Age-specific familial risks of anxiety. A nation-wide epidemiological study from Sweden

Assessment and Treatment of Anxiety Among Children and Adolescents

Among children and adolescents, anxiety disorders are common psychiatric disorders that confer risk of comorbid psychiatric disorders and social and academic impairment. This review focuses on the assessment and treatment of anxiety disorders among children and adolescents, with attention to separation anxiety disorder, social phobia disorder (social anxiety disorder), panic disorder, and generalized anxiety disorder. Comprehensive assessment of child and adolescent anxiety disorders benefits from a multimethod approach to evaluation and diagnosis, including semistructured interviews; child and informant questionnaires; collateral information from parents, teachers, pediatricians, and school psychologists; and behavioral observations. Because anxiety symptoms can include avoidance behaviors, somatic complaints, social difficulties, and sleep disturbances, consideration of a differential diagnosis is important. Among the available psychosocial interventions, cognitive-behavioral therapy (CBT) and exposure-based therapies have emerged as the most well-established treatment approaches for addressing anxiety disorders among children and adolescents. Pharmacologically, selective serotonin reuptake inhibitors (SSRIs) have been established to be safe and efficacious for the treatment of pediatric anxiety and are considered the medications of choice for this population. Research indicates that CBT plus SSRI medication is the most effective treatment of anxiety for youths ages seven to 17, compared with either CBT or medication alone. Medication monotherapy and CBT monotherapy have also been demonstrated to be effective treatments.

Is the use of antidepressants associated with patient-reported outcomes following total hip replacement surgery?

Background and purpose - Patients with anxiety and/or depression tend to report less pain reduction and less satisfaction with surgical treatment. We hypothesized that the use of antidepressants would be correlated to patient-reported outcomes (PROs) 1 year after total hip replacement (THR), where increased dosage or discontinuation would be associated with worse outcomes. Patients and methods - THR cases with pre- and postoperative patient-reported outcome measures (PROMs) were selected from the Swedish Hip Arthroplasty Register (n = 9,092; women: n = 5,106). The PROMs were EQ-5D, visual analog scale (VAS) for pain, Charnley class, and VAS for satisfaction after surgery. These cases were merged with a national database of prescription purchases to determine the prevalence of antidepressant purchases. Regression analyses were performed where PROs were dependent variables and sex, age, Charnley class, preoperative pain, preoperative health-related quality of life (HRQoL), patient-reported anxiety/depression, and antidepressant use were independent variables. Results - Antidepressants were used by 10% of the cases (n = 943). Patients using antidepressants had poorer HRQoL and higher levels of pain before and after surgery and they experienced less satisfaction. Preoperative antidepressant use was independently associated with PROs 1 year after THR regardless of patient-reported anxiety/depression. Interpretation - Antidepressant usage before surgery was associated with reduced PROs after THR. Cases at risk of poorer outcomes may be identified through review of the patient's medical record. Clinicians are encouraged to screen for antidepressant use preoperatively, because their use may be associated with PROs after THR.

Cross-generational influences on childhood anxiety disorders: pathways and mechanisms

Anxiety disorders are common across the lifespan, cause severe distress and impairment, and usually have their onset in childhood. Substantial clinical and epidemiological research has demonstrated the existence of links between anxiety and its disorders in children and parents. Research on the pathways and mechanisms underlying these links has pointed to both behavioral and biological systems. This review synthesizes and summarizes several major aspects of this research. Behavioral systems include vicarious learning, social referencing, and modeling of parental anxiety; overly protective or critical parenting styles; and aspects of parental responses to child anxiety including family accommodation of the child's symptoms. Biological systems include aspects of the prenatal environment affected by maternal anxiety, development and functioning of the oxytocinergic system, and genetic and epigenetic transmission. Implications for the prevention and treatment of child anxiety disorders are discussed, including the potential to enhance child anxiety treatment outcomes through biologically informed parent-based interventions.

Parental involvement: contribution to childhood anxiety and its treatment

Anxiety disorders are prevalent in youth. Despite demonstrated efficacy of cognitive behavioral therapy (CBT), approximately 40% of anxiety-disordered youth remain unresponsive to treatment. Because developmental and etiological models suggest that parental factors are relevant to the onset and maintenance of childhood anxiety, researchers have proposed and investigated family-based interventions with increased parent work in treatment, aiming to improve the efficacy of treatment for childhood anxiety. However, contrary to what theoretical models suggest, data to date did not indicate additive benefit of family-based CBT in comparison with child-centered modality. Is parent/family involvement unnecessary when treating childhood anxiety disorders? Or could there be the need for specificity (tailored family-based treatment) that is guided by a revised conceptualization that improves the implementation of a family-based intervention? The current review examines (1) relevant parental factors that have been found to be associated with the development and maintenance of childhood anxiety and (2) interventions that incorporate parental involvement. Relevant findings are integrated to formulate a "targeted" treatment approach for parental involvement in CBT for youth anxiety. Specifically, there is potential in the assessment of parent/family factors prior to treatment (for appropriateness) followed by a target-oriented implementation of parent training.

Family load estimates and risk factors of anxiety disorders in a nationwide three generation study

The present study investigated how often anxiety disorders with different ages of onset occurred in affected families compared to control families. Furthermore, the study addressed the impact of sex, region of residence, year and month of birth, and parental age at birth. The sample included N=1373 child and adolescent psychiatric participants born between 1952 and 2000 and registered in the Danish Psychiatric Central Register (DPCR) who developed an anxiety disorder before the age of 18. N =4019 controls without any psychiatric diagnosis before age 18, were matched for age, sex, and residential region. Psychiatric diagnoses were also obtained for parents, siblings, and offspring. A family load component was obtained by using various mixed regression models. Anxiety disorders occurred significantly more often in case than in control families. Having a mother, father, or a sibling with the disorder was proven to be a risk factor. Female sex, year of birth, and region of residence were also associated with having an anxiety disorder. Furthermore, case relatives did not develop an anxiety disorder earlier than control relatives. These findings, based on a very large and representative dataset, provide further and solid evidence for the family aggregation of anxiety disorders.

Sibling risk of anxiety disorders based on hospitalizations in Sweden

AIMS

This study used nationwide hospital records to examine sibling risk of any type of anxiety disorder in Sweden over a 40-year period.

METHODS

This study, carried out between 1 January 1968 and 31 December 2007, of the entire population of Sweden, linked information on family relationships from the nationwide Multi-Generation Register with information from the nationwide Swedish Hospital Discharge Register on first diagnosis of anxiety disorder. A total of 42,602 persons hospitalized for anxiety disorders and 2093 affected siblings were identified. Standardized incidence ratios (SIR) were calculated by comparing risk in siblings of persons hospitalized for anxiety disorders with risk in persons whose siblings had no hospital diagnosis of anxiety disorders.

RESULTS

The sibling risk was 2.26, which was independent of sex and age differences between siblings. The SIR was highest in siblings <20 years of age (2.83). Analysis of risk by subtype showed that having a sibling diagnosed with any anxiety disorder resulted in increased risks of a number of disorders; the highest increased risk was of social phobia (SIR 3.68, 95% confidence interval, 1.68-7.69). Risk of panic disorder, generalized anxiety disorder, mixed anxiety and depressive disorder, and obsessive-compulsive disorder was raised in female but not male siblings.

CONCLUSIONS

Heritable effects likely play an important role in the cause of anxiety disorders, but the extent of their role remains to be established. Important contributions could be made by studies of gene-environment interactions that have sufficient sample sizes to produce reliable results.

Childhood adversity and chronicity of mood disorders

To evaluate the potential impact of early childhood problems on the chronicity of mood disorders. A representative cohort from the population was prospectively studied from ages 19/20 to 39/40. Unipolar (UP) and bipolar disorders (BP) were operationally defined applying broad Zurich criteria for bipolarity. Chronicity required the presence of symptoms for more days than not over 2 years prior to an interview, or almost daily occurrence for 1 year. A family history and a history of childhood problems were taken at ages 27/28 and 29/30. Data include the first of multiple self-assessments with the Symptom-Checklist-90 R at age 19/20, and mastery and self-esteem assessed 1 year later. A factor analysis of childhood problems yielded two factors: family problems and conduct problems. Sexual trauma, which did not load on either factor, and conduct problems were unrelated to chronicity of UP or BP or both together. In contrast, childhood family problems increased the risk of chronicity by a factor of 1.7. An anxious personality in childhood and low self-esteem and mastery in early adulthood were also associated with chronicity. Childhood family problems are strong risk factors for the chronicity of mood disorders (UP and BP). The risk may be mediated partly by anxious personality traits, poor coping and low self-esteem.