Anxiety Disorders: Kroenke K

Kroenke K. · No affiliation provided · Gen Hosp Psychiatry. · Pubmed #10880706 No free full text.

This publication has no abstract.

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.

Kroenke K, Rosmalen JG. · Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA. · Med Clin North Am. · Pubmed #16843765 No free full text.

Abstract: Half of all outpatient encounters are precipitated by physical complaints, of which one third to one half are medically unexplained symptoms, and 20% to 25% are chronic or recurrent. Many of the patients suffer from one or more discrete symptoms, whereas others have functional somatic syndromes. Individual symptoms and somatic syndromes are associated with impaired quality of life, increased health care use, and diminished patient and provider satisfaction. This article provides an overview of (1) unexplained symptoms and somatization; (2) limitations of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition in classifying somatoform disorders; (3) predictors of psychiatric comorbidity in patients who have physical symptoms; and (4) measurement and management of symptoms.

Jackson JL, O'Malley PG, Kroenke K. · Department of Medicine, Uniformed Services University of Health Sciences, Bethesda, MD 20814, USA. · CNS Spectr. · Pubmed #16575378 links to  free full text

Abstract: Somatic symptoms are common in primary care and clinicians often prescribe antidepressants as adjunctive therapy. There are many possible reasons why this may work, including treating comorbid depression or anxiety, inhibition of ascending pain pathways, inhibition of prefrontal cortical areas that are responsible for "attention" to noxious stimuli, and the direct effects of the medications on the syndrome. There are good theoretical reasons why antidepressants with balanced norepinephrine and serotonin effects may be more effective than those that act predominantly on one pathway, though head-to-head comparisons are lacking. For the 11 painful syndromes review in this article, cognitive-behavioral therapy is most consistently demonstrated to be effective, with various antidepressants having more or less randomized controlled data supporting or refuting effectiveness. This article reviews the randomized controlled trial data for the use of antidepressant and cognitive-behavior therapy for 11 somatic syndromes: irritable bowel syndrome, chronic back pain, headache, fibromyalgia, chronic fatigue syndrome, tinnitus, menopausal symptoms, chronic facial pain, noncardiac chest pain, interstitial cystitis, and chronic pelvic pain. For some syndromes, the data for or against treatment effectiveness is relatively robust, for many, however, the data, one way or the other is scanty.

Clauw DJ, Engel CC, Aronowitz R, Jones E, Kipen HM, Kroenke K, Ratzan S, Sharpe M, Wessely S. · Department of Medicine, University of Michigan School of Medicine, USA. · J Occup Environ Med. · Pubmed #14534444 No free full text.

Abstract: Twelve years of concern regarding a possible "Gulf War syndrome" has now given way to societal concerns of a "World Trade Center syndrome" and efforts to prevent unexplained symptoms following the most recent war in Iraq. These events serve to remind us that unexplained symptoms frequently occur after war and are likely after terrorist attacks. An important social priority is to recognize, define, prevent, and care for individuals with unexplained symptoms after war and related events (eg, terrorism, natural or industrial disasters). An international, multidisciplinary, and multiinstitutional consensus project was completed to summarize current knowledge on unexplained symptoms after terrorism and war.

Kroenke K. · Department of Medicine and Regenstrief Institute for Health Care, Indiana University School of Medicine, Indianapolis, USA. · Int J Methods Psychiatr Res. · Pubmed #12830308 No free full text.

Abstract: Somatic symptoms are the leading cause of outpatient medical visits and also the predominant reason why patients with common mental disorders such as depression and anxiety initially present in primary care. At least 33% of somatic symptoms are medically unexplained, and these symptoms are chronic or recurrent in 20% to 25% of patients. Unexplained or multiple somatic symptoms are strongly associated with coexisting depressive and anxiety disorders. Other predictors of psychiatric co-morbidity include recent stress, lower self-rated health and higher somatic symptom severity, as well as high healthcare utilization, difficult patient encounters as perceived by the physician, and chronic medical disorders. Antidepressants and cognitive-behavioural therapy are both effective for treatment of somatic symptoms, as well as for functional somatic syndromes such as irritable bowel syndrome, fibromyalgia, pain disorders, and chronic headache. A stepped care approach is described, which consists of three phases that may be useful in the care of patients with somatic symptoms.

Poleshuck EL, Bair MJ, Kroenke K, Watts A, Tu X, Giles DE. · University of Rochester Medical Center, 300 Crittenden Blvd., Rochester, NY 14642, USA. · Psychosomatics. · Pubmed #19567767 No free full text.

Abstract: BACKGROUND: The prevalence and consequences of comorbid pain and depression in gynecology patients are understudied. OBJECTIVE: The purpose of the study was to determine the prevalence of pain, depression, and their co-occurrence among gynecology patients, and to examine how pain and depression are associated with additional comorbid mental disorders. METHOD: Self-reported pain, depressive symptoms, other mental-disorder symptoms, functional status, interpersonal distress, and abuse were assessed in 1,647 gynecology patients by use of the Patient Health Questionnaire and the Medical Outcomes Study (SF-20). RESULTS: Moderate-to-severe pain was reported by 29% of patients; depression, by 21%; with both present in 10.3%. Comorbid pain and depression was associated with anxiety, suicidal or death ideation, functional impairment, interpersonal distress, and physical or sexual abuse. DISCUSSION: Innovative approaches are needed to assess and treat gynecology patients with comorbid pain and depression, given the degree of overlap between them.

Kroenke K, Krebs EE, Bair MJ. · Division of General Internal Medicine and Geriatrics, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA. · Gen Hosp Psychiatry. · Pubmed #19410099 No free full text.

Abstract: OBJECTIVES: Chronic pain is one of the most prevalent, costly and disabling conditions in both clinical practice and the workplace, yet often remains inadequately treated. Moreover, chronic pain commonly co-occurs with depression, anxiety and somatoform disorders, and adversely affects response of these conditions to psychiatric treatments. This article provides an evidence-based approach to the pharmacotherapy of chronic pain. METHODS: This narrative review is derived largely from meta-analyses and systematic reviews published since 2005. For a few medications, findings from multiple recent trials are synthesized if a systematic review had not yet been published. Classes of medications are first reviewed, followed by an overview of four common pain disorders: neuropathic pain, low back pain, fibromyalgia and osteoarthritis. RESULTS: A stepped care approach based upon existing evidence includes (1) simple analgesics (acetaminophen or nonsteroidal anti-inflammatory drugs); (2) tricyclic antidepressants (if neuropathic, back or fibromyalgia pain) or tramadol; (3) gabapentin, duloxetine or pregabalin if neuropathic pain; (4) cyclobenzaprine, pregabalin, duloxetine, or milnacipran for fibromyalgia; (5) topical analgesics (capsaicin, lidocaine, salicylates) if localized neuropathic or arthritic pain; and (6) opioids. Disease-specific recommendations for neuropathic, low back, fibromyalgia and osteoarthritis pain are reviewed. CONCLUSIONS: A number of medications have proven effective in chronic pain disorders and their use individually or in combination should improve the management of chronic pain.

Strine TW, Dhingra SS, Kroenke K, Qayad M, Ribble JL, Okoro CA, Balluz LS, Dube SR, Lando J, Mokdad AH. · Division of Adult and Community Health, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Mailstop K-66, Atlanta, GA 30341, USA. · Int J Public Health. · Pubmed #19214381 No free full text.

Abstract: OBJECTIVE: To examine the prevalence of depression and anxiety in the United States by state and MMSA. METHOD: The 2006 Behavioral Risk Factor Surveillance System collected depression and anxiety data on 74 metropolitan and micropolitan statistical areas (MMSAs) and 41 states/territories (n = 217,379). RESULTS: The national prevalence of current depression, lifetime diagnosis of depression, and lifetime diagnosis of anxiety is 8.7 %, 15.7 %, and 11.3 %, respectively. There is considerable variability within and across states for all three measures. The most striking within-state difference in current depression between MMSAs is in California: 5.4 % and 11.3 %. CONCLUSION: This variation in mental health at the state and MMSA levels calls for development and implementation of local programs.

Engel CC, Oxman T, Yamamoto C, Gould D, Barry S, Stewart P, Kroenke K, Williams JW, Dietrich AJ. · Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA. · Mil Med. · Pubmed #19160608 No free full text.

Abstract: BACKGROUND: U.S. military ground forces report high rates of war-related traumatic stressors, posttraumatic stress disorder (PTSD), and depression following deployment in support of recent armed conflicts in Iraq and Afghanistan. Affected service members do not receive needed mental health services in most cases, and they frequently report stigma and significant structural barriers to mental health services. Improvements in primary care may help address these issues, and evidence supports the effectiveness of a systems-level collaborative care approach. OBJECTIVE: To test the feasibility of systems-level collaborative care for PTSD and depression in military primary care. We named our collaborative care model "Re-Engineering Systems of Primary Care for PTSD and Depression in the Military" (RESPECT-Mil). METHODS: Key elements of RESPECT-Mil care include universal primary care screening for PTSD and depression, brief standardized primary care diagnostic assessment for those who screen positive, and use of a nurse "care facilitator" to ensure continuity of care for those with unmet depression and PTSD treatment needs. The care facilitator assists primary care providers with follow-up, symptom monitoring, and treatment adjustment and enhances the primary care interface with specialty mental health services. We report assessments of feasibility of RESPECT-Mil implementation in a busy primary care clinic supporting Army units undergoing frequent Iraq, Afghanistan, and other deployments. RESULTS: Thirty primary care providers (family physicians, physician assistants, and nurse practitioners) were trained in the model and in the care of depression and PTSD. The clinic screened 4,159 primary care active duty patient visits: 404 screens (9.7%) were positive for depression, PTSD, or both. Sixty-nine patients participated in collaborative care for 6 weeks or longer, and the majority of these patients experienced clinically important improvement in PTSD and depression. Even although RESPECT-Mil participation was voluntary for providers, only one refused participation. No serious adverse events were noted. CONCLUSIONS: Collaborative care is an evidence-based approach to improving the quality of primary care treatment of anxiety and depression. Our version of collaborative care for PTSD and depression, RESPECT-Mil, is feasible, safe, and acceptable to military primary care providers and patients, and participating patients frequently showed clinical improvements. Efforts to implement and evaluate collaborative care approaches for mental disorders in populations at high risk for psychiatric complications of military service are warranted.

Strine TW, Mokdad AH, Balluz LS, Gonzalez O, Crider R, Berry JT, Kroenke K. · Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Behavioral Surveillance Branch, 4770 Buford Highway, N.E., Mailstop K-66, Atlanta, GA 30341, USA. · Psychiatr Serv. · Pubmed #19033164 No free full text.

Abstract: OBJECTIVE: This study examined the unadjusted and adjusted prevalence estimates of depression and anxiety at the state level and examined the odds ratios of depression and anxiety for selected risk behaviors, obesity, and chronic diseases. METHODS: The 2006 Behavioral Risk Factor Surveillance Survey, a random-digit-dialed telephone survey, collected depression and anxiety data from 217,379 participants in 38 states, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands. Current depressive symptoms were assessed with the standardized and validated eight-item Patient Health Questionnaire, and lifetime diagnosis of depression and anxiety was assessed by two additional questions (one question for each diagnosis). RESULTS: The overall prevalence of current depressive symptoms was 8.7% (range by state and territory, 5.3%-13.7%); of a lifetime diagnosis of depression, 15.7% (range, 6.8%-21.3%); and of a lifetime diagnosis of anxiety, 11.3% (range, 5.4%-17.2%). After sociodemographic characteristics, adverse health behaviors, and chronic illnesses were adjusted for, cardiovascular disease, diabetes, asthma, smoking, and obesity were all significantly associated with current depressive symptoms, a lifetime diagnosis of anxiety, and a lifetime diagnosis of depression. Physically inactive adults were significantly more likely than those who were physically active to have current depressive symptoms or a lifetime diagnosis of depression, whereas those who drank heavily were significantly more likely than those who did not to have current depressive symptoms or a lifetime diagnosis of anxiety. CONCLUSIONS: Depression and anxiety were strongly associated with common chronic medical disorders and adverse health behaviors. Examination of mental health should therefore be an integral component of overall health care.

Bair MJ, Wu J, Damush TM, Sutherland JM, Kroenke K. · VA Health Services Research and Development, Center of Excellence on Implementation of Evidenced-Based Practices, Roudebush VA Medical Center, Indianapolis, Indiana 46202, USA. · Psychosom Med. · Pubmed #18799425 No free full text.

Abstract: OBJECTIVE: To assess the relationship between depression and anxiety comorbidity on pain intensity, pain-related disability, and health-related quality of life (HRQL). METHODS: Analysis of baseline data from the Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) study. All patients (n = 500) had chronic pain (>or=3-month duration) of the low back, hip, or knee. Patients with depression were oversampled for the clinical trial component of SCAMP and thus represented 50% of the study population. Patients were categorized according to pain comorbid with depression, anxiety, or both. We used analysis of variance and multivariate analysis of variance models to assess the relationships between independent and dependent variables. RESULTS: Participants had a mean age of 59 years; they were 55% women, 56% White, and 40% Black. Fifty-four percent (n = 271) reported pain only, 20% (n = 98) had pain and depression, 3% (n = 15) had pain and anxiety, and 23% (n = 116) had pain, depression, and anxiety. Patients with pain and both depression and anxiety experienced the greatest pain severity (p < .0001) and pain-related disability (p < .0001). Psychiatric comorbidity was strongly associated with disability days in the past 3 months (p < .0001), with 18.1 days reported by patients with pain only, 32.2 days by those with pain and anxiety, 38.0 days by those with pain and depression, and 42.6 days in those with all three conditions. We found a similar pattern of poorer HRQL (p < .0001) in those with pain, depression, and anxiety. CONCLUSIONS: The added morbidity of depression and anxiety with chronic pain is strongly associated with more severe pain, greater disability, and poorer HRQL.

Mussell M, Kroenke K, Spitzer RL, Williams JB, Herzog W, Löwe B. · Department of Psychosomatic and General Internal Medicine, University of Heidelberg, Heidelberg, Germany. · J Psychosom Res. · Pubmed #18501261 No free full text.

Abstract: OBJECTIVE: Results from general population studies suggest a relationship between gastrointestinal (GI) symptoms, depression, and anxiety. However, no primary care study has investigated this issue. This study investigates the prevalence of GI symptoms in primary care and their association with depression and anxiety. METHOD: Within a cross-sectional survey, 2091 consecutive patients from 15 primary care clinics in the United States completed self-report questionnaires regarding GI symptoms [15-item Patient Health Questionnaire (PHQ-15)], anxiety [seven-item Generalized Anxiety Disorder Scale (GAD-7)], and depression (PHQ-8). Of those, 965 randomly selected patients additionally underwent a criterion standard diagnostic telephone interview (Structured Clinical Interview for DSM-IV) for the most common anxiety disorders. RESULTS: A total of 380 [18% (95% CI, 16.3% to 19.3%)] patients reported to be substantially bothered by at least one GI symptom in the previous 4 weeks. The prevalence of severe levels of depression (PHQ-8 score > or =15) was nearly fivefold in patients with GI symptoms compared to patients without GI symptoms (19.1% vs. 3.9%; P<.001), and the prevalence of severe levels of anxiety (GAD-7 score > or =15) was nearly fourfold in patients with GI symptoms compared to patients without GI symptoms (19.4% vs. 5.6%; P<.001). Similarly, with each additional GI symptom, the odds for an interview-based diagnosis of specific anxiety disorders increased significantly: For example, compared to patients with no GI symptom, the odds ratio (OR) (95% CI) for generalized anxiety disorder in patients with one GI symptom was 3.7 (2.0 to 6.9); in patients with two GI symptoms, OR=6.5 (3.1 to 13.6); and in patients with three GI symptoms, OR=7.2 (2.7 to 18.8). CONCLUSION: GI symptoms are associated significantly with depression and anxiety in primary care. It is suggested to screen as a routine for anxiety and depression in patients with GI symptoms and, if indicated, to initiate specific treatment.

Jackson JL, Kroenke K. · Department of Medicine, Uniformed Services University of the Health Sciences, USA. · Psychosom Med. · Pubmed #18434494 No free full text.

Abstract: BACKGROUND: To determine the prevalence, impact, and prognosis of multisomatoform disorder (MSD) over a 5-year period in a primary care population. Although somatization is prevalent in primary care, patients rarely meet Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria for somatization disorder. MSD, defined as > or = 3 bothersome, medically unexplained somatic symptoms, has been proposed as a more inclusive disorder. METHODS: A total of 500 adults presenting to a primary care clinic with a physical symptom were screened with the Primary Care Evaluation of Mental Disorders. Symptom count was assessed with the Patient Health Questionnaire 15-item somatic symptom scale. Additional baseline measures included functional status and symptom characteristics. Follow-up surveys at 2 weeks, 3 months, and 5 years assessed functioning, symptom outcome, psychiatric diagnoses, and patient satisfaction. Physician surveys assessed encounter difficulty. Utilization was obtained from our health database. RESULTS: MSD had an 8% prevalence at both baseline (n = 38/500) and at 5 years (n = 33/387). MSD persisted in 21% of those with MSD at baseline, and developed in 7% of those without MSD at baseline. MSD at baseline was a predictor of MSD at 5 years (relative risk (RR) = 2.7, 1.5-5.1). MSD patients were more likely to have comorbid mental disorders (RR = 1.5, 1.1-2.3) and be rated "difficult" by their clinicians (p = .02). They also reported worse functional status at all time points assessed (p < .001 for all), were less likely to experience symptom improvement, and had higher utilization rates (34.1 versus 23.1 visits; p = .006). CONCLUSIONS: MSD identifies a group of patients who are less likely to experience symptom improvement and have significant functional impairment and higher utilization rates.

Löwe B, Spitzer RL, Williams JB, Mussell M, Schellberg D, Kroenke K. · Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf and Hamburg-Eilbek (Schön Clinics), Germany. · Gen Hosp Psychiatry. · Pubmed #18433651 No free full text.

Abstract: OBJECTIVE: To determine diagnostic overlap of depression, anxiety and somatization as well as their unique and overlapping contribution to functional impairment. METHOD: Two thousand ninety-one consecutive primary care clinic patients participated in a multicenter cross-sectional survey in 15 primary care clinics in the United States (participation rate, 92%). Depression, anxiety, somatization and functional impairment were assessed using validated scales from the Patient Health Questionnaire (PHQ) (PHQ-8, eight-item depression module; GAD-7, seven-item Generalized Anxiety Disorder Scale; and PHQ-15, 15-item somatic symptom scale) and the Short-Form General Health Survey (SF-20). Multiple linear regression analyses were used to investigate unique and overlapping associations of depression, anxiety and somatization with functional impairment. RESULTS: In over 50% of cases, comorbidities existed between depression, anxiety and somatization. The contribution of the commonalities of depression, anxiety and somatization to functional impairment substantially exceeded the contribution of their independent parts. Nevertheless, depression, anxiety and somatization did have important and individual effects (i.e., separate from their overlap effect) on certain areas of functional impairment. CONCLUSIONS: Given the large syndrome overlap, a potential consideration for future diagnostic classification would be to describe basic diagnostic criteria for a single overarching disorder and to optionally code additional diagnostic features that allow a more detailed classification into specific depressive, anxiety and somatoform subtypes.

Jackson JL, Passamonti M, Kroenke K. · Department of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA. · Psychosom Med. · Pubmed #17401055 links to  free full text

Abstract: OBJECTIVE: To assess 5-year mental disorder recognition rates and determine the natural history of mental disorders in primary care. METHODS: A prospective cohort of adults presenting to a primary care walk-in clinic with a physical symptom were evaluated at baseline (n = 500) and at 5 years (n = 387) for mental disorders with the Primary Care Evaluation of Mental Disorders (PRIME-MD). Additional measures included functional status (Medical Outcomes Study SF-6; MOS-SF6), Patient Health Questionnaire-15, Satisfaction (Rand-9), unmet expectations, and symptom outcome. Patients self-reported whether their disorder was diagnosed or treated at the 5-year follow-up. RESULTS: At baseline, 29% of patients had a mental disorder (major depression: 8.4%, minor depression 10.4%, Panic disorder 1.4%, generalized anxiety disorder 2%, anxiety not otherwise specified (NOS) 11.4%); of these patients, 26% had more than one mental disorder. Over 5 years, 33% were recognized. Threshold disorders were more likely to be recognized (major depression 56%, panic 100%, generalized anxiety disorder 88%) than subthreshold disorders (minor depression 20%, anxiety NOS 25%). Correlates of recognition included having a threshold or multiple disorders; recognition was associated with greater likelihood of persistence. Most patients with subthreshold disorders at baseline had no disorder at 5 years and few progressed to threshold disorders (minor to major depression 12%, anxiety NOS to generalized anxiety or panic 8%). CONCLUSIONS: Mental disorders are common and their recognition and treatment remain low. Subthreshold disorders have a better prognosis. Patients with threshold or multiple disorders, worse functioning or persistence of their disorder were more likely to be diagnosed.

Kroenke K, Spitzer RL, Williams JB, Monahan PO, Löwe B. · Regenstrief Institute for Health Care and Indiana University, Indianapolis, Indiana 46202, USA. · Ann Intern Med. · Pubmed #17339617 links to  free full text

Abstract: BACKGROUND: Anxiety, although as common as depression, has received less attention and is often undetected and undertreated. OBJECTIVE: To determine the current prevalence, impairment, and comorbidity of anxiety disorders in primary care and to evaluate a brief measure for detecting these disorders. DESIGN: Criterion-standard study performed between November 2004 and June 2005. SETTING: 15 U.S. primary care clinics. PARTICIPANTS: 965 randomly sampled patients from consecutive clinic patients who completed a self-report questionnaire and agreed to a follow-up telephone interview. MEASUREMENTS: 7-item anxiety measure (Generalized Anxiety Disorder [GAD]-7 scale) in the clinic, followed by a telephone-administered, structured psychiatric interview by a mental health professional who was blinded to the GAD-7 results. Functional status (Medical Outcomes Study Short Form-20), depressive and somatic symptoms, and self-reported disability days and physician visits were also assessed. RESULTS: Of the 965 patients, 19.5% (95% CI, 17.0% to 22.1%) had at least 1 anxiety disorder, 8.6% (CI, 6.9% to 10.6%) had posttraumatic stress disorder, 7.6% (CI, 5.9% to 9.4%) had a generalized anxiety disorder, 6.8% (CI, 5.3% to 8.6%) had a panic disorder, and 6.2% (CI, 4.7% to 7.9%) had a social anxiety disorder. Each disorder was associated with substantial impairment that increased significantly (P < 0.001) as the number of anxiety disorders increased. Many patients (41%) with an anxiety disorder reported no current treatment. Receiver-operating characteristic curve analysis showed that both the GAD-7 scale and its 2 core items (GAD-2) performed well (area under the curve, 0.80 to 0.91) as screening tools for all 4 anxiety disorders. LIMITATION: The study included a nonrandom sample of selected primary care practices. CONCLUSIONS: Anxiety disorders are prevalent, disabling, and often untreated in primary care. A 2-item screening test may enhance detection.

Ang DC, Peloso PM, Woolson RF, Kroenke K, Doebbeling BN. · Division of Rheumatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA. · Clin J Pain. · Pubmed #16788343 No free full text.

Abstract: OBJECTIVE: We sought to determine the predictors of incident chronic widespread pain (CWP), specifically, the effect of preexisting symptoms, stress, and psychosocial factors in the subsequent development of CWP among veterans from the first Gulf War (GW). METHODS: We conducted a structured telephone survey (baseline) of military personnel originally from Iowa who were either eligible for or deployed to Operation Desert Shield/Desert Storm, approximately 5 years postconflict. We conducted a follow-up, clinical, in-person study of those who met a priori-defined outcomes of symptoms of cognitive dysfunction, depression, or CWP, and also a sample of those who did not meet any of the outcomes of interest. RESULTS: A total of 370 of 602 evaluated GW veterans were free of CWP 5 years postconflict. At follow-up, 69 (19%) of these had developed CWP. A positive family history of medically unexplained persistent symptoms [odds ratio (OR)=4.8 (2.3, 13.2)] was strongly associated with CWP. At baseline, individuals who reported preexisting symptoms of bronchitis [OR=4.9 (1.9, 12.3)] and cognitive dysfunction [OR=2.1 (1.1, 4.2)] were more likely to develop CWP. Alcohol use [OR=0.2 (0.1, 0.7)] was protective against CWP. Rather than combat-related exposure per se, the perception of stress at the time of the GW [OR=1.6 (1.1, 2.3)] correlated with CWP. DISCUSSION: Among the GW veterans evaluated longitudinally in this study, family history, predeployment symptoms, and the level of perceived stress during the GW were associated with subsequent development of CWP.

Spitzer RL, Kroenke K, Williams JB, Löwe B. · Biometrics Research Department, New York State Psychiatric Institute, New York, NY 10032, USA. · Arch Intern Med. · Pubmed #16717171 links to  free full text

Abstract: BACKGROUND: Generalized anxiety disorder (GAD) is one of the most common mental disorders; however, there is no brief clinical measure for assessing GAD. The objective of this study was to develop a brief self-report scale to identify probable cases of GAD and evaluate its reliability and validity. METHODS: A criterion-standard study was performed in 15 primary care clinics in the United States from November 2004 through June 2005. Of a total of 2740 adult patients completing a study questionnaire, 965 patients had a telephone interview with a mental health professional within 1 week. For criterion and construct validity, GAD self-report scale diagnoses were compared with independent diagnoses made by mental health professionals; functional status measures; disability days; and health care use. RESULTS: A 7-item anxiety scale (GAD-7) had good reliability, as well as criterion, construct, factorial, and procedural validity. A cut point was identified that optimized sensitivity (89%) and specificity (82%). Increasing scores on the scale were strongly associated with multiple domains of functional impairment (all 6 Medical Outcomes Study Short-Form General Health Survey scales and disability days). Although GAD and depression symptoms frequently co-occurred, factor analysis confirmed them as distinct dimensions. Moreover, GAD and depression symptoms had differing but independent effects on functional impairment and disability. There was good agreement between self-report and interviewer-administered versions of the scale. CONCLUSION: The GAD-7 is a valid and efficient tool for screening for GAD and assessing its severity in clinical practice and research.

Kroenke K, Messina N, Benattia I, Graepel J, Musgnung J. · Indiana University School of Medicine, Indianapolis, IN, USA. · J Clin Psychiatry. · Pubmed #16426091 No free full text.

Abstract: OBJECTIVE: This pilot study explored the efficacy and tolerability of extended-release venlafaxine (venlafaxine ER) in anxious and/or depressed patients with multisomatoform disorder (MSD). METHOD: This 12-week, multicenter, randomized, double-blind study evaluated adult primary care outpatients with MSD and comorbid major depressive disorder, generalized anxiety disorder, or social anxiety disorder (DSM-IV criteria). The intent-to-treat population included 112 patients (venlafaxine ER, N = 55; placebo, N = 57). The primary efficacy variable was the change in the 15-item Patient Health Questionnaire (PHQ-15) somatic symptom severity score. Secondary outcomes included the Hamilton Rating Scale for Depression (HAM-D-17) and for Anxiety (HAM-A), Clinical Global Impressions-Severity of Illness (CGI-S) and -Improvement (CGI-I) scales, McGill Quality of Life Questionnaire Physical Symptoms Scale (MQOL-PS), and Medical Outcomes Study Short-Form 36-Item questionnaire (MOS SF-36). Data were collected from April 2003 to December 2003. RESULTS: The decline by week 12 in PHQ-15 scores was significant (p < .0001) in both groups; however, the difference between the venlafaxine ER and placebo groups (-8.3 vs. -6.6, respectively) was not (p = .097). Improvement was greater with venlafaxine ER than placebo on the PHQ-15 pain subscale (p = .03), SF-36 bodily pain scale (26.1 vs. 14.5, p = .03), MQOL-PS (-11.7 vs. -6.0, p = .02), HAM-A psychic anxiety subscale (p = .02), SF-36 mental component summary (p = .03), time to response (54 vs. 71 days, p = .01), and CGI-I scale (p = .009). Venlafaxine ER was generally well tolerated. CONCLUSION: These results suggest that venlafaxine ER may be effective in relieving some types of somatic physical symptoms, particularly pain, in patients with depression and/or anxiety disorders.

Rollman BL, Belnap BH, Mazumdar S, Zhu F, Kroenke K, Schulberg HC, Katherine Shear M. · Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. · J Gen Intern Med. · Pubmed #16050857 links to  free full text

Abstract: BACKGROUND: Panic disorder (PD) and generalized anxiety disorder (GAD) are often unrecognized by primary care physicians (PCPs). The Primary Care Evaluation of Mental Disorders (PRIME-MD) has been used as a case-finding instrument for depression. Yet, little is known on its usefulness as a case-finding tool for anxiety disorders within the context of a clinical trial. OBJECTIVE: To examine the: (1) completion rate of the PRIME-MD by patients approached to enroll in a treatment study for PD and GAD; (2) distribution of anxiety diagnoses generated; (3) severity of PD and GAD episodes thus identified; and (4) level of PCPs' agreement with these diagnoses. DESIGN: Cross-sectional interview. PATIENTS: Individuals aged 18 to 64 who presented for care at 4 primary care practices. MEASUREMENTS: The PRIME-MD, Structured Interview Guide for the Hamilton Anxiety Rating Scale (SIGH-A), and the Panic Disorder Severity Scale (PDSS). RESULTS: Of the 6,700 patients who completed the PRIME-MD Patient Questionnaire (PQ), 2,926 (44%) screened positive for an anxiety disorder, and 1,216 (42%) met preliminary study eligibility and consented to the PRIME-MD Anxiety Module. Of these, 619 (51%) had either GAD (308), PD (94), or both (217) disorders. Later, 329 completed a telephone interview. Of these, 59% with GAD and 68% with PD reported moderate or greater levels of anxiety symptoms on the SIGH-A and PDSS, respectively, and PCPs agreed with the PRIME-MD diagnosis for 98% of these patients. CONCLUSIONS: The PRIME-MD can efficiently screen patients for PD and GAD. Although patients thus identified endorse a wide range of anxiety symptoms, PCPs often agree with the diagnosis.

Löwe B, Gräfe K, Ufer C, Kroenke K, Grünig E, Herzog W, Borst MM. · Department of General Internal and Psychosomatic Medicine, University of Heidelberg, Medical Center, Im Neuenheimer Feld 410, D-69120 Heidelberg, Germany. · Psychosom Med. · Pubmed #15564346 links to  free full text

Abstract: OBJECTIVE: This is the first study that investigates the prevalence and actual treatment of anxiety, depression, and other mental disorders in patients with pulmonary hypertension (PH). The prevalence of mental disorders in patients with PH was compared with parallel groups of primary care patients and patients with inflammatory rheumatic diseases, and the relationship between functional status and prevalence of mental disorders was determined. METHODS: The patient group with PH (70.1% female; mean age, 47.8 +/- 12.7 years) and the two comparison groups, which were matched by age and sex, consisted of 164 patients each. Patients completed self-administered instruments, including the Patient Health Questionnaire for the diagnosis of mental disorders. New York Heart Association (NYHA) functional class was assessed in all patients with PH. RESULTS: Thirty-five percent of the patients with PH suffered from mental disorders, with the most common being major depressive disorder (15.9%) and panic disorder (10.4%). Both panic disorder and panic attacks were significantly more prevalent in patients with PH than in either patients with inflammatory rheumatic diseases or primary care patients. The prevalence of mental disorders in patients with PH increased significantly with functional impairment, from 17.7% (NYHA class I) to 61.9% (NYHA class IV). Only 24.1% of the patients with PH with mental disorders were receiving psychopharmacological or psychotherapeutic treatment. CONCLUSIONS: Anxiety and depression are frequent in patients with PH and increase as the severity of disease progresses. Given the fact that safe and efficacious treatments of mental disorders are available, greater importance should be attached to the diagnosis and treatment of these conditions in patients with PH.

Culpepper L, Davidson JR, Dietrich AJ, Goodman WK, Kroenke K, Schwenk TL. · Department of Family Medicine, Boston Medical Center, MA, USA. · J Clin Psychiatry. · Pubmed #15291649 No free full text.

This publication has no abstract.

Löwe B, Spitzer RL, Gräfe K, Kroenke K, Quenter A, Zipfel S, Buchholz C, Witte S, Herzog W. · Department of General Internal and Psychosomatic Medicine, University of Heidelberg, Medical Hospital, Bergheimer Strasse 58, D-69115, Heidelberg, Germany. · J Affect Disord. · Pubmed #14706723 No free full text.

Abstract: BACKGROUND: The aim of this study was to compare the validity of the Hospital Anxiety and Depression Scale (HADS), the WHO (five) Well Being Index (WBI-5), the Patient Health Questionnaire (PHQ), and physicians' recognition of depressive disorders, and to recommend specific cut-off points for clinical decision making. METHODS: A total of 501 outpatients completed each of the three depression screening questionnaires and received the Structured Clinical Interview for DSM-IV (SCID) as the criterion standard. In addition, treating physicians were asked to give their psychiatric diagnoses. Criterion validity and Receiver Operating Characteristics (ROC) were determined. Areas under the curves (AUCs) were compared statistically. RESULTS: All depression scales showed excellent internal consistencies (Cronbach's alpha: 0.85-0.90). For 'major depressive disorder', the operating characteristics of the PHQ were significantly superior to both the HADS and the WBI-5. For 'any depressive disorder', the PHQ showed again the best operating characteristics but the overall difference did not reach statistical significance at the 5% level. Cut-off points that can be recommended for the screening of 'major depressive disorder' had sensitivities of 98% (PHQ), 94% (WBI-5), and 85% (HADS). Corresponding specificities were 80% (PHQ), 78% (WBI-5), and 76% (HADS). In contrast, physicians' recognition of 'major depressive disorder' was poor (sensitivity, 40%; specificity, 87%). LIMITATIONS: Our sample may not be representative of medical outpatients, but sensitivity and specificity are independent of disorder prevalence. CONCLUSIONS: All three questionnaires performed well in depression screening, but significant differences in criterion validity existed. These results may be helpful in the selection of questionnaires and cut-off points.

Löwe B, Gräfe K, Kroenke K, Zipfel S, Quenter A, Wild B, Fiehn C, Herzog W. · Department of General Internal and Psychosomatic Medicine, University of Heidelberg, Medical Hospital, Heidelberg, Germany. · Psychosom Med. · Pubmed #14508018 links to  free full text

Abstract: OBJECTIVE: Psychiatric comorbidity in medical outpatients is associated with personal suffering and reduced psychosocial functioning. Simple clinical indicators are needed to improve recognition and treatment of psychiatric comorbidity. This study aimed to identify predictors of psychiatric comorbidity for diagnostic use in busy medical settings and to describe their criterion validity. METHODS: The SCID was adopted as the independent criterion standard for the presence of a psychiatric comorbidity in 357 patients (68% female; mean age, 43 years) of six internal medicine outpatient clinics and 12 general practices. Potential indicators of psychiatric comorbidity were investigated by means of patient and physician questionnaires. Logistic regression analyses were used to identify independent predictors of psychiatric comorbidity, and their operating characteristics were determined. RESULTS: Of 18 indicators, the four most important predictors of psychiatric comorbidity were identified: a screening question for nervousness, anxiety, or worries (odds ratio, 11.9; p <.001), a screening question for depressed mood (odds ratio, 8.8; p <.001), the self-report of three or more bothersome physical symptoms (odds ratio, 3.2; p =.001), and feeling distressed by partner difficulties (odds ratio, 2.7; p =.006). The combined assessment of the four predictors resulted in positive predictive values as high as 100%, negative predictive values as high as 91%, sensitivities as high as 86%, and specificities as high as 100%. CONCLUSIONS: The identification of mental disorders in medical outpatients could be substantially improved by the knowledge and use of four easily accessible predictors. When the presence of one or more of these predictors can be confirmed, it is suggested that the patient undergo further evaluation to determine more precisely the presence and specific type of psychiatric disorder being identified.