Comorbidities and associated treatment charges in patients with anxiety disorders

Comorbidity and diagnosis distribution in transdiagnostic treatments for emotional disorders: A systematic review of randomized controlled trials

The advantages of transdiagnostic protocols for emotional disorders (ED) (anxiety and depression) include the ability to treat multiple psychological disorders using the same treatment protocol, and the capacity to better address comorbidity. Comorbidity in ED has been associated with higher rates of severity, functional impairment, and chronicity. However, no attempts have been made in the literature to systematically review whether these studies include assessments to evaluate the treatment response in comorbid diagnoses, in addition to the principal diagnosis. Moreover, transdiagnostic treatments have been developed for a range of ED, but to date no study has analyzed the real distribution of diagnoses in these studies. The current study aimed to analyze: a) whether treatment response in comorbidity is evaluated in transdiagnostic treatments for ED; b) what diagnoses are targeted in transdiagnostic treatments for ED; and c) the real distribution of the diagnoses at baseline in these studies. A systematic search of the literature was conducted in PsycINFO, PubMed, EMBASE, and the Cochrane Library. Fifty-two randomized controlled trials were identified, with a total of 7007 adult participants. The results showed that, although most of the studies reported data on comorbidity at baseline, only 40% of them examined the effects of the intervention on the comorbid disorders. The most commonly targeted diagnoses in transdiagnostic protocols were panic/agoraphobia, generalized anxiety, social anxiety, and depression. Other disorders, such as obsessive-compulsive disorder, posttraumatic stress disorder, and anxiety/depression not otherwise specified, were marginally included in these studies. Regarding the distribution of diagnoses at baseline, generalized anxiety, panic/agoraphobia, social anxiety, and depression were the most frequently observed, whereas depression not otherwise specified was the least represented. The results highlight the importance of assessing comorbidity in addition to the principal diagnoses in transdiagnostic treatments, in order to draw conclusions about the true potential of these interventions to improve comorbid symptoms. Implications of the current study and directions for future research are discussed.

Therapeutical strategies for anxiety and anxiety-like disorders using plant-derived natural compounds and plant extracts

Anxiety and anxiety-like disorders describe many mental disorders, yet fear is a common overwhelming symptom often leading to depression. Currently two basic strategies are discussed to treat anxiety: pharmacotherapy or psychotherapy. In the pharmacotherapeutical clinical approach, several conventional synthetic anxiolytic drugs are being used with several adverse effects. Therefore, studies to find suitable safe medicines from natural sources are being sought by researchers. The results of a plethora experimental studies demonstrated that dietary phytochemicals like alkaloids, terpenes, flavonoids, phenolic acids, lignans, cinnamates, and saponins or various plant extracts with the mixture of different phytochemicals possess anxiolytic effects in a wide range of animal models of anxiety. The involved mechanisms of anxiolytics action include interaction with γ-aminobutyric acid A receptors at benzodiazepine (BZD) and non-BZD sites with various affinity to different subunits, serotonergic 5-hydrodytryptamine receptors, noradrenergic and dopaminergic systems, glutamate receptors, and cannabinoid receptors. This review focuses on the use of both plant-derived natural compounds and plant extracts with anxiolytic effects, describing their biological effects and clinical application.

Efficacy of transdiagnostic cognitive behaviour therapy for anxiety disorders: a systematic review and meta-analysis of published outcome studies

Transdiagnostic approaches to cognitive behaviour therapy (TCBT) of anxiety disorders have drawn increasing interest and empirical testing over the past decade. In this paper, we review evidence of the overall efficacy of TCBT for anxiety disorders, as well as TCBT efficacy compared with wait-list, treatment-as-usual, and diagnosis-specific cognitive behaviour therapy (CBT) controls. A total of 11 studies reporting 12 trials (n = 1933) were included in the systematic review. Results from the meta-analysis of 11 trials suggest that TCBT was generally associated with positive outcome; TCBT patients did better than wait-list and treatment-as-usual patients, and treatment gains were maintained through follow-up. The pooled estimate showed a moderate treatment effect, however with large heterogeneity suggesting differences in treatment effects between the studies. Also, all the included trials, apart from one, were judged to be associated with a high risk of bias. Only one study compared TCBT with diagnosis-specific CBT suggesting treatment effect of TCBT to be as strong as diagnosis-specific CBT. This study not only cautiously supports evidence for the efficacy of TCBT, but also suggests the need for more high-quality, large-scaled studies in this area. Transdiagnostic treatments offer great clinical promise as an affordable and pragmatic treatment for anxiety disorders and as a specialized treatment for co-morbid and other-specified anxiety disorders.

Anxiety disorders, hypertension, and cardiovascular risk: a review

Hypertension, coronary heart disease (CHD), and anxiety disorders all cause substantial morbidity to patients and costs to the healthcare system. Associations between these diseases have been hypothesized and studied for decades. In particular, psychosocial stressors associated with anxiety disorders raise autonomic arousal via the hypothalamic-pituitary axis which increases circulating catecholamines. This heightened arousal is associated with an increased risk of hypertension and a pro-inflammatory state and, consequently, development of coronary heart disease. This association holds across the spectrum of anxiety disorders (generalized anxiety, posttraumatic stress disorder, panic disorder, and obsessive compulsive disorder) and also when controlling for comorbid conditions such as depression and physical ailments. Multiple cross sectional studies reveal a positive association between anxiety and hypertension. These associations are bidirectional, with those with hypertension being more likely to have anxiety and those with anxiety being more likely to have hypertension. However, a few studies have shown no association. Longitudinal studies point to an increased risk of development of hypertension in patients who suffer from anxiety. More convincing studies show links between anxiety symptoms and disorders, including panic disorder and PTSD, and cardiovascular outcomes. Drawing broad conclusions from these studies is challenging, however, given the multiplicity of scales used to measure anxiety disorders. Anxiety, hypertension, and CHD are common conditions seen in primary care, and anxiety may be an important predictor of future CHD outcomes. Better recognition of the association of these conditions and the possible roles of each in development of the other should alert primary care providers to be vigilant in monitoring and treating anxiety, hypertension, and CHD.

Potential contribution of oxidative stress and inflammation to anxiety and hypertension

Previously, we have published that pharmacological induction of oxidative stress causes anxiety-like behavior in rats and also is associated with hypertension in these animals. Here, we report that sub-chronic induction of oxidative stress via pharmacological induction leads to i) reduction in glyoxalase (GLO)-1 and glutathione reductase (GSR)-1 expression; ii) calpain mediated reduction of brain derived neurotrophic factor (BDNF) levels; iii) NFκB mediated upregulation of proinflammatory factors interleukin (IL)-6 and tumor necrosis factor (TNF)-α and elevated angiotensin (AT)-1 receptor levels in hippocampus, amygdala and locus coeruleus regions of the brain. Acute oxidative stress has opposite effects. We speculate that regulation of GLO1, GSR1, BDNF, NFκB and AT-1 receptor may contribute to anxiety-like behavior and hypertension in rats.

Antipsychotic drug use among elderly nursing home residents in the United States

BACKGROUND

Antipsychotic utilization in elderly nursing home residents has increased substantially in recent years, primarily due to the use of atypical antipsychotic agents. However, few studies have examined antipsychotic utilization patterns in nursing home residents in the United States since the introduction of atypical agents in the 1990s.

OBJECTIVE

The goal of this study was to examine the prevalence of and the factors associated with antipsychotic drug use among elderly nursing home residents in the United States.

METHODS

This study involved a cross-sectional analysis of prescription and resident data files from the 2004 National Nursing Home Survey (NNNHS). The analysis focused on the use of 11 typical and 6 atypical antipsychotic agents among a nationally representative sample of elderly patients (aged > or =65 years). Descriptive weighted analysis was performed to examine antipsychotic prevalence patterns. Multiple logistic regression analysis within the conceptual framework of the Andersen behavioral model was used to examine the factors associated with antipsychotic drug use among the elderly nursing home residents.

RESULTS

According to the 2004 NNHS, 0.32 million elderly nursing home residents received antipsychotic medications, for an overall prevalence of 24.82%. Most received atypical agents (23.45%), while 1.90% received typical agents. Frequently reported diagnoses among the elderly using an antipsychotic agent were dementia (70%), depression (41%), and anxiety (18%). Among the predisposing characteristics, female gender and age (> or =85 years) were negatively associated with antipsychotic drug use. Need factors such as increasing dependence in decision-making ability regarding tasks of daily life, depressed mood indicators, behavioral symptoms, history of falls, and bowel incontinence were positively associated with antipsychotic drug use. In addition to the use of antipsychotic agents in schizophrenia and bipolar mania, this study found high use in conditions such as dementia, anxiety, depression, and parkinsonism in the elderly.

CONCLUSIONS

Nearly 1 in 4 elderly nursing home residents in the United States received antipsychotic agents. Predisposing and need factors played a vital role in determining the use of antipsychotic agents in these elderly patients. Overall, the study findings suggest that there is a need to monitor antipsychotic drug use by elderly patients in US nursing homes in light of recent efficacy and safety data on atypical agents.

Anxiety and unrecognized high blood pressure in U.S. ambulatory care settings: an analysis of the 2005 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey

OBJECTIVE

To determine for U.S. ambulatory visits for anxiety how often high blood pressure is unrecognized and the factors associated with being unrecognized.

METHODS

Analyzed data from the 2005 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey looking at visits for anxiety by patient complaint or provider diagnosis and determined if a hypertension diagnosis was included for visits in which measured blood pressure was in the hypertensive range. This was compared to total visits in the NAMCS and NHAMCS. Logistic regression determined predictors of high blood pressure going unrecognized for visits for anxiety.

RESULTS

Of visits for anxiety in 2005 with elevated blood pressure, 32.5% were unrecognized. This compares to 24.6% unrecognized for all visits with hypertension/elevated blood pressure. At visits in which anxiety medications were prescribed (OR 2.44 95% CI 1.01-5.89) and for Hispanic ethnicity (OR 13.9 95% CI 1.46-132.03), high blood pressure was more likely to be unrecognized. High blood pressure was less likely to be unrecognized for those 45 to 64 years old (OR 0.21 95% CI 0.07-0.62), visits not with the primary care provider (OR 0.09 95% CI 0.03-0.33), visits for a chronic problem (OR 0.26 95% CI 0.08-0.86), and visits at which anti-hypertensive medications were prescribed (OR 0.005 95% CI 0.001-0.04).

CONCLUSIONS

Anxiety is a common reason for visits in U.S. ambulatory settings. Many of these visits have concomitant high blood pressure, a large proportion of which may go unrecognized. Efforts to educate physicians about these issues may help reduce the level of unrecognized high blood pressure in those with anxiety.

Vascular factors and risk for neuropsychiatric symptoms in Alzheimer's disease: the Cache County Study

OBJECTIVE

To examine, in an exploratory analysis, the association between vascular conditions and the occurrence of neuropsychiatric symptoms (NPS) in a population-based sample of incident Alzheimer's disease (AD).

METHODS

The sample consisted of 254 participants, identified through two waves of assessment. NPS were assessed using the Neuropsychiatric Inventory. Prior to the onset of AD, data regarding a history of stroke, hypertension, hyperlipidemia, heart attack or coronary artery bypass graft (CABG), and diabetes were recorded. Logistic regression procedures were used to examine the relationship of each vascular condition to individual neuropsychiatric symptoms. Covariates considered were age, gender, education, APOE genotype, dementia severity, and overall health status.

RESULTS

One or more NPS were observed in 51% of participants. Depression was most common (25.8%), followed by apathy (18.6%), and irritability (17.7%). Least common were elation (0.8%), hallucinations (5.6%), and disinhibition (6.0%). Stroke prior to the onset of AD was associated with increased risk of delusions (OR = 4.76, p = 0.02), depression (OR = 3.87, p = 0.03), and apathy (OR = 4.48, p = 0.02). Hypertension was associated with increased risk of delusions (OR = 2.34, p = 0.02), anxiety (OR = 4.10, p = 0.002), and agitation/aggression (OR = 2.82, p = 0.01). No associations were observed between NPS and diabetes, hyperlipidemia, heart attack or CABG, or overall health.

CONCLUSIONS

Results suggest that a history of stroke and hypertension increase the risk of specific NPS in patients with AD. These conditions may disrupt neural circuitry in brain areas involved in NPS. Findings may provide an avenue for reduction in occurrence of NPS through the treatment or prevention of vascular risk conditions.

Hypertension – A Possible Vulnerability Marker for Depression in Patients with End-Stage Renal Disease

OBJECTIVE

This study explored the association of hypertension and psychiatric morbidity in patients with end-stage renal disease (ESRD) under adjusted personality characteristics and parental attachment.

METHODS

The mental health of 121 patients with ESRD in a general teaching hospital was evaluated using the 12-item version of the Chinese Health Questionnaire (CHQ). Only 40 males and 49 females completed all the questionnaires. Ten of the 40 males and 21 of the 49 females had high scores (> or = 4) and were allotted to the case group (n = 31). The remaining 58 patients constituted the control group (CHQ < 4).

RESULTS

The logistic regression model showed that hypertension, gender, and neuroticism are statistically significant covariates. Hypertension, especially, was strongly associated with depressive vulnerability (odds ratio of hypertension versus without hypertension = 9.07:1). Structural equation modeling revealed that gender difference and hypertension directly influenced the individuals' mental health status and that the influence of hypertension on mental health was highly variable.

CONCLUSION

A parsimonious structural equation model provided considerable evidence that hypertension could have an important effect on depression in ESRD patients, when predisposing factors, such as personality characteristics and parental attachment, gender, duration of hemodialysis and other medical diseases were adjusted. Hence, hypertension might be a mediating factor of depressive vulnerability in ESRD patients underling genetic and environmental problems.

Behavioral effects of prenatal folate deficiency in mice

BACKGROUND

Folate supplementation decreases the incidence of birth defects such as neural tube defects (NTDs). We and others have shown that gestational dietary folate deficiency that does not produce overt NTDs can alter fetal neural histology. Accordingly, murine offspring were examined for the possible functional consequences of prenatal folate deficiency.

METHODS

CD-1 mice were fed a diet of chow containing 400, 600, or 1200 nmol of folic acid/kg of chow for eight weeks prior to breeding and until GD18, at which time all dams were placed on folate-replete chow. Behavioral tests of male and female offspring included righting reflex, negative geotaxis, forelimb hanging, motor coordination, open field activity, and elevated plus maze activity.

RESULTS

Of greatest significance, the adult offspring that were prenatally folate-deficient exhibited more anxiety-related behavior in the elevated plus maze. Offspring of the 400 nmol of folic acid/kg of chow diet group exhibited significantly shorter durations in the open arms and longer durations in the closed arms. Further, these two behaviors were dose-related. There was also a trend for the prenatally folate-deficient adult mice to exhibit more thigmotaxis (wall-hugging) behavior in the open field, entering the central area less frequently than controls. There were few other differences in tested behaviors between folate-deficient and folate-replete mice.

CONCLUSIONS

Prenatal folate deficiency that is repleted at birth can manifest later with increased anxiety 9-12 weeks after birth.

Anxiety and medical disorders

Anxiety symptoms and disorders are associated with a range of general medical disorders. This association may be a physiologic consequence of the general medical disorder, a psychologic reaction to the experience of having a medical illness, a side effect of treatment, or a chance occurrence. This article briefly reviews the associations of panic disorder with seizure disorder, Klüver-Bucy syndrome, mitral valve prolapse, and respiratory disorders; of generalized anxiety disorder with chronic obstructive airway disease and cardiovascular and endocrine disorders; of social anxiety disorder with Parkinson's disease; of obsessive-compulsive disorder with striatal disorders; and of posttraumatic stress disorder with head injury and pain. Such associations provide important clues for understanding the neurobiology of anxiety disorders.

Asthma and internalizing behavior problems in adolescence: a longitudinal study

OBJECTIVE

Clinical studies of asthmatic children have found an association between lung disease and internalizing behavior problems. The causal direction of this association is, however, unclear. This article examines the nature of the relationship between behavior and asthma problems in childhood and adolescence.

METHODS

Data were analyzed on 5135 children from the Mater University Study of Pregnancy and its outcomes (MUSP), a large birth cohort of mothers and children started in Brisbane, Australia, in 1981. Lung disease was measured from maternal reports of asthma/bronchitis when the children were aged 5 and maternal reports of asthma symptoms when the children were aged 14. Symptoms of internalizing behaviors were obtained by maternal reports (Child Behavior Checklist) at 5 years and by maternal and children's reports at 14 years (Child Behavior Checklist and Youth Self Report).

RESULTS

Although there was no association between prevalence of asthma and externalizing symptoms, asthma and internalizing symptoms were significantly associated in cross-sectional analyses at 5 and 14 years. In prospective analyses, after excluding children with asthma at 5 years, internalizing symptoms at age 5 were not associated with the development of asthma symptoms at age 14. After excluding children with internalizing symptoms at 5 years, those who had asthma at 5 years had greater odds of developing internalizing symptoms at age 14.

CONCLUSION

Children who have asthma/bronchitis by the age of 5 are at greater risk of having internalizing behavior problems in adolescence.