Denise A. Chavira

Delivery of evidence-based treatment for multiple anxiety disorders in primary care: a randomized controlled trial.

CONTEXT Improving the quality of mental health care requires moving clinical interventions from controlled research settings into real-world practice settings. Although such advances have been made for depression, little work has been performed for anxiety disorders. OBJECTIVE To determine whether a flexible treatment-delivery model for multiple primary care anxiety disorders (panic, generalized anxiety, social anxiety, and posttraumatic stress disorders) would be better than usual care (UC). DESIGN, SETTING, AND PATIENTS A randomized controlled effectiveness trial of Coordinated Anxiety Learning and Management (CALM) compared with UC in 17 primary care clinics in 4 US cities. Between June 2006 and April 2008, 1004 patients with anxiety disorders (with or without major depression), aged 18 to 75 years, English- or Spanish-speaking, were enrolled and subsequently received treatment for 3 to 12 months. Blinded follow-up assessments at 6, 12, and 18 months after baseline were completed in October 2009. INTERVENTION CALM allowed choice of cognitive behavioral therapy (CBT), medication, or both; included real-time Web-based outcomes monitoring to optimize treatment decisions; and a computer-assisted program to optimize delivery of CBT by nonexpert care managers who also assisted primary care clinicians in promoting adherence and optimizing medications. MAIN OUTCOME MEASURES Twelve-item Brief Symptom Inventory (BSI-12) anxiety and somatic symptoms score. Secondary outcomes included proportion of responders (> or = 50% reduction from pretreatment BSI-12 score) and remitters (total BSI-12 score < 6). RESULTS A significantly greater improvement for CALM vs UC in global anxiety symptoms was found (BSI-12 group mean differences of -2.49 [95% confidence interval {CI}, -3.59 to -1.40], -2.63 [95% CI, -3.73 to -1.54], and -1.63 [95% CI, -2.73 to -0.53] at 6, 12, and 18 months, respectively). At 12 months, response and remission rates (CALM vs UC) were 63.66% (95% CI, 58.95%-68.37%) vs 44.68% (95% CI, 39.76%-49.59%), and 51.49% (95% CI, 46.60%-56.38%) vs 33.28% (95% CI, 28.62%-37.93%), with a number needed to treat of 5.27 (95% CI, 4.18-7.13) for response and 5.50 (95% CI, 4.32-7.55) for remission. CONCLUSION For patients with anxiety disorders treated in primary care clinics, CALM compared with UC resulted in greater improvement in anxiety symptoms, depression symptoms, functional disability, and quality of care during 18 months of follow-up. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00347269.

Validation of a Brief Measure of Anxiety-Related Severity and Impairment: The Overall Anxiety Severity and Impairment Scale (OASIS)

BACKGROUND The Overall Anxiety Severity and Impairment Scale (OASIS) is a 5-item self-report measure that can be used to assess severity and impairment associated with any anxiety disorder or multiple anxiety disorders. A prior investigation with a nonclinical sample supported the reliability and validity of the OASIS; however, to date it has not been validated for use in clinical samples. METHODS The present study assessed the psychometric properties of the OASIS in a large sample (N=1036) of primary care patients whose physicians referred them to an anxiety disorders treatment study. Latent structure, internal consistency, convergent/discriminant validity, and cut-score analyses were conducted. RESULTS Exploratory and confirmatory factor analyses supported a unidimensional structure. The five OASIS items displayed strong loadings on the single factor and had a high degree of internal consistency. OASIS scores demonstrated robust correlations with global and disorder-specific measures of anxiety, and weak correlations with measures of unrelated constructs. A cut-score of 8 correctly classified 87% of this sample as having an anxiety diagnosis or not. LIMITATIONS Convergent validity measures consisted solely of other self-report measures of anxiety. Future studies should evaluate the convergence of OASIS scores with clinician-rated and behavioral measures of anxiety severity. CONCLUSIONS Overall, this investigation suggests that the OASIS is a valid instrument for measurement of anxiety severity and impairment in clinical samples. Its brevity and applicability to a wide range of anxiety disorders enhance its utility as a screening and assessment tool.

Comorbidity of generalized social anxiety disorder and depression in a pediatric primary care sample

BACKGROUND Comorbidity between adult social anxiety disorder and major depression is extensive. Considerably less information about this relationship is available among youth. METHODS A randomly selected (from enrollees in a pediatric primary care clinic) sample of 190 families with children between the ages of 8 and 17 responded by mail to questionnaires assessing social anxiety, depression, and social functioning. Parents also completed a semi-structured telephone diagnostic interview about their child. RESULTS The generalized type of social anxiety disorder was highly comorbid with major depression, generalized anxiety disorder, specific phobias, and ADHD, while little comorbidity was present for the nongeneralized subtype of social anxiety disorder. Logistic regression analyses indicated that generalized social anxiety disorder was the only anxiety disorder associated with an increased likelihood of major depression (OR=5.1). In all cases, social anxiety disorder had a significantly earlier age of onset than major depression. LIMITATIONS This study relies on cross-sectional data and diagnoses are based on parent reporting of child behavior. CONCLUSIONS Generalized social anxiety disorder is strongly associated with depressive illness in youth. Screening and treatment approaches that consider both social anxiety and depressive symptoms are necessary. Early intervention to treat social anxiety disorder may prevent later depressive disorders.

Nature of anxiety comorbid with attention deficit hyperactivity disorder in children from a pediatric primary care setting.

The clinical characteristics of children with comorbid anxiety and attention deficit hyperactivity disorder (ADHD were examined. A sample of children from a pediatric primary care practice was assessed for anxiety disorders and ADHD. We defined four groups of children: (1) anxiety disorders only with no ADHD (n=54); (2) ADHD-only with no anxiety disorder (n=15); (3) neither ADHD nor an anxiety disorder (n=107); and (4) comorbid ADHD and anxiety disorder (n=14). Approximately 50% of children with ADHD had a comorbid anxiety disorder, and approximately 20% of children with an anxiety disorder had comorbid ADHD. The presence of comorbid ADHD and anxiety was associated with more attentional problems, school fears, and mood disorders and lower levels of social competence compared to children who had either ADHD-only or anxiety-only. Children with comorbid anxiety disorders and ADHD have more severe symptoms and are more impaired than children with either condition alone. Interventions need to be tailored to address the complexity of these comorbid conditions and their associated sequelae.

ADHD Prevalence and Association with Hoarding Behaviors in Childhood-Onset OCD

Background: It has been suggested that attention‐deficit hyperactivity disorder (ADHD) and obsessive–compulsive disorder (OCD), both neurodevelopmental disorders with onset in childhood, are highly comorbid, but previous studies examining ADHD and OCD comorbidity have been quite variable, partly because of inconsistency in excluding individuals with tic disorders. Similarly, ADHD has been postulated to be associated with hoarding although this potential relationship is largely methodologically unexplored. This study aimed to examine the prevalence of ADHD among individuals with childhood‐onset OCD but without comorbid tic disorders, as well as to examine the relationship between clinically significant hoarding behaviors (hoarding) and ADHD. Method: ADHD prevalence rates and the relationship between ADHD and hoarding were examined in 155 OCD‐affected individuals (114 probands and 41 relatives, age range 4–82 years) recruited for genetic studies and compared to pooled prevalence rates derived from previously published studies. Results: In total, 11.8% met criteria for definite ADHD, whereas an additional 8.6% had probable or definite ADHD (total=20.4%). In total, 41.9% of participants with ADHD also had hoarding compared to 29.2% of participants without ADHD. Hoarding was the only demographic or clinical variable independently associated with ADHD (odds ratio=9.54, P<0.0001). Conclusion: ADHD rates were elevated in this sample of individuals with childhood‐onset OCD compared to the general population rate of ADHD, and there was a strong association between ADHD and clinically significant hoarding behavior. This association is consistent with recent studies suggesting that individuals with hoarding may exhibit substantial executive functioning impairments and/or abnormalities, including attentional problems. Depression and Anxiety, 2010.

The scale of ethnic experience: development and psychometric properties.

The Scale of Ethnic Experience (SEE) is a new self-report instrument designed to measure multiple ethnicity-related cognitive constructs across ethnic groups. We present the development and psychometric properties here. We generated and refined an item pool using expert consultants and culturally diverse focus groups. We derived a final 32-item version of the SEE based on separate factor analyses of data from college students in 4 ethnic groups: African Americans, Caucasian Americans, Filipino Americans, and Mexican Americans. Four factors were consistent across the ethnic groups: Ethnic Identity, Perceived Discrimination, Mainstream Comfort, and Social Affiliation. We found evidence of test–retest reliability, internal consistency, and criterion and construct validity for all groups. Finally, we cross-validated the factor structure of the SEE in a culturally diverse sample. Results support the reliability and validity of the SEE as a multidimensional measure of ethnicity-related cognitive constructs that can be used across American ethnic groups.

A Common Genetic Variant in the Neurexin Superfamily Member CNTNAP2 Is Associated with Increased Risk for Selective Mutism and Social Anxiety-Related Traits

BACKGROUND Selective mutism (SM), considered an early-onset variant of social anxiety disorder, shares features of impaired social interaction and communication with autism spectrum disorders (ASDs) suggesting a possible shared pathophysiology. We examined association of a susceptibility gene, contactin-associated protein-like 2 (CNTNAP2), for ASDs and specific language impairment with SM and social anxiety-related traits. METHODS Sample 1 subjects were 99 nuclear families including 106 children with SM. Sample 2 subjects were young adults who completed measures of social interactional anxiety (n = 1028) and childhood behavioral inhibition (n = 920). Five single nucleotide polymorphisms in CNTNAP2 (including rs7794745 and rs2710102, previously associated with ASDs) were genotyped. RESULTS Analyses revealed nominal significance (p = .018) for association of SM with rs2710102, which, with rs6944808, was part of a common haplotype associated with SM (permutation p = .022). Adjusting for sex and ancestral proportion, each copy of the rs2710102*a risk allele in the young adults was associated with increased odds of being >1 SD above the mean on the Social Interactional Anxiety Scale (odds ratio = 1.33, p = .015) and Retrospective Self-Report of Inhibition (odds ratio = 1.40, p = .010). CONCLUSIONS Although association was found with rs2710102, the risk allele (a) for the traits studied here is the nonrisk allele for ASD and specific language impairment. These findings suggest a partially shared etiology between ASDs and SM and raise questions about which aspects of these syndromes are potentially influenced by CNTNAP2 and mechanism(s) by which these influences may be conveyed.

Ethnicity and four personality disorders.

The current study examined the relationship between ethnicity and DSM-IV personality disorders. The distribution of four personality disorders--borderline (BPD), schizotypal (STPD), avoidant (AVPD), and obsessive-compulsive (OCPD)--along with their criteria sets, were compared across three ethnic groups (Caucasians, African Americans, and Hispanics) using both a clinician-administered diagnostic interview and a self-report instrument. Participants were 554 patients drawn from the Collaborative Longitudinal Personality Disorders Study (CLPS) who comprised these three ethnic groups and met personality disorder criteria based on reliably administered semistructured interviews. Chi-square analyses revealed disproportionately higher rates of BPD in Hispanic than in Caucasian and African American participants and higher rates of STPD among African Americans when compared to Caucasians. Self-report data reflected similar patterns. The findings suggest that in treatment-seeking samples, Caucasians, Hispanics, and African Americans may present with different patterns of personality pathology. The factors contributing to these differences warrant further investigation.

The impact of medical comorbidity on mental health and functional health outcomes among children with anxiety disorders.

Objective: Medical comorbidity is common among children with anxiety disorders; however, little is known about the impact of such comorbidity on mental and functional health outcomes. Even less is known about these problems in high-risk samples of youth. Method: Participants in this study were youth with at least one anxiety disorder with a physical illness (N = 77) or without a physical illness (N = 73), as well as youth with at least one physical illness (but no anxiety disorder) (N = 438). These youth were recruited as part of the Patterns of Care study in which the original set of participants (N = 1715) were randomly sampled from one of five public sectors of care (e.g., juvenile justice, child welfare, mental health, alcohol and substance use services, school services for children with serious emotional disturbance) in San Diego County. Psychiatric diagnoses were assessed with a structured interview and three standardized measures were used to assess child health, emotional, and behavior functioning. Results: At least half of children with anxiety disorders had a comorbid physical illness. Allergies and asthma were the most common comorbid physical illnesses. Children with anxiety disorders who had a comorbid physical illness exhibited greater levels of emotional problems, more somatic complaints, and more functional impairment than anxious children without a physical illness as well as than children with physical illness alone. Parents of children in the comorbid group also reported greater caregiver strain than the other two groups. Conclusions: Children with anxiety disorders have high rates of chronic illnesses such as asthma and allergies. These children experience considerable impairment and likely have unique needs that may complicate usual care.

Functioning and disability levels in primary care out-patients with one or more anxiety disorders.

BACKGROUND Anxiety disorders are the most prevalent mental health disorders and are associated with substantial disability and reduced well-being. It is unknown whether the relative impact of different anxiety disorders is due to the anxiety disorder itself or to the co-occurrence with other anxiety disorders. This study compared the functional impact of combinations of anxiety disorders in primary care out-patients. METHOD A total of 1004 patients with panic disorder (PD), generalized anxiety disorder (GAD), social anxiety disorder (SAD) or post-traumatic stress disorder (PTSD) provided data on their mental and physical functioning, and disability. Multivariate regressions compared functional levels for patients with different numbers and combinations of disorders. RESULTS Of the patients, 42% had one anxiety disorder only, 38% two, 16% three and 3% all four. There were few relative differences in functioning among patients with only one anxiety disorder, although those with SAD were most restricted in their work, social and home activities and those with GAD were the least impaired. Functioning levels tended to deteriorate as co-morbidity increased. CONCLUSIONS Of the four anxiety disorders examined, GAD appears to be the least disabling, although they all have more in common than in distinction when it comes to functional impairment. A focus on unique effects of specific anxiety disorders is inadequate, as it fails to address the more pervasive impairment associated with multiple anxiety disorders, which is the modal presentation in primary care.