Comprehensive review of generalized anxiety disorder in primary care in Europe

Psychometric network analysis of the Patient Health Questionnaire-4 (PHQ-4) in Paraguayan general population

BACKGROUND

Depression and anxiety are two of the most prevalent and disabling mental disorders worldwide, both in the general population and in outpatient clinical settings.

OBJECTIVE

This study aimed to analyze the psychometric properties of the Patient Health Questionnaire-4 (PHQ-4) based on network analysis metrics.

METHODS

A total of 911 Paraguayans (23.71% women and 76.29% men; mean age 31.25 years, SD = 10.63), selected by non-probabilistic convenience sampling, participated in the study. Network analysis was used to evaluate the internal structure, reliability, and measurement invariance between men and women.

RESULTS

The results revealed that the PHQ-4 is a unidimensional measure through Exploratory Graph Analysis (EGA). Reliability, through structural consistency, identified that 100% of the time, only a single dimension was obtained, and all items remained stable, as they were always replicated within the empirical dimension. The unidimensional structure has shown evidence of configural invariance; therefore, the network structure functioned equally among the different sex groups.

CONCLUSION

The PHQ-4 presented optimal preliminary evidence of validity based on its internal structure, reliability, and invariance between sexes. Therefore, it may be useful as an accurate and brief measure of anxiety and depressive symptoms in the Paraguayan context.

A contribution to the French validation of the clinical anxiety scale amongst health care workers in Switzerland

BACKGROUND

Anxiety disorders are frequent but remain often underdiagnosed and undertreated. Hence, valid screening instruments are needed to enhance the diagnostic process. The Clinical Anxiety Scale (CAS) is a 25-item anxiety screening tool derived from the Hamilton Anxiety Scale (HAM-A). However, this scale is not available in French. The General anxiety disorder - 7 (GAD-7) scale, which has been validated in French, is a 7-item instrument with good psychometric properties. This study contributes to the validation of an adapted French version of the CAS, using the GAD-7 as the reference.

METHODS

A forward-backward English-French-English translation of the CAS was performed according to standard practice. The French versions of the CAS and GAD-7 were completed by 127 French speaking healthcare professionals. CAS internal consistency was assessed using Crohnbach's alpha, and test-retest reliability was tested after 15 days in a subsample of 30 subjects. Convergent validity with GAD-7 was assessed using Pearson's correlation coefficient. Test-retest reliability was explored using one-way random effects model to calculate the intra-class correlation coefficient (ICC).

RESULTS

French CAS showed excellent internal consistency (Cronbach's alpha 0.97), high convergent validity with GAD-7 (Pearson's R 0.81, p < 0.001), and very good test-retest reliability (ICC = 0.97, 95% CI 0.93-0.98).

CONCLUSION

The proposed French version of the CAS showed high reliability and validity that need to be further investigated in different populations.

Intolerance-of-uncertainty therapy versus metacognitive therapy for generalized anxiety disorder in primary health care: A randomized controlled pilot trial

OBJECTIVE

This randomized controlled pilot study investigated the feasibility of a future full-scale RCT to compare the effects of intolerance-of-uncertainty therapy (IUT) and metacognitive therapy (MCT) in primary health care patients with generalized anxiety disorder (GAD). Preliminary treatment effects were also evaluated.

MATERIALS AND METHODS

64 patients with GAD at a large primary health care center in Stockholm, Sweden, were randomized to IUT or MCT. Feasibility outcomes included participant recruitment and retention, willingness to receive psychological treatment, and therapists' competence in and adherence to treatment protocols. Self-reported scales were used to assess treatment outcomes, including worry, depression, functional impairment, and quality of life.

RESULTS

Recruitment was satisfactory, and dropout was low. On a scale from 0 to 6, participants were satisfied with participating in the study (M = 5.17, SD = 1.09). Following brief training, therapists' competence was rated as moderate, and adherence was rated as weak to moderate. From pre- to post-treatment, reductions on the primary treatment outcome measure of worry were of a large effect size and statistically significant in both the IUT and MCT conditions (Cohen's d for IUT = -2.69, 95% confidence interval [-3.63, -1.76] and d for MCT = -3.78 [-4.68, -2.90]). The between-group effect size from pre- to post-treatment was large and statistically significant (d = -2.03 [-3.31, -0.75]), in favor of the MCT condition.

CONCLUSION

It is feasible to carry out a full-scale RCT to compare the effects of IUT to MCT for patients with GAD in primary health care. Both protocols seem effective, and MCT seems superior to IUT, but a full-scale RCT is needed to confirm these conclusions.

TRIAL REGISTRATION

ClinicalTrials.gov (no. NCT03621371).

Efficacy of Agomelatine 25-50 mg for the Treatment of Anxious Symptoms and Functional Impairment in Generalized Anxiety Disorder: A Meta-Analysis of Three Placebo-Controlled Studies

Introduction

The purpose of this study is to investigate the effects of agomelatine on anxious symptoms and functional impairment in a pooled dataset from randomized placebo-controlled trials for generalized anxiety disorder (GAD).

Methods

Data from three randomized, placebo-controlled trials that evaluated the efficacy of agomelatine 25–50 mg were pooled. The short-term (12 weeks) efficacy of agomelatine was assessed in regards to (1) anxious symptoms using the Hamilton Anxiety Scale (HAM-A), and (2) functional impairment using the Sheehan Disability Scale (SDS). Meta-analysis using a random effect model was used to assess differences between groups. Remission and response rates for the HAM-A and SDS were calculated, and analyses were repeated in participants with more severe anxiety symptoms.

Results

In total, 669 patients (340 on agomelatine; 329 on placebo) were included in the analyses. Compared to placebo, the agomelatine group had a significant reduction in HAM-A total score at week 12 (between group difference: 6.30 ± 2.51, p = 0.012). Significant effects were also found for symptom response on the HAM-A (67.1% of patients on agomelatine vs. 32.5% on placebo) and symptom remission (38.8% of patients on agomelatine vs. 17.3% on placebo). Compared to placebo, there was a significant difference in favour of the agomelatine group at week 12 on the SDS total score (5.11 ± 1.81, p = 0.005). Significant effects were also found for functional response on the SDS (79.1% of patients on agomelatine vs. 43.2% of placebo) and functional remission (55.2% of patients on agomelatine vs. 25.4% on placebo). All findings for anxious symptoms and functional impairment were confirmed in the subset of more severely anxious patients. Agomelatine was well tolerated by patients.

Conclusion

This meta-analysis confirms that agomelatine reduces anxiety symptoms and improves the global functioning of GAD patients.

Supplementary Information

The online version of this article (10.1007/s12325-020-01583-9) contains supplementary material, which is available to authorized users.

Psychometric Properties of the General Anxiety Disorders-7 Scale Using Categorical Data Methods: A Study in a Sample of University Attending Ethiopian Young Adults

BACKGROUND

Few studies have investigated the psychometric validation of the General Anxiety Disorders-7 Scale (GAD-7) using appropriate data assumptions. This study examined the reliability, factorial validity, divergent validity, and item analysis of the GAD-7 using categorical data methods in a sample of Ethiopian young adults.

METHODS

A sample of 270 students in the age group (18-20 years) was recruited during February-May of 2017 in this cross-sectional study using simple random sampling. The participants completed a tool for socio-demographic details, the GAD-7, and the Perceived Stress Scale-10 (PSS-10).

RESULTS

The cumulative variance rule (> 40%), the scree test, Kaiser's criteria (Eigenvalues > 1), and the parallel analysis found a 1-factor model for the GAD-7 (factor loadings, 0.38 to 0.63). Fit indices suggested a 1-factor model: the tests applied included the weighted root mean square residual (0.030), comparative fit index (1.000), the goodness of fit index (1.00), root mean square error of approximation (0.037) and the non-normed fit index (1.00). McDonald's Omega (0.772) implied that the scores had adequate internal consistency. Divergent validity was supported by significant but weak correlations that were found between the GAD-7 and PSS-10 scores (r = 0.11 to 0.25, p<0.05).

CONCLUSION

The psychometric validity of the GAD-7 in Ethiopian university attending young adults was supported by the categorical data method.

Effectiveness of a web-based decision aid for patients with generalised anxiety disorder: a protocol for a randomised controlled trial

INTRODUCTION

Patients with generalised anxiety disorder (GAD) have concerns and needs about their health and the healthcare they receive. Patient decision aids (PtDAs) are tools that assist patients in making health decisions, when there is uncertainty about treatment choice, incorporating their personal preferences and values about the available treatment options. PtDAs can improve shared decision-making and lead to better treatment outcomes. The aim of this study is to evaluate the effectiveness of a web-based PtDA for patients with GAD in primary care (PC).

METHODS AND ANALYSIS

The general study design is comprised of two stages: (1) development of a web-based PtDA for patients with GAD, derived from an evidence-based Clinical Practice Guideline and (2) assessment of the effectiveness of the PtDA in a randomised controlled trial (RCT) design, in PC centres in Tenerife (Spain). This RCT will be carried out with 124 patients with GAD, comparing the PtDA to a fact sheet with general information on mental health. Patients will review the PtDA in one session accompanied by a researcher. Post-intervention measures will be administered immediately after the intervention and at 3-month follow-up. The primary outcome will be decisional conflict. Secondary outcomes will include knowledge about GAD and its treatment, treatment preference, concordance between treatment preference and choice, and decision quality (knowledge ≥60% and concordant decision).

ETHICS AND DISSEMINATION

The project received ethics approval from the local committee at Nuestra Señora de la Candelaria (HUNSC) University Hospital in Santa Cruz de Tenerife (code: CHUNSC_2019_58). Informed consent will be obtained from each participant before randomisation. Results from the trial will be submitted for publication in international peer-reviewed scientific journals and will be disseminated through workshops and local and international conferences.

TRIAL REGISTRATION NUMBER

NCT04364958.

Psychometric Properties of the Generalized Anxiety Disorder Scale Among Saudi University Male Students

BACKGROUND

Various screening tools have been designed and developed to identify individuals with generalized anxiety disorder (GAD). The current study aimed to assess the psychometric validation of the GAD-7 in Saudi university male students.

METHODS

Healthy university male students (n= 192) participated in this cross-sectional study. All the participants were informed about the study details. Participants were asked to complete the GAD-7, the Sleep Hygiene Index (SHI), Perceived Stress Scale (PSS), and demographic details.

RESULTS

In general, the range of the GAD total score was 0-21. There was no issue of the ceiling or floor effects as only 12.5% of participants reported the minimum score of 0, and none of the participants reported the maximum score of 21. The internal consistency score of the GAD-7 was found to be good (Cronbach's alpha = 0.83). The internal homogeneity between item scores was 0.22-0.57 as indicated by the "Spearman correlation coefficient (r)". The total scores and individual item scores of the GAD-7 were statistically associated with the PSS total score (correlation coefficient r = 0.21-0.37), and scores of the 8th and 13th item of the SHI (correlation coefficient r = 0.17-0.26, and 0.21-0.40, respectively). The exploratory factor and confirmatory factor loadings of the GAD-7 items were ranged from 0.60 to 0.81 and 0.51 to 0.80, respectively.

CONCLUSION

This study supported the use of the GAD-7 to assess the anxiety level among Saudi university students.

Six-month prevalence and correlates of generalized anxiety disorder among primary care patients aged 70 years and above: Results from the ESA-services study

OBJECTIVES

To estimate the 6-month prevalence of generalized anxiety disorder (GAD) in primary care patients aged 70 years and above and to describe their clinical profile, including types of worries.

METHODS/DESIGN

Participants (N = 1193) came from the Étude sur la Santé des Aînés (ESA) services study conducted in Quebec, Canada. An in-person structured interview was used to identify GAD and other anxiety/depressive disorders as well as to identify types of worries. Three groups were created (ie, patients with GAD, patients with another anxiety disorder, and patients without anxiety disorders) and compared on several sociodemographic and clinical characteristics using multinomial logistic regression analyses.

RESULTS

The 6-month prevalence of GAD was 2.7%. Findings also indicated that the most common types of worries were about health, being a burden for loved ones, and losing autonomy. Compared with respondents without anxiety disorders, older patients with GAD were more likely to be women, be more educated, suffer from depression, use antidepressants, be unsatisfied with their lives, and use health services. In comparison with respondents with another anxiety disorder, those with GAD were 4.5 times more likely to suffer from minor depression.

CONCLUSIONS

GAD has a high prevalence in primary care patients aged 70 years and above. Clinicians working in primary care settings should screen for GAD, since it remains underdiagnosed. In addition, it may be associated with depression and life dissatisfaction. Screening tools for late-life GAD should include worry themes that are specific to aging.

A computerized version of the Patient Health Questionnaire-4 as an ultra-brief screening tool to detect emotional disorders in primary care

BACKGROUND

The Patient Health Questionnaire-4 (PHQ-4) is an ultra-brief self-report consisting of a 2-item depression scale (PHQ-2) and a 2-item anxiety scale (GAD-2). The aim of the present study is to determine the psychometric properties of a computerized version of the PHQ-4 used to detect emotional disorders (anxiety and depression) in the primary care setting.

METHOD

A total of 1052 patients with suspected anxiety, depression, or somatic symptoms were recruited from 28 primary care centres participating in the PsicAP trial and completed the full version of the computerized PHQ. In addition, 178 of these patients also underwent in clinical interviews as a gold standard.

RESULTS

Confirmatory factor analyses showed very good fit indices for a two-factor solution. This model was structurally invariant among the various age and gender groups and internal consistency was acceptable (PHQ-4; α = .83, PHQ-2; α = .86, and GAD-2; α = .76). The best cut-off points to obtain high sensitivity values was 3, on both the PHQ-2 (major depressive disorder) and the GAD-2 (generalized anxiety disorder). The criterion validity (sensitivity and specificity) for the PHQ-2 were .90 and .61 and for the GAD-2, .88 and 0.61.

LIMITATIONS

The study was not designed as a prevalence study. Therefore, does not contain information on patients whose general practitioners do not consider them to suffer emotional disorders.

CONCLUSION

This is the first study to provide evidence for the reliability and validity of a computerized version of the PHQ-4. This computerized tool can be used to detect depression and anxiety in a primary care setting.

Neurobiological Mechanisms of Stress Resilience and Implications for the Aged Population

BACKGROUND

Stress is a common reaction to an environmental adversity, but a dysregulation of the stress response can lead to psychiatric illnesses such as major depressive disorder (MDD), post-traumatic stress disorder (PTSD), and anxiety disorders. Yet, not all individuals exposed to stress will develop psychiatric disorders; those with enhanced stress resilience mechanisms have the ability to adapt successfully to stress without developing persistent psychopathology. Notably, the potential to enhance stress resilience in at-risk populations may prevent the onset of stress-induced psychiatric disorders. This novel idea has prompted a number of studies probing the mechanisms of stress resilience and how it can be manipulated.

METHODS

Here, we review the neurobiological factors underlying stress resilience, with particular focus on the serotoninergic (5-HT), glutamatergic, and γ-Aminobutyric acid (GABA) systems, as well as the hypothalamic-pituitary axis (HPA) in rodents and in humans. Finally, we discuss stress resiliency in the context of aging, as the likelihood of mood disorders increases in older adults.

RESULTS

Interestingly, increased resiliency has been shown to slow aging and improved overall health and quality of life. Research in the neurobiology of stress resilience, particularly throughout the aging process, is a nascent, yet, burgeoning field.

CONCLUSION

Overall, we consider the possible methods that may be used to induce resilient phenotypes, prophylactically in at-risk populations, such as in military personnel or in older MDD patients. Research in the mechanisms of stress resilience may not only elucidate novel targets for antidepressant treatments, but also provide novel insight about how to prevent these debilitating disorders from developing.

Clinical characteristics of generalized anxiety disorder: older vs. young adults

BACKGROUND

Generalized anxiety disorder (GAD) is one of the most common anxiety disorders in older people. Although GAD in older adults seems to differ in many aspects like clinical presentation, severity and treatment response, there is a paucity of comparative research.

AIMS

The aim of the study is to compare the clinical presentation of GAD between older and young adults.

METHODS

One hundred and two non-demented older patients (age ≥65) and 64 young patients (age <45) who were diagnosed with GAD according to the DSM-IV-TR criteria were included to the study. Socio-demographic Data Form, the Structured Clinical Interview for DSM Disorders-1 (SCID-1), the Questionnaire for the Suggested Behavioral Criteria of GAD for DSM-5, the Hamilton Depression Scale (HAM-D), the Generalized Anxiety Disorder Severity Scale (GADSS) and the Sheehan Disability Scale (SDS) were applied to both groups.

RESULTS AND CONCLUSIONS

Older GAD patients had more disturbances of sleep, less reassurance seeking behaviors, higher rates of depression and higher depression severity when compared to the young patients. Although older people seemed to have a lower severity of GAD, they had higher disability due to worries. Older patients worried more about their own health and family well-being, whereas young patients worried more about future and other's health.

Psychometric evaluation of the Generalized Anxiety Disorder Screener GAD-7, based on a large German general population sample

BACKGROUND

The Generalized Anxiety Disorder Scales GAD-7 and GAD-2 are instruments for the assessment of anxiety. The aims of this study are to test psychometric properties of these questionnaires, to provide normative values, and to investigate associations with sociodemographic factors, quality of life, psychological variables, and behavioral factors.

METHODS

A German community sample (n=9721) with an age range of 18-80 years was surveyed using the GAD-7 and several other questionnaires.

RESULTS

Confirmatory factor analyses confirmed the unidimensionality and measurement invariance of the GAD-7 across age and gender. Females were more anxious than males (mean scores: M=4.07 vs. M=3.01; effect size: d=0.33). There was no linear age trend. A total of 5.9% fulfilled the cut-off criterion of 10 and above. Anxiety was correlated with low quality of life, fatigue, low habitual optimism, physical complaints, sleep problems, low life satisfaction, low social support, low education, unemployment, and low income. Cigarette smoking and alcohol consumption were also associated with heightened anxiety, especially in women. When comparing the GAD-7 (7 items) with the ultra-short GAD-2 (2 items), the GAD-7 instrument was superior to the GAD-2 regarding several psychometric criteria.

LIMITATIONS

The response rate (33%) was low. Because of the cross-sectional character of the study, causal conclusions cannot be drawn. A further limitation is the lack of a gold standard for diagnosing anxiety.

CONCLUSIONS

The GAD-7 can be recommended for use in clinical research and routine.

Presurgical assessment of bariatric patients with the Patient Health Questionnaire (PHQ)--a screening of the prevalence of psychosocial comorbidity

BACKGROUND

Bariatric surgery has gained increasing relevance due to the dramatic rise in morbid obesity prevalence. A sound body of scientific literature demonstrates positive long-term outcome of bariatric surgery in decreasing mental and physical health morbidity. Still, there is a need for a manageable presurgical screening to assess major mental disorders. The aim of this study was to assess the frequency of common psychiatric syndromes in bariatric surgery candidates using a computerized version of the Patient Health Questionnaire (PHQ).

METHODS

In a prospective cohort study from August 2009 to July 2011 morbidly obese individuals seeking bariatric treatment were evaluated for mental health disorders using the PHQ (computerized German version).

RESULTS

A total of 159 patients were included in this study. The median age of participants was 42 years, the median BMI was 49 kg/m(2). The PHQ revealed a prevalence of 84 % for mental health disorders, 50 % of the participants had three or more mental health disorders. A high somatic symptom burden (46 %), depressive syndromes (62 %) and anxiety disorders (29 %) were the most frequent psychiatric syndromes. The median number of psychiatric syndromes was 3 for women and 1 for men (p = 0.007). No correlation between BMI and a single syndrome or the sum of syndromes was observed.

CONCLUSION

84 % of the patients seeking bariatric treatment were screened positive for at least one mental health disorder. The computerized PHQ with automated reporting appears to be a useful instrument for presurgical assessment of bariatric patients in routine medical settings.

Comparative effectiveness and costs of generic and brand-name gabapentin and venlafaxine in patients with neuropathic pain or generalized anxiety disorder in Spain

Objective

To explore adherence/persistence with generic gabapentin/venlafaxine versus brand-name gabapentin/venlafaxine (Neurontin^®/Vandral^®) in peripheral neuropathic pain (pNP) or generalized anxiety disorder (GAD), respectively, and whether it is translated into different costs and patient outcomes in routine medical practice.

Methods

A retrospective, new-user cohort study was designed. Electronic medical records (EMR) of patients included in the health plan of Badalona Serveis Assistencials SA, Barcelona, Spain were exhaustively extracted for analysis. Participants were beneficiaries aged 18+ years, followed between 2008 and 2012, with a pNP/GAD International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code, who initiated treatment with generic or brand-name gabapentin or venlafaxine. Assessments included 1-year treatment persistence and adherence (medication possession ratio), health care costs, and reduction in severity of pain and anxiety symptoms.

Results

A total of 2,210 EMR were analyzed; 1,369 on gabapentin (brand 400; generic 969) and 841 on venlafaxine (brand 370 and generic 471). Brand-name gabapentin and venlafaxine were both significantly associated with longer persistence than generic: 7.3 versus 6.3 months, P<0.001; and 8.8 versus 8.1 months, P<0.05, respectively. Brand-name was associated with higher adherence: 86.5% versus 81.3%, P<0.001; and 82.1% versus 79.0%, P<0.05, respectively. Adjusted average costs were higher with generic compared with brand: €1,277 versus €1,057 (difference of €220 per patient; P<0.001) for gabapentin; and €1,110 versus €928 (difference of €182 per patient; P=0.020) for venlafaxine, both because of more use of medical visits and concomitant medication. Compared with generic, brand-name was associated with higher reduction in pain (7.8%; P<0.001) and anxiety (13.2%; P<0.001).

Conclusion

Patients initiating brand-name gabapentin or venlafaxine were more likely to adhere and persist on treatment of pNP or GAD, have lower health care costs, and show further reduction of pain and anxiety symptoms than with generic drugs in routine medical practice.

Learning from the past and looking to the future: Emerging perspectives for improving the treatment of psychiatric disorders

Modern neuropsychopharmacology commenced in the 1950s with the serendipitous discovery of first-generation antipsychotics and antidepressants which were therapeutically effective yet had marked adverse effects. Today, a broader palette of safer and better-tolerated agents is available for helping people that suffer from schizophrenia, depression and other psychiatric disorders, while complementary approaches like psychotherapy also have important roles to play in their treatment, both alone and in association with medication. Nonetheless, despite considerable efforts, current management is still only partially effective, and highly-prevalent psychiatric disorders of the brain continue to represent a huge personal and socio-economic burden. The lack of success in discovering more effective pharmacotherapy has contributed, together with many other factors, to a relative disengagement by pharmaceutical firms from neuropsychiatry. Nonetheless, interest remains high, and partnerships are proliferating with academic centres which are increasingly integrating drug discovery and translational research into their traditional activities. This is, then, a time of transition and an opportune moment to thoroughly survey the field. Accordingly, the present paper, first, chronicles the discovery and development of psychotropic agents, focusing in particular on their mechanisms of action and therapeutic utility, and how problems faced were eventually overcome. Second, it discusses the lessons learned from past successes and failures, and how they are being applied to promote future progress. Third, it comprehensively surveys emerging strategies that are (1), improving our understanding of the diagnosis and classification of psychiatric disorders; (2), deepening knowledge of their underlying risk factors and pathophysiological substrates; (3), refining cellular and animal models for discovery and validation of novel therapeutic agents; (4), improving the design and outcome of clinical trials; (5), moving towards reliable biomarkers of patient subpopulations and medication efficacy and (6), promoting collaborative approaches to innovation by uniting key partners from the regulators, industry and academia to patients. Notwithstanding the challenges ahead, the many changes and ideas articulated herein provide new hope and something of a framework for progress towards the improved prevention and relief of psychiatric and other CNS disorders, an urgent mission for our Century.

Cultural-based biases of the GAD-7

The GAD-7 is a popular measure of generalized anxiety disorder (GAD) symptoms that has been used across many cultural groups. Existing evidence demonstrates that the prevalence of GAD varies across self-identified ethnic/cultural groups, a phenomenon that some researchers attribute to cross-cultural measurement error rather than to actual differences in rates of GAD. Nonetheless, the effect of culture on factor structure and response patterns to the GAD-7 have not been examined and could result over- or under-estimated GAD-7 scores across different cultural groups. The current investigation assessed the factor structure of the GAD-7 in White/Caucasian, Hispanic, and Black/African American undergraduates and tested for cultural-based biases. A modified one-factor model exhibited good fit across subsamples. Results revealed that Black/African American participants with high GAD symptoms scored lower on the GAD-7 than other participants with similar GAD symptoms. Results highlight the need for culturally sensitive GAD screening tools.

Risk factors for late-onset generalized anxiety disorder: results from a 12-year prospective cohort (the ESPRIT study)

Generalized anxiety disorder (GAD) is a chronic and highly prevalent disorder associated with increased disability and mortality in the elderly. Treatment is difficult with low rate of full remission, thus highlighting the need to identify early predictors for prevention in elderly people. The aim of this study is to identify and characterize incident GAD predictors in elderly people. A total of 1711 individuals aged 65 years and above and free of GAD at baseline were randomly recruited from electoral rolls between 1999 and 2001 (the prospective ESPRIT study). The participants were examined at baseline and five times over 12 years. GAD and psychiatric comorbidity were diagnosed with a standardized psychiatric examination, the Mini-International Neuropsychiatry Interview on the basis of DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition) criteria and validated by a clinical panel. During the follow-up, 8.4% (95% confidence interval=7.1-9.7%) of the participants experienced incident GAD, 80% being first episodes; the incident rate being 10 per 1000 person-years. The principal predictors of late-onset incident GAD over 12 years derived from a multivariate Cox model were being female, recent adverse life events, having chronic physical (respiratory disorders, arrhythmia and heart failure, dyslipidemia, cognitive impairment) and mental (depression, phobia and past GAD) health disorders. Poverty, parental loss or separation and low affective support during childhood, as well as history of mental problems in parents were also significantly and independently associated with incident GAD. GAD appears as a multifactorial stress-related affective disorder resulting from both proximal and distal risk factors, some of them being potentially modifiable by health care intervention.

Epidemiology of generalized anxiety disorder in Canadian military personnel

Introduction: This study examined the prevalence, clinical characteristics, help seeking patterns, and military experiences associated with past-year generalized anxiety disorder (GAD) using a representative sample of military personnel. Methods: Data were from the Canadian Community Health Survey–Canadian Forces Supplement ( n = 5,115 Regular Force, n = 3,286 Reserve Force), conducted by Statistics Canada on behalf of the Department of National Defence in 2002. GAD and other mental disorders were assessed using the World Mental Health Composite International Diagnostic Interview. Clinical features of GAD of interest included mean age of onset and episode length, symptoms, degree of impairment and co-occurring disorders, and perceived need for help and help seeking. Multivariate logistic regression models were conducted to examine the sociodemographic, military characteristics, and mental disorders correlated with past-year GAD. Results: Past-year and lifetime prevalence rates of GAD were 1.7% and 4.4%, respectively. The majority of military personnel with past-year GAD reported being severely impaired at work and in their relationships and social life. Those with past-year GAD, relative to those without it, had higher odds of having another mental disorder. Of military personnel with past-year GAD, 72.2% had sought help. Regular Force personnel, relative to reservists, had higher odds of having past-year GAD, as did individuals who witnessed atrocities. Discussion: GAD is modestly prevalent in the Canadian military and is associated with considerable functional impairment. Nevertheless, high rates of help seeking for GAD may speak to the availability, accessibility, and acceptability of mental health care in the Canadian Armed Forces.

Generalized anxiety in community-dwelling elderly: Prevalence and clinical characteristics

BACKGROUND

Generalized anxiety disorder (GAD) is a chronic and disabling disorder with a low rate of full remission. As it is commonly assumed that cases in the elderly principally represent the continuing chronic course of early onset illness, there has been little research into the clinical characteristics, including comorbid psychiatric and physical conditions, which may be specific to older people.

METHODS

Lifetime GAD and psychiatric comorbidity were diagnosed in 1974 community-dwelling elderly people aged 65 or over using a standardized psychiatric examination, the MINI, based on DSM-IV criteria. Multivariate regression analyses were adjusted for socio-demographic, lifestyle, biological, and clinical variables, as well as adverse life events.

RESULTS

The lifetime prevalence of GAD was 11% (95% CI=9.6-12.4%) of whom 24.6% reported a late onset with a first episode after 50 years of age. The 6-month current prevalence was 4.6% (95% CI=3.7-5.5%). Most of the prevalent cases were recurrent but only 36.3% were receiving treatment. Fourteen percent were comorbid with major depression and 34% with phobia but their associated factors differed. The factors associated with pure GAD were being female, having cognitive impairment, lower body mass index, reporting low affective support during childhood, taking a high number of somatic medications independently of other mental health factors, e.g. psychotropic medication use, major depression, and phobia.

LIMITATIONS

The study is limited by cross-sectional design.

CONCLUSIONS

Our data indicate that GAD prevalence is high in elderly people with a late-life onset of GAD in 25% of cases. GAD in the elderly is not just a severity marker of depression and is clinically distinct from phobia, the other major anxiety disorder of the elderly.

Economic and humanistic burden of illness in generalized anxiety disorder: an analysis of patient survey data in Europe

BACKGROUND

Whilst studies suggest that generalized anxiety disorder (GAD) represents a considerable health care burden in Europe, there is a paucity of published evidence. This study investigated the burden of illness associated with GAD across five European countries (France, Germany, Italy, Spain, and the UK).

METHODS

Information from the 2008 European National Health and Wellness Survey database was analyzed. Bivariate, multivariate, and cost analyses were used to compare patients with GAD and propensity-matched controls.

RESULTS

Compared with non-GAD controls, patients with GAD had more comorbidities and were more likely to smoke but less likely to be employed, use alcohol, or take exercise. They also had significantly worse health-related quality of life, and significantly greater work impairment and resource use, which increased as GAD severity increased. Within-country analyses demonstrated results similar to those for the five European countries overall, with the largest differences in resource use between patients with GAD and non-GAD controls documented in France and Germany. The average mean differences in direct costs were relatively small between the GAD groups and controls; however, indirect costs differed substantially. Costs were particularly high in Germany, mainly due to higher salaries leading to higher costs associated with absence from work. The limitation of this study was that the data were from a self-reported Internet survey, making them subject to reporting bias and possibly sample bias.

CONCLUSION

Across all five European countries, GAD had a significant impact on work impairment, resource use, and economic costs, representing a considerable individual and financial burden that increased with severity of disease. These data may help us to understand better the burden and costs associated with GAD.