Baseline Anxiety Disorders Research Articles

CHILDHOOD MALTREATMENT AND THE COURSE OF DEPRESSIVE AND ANXIETY DISORDERS: THE CONTRIBUTION OF PERSONALITY CHARACTERISTICS.

We investigated the effect of childhood maltreatment on predicting the 4-year course of depressive and anxiety disorders and the possible mediating role of personality characteristics in the association between childhood maltreatment and illness course. Longitudinal data in a large sample of participants with baseline depressive and/or anxiety disorders (n = 1,474, 18-65 years) were collected in the Netherlands Study of Depression and Anxiety. At baseline, childhood maltreatment was assessed with a semistructured interview. Personality trait questionnaires (Neuroticism-Extroversion-Openness Five Factor Inventory, Mastery scale, and Leiden Index of Depression Sensitivity), recent stressful life events (List of Threatening Experiences Questionnaire), and psychosocial variables were administered. The Life Chart Interview was used to determine the time to remission of depressive and/or anxiety disorders. At baseline, 846 participants (57.4%) reported any childhood maltreatment. Childhood maltreatment had a negative impact on psychosocial functioning and was predictive of more unfavorable personality characteristics and cognitive reactivity styles (P < 0.001). Childhood maltreatment was a significant predictor of lower likelihood of remission of depressive and/or anxiety disorders (HR = 0.94, P < 0.001). High levels of neuroticism, hopelessness, external locus of control, and low levels of extraversion were mediating the relationship between childhood maltreatment and 4-year remission of depressive and anxiety disorders. Certain personality characteristics are key players in the mechanism linking childhood maltreatment to an adverse illness course of depressive and anxiety disorders. Early interventions--reducing neuroticism and hopelessness, and enhancing extraversion and locus of control--might contribute to a better prognosis in a "high-risk" group of depressive and anxiety disorders.

Depressive and anxiety disorders: Associated with losing or gaining weight over 2 years?

This longitudinal study examines to what extent different depressive and anxiety disorders and clinical characteristics are associated with subsequent weight change, while controlling for baseline weight, sociodemographics, health status, psychotropic medication use and (un)healthy lifestyle factors. Data are from a sample of 2447 respondents aged 18–65 years of the Netherlands Study of Depression and Anxiety (NESDA). Baseline depressive disorders and anxiety disorders were determined with the Composite International Diagnostic Interview (CIDI). Weight at baseline and after 2 years was measured and analyzed as continuous change score (mean change in weight 1kg) and in categories of significant weight loss (<1S.D. weight change equaling <4kg), weight maintenance and weight gain (>1S.D., >6kg). After full adjustment for covariates baseline comorbid anxiety and depressive disorder and baseline Major Depressive Disorder (MDD) were associated with significant 2-year weight gain. Both current and remitted MDD at baseline and a baseline dysthymia, but none of the anxiety disorders, were associated with significant weight loss. This longitudinal study confirms a U-curved link between depression and weight change over 2 years. Furthermore, a dose–response effect of depression severity on 2-year weight gain was found.

Preschool irritability predicts child psychopathology, functional impairment, and service use at age nine.

Little is known about the predictive validity and clinical significance of chronic irritability during early childhood. This prospective, longitudinal study examined associations of preschool chronic irritability with psychiatric disorders, functional impairment, and service use at age nine in a large community sample. Four hundred and forty-six children were assessed at age three and again at age nine. Child psychopathology and functional impairment were assessed at age three with the Preschool Age Psychiatric Assessment (PAPA) with parents and at age nine with the Kiddie-Schedule of Affective Disorders and Schizophrenia (K-SADS) with parents and children. Items from the PAPA were used to create a dimensional measure of chronic irritability at age three. At age nine, mothers, fathers, and youth completed the Child Depression Inventory (CDI) and the Screen for Anxiety Related Disorders (SCARED). Chronic irritability at age three predicted any current and lifetime anxiety disorders at age nine, current and lifetime generalized anxiety disorder, and current separation anxiety, after controlling for baseline anxiety disorders. In addition, preschool irritability predicted increases in anxiety and disruptive behavior disorder symptoms on the K-SADS, and maternal and paternal reports of depressive and anxiety symptoms on the CDI and SCARED. Lastly, preschool irritability predicted greater functional impairment and outpatient treatment use, even after controlling for all psychiatric disorders at baseline. Findings underscore the central role of irritability in developmental psychopathology and support the importance of early detection and interventions targeting preschool irritability.

Impact of childhood life events and childhood trauma on the onset and recurrence of depressive and anxiety disorders.

To investigate the effect of childhood life events and childhood trauma on the onset and recurrence of depressive and/or anxiety disorders over a 2-year period in participants without current psychopathology at baseline. Longitudinal data in a large sample of participants without baseline DSM-IV depressive or anxiety disorders (n = 1,167, aged 18 to 65 years; assessed between 2004-2007) were collected in the Netherlands Study of Depression and Anxiety (NESDA). Childhood life events and childhood trauma were assessed at baseline with a semistructured interview. The Composite International Diagnostic Interview, based on DSM-IV criteria, was used to diagnose first onset or recurrent depressive and/or anxiety disorders over a 2-year period. At baseline, 172 participants (14.7%) reported at least 1 childhood life event, and 412 (35.3%) reported any childhood trauma. During 2 years of follow-up, 226 participants (19.4%) developed a new (n = 58) or recurrent (n = 168) episode of a depressive and/or anxiety disorder. Childhood life events did not predict the onset and recurrence of depressive or anxiety disorders. Emotional neglect and psychological, physical, and sexual abuse were all associated with an increased risk of first onset and recurrence of either depressive or comorbid disorders (P < .001), but not of anxiety disorders. In multivariate models, emotional neglect was the only significant independent predictor of first onset and recurrence of any depressive or comorbid disorder (P = .002). These effects were primarily mediated by the severity of (subclinical) depressive symptoms at baseline and, to a lesser extent, by a prior lifetime diagnosis of a depressive and/or anxiety disorder. Childhood maltreatment is a key environmental risk factor, inducing vulnerability to develop new and recurrent depressive and comorbid anxiety and depressive episodes.

Anxiety disorders and risk for alcohol use disorders: The moderating effect of parental support

BackgroundThere have been mixed findings on the temporal relation between anxiety disorders and alcohol use disorders (AUDs), suggesting that the pathway to AUDs may differ among individuals. The aim of the current study was to test whether parental support moderated the association between anxiety disorders and the development of AUDs. We also tested whether our effects differed as a function of age of AUD onset. Methods817 individuals were assessed for lifetime diagnoses of psychopathology during 4-waves between adolescence (mean age=16) and adulthood (mean age=30). ResultsProportional hazards model analyses indicated that baseline anxiety disorders interacted with baseline perceived maternal support to prospectively predict onset of AUDs. At high levels of maternal support, anxiety disorders were associated with a reduced risk for AUD onset (HR=0.74, 95% CI=0.55–1.00). However, this effect was more robust for AUDs that developed prior to age 20. At low levels of maternal support, anxiety disorders were associated with an increased risk for AUD onset (HR=1.65, 95% CI=1.21–2.26). This effect was present for AUDs that developed across adolescence and adulthood. Paternal support was not associated with AUDs and did not interact with anxiety disorders. ConclusionsPrevention and intervention efforts targeted at maternal support in adolescents with anxiety disorders may be valuable, as this may represent a factor that has a significant impact on the developmental course of AUDs.

Depressive and Anxiety Disorders Predicting First Incidence of Alcohol Use Disorders

Depressive and anxiety disorders may predict first incidence of alcohol abuse and alcohol dependence. This study aims to identify those persons who are at an increased risk of developing alcohols abuse or alcohol dependence by considering the heterogeneity of depressive and anxiety disorders and exploring the role of other risk factors. In a large sample of persons with and without baseline DSM-IV depressive or anxiety disorders (n = 2,676; 18-65 years; assessed in 2004-2007), the first incidences of DSM-IV alcohol abuse and alcohol dependence during a 4-year follow-up were considered as primary outcomes. Status (remitted or current disorder), severity, and type (specific disorders) of depressive and anxiety disorders were assessed, as well as other risk factors, such as sociodemographic, vulnerability, and addiction-related factors. Cumulative first-incidence rates of alcohol abuse and alcohol dependence were 2.0% and 3.0%, respectively. Persons with current, but not remitted, depressive or anxiety disorders were at an increased risk of a first incidence of alcohol dependence (hazard ratio [HR] = 2.69; 95% CI, 1.37-5.29), but not first incidence of alcohol abuse (HR = 0.55; 95% CI, 0.28-1.09). Although this association was not conditional on the type of disorder, first-incidence rates of alcohol dependence gradually increased with the number of depressive and anxiety disorders (HR per SD increase = 1.65; 95% CI, 1.37-2.00). Subthreshold alcohol problems especially (P < .001), but also recent negative life events (P = .06), were additional independent predictors of first incidence of alcohol dependence. Current depressive disorder, anxiety disorder, or both significantly predicted first incidence of alcohol dependence, which stresses the importance of addiction prevention strategies for depressed and anxious patients in mental health settings. Subthreshold alcohol problems and recent negative life events may help to identify persons at an increased risk for developing alcohol dependence.

First-incidence of DSM-IV mood, anxiety and substance use disorders and its determinants: Results from the Netherlands Mental Health Survey and Incidence Study-2

BackgroundProspective studies measuring first-incidence of DSM-IV mood, anxiety and substance use disorders in the general population are rare. We assessed these incidence rates in the Dutch population; and identified baseline sociodemographic, physical and psychopathological variables, and negative changes in sociodemographics and physical health between baseline and follow-up, as determinants of first-onset main categories of disorders. MethodData are from NEMESIS-2, a representative face-to-face survey including 5303 subjects aged 18–64 interviewed twice (2007–2009; 2010–2012) with the CIDI 3.0. ResultsIn three years, 8.86% of adults without prior psychopathology experienced any mental disorder, corresponding with 3.09 cases per 100 person-years. Incidence was highest for anxiety (1.69 per 100 person-years) and mood disorder (1.65), and lowest for substance use disorder (0.97). For the separate disorders, incidence was highest for major depression (1.58), specific phobia (0.79) and alcohol abuse (0.73). For mood and anxiety disorder, incidence rate was higher among women and for substance use disorder it was higher among men. Age was inversely related to all disorder categories. Changes in sociodemographics, like no longer living with a partner and decrease in income, were stronger determinants than the corresponding sociodemographics. Incident mood disorder was predicted by baseline anxiety and substance use disorder, incident anxiety disorder by mood and substance use disorder, and incident substance use disorder by adult ADHD. LimitationsValidity of lifetime diagnoses can be questioned because of difficulty of accurate recall. Only determinants of categories of disorders were studied, due to low numbers of incident cases of most separate disorders. ConclusionFirst-onset of mental disorders in a 3-year period is not an uncommon phenomenon. Results about determinants of incident disorders are important for prevention and early intervention initiatives aimed at reducing burden of mental disorders.

Cigarette smoking, nicotine dependence and anxiety disorders: a systematic review of population-based, epidemiological studies

BackgroundMultiple studies have demonstrated that rates of smoking and nicotine dependence are increased in individuals with anxiety disorders. However, significant variability exists in the epidemiological literature exploring this relationship, including study design (cross-sectional versus prospective), the population assessed (random sample versus clinical population) and diagnostic instrument utilized.MethodsWe undertook a systematic review of population-based observational studies that utilized recognized structured clinical diagnostic criteria (Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD)) for anxiety disorder diagnosis to investigate the relationship between cigarette smoking, nicotine dependence and anxiety disorders.ResultsIn total, 47 studies met the predefined inclusion criteria, with 12 studies providing prospective information and 5 studies providing quasiprospective information. The available evidence suggests that some baseline anxiety disorders are a risk factor for initiation of smoking and nicotine dependence, although the evidence is heterogeneous and many studies did not control for the effect of comorbid substance use disorders. The identified evidence however appeared to more consistently support cigarette smoking and nicotine dependence as being a risk factor for development of some anxiety disorders (for example, panic disorder, generalized anxiety disorder), although these findings were not replicated in all studies. A number of inconsistencies in the literature were identified.ConclusionsAlthough many studies have demonstrated increased rates of smoking and nicotine dependence in individuals with anxiety disorders, there is a limited and heterogeneous literature that has prospectively examined this relationship in population studies using validated diagnostic criteria. The most consistent evidence supports smoking and nicotine dependence as increasing the risk of panic disorder and generalized anxiety disorder. The literature assessing anxiety disorders increasing smoking and nicotine dependence is inconsistent. Potential issues with the current literature are discussed and directions for future research are suggested.

Predicting future suicide attempts among depressed suicide ideators: A 10-year longitudinal study

Suicidal ideation and attempts are a major public health problem. Research has identified many risk factors for suicidality; however, most fail to identify which suicide ideators are at greatest risk of progressing to a suicide attempt. Thus, the present study identified predictors of future suicide attempts in a sample of psychiatric patients reporting suicidal ideation. The sample comprised 49 individuals who met full DSM-IV criteria for major depressive disorder and/or dysthymic disorder and reported suicidal ideation at baseline. Participants were followed for 10 years. Demographic, psychological, personality, and psychosocial risk factors were assessed using validated questionnaires and structured interviews. Phi coefficients and point-biserial correlations were used to identify prospective predictors of attempts, and logistic regressions were used to identify which variables predicted future attempts over and above past suicide attempts. Six significant predictors of future suicide attempts were identified – cluster A personality disorder, cluster B personality disorder, lifetime substance abuse, baseline anxiety disorder, poor maternal relationship, and poor social adjustment. Finally, exploratory logistic regressions were used to examine the unique contribution of each significant predictor controlling for the others. Comorbid cluster B personality disorder emerged as the only robust, unique predictor of future suicide attempts among depressed suicide ideators. Future research should continue to identify variables that predict transition from suicidal thoughts to suicide attempts, as such work will enhance clinical assessment of suicide risk as well as theoretical models of suicide.

Anxiety symptoms and disorder predict activity limitations in the elderly

In the elderly, little attention has been paid to anxiety both on a symptom dimension and as a disorder, as an independent risk factor for the incidence of activity limitations. In a community-dwelling cohort of 1581 persons aged 65+, the association between trait anxiety symptoms (Spielberger Trait, third highest tertile) and baseline DSM-IV anxiety disorder, and 7-year incident activity limitations was determined using mixed logistic regression models. Repeated measures of activity limitations included, by increased severity level: social restriction (neighbourhood and house confined), mobility (Rosow and Breslau scale) and limitations in instrumental activities of daily living (IADL). Of the sample, 14.2% had an anxiety disorder at baseline. Adjusting for baseline socio-demographic and health variables, depression (past and current), antidepressant and anxiolytic drugs, baseline anxiety disorder was associated with an increased risk of incident IADL limitation (OR (95% CI): 1.84 (1.01-3.39), p=0.048) and trait anxiety with increased incidence of social restriction (OR (95% CI): 2.41 (1.42-4.09), p=0.001). Associations remained significant in participants free of depressive symptoms at baseline (OR (95% CI): 2.92 (1.41-6.05), p=0.004; OR (95% CI): 3.21 (1.31-7.89), p=0.011, respectively). Activity limitations were self-reported and may have been over-reported in participants with anxiety. Both trait anxiety symptomatology and anxiety disorder were independently associated with increased incidence of activity limitations with a gradient of severity: trait anxiety associated with incident social restriction and anxiety disorder with more severe IADL limitations, suggesting that anxiety is a predictor of activity limitations in the elderly independently of depression comorbidity.

Moderators and non-specific predictors of treatment outcome for anxiety disorders: A comparison of cognitive behavioral therapy to acceptance and commitment therapy.

Understanding for whom, and under what conditions, treatments exert their greatest effects is essential for developing personalized medicine. Research investigating moderators of outcome among evidence-based treatments for anxiety disorders is lacking. The current study examined several theory-driven and atheoretical putative moderators of outcome in cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT). Eighty-seven patients with a Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000) anxiety disorder completed 12 sessions of ACT or CBT and were assessed with a self-report measure of anxiety at baseline, post-treatment, and 6- and 12-month follow-up assessments. CBT outperformed ACT among those at moderate levels of baseline anxiety sensitivity, and among those with no comorbid mood disorder. ACT outperformed CBT among those with comorbid mood disorders. Higher baseline neuroticism was associated with poorer outcome across treatment conditions. Neither moderation nor general prediction was observed for baseline anxiety disorder comorbidity, race/ethnicity, gender, age, or baseline severity of the principal anxiety disorder. When including all randomized participants who completed the pre-treatment assessment (N = 121), a similar pattern was observed. Prescriptive recommendations for clinical practice and directions for future research are discussed.

Role of Self-medication in the Development of Comorbid Anxiety and Substance Use Disorders

Self-medication of anxiety symptoms with alcohol, other drugs, or both has been a plausible mechanism for the co-occurrence of anxiety disorders and substance use disorders. However, owing to the cross-sectional nature of previous studies, it has remained unknown whether self-medication of anxiety symptoms is a risk factor for the development of incident substance use disorder or is a correlate of substance use. To examine whether self-medication confers risk of comorbidity. A longitudinal, nationally representative survey was conducted by the National Institute on Alcohol Abuse and Alcoholism. The National Epidemiologic Survey on Alcohol and Related Conditions assessed DSM-IV psychiatric disorders, self-medication, and sociodemographic variables at 2 time points. The United States. A total of 34653 US adults completed both waves of the survey. Wave 1 was conducted in 2001-2002, and wave 2 interviews occurred 3 years later (2004-2005). Incident substance use disorders in participants with baseline anxiety disorders and incident anxiety disorders in those with baseline substance use disorders. Logistic regression analyses revealed that self-medication conferred a heightened risk of new-onset substance use disorders in those with baseline anxiety disorders (adjusted odds ratios [AORs], 2.50-4.99 [P<.01]). Self-medication was associated with an increased risk of social phobia (AOR in baseline alcohol use disorders, 2.13 [P=.004]; AOR in baseline drug use disorders, 3.17 [P=.001]). Self-medication in anxiety disorders confers substantial risk of incident substance use disorders. Conversely, self-medication in substance use disorders is associated with incident social phobia. These results not only clarify several pathways that may lead to the development of comorbidity but also indicate at-risk populations and suggest potential points of intervention in the treatment of comorbidity.

Anxiety, Depression, and 1‐Year Incident Cognitive Impairment in Community‐Dwelling Older Adults

To examine in men and women the independent associations between anxiety and depression and 1-year incident cognitive impairment and to examine the association of cognitive impairment, no dementia (CIND) and incident cognitive impairment with 1-year incident anxiety or depression. Prospective cohort study. General community. Population-based sample of 1,942 individuals aged 65 to 96. Two structured interviews 12 months apart evaluated anxiety and mood symptoms and disorders according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. Incident cognitive impairment was defined as no CIND at baseline and a follow-up Mini-Mental State Examination score at least 2 points below baseline and below the 15th percentile according to normative data. The associations between cognitive impairment and anxiety or depression were assessed using logistic regression adjusted for potential confounders. Incident cognitive impairment was, independently of depression, associated with baseline anxiety disorders in men (odds ratio (OR)=6.27, 95% confidence interval (CI)=1.39-28.29) and anxiety symptoms in women (OR=2.14, 95%=1.06-4.34). Moreover, the results indicated that depression disorders in men (OR=8.87, 95%=2.13-36.96) and anxiety symptoms in women (OR=4.31, 95%=1.74-10.67) were particularly linked to incident amnestic cognitive impairment, whereas anxiety disorders in men (OR=12.01, 95%=1.73-83.26) were especially associated with incident nonamnestic cognitive impairment. CIND at baseline and incident cognitive impairment were not associated with incident anxiety or depression. Anxiety and depression appear to have different relationships with incident cognitive impairment according to sex and the nature of cognitive impairment. Clinicians should pay particular attention to anxiety in older adults because it may shortly be followed by incident cognitive treatment.

School-Based Interventions for Anxious Children: 3-, 6-, and 12-Month Follow-ups

Objective To follow 61 participants (7–11 years old) from a study that compared three school-based interventions for anxious children: group cognitive-behavioral therapy (CBT) for children, group CBT for children plus parent training, and no-treatment control to determine whether posttreatment benefits are sustained longitudinally. Method Parent, child, and clinician report measures of child anxiety were completed at 3,6, and 12 months posttreatment. Semistructured diagnostic interviews were administered at 6- and 12-month follow-ups. For initial analyses, the group CBT and group CBT plus parent training conditions were collapsed into one group and compared to control. When significant results were found, each active treatment group was compared to control. Results Across several measures, the collapsed CBT group sustained significant improvement in anxiety severity and impairment across a 12-month period compared to control. There were no significant differences between the three groups on remission of baseline anxiety disorders or incidence of new anxiety disorders during the follow-up. Several parent-report measures at 3 and 6 months posttreatment suggested that group CBT for children plus parent training provided additional benefit over the group CBT for children when each was compared to the control group. Conclusions School-based CBT appears effective in decreasing anxiety symptoms up to 12 months posttreatment for anxious children. J. Am. Acad. Child Adolesc. Psychiatry, 2008; 47(9): 1039–1047.

Anxiety disorders and risk for suicide attempts: findings from the Baltimore Epidemiologic Catchment area follow-up study

Our objective was to determine whether the presence of an anxiety disorder was a risk factor for future suicide attempts. Data were drawn from the 13-year follow-up Baltimore Epidemiological Catchment Area survey (n=1,920). Multiple logistic regression analysis was used to determine the association between baseline anxiety disorders (social phobia, simple phobia, obsessive-compulsive disorder, panic attacks, or agoraphobia) and subsequent onset suicide attempts. The presence of one or more anxiety disorders at baseline was significantly associated with subsequent onset suicide attempts (adjusted odds ratio 2.20, 95% confidence interval 1.04-4.64) after controlling for sociodemographic variables and all baseline mental disorders assessed in the survey. These findings suggest that anxiety disorders are independent risk factors for suicide attempts, and underscore the importance of anxiety disorders as a serious public health problem.

Suicide Attempt Characteristics, Diagnoses, and Future Attempts: Comparing Multiple Attempters to Single Attempters and Ideators

To compare psychiatric diagnoses and future suicide attempt outcomes of multiple attempters (MAs), single attempters (SAs), and ideators. Two hundred twenty-eight teens who reported recent ideation or a lifetime suicide attempt in a screening of 1,729 high school students completed the Adolescent Suicide Interview, which provided information on attempt number and characteristics and mood, anxiety, and substance use disorder modules of the Diagnostic Interview Schedule for Children; 191 were reinterviewed 4 to 6 years later to ascertain interval attempts and psychiatric disorder. Between screening and follow-up, 33 (17%) teens made an attempt, 12 of whom were previously classified as lifetime MAs (more than one attempt) and six as SAs. MAs more often met criteria for any one of the DSM diagnoses assessed at baseline (mood, anxiety, or substance use disorder; 71%), compared with SAs (39%) and ideators (41%), and at follow-up (mood, anxiety, substance use, or disruptive behavior disorder; 69%) compared with SAs (36%) (p <.05). As reported at baseline, MAs (versus SAs) more often wished to die during their attempt (53% versus 23%), less often planned their attempt for intervention (44% versus 76%), and more often regretted recovery (26% versus 7%; p <.05). Baseline MAs had significantly higher odds of making a later attempt compared to ideators (odds ratio 4.0, 95% confidence interval 1.5-10.2) and SAs (odds ratio 4.6, 95% confidence interval 1.0-20.2). No participants committed suicide during follow-up. SAs who made another attempt (versus those who did not) more often met criteria for a baseline anxiety disorder and more often wished to die during their baseline attempt. MAs more strongly predict later suicidality and diagnosis than SAs and ideation. Forms that assess past suicide attempts should routinely inquire about frequency of attempts. The similarity between the present findings and those of clinical samples suggests that screening may yield a representative sample of suicide attempters and ideators.

Follow-up Study of Anxiety Disorder and Alcohol Dependence in Comorbid Alcoholism Treatment Patients

Anxiety disorders are present in a high percentage of alcoholism treatment patients. We tested the prediction that having a comorbid anxiety disorder increases the prospective risk for relapse to drinking after alcoholism treatment. We also explored the prospective associations of specific anxiety syndromes (and depression) with drinking and anxiety outcomes. We assessed the diagnostic status and daily drinking patterns of 82 individuals approximately one week after they entered alcoholism treatment (baseline) and again approximately 120 days later (follow-up) (n=53). Consistent with study predictions, those with a baseline anxiety disorder (approximately 55%) were significantly more likely than others to meet various definitions of drinking relapse over the course of the follow-up. Regression models showed that baseline social phobia was the single best predictor of a return to any drinking after treatment, whereas panic disorder was the single best predictor of a relapse to alcohol dependence after treatment. Having multiple anxiety disorders (versus any specific anxiety disorder) at the baseline was the strongest predictor of having at least one active ("persistent") anxiety disorder at the follow-up. Cross-sectional analysis at the follow-up showed that anxiety disorder persisted in the absence of a relapse to alcohol dependence far more often than relapse to alcohol dependence occurred in the absence of a persistent anxiety disorder. Screening for comorbid anxiety disorder in alcoholism treatment patients is warranted and, where found, should be considered a marker of high relapse risk relative to that of noncomorbid patients. The capacity of specific anxiety treatment to mitigate relapse risk among comorbid patients remains an open question.

Primary anxiety disorders and the development of subsequent alcohol use disorders: a 4-year community study of adolescents and young adults.

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.

A cross-national study of the course of persistent pain in primary care

Data from the World Health Organization's study of psychological problems in general health care were used to examine the course of persistent pain syndromes among primary care patients. Across 15 sites in 14 countries, 3197 randomly selected primary care patients completed baseline and 12-month follow-up assessments of pain, other somatic symptoms, and anxiety and depressive disorders (the Composite International Diagnostic Interview), and an assessment of occupational role disability (the Social Disability Schedule). Of patients with a persistent pain condition at baseline, 49% had not recovered 12 months later. The probability of non-recovery varied significantly across study centers and was significantly associated with the number of pain sites at baseline. After adjustment for age, sex, and study center, baseline anxiety or depressive disorder did not predict non-recovery of persistent pain. Among those without a persistent pain disorder at baseline, the rate of onset was 8.8% with a significant variability in risk across centers. The baseline characteristics predicting the onset of persistent pain disorder were psychological disorder, poor self-rated health, and occupational role disability. A persistent pain disorder at baseline predicted the onset of a psychological disorder to the same degree that a baseline psychological disorder predicted the subsequent onset of persistent pain. Persistent pain conditions are common among primary care patients, and the probability of resolution over 12 months is approximately 50%. We found a strong and symmetrical relationship between persistent pain and psychological disorder. Impairment of daily activities appears to be a central component of that relationship.

Health care costs associated with depressive and anxiety disorders in primary care.

The authors examined the overall health care costs associated with depression and anxiety among primary care patients. Of 2,110 consecutive primary care patients in a health maintenance organization, 1,962 were screened with the 12-item General Health Questionnaire. A stratified random sample of 615 patients were selected for further diagnostic assessment; 373 of these patients completed the Composite International Diagnostic Interview at baseline and 328 were reassessed 12 months later. Computerized cost records were used to calculate total health care costs for the 6-month period surrounding the baseline assessment and a similar period surrounding the follow-up assessment. Cost accounting data were available for 327 patients at baseline and for 206 patients at both assessments. Primary care patients with DSM-III-R anxiety or depressive disorders at baseline had markedly higher baseline costs ($2,390) than patients with subthreshold disorders ($1,098) and those with no anxiety or depressive disorder ($1,397). Large cost differences persisted after adjustment for medical morbidity. Cost differences reflected higher utilization of general medical services rather than higher mental health treatment costs. Although most patients with baseline anxiety or depressive disorders showed significant improvement, longitudinal analyses did not show any clear relationship between change in psychiatric diagnosis and change in health care cost. Among primary care patients, anxiety and depressive disorders are associated with markedly higher health care costs even after adjustment for medical comorbidity. In this small sample, improvement in depression over 1 year was not clearly associated with decreases in cost.