Gender differences in anxiety disorders: prevalence, course of illness, comorbidity and burden of illness

Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders

BACKGROUND

Anxiety and related disorders are among the most common mental disorders, with lifetime prevalence reportedly as high as 31%. Unfortunately, anxiety disorders are under-diagnosed and under-treated.

METHODS

These guidelines were developed by Canadian experts in anxiety and related disorders through a consensus process. Data on the epidemiology, diagnosis, and treatment (psychological and pharmacological) were obtained through MEDLINE, PsycINFO, and manual searches (1980-2012). Treatment strategies were rated on strength of evidence, and a clinical recommendation for each intervention was made, based on global impression of efficacy, effectiveness, and side effects, using a modified version of the periodic health examination guidelines.

RESULTS

These guidelines are presented in 10 sections, including an introduction, principles of diagnosis and management, six sections (Sections 3 through 8) on the specific anxiety-related disorders (panic disorder, agoraphobia, specific phobia, social anxiety disorder, generalized anxiety disorder, obsessive-compulsive disorder, and posttraumatic stress disorder), and two additional sections on special populations (children/adolescents, pregnant/lactating women, and the elderly) and clinical issues in patients with comorbid conditions.

CONCLUSIONS

Anxiety and related disorders are very common in clinical practice, and frequently comorbid with other psychiatric and medical conditions. Optimal management requires a good understanding of the efficacy and side effect profiles of pharmacological and psychological treatments.

Fathers' versus mothers' social referencing signals in relation to infant anxiety and avoidance: a visual cliff experiment

Infants use signals from others to guide their behavior when confronted with novel situations, a process called 'social referencing' (SR). Via SR, signs of parental anxiety can lead to infant anxiety. Little is known about differences in the effect of paternal and maternal SR signals on child anxiety. Using a visual cliff paradigm, we studied whether SR processes between fathers and their infants differed from mothers and their infants. Eighty-one infants aged 10-15 months were randomly assigned to conduct the visual cliff task with their father (n = 41) or mother (n = 40). The infant was placed on the shallow side of the cliff and the parent, standing at the deep side, was instructed to encourage the infant to cross. Results showed that although mothers showed more intense facial expressions of encouragement than fathers, no differences occurred in how fast, and with how much anxiety, infants crossed the cliff with fathers and mothers. However, path analyses showed that paternal, but not maternal, expressed anxiety was positively associated with infant expressed anxiety and avoidance. For infants who participated with their mother, infants' anxious temperament was negatively associated with infant avoidance of the cliff. Infant anxious temperament moderated the link between paternal expressed anxiety and infant avoidance: the higher the level of infant anxious temperament the stronger the positive association between paternal expressed anxiety and infant's avoidance of the cliff. Lastly, parental encouragement was unrelated to infant expressed anxiety and avoidance. Our results suggest that SR processes between fathers and their infants differ from those between mothers and their infants.

Test-retest reliability and sensitivity to change of the dimensional anxiety scales for DSM-5

OBJECTIVE

This article reports on the test-retest reliability and sensitivity to change of a set of brief dimensional self-rating questionnaires for social anxiety disorder (SAD-D), specific phobia (SP-D), agoraphobia (AG-D), panic disorder (PD-D), and generalized anxiety disorder (GAD-D), as well as a general cross-cutting anxiety scale (Cross-D), which were developed to supplement categorical diagnoses in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).

METHODS

The German versions of the dimensional anxiety scales were administered to 218 students followed up approximately 2 weeks later (Study 1) and 55 outpatients (23 with anxiety diagnoses) followed-up 1 year later (Study 2). Probable diagnostic status in students was determined by the DIA-X/M-CIDI stem screening-questionnaire (SSQ). In the clinical sample, Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) diagnoses were assessed at Time 1 using the DIA-X/M-CIDI. At Time 2, the patient-version of the Clinical Global Impression-Improvement scale (CGI-I) was applied to assess change.

RESULTS

Good psychometric properties, including high test-retest reliability, were found for the dimensional scales except for SP-D. In outpatients, improvement at Time 2 was associated with significant decrease in PD-D, GAD-D, and Cross-D scores. Discussion Major advantages of the scales include that they are brief, concise, and based on a consistent template to measure the cognitive, physiological, and behavioral symptoms of fear and anxiety. Further replication in larger samples is needed. Given its modest psychometric properties, SP-D needs refinement.

CONCLUSION

Increasing evidence from diverse samples suggests clinical utility of the dimensional anxiety scales.

PACAP in the BNST produces anorexia and weight loss in male and female rats

Recent gene association studies have implicated pituitary adenylate cyclase-activating peptide (PACAP) systems in several psychiatric disorders associated with stressor exposure, and we have argued that many of the behavioral consequences of repeated stressor exposure may depend on the expression of PACAP in the bed nucleus of the stria terminalis (BNST). One behavioral consequence of the activation of stress systems can be anorexia and subsequent weight loss, and both the activation of central PACAP systems as well as neuronal activity in the BNST have also been associated with anorexic states in rodents. Hence, we investigated the regulation of food and water intake and weight loss following BNST PACAP infusion. BNST PACAP38 dose-dependently decreased body weight, as well as food and water intake in the first 24 h following infusion. Because different BNST subregions differentially regulate stress responding, we further examined the effects of PACAP38 in either the anterior or posterior BNST. Anterior BNST PACAP38 infusion did not alter weight gain, whereas posterior PACAP38 infusion resulted in weight loss. PACAP38 infused into the lateral ventricles did not alter weight, suggesting that the effects of BNST-infused PACAP were not mediated by leakage into the ventricular system. These data suggest that PACAP receptor activation in posterior BNST subregions can produce anorexia and weight loss, and corroborate growing data implicating central PACAP activation in mediating the consequences of stressor exposure.

Posttraumatic stress disorder in a nationally representative mexican community sample

This study describes the public health burden of trauma exposure and posttraumatic stress disorder (PTSD) in relation to the full range of traumatic events to identify the conditional risk of PTSD from each traumatic event experienced in the Mexican population and other risk factors. The representative sample comprised a subsample (N = 2,362) of the urban participants of the Mexican National Comorbidity Survey (2001-2002). We used the World Health Organization's Composite International Diagnostic Interview (CIDI) to assess exposure to trauma and the presence of PTSD according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, ) in each respondents' self-reported worst traumatic event, as well as a randomly selected lifetime trauma. The results showed that traumatic events were extremely common in Mexico (68.8%). The estimate of lifetime PTSD in the whole population was 1.5%; among only those with a traumatic event it was 2.1%. The 12-month prevalence of PTSD in the whole population was 0.6%; among only those with a traumatic event it was 0.8%. Violence-related events were responsible for a large share of PTSD. Sexual violence, in particular, was one of the greatest risks for developing PTSD. These findings support the idea that trauma in Mexico should be considered a public health concern.

Cumulative effects of HIV illness and caring for children orphaned by AIDS on anxiety symptoms among adults caring for children in HIV-endemic South Africa

Adults caring for children in HIV-endemic communities are at risk for poor psychological outcomes. However, we still have a limited understanding of how various HIV impacts--including caregiver's own HIV illness, responsibilities of caring for a child orphaned by AIDS, or both--affect psychological outcomes among caregivers. Furthermore, few studies have explored the relationship between stigma, HIV, and psychological outcomes among caregivers of children in HIV-endemic communities. A cross-sectional survey conducted from 2009 to 2010 assessed anxiety among 2477 caregivers of children in HIV-endemic South Africa. Chi-square tested differences in anxiety among caregivers living with HIV, caregivers of a child orphaned by AIDS, and caregivers affected with both conditions. Multivariate logistic regressions identified whether the relationship between HIV impacts and anxiety remained after controlling for socio-demographic co-factors. Mediation analysis tested the relationship between stigma, HIV, and anxiety. The odds of meeting threshold criteria for clinically relevant anxiety symptoms were two and a half times greater among caregivers living with HIV compared to nonaffected caregivers. The odds of meeting threshold criteria for clinically relevant anxiety symptoms were greatest among caregivers living with HIV and caring for a child orphaned by AIDS. Exposure to AIDS-related stigma partially mediated the relationship between HIV and anxiety. Interventions are needed to address caregiver psychological health, particularly among caregivers affected with both conditions of living with HIV and caring for a child orphaned by AIDS.

BNST neurocircuitry in humans

Anxiety and addiction disorders are two of the most common mental disorders in the United States, and are typically chronic, disabling, and comorbid. Emerging evidence suggests the bed nucleus of the stria terminalis (BNST) mediates both anxiety and addiction through connections with other brain regions, including the amygdala and nucleus accumbens. Although BNST structural connections have been identified in rodents and a limited number of structural connections have been verified in non-human primates, BNST connections have yet to be described in humans. Neuroimaging is a powerful tool for identifying structural and functional circuits in vivo. In this study, we examined BNST structural and functional connectivity in a large sample of humans. The BNST showed structural and functional connections with multiple subcortical regions, including limbic, thalamic, and basal ganglia structures, confirming structural findings in rodents. We describe two novel connections in the human brain that have not been previously reported in rodents or non-human primates, including a structural connection with the temporal pole, and a functional connection with the paracingulate gyrus. The findings of this study provide a map of the BNST's structural and functional connectivity across the brain in healthy humans. In large part, the BNST neurocircuitry in humans is similar to the findings from rodents and non-human primates; however, several connections are unique to humans. Future explorations of BNST neurocircuitry in anxiety and addiction disorders have the potential to reveal novel mechanisms underlying these disabling psychiatric illnesses.

Bifactor structural model of symptom checklists: SCL-90-R and Brief Symptom Inventory (BSI) in a non-clinical community sample

The Derogatis symptom checklist (SCL-90-R) and its short version, the Brief Symptom Inventory (BSI), are widely used instruments, despite the fact that their factor structures were not clearly confirmed. The goals of this research were to compare four measurement models of these instruments including one-factor, nine-factor, a second-ordered factor model and a bifactor model, in addition to testing the gender difference in symptom factors in a community sample. SCL-90-R was assessed in a large community survey which included 2710 adults who represent the population of Hungary. Statistical analyses included a series of confirmatory factor analyses and multiple indicator multiple cause (MIMIC modeling). The responses to items were treated as ordinal scales. The analysis revealed that the bifactor model yielded the closest fit in both the full SCL-90-R and BSI; however the nine-factor model also had an acceptable level of fit. As for the gender differences, women scored higher on global severity, somatization, obsession-compulsion, interpersonal sensitivity, depression and anxiety factors. Men scored higher on hostility and psychoticism. The bifactor model of symptom checklist supports the concept of global symptom severity and specific symptom factors. Global symptom severity explains the large correlations between symptom factors.

New knockout model confirms a role for androgen receptors in regulating anxiety-like behaviors and HPA response in mice

Men are less likely than women to suffer from anxiety disorders. Because gonadal hormones play a crucial role in many behavioral sex differences, they may underlie sex differences in human anxiety. In rodents, testosterone (T) exerts anxiolytic effects via the androgen receptor (AR): we found that male mice with a naturally-occurring mutation rendering the AR dysfunctional, referred to as spontaneous testicular feminization mutation (sTfm), showed more anxiety-like behaviors than wildtype (WT) males. Here, we used Cre-lox recombination technology to create another dysfunctional allele for AR. These induced Tfm (iTfm) animals also displayed more anxiety-like behaviors than WTs. We further found that AR-modulation of these behaviors interacts with circadian phase. When tested in the resting phase, iTfms appeared more anxious than WTs in the open field, novel object and elevated plus maze tests, but not the light/dark box. However, when tested during the active phase (lights off), iTfms showed more anxiety-related behavior than WTs in all four tests. Finally, we confirmed a role of T acting via AR in regulating HPA axis activity, as WT males with T showed a lower baseline and overall corticosterone response, and a faster return to baseline following mild stress than did WT males without T or iTfms. These findings demonstrate that this recombined AR allele is a valuable model for studying androgenic modulation of anxiety, that the anxiolytic effects of AR in mice are more prominent in the active phase, and that HPA axis modulation by T is AR dependent.

Unique relations among anxiety sensitivity factors and anxiety, depression, and suicidal ideation

Anxiety sensitivity (AS) is composed of three lower-order dimensions, cognitive concerns, physical concerns, and social concerns. We examined the relations between AS dimensions using a more adequate assessment of subscales (ASI-3) than has previously been used, and measures of anxiety and mood disorders as well as suicidal ideation in a sample of 256 (M age = 37.10 years, SD = 16.40) treatment-seeking individuals using structural equation modeling. AS cognitive concerns was uniquely associated with generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), major depressive disorder (MDD), post-traumatic stress disorder (PTSD), and suicidal ideation. AS physical concerns was uniquely associated with OCD, social anxiety disorder (SAD), panic disorder (PD), and specific phobia. AS social concerns was uniquely associated with SAD, GAD, OCD, and MDD. These results highlight the importance of considering the lower-order AS dimensions when examining the relations between AS and psychopathology.

Differences between men and women in self-reported body mass index and its relation to drug use

Background

Obesity is a public health problem of alarming proportions, including among the university population in Latin America. The purpose of this study was to determine the relation between the self-reported body mass index and the associated drug use and health-risk behaviors.

Methods

We performed a cross-sectional, descriptive study of 3,311 Chilean university students (17–24 years). The variables weight, height, frequency of physical activity, diet quality index, and drug use were evaluated by way of a self-report questionnaire.

Results

16.7% of students were overweight and 2.1% were obese. Higher rates of overweight and obesity were observed in the men compared to women. There was a significant but moderate association between self-perceived obesity and being men and higher age, and just low with greater use of analgesics and tranquilizers with or without a prescription.

Conclusions

The punctual prevalence rates of self-reported obesity, in this sample, are consistent with other Latin American studies. The risk behaviors associated with perceived obesity in terms of gender, particularly the different pattern of drug use, highlight the importance of considering gender when designing strategies to promote health in a university setting.

Hippocampus and nitric oxide

Since it was first identified to play an important role in relaxation of blood vessels, nitric oxide has been demonstrated to regulate many biological processes, especially in the central nervous system. Of the three types of enzymes that produce nitric oxide in humans and rodents, neuronal type is found almost exclusively in the nervous system. This gaseous molecule is a nonclassical neurotransmitter, which maintains the activities of neural cells and regulates the normal functions of brain. It appears to play a role in promoting the transfer of nerve signals from one neuron to another, maintaining the synaptic strength. Meanwhile, nitric oxide is a unique regulator on neurogenesis and synaptogenesis, producing the positive or negative effects upon different signal pathways or cellular origins and locations. Based on its significant roles in neural plasticity, nitric oxide is involved in a number of central nervous diseases, such as ischemia, depression, anxiety, and Alzheimer's disease. Clarifying the profiles of nitric oxide in the brain tissues and its participation in pathophysiological processes opens a new avenue for development of new therapeutic strategies. Thus, this chapter specifies the effects of nitric oxide in the hippocampus, a key structure implicated in the modulation of mood and memories, exhibiting the trend of future research on nitric oxide.

Personality disorders and anxiety disorders: what is the relationship?

PURPOSE OF REVIEW

To systematically review the recent studies which examined the co-occurrence and relationships between anxiety disorders and personality disorders.

RECENT FINDINGS

The prevalence rates of personality disorders in patients with anxiety disorders are high, with 35% in posttraumatic stress disorder, 47% in panic disorder with agoraphobia and generalized anxiety disorder, 48% in social phobia, and 52% in obsessive-compulsive disorder. There is a high rate (39%) of the DSM cluster C personality disorders among individuals with anxiety disorders. Moreover, anxiety disorders are highly prevalent in samples of people with personality disorders, especially borderline personality disorder (80-84.8%). Personality disorders co-occurring with anxiety disorders have a number of clinical implications, including an increased risk of suicide, greater severity of anxiety disorders, and negative impact on the treatment outcome of anxiety disorders.

SUMMARY

It is important for the clinicians to look for possible personality disorders among patients with anxiety disorders. Further studies need to ascertain how best to treat individuals suffering from both anxiety disorders and personality disorders and focus on the issue of causality when these conditions co-occur.

Dissemination and implementation of prolonged exposure therapy for posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is a highly prevalent, often chronic and disabling psychiatric disorder that is associated with significant adverse health and life consequences. Although several evidence-based treatments (EBTs), including Prolonged Exposure therapy (PE), have been found effective and efficacious in reducing PTSD symptomology, the majority of individuals with this disorder receive treatments of unknown efficacy. Thus, it is imperative that EBTs such as PE be made available to PTSD sufferers through widespread dissemination and implementation. We will review some of the efforts to increase the availability of PE and the common barriers to successful dissemination and implementation. We also discuss novel dissemination strategies that are harnessing technology to overcome barriers to dissemination.

Genome-wide association study implicates a novel RNA gene, the lincRNA AC068718.1, as a risk factor for post-traumatic stress disorder in women

Posttraumatic stress disorder (PTSD) is a common and debilitating mental disorder with a particularly high burden for women. Emerging evidence suggests PTSD may be more heritable among women and evidence from animal models and human correlational studies suggest connections between sex-linked biology and PTSD vulnerability, which may extend to the disorder's genetic architecture. We conducted a genome-wide association study (GWAS) of PTSD in a primarily African American sample of women from the Detroit Neighborhood Health Study (DNHS) and tested for replication in an independent cohort of primarily European American women from the Nurses Health Study II (NHSII). We genotyped 413 DNHS women - 94 PTSD cases and 319 controls exposed to at least one traumatic event - on the Illumina HumanOmniExpress BeadChip for >700,000 markers and tested 578 PTSD cases and 1963 controls from NHSII for replication. We performed a network-based analysis integrating data from GWAS-derived independent regions of association and the Reactome database of functional interactions. We found genome-wide significant association for one marker mapping to a novel RNA gene, lincRNA AC068718.1, for which we found suggestive evidence of replication in NHSII. Our network-based analysis indicates that our top GWAS results were enriched for pathways related to telomere maintenance and immune function. Our findings implicate a novel RNA gene, lincRNA AC068718.1, as risk factor for PTSD in women and add to emerging evidence that non-coding RNA genes may play a crucial role in shaping the landscape of gene regulation with putative pathological effects that lead to phenotypic differences.

Correlates of irritability in college students with depressive symptoms

Depression is a prevalent psychiatric disorder associated with significant personal and societal burden. There is accumulating evidence for the presence of a subtype of depression characterized by the presence of irritability that is associated with increased morbidity, risk for suicidal ideation, and functional impairments in adults. Little is known about the features of depressive symptoms with and without irritability among young adults in college. The primary aim of this study was to characterize the presentation of college students with depressive symptoms and irritability. Two-hundred eighty-seven undergraduate college students with depressive symptoms with and without irritability were compared across several psychiatric and functional outcome variables. Independent samples t-tests or logistic regressions were conducted for each outcome variable using the irritability item of the Beck Depression Inventory as a dichotomous grouping variable. Analyses were conducted separately for the men and the women. Both male and female students with depressive symptoms and severe irritability reported a greater severity of depressive symptoms compared with their peers with no or mild irritability. In the women, the presence of irritability was associated with greater symptoms of anxiety, whereas in the men, it was associated with increased likelihood of engaging in risky behaviors, including compulsive use of alcohol, illicit drugs, and prescription drugs. The male and female college students with depressive symptoms with and without irritability did not differ on severity of suicidal ideation, hopelessness, or cognitive functioning. The findings from this study suggest that depressive symptoms and irritability may characterize a subtype of college students who have a greater symptom burden and with the potential need for more aggressive and prompt treatment.

Discovery of novel anxiolytic agents--the trials and tribulations of pre-clinical models of anxiety

Anxiety disorders are the most common class of mental disorders present in the general population with an estimated lifetime prevalence of any anxiety disorder being approximately 15%, while the 12-month prevalence is more than 10%. They are classified into simple phobias, social phobias, obsessive-compulsive disorder (OCD) and panic attacks. Anxiety disorders are more prevalent in females than males and respond to pharmacological and non-pharmacological (behavioral) treatments. Anxiety disorders are complex with genetic and environmental factors interacting to produce the final psychopathology. There are many tests used to detect behaviors that indicate heightened anxiety in rodents however there are few pathological models of anxiety in rodents. Most compound testing is performed on naive, non-pathologically anxious, male animals which is a potential limitation to current strategies since these animals do not reflect the anxious patient. This article briefly describes some of the most common anxiety tests used in rodent research and concludes with a short perspective on areas the field could concentrate on to improve the understanding and successful translation of novel targets into new therapies in the clinic.

Towards the development of a gender-sensitive measure of women's mental health

AIMS AND OBJECTIVES

To develop a gender-sensitive measure of women's mental health and to evaluate the measure's psychometric properties.

BACKGROUND

Mental health problems are a leading global burden of disease, and gender differences in the prevalence of these problems are well documented. Improving mental health is as important as resolving mental health problems. Although many mental health scales have been developed, few measure women's positive mental health from a gender perspective.

DESIGN

Instrument development and psychometric evaluation were used.

METHODS

First, a new mental health scale (Women's Mental Health Scale) grounded in women's subjective experiences was formulated from the narratives of four female focus groups (n = 23). The new scale was evaluated using principal component analysis and internal consistency reliability in a sample of female participants (n = 106). Next, the Women's Mental Health Scale, the Chinese version of Beck Depression Inventory-II and Social Adjustment Scale Self-Report were used in a survey of female undergraduate students (n = 163) for examining the concurrent criterion-related validity. Finally, gender differences were examined by assessing the discriminated validity of the Women's Mental Health Scale in a sample of male and female undergraduate students (n = 357). All participants were recruited from communities and universities in middle and south Taiwan.

RESULTS

A 50-item Women's Mental Health Scale with four concepts of self, interpersonal, family and social domains was developed. It revealed that the Women's Mental Health Scale had acceptable psychometric properties. There was a significant negative correlation between scores of the Women's Mental Health Scale and the Chinese version of Beck Depression Inventory-II and a significant positive correlation between scores of the Women's Mental Health Scale and Social Adjustment Scale Self-Report. There were significant gender differences in the family domain and social domain. Women reported greater mental health in the family domain and social domain than men.

CONCLUSIONS

The Women's Mental Health Scale is a promising gender-sensitive tool to measure women's mental health.

RELEVANCE TO CLINICAL PRACTICE

The Women's Mental Health Scale appears to be a gender-sensitive measure to assess the positive mental health potentials among women population.

Phosphate levels as a possible state marker in panic disorder: preliminary study of a feasible laboratory measure for routine clinical practice

OBJECTIVE

Low serum phosphate level is considered one of the metabolic adaptations to the respiratory alkalosis induced by hyperventilation associated with panic disorder. The aim of this study was to assess phosphatemia as a possible state marker for panic disorder.

METHODS

Sixteen panic disorder patients underwent clinical assessment with a semi-structured interview, a set of rating scales and the self-rated State and Trait Anxiety Inventory (STAI), as well as extraction of venous blood samples at baseline and after 12 weeks of pharmacological treatment. Ten healthy volunteers of similar sex, age and educational level filled out the STAI and gave blood samples at baseline and 12 weeks later.

RESULTS

The median (25th-75th percentiles) of phosphate levels (mg/dl) was 2.68 (2.22-3.18) among patients and 4.13 (3.74-4.70) among healthy volunteers respectively (P < 0.001). Seven (44%) patients and no healthy volunteers presented low serum phosphate (<2.50 mg/dl) at baseline; this patient abnormality was corrected in all cases after successful treatment. At baseline, the age-adjusted correlation between phosphate levels and state-anxiety was -0.66 (P < 0.001) among all 26 participants and -0.51 (P = 0.05) among the 16 panic disorder patients.

CONCLUSIONS

Measurement of phosphate levels could be easily introduced into clinical practice as a possible marker for chronic hyperventilation in panic disorder, although further investigations with larger sample sizes are necessary to characterize panic disorder patients with low versus normal phosphate levels.

Anxiety symptoms in psychotic disorders

BackgroundThe prevalence of anxiety symptoms among Australians with psychotic disorders was examined as part of the Survey of High Impact Psychosis (SHIP).MethodsA two-phase design was used. Of 7,955 people who were screen positive for psychosis and eligible, 1825 participants (18-34 years and 35-64 years) were interviewed. Data were collected on symptomatology, substance use, cognitive ability, functioning, disability, physical health, mental health service utilisation, medication use, education, employment and housing. Anxiety symptomatology was divided into generalized anxiety, panic, phobic, social anxiety and obsessive-compulsive symptoms.ResultsThe most common ICD-10 diagnoses were schizophrenia or schizoaffective disorder (63.0%) and bipolar (mania) disorder (17.5%). Overall, 59.8% (n = 1092) of participants reported experiencing anxiety symptoms in the previous 12 months. Female gender was highly associated with all domains of anxiety. Smoking was significantly associated with all domains of anxiety, except generalized anxiety. The presence of any depressive symptoms in the previous 12 months was significantly associated with all anxiety symptoms. Medication side-effects were associated with phobic and obsessive-compulsive symptoms. Social dysfunction was associated with social anxiety, and less so for obsessive-compulsive symptoms.ConclusionsAnxiety symptoms are common in people with psychotic disorders. Appropriate screening and treatment should be a clinical priority.

Increased cortical thickness in a frontoparietal network in social anxiety disorder

Social anxiety disorder (SAD) is the second leading anxiety disorder. On the functional neurobiological level, specific brain regions involved in the processing of anxiety-laden stimuli and in emotion regulation have been shown to be hyperactive and hyper-responsive in SAD such as amygdala, insula and orbito- and prefrontal cortex. On the level of brain structure, prior studies on anatomical differences in SAD resulted in mixed and partially contradictory findings. Based on previous functional and anatomical models of SAD, this study examined cortical thickness in structural magnetic resonance imaging data of 46 patients with SAD without comorbidities (except for depressed episode in one patient) compared with 46 matched healthy controls in a region of interest-analysis and in whole-brain. In a theory-driven ROI-analysis, cortical thickness was increased in SAD in left insula, right anterior cingulate and right temporal pole. Furthermore, the whole-brain analysis revealed increased thickness in right dorsolateral prefrontal and right parietal cortex. This study detected no regions of decreased cortical thickness or brain volume in SAD. From the perspective of brain networks, these findings are in line with prior functional differences in salience networks and frontoparietal networks associated with executive-controlling and attentional functions.

Sleep quality during euthymia in bipolar disorder: the role of clinical features, personality traits, and stressful life events

Background

Poor sleep quality is known to precede the onset of mood episodes and to be associated with poor treatment outcomes in bipolar disorder (BD). We sought to identify modifiable factors that correlate with poor sleep quality in BD independent of residual mood symptoms.

Methods

A retrospective analysis was conducted to assess the association between the Pittsburgh Sleep Quality Index and clinical variables of interest in euthymic patients with DSM-IV BD (n = 119) and healthy controls (HC; n = 136) participating in the Prechter Longitudinal Study of Bipolar Disorder. Multivariable linear regression models were constructed to investigate the relationship between sleep quality and demographic and clinical variables in BD and HC participants. A unified model determined independent predictors of sleep quality.

Results and discussion

Euthymic participants with BD and HC differed in all domains. The best fitting unified multivariable model of poor sleep quality in euthymic participants with BD included rapid cycling (β = .20, p = .03), neuroticism (β = .28, p = 2 × 10⁻³), and stressful life events (β = .20, p = .02). Poor sleep quality often persists during euthymia and can be a target for treatment. Clinicians should remain vigilant for treating subjective sleep complaints independent of residual mood symptoms in those sensitive to poor sleep quality, including individuals with high neuroticism, rapid cycling, and recent stressful life events. Modifiable factors associated with sleep quality should be targeted directly with psychosocial or somatic treatment. Sleep quality may be a useful outcome measure in BD treatment studies.

Predictors of the long-term course of comorbid PTSD: a naturalistic prospective study

OBJECTIVES

The study examined the long-term course of posttraumatic stress disorder (PTSD) by analyzing rates of recurrence and the predictive value of comorbid psychiatric disorders and psychosocial functioning.

METHODS

This study is based on diagnostic assessments administered at intake and subsequent follow-up interviews over a period of 15 years in a sample of 90 anxiety-disordered patients with comorbid PTSD who participated in the Harvard Brown Anxiety Research project (HARP). Kaplan-Meier life table analysis revealed a 0.20 probability of full remission during the 15 years of follow-up.

RESULTS

Latent growth model (LGM) analysis revealed that the number of trauma exposures was a predictor of a worse course of PTSD but only during some intervals of the 15-year follow-up. Subjects with full social phobia were more likely to experience worsening of PTSD over time in comparison with subjects with less severe social phobia. Role functioning in the areas of household and employment was a significant predictor of a declining course of PTSD.

CONCLUSIONS

These findings revealed the dynamic nature of the predictive value of traumatic experiences, the deleterious effect of social phobia and the long term effect of psychosocial functioning on the course of PTSD. Implications for treatment planning and development of interventions for PTSD are discussed.

Social anxiety in physical activity participation in patients with mental illness: a cross-sectional multicenter study

BACKGROUND

Social anxiety (SA) is a frequent comorbid condition in patients with mental illness. However, no data exist regarding SA in physical activity (PA) situations. The aim of the present study was to measure the level of self-reported SA in PA participation in patients with mental illness compared to healthy controls.

METHODS

Six hundred ninety-three patients with mental illness and 2,888 controls aged between 18 and 65 years completed the Physical Activity and Sport Anxiety Scale (PASAS). Group and gender differences in PASAS scores were tested by ANOVA and Scheffé's post hoc test.

RESULTS

After controlling for gender (P < .05), the patient group (men 40.2 ± 14.4; women 49.2 ± 17) scored higher on the PASAS compared to control group (men 30.6 ± 12.2; women 37.3 ± 13.7). Within both groups, women reported higher levels of SA compared to men.

CONCLUSIONS

Our data indicate that patients with mental illness reported higher levels of SA in PA situations compared to healthy control subjects. Health professionals should consider SA when trying to improve outcome and adherence of patients with mental illness to PA interventions.

Impact of sex and gonadal steroids on neonatal brain structure

There are numerous reports of sexual dimorphism in brain structure in children and adults, but data on sex differences in infancy are extremely limited. Our primary goal was to identify sex differences in neonatal brain structure. Our secondary goal was to explore whether brain structure was related to androgen exposure or sensitivity. Two hundred and ninety-three neonates (149 males) received high-resolution structural magnetic resonance imaging scans. Sensitivity to androgen was measured using the number of cytosine, adenine, guanine (CAG) triplets in the androgen receptor gene and the ratio of the second to fourth digit, provided a proxy measure of prenatal androgen exposure. There was a significant sex difference in intracranial volume of 5.87%, which was not related to CAG triplets or digit ratios. Tensor-based morphometry identified extensive areas of local sexual dimorphism. Males had larger volumes in medial temporal cortex and rolandic operculum, and females had larger volumes in dorsolateral prefrontal, motor, and visual cortices. Androgen exposure and sensitivity had minor sex-specific effects on local gray matter volume, but did not appear to be the primary determinant of sexual dimorphism at this age. Comparing our study with the existing literature suggests that sex differences in cortical structure vary in a complex and highly dynamic way across the human lifespan.

Impact of sleep quality on amygdala reactivity, negative affect, and perceived stress

OBJECTIVE

Research demonstrates a negative impact of sleep disturbance on mood and affect; however, the biological mechanisms mediating these links are poorly understood. Amygdala reactivity to negative stimuli has emerged as one potential pathway. Here, we investigate the influence of self-reported sleep quality on associations between threat-related amygdala reactivity and measures of negative affect and perceived stress.

METHODS

Analyses on data from 299 participants (125 men, 50.5% white, mean [standard deviation] age = 19.6 [1.3] years) who completed the Duke Neurogenetics Study were conducted. Participants completed several self-report measures of negative affect and perceived stress. Threat-related (i.e., angry and fearful facial expressions) amygdala reactivity was assayed using blood oxygen level-dependent functional magnetic resonance imaging. Global sleep quality was assessed using the Pittsburgh Sleep Quality Index.

RESULTS

Amygdala reactivity to fearful facial expressions predicted greater depressive symptoms and higher perceived stress in poor (β values = 0.18-1.86, p values < .05) but not good sleepers (β values = -0.13 to -0.01, p values > .05). In sex-specific analyses, men reporting poorer global sleep quality showed a significant association between amygdala reactivity and levels of depression and perceived stress (β values = 0.29-0.44, p values < .05). In contrast, no significant associations were observed in men reporting good global sleep quality or in women, irrespective of sleep quality.

CONCLUSIONS

This study provides novel evidence that self-reported sleep quality moderates the relationships between amygdala reactivity, negative affect, and perceived stress, particularly among men.

Processes linking cultural ingroup bonds and mental health: the roles of social connection and emotion regulation

Cultural and ethnic identities influence the relationships individuals seek out and how they feel and behave in these relationships, which can strongly affect mental and physical health through their impacts on emotions, physiology, and behavior. We proposed and tested a model in which ethnocultural identifications and ingroup affiliations were hypothesized explicitly to enhance social connectedness, which would in turn promote expectancy for effective regulation of negative emotions and reduce self-reported symptoms of depression and anxiety. Our sample comprised women aged 18-30 currently attending college in the Southwestern US, who self-identified as Hispanic of Mexican descent (MAs; n = 82) or as non-Hispanic White/European American (EAs; n = 234) and who completed an online survey. In the full sample and in each subgroup, stronger ethnocultural group identity and greater comfort with mainstream American culture were associated with higher social connectedness, which in turn was associated with expectancy for more effective regulation of negative emotions, fewer depressive symptoms, and less anxiety. Unexpectedly, preference for ingroup affiliation predicted lower social connectedness in both groups. In addition to indirect effects through social connection, direct paths from mainstream comfort and preference for ingroup affiliation to emotion regulation expectancy were found for EAs. Models of our data underscore that social connection is a central mechanism through which ethnocultural identities-including with one's own group and the mainstream cultural group-relate to mental health, and that emotion regulation may be a key aspect of this linkage. We use the term ethnocultural social connection to make explicit a process that, we believe, has been implied in the ethnic identity literature for many years, and that may have consequential implications for mental health and conceptualizations of processes underlying mental disorders.

Comorbid Alcohol Dependence and Anxiety Disorders: A National Survey

OBJECTIVE

The goal of this study was to describe onset of comorbid anxiety disorders and alcohol dependence based on a large national survey of the US adult population, and to explore and describe these patterns by gender.

METHODS

Using Wave 1 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) data, we compared age of onset and temporal ordering of onset of comorbid alcohol dependence and anxiety disorders. Analyses were stratified by gender. Mean ages of onset were calculated, and Wald F-tests were used to assess differences in ages of onset, accounting for the complex survey design of the NESARC. Weighted estimates were used, adjusted to be representative of the US population on various sociodemographic variables based on the 2000 Decennial Census.

RESULTS

Differences in temporal ordering were observed, but varied by disorder combination. The majority (65%) had a primary (earliest onset) anxiety disorder, while the remaining 35% had a primary alcohol dependence diagnosis. Age of onset for some individuals with an anxiety disorder comorbid with alcohol dependence was earlier than for those with an anxiety disorder alone. Among individuals with comorbid social phobia and alcohol dependence, and comorbid specific phobia and alcohol dependence, it was more common to experience anxiety disorder as the primary diagnosis. Conversely, among individuals with comorbid panic disorder and alcohol dependence, and generalized anxiety disorder and alcohol dependence, it was more common to experience alcohol dependence as the primary diagnosis. Women were more likely to report having multiple comorbid anxiety disorders. No gender differences were found in terms of age of onset or temporal ordering of onset of comorbid disorders.

CONCLUSIONS

Subsets of individuals with comorbid disorders exist, some whose primary diagnosis is alcohol dependence, and a majority of individuals whose primary diagnosis is an anxiety disorder with significant variability in age and temporal ordering of onset and few gender differences. Improved understanding of patterns of comorbidity and lag time between the onsets of specific disorders may enable us to identify potential groups for early intervention.

Early life trauma predicts self-reported levels of depressive and anxiety symptoms in nonclinical community adults: relative contributions of early life stressor types and adult trauma exposure

Exposure to early life trauma is a known risk factor for depression and anxiety disorders in adulthood. This study aimed to evaluate the relative contributions of early life versus adult trauma in predicting levels of depressive and anxiety symptoms in nonclinical community adults. 1209 nonclinical community adults (18-70 years; 45% male) were assessed for mental health status, early life stressors, lifetime trauma exposure, and self-reported levels of depressive and anxiety symptoms. A subset of the full sample subjected to group comparisons (n = 1088) indicated that early life stressor exposure primarily accounted for significantly higher depressive and anxiety symptom scores when compared against adults reporting to be free of childhood stressor or adult trauma exposure. Subsequent hierarchical multiple regression analyses of this subset using five distinct early life stressor types, namely 'Interpersonal violation', 'Family breakup', 'Disasters/war', 'Familial health trauma/death' and 'Personal health trauma' derived from principal component analysis of a wide range of self-reported early stressor events in the full sample, showed childhood 'Interpersonal violation' differentially predicted higher self-reported depressive and anxiety symptom scores in both males and females. Adult trauma exposure did not significantly predict these symptom scores. These findings underline the relative importance of exposure to 'interpersonal violation' relative to other types of early life stressors and adult trauma in the risk of depressive and anxiety symptoms in nonclinical community adults.

Prevalence and Behavioral Styles of Fear of Flying

According to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), fear of flying is a specific situational phobia, but it has a heterogeneous character because it can be influenced by many other fears. Attention toward (monitoring) or away from (blunting) threatening information is influenced by people’s control of voluntary attention. In our online questionnaire study, 9,166 subjects (age 17–70 years) were selected for participation. The Flight Anxiety Modality (FAM) questionnaire and Miller Behavioral Style Scale (MBSS) were used to measure fear of flying and behavioral style. Also, demographic information was collected. Women reported a higher FAM sum score than men, as predicted. Participants who scored higher on the MBSS were found to have also scored higher on the FAM. Participants who had never flown before scored higher on the FAM than participants who had flown before. In this sample, monitoring can be associated with an increase in fear of flying. Future research should focus on gaining a more multicultural picture of fear of flying.

Trajectories of maternal symptoms of depression and anxiety over 13 years: the influence of stress, social support, and maternal temperament

Background

Depression and anxiety are the most common mental health problems among women, with various negative impacts both for the women concerned and their families. Greater understanding of developmental trajectories of maternal symptoms of depression and anxiety over the child rearing period would have significant benefits for public health, informing prevention and treatment approaches. The aim of the current study was to examine whether stressors related to child rearing and living conditions, social support, and maternal temperament, predicted mothers’ membership in groups with different trajectories of symptoms of depression and anxiety during 13 years of the child rearing phase.

Methods

The data were from a prospective, longitudinal study of 913 mothers in Norway followed from when their children were 18 months old (time 1) until they were 14.5 years (time 6) (the TOPP study). Multinomial logistic regression analyses were used to test whether child related stressors, stressors related to the living conditions, social support and maternal temperament at time 1 predicted membership in groups based on maternal symptoms of depression and anxiety over the subsequent 13 years.

Results

Temperamental distress, followed by child related stressors, were the strongest predictors of membership in a group with high symptoms of depression and anxiety over time. Stressors related to living conditions, and social support from partner and friends/family were also significant predictors. No interaction effects among predictors were found.

Conclusions

This study indicates that factors present early in the child rearing phase may provide substantial prediction of the variance in maternal symptoms of depression and anxiety over the following 13 years. Temperamental distress and child related stressors were the strongest predictors of membership in different depression and anxiety symptom trajectory groups.

Isolation rearing attenuates social interaction-induced expression of immediate early gene protein products in the medial prefrontal cortex of male and female rats

Early life adversity and stress in humans have been related to a number of psychological disorders including anxiety, depression, and addiction. The present study used isolation rearing, a well-characterized animal model of early life adversity, to examine its effects on social behavior and immediate early gene (IEG) expression produced by exposure to a novel social experience. Male and female rats were housed in same-sex groups or in isolation for 4 weeks beginning at weaning and were tested during late adolescence. The protein products of the IEGs c-fos and Arc, as well as the neurotrophic factor BDNF were assessed in medial prefrontal cortex (mPFC) subregions (anterior cingulate, prelimbic and infralimbic) using immunohistochemistry. Aggressive and non-aggressive behaviors during novel social exposure were also assessed. Exposure to a novel conspecific produced increases in Arc and c-fos activation in the mPFC of group reared animals in a sex- and subregion-dependent fashion compared to no social exposure controls, but this increase was blunted or absent in isolated animals. Isolates engaged in more social interactions and more aggressive behavior than group reared rats. Sex differences in some behaviors as well as in Arc and BDNF expression were observed. These results indicate that isolation rearing alters IEG activation in the mPFC produced by exposure to a novel conspecific, in addition to changing social behavior, and that these effects depend in part on sex.

Stage-specific gender differences in cognitive and neuropsychiatric manifestations of vascular dementia

Studies on gender differences in the clinical manifestations of vascular dementia (VaD) are still lacking. In the present study, gender comparisons of cognitive and neuropsychiatric profiles were conducted separately for mild and moderate-to-severe VaD in a total of 467 patients with VaD. There were no significant gender differences in cognitive manifestations, except that females performed better on immediate verbal recall than males in mild stage. Women were more likely to exhibit delusions (15.5% vs 7.4%), hallucinations (9.5% vs 3.4%), and depression (43.1% vs 27.3%) in mild stage. The predominance of male patients was observed in apathy at moderate-to-severe stage (50.5% vs 34.8%). To conclude, gender differences existed in neuropsychiatric symptoms of VaD and were especially pronounced in mild stage. Delusions, hallucinations, and depression were more prevalent in females in mild VaD, with the male predominance only in apathy in the later stage.

Hippocampal nitric oxide contributes to sex difference in affective behaviors

Mechanisms underlying the female preponderance in affective disorders are poorly understood. Here we show that hippocampal nitric oxide (NO) plays a role in the sex difference of depression-like behaviors in rodents. Female mice had substantially lower NO production in the hippocampus and were significantly more likely to display negative affective behaviors than their male littermates. Eliminating the difference in the basal hippocampal NO level between male and female mice mended the sex gap of affective behaviors. Estradiol exerted a positive control on hippocampal NO production via estrogen receptor-β-mediated neuronal NO synthase expression. Thus, low estrogen in the female hippocampus accounts for lower local NO than in the male hippocampus. Although estrogen has important significance in modulating affective behaviors, it is not estrogen but NO in the hippocampus that mediates the sex difference of affective behaviors directly, because hippocampal NO was necessary for the behavioral effects of estradiol, and NO was an independent factor in modulating behaviors. Stress promoted hippocampal NO production in males because of glucocorticoid release, thus leading to local NO excess. In contrast, stress suppressed NO production in females because of decreased estrogen, thereby resulting in hippocampal NO shortage. Whereas activating cAMP response element binding protein (CREB) rescued the depression-like effects of the intrahippocampal NO donor diethylenetriamine/nitric oxide adduct (DETA/NONOate), inactivating CREB abolished the antidepressant-like effects of the intrahippocampal NO donor DETA/NONOate. Our findings suggest a molecular mechanism underlying the sex difference of affective behaviors.

Clinical features of bipolar disorder comorbid with anxiety disorders differ between men and women

BACKGROUND

Anxiety disorders are commonly comorbid with bipolar disorder (BP) and may worsen course of illness, but differential impact of specific anxiety disorders in men and women remains unknown.

METHODS

We measured the impact of comorbid panic disorder (PD), social phobia, specific phobia, and obsessive-compulsive disorder (OCD) in 460 women and 276 men with Bipolar I Disorder (BPI) or schizoaffective disorder, bipolar type from the National Institute of Mental Health Bipolar Genetics Initiative. We compared clinical characteristics in BP with and without each anxiety disorder in men and women separately correcting for family relatedness.

RESULTS

Comorbid PD, OCD, and specific phobia were more common in women with BP than men. Comorbid social phobia correlated with increased risk of alcohol abuse in BP women, but not men. Women with comorbid PD attended fewer years of school. Comorbidity with OCD was associated with earlier age at the onset of BP for both genders. Comorbid PD, OCD, and specific phobia were associated with more antidepressant trials in BP, across both genders, compared to BP patients without these anxiety disorders.

CONCLUSION

In BP, comorbid anxiety disorders are associated with increased risk for functional impairment, and women had differently associated risks than men. Clinicians should be aware of an increased risk for comorbid PD, OCD, and specific phobia in women with BP, and an increased risk of alcohol abuse in women with BD and comorbid social phobia.

The selective neuropeptide Y Y5 agonist [cPP(1-7),NPY(19-23),Ala31,Aib32,Gln34]hPP differently modulates emotional processes and body weight in the rat

The neuropeptide Y (NPY) has been suggested to act as a major regulator of emotional processes and body weight. The full spectrum of biological effects of this peptide is mediated by at least four classes of receptors known as the Y(1), Y(2), Y(4), and Y(5) subtypes. However, the respective contribution of each of these receptor subtypes, especially the Y(5) subtype, in emotional processes is still mostly unknown. In the present study, we investigated the effect of long term administration of a selective Y(5) agonist [cPP(1-7),NPY(19-23),Ala(31),Aib(32),Gln(34)]hPP on emotional processes and body weight using two rat models of emotional dysfunctions, the corticosterone (CORT)-induced anxiety model as well as the olfactory bulbectomized (OBX) model of depression and anxiety in Wistar and Sprague-Dawley rats, respectively. The sub-chronic administration of the Y(5) agonist reversed the high levels of locomotion, rearing and grooming in the open field test and the impaired social activity induced by OBX, while increased the percentage of entries and time in the open arm of the elevated plus maze in CORT-treated rats. Furthermore, this Y(5) agonist increased body weight in both strains of control rats. These data further demonstrate that Y(5) receptors are not only involved in the control of body weight but also mediate emotional processing under challenged conditions. Thus, the pharmacotherapeutic administration of a Y(5) agonist could be considered as a potentially novel strategy to alleviate some forms of anxiety and depression in humans.

Low back pain and comorbidity clusters at 17 years of age: a cross-sectional examination of health-related quality of life and specific low back pain impacts

PURPOSE

Comorbidities in adults negatively affect the course of low back pain (LBP). Little is known of the presence and/or impact of LBP comorbidities in adolescents.

METHODS

Subjects from the Raine Study cohort at age 17 years (n = 1,391) provided self-report of diagnosed medical conditions/health complaints, health-related quality of life (36-Item Short Form Health Survey [SF-36]), lifetime experience of LBP, and specific LBP impacts (taking medication, missing school/work, interference with normal/physical activities). Latent class analysis was used to estimate clusters of comorbidities based on diagnosed disorders. Profiles of SF-36 and impact were examined between clusters.

RESULTS

Four distinct comorbidity clusters were identified: cluster 1: Low probability of diagnosed LBP or any other medical condition (79.7%); cluster 2: High probability of diagnosed LBP and neck/shoulder pain, but a low probability of other diagnosed health conditions (9.6%); cluster 3: Moderate probability of diagnosed LBP and high probability of diagnosed anxiety and depression (6.9%); cluster 4: Moderate probability of diagnosed LBP and high probability of diagnosed behavioral and attention disorders (3.8%). The clusters had different SF-36 and LBP impact profiles, with clusters 3 and 4 having poorer SF-36 scores, and clusters 2 to 4 having greater risk for specific LBP impacts, than cluster 1.

CONCLUSIONS

Identified comorbidity clusters support adolescent and adult studies reporting associations between LBP, other pain areas, psychological disorders, and disability. Tracking these clusters into adulthood may provide insight into health care utilization in later life, whereas identification of these individuals early in the life span may help optimize intervention opportunities.

Course of mental symptoms in patients with stress-related exhaustion: does sex or age make a difference?

BACKGROUND

Long-term sick leave due to mental health problems, especially among women, is a substantial problem in many countries, and a major reason for this is thought to be psychosocial stress. The recovery period of different patient groups with stress-related mental health problems can differ considerably. We have studied the course of mental health symptoms during 18 months of multimodal treatment in relation to sex and age in a group of patients with stress-related exhaustion.

METHODS

The study group includes 232 patients (68% women) referred to a stress clinic and who fulfilled the criteria for Exhaustion Disorder (ED). The majority also fulfilled diagnostic criteria for depression and/or anxiety; this was similar among women and men. Symptoms were assessed at baseline, three, six, 12 and 18 months by the Shirom-Melamed Burnout Questionnaire (SMBQ) and the Hospital Anxiety and Depression scale (HAD). A total SMBQ mean score of ≥ 4 was used to indicate clinical burnout, which correlates well with the clinical diagnosis of ED.

RESULTS

There were no statistically significant differences between women and men or between young and old patients in the self-reported symptoms at baseline. The proportion that had high burnout scores decreased over time, but one-third still had symptoms of clinical burnout after 18 months. Symptoms indicating probable depression or anxiety (present in 34% and 65% of the patients at baseline, respectively) declined more rapidly, in most cases within the first three months, and were present only in one out of 10 after 18 months. The course of illness was not related to sex or age. The duration of symptoms before seeking health care, but not the level of education or co-morbid depression, was a predictor of recovery from symptoms of burnout after 18 months.

CONCLUSIONS

The course of mental illness in patients seeking specialist care for stress-related exhaustion was not related to sex or age. The burden of mental symptoms is high and similar for men and women, and at the 18 month follow-up, one-third of the study group still showed symptoms of burnout. A long duration of symptoms before consultation was associated with a prolonged time of recovery, which underlines the importance of early detection of stress-related symptoms.