Treatment of major depression in the context of panic disorder

The psychometrics of the Hospital Anxiety and Depression Scale supports a shorter -12 item- version

The diagnosis of patients suffering from both anxiety and depression is complex due to mixed effects of the two disorders. This complexity has hardened the task to find an adapted treatment for these patients. Consequently, several instruments, known as depression anxiety scales, have been developed and are now used internationally by physicians to determine the diagnosis of anxiety and depression and treat the patients accordingly. This study aims at testing the consistency and reliability of one of the main anxiety and depression scale which is composed of 14 items, the Hospital Anxiety and Depression Scale (HADS). We have used explanatory factor analysis (EFA) and factor extraction by principal component analysis (PCA) with orthogonal varimax (Kaiser Normalization) rotation on a cohort of 9706 French depressed patients. The relevance of the 14 items included in the HADS was also scrutinized by measuring the internal consistency and reliability of the global HADS removing each item one by one. Our conclusion is that the HADS could potentially gain in consistency in the detection of anxiety, notably through the revision of two of the anxiety items.

Anxious and non-anxious major depressive disorder in the World Health Organization World Mental Health Surveys

BACKGROUND

To examine cross-national patterns and correlates of lifetime and 12-month comorbid DSM-IV anxiety disorders among people with lifetime and 12-month DSM-IV major depressive disorder (MDD).

METHOD

Nationally or regionally representative epidemiological interviews were administered to 74 045 adults in 27 surveys across 24 countries in the WHO World Mental Health (WMH) Surveys. DSM-IV MDD, a wide range of comorbid DSM-IV anxiety disorders, and a number of correlates were assessed with the WHO Composite International Diagnostic Interview (CIDI).

RESULTS

45.7% of respondents with lifetime MDD (32.0-46.5% inter-quartile range (IQR) across surveys) had one of more lifetime anxiety disorders. A slightly higher proportion of respondents with 12-month MDD had lifetime anxiety disorders (51.7%, 37.8-54.0% IQR) and only slightly lower proportions of respondents with 12-month MDD had 12-month anxiety disorders (41.6%, 29.9-47.2% IQR). Two-thirds (68%) of respondents with lifetime comorbid anxiety disorders and MDD reported an earlier age-of-onset (AOO) of their first anxiety disorder than their MDD, while 13.5% reported an earlier AOO of MDD and the remaining 18.5% reported the same AOO of both disorders. Women and previously married people had consistently elevated rates of lifetime and 12-month MDD as well as comorbid anxiety disorders. Consistently higher proportions of respondents with 12-month anxious than non-anxious MDD reported severe role impairment (64.4 v. 46.0%; χ 2 1 = 187.0, p < 0.001) and suicide ideation (19.5 v. 8.9%; χ 2 1 = 71.6, p < 0.001). Significantly more respondents with 12-month anxious than non-anxious MDD received treatment for their depression in the 12 months before interview, but this difference was more pronounced in high-income countries (68.8 v. 45.4%; χ 2 1 = 108.8, p < 0.001) than low/middle-income countries (30.3 v. 20.6%; χ 2 1 = 11.7, p < 0.001).

CONCLUSIONS

Patterns and correlates of comorbid DSM-IV anxiety disorders among people with DSM-IV MDD are similar across WMH countries. The narrow IQR of the proportion of respondents with temporally prior AOO of anxiety disorders than comorbid MDD (69.6-74.7%) is especially noteworthy. However, the fact that these proportions are not higher among respondents with 12-month than lifetime comorbidity means that temporal priority between lifetime anxiety disorders and MDD is not related to MDD persistence among people with anxious MDD. This, in turn, raises complex questions about the relative importance of temporally primary anxiety disorders as risk markers v. causal risk factors for subsequent MDD onset and persistence, including the possibility that anxiety disorders might primarily be risk markers for MDD onset and causal risk factors for MDD persistence.

Depression does not affect the treatment outcome of CBT for panic and agoraphobia: results from a multicenter randomized trial

BACKGROUND

Controversy surrounds the questions whether co-occurring depression has negative effects on cognitive-behavioral therapy (CBT) outcomes in patients with panic disorder (PD) and agoraphobia (AG) and whether treatment for PD and AG (PD/AG) also reduces depressive symptomatology.

METHODS

Post-hoc analyses of randomized clinical trial data of 369 outpatients with primary PD/AG (DSM-IV-TR criteria) treated with a 12-session manualized CBT (n = 301) and a waitlist control group (n = 68). Patients with comorbid depression (DSM-IV-TR major depression, dysthymia, or both: 43.2% CBT, 42.7% controls) were compared to patients without depression regarding anxiety and depression outcomes (Clinical Global Impression Scale [CGI], Hamilton Anxiety Rating Scale [HAM-A], number of panic attacks, Mobility Inventory [MI], Panic and Agoraphobia Scale, Beck Depression Inventory) at post-treatment and follow-up (categorical). Further, the role of severity of depressive symptoms on anxiety/depression outcome measures was examined (dimensional).

RESULTS

Comorbid depression did not have a significant overall effect on anxiety outcomes at post-treatment and follow-up, except for slightly diminished post-treatment effect sizes for clinician-rated CGI (p = 0.03) and HAM-A (p = 0.008) when adjusting for baseline anxiety severity. In the dimensional model, higher baseline depression scores were associated with lower effect sizes at post-treatment (except for MI), but not at follow-up (except for HAM-A). Depressive symptoms improved irrespective of the presence of depression.

CONCLUSIONS

Exposure-based CBT for primary PD/AG effectively reduces anxiety and depressive symptoms, irrespective of comorbid depression or depressive symptomatology.

The genetics of sex differences in brain and behavior

Biological differences between men and women contribute to many sex-specific illnesses and disorders. Historically, it was argued that such differences were largely, if not exclusively, due to gonadal hormone secretions. However, emerging research has shown that some differences are mediated by mechanisms other than the action of these hormone secretions and in particular by products of genes located on the X and Y chromosomes, which we refer to as direct genetic effects. This paper reviews the evidence for direct genetic effects in behavioral and brain sex differences. We highlight the 'four core genotypes' model and sex differences in the midbrain dopaminergic system, specifically focusing on the role of Sry. We also discuss novel research being done on unique populations including people attracted to the same sex and people with a cross-gender identity. As science continues to advance our understanding of biological sex differences, a new field is emerging that is aimed at better addressing the needs of both sexes: gender-based biology and medicine. Ultimately, the study of the biological basis for sex differences will improve healthcare for both men and women.

Anxious depression: clinical features and treatment

Anxious depression has been conceptualized in at least two related but separate ways: 1) major depressive disorder with at least one comorbid Axis I anxiety disorder and 2) major depressive disorder with a high level of anxiety with or without one or more comorbid Axis I anxiety disorders. Using either definition, patients with anxious depression seem to have a more chronic course of illness, an increased incidence of suicidal thoughts and behavior, greater functional and occupational impairment, and poorer response to treatment. Multiple classes of medications are used to treat anxious depression, most commonly first- and second-generation antidepressants, atypical antipsychotics, and benzodiazepines. Certain patients with anxious depression may require lower starting doses, more gradual dose escalations, higher end point doses, longer duration of treatment, and/or early augmentation with other agents. Nonpharmacologic treatments such as targeted psychotherapy and preventative stepped-care approaches also may be effective. Well-conceived, randomized controlled treatment trials are necessary to make further gains in the management of patients with anxious depression.

Analysis of the efficacy of a psychotherapeutic program to improve the emotional status of caregivers of elderly dependent relatives

OBJECTIVES

This study examined the long-term impact of a psychotherapeutic cognitive-behavioral program with two intervention formats (traditional weekly sessions (TWS) and minimal therapist contact (MTC)) in caregivers who suffered from emotional problems due to caring for elderly dependent relatives.

METHOD

The 86 participants, who lived with the older persons at home, were randomized into one of the two intervention formats. The individual treatment program was carried out during an 8-week interval. Measures of anxiety, depression, burden, coping, social support, and self-esteem were analyzed at pre- and post-treatment, and at 1-, 3-, 6-, and 12-month follow-ups.

RESULTS

Significant effects were found in the expected direction in most of the measures analyzed. The participants in the intervention reduced significantly their levels of anxiety, depression, and burden, and they improved the levels of problem-focused coping, social support, and self-esteem. The two intervention formats had different evolutions, with better effects in the TWS format, especially at the first post-test measurements, but the differences tended to decrease over time.

CONCLUSION

These data suggest that individual psychotherapeutic interventions with caregivers are efficient to reduce their emotional problems, and that this effect is mediated by improvement both in their appraisal of the situation and in their personal resources.

Cognitive behavioral therapy for panic disorder and comorbidity: More of the same or less of more?

This study compared the effects of a higher dose of cognitive behavioral therapy (CBT) for panic disorder versus CBT for panic disorder combined with "straying" to CBT for comorbid disorders in individuals with a principal diagnosis of panic disorder with or without agoraphobia. Sixty-five participants were randomly assigned to one of two treatment conditions, either CBT focused solely upon panic disorder and agoraphobia or CBT that simultaneously addressed panic disorder and agoraphobia and, to a lesser degree, the most severe comorbid condition. Results indicated a significant reduction in panic disorder severity and a decline in severity of comorbid diagnoses across both treatment conditions. However, individuals receiving CBT focused only on panic disorder were more likely to meet high end-state functioning at post-treatment, even in intent-to-treat analyses, and report zero panic attacks at the 1-year follow-up, although this effect was not retained in intent-to-treat analyses. At follow-up, CBT focused only on panic disorder yielded more substantial improvement in the most severe baseline comorbid condition, although not in intent-to-treat analyses, and a greater proportion of individuals in this treatment condition were rated as having no comorbid diagnoses, even in intent-to-treat analyses. These findings raise the possibility that remaining focused on CBT for panic disorder may be more beneficial for both principal and comorbid diagnoses than combining CBT for panic disorder with 'straying' to CBT for comorbid disorders.

Comorbid anxiety and depression: illumination of a controversy

Depression and anxiety frequently coexist in the same individual, either concurrently or at different times, and numerous studies show that the presence of an anxiety disorder is the single strongest risk factor for development of depression. When the two coexist simultaneously, either as diagnosed disorders or subsyndromal states, they may be viewed as mixed anxiety-depression or as comorbid syndromes, i.e. separate disorders occurring concurrently. Controversy continues over the nature of the relationship between depression and anxiety, some believing they are distinct, separate entities while others - now the majority - view them as overlapping syndromes that present at different points on a phenomenological and/or chronological continuum, and share a common neurobiology, the degree of overlap depending on whether each is described at the level of symptoms, syndrome or diagnosis. Community data likely underestimate true prevalence, since affected individuals frequently present in primary care with somatic, rather than psychological, complaints. Irrespective of the nature of the relationship, patients with both disorders experience significant vocational and interpersonal impairment, and more frequent recurrence, with greater likelihood of suicide, than individuals with single disorders. Various classes of antidepressant drugs offer symptom relief for these patients, the most selective of th SSRIs holding the greatest promise for sustained clinical improvement. Yet, the crucial parameter of successful pharmacotherapy seems to be the length of treatment, ensuring enhancement of the compromised neuroprotective and neuroplastic mechanisms. Further clarification of the relationship is a prerequisite for offering effective treatment to the many patients who experience lifetime depression and anxiety.

Impact of cognitive-behavioral therapy for panic disorder on comorbidity: a controlled investigation

This study examined the effects of cognitive-behavioral therapy (CBT) for principal panic disorder with or without agoraphobia, on comorbidity in 30 individuals (16 female). To test the hypothesis that improvements in co-existing conditions were not due to spontaneous fluctuations across time, patients receiving immediate CBT were compared to those assigned to wait list (n = 11). Results indicated clinician-rated severity of comorbid specific phobia declined significantly following immediate CBT compared to no change after wait list. The number of patients without comorbidity of any severity increased after immediate CBT, with no such increase following wait list. However, the groups did not differ in the frequency of additional diagnoses or overall severity of comorbidity. In the total sample, results indicated reductions in comorbidity by 9-month follow-up, with marked declines in the severity of comorbid generalized anxiety disorder (GAD), social and specific phobia. Our findings suggest that targeted CBT for panic disorder has beneficial effects on comorbidity over the longer term and that some of its immediate effects exceed those due to the passage of time alone.

“Wenn’s nicht nur bei der Panikstörung bleibt“

Zusammenfassung. Theoretischer Hintergrund: Trotz der großen Erfolge der kognitiv-verhaltenstherapeutischen Behandlung von Panikstörungen in wissenschaftlichen Studien ist ungeklärt, ob diese Methode auch im Rahmen der Routineversorgung oder bei komplexeren Problemen erfolgreich ist. Fragestellung: Es wird überprüft, ob verhaltenstherapeutische Behandlung von Personen mit Panikstörungen auch “unter Routinebedingungen“ sowie bei Personen mit Komorbidität von Panikstörung und Schwerer Depression 1 Der Begriff “schwere Depression” wird hier synonym zum Begriff “Major Depression“ verwendet. erfolgreich ist. Methode: 165 Personen mit Panikstörung wurden 3 Gruppen zugeordnet: Panikstörung (n = 55), Panikstörung und komorbide Schwere Depression (n = 73) sowie Panikstörung und frühere Schwere Depression, die jedoch bei Beginn der Indexbehandlung remittiert war (n = 37). Messzeitpunkte waren 6 Monate vor Behandlungsbeginn, Behandlungsbeginn, Behandlungsende sowie 1 Jahr später. Ergebnisse: Bei Personen mit “reiner“ Panikstörung lassen sich die Behandlungserfolge replizieren. Personen mit Panikstörung und komorbider aktueller Depression zeigen in den meisten Variablen erhöhte Werte, jedoch ähnlich positive Veränderungen. Schlussfolgerungen: Auch bei Durchführung in Einrichtungen der Routineversorgung sowie bei Komorbidität ist verhaltenstherapeutische Angstbehandlung erfolgreich.

Treating medication-resistant panic disorder: predictors and outcome of cognitive-behavior therapy in a Brazilian public hospital

BACKGROUND

In Brazil, treatment of panic disorder is most frequently initiated with pharmacotherapy, but only half of the patients can be expected to be panic free after medication. Studies have suggested that individual or group cognitive-behavior therapy (CBT) is an effective treatment strategy for panic patients who have failed to respond to pharmacotherapy.

METHODS

Thirty-two patients diagnosed with panic disorder with agoraphobia having residual symptoms despite being on an adequate dose of medication were treated with 12 weeks of group CBT. The outcome was evaluated for panic frequency and severity, generalized anxiety, and global severity. Comorbid conditions, a childhood history of anxiety, and defense mechanism styles were assessed as potential predictors of treatment response.

RESULTS

Twenty-nine patients completed the 12-week protocol. Treatment was associated with significant reductions in symptom severity on all outcome measures (p < 0.001). Patients with depression had a poorer outcome of the treatment (p = 0.01) as did patients using more neurotic (p = 0.002) and immature defenses (p = 0.05).

CONCLUSION

Consistent with previous reports, we found that CBT was effective for our sample of treatment-resistant patients. Among these patients, depression as well as neurotic defense style was associated with a poorer outcome. The use of CBT in Brazil for treatment-resistant and other panic patients is encouraged.

Prevalence, comorbidity, disability and service utilisation. Overview of the Australian National Mental Health Survey

BACKGROUND

Health planning should be based on data about prevalence, disability and services used.

AIMS

To determine the prevalence of ICD-10 disorders and associated comorbidity, disability and service utilisation.

METHOD

We surveyed a national probability sample of Australian households using the Composite International Diagnostic Interview and other measures.

RESULTS

The sample size was 10 641 adults, response rate 78%. Close to 23% reported at least one disorder in the past 12 months and 14% a current disorder. Comorbidity was associated with disability and service use. Only 35% of people with a mental disorder in the 12 months prior to the survey had consulted for a mental problem during that year, and most had seen a general practitioner. Only half of those who were disabled or had multiple comorbidity had consulted and of those who had not, more than half said they did not need treatment.

CONCLUSIONS

The high rate of not consulting among those with disability and comorbidity is an important public health problem. As Australia has a universal health insurance scheme, the barriers to effective care must be patient knowledge and physician competence.