Anxiety Disorders: Katon W

Katon W, Roy-Byrne P. · No affiliation provided · Ann Intern Med. · Pubmed #17339624 links to  free full text

This publication has no abstract.

Roy-Byrne PP, Davidson KW, Kessler RC, Asmundson GJ, Goodwin RD, Kubzansky L, Lydiard RB, Massie MJ, Katon W, Laden SK, Stein MB. · University of Washington School of Medicine, Seattle, WA 98195, USA. · Gen Hosp Psychiatry. · Pubmed #18433653 No free full text.

Abstract: OBJECTIVE: To provide an overview of the role of anxiety disorders in medical illness. METHOD: The Anxiety Disorders Association of America held a multidisciplinary conference from which conference leaders and speakers reviewed presentations and discussions, considered literature on prevalence, comorbidity, etiology and treatment, and made recommendations for research. Irritable bowel syndrome (IBS), asthma, cardiovascular disease (CVD), cancer and chronic pain were reviewed. RESULTS: A substantial literature supports clinically important associations between psychiatric illness and chronic medical conditions. Most research focuses on depression, finding that depression can adversely affect self-care and increase the risk of incident medical illness, complications and mortality. Anxiety disorders are less well studied, but robust epidemiological and clinical evidence shows that anxiety disorders play an equally important role. Biological theories of the interactions between anxiety and IBS, CVD and chronic pain are presented. Available data suggest that anxiety disorders in medically ill patients should not be ignored and could be considered conjointly with depression when developing strategies for screening and intervention, particularly in primary care. CONCLUSIONS: Emerging data offer a strong argument for the role of anxiety in medical illness and suggest that anxiety disorders rival depression in terms of risk, comorbidity and outcome. Research programs designed to advance our understanding of the impact of anxiety disorders on medical illness are needed to develop evidence-based approaches to improving patient care.

Katon W, Lin EH, Kroenke K. · Department of Psychiatry, University of Washington School of Medicine, Seattle, WA 98195-6560, USA. · Gen Hosp Psychiatry. · Pubmed #17336664 No free full text.

Abstract: BACKGROUND: Primary care patients with anxiety and depression often describe multiple physical symptoms, but no systematic review has studied the effect of anxiety and depressive comorbidity in patients with chronic medical illnesses. METHODS: MEDLINE databases were searched from 1966 through 2006 using the combined search terms diabetes, coronary artery disease (CAD), congestive heart failure (CHF), asthma, COPD, osteoarthritis (OA), rheumatoid arthritis (RA), with depression, anxiety and symptoms. Cross-sectional and longitudinal studies with >100 patients were included as were all randomized controlled trials that measure the impact of improving anxiety and depressive symptoms on medical symptom outcomes. RESULTS: Thirty-one studies involving 16,922 patients met our inclusion criteria. Patients with chronic medical illness and comorbid depression or anxiety compared to those with chronic medical illness alone reported significantly higher numbers of medical symptoms when controlling for severity of medical disorder. Across the four categories of common medical disorders examined (diabetes, pulmonary disease, heart disease, arthritis), somatic symptoms were at least as strongly associated with depression and anxiety as were objective physiologic measures. Two treatment studies also showed that improvement in depression outcome was associated with decreased somatic symptoms without improvement in physiologic measures. CONCLUSIONS: Accurate diagnosis of comorbid depressive and anxiety disorders in patients with chronic medical illness is essential in understanding the cause and in optimizing the management of somatic symptom burden.

Roy-Byrne P, Stein MB, Russo J, Craske M, Katon W, Sullivan G, Sherbourne C. · Department of Psychiatry and Behavioral Science, University of Washington School of Medicine at Harborview Medical Center, WA 98104, USA. · Gen Hosp Psychiatry. · Pubmed #15993254 No free full text.

Abstract: OBJECTIVE: Although studies have suggested that comorbid medical illness can affect the outcome of patients with depression, little is known about whether medical illness comorbidity affects treatment outcome in patients with anxiety. METHOD: Primary care patients with panic disorder (n=232), participating in a randomized collaborative care intervention of CBT and pharmacology, were divided into those above (n=125) and below (n=107) the median for burden of chronic medical illness and assessed at 3, 6, 9 and 12 months. RESULTS: Subjects with a greater burden of medical illness were more psychiatrically ill at baseline, with greater anxiety symptom severity, greater disability and more psychiatric comorbidity. The intervention produced significant and similar increases in amount of evidence-based care, and reductions in clinical symptoms and disability that were comparable in the more and less medically ill groups. CONCLUSIONS: The comparable response of individuals with more severe medical illness suggests that CBT and pharmacotherapy for panic disorder work equally well regardless of medical illness comorbidity. However, the more severe psychiatric illness both at baseline and follow-up in these same individuals suggest that treatment programs may need to be extended in time to optimize treatment outcome.

Roy-Byrne PP, Craske MG, Stein MB, Sullivan G, Bystritsky A, Katon W, Golinelli D, Sherbourne CD. · Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine at Harborview Medical Center, Seattle, USA. · Arch Gen Psychiatry. · Pubmed #15753242 links to  free full text

Abstract: BACKGROUND: Panic disorder is a prevalent, often disabling condition among patients in the primary care setting. Although numerous studies have assessed the effectiveness of treatments for depression in primary care, few such studies have been conducted for panic disorder. OBJECTIVE: To implement and test the effectiveness of a combined pharmacotherapy and cognitive-behavioral intervention for panic disorder tailored to the primary care setting. DESIGN: Randomized, controlled study comparing intervention to treatment as usual. SETTING: Six primary care clinics associated with 3 university medical schools, serving an ethnically and socioeconomically diverse patient population. PARTICIPANTS: Two hundred thirty-two primary care patients meeting DSM-IV criteria for panic disorder. Comorbid mental and physical disorders were permitted, provided these did not contraindicate the treatment to be provided and were not acutely life threatening. INTERVENTION: Patients were randomized to receive either treatment as usual or an intervention consisting of a combination of up to 6 sessions (across 12 weeks) of cognitive-behavioral therapy (CBT) modified for the primary care setting, with up to 6 follow-up telephone contacts during the next 9 months, and algorithm-based pharmacotherapy provided by the primary care physician with guidance from a psychiatrist. Behavioral health specialists, the majority inexperienced in CBT for panic disorder, were trained to deliver the CBT and coordinated overall care, including pharmacotherapy. MAIN OUTCOMES MEASURES: Proportion of subjects remitted (no panic attacks in the past month, minimal anticipatory anxiety, and agoraphobia subscale score <10 on Fear Questionnaire) and responding (Anxiety Sensitivity Index score <20) and change over time in World Health Organization Disability Scale and short form 12 scores. RESULTS: The combined cognitive-behavioral and pharmacotherapeutic intervention resulted in sustained and gradually increasing improvement relative to treatment as usual, with significantly higher rates at all points of both the proportion of subjects remitted (3 months, 20% vs 12%; 12 months, 29% vs 16%) and responding (3 months, 46% vs 27%; 12 months, 63% vs 38%) and significantly greater improvements in World Health Organization Disability Scale (all points) and short form 12 mental health functioning (3 and 6 months) scores. These effects were obtained in spite of similar rates of delivery of guideline-concordant pharmacotherapy to the 2 groups. CONCLUSION: Delivery of evidence-based CBT and medication using the collaborative care model and a CBT-naive, midlevel behavioral health specialist is feasible and significantly more effective than usual care for primary care panic disorder.

Hegel MT, Unützer J, Tang L, Areán PA, Katon W, Noël PH, Williams JW, Lin EH. · Center for Health Services Research, UCLA Neuropsychiatric Institute, Los Angeles, CA, USA. · Am J Geriatr Psychiatry. · Pubmed #15653940 No free full text.

Abstract: OBJECTIVE: Comorbid anxiety disorders may result in worse depression treatment outcomes. The authors evaluated the effect of comorbid panic disorder and posttraumatic stress disorder (PTSD) on response to a collaborative-care intervention for late-life depression in primary care. METHODS: A total of 1,801 older adults with depression were randomized to a collaborative-care depression treatment model versus usual care and assessed at baseline, 3, 6, and 12 months, comparing differences among participants with comorbid panic disorder (N=262) and PTSD (N=191) and those without such comorbid anxiety disorders. RESULTS: At baseline, patients with comorbid anxiety reported higher levels of psychiatric and medical illness, greater functional impairment, and lower quality of life. Participants without comorbid anxiety who received collaborative care had early and lasting improvements in depression compared with those in usual care. Participants with comorbid panic disorder showed similar outcomes, whereas those with comorbid PTSD showed a more delayed response, requiring 12 months of intervention to show a significant effect. At 12 months, however, outcomes were comparable. Interactions of intervention status by comorbid PTSD or panic disorder were not statistically significant, suggesting that the collaborative-care model performed significantly better than usual care in depressed older adults both with and without comorbid anxiety. CONCLUSIONS: Collaborative care is more effective than usual care for depressed older adults with and without comorbid panic disorder and PTSD, although a sustained treatment response was slower to emerge for participants with PTSD. Intensive and prolonged follow-up may be needed for depressed older adults with comorbid PTSD.

Zatzick D, Roy-Byrne P, Russo J, Rivara F, Droesch R, Wagner A, Dunn C, Jurkovich G, Uehara E, Katon W. · Department of Psychiatry and Behavioral Sciences, the Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle 98104, USA. · Arch Gen Psychiatry. · Pubmed #15123495 links to  free full text

Abstract: CONTEXT: Although posttraumatic stress disorder (PTSD) and alcohol abuse frequently occur among acutely injured trauma survivors, few real-world interventions have targeted these disorders. OBJECTIVE: We tested the effectiveness of a multifaceted collaborative care (CC) intervention for PTSD and alcohol abuse. DESIGN: Randomized effectiveness trial. PARTICIPANTS: We recruited a population-based sample of 120 male and female injured surgical inpatients 18 or older at a level I trauma center. INTERVENTION: Patients were randomly assigned to the CC intervention (n = 59) or the usual care (UC) control condition (n = 61). The CC patients received stepped care that consisted of (1) continuous postinjury case management, (2) motivational interviews targeting alcohol abuse/dependence, and (3) evidence-based pharmacotherapy and/or cognitive behavioral therapy for patients with persistent PTSD at 3 months after injury. MAIN OUTCOME MEASURES: We used the PTSD symptomatic criteria (PTSD Checklist) at baseline and 1, 3, 6, and 12 months after injury, and alcohol abuse/dependence (Composite International Diagnostic Interview) at baseline and 6 and 12 months after injury. RESULTS: Random-coefficient regression analyses demonstrated that over time, CC patients were significantly less symptomatic compared with UC patients with regard to PTSD (P =.01) and alcohol abuse/dependence (P =.048). The CC group demonstrated no difference (-0.07%; 95% confidence interval [CI], -4.2% to 4.3%) in the adjusted rates of change in PTSD from baseline to 12 months, whereas the UC group had a 6% increase (95% CI, 3.1%-9.3%) during the year. The CC group showed on average a decrease in the rate of alcohol abuse/dependence of -24.2% (95% CI, -19.9% to -28.6%), whereas the UC group had on average a 12.9% increase (95% CI, 8.2%-17.7%) during the year. CONCLUSIONS: Early mental health care interventions can be feasibly and effectively delivered from trauma centers. Future investigations that refine routine acute care treatment procedures may improve the quality of mental health care for Americans injured in the wake of individual and mass trauma.

Roy-Byrne PP, Katon W, Cowley DS, Russo J. · Department of Psychiatry and Behavioral Sciences, Harborview Medical Center, 325 9th Ave, Box 359911, Seattle, WA 98104, USA. · Arch Gen Psychiatry. · Pubmed #11545671 links to  free full text

Abstract: BACKGROUND: Effectiveness studies have tested interventions to improve quality of care for depression in primary care, but none, to our knowledge, have been completed for panic disorder (PD) in this setting. This study sought to test the clinical effectiveness of PD pharmacotherapy embedded in a disease management framework of "collaborative care" (CC). METHODS: One hundred fifteen patients with PD from 3 primary care clinics were randomized to CC or "usual care" (UC). Patients in CC (n = 57) received educational videotapes and pamphlets; pharmacotherapy with the selective serotonin reuptake inhibitor paroxetine; 2 psychiatrist visits and 2 telephone calls in the first 8 weeks; and up to 5 telephone calls between 3 and 12 months' follow-up. Usual care patients (n = 58) were treated by their primary care physician. Telephone assessments of panic, anxiety sensitivity, depression, and disability variables were performed at 3, 6, 9, and 12 months' follow-up. Adequacy of pharmacotherapy was assessed with an algorithm based on a review of efficacy studies. RESULTS: Patients in CC were more likely to receive adequate (type, dose, duration) medication and more likely to adhere to this medication at 3 and 6 months. Random regression analyses showed that CC patients improved significantly more over time compared with UC patients on anxiety, depression, and disability measures, with the greatest effects at 3 and 6 months. CONCLUSIONS: Compared with UC, CC interventions significantly improved both quality of care and clinical and functional outcomes in primary care PD patients. Clinical differences were greatest in the first 6 months, corresponding to the greater quality of care and the greater intensity of intervention.

Zatzick DF, Roy-Byrne P, Russo JE, Rivara FP, Koike A, Jurkovich GJ, Katon W. · Department of Psychiatry and Behavioral Science, University of Washington School of Medicine, Box 359911, 98104, Seattle, WA, USA. · Gen Hosp Psychiatry. · Pubmed #11427243 No free full text.

Abstract: Posttraumatic behavioral and emotional disturbances occur frequently among physically injured hospitalized trauma survivors. This investigation was a pilot randomized effectiveness trial of a 4-month collaborative care intervention for injured motor vehicle crash and assault victims. As surgical inpatients, intervention subjects (N=16) were assigned to a trauma support specialist who provided counseling, consulted with surgical and primary care providers, and attempted postdischarge care coordination. Control subjects (N=18) received usual posttraumatic care. For all participants, posttraumatic stress disorder (PTSD) and depressive symptoms, episodic alcohol intoxication, and functional limitations were evaluated during the hospitalization and 1 and 4 months postinjury. Study logs and field notes revealed that over 75% of intervention activity occurred in the first month after the trauma. One-month post-trauma intervention subjects when compared to controls demonstrated statistically significant decreases in PTSD symptoms as well as a reduction in depressive symptoms. However, at the 4-month assessment, intervention subjects evidenced no significant improvements in PTSD and depressive symptoms, episodic alcohol intoxication, or functional limitations. Future larger scale trials of stepped collaborative care interventions for physically injured trauma survivors are recommended.

Roy-Byrne PP, Katon W, Cowley DS, Russo JE, Cohen E, Michelson E, Parrot T. · Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA. · Gen Hosp Psychiatry. · Pubmed #11072056 No free full text.

Abstract: Studies suggest that the recognition of depression by primary care physicians (PCPs) is most likely in more symptomatic and impaired patients. As part of a randomized effectiveness study in primary care patients with panic disorder, we examined the baseline characteristics of study patients who were recruited by waiting room screen procedure (n=69) versus patients who were referred to the study by their PCP (n=41). Patients referred by their physicians had a significantly higher frequency of panic attacks, more intense attacks, and more anticipatory anxiety on the Panic Disorder Severity Scale, while screen-identified patients were more medically ill and had worse physical functioning on the SP36. There were no differences in anxiety sensitivity, phobic avoidance, depression, other SF36 measures, disability, or medical service utilization. In conclusion, differences in referred versus screened patients are mostly specific for panic attack-related symptoms, consistent with the notion that patients with more prominent physical symptoms (i.e., panic attacks) are more often recognized and referred in busy clinical settings. The better medical status and physical functioning of referred patients may indicate greater physician recognition of panic in patients who appear less medically ill. However, the many clinical and functional similarities between these two patient samples suggests that symptomatic primary care patients with panic may not always be identified by their PCPs and argues for the value of population-based screening for panic in primary care.

Stein MB, Roy-Byrne PP, McQuaid JR, Laffaye C, Russo J, McCahill ME, Katon W, Craske M, Bystritsky A, Sherbourne CD. · Department of Psychiatry, University of California, San Diego, La Jolla 92093-0985, USA. · Psychosom Med. · Pubmed #10367617 links to  free full text

Abstract: OBJECTIVE: The purpose of this study was to determine the utility of a brief screening tool for panic disorder in the primary care setting. METHODS: A total of 1476 primary care outpatients in three primary care medical clinics on the West Coast of the United States were studied. Patients completed a brief self-report measure, the five-item Autonomic Nervous System Questionnaire (ANS), while in the waiting room. The presence of DSM-IV panic disorder was subsequently determined in groups of "screen-positive" and "screen-negative" subjects using the Composite International Diagnostic Interview. A subset of patients (N = 511) also completed the 21-item Beck Anxiety Inventory. Indices of diagnostic utility were calculated using receiving operating characteristic analyses to guide the selection of optimal cutoff levels. RESULTS: The two-question version of the ANS had excellent sensitivity (range = 0.94-1.00 across the three clinic sites) and negative predictive value (0.94-1.00) but low specificity (0.25-0.59) and positive predictive value (range 0.18-0.40). The three- and five-question versions of the ANS had only modestly improved specificity, and this was achieved at the cost of reduced sensitivity and increased respondent burden to complete the questionnaire. The 21-item Beck Anxiety Inventory had maximal clinical utility at a cutoff level of > or =20, but sensitivity was lower than desirable for a screening instrument (0.67). CONCLUSIONS: The two-question version of the ANS shows promise as a screening instrument for panic disorder in the primary care setting.

Ghesquiere A, Fan MY, Berliner L, Rivara FP, Jurkovich GJ, Russo J, Katon W, Zatzick DF. · Department of Psychiatry & Behavioral Sciences, Harborview Medical Center, University of Washington School of Medicine, Seattle, WA 98104-2499, USA. · J Trauma Stress. · Pubmed #18956447 No free full text.

Abstract: Few investigations have simultaneously assessed concordance between youth and parent ratings of posttraumatic stress disorder (PTSD) symptoms and functioning. Randomly sampled adolescent injury survivors ages 12-18 and their parents were assessed on the inpatient ward and again at 2, 5, and 12-months postinjury (N = 99). Adolescent PTSD symptoms and functioning were rated by both adolescents and parents. Parent PTSD was also assessed; 27% of parents endorsed symptoms consistent with a diagnosis of PTSD over the course of the year after adolescent injury. The PTSD positive parents demonstrated significantly greater discordance in ratings of adolescent PTSD symptoms, family cohesion, and mental health functioning. These findings suggest caution in clinical and policy applications of parental ratings of adolescent symptomatic and functional outcomes after injury.

Richardson LP, Russo JE, Lozano P, McCauley E, Katon W. · Department of Pediatrics, University of Washington School of Medicine, Box 354920, Seattle, WA 98115, USA. · Gen Hosp Psychiatry. · Pubmed #18774422 No free full text.

Abstract: OBJECTIVE: To assess whether youth with asthma and comorbid anxiety and depressive disorders have higher health care utilization and costs than youth with asthma alone. METHODS: A telephone survey was conducted among 767 adolescents (aged 11 to 17 years) with asthma. Diagnostic and Statistical Manual-4th Version (DSM-IV) anxiety and depressive disorders were assessed via the Diagnostic Interview Schedule for Children. Health care utilization and costs in the 12 months pre- and 6 months post-interview were obtained from computerized health plan records. Multivariate analyses were used to determine the impact of comorbid depression and anxiety on medical utilization and costs. RESULTS: Unadjusted analyses showed that compared to youth with asthma alone, youth with comorbid anxiety/depressive disorders had more primary care visits, emergency department visits, outpatient mental health specialty visits, other outpatient visits and pharmacy fills. After controlling for asthma severity and covariates, total health care costs were approximately 51% higher for youth with depression with or without an anxiety disorder but not for youth with an anxiety disorder alone. Most of the increase in health care costs was attributable to nonasthma and non-mental health-related increases in primary care and laboratory/radiology expenditures. CONCLUSIONS: Youth with asthma and comorbid depressive disorders have significantly higher health care utilization and costs. Most of these costs are due to increases in non-mental health and nonasthma expenses. Further study is warranted to evaluate whether improved mental health treatment and resulting increases in mental health costs would be balanced by savings in medical costs.

Zatzick DF, Jurkovich GJ, Fan MY, Grossman D, Russo J, Katon W, Rivara FP. · Department of Psychiatry and Behavioral Sciences, Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Campus Box 359896, 325 Ninth Ave, Seattle, WA 98104, USA. · Arch Pediatr Adolesc Med. · Pubmed #18606935 links to  free full text

Abstract: OBJECTIVE: To assess the association between early posttraumatic stress disorder (PTSD) and depressive symptoms and functional and quality-of-life outcomes among injured youth. DESIGN: Prospective cohort study. SETTING: Combined pediatric-adult level I trauma center. PARTICIPANTS: Randomly sampled adolescent injury survivors aged 12 to 18 years (N = 108) were recruited from surgical inpatient units. MAIN EXPOSURES: Posttraumatic stress disorder and depressive symptom levels in the days and weeks immediately following injury. We also collected relevant adolescent demographic, injury, and clinical characteristics. MAIN OUTCOME MEASURE: Multiple domains of adolescent functional impairment were assessed with the 87-item Child Health Questionnaire (CHQ-87) at 2, 5, and 12 months after injury. RESULTS: The investigation attained greater than 80% adolescent follow-up at each assessment after injury. Mixed-model regression was used to assess the association between baseline levels of PTSD and depressive symptoms and subsequent functional outcomes longitudinally. High baseline PTSD symptom levels were associated with significant impairments in CHQ-87 Role/Social Behavioral, Role/Social Physical, Bodily Pain, General Behavior, Mental Health, and General Health Perceptions subscales. High baseline depressive symptoms were associated with significant impairments in CHQ-87 Physical Function, Role/Social Emotional, Bodily Pain, Mental Health, Self-esteem, and Family Cohesion subscales. CONCLUSIONS: Early PTSD and depressive symptoms are associated with a broad spectrum of adolescent functional impairment during the year after physical injury. Coordinated investigative and policy efforts that refine mental health screening and intervention procedures have the potential to improve the functioning and well-being of injured youth treated in the acute care medical setting.

Katon W, Russo J, Richardson L, McCauley E, Lozano P. · Departments of Psychiatry, University of Washington School of Medicine, Seattle, Washington 98195-6560, USA. · Ambul Pediatr. · Pubmed #18501865 links to  free full text

Abstract: OBJECTIVE: Prior studies have shown a low rate of accurate identification by primary care physicians of mental health disorders in youth. This study tested the psychometric properties of 2 brief mental health screening questionnaires, the Mood and Feelings Questionnaire, short form, (MFQ-SF) and Childhood Anxiety Sensitivity Index (ASI), in a large sample of youth. METHODS: In a sample of 1375 youth aged 11 to 17 (779 with asthma, 596 randomly selected controls) enrolled in a health maintenance organization, the psychometric properties (optimum cutoffs on receiver operator characteristic (ROC) curves, sensitivity, specificity, positive and negative predictive values) of 2 brief anxiety and depression screens were compared with a gold standard-structured psychiatric interview. RESULTS: Both the MFQ-SF and ASI performed well on ROC analysis for screening youth for 1 or more Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) anxiety or depressive disorders. The MFQ-SF performed better on ROC analysis than the ASI for youth with major depression (area under the curve of 0.84 vs 0.77). For screening youth with anxiety disorders, ROC curves showed that both the MFQ-SF and ASI only performed in the fair range (area under the curve of 0.76). CONCLUSION: The MFQ-SF and ASI are 2 relatively brief questionnaires that performed well for screening youth for 1 or more DSM-IV anxiety or depressive disorders. The MFQ-SF performed better than the ASI for screening youth with major depression. Use of these instruments could increase the accuracy of identification of mental health disorders in youth by primary care physicians.

Katon W, Lozano P, Russo J, McCauley E, Richardson L, Bush T. · Department of Psychiatry, University of Washington School of Medicine, Seattle, Washington 98195-6560, USA. · J Adolesc Health. · Pubmed #17950165 links to  free full text

Abstract: PURPOSE: To determine the prevalence of anxiety and depressive disorders in youth with asthma compared with a control sample of youth and to determine the sociodemographic and clinical characteristics associated with having one or more anxiety/depressive disorders among youth with asthma. METHODS: A telephone interview was offered to all youth aged 11-17 years with asthma (N = 781) and a random sample of similar aged controls (N = 598) enrolled in a Health Maintenance Organization. The C-DISC-4.0 was used to diagnose anxiety and depressive disorders and reliable and valid questionnaires were used to assess severity of anxiety and depressive symptoms. Automated diagnostic, pharmacy and health use data were used to measure asthma treatment intensity, asthma severity and nonasthmatic medical comorbidity. One parent was interviewed to assess sociodemographic variables, child/adolescent psychiatric symptoms and to confirm the asthma diagnosis. RESULTS: In all, 16.3% of youth with asthma compared with 8.6% of youth without asthma met DSM-IV criteria for one or more anxiety and depressive disorders (OR = 1.92, 95% CI = 1.13-3.28). Independent factors associated with a significantly higher likelihood of meeting criteria for one or more anxiety or depressive disorders included female gender [OR = 1.96 (95% CI = 1.27, 3.03)], living in a single-parent household, [OR = 1.96 (95% CI = 1.26, 3.07)], more parent-reported externalizing behaviors [OR = 1.03 (95% CI = 1.01, 1.05)], more recent diagnosis of asthma [OR = 0.94 (95% CI = 0.89, 0.98)], and more impairment on the asthma physical health scale [OR = 0.95 (95% CI = 0.94, 0.96)]. CONCLUSIONS: Youth with asthma have an almost twofold higher prevalence of comorbid DSM-IV anxiety and depressive disorders compared with control youth. Clinical factors associated with meeting criteria for one or more anxiety and depressive included more recent asthma diagnosis, more impairment on the asthma physical health scale, and increased externalizing behaviors.

McCauley E, Katon W, Russo J, Richardson L, Lozano P. · Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA 98195, USA. · Gen Hosp Psychiatry. · Pubmed #17484938 No free full text.

Abstract: OBJECTIVE: This study aimed to assess the association of anxiety and depression with psychosocial and asthma-related functional impairment in a large-population-based sample of adolescents with asthma. METHOD: The sample consisted of 767 youths ages 11 to 17 with a documented diagnosis of, and active treatment for, asthma. Telephone interviews were completed with each youth and one parent to assess asthma-related symptoms and self-report of psychosocial and asthma-related functional status. Structured diagnostic interviews (Computerized Diagnostic Interview Schedule for Children) were administered to determine psychiatric diagnoses. Weighted multiple linear regression models were employed to identify variables that were independently and significantly associated with levels of functioning. RESULTS: One hundred twenty-five youths (16.2%) met DSM-IV criteria for one or more anxiety and depressive disorders in the last 12 months. After controlling for demographic variables, greater severity of self-reported depressive and anxiety symptoms and presence of one or more DSM-IV anxiety or depressive diagnosis were associated with psychosocial and asthma-related functional status. The mental health factors were more strongly associated with measures of asthma and psychological functional outcomes than the modified Health Plan Employer Data and Information Set asthma risk measure. CONCLUSIONS: Increased awareness of the need to assess and effectively treat psychiatric symptoms in youth with asthma may reduce the functional burden associated with asthma.

Bush T, Richardson L, Katon W, Russo J, Lozano P, McCauley E, Oliver M. · Center for Health Studies, Group Health Cooperative, Seattle, Washington 98101-1448, USA. · J Adolesc Health. · Pubmed #17448400 No free full text.

Abstract: PURPOSE: To evaluate the association between mental health indicators (including meeting criteria for one or more DSM-IV [Diagnostic and Statistical Manual of Mental Disorders-fourth edition] anxiety or depressive disorders) and susceptibility to smoking or current smoking among youth with asthma and to evaluate the impact of smoking on asthma symptoms and self-management. METHODS: We conducted telephone interviews with a population-based sample of 11- to 17-year-old youth and their parents (n = 769). Interview content included questions on smoking behaviors, asthma symptoms and treatment, externalizing behavior, and a structured psychiatric interview to assess DSM-IV anxiety and depressive disorders. RESULTS: Five percent of youth were smokers and 10.6% indicated that they were "susceptible to smoking." Smoking was more common among youth with mental health disorders. Anxiety/depressive disorders were present in 14.5% of nonsmokers, 19.8% of susceptible nonsmokers, and 37.8% of smokers. After controlling for important covariates, youth with more than one anxiety and depressive disorder were at over twofold increased risk for being a smoker. Similarly, for each one-point increase in externalizing disorder symptoms, youth had a 10% increase in likelihood of being a smoker and a 4% increase in risk for "susceptibility to smoking." Youth who were smokers reported more asthma symptoms, reduced functioning due to asthma, less use of controller medicines, and more use of rescue medications. CONCLUSIONS: Comorbid mental health disorders are associated with increased risk of smoking in youth with asthma. Smoking is associated with increased asthma symptom burden and decreased controller medication use. Interventions for youth with asthma should consider screening for and targeting these behavioral concerns.

Ludman E, Katon W, Russo J, Simon G, Von Korff M, Lin E, Ciechanowski P, Kinder L. · Center for Health Studies, Group Health Cooperative, Seattle, WA 98101, USA. · Gen Hosp Psychiatry. · Pubmed #17088162 No free full text.

Abstract: OBJECTIVE: The objective of this study was to examine the prevalence of panic episodes in persons with diabetes and the demographic, behavioral and clinical characteristics associated with panic symptoms in persons with diabetes. METHOD: A survey mailed to 4385 patients with diabetes assessed recent experiences of panic episodes, depression, diabetes symptoms, quality of life, disability, smoking status and body mass index. Automated medical record data were used to measure diabetes treatment, hemoglobin A1c (Hb(A1c)) levels, diabetes complications and medical comorbidity. RESULTS: One hundred ninety-three (4.4%) participants reported recent panic episodes, among whom 54.5% also met criteria for major depression. After accounting for the effects of depression, panic episodes were associated with higher Hb(A1c) values, increased diabetic complications and symptoms, greater disability and lower self-rated health and functioning. CONCLUSION: Panic is strongly associated with decrements in disease status and functioning. Since panic is often comorbid with depression, efforts to address psychological disorders among persons with diabetes may need to pay increased attention to anxiety and mood disorders.

Zatzick DF, Grossman DC, Russo J, Pynoos R, Berliner L, Jurkovich G, Sabin JA, Katon W, Ghesquiere A, McCauley E, Rivara FP. · Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA 98104, USA. · J Am Acad Child Adolesc Psychiatry. · Pubmed #17003664 No free full text.

Abstract: OBJECTIVE: Adolescents constitute a high-risk population for traumatic physical injury, yet few longitudinal investigations have assessed the development of posttraumatic stress disorder (PTSD) symptoms over time in representative samples. METHOD: Between July 2002 and August 2003, 108 randomly selected injured adolescent patients ages 12 to 18 and their parents were interviewed at baseline and again 2, 5, and 12 months postinjury. Initially, participants were screened for PTSD symptoms with the PTSD Reaction Index (PTSD-RI) and depressive symptoms with the Center for Epidemiologic Studies Depression Scale, as well as preinjury trauma. Random-coefficient regression was used to assess the association between baseline clinical, injury, and demographic characteristics and the development and maintenance of PTSD symptoms longitudinally. RESULTS: Between 19% and 32% of adolescents screened positive for PTSD (i.e., had PTSD-RI scores of > or =38) during the course of the 12 months after the injury. Higher initial adolescent PTSD and depressive symptoms, higher emergency department heart rate, greater objective event severity, and greater parental preinjury trauma were significant independent predictors of higher adolescent PTSD symptoms. CONCLUSIONS: For a substantive minority of hospitalized adolescents, high PTSD symptom levels persist during the 12 months after injury. Clinical characteristics readily identifiable after the acute injury predict the development of PTSD symptoms over time. Real-world clinical trials that test screening and intervention procedures for representative samples of at-risk youths are warranted.

Richardson LP, Lozano P, Russo J, McCauley E, Bush T, Katon W. · Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington 98115, USA. · Pediatrics. · Pubmed #16950996 links to  free full text

Abstract: OBJECTIVE: The purpose of this work was to examine the relationship between youth-reported asthma symptoms, presence of anxiety or depressive disorders, and objective measures of asthma severity among a population-based sample of youth with asthma. METHODS: We conducted a telephone survey of 767 youth with asthma (aged 11-17 years) enrolled in a staff model health maintenance organization. The Diagnostic Interview Schedule for Children was used to diagnose Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, anxiety and depressive disorders; the Child Health Status-Asthma questionnaire (modified) was used to assess asthma symptoms; and automated administrative data were used to measure asthma treatment intensity and severity. Analyses of covariance were performed to determine whether the number of anxiety and depressive symptoms was related to the number of asthma symptoms. Logistic regression analyses were used to evaluate the strength of association between individual symptoms of asthma and the presence of an anxiety or depressive disorder and objective measures of asthma severity. RESULTS: After adjusting for demographic characteristics, objective measures of asthma severity, medical comorbidity, and asthma treatment intensity, youth with > or = 1 anxiety or depressive disorder (N = 125) reported significantly more days of asthma symptoms over the previous 2 weeks than youth with no anxiety or depressive disorders. The overall number of reported asthma symptoms was significantly associated with the number of anxiety and depressive symptoms endorsed by youth. In logistic regression analyses, having an anxiety or depressive disorder was also strongly associated with each of the 6 asthma-specific symptoms, as well as the 5 related nonspecific somatic symptoms contained in the Child Health Status-Asthma questionnaire. CONCLUSIONS: The presence of an anxiety or depressive disorder is highly associated with increased asthma symptom burden for youth with asthma.

Katon W, Russo J, Sherbourne C, Stein MB, Craske M, Fan MY, Roy-Byrne P. · Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, 98195-6560, USA. · Psychol Med. · Pubmed #16403243 No free full text.

Abstract: BACKGROUND: Panic disorder is a prevalent, often disabling, disorder among primary-care patients, but there are large gaps in quality of treatment in primary care. This study describes the incremental cost-effectiveness of a combined cognitive behavioral therapy (CBT) and pharmacotherapy intervention for patients with panic disorder versus usual primary-care treatment. METHOD: This randomized control trial recruited 232 primary-care patients meeting DSM-IV criteria for panic disorder from March 2000 to March 2002 from six primary-care clinics from university-affiliated clinics at the University of Washington (Seattle) and University of California (Los Angeles and San Diego). Patients were randomly assigned to receive either treatment as usual or a combined CBT and pharmacotherapy intervention for panic disorder delivered in primary care by a mental health therapist. Intervention patients had up to six sessions of CBT modified for the primary-care setting in the first 12 weeks, and up to six telephone follow-ups over the next 9 months. The primary outcome variables were total out-patient costs, anxiety-free days (AFDs) and quality adjusted life-years (QALYs). RESULTS: Relative to usual care, intervention patients experienced 60.4 [95% confidence interval (CI) 42.9-77.9] more AFDs over a 12-month period. Total incremental out-patient costs were 492 US dollars higher (95% CI 236-747 US dollars ) in intervention versus usual care patients with a cost per additional AFD of 8.40 US dollars (95% CI 2.80-14.0 US dollars ) and a cost per QALY ranging from 14,158 US dollars (95% CI 6,791-21,496 US dollars ) to 24,776 US dollars (95% CI 11,885-37,618 US dollars ). The cost per QALY estimate is well within the range of other commonly accepted medical interventions such as statin use and treatment of hypertension. CONCLUSIONS: The combined CBT and pharmacotherapy intervention was associated with a robust clinical improvement compared to usual care with a moderate increase in ambulatory costs.

Stein MB, Roy-Byrne PP, Craske MG, Bystritsky A, Sullivan G, Pyne JM, Katon W, Sherbourne CD. · Department of Psychiatry, University of California San Diego, La Jolla, CA 92093-0985, USA. · Med Care. · Pubmed #16299426 No free full text.

Abstract: OBJECTIVE: The objective of this study was to examine the relative impact of anxiety disorders and major depression on functional status and health-related quality of life of primary care outpatients. METHOD: Four hundred eighty adult outpatients at an index visit to their primary care provider were classified by structured diagnostic interview as having anxiety disorders (panic disorder with or without agoraphobia, social phobia, and posttraumatic stress disorder; generalized anxiety disorder was also assessed in a subset) with or without major depression. Functional status, sick days from work, and health-related quality of life (including a preference-based measure) were assessed using standardized measures adjusting for the impact of comorbid medical illnesses. Relative impact of the various anxiety disorders and major depression on these indices was evaluated. RESULTS: In multivariate regression analyses simultaneously adjusting for age, sex, number of chronic medical conditions, education, and/or poverty status, each of major depression, panic disorder, posttraumatic stress disorder, and social phobia contributed independently and relatively equally to the prediction of disability and functional outcomes. Generalized anxiety disorder had relatively little impact on these indices when the effects of comorbid major depression were considered. Overall, anxiety disorders were associated with substantial decrements in preference-based health states. CONCLUSIONS: These observations demonstrate that the presence of each of 3 common anxiety disorders (ie, panic disorder, posttraumatic stress disorder, and social phobia)-over and above the impact of chronic physical illness, major depression, and other socioeconomic factors-contributes in an approximately additive fashion to the prediction of poor functioning, reduced health-related quality of life, and more sick days from work. Greater awareness of the deleterious impact of anxiety disorders in primary care is warranted.

Boiko P, Katon W, Guerra JC, Mazzoni S. · Department of Environmental Health, School of Public Health and Community Medicine, University of Washington, 4545 49th Avenue NE, Seattle, WA 98105, USA. · J Immigr Health. · Pubmed #15744475 No free full text.

Abstract: Debilitating mental illness is treatable if found. There is no validated self-administered mental illness evaluation tool for immigrant Hispanic farm workers with variable literacy levels. This study tested sensitivity and specificity of an audiotaped survey developed for low literacy levels compared with standard interview instruments. Subjects from 11 migrant camps completed a self-administered audiotaped survey in Spanish to diagnose major depression, substance abuse, panic and generalized anxiety, and domestic violence. Primary care clinics assisted in finding camps and provided follow-up treatment. For 154 men and 156 women, the audio tool was most sensitive for major depression and specific for anxiety disorder, alcohol abuse, and domestic violence. Seventy percent of those diagnosed with major depression received appropriate treatment. This study validated an inexpensive, self-administered audio tool to evaluate the mental health of immigrant Hispanic farm workers with a wide range of literacy levels.

Zatzick D, Russo J, Rivara F, Roy-Byrne P, Jurkovich G, Katon W. · Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA 98104-2499, USA. · Gen Hosp Psychiatry. · Pubmed #15694219 No free full text.

Abstract: Each year, approximately 2.5 million Americans require inpatient admissions after sustaining traumatic physical injuries. Few investigations have assessed the routine detection and treatment of acute care inpatients with high levels of posttraumatic distress. A representative sample of 101 hospitalized patients with acute injuries was screened for posttraumatic stress disorder (PTSD) and depressive symptoms, as well as substance intoxication. Patients' medical records were reviewed for documentation of psychiatric symptoms and diagnoses and the initiation of early evaluation and treatment. High levels of PTSD and/or depressive symptoms were present in over 50% of patients. Although providers frequently noted symptomatic distress, few symptomatic patients received formal diagnoses, evaluations or treatment. Patients who had positive substance toxicology screens on admission infrequently received in-depth evaluation or treatment. A substantial number of injured trauma survivors have high levels of symptomatic distress that are inconsistently evaluated and treated in the acute care medical setting. Mental health interventions appear to be feasibly and effectively delivered from trauma centers. Therefore, ongoing investigation and policy initiatives informing the detection and treatment of patients with psychiatric disturbances in acute care could substantially enhance the quality of mental health care for injured survivors of individual and mass trauma.