Sex differences in depression: a role for preexisting anxiety

Gender differences in depression: findings from the STAR*D study

BACKGROUND

Epidemiologic research consistently reports gender differences in the rates and course of major depressive disorder (MDD). The STAR*D (Sequenced Treatment Alternatives to Relieve Depression) multicenter trial provides a unique opportunity to explore gender differences in outpatients with nonpsychotic MDD.

METHODS

This sample included the first 1500 outpatients with MDD who enrolled in STAR*D. Nearly two-thirds of the sample (62.8%) were women. Baseline sociodemographic factors, comorbidities, and illness characteristics were analyzed by gender.

RESULTS

Women (62.8% of the sample) had a younger age at onset of the first major depressive episode. They commonly reported concurrent symptoms consistent with anxiety disorders, somatoform disorder, and bulimia as well as atypical symptoms. Alcohol and drug abuses were more common in men.

LIMITATIONS

This report is a subpopulation of the entire STAR*D sample. These exploratory analyses aimed to identify potential gender differences for further hypothesis testing.

CONCLUSIONS

The gender-specific rate of MDD in this study population is proportional to rates found in community samples with a 1.7:1 prevalence of MDD in women vs. men which argues against increased treatment seeking in women.

Effect of chronic treatment with ladostigil (TV-3326) on anxiogenic and depressive-like behaviour and on activity of the hypothalamic-pituitary-adrenal axis in male and female prenatally stressed rats

OBJECTIVE

The aim of the study is to investigate the effect of ladostigil, a cholinesterase and brain-selective monoamine oxidase (MAO) inhibitor, on anxiogenic and depressive-like behaviour and the response of the hypothalamic-pituitary-adrenal axis to stress in prenatally stressed (PS) male and female rats.

METHODS

Ladostigil (17 mg/kg/day) was administered daily for 6 weeks to control and PS rats aged 6 weeks. Behaviour was assessed in the elevated plus maze (EPM) and forced swim tests (FST). Plasma corticosterone (COR) was measured before, 30 and 90 min after exposure to stress.

RESULTS

Ladostigil inhibited brain MAO-A and B by more than 60%, significantly reduced hyperanxiety of male and female PS rats in the EPM and depressive-like behaviour in the FST without affecting that of controls and restored the delayed return to baseline of plasma COR in PS rats after exposure to stress to that of control rats.

CONCLUSIONS

A novel brain-selective MAO inhibitor, ladostigil can selectively reverse the behavioural and neurochemical effects induced by prenatal stress without affecting the behaviour of controls.

Expression of c-fos and BDNF mRNA in subregions of the prefrontal cortex of male and female rats after acute uncontrollable stress

Women exhibit higher lifetime prevalences of stress-related disorders than men. These disorders have been associated with changes in prefrontal cortex structure and function. Here, we examine the effects of acute inescapable stress, an animal model of behavioral depression and post-traumatic stress disorder, on plasma corticosterone (CORT) and on c-fos mRNA and brain-derived neurotrophic factor (BDNF) mRNA in regions of the prefrontal and frontal cortex in male and cycling female rats. Inescapable stress consisted of 100 1 mA tailshocks, and no-stress controls remained in their home cages. Rats were sacrificed immediately (0 min) or 60 min after termination of the stressor. CORT levels were increased at both 0 and 60 min post-stress termination relative to controls, and the increase was greater in females at both time points. c-fos mRNA expression increased at 0 min in prefrontal cortical regions, but this increase was greater in males than estrus and proestrus females. At 60 min, c-fos mRNA levels were lower than at 0 min in males but not females. No correlations between CORT and c-fos mRNA levels in prefrontal regions were observed in females in the stress groups, but significant correlations were observed in males in several prefrontal regions. BDNF mRNA expression was greater in control females than control males. Inescapable stress increased BDNF mRNA expression at 0 but not 60 min in males, but there was no effect of inescapable stress on BDNF mRNA in females. These results reveal sex differences in inescapable stress-induced gene expression that may have implications for differences in vulnerability to stress-related disorders.

Families at high and low risk for depression: a three-generation startle study

BACKGROUND

Anxiety symptoms might be a vulnerability factor for the development of major depressive disorder (MDD). Because elevated startle magnitude in threatening contexts is a marker for anxiety disorder, the present study investigated the hypothesis that enhanced startle reactivity would also be found in children and grandchildren of individuals with MDD.

METHODS

The magnitude of startle was investigated in two tests (anticipation of an unpleasant blast of air and during darkness) in children (second generation) and grandchildren (third generation) of probands with (high risk) or without (low risk) MDD (first generation).

RESULTS

Startle discriminated between the low- and high-risk groups. In the probands' children, the high-risk group showed increased startle magnitude throughout the fear-potentiated startle test. In the probands' grandchildren, a gender-specific abnormality was found in the high-risk group with high-risk girls, but not boys, exhibiting elevated startle magnitude throughout the procedure.

CONCLUSIONS

Increased startle reactivity in threatening contexts, previously found in patients with anxiety disorder and in children of parents with an anxiety disorder, might also constitute a vulnerability marker for MDD. These findings suggest that there might be common biologic diatheses underlying depression and anxiety.

Oestrogen and testosterone modulate the firing activity of dorsal raphe nucleus serotonergic neurones in both male and female rats

Women are twice as likely to suffer from mood disorders than men. Moreover, a growing body of evidence suggests a reciprocal modulation between sex steroids and the serotonin (5-HT) system. A previous study from our laboratory has shown that the progesterone metabolites 5beta-pregnane-3,20-dione (5beta-DHP) and 5alpha-pregnan-3alpha-ol,20-one (3alpha,5alpha-THP), as well as dehydroepiandrosterone (DHEA), increase the firing activity of dorsal raphe nucleus (DRN) 5-HT neurones in female rats. The present study was undertaken to assess the effects of these steroids in male rats, as well as the effects of testosterone and 17beta-oestradiol (17beta-E) in both sexes, and finally to evaluate gender differences in the modulation of the 5-HT neuronal firing activity by these different neuroactive steroids. Male rats were treated i.c.v., for 7 days, with a dose of 50 microg/kg/day of one of the following steroids: progesterone, 5beta-DHP, 3alpha,5alpha-THP, DHEA, testosterone, 17beta-hydroxy-5alpha-androstan-3-one (5alpha-DHT) and 17beta-E. Some rats also received a 3-day administration of testosterone (50 microg/kg/day, i.c.v). Females were treated in the same fashion with testosterone and 17beta-E. Extracellular unitary recordings of 5-HT neurones, obtained in vivo in the DRN of these rats, revealed that testosterone and 17beta-E increased the firing activity of 5-HT neurones in both males and females. In males, the effect of testosterone could already be seen after 3 days of treatment. Neither castration nor any treatment with other steroids significantly modified the firing rate of male 5-HT neurones. Taken together with previous findings, the results of the present study indicate both similarities and differences between sexes in the modulation of 5-HT neurones by some steroids. This could prove important in understanding gender differences in mood disorders.

Early puberty in girls: the case of premature adrenarche

In this article we examine the issue of early puberty in girls. First, a brief overview of normal pubertal development is provided, including the two endocrine components of puberty: gonadarche and adrenarche. Second, we critically discuss the controversy regarding whether puberty truly is occurring earlier in girls. Third, we emphasize one type of early puberty, the case of premature adrenarche (PA). PA is used to illustrate the importance of identifying types of early puberty, evaluating the types to determine causality, determining whether follow-up of early puberty is necessary, and showing the potential ramifications of ignoring this variation in pubertal development. Findings from a pilot study comparing PA and on-time puberty children are used to show the importance of determining whether early puberty is normal in all cases.

Chronic ultra-mild stress improves locomotor performance of B6D2F1 mice in a motor risk situation

Chronic low grade stress predispose to psychopathological disorders. We consistently showed that chronic ultra-mild stress (CUMS) applied to B6D2F1 female mice induced behavioral disinhibition in several conflict exploration models. Insufficient reactivity to conflicts may be maladaptive and lead to inappropriate appreciation of potential risks and impaired ability to cope with those. Therefore, the purpose of the study was to assess the effect of a CUMS procedure on the behavior of mice in a motor risk situation based on multisensory conflict. Following three weeks exposure to various mild stressors, stressed and control B6D2F1 mice were tested on the rotating beam to determine how CUMS exposure affected balance control, posture stability and locomotor performance in response to a sensory-motor challenge. Detailed behavioral analysis included several parameters, both postural (height of the trunk, tail angle, number of imbalances, falls and head movements) and kinetic (mean velocity on the beam, distance covered with large and small movements, plus time spent in no-motion episodes). Comparisons between control and stressed mice showed that CUMS exposure increased mean velocity and improved locomotor performance in the learning task. In addition, sensitivity to sensory conflict seemed to be reduced in stressed mice, which displayed fewer behavioral adjustments to the increasing difficulty of the test compared to control mice. The results are discussed in terms of the possible influence of disturbances in behavioral and attentional inhibitory processes following CUMS exposure. Whether longer periods of CUMS exposure would shift the performance on the RTB from improvement to deterioration remain to be established.

The circumplex model of affect: an integrative approach to affective neuroscience, cognitive development, and psychopathology

The circumplex model of affect proposes that all affective states arise from cognitive interpretations of core neural sensations that are the product of two independent neurophysiological systems. This model stands in contrast to theories of basic emotions, which posit that a discrete and independent neural system subserves every emotion. We propose that basic emotion theories no longer explain adequately the vast number of empirical observations from studies in affective neuroscience, and we suggest that a conceptual shift is needed in the empirical approaches taken to the study of emotion and affective psychopathologies. The circumplex model of affect is more consistent with many recent findings from behavioral, cognitive neuroscience, neuroimaging, and developmental studies of affect. Moreover, the model offers new theoretical and empirical approaches to studying the development of affective disorders as well as the genetic and cognitive underpinnings of affective processing within the central nervous system.

Familial transmission of mood disorders: convergence and divergence with transmission of suicidal behavior

OBJECTIVE

Both mood disorder and suicidal behavior are familial. In this study, the authors examine the factors associated with the familial transmission of these two related conditions to learn which are shared or unique risk factors for familial transmission.

METHOD

The 285 offspring of 141 probands with mood disorder were studied. Proband and offspring characteristics associated with offspring mood disorder were examined by univariate statistics, logistic and Cox regression, and path analysis.

RESULTS

Parental history of sexual abuse was associated with an increased risk of offspring mood disorder. The relationship between parent sexual abuse and offspring mood disorder was mediated by offspring impulsive aggression, sexual abuse, and anxiety disorder. In offspring, higher levels of impulsive aggression were associated with earlier age at onset of mood disorder. Offspring suicide attempt was mainly related to offspring mood disorder, with additional contributions from offspring sexual abuse and impulsive aggression.

CONCLUSIONS

The pathways associated with the familial transmission of mood disorder and of suicide attempt are similar but not identical. Prevention of early-onset mood disorder by targeting high- risk families may help to prevent the transmission of suicidal behavior. Because these data are cross-sectional, these results must be confirmed by prospective follow-up.

Comorbidity of generalized social anxiety disorder and depression in a pediatric primary care sample

BACKGROUND

Comorbidity between adult social anxiety disorder and major depression is extensive. Considerably less information about this relationship is available among youth.

METHODS

A randomly selected (from enrollees in a pediatric primary care clinic) sample of 190 families with children between the ages of 8 and 17 responded by mail to questionnaires assessing social anxiety, depression, and social functioning. Parents also completed a semi-structured telephone diagnostic interview about their child.

RESULTS

The generalized type of social anxiety disorder was highly comorbid with major depression, generalized anxiety disorder, specific phobias, and ADHD, while little comorbidity was present for the nongeneralized subtype of social anxiety disorder. Logistic regression analyses indicated that generalized social anxiety disorder was the only anxiety disorder associated with an increased likelihood of major depression (OR=5.1). In all cases, social anxiety disorder had a significantly earlier age of onset than major depression.

LIMITATIONS

This study relies on cross-sectional data and diagnoses are based on parent reporting of child behavior.

CONCLUSIONS

Generalized social anxiety disorder is strongly associated with depressive illness in youth. Screening and treatment approaches that consider both social anxiety and depressive symptoms are necessary. Early intervention to treat social anxiety disorder may prevent later depressive disorders.

Neurochemical and behavioral alterations in glucocorticoid receptor-impaired transgenic mice after chronic mild stress

Mice (GR-i) bearing a transgene encoding a glucocorticoid receptor (GR) antisense RNA under the control of a neuron-specific neurofilament promoter were used to investigate the effects of a 4 week chronic mild stress (CMS) on the hypothalamo-pituitary-adrenocortical (HPA) axis and the serotoninergic system in a transgenic model of vulnerability to affective disorders. GR-i mice showed a decrease in both GR-specific binding (hippocampus and cerebral cortex) and GR mRNA levels [hippocampus, cerebral cortex, and dorsal raphe nucleus (DRN)] as well as a deficit in HPA axis feedback control (dexamethasone test) compared with paired wild-type (WT) mice. In the latter animals, CMS exposure caused a significant decrease in both GR mRNA levels and the density of cytosolic GR binding sites in the hippocampus, whereas, in the DRN, GR mRNA levels tended to increase. In contrast, in stressed GR-i mice, both GR mRNA levels and the density of GR binding sites were significantly increased in the hippocampus, cerebral cortex, and DRN. Electrophysiological recordings in brainstem slices and [gamma-35S]GTP-S binding measurements to assess 5-HT1A receptor functioning showed that CMS exposure produced a desensitization of DRN 5-HT1A autoreceptors in WT, but not in GR-i, mice. In addition, CMS was found to facilitate choice behavior of WT, but not GR-i, mice in a decision-making task derived from an alternation paradigm. These results demonstrate that impaired GR functioning affects normal adaptive responses of the HPA axis and 5-HT system to CMS and alters stress-related consequences on decision-making behaviors.

Anxiety and depression: a 40-year perspective on relationships regarding prevalence, distribution, and comorbidity

OBJECTIVE

Building on a report about the prevalence of depression over time, this paper examines historical trends regarding anxiety in terms of its prevalence, its distribution by age and gender, and its comorbidity with depression. Methods for conducting such time trend analysis are reviewed.

METHOD

Representative samples of adults were selected and interviewed in 1952, 1970, and 1992. Logistic regressions were used for statistical analysis.

RESULTS

Although twice as common as depression, the prevalence of anxiety was equally stable. Anxiety was consistently and significantly more characteristic of women than men. A re-distribution of rates in 1992 indicated that depression but not anxiety had significantly increased among younger women (P = 0.03). Throughout the study, approximately half of the cases of anxiety also suffered depression.

CONCLUSION

The relationships between anxiety and depression remained similar over time with the exception that depression came to resemble anxiety as a disorder to which women were significantly more vulnerable than men. Social and historical factors should be investigated to assess their relevance to this change.

A test of the tripartite model of anxiety and depression in elementary and high school boys and girls

The applicability of the tripartite model of emotion, which distinguishes the shared aspect of depression and anxiety, negative affect (NA), from their respective specific components of low positive affect (PA) and physiological hyperarousal (PH), was examined in 472 elementary and high school students. The relations among depression, anxiety, and the three tripartite dimensions were examined for the total sample and across four subgroups based on age and gender. High school girls reported more depression, anxiety, NA, and PH than the other groups, and lower PA as assessed by the PANAS-C, but not the AFARS. Using structural equation modeling, the tripartite model proved to be a reasonably good fit for the total sample. Among the subgroups, the best fit was found for high school girls. However, several findings for the total sample and for individual subgroups were not consistent with the tripartite model, raising issues related to the independence and specificity of the tripartite constructs and their measurement. Alternative age- and gender-specific models to better account for the shared and unique aspects of depression and anxiety in children need to be explored.

From diathesis to dimorphism: the biology of gender differences in depression

Unipolar depression is more common in women than men. We pursue a unifying explanation for the sex difference in the incidence of depression that emerges at puberty and is unlikely to be fully explained as an artifact or as a result of socialization or contemporary sex roles. Because symptomatic anxiety disorders show a similar female preponderance in women, we consider the biology of anxiety disorders and their links to depression. Rather than viewing gender as directly determining differential unipolar depression rates, we hypothesize a primary postpubertal effect of gonadal hormones on limbic system hyperactivity, which predisposes women to potentially higher rates of certain anxiety and depressive disorders.

Anxiety disorders in women

Women have higher overall prevalence rates for anxiety disorders than men. Women are also much more likely than men to meet lifetime criteria for each of the specific anxiety disorders: generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), social anxiety disorder (SAD), posttraumatic stress disorder (PTSD), simple phobia, panic disorder, and agoraphobia. Considerable evidence suggests that anxiety disorders remain underrecognized and undertreated despite their association with increased morbidity and severe functional impairment. Increasing evidence suggests that the onset, presentation, clinical course, and treatment response of anxiety disorders in women are often distinct from that associated with men. In addition, female reproductive hormone cycle events appear to have a significant influence on anxiety disorder onset, course, and risk of comorbid conditions throughout a woman's life. Further investigations concerning the unique features present in women with anxiety disorders are needed and may represent the best strategy to increase identification and optimize treatment interventions for women afflicted with these long-neglected psychiatric disorders.

Public health context of women's mental health research

As more attention is directed to the mental health care of women, sex and gender differences in research design and in regulatory policies have interfaced with clinical care and public policy. An emphasis on women's mental health issues in the provision of treatment and care as well as the design of large-scale screening strategies to identify and treat women with mental disorders promises to be effective public health approaches to reducing the burden of mental illness in women. The past decade has seen increased emphasis on women's mental health and sex/gender differences in the federal sector and in the research community. Federal regulations (summarized in the NIH Outreach Notebook) call for the inclusion of women and minorities in NIH-funded clinical research. The regulations also place emphasis on gender analysis of the results of clinical trials, in particular phase III trials, the findings of which are likely to influence practice. There has been substantial progress toward the goal of including women in research, but more remains to be done. A 2000 GAO report titled "Women's Health: NIH Has Increased Its Efforts to Include Women in Research" commended NIH for tracking the number of women in clinical research but the report also noted that relatively few NIH-funded studies, including major clinical trials, had reported findings by gender of study participants. This was seen as an impediment to progress in developing gender-based effective treatments. In the past decade, the women's health field has moved beyond an exclusive emphasis on women's reproductive function to one that defines health as a scientific enterprise to identify clinically important sex and gender differences in prevalence, etiology, course, and treatment of illnesses affecting men and women in the population as well as conditions specific to women. Nonetheless, for mental disorders, women's reproductive function and its impact on mental health conditions is still understudied. Based on the epidemiology of mental disorders, the course of mental disorders in women in relation to reproductive transitions remains an important issue for the mental health field because the burden of mental disorders, such as depression and anxiety, fall disproportionately on women of childbearing and childrearing age. The public health emphasis on women's mental health does not lessen the basic scientific opportunities to be had by a focus on gender and sex differences. A 2001 report of the Institute of Medicine titled "Exploring the Biological Contributions to Health: Does Sex Matter?" underscores the benefit to health care of looking for sex differences at the biological level. Basic and clinical neuroscience research is rapidly accruing a knowledge base that will provide information at the level of genes and cells of the influences of biological sex on mental health outcomes in both women and men. A focus on women's mental health and gender/sex differences research promises to yield improvement in treatments and services and thereby to improve the public health as well as to increase fundamental knowledge about the etiology and neurophysiology of mental disorders.

Gender differences in unipolar depression: an update of epidemiological findings and possible explanations

OBJECTIVE

To give an update on epidemiological findings on sex differences in the prevalence of unipolar depression and putative risk factors.

MATERIAL AND METHODS

Systematic review of the literature.

RESULTS

Recent epidemiological research yields additional evidence for a female preponderance in unipolar depression, holding true across different cultural settings. Current explanations include artefacts, genetic, hormonal, psychological and psychosocial risk factors. Rather consistently, intrapsychic and psychosocial gender role related risk factors have been identified which may contribute to the higher depression risk in women. Gender role aspects are also reflected in endocrine stress reactions and possibly influence associated neuropsychological processes.

CONCLUSION

There is a need for more integrative models taking into account psychological, psychosocial, and macrosocial risk factors as well as their interactions, which also connect these factors with physiological and endocrine responses. Furthermore, it is conceivable that across the life span, as well as across cultural settings, individual risk factors will add with varying emphasis to the higher prevalence of depression in women.

Point prevalence of psychiatric disorders during the second trimester of pregnancy: a population-based study

OBJECTIVE

This study was undertaken to determine the point prevalence of psychiatric disorders during the second trimester of pregnancy in a population-based sample of pregnant women.

STUDY DESIGN

Participants were 1795 consecutive pregnant women attending routine ultrasound screening at two obstetric clinics in Northern Sweden during 1 year. The Primary Care Evaluation of Mental Disorders (PRIME-MD) was used for evaluating.

RESULTS

Overall, 1734 (96.6%) of the women filled in the PRIME-MD patient questionnaire. Psychiatric disorders were present in 14.1% of the women. Major depression was prevalent in 3.3% of patients and minor depression in 6.9% of patients. Anxiety disorders were encountered in 6.6% of patients. Women with psychiatric disorders displayed significantly more somatic symptoms and more pronounced fear of childbirth. Among diagnosed patients, only 5.5% had some form of treatment.

CONCLUSION

The prevalence of mood and anxiety disorders in this unselected population of pregnant women was high and the majority of the women were found to be undiagnosed and untreated.

The roots of depression in adolescent girls: is menarche the key?

Before adolescence, the rates of depression are similar in girls and boys (or are slightly higher in boys). Yet with the onset of puberty, the gender proportion of depression dramatically shifts to a two girls to one boy ratio. What, then, is the relationship between menarche and the onset of major depression in early adolescence? Recent literature intimates that vulnerability to depression may be rooted in an intricate meld of genetic traits, normal female hormonal maturational processes, and gender socialization. Information regarding gender differences in the presentation of depressive symptoms is provided along with biologic, psychologic, and sociologic factors contributing to depression in adolescent girls. The burden of illness associated with onset of depression after menarche reinforces the importance of prevention or else expeditious recognition and intervention.

Residual symptoms in depression: an emerging therapeutic target

Residual symptoms, despite successful response to therapy, appear to be the rule in unipolar depression. Most of the residual symptoms occur in the prodromal phase of illness. Residual symptoms are associated with biological correlates, mainly involving the hypothalamic-pituitary-adrenal (HPA) axis and the sleep architecture. They are powerful predictors of relapse. These findings have led to the hypothesis that residual symptoms upon recovery may progress to become prodromal symptoms of relapse. A sequential strategy (encompassing pharmacotherapy in the acute phase of illness and cognitive behavioral therapy in its residual phase) has been developed and was found to be effective in decreasing relapse rate in controlled studies. A largely untested assumption in unipolar depression is that pharmacological strategies that are effective in the short term are the most suitable for postacute and residual phases or maintenance. The literature on subclinical symptomatology calls for specific, stage-oriented, therapeutic approaches. The efficacy of antidepressant drugs may be assessed not only on differential remission rates, but also on differential amount of residual symptomatology after response.

The relationship between parental diagnosis, offspring temperament and offspring psychopathology: a longitudinal analysis

BACKGROUND

The study examines the relationship between child temperament and a diagnosis of anxiety and/or depression as an adult and what influence parent psychopathology may have on the temperament-diagnosis relationship.

METHODS

The sample consists of 151 offspring who were initially selected as being at high or low risk for major depression on the basis of the presence or absence of a lifetime history of MDD in their parents. The parents and offspring were independently interviewed with a modified version of the Schedule for Affective Disorders and Schizophrenia-Lifetime (Mannuzza et al., 1986) and completed a battery of instruments which included the Dimensions of Temperament Survey (Lerner et al., 1982). They were interviewed three times during the course of the study: Time 1, Time 2, and Time 10.

RESULTS

There is a similar distribution of offspring disorders in the same parental diagnostic groups. There is a significant temperamental difference between the offspring of parents with a single disorder in comparison to offspring of parents with comorbid disorder. The former is characterized by significantly greater levels of adaptability/approachability. Low attention span at Time 1 is significantly predictive of an offspring lifetime diagnosis of major depression controlling for ADHD in comparison to offspring with neither disorder. Greater irritability, higher activity level and lower adaptability at Time 1 were significantly predictive of offspring lifetime diagnosis of comorbid disorder in comparison to the MDD only group.

LIMITATIONS

This is a retrospective cohort study using a temperament measure from Time 1 versus lifetime diagnoses and consisting of a relatively small sample size for several of the diagnostic categories.

CONCLUSIONS

There appears to be a link between parental psychopathology and offspring temperament. The data also provide further support for the notion that comorbid anxiety and depression disorder is a distinct entity in comparison to MDD only and new evidence that it may be predicted by a specific underlying temperament profile.

Gender differences in depression risk and coping factors in a clinical sample

OBJECTIVE

To examine gender differences in depression risk and coping factors in a clinical sample of patients with a diagnosis of DSM-IV major depression.

METHOD

Patients were assessed for substance use and abuse, family history of psychiatric disorder, interpersonal depressogenic factors and lifetime history of anxiety disorders. Trait anxiety, coping styles when depressed, parental bonding, marital features and personality style were also measured. Patients were reassessed at 12-month follow-up.

RESULTS

There were few gender differences in experience of depression (either in duration, type or severity prior to treatment) in a group with established episodes of major depression but women reported more emotional arousability when depressed. Women reported higher rates of dysfunctional parenting and childhood sexual abuse, and rated their partners as less caring and as more likely to be a depressogenic stressor. Men were more likely to have a generalized anxiety disorder at assessment, to use recreational drugs prior to presentation. Men were rated as having a more rigid personality style and 'Cluster A' personality traits both at assessment and follow-up.

CONCLUSION

There were few gender differences in severity or course of established episodes of major depression. Gender differences were related to levels of arousal, anxiety disorders, and repertoires for dealing with depression, rather than depressive symptoms per se.

Emergency mental health management in bioterrorism events

The United States has not suffered significant psychosocial or medical consequences from the use of biological weapons within its territories. This has contributed to a "natural" state of denial at the community level. This denial could amplify the sense of crisis, anxiety, fear, chaos, and disorder that would accompany such a bioterrorist event. A key part of primary prevention involves counteracting this possibility before an incident occurs. Doing so will require realistic information regarding the bioterrorism threat followed by the development of a planned response and regular practice of that response. Unlike in natural disasters or other situations resulting in mass casualties, emergency department physicians or nurses and primary care physicians (working in concert with epidemiologic agencies), rather than police, firemen, or ambulance personnel, will be most likely to first identify the unfolding disaster associated with a biological attack. Like community leaders, this group of medical responders must be aware of its own susceptibility to mental health sequelae and performance decrement as the increasing demands of disaster response outpace the availability of necessary resources. A bioterrorist attack will necessitate treatment of casualties who experience neuropsychiatric symptoms and syndromes. Although symptoms may result from exposure to infection with specific biological agents, similar symptoms may result from the mere perception of exposure or arousal precipitated by fear of infection, disease, suffering, and death. Conservative use of psychotropic medications may reduce symptoms in exposed and uninfected individuals, as may cognitive-behavioral interventions. Clear, consistent, accessible, reliable, and redundant information (received from trusted sources) will diminish public uncertainty about the cause of symptoms that might otherwise prompt persons to seek unnecessary treatment. Training and preparation for contingencies experienced in an attack have the potential to enhance delivery of care. Initiating supportive social, psychotherapeutic, and psychopharmacologic treatments judiciously for symptoms and syndromes known to accompany the traumatic stress response can aid the efficient treatment of some patients and reduce long-term morbidity in affected individuals. Preventive strategies and planning must take into account the idea that specific groups within the population are at higher risk for psychiatric morbidity. First responders comprise one group at psychologic risk in this situation, and healthcare providers comprise another. These and other high-risk groups will benefit from the same supportive interventions developed for the community as a whole.

Pediatric bipolar mood disorder

The diagnosis of bipolar mood disorder (BP) in preadolescents (pediatric mania) has generated considerable controversy in terms of its estimated prevalence and validity as a diagnostic category. The relative paucity of systematic studies and the current diagnostic confusion related to the disorder are often attributed to the apparent discontinuities in the childhood versus adult presentation of the illness, namely, irritability as the predominant "mood" of mania and a continuous course of symptoms. The goal of this article is to review the current literature and identify sources of confusion relating to pediatric mania by considering results to date within a larger context that include findings from studies on (1) BP illness in adults, (2) mood disorders across the lifespan, (3) the role of development in symptom expression, and (4) patterns of heritability in psychiatric disorders. Whereas much remains to be investigated in the validation of the diagnosis for children, integrating results across studies may provide a framework for understanding the differences in the presentation of severe mood disorders in children and adults.

Relation between anxiety and depressive disorders in childhood and adolescence

Current research indicates that there is a strong relationship between pediatric anxiety disorders and depression. Assessment measures show high rates of correlation between depression and anxiety and much of the overlap may be related to a common domain of negative affectivity. Anxious youth and depressed youth share a cognitive style marked by a negative bias in information processing. Anxiety disorders and depression are frequently comorbid in children and adolescents. About 25-50% of depressed youth have comorbid anxiety disorders and about 10-15% of anxious youth have depression. Twin and family studies have demonstrated that pediatric anxiety disorders and depression likely share some common genetic factors or influences. Selective serotonin reuptake inhibitors and cognitive-behavioral therapy have been shown in randomized controlled trials to be efficacious for both pediatric depression and anxiety disorders. Integrating the treatment literature with studies of phenomenology, biology and genetics indicates that pediatric anxiety disorders and depression may share a genetically determined neurobiological component that could involve neural circuits that include or are modulated by serotonergic neurons. This component could contribute to the negative affective temperament that appears to be common in both pediatric depression and anxiety disorders.

Graphing survival curve estimates for time-dependent covariates

Graphical representation of statistical results is often used to assist readers in the interpretation of the findings. This is especially true for survival analysis where there is an interest in explaining the patterns of survival over time for specific covariates. For fixed categorical covariates, such as a group membership indicator, Kaplan-Meier estimates (1958) can be used to display the curves. For time-dependent covariates this method may not be adequate. Simon and Makuch (1984) proposed a technique that evaluates the covariate status of the individuals remaining at risk at each event time. The method takes into account the change in an individual's covariate status over time. The survival computations are the same as the Kaplan-Meier method, in that the conditional survival estimates are the function of the ratio of the number of events to the number at risk at each event time. The difference between the two methods is that the individuals at risk within each level defined by the covariate is not fixed at time 0 in the Simon and Makuch method as it is with the Kaplan-Meier method. Examples of how the two methods can differ for time dependent covariates in Cox proportional hazards regression analysis are presented.

Patients with psychiatric disorders in gynecologic practice

OBJECTIVE

The relationship between different gynecologic complaints and somatic symptoms was studied in a gynecologic population in which the prevalence of psychiatric disorders had been established.

STUDY DESIGN

The prevalence of depression and anxiety in the unselected population of 1013 subjects was 27.2% and 12.1%, respectively, as assessed by the Primary Care Evaluation of Mental Disorders (PRIME-MD). The subjects' medical charts were reviewed after the PRIME-MD diagnosis was made.

RESULTS

Depression and anxiety disorders were significantly more common among those seeking care for abdominal pain, those who made frequent and unscheduled visits, and those who were hospitalized for acute care. All the physical symptoms indicated in the PRIME-MD Patient Health Questionnaire were more common among women with a psychiatric diagnosis compared with controls.

CONCLUSIONS

The majority of cases of depression and anxiety in women are undiagnosed and untreated, and patients with these disorders often present with physical symptoms. Because gynecologic outpatients with abdominal pain, frequent and unscheduled visits, and admissions due to acute illness are more likely to have a psychiatric disorder, it is desirable that gynecologists recognize and treat these problems.

Comorbidity of depression in children and adolescents: models and evidence from a prospective high-risk family study

Despite abundant research demonstrating the magnitude of comorbidity and its importance in understanding childhood psychopathology, there has been limited empirical research designed to examine the nature and causes of comorbidity among youth. This article reviews the current literature on the magnitude and mechanisms of depressive comorbidity and presents data to exemplify the application of high-risk and longitudinal study designs to investigate patterns and explanations for comorbidity. A prospective family study of offspring at high and low risk for the development of anxiety was used to examine the specificity of familial comorbidity of depression and anxiety and the longitudinal stability of "pure" and comorbid disorders over an 8-year period. Findings suggest some specificity of familial expression, as well as longitudinal specificity, of depression and anxiety. The onset of depression follows the onset of most anxiety subtypes, suggesting the sequential nature of depressive comorbidity. Evaluation of mechanisms for comorbidity is important for the identification of homogeneous syndrome categories that will inform research designed to gain understanding of the pathogenesis of mood or anxiety disorders.

Is any female preponderance in depression secondary to a primary female preponderance in anxiety disorders?

OBJECTIVE

National community studies consistently identify higher rates of both depressive and anxiety disorders in women. The female preponderance in depression could be primary or, alternatively, a sex difference in anxiety could determine the differential depression rates. We therefore pursue whether the female preponderance in depression is secondary to a female preponderance in anxiety disorders in a community sample.

METHOD

We analyse relevant data from the National Comorbidity Study (NCS) database, examining in particular whether sex differences in anxiety (here those meeting criteria for panic disorder, agoraphobia without panic disorder, generalized anxiety and social phobia) influenced sex differences in the prevalence of both major depression and dysthymia.

RESULTS

Survival analyses indicated that, for both major depression and dysthymia, and within subsamples of those with early onset and late onset depression, both female sex and a preceding anxiety disorder made significant contributions, with preceding anxiety making the consistently stronger contribution of the two.

CONCLUSION

A proportion of the female preponderance in major depression and dysthymia in the general community appears determined by a primary sex difference in anxiety.

Corticosteroids in relation to fear, anxiety and psychopathology

Corticosteroids play extremely important roles in fear and anxiety. The mechanisms by which corticosteroids exert their effects on behavior are often indirect, because, although corticosteroids do not regulate behavior, they induce chemical changes in particular sets of neurons making certain behavioral outcomes more likely in certain contexts as a result of the strengthening or weakening of particular neural pathways. The timing of corticosteroid increase (before, during or after exposure to a stressor) determines whether and how behavior is affected. The present review shows that different aspects of fear and anxiety are affected differentially by the occupation of the mineralocorticoid receptor (MR) or glucocorticoid receptor (GR) at different phases of the stress response. Corticosteroids, at low circulating levels, exert a permissive action via brain MRs on the mediation of acute freezing behavior and acute fear-related plus-maze behavior. Corticosteroids, at high circulating levels, enhance acquisition, conditioning and consolidation of an inescapable stressful experience via GR-mechanisms. Brain GR-occupation also promotes processes underlying fear potentiation. Fear potentiation can be seen as an adjustment in anticipation of changing demands. However, such feed-forward regulation may be particularly vulnerable to dysfunction. MR and/or GR mechanisms are involved in fear extinction. Brain MRs may be involved in the extinction of passive avoidance, and GRs may be involved in mediating the extinction of active avoidance. In the developing brain, corticosteroids play a facilitatory role in the ontogeny of freezing behavior, probably via GRs in the dorsal hippocampus, and their influence on the development of the septo-hippocampal cholinergic system. Corticosteroids can exert maladaptive rather than adaptive effects when their actions via MRs and GRs are chronically unbalanced due to chronic stress. Both mental health of humans and animal welfare is likely to be seriously threatened after psychosocial stress, prolonged stress, prenatal stress or postnatal stress, especially when maternal care or social support is absent, because these can chronically dysregulate the central MR/GR balance. In such circumstances the normally adaptive corticosteroid responses can become maladaptive.

Prevalence of psychiatric disorders in gynecologic outpatients

OBJECTIVE

This study was undertaken to determine the point prevalence of psychiatric disorders in an unselected gynecologic population.

STUDY DESIGN

Participants were 1013 consecutive women attending 2 outpatient gynecology clinics in northern Sweden between November 16 and December 15, 1998. The Primary Care Evaluation of Mental Disorders (PRIME-MD) was used as a diagnostic tool for evaluating mood, anxiety, and eating disorders.

RESULTS

Overall, 897 patients (88.5%) filled in the diagnostic tool's patient questionnaire. Psychiatric disorders were present in 30.5% of the patients. Mood disorders were most common; major depression was prevalent in 10.1% of patients and minor depression was seen in 12.4% of patients. Anxiety disorders were also common and were encountered in 12.1% of patients. Among patients with a diagnosis, only 21.4% had some form of treatment.

CONCLUSIONS

The prevalence of mood and anxiety disorders in an outpatient gynecology clinic is high. The majority of women with a diagnosis based on the diagnostic tool did not have a previous diagnosis and were untreated.

Gender differences in depression. Critical review

BACKGROUND

With few exceptions, the prevalence, incidence and morbidity risk of depressive disorders are higher in females than in males, beginning at mid-puberty and persisting through adult life.

AIMS

To review putative risk factors leading to gender differences in depressive disorders.

METHOD

A critical review of the literature, dealing separately with artefactual and genuine determinants of gender differences in depressive disorders.

RESULTS

Although artefactual determinants may enhance a female preponderance to some extent, gender differences in depressive disorders are genuine. At present, adverse experiences in childhood, depression and anxiety disorders in childhood and adolescence, sociocultural roles with related adverse experiences, and psychological attributes related to vulnerability to life events and coping skills are likely to be involved. Genetic and biological factors and poor social support, however, have few or no effects in the emergence of gender differences.

CONCLUSIONS

Determinants of gender differences in depressive disorders are far from being established and their combination into integrated aetiological models continues to be lacking.

Gender differences in the rate of comorbid axis I disorders in depressed outpatients

We examined gender differences in comorbid Axis I disorders in 236 outpatients with major depression. Axis I comorbidity, age of onset of depression and comorbid disorder were assessed with the SCID-P. Depression severity was assessed with the HAM-17. The results indicated that males had a higher rate of comorbid substance abuse/dependence, while females had a higher rate of comorbid bulimia nervosa. These results are consistent with previous research, with the marked exception that females did not have higher rates of anxiety disorders in general, and in particular, panic disorder, simple and social phobia, obsessive-compulsive disorder and agoraphobia. It is concluded that the female predominance in anxiety disorders found in general population studies may be due to comorbidity with depression.

Trouble sleeping and anxiety/depression in childhood

The purpose of this report was to estimate the association between children's trouble sleeping and anxiety/depression at ages 6 and 11, cross-sectionally and prospectively. Data come from a study of the psychiatric sequelae of low birth weight (LBW: <2500 g). LBW and normal birth weight children were randomly selected from the 1983-1985 newborn lists of an urban and a suburban hospital. Eight hundred and twenty-three children participated at age 6 and, of those, 717 (87.1%) participated at age 11. Achenbach's Child Behavior Checklist (CBCL) and the Teacher Report Form (TRF) were used to obtain ratings of psychiatric problems. The CBCL asked if the child had trouble sleeping during the past 6 months. Children with trouble sleeping had significantly increased odds of anxiety/depression based on mothers' reports (OR=6.9, 95% CI 4.1-11. 4) but not teachers' reports (OR=1.1, 95% CI 0.4-2.7). There was a greater association between sleep and depression at age 11 than at age 6, and among suburban than among urban children. These findings remained when adjusted for birthweight, sex, and mother's history of major depressive disorder. Profile analysis indicated a stronger association of trouble sleeping with anxiety/depression than other psychiatric problems. The association of trouble sleeping at age 6 with incidence of depression at age 11 was not statistically significant (suburban children RR=2.22, 95% CI 0.53-9.23; urban children RR=0.92, 95% CI 0.20-4.18).

Future directions in anxiety disorders: profiles and perspectives of leading contributors

Eight of the most influential clinicians and researchers in the study and treatment of anxiety disorders were identified by polling professional members of the Anxiety Disorders Association of America. These eight individuals are (in alphabetical order): James C. Ballenger, David H. Barlow, Aaron T. Beck, David M. Clark, Edna B. Foa, Rick G. Heimberg, Donald F. Klein, and Isaac M. Marks. Each offered their thoughts on a set of questions concerning the current and future status of the anxiety disorders field. Profiles and perspectives of these individuals are presented.

Gender differences in the recognition of depression in old age

OBJECTIVE

The study should answer the question of whether identical symptom presentations of depression in male and female patients leads to similar recognition rates in primary care.

METHOD

We performed a survey in primary care. Two written case vignettes were presented to 170 family physicians in a face-to-face interview which took place in their practices. The case vignettes described either a mildly depressed otherwise healthy old patient (case 1) or a severely depressed patient with somatic comorbidity (case 2). For each case different versions with regard to patients' gender were used: in case 1 only the gender of the patient varied; in case 2 both the gender and the anamnesis (stroke/hypothyroidism) varied. Afterwards the interviewers asked standardised open questions. The physicians were not aware of the mental health focus and the gender focus of the study.

RESULTS

The study is representative with a response rate of 77.6%. For primary diagnosis, the female versions were given the diagnosis of depression more often. There was a non-significant trend that female physicians considered depression more often.

CONCLUSION

The results show that gender-related experience and stereotypes on the physicians' side influence the diagnosis of (old age) depression in primary care. Further studies should elucidate the influence of the physicians' gender on the management of psychiatric disorders.

Psychological predictors of single and recurrent major depressive episodes

AIM

To examine for differential psychological risk factors in a nonclinical sample having single or recurrent episodes of major depression.

METHODS

A cohort of 164 subjects was assessed initially in 1978 in their last year of teacher training, and at five-yearly intervals in 1983, 1988 and 1993. Experience of episodes of DSM major depression and anxiety disorders from each wave were summed and three groups (nil, one, and two or more episodes of major depression) were derived. The cohort also completed a series of self-report measures including neuroticism, state and trait depression, self-esteem, dependency, childhood parental environment and social support.

RESULTS

The group with two or more episodes were distinctly more likely to have met lifetime criteria for an anxiety disorder and to have had multiple anxiety disorder diagnoses over their lifetime. Groups with one or more episodes reported higher mean scores for trait depression, neuroticism and maternal overprotection and lower mean scores for paternal care and self esteem at baseline in 1978, but these variables did not predict differences between groups with single and recurrent episodes. At 1993, those with two or more episodes differed from those with none and single episodes in reporting lower trait depression scores and decreased perception of satisfactory social support over time, suggesting a psychological scarring effect for those with repeated episodes.

Gender differences in the prevalence of depression: a survey in primary care

Epidemiological surveys demonstrate that unipolar depression is more common in females than in males. Gender-specific cultural and social factors may contribute to the female preponderance. This study explores this possibility in a cross-cultural sample of general-practice patients systematically recruited in the WHO study "Psychological Problems in Primary Care" conducted in 14 countries with identical sampling and assessment strategies. Although absolute prevalence rates are broadly varying between centers proposing that the gender ratio is nearly constant with 1:2. The cultural context does not contribute substantially to the female preponderance. This study lends some support to previous observations that the magnitude of female preponderance is associated with the number of symptoms associated with depression requested for caseness and inversely related to the degree of social impairment. Matching social role variables (marital status, children, occupational status) between females and males reduces the female excess by about 50% across all centers. Therefore, we conclude that social factors are inducing part of the preponderance of females among depressed cases.

Effectiveness of Intervention Into SUBSTANCE ABUSE DISORDERS in Women With Comorbid Depression

Victimization was supported by the occurrence of various forms of abuse--sexual, physical, and emotional--and the difficulty in establishing healthy intimate relationships. Because relapse is common, nurses must be alert for faulty negative thinking, behaviors, and feelings that might lead to relapse.

Gay, lesbian, and bisexual youth risks for emotional, physical, and social problems: results from a community-based survey

OBJECTIVE

Health problems of gay, lesbian, and bisexual (GLB) youth are reported as differing from those of heterosexual youth. Increased depression, suicide, substance use, homelessness, and school dropout have been reported. Most studies of GLB youth use clinical or convenience samples. The authors conducted a community school-based health survey that included an opportunity to self-identify as GLB.

METHOD

An anonymous self-report health care questionnaire was used during a community-based survey in 2 high schools in an upper middle class district.

RESULTS

Significantly increased health risks for self-identified GLB youth were found in mental health, sexual risk-taking, and general health risks compared with self-identified heterosexuals, but not in health domains associated with substance abuse, homelessness, or truancy.

CONCLUSIONS

Self-identified GLB youth in community settings are at greater risk for mental health, sexual risk-taking, and poorer general health maintenance than their heterosexual peers.

Serotonin receptor 1A knockout: an animal model of anxiety-related disorder

To investigate the contribution of individual serotonin (5-hydroxytryptamine; 5-HT) receptors to mood control, we have used homologous recombination to generate mice lacking specific serotonergic receptor subtypes. In the present report, we demonstrate that mice without 5-HT1A receptors display decreased exploratory activity and increased fear of aversive environments (open or elevated spaces). 5-HT1A knockout mice also exhibited a decreased immobility in the forced swim test, an effect commonly associated with antidepressant treatment. Although 5-HT1A receptors are involved in controlling the activity of serotonergic neurons, 5-HT1A knockout mice had normal levels of 5-HT and 5-hydroxyindoleacetic acid, possibly because of an up-regulation of 5-HT1B autoreceptors. Heterozygote 5-HT1A mutants expressed approximately one-half of wild-type receptor density and displayed intermediate phenotypes in most behavioral tests. These results demonstrate that 5-HT1A receptors are involved in the modulation of exploratory and fear-related behaviors and suggest that reductions in 5-HT1A receptor density due to genetic defects or environmental stressors might result in heightened anxiety.

Predictors of treatment efficacy in a clinical trial of three psychosocial treatments for adolescent depression

OBJECTIVE

To assess the predictors of treatment outcome across treatments, as well as those associated with differential treatment response.

METHOD

One hundred seven adolescent outpatients, aged 13 to 18 years, with DSM-III-R major depression were randomly assigned to one of three manual-based, brief (12 to 16 sessions) psychosocial treatments: cognitive-behavioral therapy (CBT), systemic-behavioral family therapy, or nondirective supportive therapy. Those with good and poor outcomes were compared.

RESULTS

Continued depression was predicted by clinical referral (versus via advertisement) and was in part mediated by hopelessness. Other predictors of depression were comorbid anxiety disorder and higher levels of cognitive distortion and hopelessness at intake. Achievement of clinical remission was predicted by a higher level of self-reported depression. Poorer functional status was predicted by a higher level of initial interviewer-rated depression. Comorbid anxiety and maternal depressive symptoms predicted differential treatment efficacy. CBT's performance continued to be robust with respect to nondirective supportive therapy, even in the presence of the above-noted adverse predictors.

CONCLUSION

Predictors of poor outcome may give clues as to how to boost treatment response. Subjects who come to treatment for clinical trials via advertisement (versus clinical referral) may show more favorable treatment responses. CBT is likely to be a robust intervention even in more complex and difficult-to-treat patients.

Lack of ovarian steroid hormone regulation of norepinephrine transporter mRNA expression in the non-human primate locus coeruleus

Decreases in ovarian steroids can negatively affect mood, and drugs which block the norepinephrine transporter (NET) or the serotonin transporter (SERT) alleviate depression. However, the respective contribution of the noradrenergic and serotonergic systems may vary depending upon the etiology of the depression. We previously demonstrated that E and P alter gene expression for tryptophan hydroxylase (TPH) and for the serotonin reuptake transporter (SERT) in raphe neurons of the rhesus monkey. In this study, we questioned whether the noradrenergic system contributes to depression related to the reproductive function in women, using a non-human primate model of the menstrual cycle. The effect of estrogen (E) or E plus progesterone (P) on the expression of the NET gene in the locus coeruleus (LC) was examined with in situ hybridization for NET mRNA. In addition, we questioned whether the neurons of the LC contain nuclear E or P receptors (ER/PR). Hence, immunocytochemistry for ER and PR were performed on adjacent sections. Treatment groups consisted of monkeys (n = 4 per treatment) which were ovariectomized/hysterectomized (spayed), E-treated (28 days) and E+P-treated (14 days E, +14 days E+P). Expression of mRNA for NET was unchanged at any level of the LC due to steroid treatment (p > .05). Neither ER nor PR were detected in the LC of any treatment group. Therefore, E and P in a treatment paradigm which mimics the menstrual cycle do not directly regulate NET mRNA expression in the non-human primate LC. In addition, the noradrenergic neurons of the primate LC lack nuclear receptors for ovarian steroids. These data suggest that the noradrenergic system may not contribute significantly to depression related to changes in ovarian hormones.

Lifetime comorbidity among anxiety disorders and between anxiety disorders and other mental disorders in adolescents

We examine the lifetime comorbidity among anxiety disorders, and between anxiety disorders and other mental disorders, in a large (n = 1,507) community sample of high school students on whom extensive diagnostic data were available. Three diagnostic groups were formed: those with a lifetime anxiety disorder (n = 134); those with a nonanxiety disorder (n = 510); and those who had never met criteria for a mental disorder (n = 863). The intra-anxiety comorbidity rate was relatively low (18.7%), and was strongly associated with being female (92%). The lifetime comorbidity between anxiety and other mental disorders (primarily MDD) was substantial (73.1%) and was not associated with being female.

The Screen for Child Anxiety Related Emotional Disorders (SCARED): scale construction and psychometric characteristics

OBJECTIVE

To develop a reliable and valid child and parent self-report instrument to screen children with anxiety disorders.

METHOD

An 85-item questionnaire was administered to 341 outpatient children and adolescents and 300 parents. Utilizing item analyses and factor analyses, the original scale was reduced to 38 items. A subsample of children (n = 88) and parents (n = 86) was retested an average of 5 weeks (4 days to 15 weeks after the initial screening.

RESULTS

The child and parent Screen for Child Anxiety Related Emotional Disorders (SCARED) both yielded five factors: somatic/panic, general anxiety, separation anxiety, social phobia For the total score and each of the five factors, both the child and parent SCARED demonstrated good internal consistency (alpha = .74 to .93), test-retest reliability (intraclass correlation coefficients = .70 to .90), discriminative validity (both between anxiety and other disorders and within anxiety disorders), and moderate parent-child agreement (r = .20 to .47, p < .001, all correlations).

CONCLUSIONS

The SCARED shows promise as a screening instrument for anxiety disorders. Future studies using the SCARED in community samples are indicated.