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Identifying target groups for the prevention of anxiety disorders in the general population
Abstract
To avert the public health consequences of anxiety disorders, prevention of their onset and recurrence is necessary. Recent studies have shown that prevention is effective. To maximize the health gain and minimize the effort, preventive strategies should focus on high-risk groups.
Using data from a large prospective national survey, high-risk groups were selected for i) the prevention of first ever (n = 4437) and ii) either first-ever or recurrent incident anxiety disorders (n = 4886). Indices used were: exposure rate, odds ratio, population attributable fraction and number needed to be treated. Risk indicators included sociodemographic, psychological and illness-related factors.
Recognition of a few patient characteristics enables efficient identification of high-risk groups: (subthreshold) panic attacks; an affective disorder; a history of depressed mood; a prior anxiety disorder; chronic somatic illnesses and low mastery.
Preventive efforts should be undertaken in the selected high-risk groups.
... Moreover, subthreshold anxiety disorders are associated with functional limitations (Batelaan et al., 2007a;Fehm et al., 2008;Haller et al., 2014;Hendriks et al., 2014;Karsten et al., 2011;Kessler et al., 2005;Kinley et al., 2009;Maier et al., 2000), high disease burden (Fehm et al., 2008;Haller et al., 2014;Melse et al., 2000;Mendlowicz, 2000;Saarni et al., 2007Saarni et al., , 2006, and substantial societal costs (Batelaan et al., 2007b;Haller et al., 2014;Marciniak et al., 2004;Smit et al., 2006), though to a somewhat lesser extent than anxiety disorders. Furthermore, subthreshold anxiety disorder predicts the onset of anxiety disorders in adolescents (Goodwin et al., 2004;Shankman et al., 2009;Wolitzky-Taylor et al., 2014), adults (Baillie and Rapee, 2005;Batelaan et al., 2012aBatelaan et al., , 2010Goodwin and Hamilton, 2001;Kinley et al., 2011) and older adults (Smit et al., 2007). These findings signify that the presence of subthreshold anxiety disorders is important, both for the individual as well as for society. ...
... There appears to be no existing research investigating risk indicators for the course of subthreshold anxiety disorder. Risk indicators for the onset of anxiety disorders have however been investigated (Batelaan et al., 2010;Craske and Zucker, 2001;de Graaf et al., 2013ade Graaf et al., , 2002Smit et al., 2007). It is likely that risk indicators which enhance anxiety do so irrespective of severity, therefore risk indicators for the course of subthreshold anxiety disorder were expected to be similar to risk indicators for the onset of full-blown anxiety disorders. ...
... Other research investigating risk indicators for the course of subthreshold anxiety symptoms in adults is to our knowledge non-existent. The risk indicators significantly related to persistent and progressive subthreshold anxiety disorder found in this study did overlap with the risk indicators identified for the onset of anxiety disorders (Batelaan et al., 2010;Craske and Zucker, 2001;de Graaf et al., 2013ade Graaf et al., , 2002Smit et al., 2007). Several risk indicators were significantly stronger associated with progressive symptoms than with persistent symptoms: childhood abuse, neuroticism, number of subthreshold anxiety symptoms at T 1 , mental functioning and physical functioning. ...
Background
This study examined the prevalence, course and risk indicators of subthreshold anxiety disorder to determine the necessity and possible risk indicators for interventions.
Methods
Data were derived from the ‘Netherlands Mental Health Survey and Incidence Study-2’ (NEMESIS-2), a psychiatric epidemiological cohort study among the general population (n = 4528). This study assessed prevalence, characteristics, and three-year course of subthreshold anxiety disorder (n = 521) in adults, and compared them to a no anxiety group (n = 3832) and an anxiety disorder group (n = 175). Risk indicators for persistent and progressive subthreshold anxiety disorder were also explored, including socio-demographics, vulnerability factors, psychopathology, physical health and functioning.
Results
The three-year prevalence of subthreshold anxiety disorder was 11.4%. At three-year follow-up, 57.3% had improved, 29.0% had persistent subthreshold anxiety disorder and 13.8% had progressed to a full-blown anxiety disorder. Prevalence, characteristics and course of subthreshold anxiety disorder were in between both comparison groups. Risk indicators for persistent course partly overlapped with those for progressive course and included vulnerability and psychopathological factors, and diminished functioning.
Limitations
Course analysis were restricted to the development of anxiety disorders, other mental disorders were not assessed. Moreover, due to the naturalistic design of the study the impact of treatment on course cannot be assessed.
Conclusions
Subthreshold anxiety disorder is relatively prevalent and at three-year follow-up a substantial part of respondents experienced persistent symptoms or had progressed into an anxiety disorder. Risk indicators like reduced functioning may help to identify these persons for (preventative) treatment and hence reduce functional limitations and disease burden.
... Although many trials have examined the efficacy of short-term treatments in anxiety disorders, few trials have examined how those treatment gains are maintained (Batelaan et al., 2010;Bruce et al., 2005;Calkins et al., 2009;Rodriguez et al., 2005;Scholten et al., 2013). Anxiety recurrence is the emergence of symptoms after remission has been achieved. ...
... Previous research has found that baseline anxiety severity Scholten et al., 2013), anxiety sensitivity (fear that anxiety symptoms will be noticed by others or that the symptoms indicate serious illness) (Calkins et al., 2009;Mitchell et al., 2014;Scholten et al., 2013), and depression (Batelaan et al., 2010;Bruce et al., 2005;Rodriguez et al., 2005) are associated with anxiety recurrence. Higher rates of anxiety recurrence have been identified in patients with generalized anxiety disorder (GAD) and panic disorder (PD) compared to other anxiety disorders (Rodriguez et al., 2005). ...
... Still, little is known about predictors of anxiety recurrence in the primary care setting (Rodriguez et al., 2006), where most patients with anxiety receive treatment (Young et al., 2001). Moreover, prior studies examining risk factors for anxiety recurrence have 1) relied on lifetime anxiety diagnoses to retrospectively determine anxiety remission and recurrence making them vulnerable to recall bias (Batelaan et al., 2010;Calkins et al., 2009;Scholten et al., 2013) or 2) used observational designs instead of monitoring for recurrence after a course of treatment (Batelaan et al., 2010;Bruce et al., 2005;Calkins et al., 2009;Rodriguez et al., 2005;Scholten et al., 2013). ...
... Certain risk factors have been associated with anxiety and related disorders and should increase the clinician's index of suspicion (Table 6) [4,9,[33][34][35][36][37]. A family [33] or personal history of mood or anxiety disorders [34,35] is an important predictor of anxiety symptoms. ...
... Certain risk factors have been associated with anxiety and related disorders and should increase the clinician's index of suspicion (Table 6) [4,9,[33][34][35][36][37]. A family [33] or personal history of mood or anxiety disorders [34,35] is an important predictor of anxiety symptoms. In addition, family history is associated with a more recurrent course, greater impairment, and greater service use [33]. ...
... phobias and for separation anxiety disorder (seven to 14 years), but later for GAD, panic disorder, and PTSD (24-50 years) [1,2]. Loneliness [38], low education [38], and adverse parenting [39], as well as chronic somatic illnesses, such as cardiovascular disease, diabetes, asthma, and obesity may increase the risk for a lifetime diagnosis of anxiety [34,40]. Comorbid medical and psychiatric disorders Anxiety and related disorders frequently co-occur with other psychiatric disorders [3]. ...
Background
Anxiety and related disorders are among the most common mental disorders, with lifetime prevalence reportedly as high as 31%. Unfortunately, anxiety disorders are under-diagnosed and under-treated.
Methods
These guidelines were developed by Canadian experts in anxiety and related disorders through a consensus process. Data on the epidemiology, diagnosis, and treatment (psychological and pharmacological) were obtained through MEDLINE, PsycINFO, and manual searches (1980–2012). Treatment strategies were rated on strength of evidence, and a clinical recommendation for each intervention was made, based on global impression of efficacy, effectiveness, and side effects, using a modified version of the periodic health examination guidelines.
Results
These guidelines are presented in 10 sections, including an introduction, principles of diagnosis and management, six sections (Sections 3 through 8) on the specific anxiety-related disorders (panic disorder, agoraphobia, specific phobia, social anxiety disorder, generalized anxiety disorder, obsessive-compulsive disorder, and posttraumatic stress disorder), and two additional sections on special populations (children/adolescents, pregnant/lactating women, and the elderly) and clinical issues in patients with comorbid conditions.
Conclusions
Anxiety and related disorders are very common in clinical practice, and frequently comorbid with other psychiatric and medical conditions. Optimal management requires a good understanding of the efficacy and side effect profiles of pharmacological and psychological treatments.
... Third, screening implies that risk factors for anxiety disorders are known and can be assessed accurately. Previously, we defined target groups for the prevention of anxiety disorders, in which the largest public health benefit for the lowest effort can be achieved [17]. These target groups consist of individuals 1) with a (subthreshold) panic attack in the past year, 2) with an affective disorder in the past year, or 3) with a history of anxiety disorders combined with low mastery. ...
... 10 Case-finding should be a continuing process and not a " once and for all " project. history of anxiety disorders combined with low mastery [17]. To screen for panic attacks and affective disorder, we used screening questions regarding panic and depressive mood from the Web-based Screening Questionnaire (WSQ;[19]). ...
... The total score provides information about the degree of control one assumes to have over his life. In correspondence with previous research [17,21], low mastery was defined as a score lower than or equal to 18. A possible high risk status was regarded present if individuals reported positively on 1) the screening question of panic attacks, or 2) the screening question on depressive mood, or 3) on the questions regarding anxiety problems in the past that had resulted in limited functioning or suffering or for which treatment was indicated, combined with low mastery. ...
Background
Anxiety disorders are highly prevalent in primary care and cause a substantial burden of disease. Screening on risk status, followed by preventive interventions in those at risk may prevent the onset of anxiety disorders, and thereby reduce the disease burden. The willingness to participate in screening and interventions is crucial for the scope of preventive strategies, but unknown. This feasibility study, therefore, investigated participation rates of screening and preventive services for anxiety disorders in primary care, and explored reasons to refrain from screening.
Methods
In three general practices, screening was offered to individuals visiting their general practitioner (total n = 2454). To assess risk status, a 10-item questionnaire was followed by a telephone interview (including the CIDI) when scoring above a predefined threshold. Preventive services were offered to those at risk. Participation rates for screening and preventive services for anxiety disorders were assessed. Those not willing to be screened were asked for their main reason to refrain from screening.
Results
Of all individuals, 17.3% participated in initial screening, and of those with a possible risk status, 56.0% continued screening. In 30.1% of those assessed, a risk status to develop an anxiety disorder was verified. Of these, 22.6% already received some form of mental health treatment and 38.7% of them agreed to participate in a preventive intervention and were referred. The most frequently mentioned reasons to refrain from screening were the emotional burden associated with elevated risk status, the assumption not to be at risk, and a lack of motivation to act upon an elevated risk status by using preventive services.
Conclusions
Screening in general practice, followed by offering services to prevent anxiety disorders in those at risk did not appear to be a feasible strategy due to low participation rates. To enable the development of feasible and cost-effective preventive strategies, exploring the reasons of low participation rates, considering involving general practitioners in preventive strategies, and looking at preventive strategies in somatic health care with proven feasibility may be helpful.
... Prevention of anxiety disorders is necessary to improve the health of the population (Batelaan et al., 2010), and this intervention should be focused on patients with risk factors, with the aim of being as costeffective as possible (Meulenbeek et al., 2008;Smit et al., 2009). The main risk factors identified in previous studies are: to have previously suffered from panic attacks or another anxiety disorder; depression or other affective disorder; and chronic somatic illnesses or stressful life events (such as job loss) (Batelaan et al., 2010;Haro et al., 2006;Moreno-Peral et al., 2014). ...
... Prevention of anxiety disorders is necessary to improve the health of the population (Batelaan et al., 2010), and this intervention should be focused on patients with risk factors, with the aim of being as costeffective as possible (Meulenbeek et al., 2008;Smit et al., 2009). The main risk factors identified in previous studies are: to have previously suffered from panic attacks or another anxiety disorder; depression or other affective disorder; and chronic somatic illnesses or stressful life events (such as job loss) (Batelaan et al., 2010;Haro et al., 2006;Moreno-Peral et al., 2014). ...
... By contrast, those with a diminished sense of mastery are more likely to interpret events as threatening and are at greater risk of anxiety in the face of stressors. Empirically, mastery has been identified as a prospective predictor of anxiety in several large population and probability samples (Batelaan et al., 2010;de Beurs et al., 2005;Roberts, Roberts, & Chan, 2009). ...
... A sum score is calculated such that higher scores represent higher levels of self-mastery. Variations of this measure have been shown to predict future levels of anxiety in several large population and probability samples (Batelaan et al., 2010;de Beurs et al., 2005;Roberts et al., 2009). Cronbach's a in the current sample was .79. ...
Developing a better understanding of modifiable psychological factors that account for gender differences in anxiety may provide insight into interventions that can be used to target these risk processes. The authors developed a mediational model to examine the degree to which gender differences in anxiety are explained by instrumentality and mastery while controlling for the influence of environmental stress and social desirability. Undergraduates (159 men and 239 women) completed an online questionnaire including measures of mastery, instrumentality, daily hassles, social desirability, and anxiety. Women reported significantly lower levels of instrumentality and mastery and higher levels of anxiety than men. Path analyses indicated that instrumentality and mastery were both significant mediators of the relationship between gender and anxiety after controlling for social desirability and hassles. The addition of a direct path from gender to anxiety was not significant and did not improve the fit of the model. These findings suggest that differences in gender socialization and mastery learning experiences for men and women help account for the female preponderance of anxiety. Interventions aimed at building instrumentality and mastery, particularly among girls, may help buffer against anxiety.
... 6 Furthermore, it was shown that panic attacks significantly increase the risk of onset of mental disorders. [12][13][14][15][16][17] In addition, a few studies have reported an impact of past panic attacks on psychopathology, 4,12,16 suggesting that even a history of panic attacks should raise awareness among clinicians for current and future psychopathology. ...
... By demonstrating that panic is associated with high levels of comorbid psychiatric disorders across the diagnostic spectrum, with prevalence rates increasing with each level of panic, our results are consistent with and extend prior cross-sectional findings. 3,4,6,10,11 Although the impact of panic on onset of psychopathology has been demonstrated previously, [12][13][14][15][16][17] They reported only very minor differences between panic attacks and panic disorder in predicting psychopathology. Risk estimates in our study were somewhat higher in those with panic disorder compared to panic attacks. ...
One of the proposed revisions for DSM-5 is to rate panic attacks as a separate dimension across all mental disorders. The idea is that panic attacks occurring outside panic disorder are a dimension predicting important clinical outcomes. The aim of this study was to validate the proposition for DSM-5 that panic attacks have predictive value for overall psychopathology onset, course, and functioning.
Data were derived from the Netherlands Mental Health Survey and Incidence Study (NEMESIS), a prospective population-based study. Using the Composite International Diagnostic Interview (with classifications based on DSM-III-R), 5,571 subjects were selected who had (1) no panic history, (2) a history of panic attacks (but no panic disorder), (3) current panic attacks, or (4) current panic disorder. The impact of panic status on the prevalence of anxiety, affective, alcohol, and any mental disorders; on the onset and persistence of these disorders during 3-year follow-up; and on levels of functioning during 3-year follow-up (as assessed with the 36-Item Short-Form Health Survey) was examined.
Current panic attacks outside the realm of panic disorder were associated with increased prevalence of mental disorders (χ23 = 490.6; P < .001), increased onset of mental disorders (hazard ratio = 4.42; 95% CI, 2.88-6.80), persistence of mental disorders (odds ratio = 2.72; 95% CI, 1.53-4.82), and impaired functioning during 3-year follow-up (F = 69.67; P < .001). Although the impact was smaller than for panic disorder, the associations identified for panic attacks were consistent and significant and were, to a lesser extent, also found for a history of panic attacks.
Given the consistent impact of panic attacks on various aspects of psychopathology, the proposition to dimensionally rate panic attacks across all mental disorders may be of great value for clinical care.
... 11 As is the case with interventions aimed at preventing the first onset of depression or anxiety (primary prevention), participation in RPIs is limited, and therefore the potential health gain cannot be gauged. [12][13][14][15][16] For this reason, it is crucial to understand patients' motives for refusing to participate in relapse prevention, to learn from those who do participate, and to be aware of patients' preferences regarding form and content of the intervention. The goals of this qualitative study were: (1) to investigate reasons why patients with remitted anxiety or depressive disorders refuse CBT RPIs, (2) to compare those reasons with reasons that cause other patients to participate, and (3) to gain insight into patients' preferences regarding the form and content of RPIs. ...
Background:
Anxiety and depressive disorders frequently recur, but participation in effective psychological interventions to prevent relapse is limited. The reasons for nonparticipation are largely unknown, hampering successful implementation. The aims of this study were: (1) to investigate reasons why patients with remitted anxiety or depressive disorders refuse cognitive-behavioral therapy relapse prevention interventions (RPIs), (2) to compare these reasons with reasons to participate, and (3) to gain insight into patients' preferences regarding relapse prevention.
Methods:
A qualitative study was conducted in which data were gathered from 52 semistructured interviews with patients who either refused or agreed to participate in psychological relapse prevention. The constant comparative method was used.
Results:
The data showed that those who refused to participate (1) did have knowledge about relapse risks in general, (2) but did not relate this risk to themselves, and therefore, did not feel the need for relapse prevention, or (3) declined to participate for logistical reasons or reasons related to the content of the intervention. Preferences concerning the form and content of RPIs were very diverse.
Conclusions:
Psychoeducation on relapse should be provided to patients to help them relate recurrence risks to themselves. RPIs should also be individually tailored.
... Stages 0, 1A and 1B were labeled 'subclinical' stages and were assigned in subjects without Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) anxiety disorders but who did have at least one risk factor for developing an anxiety disorder. Three risk factors for developing an anxiety disorder were derived from the literature: lifetime history of anxiety disorders (Batelaan et al., 2010;Moreno-Peral et al., 2014), exposure to childhood trauma (Graaf et al., 2002;Macmillan et al., 2001;Moreno-Peral et al., 2014) and family history for psychiatric disorders (Hyland et al., 2016;Moreno-Peral et al., 2014). Stage 0 was assigned to subjects with low symptom severity, stage 1A to subjects with mild to moderate symptom severity and stage 1B to subjects with moderate to severe symptom severity. ...
Background
Clinical staging is a paradigm in which stages of disease progression are identified; these, in turn, have prognostic value. A staging model that enables the prediction of long-term course in anxiety disorders is currently unavailable but much needed as course trajectories are highly heterogenic. This study therefore tailored a heuristic staging model to anxiety disorders and assessed its validity.
Methods
A clinical staging model was tailored to anxiety disorders, distinguishing nine stages of disease progression varying from subclinical stages (0, 1A, 1B) to clinical stages (2A–4B). At-risk subjects and subjects with anxiety disorders ( n = 2352) from the longitudinal Netherlands Study of Depression and Anxiety were assigned to these nine stages. The model’s validity was assessed by comparing baseline (construct validity) and 2-year, 4-year and 6-year follow-up (predictive validity) differences in anxiety severity measures across stages. Differences in depression severity and disability were assessed as secondary outcome measures.
Results
Results showed that the anxiety disorder staging model has construct and predictive validity. At baseline, differences in anxiety severity, social avoidance behaviors, agoraphobic avoidance behaviors, worrying, depressive symptoms and levels of disability existed across all stages (all p-values < 0.001). Over time, these differences between stages remained present until the 6-year follow-up. Differences across stages followed a linear trend in all analyses: higher stages were characterized by the worst outcomes. Regarding the stages, subjects with psychiatric comorbidity (stages 2B, 3B, 4B) showed a deteriorated course compared with those without comorbidity (stages 2A, 3A, 4A).
Conclusion
A clinical staging tool would be useful in clinical practice to predict disease course in anxiety disorders.
... Where effective relapse prevention programmes for depressive disorders are available and relapse prevention for anxiety disorders should be developed, implementation of these programmes is, and will continue to be a challenge [22]. Although uptake rates of relapse prevention interventions are unknown, we do know that preventive interventions for depression and anxiety suffer from low uptake rates [23,24] and this is probably similar in relapse prevention. Several factors are crucial for successful implementation, and patient preferences play a major role. ...
Background:
Anxiety and depressive disorders are increasingly being viewed as chronic conditions with fluctuating symptom levels. Relapse prevention programmes are needed to increase self-management and prevent relapse. Fine-tuning relapse prevention programmes to the needs of patients may increase uptake and effectiveness.
Materials and methods:
A discrete choice experiment (DCE) was conducted amongst patients with a partially or fully remitted anxiety or depressive disorder. Patients were presented 20 choice tasks with two hypothetical treatment scenarios for relapse prevention, plus a "no treatment" option. Each treatment scenario was based on seven attributes of a hypothetical but realistic relapse prevention programme. Attributes considered professional contact frequency, treatment type, delivery mode, programme flexibility, a personal relapse prevention plan, time investment and effectiveness. Choice models were estimated to analyse the data.
Results:
A total of 109 patients with a partially or fully remitted anxiety or depressive disorder completed the DCE. Attributes with the strongest impact on choice were high effectiveness, regular contact with a professional, low time investment and the inclusion of a personal prevention plan. A high heterogeneity in preferences was observed, related to both clinical and demographic characteristics: for example, a higher number of previous treatment episodes was related to a preference for a higher frequency of contact with a professional, while younger age was related to a stronger preference for high effectiveness.
Conclusions:
This study using a DCE provides insights into preferences for a relapse prevention programme for anxiety and depressive disorders that can be used to guide the development of such a programme.
... [1][2][3][4][5][6] Consequently, when combined with high prevalence rates and functional limitations, 7 8 anxiety disorders score highly on burden of disease rankings. [9][10][11][12] Optimising the long term prognosis, including prevention of relapse, 13 is an important strategy to decrease the burden of disease related to anxiety. ...
Objectives
To examine the risk of relapse and time to relapse after discontinuation of antidepressants in patients with anxiety disorder who responded to antidepressants, and to explore whether relapse risk is related to type of anxiety disorder, type of antidepressant, mode of discontinuation, duration of treatment and follow-up, comorbidity, and allowance of psychotherapy.
Design
Systematic review and meta-analyses of relapse prevention trials.
Data sources
PubMed, Cochrane, Embase, and clinical trial registers (from inception to July 2016).
Study selection
Eligible studies included patients with anxiety disorder who responded to antidepressants, randomised patients double blind to either continuing antidepressants or switching to placebo, and compared relapse rates or time to relapse.
Data extraction
Two independent raters selected studies and extracted data. Random effect models were used to estimate odds ratios for relapse, hazard ratios for time to relapse, and relapse prevalence per group. The effect of various categorical and continuous variables was explored with subgroup analyses and meta-regression analyses respectively. Bias was assessed using the Cochrane tool.
Results
The meta-analysis included 28 studies (n=5233) examining relapse with a maximum follow-up of one year. Across studies, risk of bias was considered low. Discontinuation increased the odds of relapse compared with continuing antidepressants (summary odds ratio 3.11, 95% confidence interval 2.48 to 3.89). Subgroup analyses and meta-regression analyses showed no statistical significance. Time to relapse (n=3002) was shorter when antidepressants were discontinued (summary hazard ratio 3.63, 2.58 to 5.10; n=11 studies). Summary relapse prevalences were 36.4% (30.8% to 42.1%; n=28 studies) for the placebo group and 16.4% (12.6% to 20.1%; n=28 studies) for the antidepressant group, but prevalence varied considerably across studies, most likely owing to differences in the length of follow-up. Dropout was higher in the placebo group (summary odds ratio 1.31, 1.06 to 1.63; n=27 studies).
Conclusions
Up to one year of follow-up, discontinuation of antidepressant treatment results in higher relapse rates among responders compared with treatment continuation. The lack of evidence after a one year period should not be interpreted as explicit advice to discontinue antidepressants after one year. Given the chronicity of anxiety disorders, treatment should be directed by long term considerations, including relapse prevalence, side effects, and patients’ preferences.
... The most explicit example is panic attacks. Based on their negative impact on a variety of disorders, [13][14][15] panic attacks are included as a specifier in the fifth edition of the Diagnostic Manual of Mental Disorders (DSM-5) 16 to alert clinicians to unfavorable outcomes. ...
Objective:
Obsessive-compulsive symptoms (OCS) co-occur frequently with anxiety and depressive disorders, but the nature of their relationship and their impact on severity of anxiety and depressive disorders is poorly understood. In a large sample of patients with anxiety and depressive disorders, we assessed the frequency of OCS, defined as a Young Adult Self-Report Scale-obsessive-compulsive symptoms score >7. The associations between OCS and severity of anxiety and/or depressive disorders were examined, and it was investigated whether OCS predict onset, relapse, and persistence of anxiety and depressive disorders.
Methods:
Data were obtained from the third (at 2-year follow-up) and fourth wave (at 4-year follow-up) of data collection in the Netherlands Study of Anxiety and Depression cohort, including 469 healthy controls, 909 participants with a remitted disorder, and 747 participants with a current anxiety and/or depressive disorder.
Results:
OCS were present in 23.6% of the total sample, most notably in those with current combined anxiety and depressive disorders. In patients with a current disorder, OCS were associated with severity of this disorder. Moreover, OCS predicted (1) first onset of anxiety and/or depressive disorders in healthy controls (odds ratio [OR], 5.79; 95% confidence interval [CI], 1.15 to 29.14), (2) relapse in those with remitted anxiety and/or depressive disorders (OR, 2.31; 95% CI, 1.55 to 3.46), and (3) persistence in patients with the combination of current anxiety and depressive disorders (OR, 4.42; 95% CI, 2.54 to 7.70) within the 2-year follow-up period Conclusions: OCS are closely related to both the presence and severity of anxiety and depressive disorders and affect their course trajectories. Hence, OCS might be regarded as a course specifier signaling unfavorable outcomes. This specifier may be useful in clinical care to adapt and intensify treatment in individual patients.
... As a result, researchers have concluded that panic attacks may represent a nonspecific risk factor for psychopathology and that the severity and frequency of the attacks may predict the onset of other anxiety and mood disorders (Baillie & Rapee, 2005;Goodwin et al., 2004;Kessler et al., 2006;Kinley et al., 2011). Therefore the accurate examination of panic symptoms and assessment of latent panic severity may lead to improvements in the identification, prevention, and treatment of panic attacks and subsequent psychopathology in high risk individuals of the population (Batelaan et al., 2010), and may reduce the associated burden on the individual and public health care system (Roy-Byrne et al., 2006;Skapinakis et al., in press). ...
BACKGROUND: Unexpected panic attacks may represent a non-specific risk factor for future depression and anxiety disorders. The examination of panic symptoms and associated latent severity levels may lead to improvements in the identification, prevention, and treatment of panic attacks and subsequent psychopathology for 'at risk' individuals in the general population. METHODS: The current study utilised item response theory to assess the DSM-IV symptoms of panic in relation to the latent severity level of the panic attack construct in a sample of 5913 respondents from the National Epidemiologic Survey on Alcohol and Related conditions. Additionally, differential item functioning (DIF) was assessed to determine if each symptom of panic targets the same level of latent severity between different sociodemographic groups (male/female, young/old). RESULTS: Symptoms indexing 'choking', 'fear of dying', and 'tingling/numbness' are some of the more severe symptoms of panic whilst 'heart racing', 'short of breath', 'tremble/shake', 'dizzy/faint', and 'perspire' are some of the least severe symptoms. Significant levels of DIF were detected in the 'perspire' symptom between males and females and the 'fear of dying' symptom between young and old respondents. LIMITATIONS: The current study was limited to examining cross-sectional data from respondents who had experienced at least one panic attack across their lifetime. CONCLUSIONS: The findings of the current study provide additional information regarding panic symptoms in the general population that may enable researchers and clinicians to further refine the detection of 'at-risk' individuals who experience threshold and sub-threshold levels of panic.
... The methodology used to select high-risk groups was developed by Smit et al. (2004), and has been used in previous research (Schoevers et al., 2006;Smit et al., 2006;2007;Batelaan et al., 2010). First, the risk indicators that are most strongly related to the onset of depression were selected from our set of putative risk indicators, based on the magnitude of their odds ratio (OR). ...
Depression in informal caregivers of persons with dementia is a major, costly and growing problem. However, it is not yet clear which caregivers are at increased risk of developing depression. With this knowledge preventive strategies could focus on these groups to maximize health gain and minimize effort.
The onset of clinically relevant depression was measured with the Center for Epidemiologic Studies - Depression Scale in 725 caregivers who were not depressed at baseline and who were providing care for a relative with dementia. Caregivers were followed over 18 months. The indices calculated to identify the most important risk indicators were: odds ratio, attributable fraction, exposure rate and number needing to be treated.
The following significant indicators of depression onset were identified: increased initial depressive symptoms, poor self-rated health status and white or Hispanic race/ethnicity. The incidence of depression would decrease by 72.3% (attributive fraction) if these risk indicators together are targeted by a completely effective intervention. Race/ethnicity was not a significant predictor if caregivers of patients who died or were institutionalized were left out of the analyses.
Detection of only a few characteristics makes it possible to identify high-risk groups in an efficient way. Focusing on these easy-to-assess characteristics might contribute to a cost-effective prevention of depression in caregivers.
Angsterkrankungen stellen mit einer 12-Monats-Prävalenz von 14% die häufigsten psychischen Erkrankungen in der westlichen Gesellschaft dar. Angesichts der hohen querschnittlichen wie sequentiellen Komorbidität von Angsterkrankungen, der ausgeprägten individuellen Einschränkungen sowie der hohen ökonomischen Belastung für das Gesundheitssystem ist neben therapeutischen Behandlungsansätzen die Entwicklung von kurzzeitigen, kostengünstigen und leicht zugänglichen Präventionsmaßnahmen von großer Bedeutung und steht zunehmend im Fokus des gesundheitspolitischen Interesses, um die Inzidenz von Angsterkrankungen zu reduzieren. Voraussetzung für die Entwicklung von gezielten und damit den effektivsten Präventionsmaßnahmen sind valide Risikofaktoren, die die Entstehung von Angsterkrankungen begünstigen. Ein Konstrukt, das in der Literatur als subklinisches Symptom in Form einer kognitiven Vulnerabilität für Angsterkrankungen und damit als Risikofaktor angesehen wird, ist die sogenannte Angstsensitivität (AS). AS umfasst die individuelle Tendenz, angstbezogene körperliche Symptome generell als bedrohlich einzustufen und mit aversiven Konsequenzen zu assoziieren. Das Ziel der vorliegenden Arbeit war daher die Etablierung und Validierung eines Präventionsprogramms zur Reduktion der AS an einer nicht-klinischen Stichprobe von 100 Probanden (18-30 Jahre) mit einer erhöhten AS (Anxiety Sensitivity Index [ASI-3] ≥17) sowie die Rekrutierung von 100 alters- und geschlechtsangeglichenen Probanden mit niedriger Angstsensitivität (ASI-3 <17). In einem randomisiert-kontrollierten Studiendesign durchliefen die Probanden mit hoher AS entweder das über fünf Wochen angelegte „Kognitive Angstsensitivitätstraining“ (KAST) als erste deutschsprachige Übersetzung des Computer-basierten „Cognitive Anxiety Sensitivity Treatment“ (CAST) von Schmidt et al. (2014) oder wurden der Wartelisten-Kontrollgruppe zugeteilt. Das KAST Training bestand aus einer einmaligen Vermittlung kognitiv-behavioraler Psychoedukation zum Thema Stress und Anspannung sowie deren Auswirkungen auf den Körper und der Anleitung von zwei interozeptiven Expositionsübungen (‚Strohhalm-Atmung‘ und ‚Hyperventilation‘), die über den anschließenden Zeitraum von fünf Wochen in Form von Hausaufgaben wiederholt wurden. Es konnte gezeigt werden, dass die Teilnehmer des KAST-Programms nach Beendigung des Trainings (T1) eine signifikant niedrigere AS-Ausprägung im Vergleich zur Wartelisten-Kontrollgruppe aufwiesen und diese Reduktion auch über den Katamnese-Zeitraum von sechs Monaten (T2) stabil blieb. Ergänzend wurde auch die Targetierbarkeit weiterer intermediärer Risikomarker wie der Trennungsangst (TA), des Index der kardialen Sensitivität sowie der Herzratenvariabilität (HRV) untersucht, die jedoch nicht durch das KAST-Training direkt verändert werden konnten. Im Vergleich der Subgruppen von Probanden mit hoher AS und gleichzeitig hoher TA (Adult Separation Anxiety Questionnaire [ASA-27] ≥22) und Probanden mit hoher AS, aber niedriger TA (ASA-27 <22) zeigte sich, dass die AS-TA-Hochrisikogruppe ebenfalls gut von der KAST-Intervention profitieren und eine signifikante Reduktion der AS erzielen konnte, indem sie sich bei T1 dem Niveau der Gruppe mit niedriger TA anglich. Zudem korrelierte die prozentuale Veränderung der Einstiegswerte der inneren Anspannung während der Strohhalm-Atmungsübung positiv mit der prozentualen Veränderung der dimensionalen TA bei T1. Zusammenfassend weisen die Ergebnisse der vorliegenden Arbeit erstmalig auf die Wirksamkeit der deutschsprachigen Übersetzung des CAST-Programms (Schmidt et al., 2014), eines Computer-basierten, und damit leicht zu implementierenden sowie kostengünstigen Programms, in Bezug auf die Reduktion der AS sowie indirekt der TA hin und können damit zur indizierten und demnach besonders effektiven Prävention von Angsterkrankungen in Hochrisikogruppen beitragen.
Les cellules gliales dont les astrocytes - au moins aussi nombreux que les neurones dans le cerveau - joueraient un rôle important dans l'anxiété, la dépression et probablement dans la réponse aux antidépresseurs. Plusieurs études menées chez l'Homme et l'animal vont dans ce sens puisqu'elles mettent en évidence une association entre des changements d'expression de différents marqueurs astrocytaires et la sévérité de ces troubles psychiatriques. C'est notamment le cas de la connexine 43 (Cx43), une protéine transmembranaire impliquée dans la formation de deux unités fonctionnelles distinctes : les jonctions communicantes (JCs) qui assurent la communication entre deux astrocytes voisins et les hémicanaux (HCs) dont le rôle est de libérer de molécules neuro-actives (gliotransmetteurs i.e. glutamate, ATP, D-sérine) dans la fente synaptique. En effet, une diminution de l'expression des Cx43 a été rapportée dans différentes régions cérébrales de patients dépressifs et dans des modèles murins de dépression. En revanche, d'un point de vue fonctionnel, l'induction d'un phénotype "anxio-dépressif" serait associée à une diminution de l'activité des JCs et à une augmentation de l'activité des HCs. Face à ces effets opposés, l'objectif de cette thèse était de caractériser plus finement le rôle des Cx43 dans les comportements "anxio-dépressifs" et la réponse aux psychotropes en utilisant des approches d'inactivation génétiques et pharmacologiques de ces protéines. Nos résultats montrent que l'inactivation génétique des Cx43 dans l'hippocampe n'entraine aucun effet neuro-comportemental. En revanche, dans un modèle de dépression basé sur l'exposition chronique des souris à la corticostérone (modèle CORT), l'inactivation génétique des Cx43 exerce des effets de type anxiolytiques-antidépresseurs. D'un point de vue mécanistique, ces effets seraient liés à une diminution de la libération hippocampique de glutamate par les HCs et à une atténuation de la réactivité de l'axe hypothalamo-hypophysaire (HPA). Concernant l'inactivation pharmacologique des Cx43, nos travaux apportent des évidences expérimentales sur le fait que l'administration systémique de carbenoxolone, un bloqueur des connexines, potentialise la réponse aiguë d'un inhibiteur de recapture de la sérotonine en conditions basales, mais s'oppose à ses effets bénéfiques chroniques dans un modèle de dépression. Le microenvironnement cellulaire semble donc essentiel dans la manière dont les Cx43 influencent la réponse aux antidépresseurs. L'ensemble de ces résultats de thèse laissent entrevoir un rôle des Cx43 astrocytaires dans la régulation de l'humeur via la modulation de circuits neuronaux convergeant vers l'axe HPA. Ils soulignent également l'intérêt de moduler les Cx43 pour renforcer l'activité thérapeutiques des antidépresseurs actuellement disponibles. Les futures recherches devront préciser les modalités de ces nouvelles stratégies combinant des agents pharmacologiques à tropisme astrocytaire et neuronal.
Earlier studies suggested that specific Echinacea preparations might decrease anxiety. To further study the issue, we performed a double blind, placebo controlled trial with a standardized Echinacea angustifolia root extract. Participants were volunteers scoring above 45 points on the state or on the trait subscale of the State Trait Anxiety Inventory (STAI). They were treated with 40 mg Echinacea or with placebo tablets twice daily for 7 days followed by a 3 week‐long washout period. Participants were also administered the Beck Depression Inventory (BDI) and the Perceived Stress Scale (PSS). In the Echinacea group, state anxiety scores decreased by approximately 11 points by the end of the treatment period, whereas the decrease was around 3‐points in the placebo group (p< 0.01). The effect maintained over the washout period. The difference from placebo was significant from the 7th day of treatment throughout. Changes were less robust with trait anxiety scores, but the preparation performed better than placebo in patients with high baseline anxiety. Neither BDI nor PSS scores were affected by the treatments. Adverse effects were rare and mild, and all were observed in the placebo group. These findings suggest that particular Echinacea preparations have significant beneficial effects on anxiety in humans.
Objective:
To develop a more reliable and comprehensive version of the Parental Facilitation of Mastery Scale (PFMS) METHOD: In Study 1, 387 undergraduates completed an expanded PFMS (PFMS-II) and measures of parenting, perceived control, responses to early life challenges, and psychopathology. In Study 2, 182 trauma-exposed community participants completed the PFMS-II and measures of perceived control, psychopathology, and well-being RESULTS: In Study 1, exploratory factor analysis of the PFMS-II revealed two factors. These factors replicated in Study 2; one item was removed to achieve measurement invariance across race. The final PFMS-II comprised a 10-item overprotection scale and a 7-item challenge scale. In both samples, this measure demonstrated good convergent and discriminant validity and was more reliable than the original PFMS. Parental challenge was a unique predictor of perceived control in both samples CONCLUSION: The PFMS-II is a valid measure of important parenting behaviors not fully captured in other measures.
Objective:
Symptoms and disorders of anxiety are highly prevalent among older adults; however, late-life anxiety disorders remain underdiagnosed. The objective of this study was to (1) estimate the prevalence of late-life threshold and subthreshold generalized anxiety disorder (GAD), (2) examine sociodemographic and health correlates associated with membership in these groups, (3) assess 3-year conversion rates of these groups, and (4) explore characteristics associated with 3-year conversion to GAD.
Methods:
Using Waves 1 and 2 of the National Epidemiological Survey of Alcohol and Related Conditions, 13,420 participants aged 55-98 years were included in this study.
Results:
Subthreshold GAD was more highly prevalent than threshold GAD and was interposed between asymptomatic and GAD groups in terms of severity of health characteristics. Although most participants with subthreshold and threshold GAD were asymptomatic by Wave 2, differences in disability persisted. Subthreshold GAD at baseline was not a predictor of threshold GAD at follow-up.
Conclusion:
These findings suggest that late-life GAD should be conceptualized as a dimensional rather than categorical construct. The temporal stability of anxiety-associated disability further suggests that subthreshold GAD bears clinical significance. However, the suitability and efficacy of interventions for minimizing negative sequelae in this group remain to be determined.
Objectives
Symptoms and disorders of anxiety are highly prevalent among older adults; however late-life anxiety disorders remain underdiagnosed. The objective of this study was to (i) estimate the prevalence of late-life threshold and sub-threshold GAD, (ii) examine sociodemographic and health correlates associated with membership in these groups, (iii) assess three-year conversion rates of these groups, and (iv) explore characteristics associated with three-year conversion to GAD.
Methods
Using Waves 1 and 2 of the National Epidemiological Survey of Alcohol and Related Conditions (NESARC), a total of 13,420 participants aged 55-98 years were included in this study.
Results
Sub-threshold GAD was more highly prevalent than threshold GAD, and was interposed between asymptomatic and GAD groups in terms of severity of health characteristics. Although the majority of participants with sub-threshold and threshold GAD were asymptomatic by Wave 2, differences in disability persisted. Sub-threshold GAD at baseline was not a predictor of threshold GAD at follow-up.
Conclusions
These findings suggest that late-life GAD should be conceptualized as a dimensional rather than categorical construct. The temporal stability of anxiety-associated disability further suggests that sub-threshold GAD bears clinical significance. However, the suitability and efficacy of interventions for minimizing negative sequelae in this group remain to be determined.
The Composite International Diagnostic Interview (CIDI), written at the request of the World Health Organization/US Alcohol, Drug Abuse, and Mental Health Administration Task Force on Psychiatric Assessment Instruments, combines questions from the Diagnostic Interview Schedule with questions designed to elicit Present State Examination Items. It is fully structured to allow administration by lay interviewers and scoring of diagnoses by computer. A special Substance Abuse Module covers tobacco, alcohol, and other drug abuse in considerable detail, allowing the assessment of the quality and severity of dependence and its course. This article describes the design and development of the CIDI and the current field testing of a slightly reduced "core" version. The field test is being conducted in 19 centers around the world to assess the interviews' reliability and its acceptability to clinicians and the general populace in different cultures and to provide data on which to base revisions that may be found necessary. In addition, questions to assess International Classification of Diseases, ninth revision, and the revised DSM-III diagnoses are being written. If all goes well, the CIDI will allow investigators reliably to assess mental disorders according to the most widely accepted nomenclatures in many different populations and cultures.
The authors examined the amount and durability of change in the cognitive content of 156 adult outpatients with recurrent major depressive disorder after treatment with cognitive therapy. The pre– post magnitude of change was large for the Attributional Style Questionnaire Failure composite (d = 0.79), Dysfunctional Attitudes Scale (d = 1.05), and Self-Efficacy Scale (d = 0.83), and small for the Attributional Style Questionnaire Success composite (d = 0.30). Changes in cognitive content were clinically significant, as defined by their 64%–87% scores overlapping with score distributions from community dwellers. Improvement was durable over a 2-year follow-up. Changes in negative cognitive content could be detected early and distinguished responders from nonresponders. In responders, continuation-phase cognitive therapy was associated with further improvements on only 1 measure of cognitive content. Early changes in negative cognitive content did not predict later changes in depressive symptoms, which the authors discuss in the context of methodological challenges and the cognitive theory of depression.
The project aims to investigate the efficacy of a preventive cognitive behavioural intervention delivered via the Internet to individuals at risk of developing anxiety disorders. There is increasing evidence that suggests anxiety sensitivity may act as a premorbid risk factor for the development of anxiety pathology and panic disorder. Eighty-three university students with elevated anxiety sensitivity were randomly allocated to either an intervention group (n = 43), who worked through the Internet based program over a period of 6 weeks, or a waitlist control group (n = 40). Significant treatment effects were found for anxiety related cognitions and symptoms of depression, and a non-significant trend for anxiety sensitivity. These outcomes were related to expectancy but not to program utilization. Implications for the prevention of anxiety via the Internet are discussed.
Panic disorder affects many people, is associated with a formidable disease burden, and imposes costs on society. The annual influx of new cases of panic disorder is substantial. From the public health perspective it may therefore be a sound policy to reduce the influx of new cases, to maintain the quality of life in many people, and to avoid the economic costs associated with the full-blown disorder. For this purpose, prevention is needed. Here we present the first economic evaluation of such an intervention.
Randomised trial of 117 people with panic disorder symptoms not meeting the diagnostic criteria of DSM-IV panic disorder. The interventions were time-limited cognitive-behavioural therapy v care-as-usual. The central clinical endpoint was DSM-IV panic disorder-free survival over 3 months. Costs were calculated from the societal perspective. Using the bootstrap method, incremental cost-effectiveness ratios were obtained, placed in 95% confidence intervals, projected on the cost-effectiveness plane, and presented as acceptability curves.
The median incremental cost-effectiveness ratio is euro6,198 (95% CI 2,435 - 60,731) per PD-free survival gained, which has a likelihood of 75.2% of being more acceptable from a cost-effectiveness point of view than care-as-usual when a willingness-to-pay ceiling is assumed of euro10,000 per PD-free survival. The most significant cost driver was therapists' time. A sensitivity analysis indicated that cost-effectiveness improves when the number of therapist hours is reduced.
This is the first economic evaluation alongside a prevention trial in panic disorder. The small sample (n = 117) and the short time horizon of 3 months preclude firm conclusions, but our findings suggest that the intervention may be acceptable from a cost-effectiveness point of view, especially when therapist involvement can be kept minimal. Nevertheless, our results must await replication in a larger trial with longer follow-up times before we can confidently recommend implementation of the intervention on a broad scale. In the light of our findings and given the burden of panic disorder, such a new trial is well worth the effort.
Panic disorder (PD) is a common, severe and persistent mental disorder, associated with a high degree of distress and occupational and social disability. A substantial proportion of the population experiences subthreshold and mild PD and is at risk of developing a chronic PD. A promising intervention, aimed at preventing panic disorder onset and reducing panic symptoms, is the 'Don't Panic' course. It consists of eight sessions of two hours each. The purpose of this study is to evaluate the effectiveness of this early intervention - based on cognitive behavioural principles - on the reduction of panic disorder symptomatology. We predict that the experimental condition show superior clinical and economic outcomes relative to a waitlisted control group.
A pragmatic, pre-post, two-group, multi-site, randomized controlled trial of the intervention will be conducted with a naturalistic follow-up at six months in the intervention group. The participants are recruited from the general population and are randomized to the intervention or a waitlist control group. The intervention is offered by community mental health centres. Included are people over 18 years of age with subthreshold or mild panic disorder, defined as having symptoms of PD falling below the cut-off of 13 on the Panic Disorder Severity Scale-Self Report (PDSS-SR). Primary outcomes are panic disorder and panic symptoms. Secondary outcomes are symptoms of agoraphobia, anxiety, cognitive aspects of panic disorder, depressive symptoms, mastery, health-related quality of life, and cost-effectiveness. We will examine the following variables as potential mediators: cognitive aspects of panic disorder, symptoms of agoraphobia, anxiety and mastery. Potential moderating variables are: socio-demographic characteristics, panic disorder, agoraphobia, treatment credibility and mastery.
This study was designed to evaluate the (cost) effectiveness of an early intervention based on cognitive behavioural principles. The strong external validity is one of the strengths of the study design.
Current Controlled Trials ISRCTN33407455.
A growing number of studies have tested the efficacy of preventive interventions in reducing the incidence of depressive disorders. Until now, no meta-analysis has integrated the results of these studies.
The authors conducted a meta-analysis. After a comprehensive literature search, 19 studies were identified that met inclusion criteria. The studies had to be randomized controlled studies in which the incidence of depressive disorders (based on diagnostic criteria) in an experimental group could be compared with that of a control group.
The mean incidence rate ratio was 0.78, indicating a reduction of the incidence of depressive disorders by 22% in experimental compared with control groups. Heterogeneity was low to moderate (I(2)=33%). The number needed to treat to prevent one case of depressive disorder was 22. Moderator analyses revealed no systematic differences between target populations or types of prevention (universal, selective, or indicated). The data included indications that prevention based on interpersonal psychotherapy may be more effective than prevention based on cognitive-behavioral therapy.
Prevention of new cases of depressive disorders does seem to be possible. Prevention may become an important way, in addition to treatment, to reduce the enormous public health burden of depression in the coming years.
Coping refers to behavior that protects people from being psychologically harmed by problematic social experience, a behavior that importantly mediates the impact that societies have on their members. The protective function of coping behavior can be exercised in 3 ways: by eliminating or modifying conditions giving rise to problems; by perceptually controlling the meaning of experience in a manner that neutralizes its problematic character; and by keeping the emotional consequences of problems within manageable bounds. The efficacy of a number of concrete coping behaviors representing these 3 functions was evaluated. Results indicate that individuals' coping interventions are most effective when dealing with problems within the close interpersonal role areas of marriage and child-rearing and least effective when dealing with the more impersonal problems found in occupation. The effective coping modes are unequally distributed in society, with men, the educated, and the affluent making greater use of the efficacious mechanisms.
The family history method, in which an informant is asked about the history of psychiatric illness in relatives, is widely used in psychiatric research. Previous research has examined the influence on family history information of characteristics of the relative. In this report, the authors seek to clarify the impact on family history reporting of the psychiatric history of the informant.
Both members of female twin pairs from a population-based twin registry were asked about the history of major depression, generalized anxiety disorder, and alcoholism in their mother and father. The authors examined twin pairs discordant for each of the three diagnoses and predicted that the affected twin would report higher rates of the same disorder in her parent than would the unaffected twin.
Twins with a history of major depression or generalized anxiety disorder but not twins with alcoholism were significantly more likely to report the same disorder in their parents than were their unaffected co-twins.
For major depression and generalized anxiety disorder, a family history diagnosis appears to reflect the psychiatric history of both the relative and the informant. Caution may be needed in the interpretation of results based on the family history method, although the magnitude of this problem may be attenuated by the use of multiple informants.
The causal relationships between neuroticism (N), long-term difficulties (LTDs), life situation change (LSC), and psychological distress (PD) were examined using self-report and interview data from a 7-year, 3-wave study in a general population sample (N = 296). LTDs were classified as either endogenous (dependent) or exogenous (independent). We found that earlier neuroticism had a strong direct and a moderate indirect effect (through endogenous LTDs) on PD. The direct effect was strikingly stronger than those of LTDs and LSC. In addition, much correlation between endogenous LTDs, LSC, and PD could be attributed to the confounding effects of earlier neuroticism. High neuroticism tended to strengthen the effect of LSC on PD. These findings suggest that temperamental dispositions are more powerful than environmental factors in predicting PD.
The National Comorbidity Survey is a nationally representative survey of the prevalences and correlates of DSM-III-R disorders in the US household population.
Retrospective age-at-onset reports were used to study predictive relationships between lifetime panic and depression.
Strong associations were found between the lifetime prevalences of panic and major depressive episodes (odds ratios: for panic attacks with depression, 6.2; for panic disorder with depression, 6.8). These associations were not significantly influenced by the inclusion or exclusion of respondents with mania. Temporally primary depression predicted a first onset of subsequent panic attacks but not of panic disorder. Temporally primary panic attacks, with or without panic disorder and whether or not the panic was persistent, predicted a first onset of subsequent major depression. The associations between panic attack and depression were attenuated in models that controlled for prior traumatic life experiences and histories of other DSM-III-R disorders.
Lifetime panic-depression comorbidity characterizes most community respondents with panic disorder and a substantial few of those with major depression. The absence of a dose-response relationship suggests that primary panic attack is a marker, rather than a causal risk factor, of subsequent depression. Primary depression, in comparison, appears to be a genuine risk factor for secondary panic attacks. That primary depression predicts panic attacks but not panic disorder suggests that secondary panic is a severity marker of depression rather than a comorbid condition. These results are far from definitive because they are based on retrospective reports, lay-administered diagnostic interviews, and only 1 survey. However, they raise important questions that could lead to a fundamental rethinking of panic-depression comorbidity if they are replicated in future epidemiological and clinical studies.
Quality-of-life indices have been used in medical practice to estimate the impact of different diseases on functioning and well-being and to compare outcomes between different treatment modalities. An integrated view of the issue of quality of life in patients with anxiety disorders can provide important information regarding the nature and extent of the burden associated with these disorders and may be useful in the development of strategies to deal with it.
A review of epidemiological and clinical studies that have investigated quality of life (broadly conceptualized) in patients with panic disorder, social phobia, posttraumatic stress disorder, generalized anxiety disorder, and obsessive-compulsive disorder was conducted by searching MEDLINE and PsycLIT citations from 1984 to 1999. A summary of the key articles published in this area is presented.
The studies reviewed portray an almost uniform picture of anxiety disorders as illnesses that markedly compromise quality of life and psychosocial functioning. Significant impairment can also be found in individuals with subthreshold forms of anxiety disorders. Effective pharmacological or psychotherapeutic treatment has been shown to improve the quality of life for patients with panic disorder, social phobia, and posttraumatic stress disorder. Limitations in current knowledge in this area are identified, and suggestions for needed future research are provided.
It is expected that a more thorough understanding of the impact on quality of life will lead to increased public awareness of anxiety disorders as serious mental disorders worthy of further investment in research, prevention, and treatment.
This article discusses the effects of sociodemographics and the presence of psychiatric disorders diagnosed in the 12 months before the first interview by using the Diagnostic and Statistical Manual of Mental Disorders: DSM-III-R, third edition, revised, on three types of attrition (failure to locate, refusal to participate, morbidity/mortality) in the second wave (1997-1998) of the Netherlands Mental Health Survey and Incidence Study, a longitudinal, general population survey of psychopathology among 7,076 subjects aged 18-64 years. Compared with those reinterviewed successfully, persons not located at the 1-year follow-up (n = 219) were more often younger, poorly educated, urban, not cohabiting with a steady partner, and born outside the Netherlands. Refusers (n = 923) had a lower educational level. Morbidity/mortality (n = 72) was associated with higher age, lower educational level, not being employed, and somatic disorders. After adjustment for sociodemographics, none of the disorders was positively associated with refusal. Failure to locate was linked to agoraphobia, alcohol abuse, and the categories of mood, substance use, and eating disorders. Morbidity/mortality was linked to dysthymia, agoraphobia, simple phobia, obsessive-compulsive disorder, and the category of anxiety disorders. Overall attrition was only slightly higher among respondents with one or more disorders (odds ratio = 1.20, 95% confidence interval: 1.04, 1.38). Thus, psychopathology has only weak-to-moderate effects on attrition and is mainly related to failure to locate and morbidity/mortality but not to refusal.
The authors conducted meta-analyses of data from family and twin studies of panic disorder, generalized anxiety disorder, phobias, and obsessive-compulsive disorder (OCD) to explore the roles of genetic and environmental factors in their etiology.
MEDLINE searches were performed to identify potential primary studies of these disorders. Data from studies that met inclusion criteria were incorporated into meta-analyses that estimated summary statistics of aggregate familial risk and heritability for each disorder.
For family studies, odds ratios predicting association of illness in first-degree relatives with affection status of the proband (disorder present or absent) were homogeneous across studies for all disorders. The calculated summary odds ratios ranged from 4 to 6, depending on the disorder. Only for panic disorder and generalized anxiety disorder could the authors identify more than one large-scale twin study for meta-analysis. These yielded heritabilities of 0.43 for panic disorder and 0.32 for generalized anxiety disorder. For panic disorder, the remaining variance in liability could be attributed primarily to nonshared environment. For generalized anxiety disorder, this was true for men, but for women, a potentially significant role for common familial environment was also seen.
Panic disorder, generalized anxiety disorder, phobias, and OCD all have significant familial aggregation. For panic disorder, generalized anxiety disorder, and probably phobias, genes largely explain this familial aggregation; the role of family environment in generalized anxiety disorder is uncertain. The role of nonshared environmental experience is significant, underscoring the importance of identifying putative environmental risk factors that predispose individuals to anxiety.
Cross-sectional findings in community surveys of adults suggest that adolescent anxiety disorders are strong predictors of the subsequent onset of alcohol use, abuse and dependence. However, prospective data that follow a sample of adolescents into adulthood are needed to confirm these associations.
Baseline and 4-year follow-up data from the EDSP-Study, a prospective community survey of 3021 (2548 at follow-up) adolescents and young adults aged 14 to 24 years at baseline carried out in Munich, were used. DSM-IV anxiety disorders, alcohol use and alcohol use disorders were assessed with the Munich-Composite-International-Diagnostic-Interview (M-CIDI). Multiple logistic regression analysis, controlling for age, gender, other mental disorders, substance use disorders and antisocial behaviour was used to study the associations of baseline anxiety disorders with the subsequent onset and course of alcohol use and alcohol disorders.
Baseline social phobia significantly predicts the onsets of regular use and hazardous use and the persistence of dependence. Panic attacks significantly predict the onsets of hazardous use and abuse as well as the persistence of combined abuse/dependence. Panic disorder significantly predicts the persistence of combined abuse/dependence. Other anxiety disorders do not significantly predict any of the outcomes.
Panic and social phobia are predictors of subsequent alcohol problems among adolescents and young adults. Further studies are needed to investigate the underlying mechanisms and the potential value of targeted early treatment of primary panic and social phobia to prevent secondary alcohol use disorders.
This manuscript examines the impact of mental health state and specific mental and physical disorders on work role disability and quality of life in six European countries.
The ESEMeD study was conducted in: Belgium, France, Germany, Italy, the Netherlands and Spain. Individuals aged 18 years and over who were not institutionalized were eligible for an in-home computer-assisted interview. Common mental disorders, work loss days (WLD) in the past month and quality of life (QoL) were assessed, using the WMH-2000 version of the CIDI, the WHODAS-II, and the mental and physical component scores (MCS, PCS) of the 12-item short form, respectively. The presence of five chronic physical disorders: arthritis, heart disease, lung disease, diabetes and neurological disease was also assessed. Multivariate regression techniques were used to identify the independent association of mental and physical disorders while controlling for gender, age and country.
In each country, WLD and loss of QoL increased with the number of disorders. Most mental disorders had approximately 1.0 SD-unit lower mean MCS and lost three to four times more work days, compared with people without any 12-month mental disorder. The 10 disorders with the highest independent impact on WLD were: neurological disease, panic disorder, PTSD, major depressive episode, dysthymia, specific phobia, social phobia, arthritis, agoraphobia and heart disease. The impact of mental vs. physical disorders on QoL was specific, with mental disorders impacting more on MCS and physical disorders more on PCS. Compared to physical disorders, mental disorders had generally stronger 'cross-domain' effects.
The results suggest that mental disorders are important determinants of work role disability and quality of life, often outnumbering the impact of common chronic physical disorders.
To describe the 12-month and lifetime prevalence rates of mood, anxiety and alcohol disorders in six European countries.
A representative random sample of non-institutionalized inhabitants from Belgium, France, Germany, Italy, the Netherlands and Spain aged 18 or older (n = 21425) were interviewed between January 2001 and August 2003. DSM-IV disorders were assessed by lay interviewers using a revised version of the Composite International Diagnostic Interview (WMH-CIDI).
Fourteen per cent reported a lifetime history of any mood disorder, 13.6% any anxiety disorder and 5.2% a lifetime history of any alcohol disorder. More than 6% reported any anxiety disorder, 4.2% any mood disorder, and 1.0% any alcohol disorder in the last year. Major depression and specific phobia were the most common single mental disorders. Women were twice as likely to suffer 12-month mood and anxiety disorders as men, while men were more likely to suffer alcohol abuse disorders.
ESEMeD is the first study to highlight the magnitude of mental disorders in the six European countries studied. Mental disorders were frequent, more common in female, unemployed, disabled persons, or persons who were never married or previously married. Younger persons were also more likely to have mental disorders, indicating an early age of onset for mood, anxiety and alcohol disorders.
Mental health survey data are now being used proactively to decide how the burden of disease might best be reduced.
To study the cost-effectiveness of current and optimal treatments for mental disorders and the proportion of burden avertable by each.
Data for three affective, four anxiety and two alcohol use disorders and for schizophrenia were compared interms of cost, burden averted and efficiency of current and optimal treatment. We then calculated the burden unavertable given current knowledge. The unit of health gain was a reduction in the years lived with disability (YLDs).
Summing across all disorders, current treatment averted 13% of the burden, at an average cost of 30,000 Australian dollars per YLD gained. Optimal treatment at current coverage could avert 20% of the burden, at an average cost of 18,000 Australian dollars per YLD gained. Optimal treatment at optimal coverage could avert 28% of the burden, at 16,000 Australian dollars per YLD gained. Sixty per cent of the burden of mental disorders was deemed to be unavertable.
The efficiency of treatment varied more than tenfold across disorders. Although coverage of some of the more efficient treatments should be extended, other factors justify continued use of less-efficient treatments for some disorders.
The purpose of the study was to examine the relationship between panic attack and the onset of specific mental disorders and severe psychopathology across the diagnostic spectrum among adolescents and young adults.
Data were drawn from the Early Developmental Stages of Psychopathology Study (N=3,021), a 5-year prospective longitudinal study of psychopathology among youths ages 14-24 years at baseline in the community. Multiple logistic regression analyses were used to examine the associations between panic attacks at baseline, comorbid mental disorders in adolescence, and the risk of mental disorders across the diagnostic spectrum at follow-up.
The large majority of subjects with panic attacks at baseline developed at least one DSM-IV mental disorder at baseline (89.4% versus 52.8% of subjects without panic attacks). Subjects with panic attacks at baseline had significantly higher baseline levels of any anxiety disorder (54.6% versus 25.0%), any mood disorder (42.7% versus 15.5%), and any substance use disorder (60.4% versus 27.5%), compared to subjects without panic attacks at baseline. Preexisting panic attacks significantly increased the risk of onset of any anxiety disorder, social phobia, specific phobia, generalized anxiety disorder, any substance use disorder, and any alcohol use disorder at follow-up in young adulthood, and these associations persisted after adjustment for all comorbid mental disorders assessed at baseline. More than one-third (37.6% versus 9.8%) of the subjects with panic attack at baseline met the criteria for at least three mental disorders at follow-up during young adulthood.
Panic attacks are associated with significantly increased odds of mental disorders across the diagnostic spectrum among young persons and appear to be a risk factor for the onset of specific anxiety and substance use disorders. Investigation of key family, environmental, and individual factors associated with the onset of panic attacks, especially in youth, may be an important direction for future research.
The authors sought to observe the long-term clinical course of anxiety disorders over 12 years and to examine the influence of comorbid psychiatric disorders on recovery from or recurrence of panic disorder, generalized anxiety disorder, and social phobia.
Data were drawn from the Harvard/Brown Anxiety Disorders Research Program, a prospective, naturalistic, longitudinal, multicenter study of adults with a current or past history of anxiety disorders. Probabilities of recovery and recurrence were calculated by using standard survival analysis methods. Proportional hazards regression analyses with time-varying covariates were conducted to determine risk ratios for possible comorbid psychiatric predictors of recovery and recurrence.
Survival analyses revealed an overall chronic course for the majority of the anxiety disorders. Social phobia had the smallest probability of recovery after 12 years of follow-up. Moreover, patients who had prospectively observed recovery from their intake anxiety disorder had a high probability of recurrence over the follow-up period. The overall clinical course was worsened by several comorbid psychiatric conditions, including major depression and alcohol and other substance use disorders, and by comorbidity of generalized anxiety disorder and panic disorder with agoraphobia.
These data depict the anxiety disorders as insidious, with a chronic clinical course, low rates of recovery, and relatively high probabilities of recurrence. The presence of particular comorbid psychiatric disorders significantly lowered the likelihood of recovery from anxiety disorders and increased the likelihood of their recurrence. The findings add to the understanding of the nosology and treatment of these disorders.
Errors in Byline, Author Affiliations, and Acknowledgment. In the Original Article titled “Prevalence, Severity, and Comorbidity of 12-Month DSM-IV Disorders in the National Comorbidity Survey Replication,” published in the June issue of the ARCHIVES (2005;62:617-627), an author’s name was inadvertently omitted from the byline on page 617. The byline should have appeared as follows: “Ronald C. Kessler, PhD; Wai Tat Chiu, AM; Olga Demler, MA, MS; Kathleen R. Merikangas, PhD; Ellen E. Walters, MS.” Also on that page, the affiliations paragraph should have appeared as follows: Department of Health Care Policy, Harvard Medical School, Boston, Mass (Drs Kessler, Chiu, Demler, and Walters); Section on Developmental Genetic Epidemiology, National Institute of Mental Health, Bethesda, Md (Dr Merikangas). On page 626, the acknowledgment paragraph should have appeared as follows: We thank Jerry Garcia, BA, Sara Belopavlovich, BA, Eric Bourke, BA, and Todd Strauss, MAT, for assistance with manuscript preparation and the staff of the WMH Data Collection and Data Analysis Coordination Centres for assistance with instrumentation, fieldwork, and consultation on the data analysis. We appreciate the helpful comments of William Eaton, PhD, Michael Von Korff, ScD, and Hans-Ulrich Wittchen, PhD, on earlier manuscripts. Online versions of this article on the Archives of General Psychiatry Web site were corrected on June 10, 2005.
• The Composite International Diagnostic Interview (CIDI), written at the request of the World Health Organization/US Alcohol, Drug Abuse, and Mental Health Administration Task Force on Psychiatric Assessment Instruments, combines questions from the Diagnostic Interview Schedule with questions designed to elicit Present State Examination items. It is fully structured to allow administration by lay interviewers and scoring of diagnoses by computer. A special Substance Abuse Module covers tobacco, alcohol, and other drug abuse in considerable detail, allowing the assessment of the quality and severity of dependence and its course. This article describes the design and development of the CIDI and the current field testing of a slightly reduced "core" version. The field test is being conducted in 19 centers around the world to assess the interviews' reliability and its acceptability to clinicians and the general populace in different cultures and to provide data on which to base revisions that may be found necessary. In addition, questions to assess International Classification of Diseases, ninth revision, and the revised DSM-III diagnoses are being written. If all goes well, the CIDI will allow investigators reliably to assess mental disorders according to the most widely accepted nomenclatures in many different populations and cultures.
Anxiety disorders are among the most prevalent of all psychological disorders and are potentially amenable to early intervention and prevention. In this article, we review the various costs associated with anxiety disorders that make early prevention a valuable endeavor. Also, we considered extant data regarding risk factors for anxiety disorders, as knowledge of risk factors permits the targeting of a select group of the population considered to be most likely to develop anxiety disorders. Existing efficacy research on prevention for anxiety disorders is promising, but an overarching model to guide further research and development is lacking. We propose such models to guide high-risk sample selection including the content and format of prevention efforts.
The goal of this study was to empirically test a prevention program for panic disorder. Participants who had experienced at least 1 panic attack in the last 12 months and at least moderate anxiety sensitivity, but did not meet criteria for panic disorder, were randomly assigned to either a 1-day prevention workshop group or a wait-list control group. Participants were followed for 6 months. Relative to the wait-list control, workshop participants were less likely to develop panic disorder and reported significantly more improvement in panic attacks and avoidance of social situations. Satisfaction with the workshop predicted outcome 6 months later. These findings suggest that prevention may be a viable option for panic disorder, and one that warrants further development.
To provide an overview of the World Health Organization (WHO) International Consortium in Psychiatric Epidemiology (ICPE), to introduce the World Mental Health 2000 (WMH2000) Initiative and to discuss methodological issues that the ICPE is grappling with in planning the WMH2000 Initiative.
We review the history, mission and organization of the ICPE and the rationale behind the WMH2000 Initiative. We review methodological research underlying major design and implementation decisions regarding the WMH2000 surveys.
The ICPE is an international consortium created to facilitate cross-national comparative epidemiological research using the WHO Composite International Diagnostic Interview (CIDI). The first-phase core ICPE surveys, which we are currently analysing, include over 33 000 interviews in seven countries, with an additional set of over 30 000 interviews in seven countries ready to be added to the master file within the next year. The WMH2000 Initiative will include a third series of CIDI surveys that include an anticipated 100000 additional interviews in 10 countries. A series of complex methodological challenges confront us in designing and implementing the WMH2000 surveys. These include issues in the conceptualization and measurement of impairment and disablement, the implementation of standardized quality control procedures across countries, and the blending of epidemiological and clinical interviewing methods to obtain a valid cross-national characterization of disorder prevalences. Our current plans regarding these issues are discussed.
Valid and representative general population epidemiological data on patterns, predictors and adverse consequences of psychiatric disorders are needed as a foundation for public health initiatives. The efforts of the ICPE promise to provide data of this sort for many regions in the world. Formidable methodological and logistical challenges arise in implementing this agenda, but we are confident that these challenges can be met by building on the firm foundation already established in the ongoing ICPE collaboration.
There is increasing evidence that subthreshold forms of psychopathology are both common and clinically relevant. To enable classification of these subthreshold forms of psychopathology, it may be useful to distinguish not only a threshold for illness but also for health. Our aim was to investigate this with regard to panic.
Data were derived from the Netherlands Mental Health Survey and Incidence Study (NEMESIS), which is based on a large representative sample of the adult general population (18-65 years) of The Netherlands (n=7076). The Composite International Diagnostic Interview was used as a diagnostic instrument. By defining two thresholds, three groups were formed: panic disorder, subthreshold panic disorder and no-panic. These groups were compared using multinomial regression analysis, chi2 and analysis of variance.
The 12-month prevalence of panic disorder was 2.2% while that of subthreshold panic disorder was 1.9%. Symptom profiles and risk indicators associated with panic disorder and subthreshold panic disorder were similar, and half of the risk indicators were more strongly associated with panic disorder than with subthreshold panic disorder. Subthreshold panic disorder occupied an intermediate position between panic disorder and no-panic with regard to the number of symptoms, the percentage of subjects with co-morbidity, and functioning.
Subthreshold panic disorder is common, and seems clinically relevant, but is milder than panic disorder. These results thus support the use of a double threshold in panic. Further research should focus on the positioning of the thresholds, the course of subthreshold panic disorder and its treatment options.
This study seeks to examine the incidence of social phobia in the general population and to establish a number of risk indicators.
Data were derived from the Netherlands Mental Health Survey and Incidence Study (NEMESIS) which is a population based prospective study (n=7076). A sample of adults aged 18-64 years (n=5618) were re-interviewed 1 year later using Composite International Diagnostic Interview (CIDI).
The 12-month incidence of DSM-III-R social phobia was 1.0%. Low education, low mastery, low self-esteem, emotional neglect in childhood and ongoing difficulties were found to be risk indicators. After including other mental disorders as risk indicators in the model, the incidence was found to be more common among those with low mastery, major depression, subthreshold social phobia, emotional neglect, negative life events, and low education.
The incidence of social phobia can be predicted relatively well with psychosocial variables and comorbidity.
We assessed the prevalence of perceived stigma among persons with mental disorders and chronic physical conditions in an international study.
Perceived stigma (reporting health-related embarrassment and discrimination) was assessed among adults reporting significant disability. Mental disorders were assessed with Composite International Diagnostic Interview (CIDI) 3.0. Chronic conditions were ascertained by self-report. Household-residing adults (80,737) participated in 17 population surveys in 16 countries.
Perceived stigma was present in 13.5% (22.1% in developing and 11.7% in developed countries). Suffering from a depressive or an anxiety disorder (vs. no mental disorder) was associated with about a twofold increase in the likelihood of stigma, while comorbid depression and anxiety was even more strongly associated (OR 3.4, 95%CI 2.7-4.2). Chronic physical conditions showed a much lower association.
Perceived stigma is frequent and strongly associated with mental disorders worldwide. Efforts to alleviate stigma among individuals with comorbid depression and anxiety are needed.
Most research on treatment for panic disorder has involved chronic forms of the illness. To determine the efficacy of early intervention, the authors examined the effects of treatment for patients with panic attacks who were seen in the emergency room, which is the first point of contact with the health delivery system for many persons with panic attacks.
The subjects were 33 patients with panic attacks seen in two emergency rooms. The presence of panic attacks was confirmed with a modified version of the Structured Clinical Interview for DSM-III-R; approximately 40% of the patients met the DSM-III-R criteria for panic disorder with agoraphobia. The patients were randomly assigned to groups receiving reassurance (N = 16) or exposure instruction (N = 17). Scores on the Fear Questionnaire agoraphobia subscale, Mobility Inventory, and Beck Depression Inventory and the frequency of panic attacks were determined at baseline, 3 months, and 6 months.
The subjects who received exposure instruction significantly improved over the 6-month period on depression, avoidance, and panic frequency. The reassurance subjects did not improve on any measure and eventually reported more agoraphobic avoidance.
These results suggest that early intervention with exposure instruction may reduce the long-term consequences of panic attacks. The exposure instruction was of value even though the subjects had relatively low levels of avoidance at the outset of the study.
The structures of two epidemiologic parameters are explored. One, the ''etiologic fraction'', relates to markers of increased risk, and it is the proportion of disease attributable to the marker and/or to factors associated with it. The other, the ''prevented fraction,'' is the equivalent of this for a marker of reduced risk. It is shown that both parameters depend, in different ways, on the frequency of the marker among cases of the disease, and on the ''standardized morbidity ratio'' for those with the marker. Point estimation of these parameters is often straight forward, particularly in case control studies.
This paper reviews reliability and validity studies of the WHO - Composite International Diagnostic Interview (CIDI). The CIDI is a comprehensive and fully standardized diagnostic interview designed for assessing mental disorders according to the definitions of the Diagnostic Criteria for Research of ICD-10 and DSM-III-R. The instrument contains 276 symptom questions many of which are coupled with probe questions to evaluate symptom severity, as well as questions for assessing help-seeking behavior, psychosocial impairments, and other episode-related questions. Although primarily intended for use in epidemiological studies of mental disorders, it is also being used extensively for clinical and other research purposes. The review documents the wide spread use of the instrument and discusses several test-retest and interrater reliability studies of the CIDI. Both types of studies have confirmed good to excellent Kappa coefficients for most diagnostic sections. In international multicenter studies as well as several smaller center studies the CIDI was judged to be acceptable for most subjects and was found to be appropriate for use in different kinds of settings and countries. There is however still a need for reliability studies in general population samples, the area the CIDI was primary intended for. Only a few selected aspects of validity have been examined so far, mostly in smaller selected clinical samples. The need for further procedural validity studies of the CIDI with clinical instruments such as the SCAN as well as cognitive validation studies is emphasized. The latter should focus on specific aspects, such as the use of standardized questions in the elderly, cognitive probes to improve recall of episodes and their timing, as well as the role of order effects in the presentation of diagnostic sections.
Bruzzi et al. (1985, American Journal of Epidemiology 122, 904-914) provided a general logistic-model-based estimator of the attributable fraction for case-control data, and Benichou and Gail (1990, Biometrics 46, 991-1003) gave an implicit-delta-method variance formula for this estimator. The Bruzzi et al. estimator is not, however, the maximum likelihood estimator (MLE) based on the model, as it uses the model only to construct the relative risk estimates, and not the covariate-distribution estimate. We here provide maximum likelihood estimators for the attributable fraction in cohort and case-control studies, and their asymptotic variances. The case-control estimator generalizes the estimator of Drescher and Schill (1991, Biometrics 47, 1247-1256). We also present a limited simulation study which confirms earlier work that better small-sample performance is obtained when the confidence interval is centered on the log-transformed point estimator rather than the original point estimator.
Mental disorders impose a multi-billion dollar burden on the economy each year; translating the burden into economic terms is important to facilitate formulating policies about the use of resources.
For direct costs, data were obtained from national household interview and provider surveys; for morbidity costs, a timing model was used that measures the lifetime effect on current income of individuals with mental disorders, taking into account the timing of onset and the duration of these disorders, based on regression analysis of Epidemiologic Catchment Area study data.
The total economic costs of mental disorders amounted to US$147.8 billion in 1990. Anxiety disorders are the most costly, amounting to $46.6 billion, or 31.5% of the total; schizophrenic disorders accounted for $32.5 billion, affective disorders for $30.4 billion, and other mental disorders for $38.4 billion.
Mental illnesses, especially anxiety disorders, are costly to society. Although anxiety disorders have a higher prevalence than affective disorders and schizophrenia, use of medical care services is lowest for anxiety disorders. Anxiety disorders appear to be under-recognised and untreated even though treatment interventions have been shown to be effective and can be delivered in a cost-efficient manner.
The study investigates the lifetime and 12-month prevalence, symptoms, age of onset and comorbidity patterns of DSM-IV panic attacks and panic disorder in a community sample of 3021 adolescents and young adults aged 14-24 years. Findings are based on DSM-IV symptoms and diagnoses assessed by interviews using a computerised, extended version of the Munich Composite International Diagnostic Interview (M-CIDI). Lifetime prevalence of DSM-IV panic disorder among 14-24 year-olds was 1.6% (0.8% with and 0.8% without agoraphobia). Panic symptoms were found to be quite frequent (13.1%) in the community, with lifetime prevalence of DSM-IV panic attack at 4.3% (12-month prevalence, 2.7%), with first onset rarely before puberty. Women were considerably more likely to have panic disorder and to have an earlier age of onset than males. Occurrence of DSM-IV panic attacks was strongly related to the subsequent development of various forms of mental disorders--not only panic disorder and agoraphobia. The conditional probability in those with panic attacks to develop other forms of mental disorders was 63% in males and 40% in females. Particularly 'late onset' panic attacks (after the age of 18 years) are associated strongly with the development of multimorbidity of mental disorders. This suggests that panic attacks are generally highly indicative for more severe psychopathology and not only for panic disorder and agoraphobia.
This article reports the initial results of a prospective study on the prevalence of psychiatric disorders in the Dutch population aged 18-64. The objectives and the design of the study are described elsewhere in this issue. A total of 7076 people were interviewed in person in 1996. The presence of the following disorders was determined by means of the CIDI: mood disorders, anxiety disorders, eating disorders, schizophrenia and other non-affective psychoses, and substance use disorders. Psychiatric disorders were found to be quite common. Some 41.2% of the adult population under 65 had experienced at least one DSM-III-R disorder in their lifetime, among them 23.3% within the preceding year. No gender differences were found in overall morbidity. Depression, anxiety, and alcohol abuse and dependence were most prevalent, and there was a high degree of comorbidity between them. The prevalence rate encountered for schizophrenia was lower (0.4% lifetime) than generally presumed. A comparison with findings from other countries is made. Relevant determinants of psychiatric morbidity were analysed.
The article describes the objectives and design of a prospective study of the prevalence, incidence and course of psychiatric disorders in a representative sample of non-institutionalized Dutch adults. A total of 7146 men and women aged 18-64, contacted through a multistage sample of municipalities and households, were interviewed at home in 1996. The primary diagnostic instrument was the CIDI, which determines the lifetime occurrence of DSM-III-R disorders. The disorders included were: mood disorders, anxiety disorders, eating disorders, schizophrenia and other non-affective psychotic disorders, and dependence and abuse of psychoactive substances. Follow-up measurements in the same sample were scheduled at 12 and 36 months. The net response to the first measurement was 69.7%. Poststratification weightings were applied for gender, age, marital status and degree of urbanization. Limitations and advantages of the study design are discussed. Findings are reported elsewhere in this issue.
To investigate determinants of 12-month first incidence of DSM-III-R mood disorder (MD), anxiety disorder (AD) and substance use disorder (SUD) in the general population.
Data are from the Netherlands Mental Health Survey and Incidence Study (NEMESIS), a prospective epidemiologic study in which a representative sample of 7076 adults aged 18-64 years were interviewed with the Composite International Diagnostic Interview. New cases diagnosed 12 months after baseline were compared with never diagnosed controls on sociodemographic and psychosocial variables.
Multivariate, the only demographic variable associated with incidence of MD was female gender. The strongest predictors were negative life events and ongoing difficulties. High level of neuroticism was also associated. Incidence of AD was likewise predicted by female gender. Negative life events and ongoing difficulties were also significant predictors, though weaker than for MD. Incidence of SUD was more common among males, young adults, people not living with a partner and those experiencing positive life events.
Incident MD and AD were predicted more strongly by life events, and SUD more strongly by demographic factors.
To determine the association between panic attacks and the risk of major depression among young adults in the community.
Data were drawn from a 21-year longitudinal birth cohort study (n = 1, 265). Multiple logistic regression analyses were used to determine the association between panic attacks in adolescence (age 15-21 years) and the risk of current major depression (past month).
Having a panic attack in the preceding 3 years was significantly associated with elevated risk of current major depression (past month) at the ages of 18 and 21. This association persisted after adjusting for a range of fixed social, family and individual risk factors for psychopathology, history of major depression, comorbid psychiatric disorder and life adversity among both males (OR = 8.9; 95% CI = 3.9-20.4) and females (OR = 2.3; 95% CI = 1.2-4.2).
These data are consistent with and extend previous work by showing that panic attack increases the risk of current major depression, independent of the effects of psychiatric comorbidity and other early risk factors for psychopathology, though much of this relationship appears to be explained by common risk factors and comorbidity. These data show new evidence of interaction between gender and panic attacks in the risk of depression among young persons. Replication of these findings is needed, as are future studies that further investigate the underlying mechanism of this association.
Given the existing economic constraints, prevention of depression has to be carefully targeted, and applied where it is likely to yield the highest possible health benefits at the lowest possible cost.
To identify those risk factors of depression that have the greatest use potential from the perspective of prevention.
Data were derived from a population-based prospective cohort of 4664 adults who had never experienced a depression. Their health status was re-examined after 1 year. Incidence rate ratios (IRR), population attributable risks (PAR) and numbers needed to be treated (NNT) were calculated to create a hierarchy of risk factors.
Selecting high-risk groups with migraine, abdominal and respiratory complaints and markers of vulnerability or childhood trauma appears to be an indicated strategy.
This study illustrates how epidemiology can contribute towards setting a Research and Development agenda for primary prevention of depression.
Major depression is the largest single cause of nonfatal disease burden in Australia. Effective drug and psychological treatments exist, yet are underused.
To quantify the burden of disease currently averted in people seeking care for major depression and the amount of disease burden that could be averted in these people under optimal episodic and maintenance treatment strategies.
Modeling impact of current and optimal treatment strategies based on secondary analysis of mental health survey data, studies of the natural history of major depression, and meta-analyses of effectiveness data. Monte Carlo simulation of uncertainty in the model.
The cohort of Australian adults experiencing an episode of major depression in 2000 are modeled through "what if" scenarios of no treatment, current treatment, and optimal treatment strategies with cognitive behavioral therapy or antidepressant drug treatment.
Disability-Adjusted Life Year.
Current episodic treatment averts 9% (95% uncertainty interval, 6%-12%) of the disease burden of major depression in Australian adults. Optimal episodic treatment with cognitive behavioral therapy could avert 28% (95% uncertainty interval, 19%-39%) of this disease burden, and with drugs 24% (95% uncertainty interval, 19%-30%) could be averted. During the 5 years after an episode of major depression, current episodic treatment patterns would avert 13% (95% uncertainty interval, 10%-17%) of Disability-Adjusted Life Years, whereas maintenance drug treatment could avert 50% (95% uncertainty interval, 40%-60%) and maintenance cognitive behavioral therapy could avert 52% (95% uncertainty interval, 42%-64%), even if adherence of around 60% is taken into account.
Longer-term maintenance drug or psychological treatment strategies are required to make significant inroads into the large disease burden associated with major depression in the Australian population.
To review current evidence for the clinical and cost-effectiveness of self-management interventions for panic disorder, phobias and obsessive-compulsive disorder (OCD).
Papers were identified through computerized searches of databases for the years between 1995 and 2003, manual searches and personal contacts. Only randomized-controlled trials were reviewed.
Ten studies were identified (one OCD, five panic disorder, four phobias). Effective self-management interventions included cognitive-behavioural therapy (CBT) and exposure to the trigger stimuli for phobias and panic disorders. All involved homework. There was evidence of effectiveness in terms of improved symptoms and psychological wellbeing when compared with standard care, waiting list or relaxation. Brief interventions and computer-based interventions were effective for most participants. In terms of quality, studies were mainly based on small samples, lacked long-term follow-up, and failed to address cost-effectiveness.
Despite the limitations of reviewed studies, there appears to be sufficient evidence to warrant greater exploration of self-management in these disorders.
This paper extends previous epidemiological findings linking panic attacks with future episodes of depression and examines whether this relationship is independent of the effects of gender and neuroticism.
Composite International Diagnostic Interview (CIDI) DSM-IV diagnoses from a stratified multi-stage population survey of 10,641 Australian adults were analysed using logistic regression to examine the relationship between lifetime panic attacks, gender, neuroticism and mental disorders.
People who experienced full CIDI DSM-IV panic attacks more than 12 months ago were 4 times more likely to meet criteria for current Depressive Disorder than those who reported no attacks. Those with panic attacks in the past 12 months were 13.3 times more likely to report current Depressive Disorders. A similar pattern was also present for non-panic Anxiety Disorders (odds ratio=7.5 for lifetime, but not 12-month panic attacks, and 21.46 for 12-month panic attacks) and for Substance Use Disorders (2.1 and 4.6, respectively) suggesting a broader relationship with psychopathology than previously reported. For each of these groupings of mental disorders, panic attacks accounted for significant variability over and above the effects of gender, neuroticism, and comorbid Anxiety Disorders.
Panic attacks are associated with current and future Anxiety, Depressive, and Substance Use Disorders, and this relationship is not solely accounted for by differences in gender and neuroticism.