Showing papers in "Depression and Anxiety in 2003"

Development of a new resilience scale: The Connor‐Davidson Resilience Scale (CD‐RISC)

Abstract: Resilience may be viewed as a measure of stress coping ability and, as such, could be an important target of treatment in anxiety, depression, and stress reactions. We describe a new rating scale to assess resilience. The Connor-Davidson Resilience scale (CD-RISC) comprises of 25 items, each rated on a 5-point scale (0–4), with higher scores reflecting greater resilience. The scale was administered to subjects in the following groups: community sample, primary care outpatients, general psychiatric outpatients, clinical trial of generalized anxiety disorder, and two clinical trials of PTSD. The reliability, validity, and factor analytic structure of the scale were evaluated, and reference scores for study samples were calculated. Sensitivity to treatment effects was examined in subjects from the PTSD clinical trials. The scale demonstrated good psychometric properties and factor analysis yielded five factors. A repeated measures ANOVA showed that an increase in CD-RISC score was associated with greater improvement during treatment. Improvement in CD-RISC score was noted in proportion to overall clinical global improvement, with greatest increase noted in subjects with the highest global improvement and deterioration in CD-RISC score in those with minimal or no global improvement. The CDRISC has sound psychometric properties and distinguishes between those with greater and lesser resilience. The scale demonstrates that resilience is modifiable and can improve with treatment, with greater improvement corresponding to higher levels of global improvement. Depression and Anxiety 18:76–82, 2003. & 2003 Wiley-Liss, Inc.

Problematic internet use: proposed classification and diagnostic criteria.

Abstract: Since the mid-1990s, there have been frequent reports of individuals whose use of the computer and internet is problematic. Given the recent expansion and the expected increase in internet availability and usage in the coming years, it is important that healthcare professionals be informed about this behavior and its associated problems. Recently, psychological and psychiatric literature has described individuals that exhibit problematic internet use who often suffer from other psychiatric disorders. In the face of this comorbidity, it is essential to evaluate whether these individuals represent a distinct class of disorder, or a manifestation/coping mechanism related to other underlying diagnosis. In either event, problematic internet use negatively impacts social and emotional functioning. Based on the current limited empirical evidence, problematic internet use may best be classified as an impulse control disorder. It is therefore imperative that problematic internet use be appropriately identified among symptomatic individuals. For these reasons, we propose specific diagnostic criteria that will allow for consistent identification and assist in further study of this behavior.

Chronicity, relapse, and illness--course of panic disorder, social phobia, and generalized anxiety disorder: findings in men and women from 8 years of follow-up.

Abstract: Anxiety disorders are chronic illnesses that occur more often in women than men. Previously, we found a significant sex difference in the 5-year clinical course of uncomplicated panic disorder that was attributable to a doubling of the illness relapse rate in women compared to men. However, we have not detected a sex difference in the clinical course of panic with agoraphobia, generalized anxiety disorder (GAD), or social phobia (SP), which are conditions generally thought to be more chronic than uncomplicated panic disorder. Given that a longer follow-up period may be required to detect differences in clinical course for more enduring illnesses, we conducted further analyses on this same cohort after a more protracted interval of observation to determine whether sex differences would emerge or be sustained. Data were analyzed from the Harvard/Brown Anxiety Research Program (HARP), a naturalistic, longitudinal study that repeatedly assessed patients at 6 to 12 month intervals over the course of 8 years. Data regarding remission and relapse status were collected from 558 patients and treatment was observed but not prescribed. Cumulative remission rates were equivalent among men and women with all diagnoses. Patients who experienced remission were more likely to improve during the first 2 years of study. Women with GAD continued remitting late into the observation period and experienced fewer overall remission events by 8 years. However, the difference in course failed to reach statistical significance. Relapse rates for women were comparable to those for men who suffered from panic disorder with agoraphobia, GAD, and SP. Again, initial relapse events were more likely to occur within the first 2 years of observation. However, relapse events for uncomplicated panic in women were less restricted to the first 2 years of observation and by 8 years, the relapse rates for uncomplicated panic was 3-fold higher in women compared with men. Anxiety disorders are chronic in the majority of men and women, although uncomplicated panic is characterized by frequent remission and relapse events. Short interval follow-up shows sex differences in the remission and relapse rates for some but not all anxiety disorders. These findings suggest important differences in the clinical course among the various anxiety disorders and support nosological distinctions among the various types of anxiety. It may be that sex differences in the clinical course of anxiety disorders hold prognostic implications for patients with these illnesses.

Pregnancy anxiety and comorbid depression and anger: effects on the fetus and neonate.

Abstract: One hundred sixty-six women were classified as experiencing high or low anxiety during the second trimester of pregnancy. The high anxiety women also had high scores on depression and anger scales. In a follow-up across pregnancy, the fetuses of the high anxiety women were noted to be more active and to experience growth delays. The high anxiety mothers' high prenatal norepinephrine and low dopamine levels were followed by their neonates having low dopamine and serotonin levels. The high anxiety mothers' newborns also had greater relative right frontal EEG activation and lower vagal tone. Finally, the newborns of high anxiety mothers spent more time in deep sleep and less time in quiet and active alert states and showed more state changes and less optimal performance on the Brazelton Neonatal Behavior Assessment Scale (motor maturity, autonomic stability and withdrawal). These data highlight the need for prenatal intervention for elevated anxiety symptoms during pregnancy.

Insomnia causes, consequences, and therapeutics: an overview.

Abstract: There is growing interest in insomnia both from the perspective of recent advances in clinical management as well as research aimed at elucidating its pathophysiology. This theoretical overview of insomnia describes the negative impact, etiological considerations, and pharmacological and behavioral treatments for the disorder, with an emphasis on areas receiving increased research attention. Insomnia, the most prevalent sleep disorder, affects 10-15% of the general population. In population-based studies severe insomnia has been shown to last for a median of 4 years. In addition, insomnia has a significant negative impact on an individual's work, physical, and social performance as well as overall quality of life. Furthermore, the economic cost of insomnia related to lost productivity, work-related accidents, absenteeism, and health-care costs are enormous. There is increasing evidence linking the precipitation of insomnia to stress, and converging evidence from cognitive, endocrine, neurological, and behavioral domains provide clear evidence for hyper-arousal in insomnia. However, there remains no consensus regarding the specific etiological mechanisms of this disorder. Although the pathophysiology of primary insomnia remains an enigma, numerous treatments both pharmacological and behavioral have been developed and found to be efficacious in controlled studies. Despite the wide availability of pharmacological treatments and increased knowledge of behavioral interventions, the vast majority of individuals with insomnia do not appear to be receiving adequate treatment. The inadequate treatment of insomnia leads to several important and under-recognized consequences including subsequent development of psychiatric disease and increased substance use.

The weaker sex? Gender and post-traumatic stress disorder

Abstract: We discuss the gender-specific differences for traumatic events and Post-Traumatic Stress Disorder (PTSD) as found in the epidemiological literature. Recent research literature consistently reports three interesting findings: 1) men experience traumatic events more often, 2) women and men differ in the type of traumatic experiences they experience, and 3) women more often develop PTSD after the experience of a traumatic event. In the second part of the present article we provide some explanations for these differences. The reported higher vulnerability of women for PTSD could be due to the methodology used, the higher prevalence of childhood sexual abuse and rape in women, the different coping styles of women and men, or the more limited socio-economic resources of women.

Are there gender differences in objective and subjective sleep measures? A study of insomniacs and healthy controls.

Abstract: It is well known that insomnia is more frequent in women than in men throughout all age groups. In this respect insomnia resembles other psychiatric disorders that occur more frequently in women such as anxiety and depressive disorders. Since insomnia is frequently a symptom of anxiety and depression, it remains an open question whether the comorbidity with psychiatric disorders fully explains the gender differences in the prevalence of insomnia or whether gender influences sleep independently from psychiatric conditions. We analyzed sleep measures of patients diagnosed with a primary insomnia (n=86) and of an age- and sex-matched healthy control group (n=86) by polysomnography; additionally, subjective rating scales were available for 70 patients and 54 controls matched for mean age and sex ratio. Surprisingly, none of the sleep continuity measures (sleep duration, sleep efficiency, arousal index, and wake%), nor slow wave or REM sleep % showed significant gender differences in both insomniacs and healthy controls. Also, subjective estimates of sleep quality were comparable in both sexes. As expected, insomniacs strongly differed from the control group in all subjective measures of sleep. Polysomnography showed significantly reduced sleep duration and efficiency, increased arousal index, and slightly, but significantly, less REM sleep in the insomniacs as compared to the healthy controls. These studies indicate that gender seems to have, if any, relatively little influence on sleep per se. We hypothesize that the clear gender differences in the prevalence of insomnia are caused predominantly by gender differences in the prevalence of anxiety and depression. Primary insomnia may be, at least in a part of the cases, a subclinical or subthreshold form of anxiety or depression. Depression and Anxiety 17:162–172, 2003. © 2003 Wiley-Liss, Inc.

Pharmacological treatment of social anxiety disorder: A meta-analysis

Abstract: Placebo-controlled trials have evaluated the efficacy of several medications in the treatment of social anxiety disorder but information regarding their relative efficacy is lacking. We compared the efficacy of medications systematically studied for the treatment of social anxiety disorder using meta-analytic techniques. The methodology included a database search of articles published between January 1980 and June 2001 and manual searches of bibliographies in published manuscripts. Trials were included if they reported outcome data on the Liebowitz Social Anxiety Scale (LSAS) or a categorical measure of responder status. Data were extracted independently by two authors. The Q statistic was used to assess homogeneity across trials. All analyses were conducted using intent-to-treat data. There was substantial heterogeneity across trials. The medications with largest effect sizes were phenelzine [effect size, 1.02; 95% Confidence Interval (CI), 0.52–1.52], clonazepam (effect size, .97; 95% CI, 0.49–1.45), gabapentin (effect size, .78; 95% CI, 0.29–1.27), brofaromine (effect size, .66; 95% CI, 0.38–0.94), and the selective serotonin reuptake inhibitors (SSRIs; effect size, .65; 95% CI, 0.50–0.81). There were no statistically significant differences between medications or medication groups. However, formal methods of interim monitoring adapted for meta-analyses suggested strongest evidence of efficacy for SSRIs and brofaromine. Several medications are efficacious for the treatment of social anxiety disorder. The stability of the SSRI effect size estimate in conjunction with other evidence for safety and tolerability and their ability to treat comorbid conditions supports the use of SSRIs as the first-line treatment. Direct comparisons of SSRIs vs. other promising medications deserve consideration. Depression and Anxiety 18:29–40, 2003. © 2003 Wiley-Liss, Inc.

Childhood adversities associated with major depression and/or anxiety disorders in a community sample of Ontario: issues of co-morbidity and specificity.

Abstract: It has been well established that early adversity is a major risk factor for depression and for anxiety disorders in various populations and age groups Few studies have considered the relative strength of these associations and the possible role of co-morbid depression/anxiety in understanding them Using data from a large community sample of Ontario, Canada, we examined the relative strength of the associations between early physical abuse, sexual abuse, and/or parental strain with depression alone, anxiety alone, and co-morbid depression/anxiety The current sample consisted of 6,597 individuals 15-64 years of age who were interviewed using the World Health Organization Composite International Diagnostic Interview (CIDI) Using a multivariate design, we compared early adversity scores across four diagnostic study groups including normal controls, individuals with major depression but no anxiety disorders, individuals with one or more anxiety disorders without major depression, and individuals with co-morbid major depression and anxiety Individuals with past disorders were considered separately from those with current disorders For both past and current disorders, highly significant differences in early adversity scores were found across the four study groups A novel and robust finding, consistent across all analyses, was a marked association between early sexual abuse and co-morbid depression and anxiety but not the "pure" disorders A strong association between early parental strain and major depression (independent of anxiety) was also found The overall pattern of results suggest that there may be unique relationships linking particular adversities to particular manifestations of depression and anxiety disorders later in life A particularly strong association between early sexual abuse and co-morbid depression/anxiety was found

Brain mechanisms underlying emotional alterations in the peripartum period in rats.

Abstract: In the period before and after parturition, i.e., in pregnancy and lactation, a variety of neuroendocrine alterations occur that are accompanied by marked behavioral changes, including emotional responsiveness to external challenging situations. On the one hand, activation of neuroendocrine systems (oxytocin, prolactin) ensures reproduction-related physiological processes, but in a synergistic manner also ensures accompanying behaviors necessary for the survival of the offspring. On the other hand, there is a dramatic reduction in the responsiveness of neuroendocrine systems to stimuli not relevant for reproduction, such as the hypothalamo-pituitary-adrenal (HPA) axis responses to physical or emotional stimuli in both pregnant and lactating rats. With CRH being the main regulator of the HPA axis, downregulation of the brain CRH system may result in various behavioral, in particular emotional, adaptations of the maternal organisms, including changes in anxiety-related behavior. In support of this, the lactating rat becomes less emotionally responsive to novel situations, demonstrating reduced anxiety, and shows a higher degree of aggressive behavior in the test for agonistic behavior as well as in the maternal defense test. These changes in emotionality are independent of the innate (pre-lactation) level of anxiety and are seen in both rats bred for high as well as low levels of anxiety. Both brain oxytocin and prolactin, highly activated at this time, play a significant role in these behavioral and possibly also neuroendocrine adaptations in the peripartum period. Depression and Anxiety 17:111–121, 2003. © 2003 Wiley-Liss, Inc.

Stresses on women physicians: consequences and coping techniques.

Abstract: We review current data on types of stressors acting on women physicians, the consequences of these stressors and methods of coping with them. We undertook a systematic review of original articles published in the last 15 years and registered mainly on Medline and on the internet websites focusing on these issues. In addition to the pressures acting on all physicians, women physicians face specific stressors related to discrimination, lack of role models and support, role strain, and overload. The depression rate in women physicians does not vary from that of the general public but the rates of successful suicide and divorce are much higher. Women in academic settings are promoted more slowly, have lower salaries, receive fewer resources, and suffer from a range of micro-inequities. They often lack mentors to provide advice and guidance. They must cope with the pressures of choosing when to have a child and conflicts between being a wife and mother and having a career. Despite these pressures, they report a high degree of career satisfaction. Although women physicians suffer from a variety of stressors that can lead to career impediments, stress reactions, and psychiatric problems, generally they are satisfied with their careers. Personal coping techniques can help women deal with these stressors. Pressures will continue until attitudes and practices change in institutional settings. Some institutions are initiating changes to end discrimination against women faculty.

Comorbidity of anxiety disorders in adolescents.

Abstract: We examined the comorbidity of anxiety disorders and their clinical consequences in adolescents. The 1,035 adolescents, aged 12 to 17 years old, were randomly selected from 36 schools in the province of Bremen, Germany. Anxiety disorders and other psychiatric disorders were coded based on DSM-IV criteria using the computerized Munich version of the Composite International Diagnostic Interview. The comorbidity rate within the anxiety disorders was relatively low (14.1%). However, the comorbidity of anxiety disorders with other psychiatric disorders was high. Approximately half (51%) of the anxious adolescents had other psychiatric disorders. The most common comorbid pattern was that of anxiety and depressive disorders. Among those with both anxiety and depressive disorders, a majority of them (72%) had anxiety before that of depression. Anxious adolescents with comorbid disorders were significantly more psychologically distressed, as assessed using the SCL-90-R, and used more mental health services than adolescents with anxiety disorders only. The effect of comorbidity on mental health services utilization was stronger in males than females. The findings suggest the need to design intervention strategies to deal with cases with multiple disorders.

Selective attention in anxiety: Distraction and enhancement in visual search

Abstract: According to cognitive models of anxiety, anxiety patients exhibit an attentional bias towards threat, manifested as greater distractibility by threat stimuli and enhanced detection of them. Both phenomena were studied in two experiments, using a modified visual search task, in which participants were asked to find single target words (GAD-related, speech-related, neutral, or positive) hidden in matrices made up of distractor words (also GAD-related, speech-related, neutral, or positive). Generalized anxiety disorder (GAD) patients, social phobia (SP) patients afraid of giving speeches, and healthy controls participated in the visual search task. GAD patients were slowed by GAD-related distractor words but did not show statistically reliable evidence of enhanced detection of GAD-related target words. SP patients showed neither distraction nor enhancement effects. These results extend previous findings of attentional biases observed with other experimental paradigms. Depression and Anxiety 18:18–28, 2003. © 2003 Wiley-Liss, Inc.

Characterizing selective mutism: is it more than social anxiety?

Abstract: Selective mutism (SM) occurs when a child persistently lacks speech in some social situations but not in others, despite the ability to use and comprehend language. While considered to be related to anxiety, SM is poorly understood and studies of SM children are often based on parent reports. This study developed a unique, non-verbally based assessment protocol for SM children in order to better characterize their clinical profile, language abilities, and learning abilities. A comparison was done with a group of children of similar age, with social phobia (SP) but no SM, to search for characteristics that might distinguish SM from other anxiety disorders. Twenty-three children participated in the study (14 SM and 9 SP). The assessment protocol included standardized anxiety rating scales, cognitive and academic tests, and a speech and language assessment. SM and SP groups showed similar levels of anxiety and academic ability, but the SM group showed some language impairments relative to the SP group. Though requiring replication with a larger sample and nonclinical comparison group, the results suggest that SM children can be assessed by non-verbal means and that their disorder is characterized by anxiety and subtle language impairments.

Childhood abuse, depression, and anxiety in adult psychiatric outpatients.

Abstract: Theorists have long thought that negative experiences in childhood (e.g., abuse) may contribute to the development of psychopathology in adolescence and adulthood [e.g., Beck, 1967; Bowlby, 1973, 1980]. More recently, they have hypothesized that different types of childhood abuse may contribute specific vulnerability to certain forms of psychopathology. Specifically, theorists have suggested that childhood emotional abuse may be most strongly related to the development of depression, whereas physical abuse may be most strongly related to the development of anxiety [e.g., Ladd and Ladd, 2001; Rose and Abramson, 1992]. In contrast, childhood sexual abuse appears to be relatively nonspecific in terms of its psychopathological correlates [e.g., Kendler et al., 2000] Despite the number of studies that have examined the long-term correlates of childhood abuse [e.g., Gibb et al., 2001; Kendler et al., 2000; Silverman et al., 1996], no study of which we are aware has directly examined the relative specificity of each form of abuse to depression vs. anxiety in a clinical sample. In this study, we examined the relation between adult psychiatric outpatients’ reports of childhood emotional, physical, and sexual abuse and their current symptoms and diagnoses of depression and anxiety. We hypothesized that reports of childhood emotional abuse would be more strongly related to patients’ current depression than anxiety and that reports of childhood physical abuse would show the opposite pattern. In contrast, we predicted that reports of childhood sexual abuse would demonstrate no evidence of specificity. Participants were 552 psychiatric outpatients (mean age1⁄4 40.59 years, sd1⁄4 14.30; 57.1% women; 87.7% Caucasian). Two hundred seventy-three (49.5%) of the patients received a principal Diagnostic and Statistical Manual, 4th Edition [DSM-IV; American Psychiatric Association (APA), 1994] Axis I diagnosis of a depressive disorder (e.g., major depression and dysthymia). One hundred seventy-seven (32.1%) received a principal Axis I diagnosis of an anxiety disorder (e.g., generalized anxiety disorder or panic). One hundred one (18.3%) of the patients received other diagnoses (e.g., bipolar disorder or substance dependence). All measures were administered as part of the intake assessment. Reports of childhood emotional, physical, and sexual abuse were obtained via three dichotomously coded items. Specifically, patients were asked, ‘‘Did you ever experience emotional or verbal abuse as a child?’’ Similar questions were used to assess for childhood physical or sexual abuse. Patients were also administered the Beck Anxiety Inventory [BAI; Beck et al., 1988], Beck Depression Inventory-II [BDI-II; Beck et al., 1996], and the 24-item Hamilton Rating Scale for Depression [HRSD-24; Guy, 1976; Hamilton, 1960]. Finally, diagnoses of depressive and anxiety disorders were obtained using the Structured Clinical Interview for DSM-IV Axis I Disorders [SCID-I; First et al., 1995]. Descriptive statistics including rates of reported childhood abuse, as well as correlations among the study variables, are presented in Table 1. As can be seen in the table, reports of each type of childhood abuse were significantly related to patients’ symptoms of depression and anxiety. As hypothesized, however, reports of childhood emotional abuse were significantly more strongly correlated with outpatients’ BDIII (Z1⁄4 2.25, P1⁄4.01) and HRSD-24 (Z1⁄4 2.79, P1⁄4.003) scores than with their BAI scores. Also as hypothesized, outpatients’ reports of childhood physical abuse were significantly more strongly correlated with their BAI scores than with their BDI-II (Z1⁄4 1.86, P1⁄4.03) or HRSD-24 (Z1⁄4 1.89, P1⁄4.03) scores. In contrast, the differences in the magnitude of the correlations between outpatients’ reports of childhood sexual abuse and their BAI vs. BDI-II (Z1⁄4 0.42, P1⁄4.34) or HRSD24 (Z1⁄4 0.48, P1⁄4.32) scores were not significant. Next, w analyses were used to examine the relation between patients’ reports of childhood abuse and their diagnoses of depressive vs. anxiety disorders. Patients DEPRESSION AND ANXIETY 17:226–228 (2003)

Selective memory and memory deficits in depressed inpatients.

Abstract: We investigated memory impairment and mood-congruent memory bias in depression, using an explicit memory test and an implicit one Thirty-six severely depressed inpatients that fulfilled DSM-IV criteria for major depressive disorder and 36 healthy controls matched for sex, age, and educational level participated in the study Explicit memory was assessed with a free recall task and implicit memory with an anagram solution task Results showed that depressed and controls differed in explicit memory performance, depending on the amount of cognitive distraction between incidental learning and testing Implicit memory was not affected In addition, severely depressed patients showed a mood-congruent memory bias in implicit memory but not in explicit memory The complex pattern of results is discussed with regard to relevant theories of depression

How does premenstrual dysphoric disorder relate to depression and anxiety disorders

Abstract: Premenstrual dysphoric disorder (PMDD) is a severe variant of premenstrual syndrome that afflicts approximately 5% of all women of fertile age. The hallmark of this condition is the surfacing of symptoms during the luteal phase of the menstrual cycle, and the disappearance of symptoms shortly after the onset of menstruation. Whereas many researchers have emphasized the similarities between PMDD and anxiety disorders, and in particular panic disorder, others have suggested that PMDD should be regarded as a variant of depression. Supporting both these notions, the treatment of choice for PMDD, the serotonin reuptake inhibitors (SRIs), is also first line of treatment for depression and for most anxiety disorders. In this review, the relationship between PMDD on the one hand, and anxiety and depression on the other, is being discussed. Our conclusion is that PMDD is neither a variant of depression nor an anxiety disorder, but a distinct diagnostic entity, with irritability and affect lability rather than depressed mood or anxiety as most characteristic features. The clinical profile of SRIs when used for PMDD, including a short onset of action, suggests that this effect is mediated by other serotonergic synapses than the antidepressant and anti-anxiety effects of these drugs. Although we hence suggest that PMDD should be regarded as a distinct entity, it should be emphasized that this disorder does display intriguing similarities with other conditions, and in particular with panic disorder, which should be the subject of further studies. Also, the possibility that there are subtypes of PMDD more closely related to depression, or anxiety disorders, than the most common form of the syndrome, should not be excluded.

Obsessive-compulsive spectrum conditions in obsessive-compulsive disorder and other anxiety disorders.

Abstract: In light of current interest in an obsessive-compulsive spectrum of disorders, this study sought to determine whether comorbidity patterns support the unique relationship hypothesized between these conditions and obsessive-compulsive disorder (OCD). Comparisons were made of lifetime rates of several proposed spectrum conditions in individuals with one of three anxiety disorder principal diagnoses (OCD, social phobia, or panic disorder [PD], N=277). Spectrum conditions examined included tic-related disorders, trichotillomania, skin picking, and eating disorders, with analyses performed on rates both of clinical disorder alone, and clinical and subclinical manifestations jointly. The OCD group was found to differ from both other groups in showing 1) a greater proportion of individuals affected with any lifetime spectrum condition, 2) a greater number of lifetime spectrum conditions affecting each individual, and 3) a greater proportion of individuals having a lifetime history of multiple spectrum conditions. Analyses for specific spectrum conditions indicated differences among the anxiety disorder groups for all spectrum categories except eating disorders, though only in the case of tic-related conditions did OCD differ significantly from both comparison groups. For the other conditions, dissimilar patterns of differences were observed among the three groups, particularly when subclinical manifestations were included. These findings have conceptual and clinical implications, including 1) the salience of tic-related disorders in the OC spectrum, 2) the possibility that the relationship between spectrum conditions and anxiety disorders may take several different forms, and 3) the need for refinement of the hypothesized spectrum.

Duloxetine in treatment of anxiety symptoms associated with depression.

Abstract: Most patients with major depressive disorder (MDD) have symptoms of anxiety associated with their depression. Duloxetine, a potent and balanced dual serotonin and norepinephrine reuptake inhibitor, is effective in the treatmentof depression. We investigated its effects in treating the symptoms of anxiety in depressed patients. This investigation includes all the placebo-controlled studies of duloxetine in MDD but focuses on four trials in which duloxetine was superior to placebo on the primary outcome measure of the 17-item Hamilton Depression Rating Scale (HAMD(17)) total score. Studies 1 and 2 included duloxetine at 60 mg/d (the recommended starting and therapeutic dose) and placebo. Study 3 included duloxetine 120 mg/d (administered as 60 mg b.i.d.), fluoxetine 20 mg/d, and placebo. Study 4 included duloxetine 40 mg/d (administered as 20 mg b.i.d.), duloxetine 80 mg/d (administered as 40 mg b.i.d.), paroxetine 20 mg/d, and placebo. Anxiety was assessed in all studies using the HAMD anxiety/somatization subfactor and the anxiety-psychic item (HAMD Item 10). Studies 3 and 4 also included the Hamilton Anxiety Rating Scale (HAMA). Across the four studies, duloxetine at doses of >/=60 mg was compared with placebo on 10 outcomes and with either paroxetine or fluoxetine on 6 outcomes. In 8 comparisons, mean improvement for duloxetine was significantly greater than placebo at the last study visit and/or across all study visits. In 3 comparisons, the mean improvement for duloxetine was significantly greater than paroxetine or fluoxetine. In these studies, duloxetine provided rapid relief of anxiety symptoms associated with depression. Previous reports have summarized duloxetine's efficacy in treating the core emotional symptoms and painful physical symptoms associated with depression. Duloxetine's efficacy in treating a broad spectrum of symptoms associated with depression, including mood, anxiety, and painful physical symptoms, may be attributed to dual reuptake inhibition of both serotonin and norepinephrine. Efficacy in these three key symptom domains may in turn explain the high probabilities of remission (43-57%) observed in these studies.

The experience of disability and quality of life in social anxiety disorder.

Abstract: Although disability is a concept most often associated with role dysfunction, and quality of life is most often associated with life satisfaction, these terms are frequently used interchangeably in the literature. In contrast, this study proposes that disability and quality of life are independent but related constructs. Additionally, we propose that disability partially mediates the relationship between symptoms and quality of life. That is, greater symptoms are associated with more impairment, which is, in turn, associated with less satisfaction with one's life. Ninety-six individuals with social anxiety disorder were given measures of social anxiety symptoms, disability, and quality of life. The results of the study suggest that disability and quality of life are, in fact, distinct concepts, and the experience of disability partially mediates the relationship between a patient's experience of symptoms and his or her perceived life satisfaction.

Prevalence and relationship to delusions and hallucinations of anxiety disorders in schizophrenia.

Abstract: We investigated the prevalence of anxiety disorders in a sample of individuals with chronic schizophrenia, controlling for anxiety symptoms that may be related to delusions and hallucinations, and the possible differences in clinical variables between the groups. Individuals with a diagnosis of schizophrenia and able to give informed consent were recruited from the community. The Mini International Neuropsychiatric Interview (MINI) was administered to both confirm the DSM-IV diagnosis of schizophrenia and screen for comorbid anxiety disorders. If a comorbid anxiety disorder was found, its relation to the individual's delusions and hallucinations was examined. Clinical rating scales for schizophrenia were administered as well as rating scales for specific anxiety disorders where appropriate. Overall, anxiety disorders ranged from 0% [ for Post Traumatic Stress Disorder (PTSD)] to 26.7% [ for generalized anxiety disorder (GAD) and agoraphobia without panic] with lower rates when controlled for anxiety symptoms related to delusions and hallucinations. In investigating clinical variables, the cohort was initially divided into schizophrenics with no anxiety disorders and those with an anxiety disorder; with further analyses including schizophrenics with anxiety disorders related to delusions and hallucinations and those with anxiety disorders not related to delusions and hallucinations. The most consistent difference between all the groups was on the PANSS-G subscale. No significant differences were found on the remaining clinical variables. Comorbid anxiety disorders in schizophrenia can be related to the individual's delusions and hallucinations, though anxiety disorders can occur exclusive of these positive symptoms. Clinicians must be aware that this comorbidity exists in order to optimize an individual's treatment.

Group behavioral therapy for adolescents with tic-related and non-tic-related obsessive-compulsive disorder.

Abstract: Prior research supports the distinction between tic-related and non-tic–related obsessive–compulsive disorder (OCD) based on phenomenologic, etiologic, and neurobehavioral data. The present study examines whether response to psychosocial treatment differs in adolescents, depending on the presence of comorbid tics. Nineteen adolescents, 12–17 years of age, participated in 7-week, uncontrolled trial of group cognitive–behavioral treatment (CBT) for OCD. Eight of the patients had tic-related and eleven had non-tic–related OCD. The group CBT program included psycho-education, exposure and response prevention, cognitive strategies, and family involvement. Significant improvement was observed for all subjects on the Yale-Brown Obsessive Compulsive Scale ratings of obsessions, compulsions, and total OCD symptoms. Outcomes were similar for subjects with tic-related and non-tic–related OCD. These preliminary results suggest that the presence of comorbid tic disorders may not attenuate response to behavioral group treatment among adolescents. Depression and Anxiety 17: 73–77, 2003. & 2003 Wiley-Liss, Inc.

A model of risk for major depression: Effects of life stress and cognitive style vary by age

Abstract: Empirical studies increasingly attribute risk for depression to adverse life events, cognitive style, and possibly to the interaction between cognitive style and event type. We present an evidence-based model, developed with independent samples of adults and elderly adults, indicating that risk for major depression associated with these factors varies with age. According to the model, adverse events and need for control, the cognitive style that is a key feature of Beck's concept of autonomy, are significant risk factors for depression in younger adults but not in elderly adults. The cognitive style of sociotropy, characterized by a high need for relatedness and concern about disapproval, is a stable risk factor, independent of age, in posing a risk for depression. The effects of the interactions of adverse event type (achievement events and interpersonal events) and cognitive style in predicting depression each appear to vary with age, expanding prior work, which suggests that adverse events affecting one's personal vulnerability are likely to precipitate depression. Age-specific approaches to reducing risk for major depression are clinically important, and the model presented here suggests that the use of an age-specific perspective would advance research in stress-diathesis models for risk of depression.

Citalopram treatment of social anxiety disorder with comorbid major depression.

Abstract: Treatment of patients with both social anxiety disorder and major depression has been little studied although social anxiety disorder and depression frequently co-occur. Each disorder has been shown to respond to serotonin reuptake inhibitor treatment. Objectives of this study were to characterize a sample of these comorbid patients and to assess response to treatment with citalopram. Patients with primary DSM-IV generalized subtype of social anxiety disorder and comorbid major depression (N = 21) were assessed for symptoms of each disorder, including atypical depressive features, and functional impairment. Patients were treated with a flexible dose of open label citalopram for 12 weeks. Response rates for the intention-to-treat sample at week 12 were 14/21 (66.7%) for social anxiety disorder and 16/21 (76.2%) for depression. All continuous measures of social anxiety, depression, and functional impairment improved significantly with treatment, but depression symptoms responded more rapidly and more completely than social anxiety symptoms. Mean dose of citalopram at study endpoint was 37.6 mg/day. Only three patients (14.3%) fulfilled DSM-IV criteria for atypical features of depression, although 18 (85.7%) fulfilled the criterion for interpersonal rejection sensitivity. Citalopram treatment may benefit patients with primary social anxiety disorder and comorbid major depression, and it should be further studied in controlled trials. Improvement in social anxiety disorder symptoms lagged behind improvement in depression, and greater than 12 weeks of treatment may be required to assess full social anxiety response in patients with comorbid depression. The overlap of social anxiety disorder with atypical features of depression may primarily be due to the shared feature of rejection sensitivity.

Lack of association of catechol-O-methyltransferase gene polymorphism in obsessive-compulsive disorder.

Abstract: The COMT gene has been implicated to be involved in the pathogenesis of obsessive–compulsive disorder (OCD) and various other psychiatric disorders. COMT enzyme activity is governed by a common genetic polymorphism at codon 158 that results in substantial 3- to 4-fold variation in enzymatic activity [a high-activity COMT variant (H) and a low activity variant (L)]. This study evaluates the association between OCD and the COMT gene polymorphism. Fifty-nine OCD patients that were diagnosed according to DSM-IV criteria and 114 healthy control subjects were included in the study. PCR technique was used for molecular analysis. The genotypic pattern of distribution of the COMT gene (H/H, H/L, and L/L genotypes) was not different between the OCD patients and controls. There were no significant differences among the patients with positive family history for OCD, those with negative family history for OCD, and the controls with respect to allele frequencies of the COMT gene polymorphisms. Patients that were homozygous or heterozygous for the L allele had significantly higher insight scores (i.e., poorer insight) on Y-BOCS compared to those homozygous for the H allele. We did not find an association between OCD, family history for OCD, and the COMT gene polymorphism. This study suggests that the COMT gene polymorphism is not directly associated with OCD in our patient group. Depression and Anxiety 18:41–45, 2003. © 2003 Wiley-Liss, Inc.

Sleep in post-traumatic stress disorder and panic: convergence and divergence.

Abstract: Disturbed sleep is a common clinical problem in anxiety disorders, particularly in patients with post-traumatic stress disorder (PTSD) and panic disorder (PD). Several studies have attempted to validate the subjective sleep complaints of these disorders using laboratory polysomnography. These attempts, typically focusing on PTSD or PD independently, have demonstrated inconsistent results. To our knowledge, no such studies have attempted to directly compare and contrast sleep disturbances in PTSD and PD together. Our review of the studies of subjective sleep disturbances, sleep architecture, and sleep-related biologic phenomena suggests that a comparative characterization of sleep disturbances in these two disorders is timely. Such an inference is based on our identification of several areas of convergence and divergence between PTSD and PD found in the published literature, as well as our own preliminary investigations. Specifically, PTSD and PD seem to converge on several sleep-related parameters, namely, sleep quality, presence of episodic parasomnias, and movement time. They also appear to diverge in other important sleep-related areas such as respiratory disturbances and the particular phenomenological nature of episodic parasomnias, namely nightmares or nocturnal panic attacks. Investigations focusing on such overlapping phenomena may provide groundwork for further elucidation of central fear systems underlying these two disorders. Additionally, such sleep studies have the potential to provide important insights into ongoing efforts to develop a cohesive conceptual framework into the pathophysiologies of these disorders. Depression and Anxiety 18:187–197, 2003. © 2003 Wiley-Liss, Inc.

Factorial validity of the center for epidemiologic studies-depression (CES-D) scale in military peacekeepers

Abstract: Despite widespread use of the Center for Epidemiologic Studies Depression Scale [CES-D], there are no investigations that examine its factor structure in a military sample. Separate confirmatory factor analyses were performed on responses to the CES-D obtained from 102 female and 102 male Canadian military peacekeepers in order to compare the fit of a four-factor intercorrelated (lower-order) model to a four-factor hierarchical (higher-order) model. The intercorrelated and hierarchical models fit the data well for both women and men, with hierarchical models fitting the data slightly better for women than men. These findings suggest that, for military women and men, the CES-D can be used to measure a set of distinct but interrelated depressive symptoms as well as a global construct of depression. Implications and future directions are discussed.

Bibliometric analysis of biomedical publications on SSRI during 1980-2000.

Abstract: We performed a bibliometric study of the scientific publications referring to selective serotonin reuptake inhibitors (SSRIs). The database used was EMBASE: Psychiatry. We applied the principal bibliometric indicators: Price's and Bradford's laws on the increase or dispersion of scientific literature, Lotka's law on the productivity of authors, the participation index (PaI) of countries, the productivity index (PI) of authors, and the collaboration index. By means of manual coding, documents were classified according to type of study and to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) or nonpsychiatric categories. We analysed 3,622 original documents published between 1980 and 2000. Our results show nonfulfilment of Price's law because production on SSRIs does not grow exponentially (r=0.937 vs. r = 0.946, after linear adjustment). The journal most employed is the Journal of Clinical Psychiatry (Bradford's first zone). The United States is the most productive country (PaI=41.50). The documents were distributed in four groups: experimental pharmacology (8.38%), tolerance and safety (34.94%), clinical efficacy (49.11%), and not specified (7.56%). The drug most studied was fluoxetine (1,745 articles), followed by paroxetine (659). The DSM-IV diagnostic categories most studied were depression (834), obsessive-compulsive disorder (171), and panic disorder (75). The control antidepressants most used in comparative clinical studies were amitriptyline (51) and imipramine (42). The results of the present study show that the SSRIs are not solely antidepressant drugs, but also have a wide range of uses both within the psychiatric sphere (especially in the field of anxiety) and outside it, which explains the considerable scientific production generated in relation to these drugs.

The effect of alexithymic features on response to antidepressant medication in patients with major depression.

Abstract: There has been no follow-up study regarding the effect of alexithymic features on antidepressant treatment. This study was planned to observe whether alexithymia effects short-term treatment outcome in depression. The study included 32 alexithymic and 33 nonalexithymic outpatients with major depression. Depression was assessed on the basis of the Structured Clinical Interview for DSM-IV (SCID-I). Level of depression was measured using the 17-item Hamilton Rating Scale for Depression (HAM-D). Alexithymia was screened using the Turkish version of Toronto Alexithymia Scale (TAS-20). All patients received 20 mg/d paroxetine for 10 weeks. Alexithymic and nonalexithymic patients were compared on the HAM-D scores, TAS-20 scores, and rate of response to antidepressant medication. The rate of responders, defined by a reduction of >50% from baseline in HAM-D total score, was 21.9% in the alexithymic group and 54.5% in the nonalexithymic group. Changes in the HAM-D scores were significantly correlated with the TAS-20 scores. TAS-20 scores dropped below 61 in only 31.2% of the alexithymic patients, and 68.8% of patients remained alexithymic. Whereas 50% of patients whose TAS-20 scores dropped below 61 responded to antidepressant medication, this rate was only 9.1% among patients who remained alexithymic. These findings indicated that the stability of alexithymic features had a negative effect on antidepressant treatment in depression.

Evidence that the SSRI dose response in treating major depression should be reassessed: A meta-analysis

Abstract: The limitations in design and analysis of currently available dose-response studies of SSRI treatment of major depression have led to the conclusion that dose response is flat. We applied concepts from our companion article to determine if currently available data is consistent with a "potential" and an "expressed" dose response. Using these concepts, we performed a meta-analysis on all identifiable published fixed-dose and dose-escalation studies that reported the effect of different SSRI oral doses on efficacy. "Potential" dose response in fixed-dose studies with categorical response outcomes equaled a significant meta-analyzed slope of 3.1%/100 SSRI mg equivalents (SMEs) (SE=1.2%) or 7.8% across the dose range. Similar analysis in dose-escalation studies that reported categorical response data yielded a non-significant meta-analyzed slope of 3.7%/100 SMEs (SE=2.3%) or 9.3% across the dose range. Analyses of the "expressed" dose response demonstrated in the studies indicated a slope statistically equal to zero. The current analysis suggests a "potential" dose response can be demonstrated for SSRIs in treating major depression. The analysis suggests an "expressed" dose response could exist in best clinical practice. Study designs better tailored to address the relevant clinical question would test these hypotheses more appropriately than previous studies.