Anxiety Disorders: Beesdo K

Wittchen HU, Gloster A, Beesdo K, Schönfeld S, Perkonigg A. · Institute of Clinical Psychology and Psychotherapy, Technische Universitaet Dresden, Dresden, Germany. · CNS Spectr. · Pubmed #19169189 links to  free full text

Abstract: We reviewed epidemiological findings for the diagnosis of posttraumatic stress disorder (PTSD) and its core diagnostic features, focusing on whether epidemiology has been helpful in clarifying some of the critical diagnostic issues relevant to the revision of the Diagnostic and Statistical Manual of Mental Disorders and the International Statistical Classification of Diseases. Though epidemiology has provided increasingly rich data and knowledge regarding prevalence and incidence, patterns of onset and course, comorbidity, and risk factors for traumatic experiences and posttraumatic stress, little systematic research has been performed specifically addressing such critical diagnostic issues. Particularly, unresolved concerns remain regarding the definition of trauma, duration and impairment/distress criteria, the distinctiveness of the PTSD-syndrome, and even the position of PTSD in the classification system of mental disorders. A further exploitation of the existing data, and an improvement of existing epidemiological methods, strategies, and assessments are likely to substantially contribute to the clarification of unresolved diagnostic issues.

Shear MK, Bjelland I, Beesdo K, Gloster AT, Wittchen HU. · School of Social Work, Columbia University, New York, USA. · Int J Methods Psychiatr Res. · Pubmed #17623395 No free full text.

Abstract: Anxiety disorders, as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), comprise a relatively heterogeneous group of clinical conditions that range from specific phobias to obsessive compulsive disorder (OCD) and post-traumatic stress disorder (PTSD). The grouping under one heading refers to the fact that these seemingly heterogeneous disorders share a number of common psychopathological features and also share at least some common principles in treatment. Among the shared elements are broadly defined prototypical anxiety reactions, panic attacks, anticipatory anxiety, avoidance behaviour, a predominantly early onset, and relatively high persistence rates over time. Many of the shared diagnostic features of anxiety disorders are by their nature dimensional, and hundreds of psychometric scales have been developed to measure these diagnostic constructs across anxiety disorder and for specific diagnostic classes. This paper explores different types of dimensional approaches used in the literature and discusses how an integrated categorical/dimensional strategy might enhance the usefulness of the DSM-V. We suggest the use of cross-cutting dimensional ratings that might ultimately lead to an improved classification model. We also suggest that a staging approach to illness, based upon supplementary dimensional rating could provide useful information for clinical and research purposes.

Wittchen HU, Beesdo K, Bittner A, Goodwin RD. · Institute of Clinical Psychology and Psychotherapy, Dresden University of Technology, Chemnitzerstrasse 46, 01187 Dresden, Germany. · Eur Psychiatry. · Pubmed #14680714 No free full text.

Abstract: Anxiety and depressive disorders are common mental disorders in general population, imposing tremendous burden on both affected persons and society. Moreover, comorbidity between anxiety and depressive conditions is high, leading to substantial disability and functional impairment. Findings consistently suggest that anxiety disorders are primary to depression in the majority of comorbid cases. Yet, the question of whether anxiety disorders are risk factors for depression, and potentially even causal risk factors for the first onset of depression, remains unresolved. Recent results have shown that anxiety disorders increase the risk for subsequent depression, and also affect the course of depression, resulting in a poorer prognosis. Further, some results suggest a dose-response-relationship in revealing that a higher number of anxiety disorders and more severe impairment associated with anxiety disorders additionally increase the risk for subsequent depression. The goal of this paper is to review recent literature, summarize implications of previous findings, and suggest directions for future research regarding preventive and intervention strategies.

Beesdo K, Hoyer J, Jacobi F, Low NC, Höfler M, Wittchen HU. · Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Chemnitzer Str. 46, 01187 Dresden, Germany. · J Anxiety Disord. · Pubmed #19278819 No free full text.

Abstract: BACKGROUND: It is unclear whether generalized anxiety disorder (GAD) has a specific relationship to pain syndromes, going beyond the established association of pain with anxiety syndromes in general. METHODS: Mental disorders were assessed in a community sample (N=4181; 18-65 years) using the DSM-IV/M-CIDI. Several threshold definitions were used to define GAD and medically unexplained pain. RESULTS: The association between pain and GAD (odds ratio, OR=5.8 pain symptoms; OR=16.0 pain disorder) is stronger than the association between pain and other anxiety disorders (OR=2.4 pain symptoms; OR=4.0 pain disorder). This association extends to subthreshold level definitions of GAD with some indication for a non-linear dose-response relationship. The GAD-pain link cannot sufficiently be explained by demographic factors, comorbid mental or physical disorders. CONCLUSIONS: The association of pain and generalized anxiety is not artifactual. Compared to other anxiety syndromes, it appears to be stronger and more specific suggesting the need to explore clinical and public health implications.

Beesdo K, Lau JY, Guyer AE, McClure-Tone EB, Monk CS, Nelson EE, Fromm SJ, Goldwin MA, Wittchen HU, Leibenluft E, Ernst M, Pine DS. · Institute of Clinical Psychology and Psychotherapy, Technische Universitaet Dresden, Chemnitzer Strasse 46, Dresden, Germany. · Arch Gen Psychiatry. · Pubmed #19255377 No free full text.

Abstract: CONTEXT: Few studies directly compare amygdala function in depressive and anxiety disorders. Data from longitudinal research emphasize the need for such studies in adolescents. OBJECTIVE: To compare amygdala response to varying attention and emotion conditions among adolescents with major depressive disorder (MDD) or anxiety disorders, relative to adolescents with no psychopathology. DESIGN: Case-control study. SETTING: Government clinical research institute. PARTICIPANTS: Eighty-seven adolescents matched on age, sex, intelligence, and social class: 26 with MDD (14 with and 12 without anxiety disorders), 16 with anxiety disorders but no depression, and 45 without psychopathology. MAIN OUTCOME MEASURES: Blood oxygen level-dependent signal in the amygdala, measured by means of event-related functional magnetic resonance imaging. During imaging, participants viewed facial expressions (neutral, fearful, angry, and happy) while attention was constrained (afraid, hostility, and nose-width ratings) or unconstrained (passive viewing). RESULTS: Left and right amygdala activation differed as a function of diagnosis, facial expression, and attention condition both when patients with comorbid MDD and anxiety were included and when they were excluded (group x emotion x attention interactions, P < or = .03). Focusing on fearful face-viewing events, patients with anxiety and those with MDD both differed in amygdala responses from healthy participants and from each other during passive viewing. However, both MDD and anxiety groups, relative to healthy participants, exhibited similar signs of amygdala hyperactivation to fearful faces when subjectively experienced fear was rated. CONCLUSIONS: Adolescent MDD and anxiety disorders exhibit common and distinct functional neural correlates during face processing. Attention modulates the degree to which common or distinct amygdala perturbations manifest in these patient groups, relative to healthy peers.

Hoyer J, Beesdo K, Gloster AT, Runge J, Höfler M, Becker ES. · Clinical Psychology and Psychotherapy, Technische Universitat Dresden, Dresden, Germany. · Psychother Psychosom. · Pubmed #19218829 No free full text.

Abstract: BACKGROUND: Worry exposure (WE) is a core element of cognitive-behavioral treatment for generalized anxiety disorder (GAD). Its efficacy as a stand-alone treatment method (without further cognitive-behavioral therapy interventions) has never been tested.We aimed to examine whether WE alone is as efficacious as the empirically supported stand-alone treatment for GAD, applied relaxation (AR). METHODS: In a randomized controlled study, 73 outpatients meeting DSM-IV criteria for GAD as primary diagnosis were allocated to either WE or AR or a waiting list control group; in a 2nd randomization procedure the waiting list subjects were reallocated to WE or AR. The treatment was manualized (15 sessions with WE or AR), included 6-month and 1-year follow-ups, as well as last observation carried forward and completer analyses, and was controlled for allegiance effects.The Hamilton Anxiety Rating Scale and the State-Trait Anxiety Scale were used as primary outcome measures. Self-report scales of anxiety, worrying and depression including negative metacognition about worrying and thought suppression served as secondary outcome measures. RESULTS: The dropout rate was moderate. The pre-/posttreatment effects were high for the Hamilton Anxiety Rating Scale (standardized mean difference >1) and for the State-Trait Anxiety Inventory (standardized mean difference >0.87). The proportion of patients reaching high end state functioning was 48% (WE) and 56% (AR). WE and AR did not differ with regard to dropout rate or treatment effects. The treatment effects were stable at 6 month and 1 year follow-up. CONCLUSION: This is the first study to show that a stand-alone exposure in sensu technique--WE--is efficacious in the treatment of GAD. Both AR and WE seem to represent effective principles of change in GAD.

Knappe S, Beesdo K, Fehm L, Lieb R, Wittchen HU. · Institute of Clinical Psychology and Psychotherapy, Technische Universitaet Dresden, Chemnitzer Str. 46, 01187 Dresden, Germany. · J Neural Transm. · Pubmed #18982243 links to  free full text

Abstract: We examined parental psychopathology and family environment in subthreshold and DSM-IV threshold conditions of social anxiety disorder (SAD) in a representative cohort sample of 1,395 adolescents. Offspring and parental psychopathology was assessed using the DIA-X/M-CIDI; recalled parental rearing and family functioning via questionnaire. Diagnostic interviews in parents were supplemented by family history reports from offspring. The cumulative lifetime incidence was 23.07% for symptomatic SAD, and 18.38 and 7.41% for subthreshold and threshold SAD, respectively. The specific parent-to-offspring association for SAD occurred for threshold SAD only. For subthreshold and threshold SAD similar associations were found with other parental anxiety disorders, depression and substance use disorders. Parental rearing behaviour, but not family functioning, was associated with offspring threshold SAD, and although less strong and less consistent, also with subthreshold SAD. Results suggest a continued graded relationship between familial risk factors and offspring SAD. Parental psychopathology and negative parental styles may be used defining high-risk groups to assign individuals with already subthreshold conditions of SAD to early intervention programs.

Knappe S, Lieb R, Beesdo K, Fehm L, Low NC, Gloster AT, Wittchen HU. · Institute of Clinical Psychology and Psychotherapy, Technische Universitaet Dresden, Dresden, Germany. · Depress Anxiety. · Pubmed #18839408 No free full text.

Abstract: BACKGROUND: To examine the role of parental psychopathology and family environment for the risk of social phobia (SP) in offspring from childhood to early adulthood, encompassing the high risk period for SP. METHODS: A community sample of 1,395 adolescents was prospectively followed-up over 10 years. Offspring and parental psychopathology were assessed according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) using the Munich Composite International Diagnostic Interview (M-CIDI), and direct diagnostic interviews in parents were supplemented by family history reports. Parental rearing was assessed by the Questionnaire of Recalled Rearing Behavior administered to offspring. Family functioning was assessed by the McMaster Family Assessment Device administered to parents. RESULTS: Parental SP was associated with offspring's risk to develop SP (OR=3.3, 95%CI:1.4-8.0). Other parental anxiety disorders (OR=2.9, 95%CI:1.4-6.1), depression (OR=2.6, 95%CI:1.2-5.4), and alcohol use disorders (OR=2.8, 95%CI:1.3-6.1) were also associated with offspring SP. Parental rearing styles of overprotection, rejection, and lack of emotional warmth were associated with offspring SP. Family functioning measures were not associated with offspring SP. Analyses of interaction of parental psychopathology and parental rearing indicated combined effects on the risk for offspring SP. CONCLUSIONS: Parental psychopathology and rearing were associated with offspring SP, independently as well as in their interaction. Further delineation of these associations is warranted as malleable components of these risk factors may provide potential targets for prevention programs. In addition, parent-to-offspring transmission of other internalizing disorders should be considered to examine the degree of diagnostic specificity.

Wittchen HU, Nocon A, Beesdo K, Pine DS, Hofler M, Lieb R, Gloster AT. · Institute of Clinical Psychology and Psychotherapy, Technische Universitat Dresden, Dresden, Germany. · Psychother Psychosom. · Pubmed #18277061 No free full text.

Abstract: BACKGROUND: The relationship of panic attacks (PA), panic disorder (PD) and agoraphobia (AG) is controversial. The aim of the current study is to prospectively examine the 10-year natural course of PA, PD and AG in the first three decades of life, their stability and their reciprocal transitions. METHODS: DSM-IV syndromes were assessed via Composite International Diagnostic Interview - Munich version in a 10-year prospective-longitudinal community study of 3,021 subjects aged 14-24 years at baseline. RESULTS: (1) Incidence patterns for PA (9.4%), PD (with and without AG: 3.4%) and AG (5.3%) revealed differences in age of onset, incidence risk and gender differentiation. (2) Temporally primary PA and PD revealed only a moderately increased risk for subsequent onset of AG, and primary AG had an even lower risk for subsequent PA and PD. (3) In strictly prospective analyses, all baseline groups (PA, PD, AG) had low remission rates (0-23%). Baseline PD with AG or AG with PA were more likely to have follow-up AG, PA and other anxiety disorders and more frequent complications (impairment, disability, help-seeking, comorbidity) as compared to PD without AG and AG without PA. CONCLUSIONS: Differences in incidence patterns, syndrome progression and outcome, and syndrome stability over time indicate that AG exists as a clinically significant phobic condition independent of PD. The majority of agoraphobic subjects in this community sample never experienced PA, calling into question the current pathogenic assumptions underlying the classification of AG as merely a consequence of panic. The findings point to the necessity of rethinking diagnostic concepts and DSM diagnostic hierarchies.

Fehm L, Beesdo K, Jacobi F, Fiedler A. · Institute of Psychology, Humboldt-Unversität zu Berlin, Rudower Chaussee 18, 12489 Berlin, Germany. · Soc Psychiatry Psychiatr Epidemiol. · Pubmed #18084686 No free full text.

Abstract: BACKGROUND: There is a lack of data systematically describing subthreshold expressions of social anxiety disorder (SAD) with regard to prevalence, comorbidity, and impairment. METHODS: This analysis was based on data from the German Health Survey (GHS) and its Mental Health Supplement (GHS-MHS). Social anxiety disorder and its syndromes as well as other mental disorders were assessed with a standardized diagnostic interview (M-CIDI) in 4,174 adults. RESULTS: The 12-month prevalence rate for threshold SAD was 2.0%, subthreshold and symptomatic social anxiety (one DSM-IV criterion missing/two or more criteria missing) was found in 3.0 and 7.5% of the participants, respectively. As expected, threshold SAD was characterized by an elevated risk for comorbid disorders and associated with impairment in diverse areas of life. However, this was also true for the two subthreshold expressions of social anxiety, which were also significantly associated with higher comorbidity and greater impairment compared to the control group. CONCLUSIONS: Our results suggest that social anxiety below the diagnostic threshold is clearly associated with adverse outcomes. Prospective designs should examine the exact temporal and possible causal pathways of this burden in order to inform prevention and early intervention programs.

Nocon A, Wittchen HU, Beesdo K, Brückl T, Hofler M, Pfister H, Zimmermann P, Lieb R. · Research Group of Molecular Psychology, Max-Planck-Institute of Psychiatry, Clinical Psychology and Epidemiology, Munich, Germany. · Depress Anxiety. · Pubmed #18023003 No free full text.

Abstract: To examine the familial liability of panic disorder (PD) and agoraphobia (AG) in a community sample, namely the effect of parental PD and AG on the offspring's risk to develop either or both conditions in adolescence or adulthood. A representative community sample of N=3,021 adolescents and young adults aged 14-24 years at baseline was followed up over a period of 10 years in up to four waves. Family information was assessed by either direct interviews with at least one parent or by using subjects' family history information at either wave (N=3,014). Diagnoses and selected symptoms were assessed in both, parents and subjects, by using a standardized diagnostic interview (DSM-IV M-CIDI) with its respective family history module. (1) Parental panic attacks (PA), PD, and AG were all shown to be associated with an increased risk of offspring to also develop PA, PD, and AG. (2) Associations of parental PD were present irrespective of parental AG, whereas parental AG without PD was not associated with an increased offspring risk. (3) Outcome risk was particularly elevated in offspring of parents with PD+AG. (4) Parental PD or AG was not associated with an earlier age of onset of any syndrome in the offspring. We confirmed and expanded previous results from clinical samples that comorbid PD and AG aggregate in families. AG without PD is not familial, but it might enhance the familial transmission of PD.

Zimmermann P, Brückl T, Lieb R, Nocon A, Ising M, Beesdo K, Wittchen HU. · Molecular Psychology Unit, Max Planck Institute of Psychiatry, Munich, Germany. · Biol Psychiatry. · Pubmed #17698041 No free full text.

Abstract: BACKGROUND: The aim of the present article is to explore interaction and correlation effects between familial depression liability and selected adverse (separation and traumatic) events in predicting the first onset of a major depressive episode (MDE) in a 10-year prospective longitudinal community survey. METHODS: Analyses are based on 1982 subjects (14 to 24 years at baseline) without baseline MDE who participated during the whole study period and for whom diagnostic information about psychopathology in both parents was available. The offspring's familial depression liability was determined by aggregating information on parental depressive symptoms obtained from family history data and direct interviews with parents. Data were assessed with the Munich-Composite International Diagnostic Interview according to its DSM-IV algorithms. RESULTS: Adverse events predicted a substantially increased incidence of MDE among respondents with familial liability but not in those without familial liability. There was a significant interaction between familial liability and traumatic events with the strongest effect for the number of severe traumatic events (risk difference = 11.3%; 95% confidence interval = 3.55-19.15). Associations with familial liability were most pronounced for separation events. CONCLUSIONS: Adverse events are particularly pathogenic in individuals with familial liability. The involvement of interactions and correlations between familial liability and adversity might depend on type, severity, and number of events. Both processes are suggested to be concomitant rather than exclusive.

Beesdo K, Bittner A, Pine DS, Stein MB, Höfler M, Lieb R, Wittchen HU. · Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Germany. · Arch Gen Psychiatry. · Pubmed #17679635 links to  free full text

Abstract: CONTEXT: Epidemiological findings demonstrating an increased risk for individuals with social anxiety disorder (SAD) to develop depression have been challenged by discrepant findings from prospective longitudinal examinations in childhood and early adolescence. OBJECTIVES: To examine patterns of SAD incidence, the consistency of associations of SAD with subsequent depression, and distal and proximal predictors for subsequent depression. DESIGN: Face-to-face, 10-year prospective longitudinal and family study of up to 4 waves. The DSM-IV Munich-Composite International Diagnostic Interview was administered by clinically trained interviewers. SETTING: Community sample in Munich. PARTICIPANTS: Three thousand twenty-one individuals aged 14 to 24 years at baseline and 21 to 34 years at follow-up. MAIN OUTCOME MEASURES: Cumulative incidence of SAD and depression (major depressive episode or dysthymia). RESULTS: Cumulative incidence for SAD was 11.0%; for depression, 27.0%. Standardized person-years of incidence for SAD were highest for those aged 10 to 19 years (0.72%) and were low before (0.20%) and after (0.19%) that age range. Depression incidence was different, characterized by delayed and continued high rates. Social anxiety disorder was consistently associated with subsequent depression, independent of age at onset for SAD (relative risk range, 1.49-1.85, controlling for age and sex). Crude Cox regressions showed significant distal (eg, parental anxiety or depression, behavioral inhibition) and proximal SAD characteristics (eg, severity measures, persistence) as predictors. Most associations were attenuated in multiple models, leaving behavioral inhibition (hazard ratio, 1.30 [95% confidence interval, 1.04-1.62; P = .02]) and, less consistently, panic (hazard ratio, 1.85 [95% confidence interval, 1.08-3.18; P = .03]) as the remaining significant predictors. CONCLUSIONS: Social anxiety disorder is an early, adolescent-onset disorder related to a substantially and consistently increased risk for subsequent depression. The demonstration of proximal and particularly distal predictors for increased depression risks requires further exploration to identify their moderator or mediator role. Along with previous evidence that comorbid SAD is associated with a more malignant course and character of depression, these results call for targeted prevention with the aim of reducing the burden of SAD and its consequences.

Goodwin RD, Lieb R, Hoefler M, Pfister H, Bittner A, Beesdo K, Wittchen HU. · Max Planck Institute of Psychiatry, Kraepelinstr. 2, 80804 Munich, Germany. · Am J Psychiatry. · Pubmed #15569891 links to  free full text

Abstract: OBJECTIVE: 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. METHOD: 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. RESULTS: 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. CONCLUSIONS: 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.

Bittner A, Goodwin RD, Wittchen HU, Beesdo K, Höfler M, Lieb R. · Department of Clinical Psychology and Psychotherapy, Technical University Dresden, Dresden, Germany. · J Clin Psychiatry. · Pubmed #15163247 No free full text.

Abstract: OBJECTIVE: The goal of this study was to examine the associations between specific anxiety disorders and the risk of major depressive disorder and to explore the role of various clinical characteristics of anxiety disorders in these relationships using a prospective, longitudinal design. METHOD: The data are from a 4-year prospective, longitudinal community study, which included both baseline and follow-up survey data on 2548 adolescents and young adults aged 14 to 24 years at baseline. DSM-IV diagnoses were made using the Munich-Composite International Diagnostic Interview. RESULTS: The presence at baseline of any anxiety disorder (odds ratio [OR] = 2.2 [95% CI = 1.6 to 3.2]) and each of the anxiety disorders (specific phobia, OR = 1.9 [95% CI = 1.3 to 2.8]; social phobia, OR = 2.9 [95% CI = 1.7 to 4.8]; agoraphobia, OR = 3.1 [95% CI = 1.4 to 6.7]; panic disorder, OR = 3.4 [95% CI = 1.2 to 9.0]; generalized anxiety disorder, OR = 4.5 [95% CI = 1.9 to 10.3]) was associated with a significantly (p <.05) increased risk of first onset of major depressive disorder. These associations remained significant after we adjusted for mental disorders occurring prior to the onset of the anxiety disorder, with the exception of the panic disorder association. The following clinical characteristics of anxiety disorders were associated with a significantly (p <.05) increased risk of developing major depressive disorder: more than 1 anxiety disorder, severe impairment due to the anxiety disorder, and comorbid panic attacks. In the final model, which included all clinical characteristics, severe impairment remained the only clinical characteristic that was an independent predictor of the development of major depressive disorder (OR = 2.2 [95% CI = 1.0 to 4.4]). CONCLUSION: Our findings suggest that anxiety disorders are risk factors for the first onset of major depressive disorder. Although a number of clinical characteristics of anxiety disorders appear to play a role in the association between anxiety disorders and depression, severe impairment is the strongest predictor of major depressive disorder.

Wittchen HU, Kessler RC, Beesdo K, Krause P, Höfler M, Hoyer J. · Institute of Clinical Psychology and Psychotherapy, Technical University of Dresden, Germany. · J Clin Psychiatry. · Pubmed #12044105 No free full text.

Abstract: AIMS: Determine attitudes toward patients with generalized anxiety disorder (GAD) and major depressive episodes (MDE) in primary care; determine prevalence of GAD, MDE, and comorbid GAD/MDE among primary care patients; assess physician recognition of GAD and MDE; and describe primary care interventions for these patients. METHOD: 558 primary care physicians participated in a 1-day survey. Over 20,000 patients completed a diagnostic-screening questionnaire for GAD and MDE. Physician questionnaires included a standardized clinical appraisal of somatic and psychosocial symptoms and information on past and current treatments and a prestudy questionnaire assessing experience with and attitudes toward patients with GAD and MDE. RESULTS: 56.9% of physicians viewed GAD as a genuine mental disorder with clinical management problems and considerable patient burden; 27.4% treated GAD patients differently from MDE patients. 5.3% of patients met criteria for GAD, 6.0% for MDE, 3.8% for pure GAD, 4.4% for pure MDE, and 1.6% for comorbid GAD/MDE. Pure GAD and MDE were associated with disability, high utilization of health care resources, and suicidality, which were even higher with comorbid GAD/MDE. Physicians recognized clinically significant emotional problems in 72.5% of patients with pure GAD, 76.5% with pure MDE, and 85.4% with comorbid GAD/MDE. However, correct diagnosis was much lower (64.3% for MDE and 34.4% for GAD). Although the majority of patients with recognized GAD or MDE were treated, only a small minority with GAD were prescribed medications or referred to specialists. CONCLUSION: The high proportion of respondents with pure GAD is inconsistent with previous reports that GAD is usually comorbid with depression. GAD remains poorly recognized and inadequately treated. Improving the recognition and treatment of GAD in primary care patients is discussed relative to new treatments.

Wittchen HU, Hoyer J, Beesdo K, Krause P. · Institut für Klinische Psychologie und Psychotherapie der TU Dresden. · Fortschr Med Orig. · Pubmed #11935667 No free full text.

Abstract: The core findings of the GAD-P study (Generalized anxiety and depression in primary care) are summarized and measures to improve the quality of care of patients with generalized anxiety disorders are discussed. In addition to the identification of core research deficits the paper emphasizes the standard use of time-efficient diagnostic screening instruments, because urgently needed improved recognition and diagnosis is the prerequisite for appropriate treatment. Further the role of the media to combat stigma processes, as well as patient education materials to improve compliance and to enhance treatment outcome effects for this neglected disorder that frequently runs a chronic course are highlighted.

Hoyer I, Krause P, Höfler M, Beesdo K, Wittchen HU. · Institut für Klinische Psychologie und Psychotherapie der TU Dresden. · Fortschr Med Orig. · Pubmed #11935665 No free full text.

Abstract: BACKGROUND: Recognition rates for generalized anxiety disorder (GAS) and depression in primary care and its predictors are reported. METHODS: Based on the results of GAD-P study screening questionnaires, the investigators evaluated how many patients were correctly classified by primary care physicians a) as cases with mental disorders and b) as specific disorder cases. Socio-demographic and illness history variables of patients as well as features of physicians were analyzed as predictors of recognition by regression analyzes. RESULTS: Physicians recognized a mental disorder in more than two thirds of cases with GAS; rates were even higher in patients with comorbid anxiety and depression (85.4%). Recognition of the specific disorder was conspicuously worse in patients with GAS (34.4%) in comparison with patients with depression (64.3%). Only the variables of patients' demographic status and illness (e.g. higher age or, negatively, incident GAS) predicted recognition of a mental disorder. CONCLUSION: Generalized anxiety is often recognized as a mental disorder but seldom as the specific diagnosis of GAS. This is especially true for patients without a history of mental disorders (incident cases). Suggestions for a better recognition are discussed in the light of specific psychopharmacologic and psychotherapeutic treatment demands. The risks of chronicity of this disorder as well as the ascertained predictors of good recognition are also discussed.

Wittchen HU, Krause P, Hoyer J, Beesdo K, Jacobi F, Höfler M, Winter S. · Institut für Klinische Psychologie und Psychotherapie der TU Dresden, Max-Planck-Institut für Psychiatrie, München. · Fortschr Med Orig. · Pubmed #11935664 No free full text.

Abstract: AIM: The investigators evaluated the (target-day) point prevalence and correlates of generalized anxiety and depression in German primary care practices. METHOD: The study used a representative national sample of more than 500 primary care practices. On a target day, all primary care patients were examined by questionnaires (GAS-Q and DSQ). RESULTS: Conservatively estimated, 5.3% of all primary care patients met criteria for generalized anxiety disorder (GAD). Similar prevalence estimations were found for Major Depression. Only 30% of all GAD patients met criteria for depression cross-sectionally. Patients with GAD (whether comorbid with depression or not) were more frequently female, reported an onset of GAD mostly between ages of 25 and 45 years, had increased rates of disability and impairment in major social roles and high utilization rates of all health care resources. They also revealed a predominantly chronic course of illness over a period of several years and an increased suicide rate. The presence of physical illness increased rates of handicap/impairment days in the past month. Associated negative outcomes were found to be similar to those observed in depressive disorders. Patients with GAD reported significantly more frequently sleep, anxiety and depressive problems as primary reasons for contact. CONCLUSION: The GAD-P study highlights the significance of GAD in primary care as a condition that occurs at about the same frequency as major depression. Further, the relatively high proportion of pure GAD suggests that the frequency of depression-comorbidity of GAD has previously been overestimated.

Beesdo K, Krause P, Höfler M, Wittchen HU. · Institut für Klinische Psychologie und Psychotherapie, TU Dresden. · Fortschr Med Orig. · Pubmed #11935663 No free full text.

Abstract: This paper examines attitudes and characteristics of service providers for generalized anxiety disorders (GAD) in primary care. Based on a nationwide sample of 558 primary care doctors, the study found: 56.9% of all primary care doctors consider GAD to be an independent disorder, younger doctors more frequently than older ones. On average, they see on average at least 2.3 GAD definite patients a day. 27.4% indicate that they treat GAD differently than they treat depression. Doctors with frequent postgraduate courses on either depression or GAD reveal more favourable competence ratings with regard to recognition/diagnoses and therapy and refer such patients less frequently. Suggested treatments for GAD, however, are diffuse and by and large inconsistent with current research knowledge. Overall these findings suggest that the majority of primary care doctors view GAD as a prevalent independent disorder with special treatment needs.