Psychiatric comorbidity and depression in older adults

Trust and easy access to home care staff are associated with older adults' sense of security: a Swedish longitudinal study

AIM

Older adults are increasingly encouraged to continue living in their own homes with support from home care services. However, few studies have focused on older adults' safety in home care. This study explored associations between the sense of security and factors related to demographic characteristics and home care services.

METHODS

The mixed longitudinal design was based on a retrospective national survey. The study population consisted of individuals in Sweden (aged 65+ years) granted home care services at any time between 2016 and 2020 (n=82,834-94,714). Multiple ordinal logistic regression models were fitted using the generalised estimation equation method to assess the strength of relationship between the dependent (sense of security) and independent (demographics, health and care-related factors) variables.

RESULTS

The sense of security tended to increase between 2016 and 2020, and was significantly associated with being a woman, living outside big cities, being granted more home care services hours or being diagnosed/treated for depression (cumulative odds ratio 2-9% higher). Anxiety, poor health and living alone were most strongly associated with insecurity (cumulative odds ratio 17-64% lower). Aside from overall satisfaction with home care services, accessibility and confidence in staff influenced the sense of security most.

CONCLUSIONS

We stress the need to promote older adults' sense of security for safe ageing in place, as mandated by Swedish law. Home care services profoundly influence older adults' sense of security. Therefore, it is vital to prioritise continuity in care, establish trust and build relationships with older adults. Given the increasing shortage of staff, integrating complementary measures, such as welfare technologies, is crucial to promoting this sense of security.

Is acceptance and commitment therapy helpful in reducing anxiety symptomatology in people aged 65 or over? A systematic review

Anxiety-related mental health problems constitute a health challenge, especially in the elderly population. At present, there are few psychological treatments to reduce anxiety adapted to this group. The aim of this study was to conduct a systematic review of the literature to determine the therapeutic effects of Acceptance and Commitment Therapy (ACT) on anxiety in older adults, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Two blinded reviewers participated in the search, selection and methodological quality assessment processes; reaching satisfactory levels of agreement between reviewers (κ > 0.70). The search was performed in PubMed, Proquest Central, Scopus and Web of Science; making use of standardized terms for the construction of the algorithm. In the general search 348 studies were found. After applying the eligibility criteria and excluding duplicates, seven articles were extracted for qualitative analysis. The total number of subjects was 633, with an average age of 68.89 years (68.94% women). The analysis of methodological rigor showed moderate indices on average. The publications focused primarily on samples with a diagnosis of generalized anxiety disorder, proposing a variety of assessment tests for related dependent variables, especially depressive symptoms and psychological flexibility. Critical analysis of the findings provides evidence for the efficacy of ACT in reducing anxious and depressive symptoms in older adults. This study proposes the use of this procedure as a non-pharmacological alternative for a group usually underrepresented in the scientific literature on this topic.

Eating Behavior in Aging and Dementia: The Need for a Comprehensive Assessment

Eating behavior can change during aging due to physiological, psychological, and social changes. Modifications can occur at different levels: (1) in food choice, (2) in eating habits, and (3) in dietary intake. A good dietary behavior, like the Mediterranean dietary pattern, can be a protective factor for some aging related pathologies, such as dementia, while a worse eating behavior can lead to pathological conditions such as malnutrition. Changes in eating behavior can also be linked to the onset of dementia: for some types of dementia, such as frontotemporal dementia, dietary changes are one of the key clinical diagnostic feature, for others, like Alzheimer's disease, weight loss is a clinical reported feature. For these reasons, it is important to be able to assess eating behavior in a proper way, considering that there are normal age-related changes. An adequate assessment of dietary behavior can help to plan preventive intervention strategies for heathy aging or can help to identify abnormal behaviors that underline aging related-diseases. In this review, we have analyzed normal age-related and dementia-related changes and the tools that can be used to assess eating behavior. Thus, we make recommendations to screening and monitoring eating behavior in aging and dementia, and to adopt these tools in clinical practice.

The effects of mindfulness-based stress reduction on depression, anxiety, and stress in older adults: A systematic review and meta-analysis

Mindfulness-based stress reduction (MBSR) has been widely used to improve various physical and mental conditions. Studies show the intervention is particularly effective in alleviating depression, anxiety, and stress in working-aged adults. No recent systematic review has focused on the use of MBSR in older adults. This study aims to examine the effects of MBSR intervention on depression, anxiety, and stress symptoms of older adults. Five electronic databases were searched for relevant randomized controlled trials (RCTs) published between 1990 and 2017. Six eligible studies were included and computed for meta-analysis. The methodological quality and risk of biases across the included RCTs were assessed using the Cochrane risk of bias assessment tool. Overall, the amount of evidence is limited and of relatively low quality. The results of this review provide evidence that the MBSR is more effective than wait-list-control group to reduce depression in older adults with clinically significant symptoms immediately following the intervention. However, there is no clear evidence that the intervention reduced the perception of stress and anxiety, or that positive effects are maintained over the longer term. More robust studies involving larger sample sizes and using longer follow-up measurements are required.

Collaborative Care for Psychiatric Disorders in Older Adults: A Systematic Review

OBJECTIVE

To evaluate the mode of implementation, clinical outcomes, cost-effectiveness, and the factors influencing uptake and sustainability of collaborative care for psychiatric disorders in older adults.

DESIGN

Systematic review.

SETTING

Primary care, home health care, seniors' residence, medical inpatient and outpatient.

PARTICIPANTS

Studies with a mean sample age of 60 years and older.

INTERVENTION

Collaborative care for psychiatric disorders.

METHODS

PubMed, MEDLINE, Embase, and Cochrane databases were searched up until October 2016. Individual randomized controlled trials and cohort, case-control, and health service evaluation studies were selected, and relevant data were extracted for qualitative synthesis.

RESULTS

Of the 552 records identified, 53 records (from 29 studies) were included. Very few studies evaluated psychiatric disorders other than depression. The mode of implementation differed based on the setting, with beneficial use of telemedicine. Clinical outcomes for depression were significantly better compared with usual care across settings. In depression, there is some evidence for cost-effectiveness. There is limited evidence for improved dementia care and outcomes using collaborative care. There is a lack of evidence for benefit in disorders other than depression or in settings such as home health care and general acute inpatients. Attitudes and skill of primary care staff, availability of resources, and organizational support are some of the factors influencing uptake and implementation.

CONCLUSIONS

Collaborative care for depressive disorders is feasible and beneficial among older adults in diverse settings. There is a paucity of studies on collaborative care in conditions other than depression or in settings other than primary care, indicating the need for further evaluation.

Differences in prescribing psychotropic drugs for elderly with depression

OBJECTIVE

The escalating tendency of elderly population aged 65 and over, which grown up to 9% since 2001 in Taiwan, remarks the important issue of mental health among ageing population. Depression in the elderly is frequently undetected or inadequately treated. This study aimed to investigate the pharmacotherapy of elderly patients with depression by comparing the patterns of prescribing psychotropic drugs (psychotropics) of psychiatrists and non-psychiatrists.

METHODS

A random sampling of 5% of inpatients from the National Health Insurance (NHI) database in Taiwan from 2001 to 2003 was selected. In all, 1058 (0.9%) inpatients aged 65 and older with a diagnosis of any depressive disorder were included. The psychotropic prescribing pattern and the dosages used were analysed and compared. Physician specialties were based on the record of NHI database. Non-psychiatrists were defined by physicians other than psychiatry.

RESULTS

A total of 88% of elderly depressed inpatients had two or more comorbid physical illnesses. The most commonly prescribed psychotropics were: antidepressants (71.4%), anxiolytics (62.6%) and hypnotics (51.4%). Psychiatrists had a higher rate of prescribing psychotropics, except anxiolytics, than non-psychiatrists. Although selective serotonin reuptake inhibitors were commonly prescribed, non-psychiatrists preferred the use of tricyclic antidepressants and moclobemide. Trazodone was the most preferred antidepressant, but was generally used in low dosages.

CONCLUSION

Psychiatrists generally utilised higher dosages of newer antidepressants than non-psychiatrists. Differences in the prescribing pattern of psychotropics existed between physician specialties. Further investigations are warranted to determine how the selection and dosing of drugs influence the outcome of depression on the elderly.

Deconstructing Chronic Low Back Pain in the Older Adult: Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment: Part IV: Depression

OBJECTIVE

To present the fourth in a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults. The series presents CLBP as a syndrome, a final common pathway for the expression of multiple contributors rather than a disease localized exclusively to the lumbosacral spine. Each article addresses one of twelve important contributors to pain and disability in older adults with CLBP. This article focuses on depression.

METHODS

The evaluation and treatment algorithm, a table articulating the rationale for the individual algorithm components, and stepped-care drug recommendations were developed using a modified Delphi approach. The Principal Investigator, a three-member content expert panel, and a nine-member primary care panel were involved in the iterative development of these materials. The algorithm was developed keeping in mind medications and other resources available within Veterans Health Administration (VHA) facilities. As panelists were not exclusive to the VHA, the materials can be applied in both VHA and civilian settings. The illustrative clinical case was taken from one of the contributor's clinical practice.

RESULTS

We present an algorithm and supportive materials to help guide the care of older adults with depression, an important contributor to CLBP. The case illustrates an example of a complex clinical presentation in which depression was an important contributor to symptoms and disability in an older adult with CLBP.

CONCLUSIONS

Depression is common and should be evaluated routinely in the older adult with CLBP so that appropriately targeted treatments can be planned and implemented.

Multiple comorbidities of 21 psychological disorders and relationships with psychosocial variables: a study of the online assessment and diagnostic system within a web-based population

BACKGROUND

While research in the area of e-mental health has received considerable attention over the last decade, there are still many areas that have not been addressed. One such area is the comorbidity of psychological disorders in a Web-based sample using online assessment and diagnostic tools, and the relationships between comorbidities and psychosocial variables.

OBJECTIVE

We aimed to identify comorbidities of psychological disorders of an online sample using an online diagnostic tool. Based on diagnoses made by an automated online assessment and diagnostic system administered to a large group of online participants, multiple comorbidities (co-occurrences) of 21 psychological disorders for males and females were identified. We examined the relationships between dyadic comorbidities of anxiety and depressive disorders and the psychosocial variables sex, age, suicidal ideation, social support, and quality of life.

METHODS

An online complex algorithm based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision, was used to assign primary and secondary diagnoses of 21 psychological disorders to 12,665 online participants. The frequency of co-occurrences of psychological disorders for males and females were calculated for all disorders. A series of hierarchical loglinear analyses were performed to examine the relationships between the dyadic comorbidities of depression and various anxiety disorders and the variables suicidal ideation, social support, quality of life, sex, and age.

RESULTS

A 21-by-21 frequency of co-occurrences of psychological disorders matrix revealed the presence of multiple significant dyadic comorbidities for males and females. Also, for those with some of the dyadic depression and the anxiety disorders, the odds for having suicidal ideation, reporting inadequate social support, and poorer quality of life increased for those with two-disorder comorbidity than for those with only one of the same two disorders.

CONCLUSIONS

Comorbidities of several psychological disorders using an online assessment tool within a Web-based population were similar to those found in face-to-face clinics using traditional assessment tools. Results provided support for the transdiagnostic approaches and confirmed the positive relationship between comorbidity and suicidal ideation, the negative relationship between comorbidity and social support, and the negative relationship comorbidity and quality of life.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN121611000704998; http://www.anzctr.org.au/trial_view.aspx?ID=336143 (Archived by WebCite at http://www.webcitation.org/618r3wvOG).

Comorbidity structure of psychological disorders in the online e-PASS data as predictors of psychosocial adjustment measures: psychological distress, adequate social support, self-confidence, quality of life, and suicidal ideation

Background

A relative newcomer to the field of psychology, e-mental health has been gaining momentum and has been given considerable research attention. Although several aspects of e-mental health have been studied, 1 aspect has yet to receive attention: the structure of comorbidity of psychological disorders and their relationships with measures of psychosocial adjustment including suicidal ideation in online samples.

Objective

This exploratory study attempted to identify the structure of comorbidity of 21 psychological disorders assessed by an automated online electronic psychological assessment screening system (e-PASS). The resulting comorbidity factor scores were then used to assess the association between comorbidity factor scores and measures of psychosocial adjustments (ie, psychological distress, suicidal ideation, adequate social support, self-confidence in dealing with mental health issues, and quality of life).

Methods

A total of 13,414 participants were assessed using a complex online algorithm that resulted in primary and secondary Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision) diagnoses for 21 psychological disorders on dimensional severity scales. The scores on these severity scales were used in a principal component analysis (PCA) and the resulting comorbidity factor scores were related to 4 measures of psychosocial adjustments.

Results

A PCA based on 17 of the 21 psychological disorders resulted in a 4-factor model of comorbidity: anxiety-depression consisting of all anxiety disorders, major depressive episode (MDE), and insomnia; substance abuse consisting of alcohol and drug abuse and dependency; body image–eating consisting of eating disorders, body dysmorphic disorder, and obsessive-compulsive disorders; depression–sleep problems consisting of MDE, insomnia, and hypersomnia. All comorbidity factor scores were significantly associated with psychosocial measures of adjustment (P<.001). They were positively related to psychological distress and suicidal ideation, but negatively related to adequate social support, self-confidence, and quality of life.

Conclusions

This exploratory study identified 4 comorbidity factors in the e-PASS data and these factor scores significantly predicted 5 psychosocial adjustment measures.

Trial Registration

Australian and New Zealand Clinical Trials Registry ACTRN121611000704998; http://www.anzctr.org.au/trial_view.aspx?ID=336143 (Archived by WebCite at http://www.webcitation.org/618r3wvOG).

In systemic sclerosis, anxiety and depression assessed by hospital anxiety depression scale are independently associated with disability and psychological factors

Background. Anxious and depressive symptoms are frequent in Systemic Sclerosis (SSc). Our objective is to assess their prevalence and association with district and global disability and psychological variables. Methods. 119 SSc patients were assessed by Hospital Anxiety Depression Scale (HADS). Clinical depression and anxiety were defined for HADS score cutoff ≥8. Patients were assessed for psychological symptoms (RSES, COPE-NIV), hand (HAMIS, CHFDS, fist closure, and hand opening) and face disability (MHISS, mouth opening), global disability, and fatigue (HAQ, FACIT). Results. Both depression and anxiety in SSc are 36%. Depressive patients with comorbid anxiety have higher HADS-D score than patients with depression only (P = 0.001). HADS-A and -D are positively correlated with global disability, hands and mouth disability, fatigue, self-esteem and avoidance coping strategy, and, only HADS-A, also with social support (P < 0.05). By multiple regression, HADS-D is independently associated with FACIT-F (P < 0.001), RSES (P < 0.001), and MHISS total score (P = 0.016), together explaining 50% of variance. HADS-A is independently associated with RSES (P = 0.006), COPE-NIV SA (P = 0.003), COPE-NIV SS (P = 0.008), FACIT-F (P = 0.022), and MHISS mouth opening (P = 0.029), explaining 41% of variance. Conclusions. In SSc depression and anxiety correlate to local and global disabilities and psychological characteristics. Depressive patients with comorbid anxiety have higher level of depressive symptoms.

Trends in psychotropic use in Saskatchewan from 1983 to 2007

OBJECTIVE

There has been little research reported on trends in the use of a full spectrum of psychotropics in a general population. We provide an overview of trends in psychotropic use over a 24-year period for Saskatchewan.

METHODS

Data were drawn from the Saskatchewan Ministry of Health administrative data files. It covers antidepressants (ADs), antipsychotics, mood stabilizers, anxiolytics, stimulants, and cholinesterase inhibitors in outpatient settings. We analyzed data from 9 triennial years from 1983 to 2007. Descriptive statistics were used.

RESULTS

Among the Saskatchewan population in our study, 8.38% were prescribed at least 1 psychotropic in 1983. The prevalence decreased to 7.44% in 1989, then gradually increased to 12.90% in 2007. We found a continuous increase in the number of psychotropic prescriptions for both males and females. The trend became more marked during the 1990s. Females used more psychotropics. Family physicians were the major prescribers, and their prescriptions dramatically increased over the period. There was an increase in the prescribing of all psychotropics except for anxiolytics. AD prescriptions dramatically increased, especially from 1995 onward. The proportion of patients with 8 to 11 and 12 or more prescriptions per year also gradually increased, whereas the proportion of patients with less than 3 prescriptions per year decreased.

CONCLUSIONS

AD prescriptions are the major reason for the increasing trend of psychotropic use. Given the major role of family physicians in the use of psychotropics, the need for appropriate training and continuing education is reinforced.

The overlap of symptomatic dimensions between frontotemporal dementia and several psychiatric disorders that appear in late adulthood

Several factors make diagnosis of a possible behavioural variant of frontotemporal dementia (bvFTD) particularly challenging, especially the overlap of certain symptomatic dimensions such as apathy, disinhibition, depression, anhedonia, stereotyped behaviour, and psychosis between bvFTD and several psychiatric disorders that appear in late adulthood. We discuss the most frequent psychiatric conditions that can simulate early bvFTD symptoms, including late onset bipolar disorder, late onset schizophrenia-like psychosis, late onset depression, and attention deficit hyperactivity disorder in middle and older age.

Acceptance and Commitment Therapy with Older Adults: Rationale and Considerations

Older adults are the fastest growing segment of the population. With these changing demographics, mental health professionals will be seeing more older clients. Additionally, older adults are an underserved population in that most older adults in need of mental health services do not receive treatment. Thus, it is essential that treatments for mental and behavioral health problems are empirically supported with older adults and that mental health professionals are aware of the special needs of older adult populations. Acceptance and Commitment Therapy (ACT) is an emerging approach to the treatment of distress. The purpose of this article is to provide a rationale for using ACT with older adults based on gerontological theory and research. We also review research on ACT-related processes in later life. We present a case example of an older man with depression and anxiety whom we treated with ACT. Finally, we describe treatment recommendations and important adaptations that need to be considered when using ACT with older adults and discuss important areas for future research.

Responses to novelty and vulnerability to cocaine addiction: contribution of a multi-symptomatic animal model

Epidemiological studies have revealed striking associations between several distinct behavioral/personality traits and drug addiction, with a large emphasis on the sensation-seeking trait and the associated impulsive dimension of personality. However, in human studies, it is difficult to identify whether personality/behavioral traits actually contribute to increased vulnerability to drug addiction or reflect psychobiological adaptations to chronic drug exposure. Here we show how animal models, including the first multi-symptomatic model of addiction in the rat, have contributed to a better understanding of the relationships between different subdimensions of the sensation-seeking trait and different stages of the development of cocaine addiction, from vulnerability to initiation of cocaine self-administration to the transition to compulsive drug intake. We argue that sensation seeking predicts vulnerability to use cocaine, whereas novelty seeking, akin to high impulsivity, predicts instead vulnerability to shift from controlled to compulsive cocaine use, that is, addiction.

Alcohol use disorders in the elderly: a brief overview from epidemiology to treatment options

Alcohol-use-disorders (AUDs) afflict 1-3% of elderly subjects. The CAGE, SMAST-G, and AUDIT are the most common and validated questionnaires used to identify AUDs in the elderly, and some laboratory markers of alcohol abuse (AST, GGT, MCV, and CDT) may also be helpful. In particular, the sensitivity of MCV or GGT in detecting alcohol misuse is higher in older than in younger populations. The incidence of medical and neurological complications during alcohol withdrawal syndrome in elderly alcoholics is higher than in younger alcoholics. Chronic alcohol abuse is associated with tissue damage to several organs. Namely, an increased level of blood pressure is more frequent in the elderly than in younger adults, and a greater vulnerability to the onset of alcoholic liver disease, and an increasing risk of breast cancer in menopausal women have been described. In addition, the prevalence of dementia in elderly alcoholics is almost 5 times higher than in non-alcoholic elderly individuals, approximately 25% of elderly patients with dementia also present AUDs, and almost 20% of individuals aged 65 and over with a diagnosis of depression have a co-occurring AUD. Moreover, prevention of drinking relapse in older alcoholics is, in some cases, better than in younger patients; indeed, more than 20% of treated elderly alcohol-dependent patients remain abstinent after 4 years. Considering that the incidence of AUDs in the elderly is fairly high, and AUDs in the elderly are still underestimated, more studies in the fields of epidemiology, prevention and pharmacological and psychotherapeutic treatment of AUDs in the elderly are warranted.

Thought suppression is associated with psychological distress in homebound older adults

BACKGROUND

Engaging in thought suppression as a coping mechanism has been associated with higher rates of anxiety and depressive disorders in younger adults. Homebound older adults are a population of elders experiencing poor health and high levels of depression and anxiety. It is unclear the extent to which psychological factors, such as thought suppression, are associated with distress, given that their health and disability status may be more salient. The aim of this study was to investigate thought suppression in relation to anxiety and depressive symptoms in homebound older adults.

METHODS

Participants (N = 142) were clients of home-based case management services delivered by aging service agencies in Florida. Participants were administered a research interview that included the White Bear Suppression Inventory, Structured Clinical Interview for DSM-IV Diagnosis (SCID), Brief Symptom Inventory-18 (BSI-18), and Modified Mini-Mental Status Examination (3MS). Case managers provided standard assessments containing functional and health status of the participant.

RESULTS

After controlling for physical health and cognitive functioning, thought suppression was significantly associated with higher likelihood of clinically significant somatic, depressive, and anxiety symptoms on the BSI-18. Thought suppression was also associated with meeting criteria for a SCID depressive or adjustment disorder. Engaging in thought suppression was associated with worse mental health in this sample of homebound older adults even after taking into account physical health, disability, and cognitive functioning.

CONCLUSIONS

These findings suggest the need to develop and test interventions that may address thought suppression as a coping mechanism.

Evaluation of the factor structure and psychometric properties of the Brief Symptom Inventory-18 with homebound older adults

OBJECTIVE

Homebound older adults are at high risk for depression and anxiety. Systematic screening may increase identification of these difficulties and facilitate service usage. The purpose of this study was to investigate the factor structure, internal consistency, and concurrent validity of the Brief Symptom Inventory-18 (BSI-18) for use as a screening instrument for depression and anxiety with homebound older adults and to examine if the BSI-18 could be shortened further and exhibit comparable psychometric properties.

METHODS

A sample of 142 older adults receiving in-home aging services completed interviews that included the BSI-18 and the depression and anxiety modules of the structured clinical interview for DSM-IV.

RESULTS

Confirmatory factor analysis showed that the theorized three-factor, second-order model of the BSI-18 fit the data well (S-B X(2) = 136.17; p = 0.36). The depression and anxiety subscales exhibited high internal consistency (alpha > 0.81), whereas the somatic subscale exhibited lower internal consistency (alpha = 0.69). Receiver operator curve (ROC) analyses suggest that the BSI-18 depression and anxiety subscales were able to predict those with DSM-IV diagnoses (Depression AUC = 0.89 p < 0.001; Anxiety AUC = 0.80, p < 0.001). The ROC results suggested adapting a cut score of T = 50 to achieve optimal sensitivity and specificity. The short three-item depression scale exhibited comparable psychometric properties to the full scale, while the three-item somatic and anxiety scales exhibited lower internal consistency and sensitivity.

CONCLUSIONS

These findings provide initial evidence that the BSI-18 is valid for use with homebound older adults.

The auspicious role of the 5-HT3 receptor in depression: a probable neuronal target?

The serotonergic mechanisms have been successfully utilized by the majority of antidepressant drug discovery programmes, while the search for newer targets remains persistent. The present review focused on the serotonin type-3 receptor, the only ion channel subtype in the serotonin family. Behavioural, neurochemical, electrophysiological and molecular analyses, including the results from our laboratory, provided substantial evidence that rationalizes the correlation between serotonin type-3 receptor modulation and rodent depressive-like behaviour. Nevertheless, the reports on polymorphism of serotonin type-3 receptor genes and data from clinical studies (on serotonin type-3 receptor antagonists) were insufficient to corroborate the involvement of this receptor in the neurobiology of depression. The preclinical and clinical studies that have contradicted the antidepressant-like effects of serotonin type-3 receptor antagonists and the reasons underlying such disagreement were discussed. Finally, this critical review commended the serotonin type-3 receptor as a candidate neuronal antidepressant drug target.

Comorbidity of depressive and anxiety disorders for older Americans in the national comorbidity survey-replication

OBJECTIVE

To identify age differences in the 12-month and lifetime comorbidity of depressive and anxiety disorders for adults (18-64 years) compared with older adults (65 years and older) in a nationally representative sample of community-dwelling adults in the United States.

DESIGN

Cross-sectional epidemiologic study, using data from the National Comorbidity Survey-Replication public use dataset.

SETTING

Community-based epidemiologic survey.

PARTICIPANTS

Representative national sample of community-dwelling adults in the United States.

MEASUREMENTS

The World Health Organization Composite International Diagnostic Interview was used to assess Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition psychiatric disorders.

RESULTS

More than half of respondents with a 12-month major depressive disorder (MDD) had a comorbid anxiety disorder or dysthymia (18-64 years = 60.6%; 65 years and older = 51.8%). High rates of MDD were also found for those with anxiety disorders across both age groups, highest in the 18-64 years group for generalized anxiety disorder (28.5%) and highest in the 65 years and older group for panic disorder (36.7%). Age group did not predict 12-month diagnosis of a comorbid anxiety disorder among those with a depressive disorder in multivariate logistic regression. Onset of anxiety disorders preceded onset of depressive disorders for most older adults (77.6%).

CONCLUSIONS

Depressive and anxiety disorders frequently cooccurred in this representative sample of community-dwelling adults. Older adults experienced comorbidity to a similar extent as younger adults, suggesting high rates of comorbidity across the lifespan.

Stress and the neuroendocrinology of anxiety disorders

Stress is a risk factor for depressive and anxiety disorders. Changes in lifestyle patterns that are associated with increased stress therefore place a greater burden on mental health. Stress challenges the organism's homeostatic mechanisms, triggering a cascade of events that should, normally, maintain or allow a return to equilibrium. Stressful events are perceived by sensory systems in the brain, facilitating evaluation and comparison of the existing and previous stimuli as well as the activation of hormones responsible for energy mobilization. The limbic system coordinates the release of corticosteroids, the primary stress hormones, by modulating activation of the hypothalamic paraventricular nucleus (PVN). The amygdala, a limbic structure related to emotional behavior, has a putative role in the evaluation of emotional events and formation of fearful memories; it is also a target of the neurochemical and hormonal mediators of stress. Clinical and experimental data have correlated changes in the structure/function of the amygdala with emotional disorders such as anxiety. In this chapter we review the neuroendocrinology of the stress response, focusing on the role of the limbic system in its establishment and supplementing that information with new experimental data that demonstrates the relationship between stress and anxiety disorders; we also discuss the structural changes that occur in the amygdala after stress.