Neeltje M. Batelaan

The 7-year course of depression and anxiety in the general population

Rhebergen D, Batelaan NM, de Graaf R, Nolen WA, Spijker J, Beekman ATF, Penninx BWJH. The 7‐year course of depression and anxiety in the general population.

Thresholds for health and thresholds for illness: panic disorder versus subthreshold panic disorder.

BACKGROUND There is increasing evidence that subthreshold forms of psychopathology are both common and clinically relevant. To enable classification of these subthreshold forms of psychopathology, it may be useful to distinguish not only a threshold for illness but also for health. Our aim was to investigate this with regard to panic. METHOD Data were derived from the Netherlands Mental Health Survey and Incidence Study (NEMESIS), which is based on a large representative sample of the adult general population (18-65 years) of The Netherlands (n=7076). The Composite International Diagnostic Interview was used as a diagnostic instrument. By defining two thresholds, three groups were formed: panic disorder, subthreshold panic disorder and no-panic. These groups were compared using multinomial regression analysis, chi2 and analysis of variance. RESULTS The 12-month prevalence of panic disorder was 2.2% while that of subthreshold panic disorder was 1.9%. Symptom profiles and risk indicators associated with panic disorder and subthreshold panic disorder were similar, and half of the risk indicators were more strongly associated with panic disorder than with subthreshold panic disorder. Subthreshold panic disorder occupied an intermediate position between panic disorder and no-panic with regard to the number of symptoms, the percentage of subjects with co-morbidity, and functioning. CONCLUSIONS Subthreshold panic disorder is common, and seems clinically relevant, but is milder than panic disorder. These results thus support the use of a double threshold in panic. Further research should focus on the positioning of the thresholds, the course of subthreshold panic disorder and its treatment options.

Recurrence of anxiety disorders and its predictors

BACKGROUND The chronic course of anxiety disorders and its high burden of disease are partly due to the recurrence of anxiety disorders after remission. However, knowledge about recurrence rates and predictors of recurrence is scarce. This article reports on recurrence rates of anxiety disorders and investigates predictors of recurrence from a broad range of socio-demographic characteristics, illness-related and psychosocial putative predictors. METHODS Baseline and 2-year follow-up data were derived from the Netherlands Study of Depression and Anxiety (NESDA). Participants who had at least one lifetime anxiety disorder (panic disorder with or without agoraphobia, agoraphobia alone, social phobia or generalized anxiety disorder), but were remitted at baseline (N=429) were included. Recurrence of anxiety disorders during the 2-year follow-up period was assessed using the Composite International Diagnostic Interview, version 2.1. RESULTS Recurrence rates among pure and multiple anxiety disorders did not differ significantly and the overall recurrence rate of anxiety disorders was 23.5%. In those recurring, the incidence of a new anxiety disorder was common (32.7%). Disability and anxiety sensitivity remained predictive of recurrence of anxiety disorders in multivariable regression analysis. LIMITATIONS The included participants had more severe symptoms at baseline than the non-response group and lifetime anxiety diagnoses were assessed, retrospectively. CONCLUSIONS Recurrence of anxiety disorders is common and clinicians should be aware of the diagnostic instability within anxiety disorders. Disability and anxiety sensitivity are independent predictors of recurrence of anxiety disorders. Altering these predictors in regular cognitive behavioural therapy could contribute to the reduction of recurrence.

Anxiety and new onset of cardiovascular disease: critical review and meta-analysis

BACKGROUND Anxiety has been associated with new-onset cardiovascular disease (CVD), but the quality of this relationship is unclear. Only if anxiety is a causal, independent cardiovascular risk factor might it be a target for CVD prevention. AIMS To determine and examine the independent association and causality between anxiety and incident CVD. METHOD PubMed, EMBASE and PsycINFO databases were searched up to October 2013. A review of Hills criteria for causality and random effects meta-analysis were conducted of prospective, population-based studies examining anxiety and incident CVD in people free from CVD at baseline. RESULTS The meta-analysis comprised 37 papers (n = 1 565 699). The follow-up ranged from 1 to 24 years. Anxiety was associated with a 52% increased incidence of CVD (hazard ratio = 1.52, 95% CI 1.36-1.71). The risk seemed independent of traditional risk factors and depression. The evaluation of Hills criteria largely argued in favour of causality. CONCLUSIONS Anxiety may be of interest for CVD prevention. Future research should examine biological and behavioural underpinnings of the association in order to identify targets for intervention.

Depression, anxiety and 6-year risk of cardiovascular disease

OBJECTIVE Depression and anxiety are considered etiological factors in cardiovascular disease (CVD), though their relative contribution and differentiation by clinical characteristics have not been studied intensively. We examined 6-year associations between depressive and anxiety disorders, clinical characteristics and newly-developed CVD. METHODS DSM-IV diagnoses were established in 2510 CVD-free participants of the Netherlands Study of Depression and Anxiety. Data on subtype, severity, and psychoactive medication were collected. The 6-year incidence of CVD was assessed using Cox regression analyses adjusted for sociodemographic, health and lifestyle factors. RESULTS One-hundred-six subjects (4.2%) developed CVD. Having both current depressive and anxiety disorders (HR=2.86, 95%CI 1.49-5.49) or current depression only (HR=2.30; 95%CI 1.10-4.80) was significantly associated with increased CVD incidence, whereas current anxiety only (HR=1.48; 95%CI 0.74-2.96) and remitted disorders (HR=1.48; 95%CI 0.80-2.75) were not associated. Symptom severity was associated with increased CVD onset (e.g., Inventory of Depressive Symptomatology per SD increase: HR=1.51; 95%CI 1.25-1.83). Benzodiazepine use was associated with additional CVD risk (HR=1.95; 95%CI 1.16-3.31). CONCLUSIONS Current depressive (but not anxiety) disorder independently contributed to CVD in our sample of initially CVD-free participants. CVD incidence over 6years of follow-up was particularly increased in subjects with more symptoms, and in those using benzodiazepines.

Evidence-based pharmacotherapy of panic disorder: an update

The evidence-based pharmacotherapy of panic disorder continues to evolve. This paper reviews data on first-line pharmacotherapy, evidence for maintenance treatment, and management options for treatment-refractory patients. A Medline search of research on pharmacotherapy was undertaken, and a previous systematic review on the evidence-based pharmacotherapy of panic disorder was updated. Selective serotonin reuptake inhibitors remain a first-line pharmacotherapy of panic disorder, with the serotonin noradrenaline reuptake inhibitor venlafaxine also an acceptable early option. Temporary co-administration of benzodiazepines can be considered. Maintenance treatment reduces relapse rates, but further research to determine optimal duration is needed. For patients not responding to first-line agents several pharmacotherapy options are available, but there is a notable paucity of data on the optimal choice.

Clinical relevance of comorbidity in obsessive compulsive disorder: The Netherlands OCD Association study

BACKGROUND This study describes lifetime and current rates of comorbidity, its onset and its consequences in a large clinical sample of patients with obsessive compulsive disorder (OCD). A wide range of risk factors and clinical characteristics were also examined to determine whether pure OCD is different from OCD with current comorbidity. Finally, the temporal sequencing of the disorders was examined. METHOD Data were obtained from the Netherlands Obsessive Compulsive Disorder Association (NOCDA) study. A sample of 382 participants with current OCD (during the past month) was evaluated. RESULTS Current comorbidity occurred in 55% of patients with OCD, while 78% suffered from lifetime comorbidity. Comorbidity is associated with more severe OCD, anxiety and depressive symptoms and more negative consequences on daily life. Multiple comorbid disorders often precede OCD and influence both its course and severity. Childhood trauma and neuroticism are vulnerability factors for the development of multiple comorbid disorders in OCD. LIMITATIONS It should be noted that causal inferences about the association between risk factors and OCD are precluded since our results were based on cross-sectional data. CONCLUSION (Multiple) comorbidity in OCD is clinically relevant since it is associated with a specific pattern of vulnerability, with greater chronicity, with more severe OCD and more negative consequences on daily life. This indicates that the diagnosis and treatment of all comorbid disorders is clinically relevant, and clinicians should be especially aware of multiple disorders in cases of childhood trauma and high levels of neuroticism. Primary OCD has a different developmental and comorbidity pattern compared to secondary OCD.

Anxiety disorders and onset of cardiovascular disease: The differential impact of panic, phobias and worry

Anxiety has been linked to onset of cardiovascular disease. This study examines the differential impact of types of anxiety (panic, phobia and worry) on 3-year onset of non-fatal cardiovascular disease (CVD). By investigating anxiety disorders as opposed to anxiety symptoms and by using a reliable diagnostic instrument to assess anxiety, limitations of previous studies are considered. 5149 persons at risk for CVD were interviewed using the Composite International Diagnostic Interview. The panic-type included panic disorder and panic attacks; the phobic-type included agoraphobia and social phobia, and the worry-type included generalized anxiety disorder. CVD was self-reported and required treatment or monitoring by a doctor. Analyses were adjusted for sociodemographics, behavioral variables, and comorbid somatic and psychiatric disorders. During follow-up, 62 persons (1.2%) developed CVD. Baseline generalized anxiety disorder was strongly associated with onset of CVD (adjusted OR: 3.39). Further research should replicate findings and focus on biological underpinnings of this association.

Disability in anxiety disorders

BACKGROUND This study compares disability levels between different anxiety disorders and healthy controls. We further investigate the role of anxiety arousal and avoidance behaviour in disability, and whether differences in these symptom patterns contribute to disability differences between anxiety disorders. METHODS Data were from 1826 subjects from the Netherlands Study of Depression and Anxiety (NESDA). The Composite Interview Diagnostic Instrument was used to diagnose anxiety disorders. The World Health Organization Disability Assessment Schedule II was used to measure disability in six domains (cognition, mobility, selfcare, social interaction, life activities, participation). Severity of anxiety arousal and avoidance behaviour symptoms was measured using the Beck Anxiety Inventory and the Fear Questionnaire. RESULTS All anxiety disorders were associated with higher disability. Disability was generally highest in multiple anxiety disorder (e.g. mean disability in cognition=33.7) and social anxiety disorder (mean=32.7), followed by generalized anxiety disorder (mean=27.2) and panic disorder with agoraphobia (mean=26.3), and lowest in panic disorder without agoraphobia (mean=22.1). Anxiety arousal was more associated with disability in life activities (B=8.5, p<0.001) and participation (B=9.9, p<0.001) whereas avoidance behaviour was more associated with disability in cognition (B=7.4, p<0.001) and social interaction (B=8.6, p<0.001). Different disability patterns between anxiety disorders were not completely explained by anxiety arousal and avoidance behaviour. LIMITATIONS The cross-sectional study design precludes any causal interpretations. In order to examine the full range of comorbidity among anxiety, a greater range of anxiety disorders would have been preferable. CONCLUSIONS Disability is highest in social anxiety disorder and multiple anxiety disorder. Both anxiety arousal and avoidance behaviour are associated with higher disability levels but do not fully explain the differences across anxiety disorders.

Who is MADD? Mixed anxiety depressive disorder in the general population

BACKGROUND Diagnostic criteria for (subthreshold) mixed anxiety depression (MADD) were proposed in DSM-IV. Yet the usefulness of this classification is questioned. We therefore assessed the prevalence of MADD, and investigated whether MADD adds to separate classifications of pure subthreshold depression and anxiety. METHOD Data of the Netherlands Mental Health and Incidence Study were used. RESULTS The 12-month prevalence of MADD was 0.6%. Between the three subthreshold categories few differences were found with regard to socio-demographic variables, care utilisation and functioning. Course in MADD seems more favourable and MADD is not a stable diagnosis over time. LIMITATIONS The MADD criteria used in the present study differed slightly from the proposed criteria in DSM-IV and sample sizes were small. CONCLUSIONS Given these results, MADD is not a relevant diagnosis in terms of prevalence and consequences when classified according to the currently proposed criteria.