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Journal ArticleDOI

Mixed anxiety–depression in a 1 year follow-up study: shift to other diagnoses or remission?

TL;DR: While depressive disorders and anxiety disorders showed relatively high stability, MAD cannot be seen as a stable diagnosis: most of MAD patients remit; many of them shift to other diagnoses than depression or anxiety.
About: This article is published in Journal of Affective Disorders.The article was published on 2004-04-01 and is currently open access. It has received 47 citations till now. The article focuses on the topics: Anxiety disorder & Anxiety.

Summary (2 min read)

1. Introduction

  • A substantial number of patients suffer from depressive and anxiety symptoms without meeting official criteria of either ICD-10 or DSM-IV depressive and/or anxiety disorders (Zinbarg et al., 1994; Stein et al., 1995; see Katon and Roy-Byrne, 1991; Wittchen and Essau, 1993; Boulenger et al., 1997 for reviews).
  • To provide a clinical definition for those patients the ICD-10 (WHO, 1992) introduced the concept of mixed anxiety–depression disorder (MAD).
  • The status of the ICD-10-MAD diagnosis — in relation to depressive and anxiety disorders — needs further research.
  • Data were collected within the scope of the World Health Organization (WHO) Collaborative Study on ‘Psychological Problems in General Health Care’, which is a cross-sectional and prospectivelongitudinal international study (Sartorius et al., 1993; Üstün and Sartorius, 1995).

2. Methods

  • From the sample of the WHO Collaborative Study1 patients meeting ICD-10 criteria for a depressive episode, dysthymia, agoraphobia, panic disorder, generalised anxiety disorder (GAD), comorbid depressive and anxiety disorder, and MAD at the baseline assessment were identified and reassessed after 12 months.
  • Patients older than 65 years were excluded.
  • ICD-10 diagnoses were obtained using the Composite International Diagnostic Interview- Primary Health Care Version (CIDI-PHC), a modification of the Composite International Diagnostic Interview (CIDI; Division of Mental Health, 1990).
  • The interviewer–observer reliability coefficient (across different centres) of the CIDI-PHC was 0.92 overall, ranging between 0.81 to 1.0 on the item level.
  • Single comparisons within the whole contingency table were carried out (Jesdinsky, 1968).

3.1. Sample characteristics

  • A total of 1856 patients were identified to meet ICD- 10 criteria for a depressive episode, dysthymia, agoraphobia, panic disorder, GAD, comorbid anxiety and depressive disorder, and MAD at the baseline diagnostic assessment.
  • A total of 673 (36.3%) did not participate in the follow-up examination because they had moved and were not found anymore, because of refusal or because of death.
  • The study sample of the baseline assessment is described in Table 1.

3.2. Twelve month outcome

  • MAD, depressive episodes, dysthymia, agoraphobia, panic disorder only, GAD, and comorbid depressive and anxiety disorder showed a substantial improvement (average remission rate: 41.9%).
  • 7% of all patients had exactly the same ICD- 10-diagnosis at both assessments with MAD showing the lowest rate of stable diagnoses (1.2%).
  • The majority of MAD patients remitted or shifted to other (non-depressive and non-anxiety) diagnoses (see Table 2).
  • There were no differences regarding follow-up depression rates between patients with a depressive disorder and comorbid patients [χ2 = 0.01, df =1, not significant (n.s.)] and no significant differences regarding follow-up anxiety rates between patients with an anxiety disorder and comorbid patients at baseline (χ2 = 0.9065, df =1, n.s.).

4. Discussion

  • The data presented herein did not show temporal stability of MAD as compared to depressive and anxiety disorders.
  • The authors results are in contrast to the findings of Usall and Marquez (1999) who concluded that MAD is a stable diagnosis.
  • These authors applied DSM-IV research criteria so that their results cannot be directly compared with their findings.

4.1. Implications

  • ICD-10 MAD criteria are relatively vague compared to DSM-IV research criteria (APA, 1994) clearly specifying symptoms necessary for the MAD diagnosis.
  • For such a revision several possibilities are conceivable: Preskorn and Fast (1993) argue against a MAD diagnosis and are in favour of a careful psychiatric assessment resulting in either depression or anxiety diagnoses.
  • Either way, the present study shows that an assiduous psychiatric assessment incorporating longitudinal information (i.e., medical history and follow-up assessments) is indispensable.
  • Of course, the question arises whether the ICD-10 classification lives up to rather minor disorders frequently seen in primary care and whether an appropriate ICD-10 diagnosis suffices.
  • Especially in minor disorders, where psychotherapeutical approaches play an important role, the formulation of an individual disease model and an according treatment is much more determining.

4.2. Limitations

  • Depressive and anxiety disorders might be more severe disorders than MAD, therefore, more easily remitting.
  • Nevertheless, the remission rates for the other disorders were also quite high.
  • Moreover, GAD which also can be seen as relatively mild psychiatric condition shows a high degree of chronicity (Mancuso et al., 1993; Schweizer, 1995; Woodman et al., 1999).
  • In older patients with longer illness histories a MAD diagnosis might not be so easily corrected.
  • Other limitations are lacking information regarding treatment and remissions and relapses during the follow-up.

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Citations
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Journal ArticleDOI
TL;DR: A method to visualize comorbidity networks is proposed and it is argued that this approach generates realistic hypotheses about pathways to comor bidity, overlapping symptoms, and diagnostic boundaries, that are not naturally accommodated by latent variable models.
Abstract: The pivotal problem of comorbidity research lies in the psychometric foundation it rests on, that is, latent variable theory, in which a mental disorder is viewed as a latent variable that causes a constellation of symptoms. From this perspective, comorbidity is a (bi)directional relationship between multiple latent variables. We argue that such a latent variable perspective encounters serious problems in the study of comorbidity, and offer a radically different conceptualization in terms of a network approach, where comorbidity is hypothesized to arise from direct relations between symptoms of multiple disorders. We propose a method to visualize comorbidity networks and, based on an empirical network for major depression and generalized anxiety, we argue that this approach generates realistic hypotheses about pathways to comorbidity, overlapping symptoms, and diagnostic boundaries, that are not naturally accommodated by latent variable models: Some pathways to comorbidity through the symptom space are more likely than others; those pathways generally have the same direction (i.e., from symptoms of one disorder to symptoms of the other); overlapping symptoms play an important role in comorbidity; and boundaries between diagnostic categories are necessarily fuzzy.

918 citations

Journal ArticleDOI
TL;DR: Prevalence and symptom expression of anxiety disorders in late life, as well as risk factors, comorbidity, cognitive decline, age of onset, and treatment efficacy for older adults are reviewed.
Abstract: This review aims to address issues unique to older adults with anxiety disorders in order to inform potential changes in the DSM-V. Prevalence and symptom expression of anxiety disorders in late life, as well as risk factors, comorbidity, cognitive decline, age of onset, and treatment efficacy for older adults are reviewed. Overall, the current literature suggests: (a) anxiety disorders are common among older age individuals, but less common than in younger adults; (b) overlap exists between anxiety symptoms of younger and older adults, although there are some differences as well as limitations to the assessment of symptoms among older adults; (c) anxiety disorders are highly comorbid with depression in older adults; (d) anxiety disorders are highly comorbid with a number of medical illnesses; (e) associations between cognitive decline and anxiety have been observed; (f) late age of onset is infrequent; and (g) both pharmacotherapy and CBT have demonstrated efficacy for older adults with anxiety. The implications of these findings are discussed and recommendations for the DSM-Vare provided, including extending the text section on age-specific features of anxiety disorders in late life and providing information about the complexities of diagnosing anxiety disorders in older adults. Depression and Anxiety 27:190–211, 2010. r 2010 Wiley-Liss, Inc.

538 citations


Cites background from "Mixed anxiety–depression in a 1 yea..."

  • ...Furthermore, research has revealed a low prevalence for mixed anxiety–depression in the general adult population([98]) as well as in primary care samples,([99]) and demonstrated instability of the classification.([100]) Thus, significantly more research is needed to develop and empirically test the construct of mixed anxiety– depression in older adults before considering it as a diagnosis in its own right....

    [...]

Journal ArticleDOI
TL;DR: It is suggested that future editions of the diagnostic manual be developed under the auspices of the Institute of Medicine, with broad representation, an evidence-based approach, disinterested recommendations, and a careful attention to the risks and benefits of each suggestion for change to the individual patient, to public policy, and to forensic applications.
Abstract: The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders provides the authoritative list of what are considered to be mental disorders. This list has a tremendous impact on research, funding, and treatment, as well as a variety of civil and forensic decisions. The development of this diagnostic manual is an enormous responsibility. Provided herein are lessons learned during the course of the development of the fourth edition. Noted in particular is the importance of obtaining and publishing critical reviews, restraining the unbridled creativity of experts, conducting field trials that address key issues and concerns, and conducting forthright risk-benefit analyses. It is suggested that future editions of the diagnostic manual be developed under the auspices of the Institute of Medicine. The goal would be broad representation, an evidence-based approach, disinterested recommendations, and a careful attention to the risks and benefits of each suggestion for change to the ...

240 citations


Cites background from "Mixed anxiety–depression in a 1 yea..."

  • ...These proposed diagnoses are at times informed by a considerable body of research (Barkow et al. 2004, Liebenluft & Rich 2008, Striegel-Moore & Franko 2008, 122 Frances ·Widiger A nn u....

    [...]

Journal ArticleDOI
TL;DR: The data support the pathological significance of MADD in its negative impact upon population health and suggest Dimensional approaches to classification may provide a more parsimonious description of anxiety and depressive disorders compared with categorical approaches.
Abstract: Background The public health significance of mixed anxiety–depressive disorder (MADD) and the distinctiveness of its phenomenology have yet to be established. Aims To determine the public health significance of MADD, and to compare its phenomenology with ICD–10 anxiety, depressive, and comorbid anxiety and depressive disorders. Method Weighted analysis of data from the Great Britain National Psychiatric Morbidity survey was conducted with a representative household sample of 8580 persons aged 16–74 years. Results The 1-month prevalence of MADD was 8.8%. A fifth of all days off work in Britain occurred in this group. The symptom profile of MADD was similar to ‘pure’ ICD–10 anxiety and depression, but with a lower overall symptom count. The disorder was associated with significant impairment of health-related quality of life. Differences in health-related quality of life measures between diagnostic groups were accounted for by overall symptom severity, which remained strongly associated with health-related quality of life measures after adjusting for diagnostic group. The finding that half of the anxiety, depression and MADD cases and a third of the comorbid depression and anxiety cases grouped into a single latent class challenges the notion of these conditions as having distinct phenomenologies. Mixed presentations may be the norm in the population. Conclusions The data support the pathological significance of MADD in its negative impact upon population health. Dimensional approaches to classification may provide a more parsimonious description of anxiety and depressive disorders compared with categorical approaches. Declaration of interest None.

189 citations

Journal ArticleDOI
TL;DR: The temporal consistency of mental disorders was poor, ranging from 29% for specific personality disorders to 70% for schizophrenia, with stability greatest for in- patient diagnoses and least for out-patient diagnoses.
Abstract: Background Psychiatric disorders are among the top causes worldwide of disease burden and disability. A major criterion for validating diagnoses is stability over time. Aims To evaluate the long-term stability of the most prevalent psychiatric diagnoses in a variety of clinical settings. Method A total of 34 368 patients received psychiatric care in the catchment area of one Spanish hospital (1992–2004). This study is based on 10 025 adult patients who were assessed on at least ten occasions (360 899 psychiatric consultations) in three settings: in-patient unit, 2000–2004 ( n =546); psychiatric emergency room, 2000–2004 ( n =1408); and out-patient psychiatric facilities, 1992–2004 ( n =10 016). Prospective consistency, retrospective consistency and the proportion of patients who received each diagnosis in at least 75% of the evaluations were calculated for each diagnosis in each setting and across settings. Results The temporal consistency of mental disorders was poor, ranging from 29% for specific personality disorders to 70% for schizophrenia, with stability greatest for in-patient diagnoses and least for out-patient diagnoses. Conclusions The findings are an indictment of our current psychiatric diagnostic practice.

153 citations


Cites background from "Mixed anxiety–depression in a 1 yea..."

  • ...…has been evaluated in a number of studies (Tsuang et al, 1981; Schwartz et al, 2000; Lieb et al, 2002; Shea et al, 2002; Mojtabai et al, 2003; Barkow et al, 2004; Grilo et al, 2004; Veen et al, 2004; Culverhouse et al, 2005; Kessing, 2005a,b; McGlashan et al, 2005; Rufino et al, 2005;…...

    [...]

  • ...…et al, 2004; Grilo et al, 2004; Schimmelmann et al, 2005) – and the followup period is usually under 3 years (Schwartz et al, 2000; Shea et al, 2002; Barkow et al, 2004; Grilo et al, 2004; Veen et al, 2004; McGlashan et al, 2005; Rufino et al, 2005; Schimmelmann et al, 2005) with a…...

    [...]

  • ...These studies usually have a small number of evaluations – two or three in most of them (Schwartz et al, 2000; Lieb et al, 2002; Barkow et al, 2004; Grilo et al, 2004; Schimmelmann et al, 2005) – and the followup period is usually under 3 years (Schwartz et al, 2000; Shea et al, 2002; Barkow et al,…...

    [...]

References
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Journal ArticleDOI
TL;DR: In this article, a tripartite structure consisting of general distress, physiological hyperarousal (specific anxiety), and anhedonia (specific depression), and a diagnosis of mixed anxiety-depression was proposed.
Abstract: We review psychometric and other evidence relevant to mixed anxiety-depression. Properties of anxiety and depression measures, including the convergent and discriminant validity of self- and clinical ratings, and interrater reliability, are examined in patient and normal samples. Results suggest that anxiety and depression can be reliably and validly assessed; moreover, although these disorders share a substantial component of general affective distress, they can be differentiated on the basis of factors specific to each syndrome. We also review evidence for these specific factors, examining the influence of context and scale content on ratings, factor analytic studies, and the role of low positive affect in depression. With these data, we argue for a tripartite structure consisting of general distress, physiological hyperarousal (specific anxiety), and anhedonia (specific depression), and we propose a diagnosis of mixed anxiety-depression.

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"Mixed anxiety–depression in a 1 yea..." refers methods in this paper

  • ...Data were collected within the scope of the World Health Organization (WHO) Collaborative Study on ‘Psychological Problems in General Health Care’, which is a cross-sectional and prospectivelongitudinal international study (Sartorius et al., 1993; Üstün and Sartorius, 1995)....

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Journal ArticleDOI
TL;DR: Using a two-stage case identification process, patients from a rural primary care practice were assessed for psychiatric disorders over a 15-month period, finding that suggests restricted usefulness of specialty-based categories for the range of clinical presentations in primary care.
Abstract: • Using a two-stage case identification process, patients from a rural primary care practice were assessed for psychiatric disorders (Research Diagnostic Criteria [RDC] categories) over a 15-month period. The prevalence of all psychiatric disorders was 26.5%; 10.0% were specific RDC depressive disorders, and 5.3% were disorders without depression, usually anxiety related. Another 11.2% of patients were thought to have a disorder with significant depressive symptomatology that could not be classified into a specific depressive disorder category, a finding that suggests restricted usefulness of specialty-based categories for the range of clinical presentations in primary care. The relationship of demographic variables to specific disorders was examined; there were age, sex, and marital status differences in the rates for certain disorders, although these findings need replication using large patient samples. The prevalence findings emphasize the need for research on outcome and treatment response for depression presentations in primary care.

513 citations


"Mixed anxiety–depression in a 1 yea..." refers background in this paper

  • ...These patients are frequent in primary care (Barrett et al., 1988; Wittchen and Essau, 1993; Barlow and Campbell, 2000)....

    [...]

Frequently Asked Questions (1)
Q1. What are the contributions mentioned in the paper "Mixed anxiety–depression in a 1 year follow-up study: shift to other diagnoses or remission?" ?

In 1992, the ICD-10 introduced the concept of mixed anxiety–depression disorder ( MAD ). However, a study examining the stability of this ICD-10-diagnosis is lacking. Limitations: Detailed information regarding treatment and disorders during the follow-up interval was lacking.