomes of IAPT for older adults.

METHODS

All referrals from six Primary Care Trusts (PCT) in the East of England were used in this analysis. During each session, the therapist recorded information on anxiety symptoms using the Generalised Anxiety Disorder Questionnaire (GAD-7) and depressive symptoms with the Patient Health Questionnaire (PHQ-9). Waiting times, type of referrals and reliable recovery rates were investigated.

RESULTS

Older adults accounted for only 4% of all the IAPT referrals made between September 2008 and July 2010 in the Eastern Region. Waiting times for both IAPT assessment and treatment were slightly lower for older adult. In all centres, reliable recovery rates were higher in older adults compared to younger adults post-treatment, however these differences were not significant, with the exception of a difference in anxiety scores (χ(2)(1) = 18.6, p < 0.001). In multivariate analyses, being an older adult was associated with recovery for depression (OR = 1.30, 95% CI 1.10-1.53), anxiety (OR = 1.42, 95% CI 1.21-1.66), and overall recovery (OR = 1.31, 95% CI 1.10-1.54) after adjustment for gender, PCT region, baseline score, maximum treatment step during treatment, dropping out, and number of sessions.

CONCLUSIONS

The IAPT services were shown to be beneficial to older patients, however, access to these services in later life has been lower than expected. The service pathway for older populations needs to be better researched in order to eliminate possible obstacles in accessing services.

Adequacy of treatment received by primary care patients with anxiety disorders

BACKGROUND

We examined the adequacy of pharmacotherapy and psychotherapy received by primary care patients with anxiety disorders over up to 5 years of follow-up.

METHOD

Five hundred thirty-four primary care patients at 15 US sites, who screened positive for anxiety symptoms, were assessed for anxiety disorders. Those meeting anxiety disorder criteria were offered participation and interviewed again at six and 12 months postintake, and yearly thereafter for up to 5 years. We utilized existing definitions of appropriate pharmacotherapy and created definitions of potentially adequate psychotherapy/cognitive-behavioral therapy (CBT).

RESULTS

At intake, of 534 primary care participants with anxiety disorders, 19% reported receiving appropriate pharmacotherapy and 14% potentially adequate CBT. Overall, 28% of participants reported receiving potentially adequate anxiety treatment, whether pharmacotherapy, psychotherapy, or both. Over up to five years of follow-up, appropriate pharmacotherapy was received by 60% and potentially adequate CBT by 36% of the sample. Examined together, 69% of participants received any potentially adequate treatment during the follow-up period. Over the course of follow-up, primary care patients with MDD, panic disorder with agoraphobia, and with medicaid/medicare were more likely to receive appropriate anxiety treatment. Ethnic minority members were less likely to receive potentially adequate care.

CONCLUSIONS

Potentially adequate anxiety treatment was rarely received by primary care patients with anxiety disorders at intake. Encouragingly, rates improved over the course of the study. However, potentially adequate CBT remained much less utilized than pharmacotherapy and racial-ethnic minority members were less likely to received care, suggesting much room for improved dissemination of quality treatment.

Disparities in psychosocial functioning in a diverse sample of adults with anxiety disorders

Anxiety disorders are associated with psychosocial functional impairments, but no study has compared how these impairments might vary by ethno-racial status. We examined whether minority status was uniquely associated with functional impairments in 431 adults with anxiety disorders. Functioning was measured in the rater-assessed domains of: Global Assessment of Functioning (GAF); global psychosocial functioning; work, relationship, and recreational functioning; and, self-reported: life satisfaction, mental health functioning, physical functioning, and disability status. After controlling for demographic and clinical variables, results revealed evidence of disparities, whereby African Americans (AAs), particularly those with low income, had worse GAF, worse global psychosocial functioning, and were more likely to be disabled compared to non-Latino Whites. Latinos, particularly those with low income, had worse global psychosocial functioning than non-Latino Whites. Results suggest AAs and Latinos are at increased risk for functional impairments not better accounted for by other demographic or clinical variables.

Trajectories of functioning after remission from anxiety disorders: 2-year course and outcome predictors

BACKGROUND

Anxiety disorders are associated with substantial functional limitations but the course of functioning following symptom remission remains largely unknown.

METHOD

Using data from the Netherlands Study of Depression and Anxiety (NESDA), we examined the 2-year trajectories of functioning in participants with chronic (n = 586) or remitting anxiety disorders (n = 385) and in healthy controls (n = 585). In participants with remitting anxiety disorders, we identified predictors of functioning from among sociodemographic, clinical and vulnerability variables. Data were analysed using linear mixed models (LMMs). Functioning was assessed with the World Health Organization Disability Assessment Schedule II (WHO DAS II).

RESULTS

At baseline, participants with remitting anxiety disorders functioned significantly better than those with chronic anxiety disorders, but significantly worse than controls. In both anxiety disorder groups, most impairment was reported in social functioning, occupational functioning and cognition. During the follow-up, functioning improved in both groups, probably due to treatments received. Participants who achieved symptom remission experienced moderate improvements in social functioning and cognition but not in occupational functioning. Of those who remitted, 45.8% reported functioning scores similar to healthy controls whereas 28.5% still functioned at the level of those with chronic anxiety disorders. Worse functioning was predicted by severe anxiety disorders, use of psychological treatment, co-morbid depressive disorders and maladaptive personality traits.

CONCLUSIONS

In anxiety disorders, symptom remission is accompanied by improvements in functioning but significant functional impairments may persist because of co-morbid disorders, lower functioning prior to the onset of the anxiety disorder or residual subthreshold anxiety symptoms.

PTSD is a chronic, fluctuating disorder affecting the mental quality of life in older adults

OBJECTIVES

Examine the longitudinal course of posttraumatic stress disorder (PTSD) in older adults and its influence on mental health quality of life (MHQoL).

DESIGN

Evaluation performed at baseline, and 3 and 6 months postrandomization as part of a longitudinal trial.

PARTICIPANTS AND SETTINGS

A total of 1,185 participants, with a mean (±SD) age of 73.53 (±5.98) years, at seven primary care sites (including five Veterans Affairs clinics), were divided into four groups, namely, no trauma (n = 661), trauma only (n = 319), partial PTSD (n = 114), and PTSD (n = 81), based on reports of trauma and associated PTSD symptoms.

MEASUREMENTS

The prevalence of comorbid depression, anxiety, and alcohol use disorders, assessed using the Diagnostic and Statistical Manual, Fourth Edition, criteria and changes in MHQoL, as assessed by the Short Form-36 mental component score.

RESULTS

At baseline, the PTSD group had higher frequencies of comorbid depression and anxiety disorders and worse MHQoL than the other groups. Both chronic (participants diagnosed with PTSD at all three assessments) and fluctuating (participants moving to or from one of the other groups) trajectories of course were observed during the follow-up period, which appeared to be separate from that of the comorbid disorders. Even after accounting for those comorbid disorders, PTSD had an independent association with poorer MHQoL at multiple time points, especially in men, whereas trauma without PTSD symptoms (trauma only) had better MHQoL.

CONCLUSIONS

PTSD had chronic and fluctuating courses, with negative effects on MHQoL, while partial PTSD might represent a transitional state, underscoring the need to better identify and treat PTSD at any phase in later life.

Comorbid depressive symptoms in treatment-seeking PTSD outpatients affect multiple domains of quality of life

PURPOSE

No study has examined the impact of the comorbid Axis I conditions on the quality of life (QoL) of patients with a primary diagnosis of PTSD. Our goal was to investigate the influence of comorbid disorders on the QoL of treatment-seeking outpatients with PTSD.

METHODS

The diagnoses of PTSD and of the comorbid disorders were established using the SCID-I. The 54 volunteers also completed the Posttraumatic Stress Disorder Checklist - Civilian Version, the BDI, the BAI, the Trauma History Questionnaire, and a socio-demographic questionnaire. Quality of life was assessed by means of the WHOQOL-BREF, a 26-item self-administered scale that measures four domains of QoL: psychological, physical, social, and environmental. Multiple linear regression models were fitted to investigate the relationship between the severity of post-traumatic, mood, and anxiety symptoms; the presence of specific current comorbid disorders and of psychotic symptoms, the number of current comorbid conditions, and a history of child abuse for each of the four domains of QoL, after adjusting for the effect of socio-demographic characteristics.

RESULTS

The severity of PTSD symptoms impacted negatively on the psychological and physical domains. The severity of depressive symptoms correlated negatively with QoL in all domains, independently of sex, age, occupation, and marital status. The psychotic symptoms impacted negatively on the environmental domain. A history of child abuse was negatively associated with the psychological and the social domains.

CONCLUSIONS

The severity of comorbid depressive symptoms is one of the most important factors in the determination of the QoL in patients with PTSD.

The impact of HIV status, HIV disease progression, and post-traumatic stress symptoms on the health-related quality of life of Rwandan women genocide survivors

PURPOSE

We examined whether established associations between HIV disease and HIV disease progression on worse health-related quality of life (HQOL) were applicable to women with severe trauma histories, in this case Rwandan women genocide survivors, the majority of whom were HIV-infected. Additionally, this study attempted to clarify whether post-traumatic stress symptoms were uniquely associated with HQOL or confounded with depression.

METHODS

The Rwandan Women's Interassociation Study and Assessment was a longitudinal prospective study of HIV-infected and uninfected women. At study entry, 922 women (705 HIV+ and 217 HIV-) completed measures of symptoms of post-traumatic stress and HQOL as well as other demographic, clinical, and behavioral characteristics.

RESULTS

Even after controlling for potential confounders and mediators, HIV+ women, in particular those with the lowest CD4 counts, scored significantly worse on HQOL and overall quality of life (QOL) than did HIV- women. Even after controlling for depression and HIV disease progression, women with more post-traumatic stress symptoms scored worse on HQOL and overall QOL than women with fewer post-traumatic stress symptoms.

CONCLUSIONS

This study demonstrated that post-traumatic stress symptoms were independently associated with HQOL and overall QOL, independent of depression and other confounders or potential mediators. Future research should examine whether the long-term impact of treatment on physical and psychological symptoms of HIV and post-traumatic stress symptoms would generate improvement in HQOL.

Epidemic Q fever in humans in the Netherlands

In 2005, Q fever was diagnosed on two dairy goat farms and 2 years later it emerged in the human population in the south of the Netherlands. From 2007 to 2010, more than 4,000 human cases were notified with an annual seasonal peak. The outbreaks in humans were mainly restricted to the south of the country in an area with intensive dairy goat farming. In the most affected areas, up to 15% of the population may have been infected. The epidemic resulted in a serious burden of disease, with a hospitalisation rate of 20% of notified cases and is expected to result in more cases of chronic Q fever among risk groups in the coming years. The most important risk factor for human Q fever is living close (<5 km) to an infected dairy goat farm. Occupational exposure plays a much smaller role. In 2009 several veterinary control measures were implemented including mandatory vaccination of dairy goats and dairy sheep, improved hygiene measures, and culling of pregnant animals on infected farms. The introduction of these drastic veterinary measures has probably ended the Q fever outbreak, for which the Netherlands was ill-prepared.

Quality of life in panic disorder: looking beyond symptom remission

PURPOSE

Panic Disorder (PD) is a classic example of a disease where symptom remission may be achieved, yet patient quality of life (QOL) remains low, providing further support for the need to measure QOL as an additional outcome in patient care. The objectives of this review are to examine the substantial QOL impairments in PD and to determine whether modern treatments for PD, which have been proven to achieve symptom remission, have been shown to restore QOL.

METHODS

We identified studies on QOL in PD from 1980 to 2010 by searching MEDLINE, PsycINFO, and PubMed databases.

RESULTS

The literature reveals substantial QOL impairments in PD, often resulting in poor sense of health, frequent utilization of medical services, occupational deficiency, financial dependency, and marital strife. Modern therapies have been demonstrated to achieve symptom remission and improve QOL in PD; however, post-treatment QOL is still significantly lower than community averages.

CONCLUSIONS

QOL needs to be added as an essential outcome measure in patient care. Further research should be conducted to better understand the nature of comorbidities in PD as well as to determine whether additional interventions that have been studied in other psychiatric disorders, such as exercise, meditation, yoga, humor, massage, and nutritional supplements, can be utilized to improve QOL in PD to normal community levels.