Comorbidity generalized anxiety disorder

Kessler RC, DuPont RL, Berglund P, Wittchen HU (1999) Impairment in piue and comorbid generalized anxiety disorder and major depression at 12 months in two national surveys. Am J Psychiatry 156 1915-1923... 

Despite these rather discouraging efficacy data, it appears that a minority of patients do experience some improvement in OC symptoms with combined SRI-buspirone treatment [Pigott et al. 1992a). It is the clinical impression of one of the authors [W. K. G.) that buspirone addition may occasionally be helpful in reducing OC symptoms in OCD patients with comorbid generalized anxiety disorder. Controlled studies with sufficient numbers of OCD patients with comorbid generalized anxiety disorder would be required to test the validity of these observations. 

Goodnick PJ, Puig A, DeVane CL, et al. Mirtazapine in major depression with comorbid generalized anxiety disorder. J Clin Psychiatry 1999 60 446-448. 

The anxiety disorders are a case in point. They comprise a range of conditions contiguous with the affective disorders and the stress responses (Table 4.1). Much overlap and comorbidity exist. Furthermore, definitions and diagnostic criteria have changed substantially over the years. For example, generalized anxiety disorder is a rare condition in its pure form, but a common condition if comorbid phobic and depressive disorders are accepted. 

Out-patient treatment is substantially cheaper than in-patient management and is generally as effective (Lowman, 1991). A French study on patients with generalized anxiety disorder estimated costs per patient over 3 months to he US 423 for hospitalization, 335 for out-patient services and 43 for medications (Souetre et al, 1994). Comorbid conditions (mostly alcoholism and depression) doubled these direct health-care costs. Over three-quarters of all patients were taking anxiolytic medication. 

The usually accepted prevalences for generalized anxiety disorder (GAD) are around 1.6% for current, 3.1% for 1 year and 5.1% lifetime (Roy-Byrne, 1996). The condition is twice as common in women as in men (Pigott, 1999). A small minority (10%) have GAD alone, and about the same proportion suffer from mixed anxiety and depression. Morbidity is high. About a half of those with uncomplicated GAD seek professional help, but two-thirds of those with comorbid GAD do so. Up to a half take medication at some point. The condition may coexist with other anxiety disorders such as phobias, with affective disorders, or with medical conditions such as unexplained chest pain and irritable bowel syndrome. 

With a lifetime prevalence of 28.8%, anxiety disorders collectively represent the most prevalent Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR)2 class of disorders, with specific phobia (12.5%) and social anxiety disorder (12.1%) being the most common.3 Recent reports from the National Comorbidity Survey Revised (NCS-R) estimate the lifetime and 1-year prevalence of generalized anxiety disorder (GAD) for those 18 years of age and older to be 5.7% and 3.1%, respectively.3,4 Rates for panic disorder (PD) are slightly lower, with an estimated 12-month prevalence of 2.7% and lifetime prevalence of 4.7%. 

In another study, Lieb et al. (2002) confirmed the cross-aggregation of anxiety disorders and depression by showing that offspring of parents with depressive disorders have not only an elevated risk for depressive disorders but also for anxiety disorders. Considering parental comorbidity, the crossaggregation between parental depression and general anxiety disorder in off-... 

Wittchen HU, Zhao S, Kessler RC, Eaton WW (1994) DSM-III-R generalized anxiety disorder in the National Comorbidity Survey. Arch Gen Psychiatry 51 355-364 Wittchen HU, Nelson CB, Lachner G (1998a) Prevalence of mental disorders and psychosocial impairments in adolescents and young adults. Psychol Med 28 109-126 Wittchen HU, Reed V, Kessler RC (1998b) The relationship of agoraphobia and panic in a community sample of adolescents and yoimg adults. Arch Gen Psychiatry 55 1017-1024... 

The mood and anxiety disorders in their various permutations constitute a major source of personal suffering and impaired ability to engage in productive Avork and interpersonal relationships. Between 5 and 9% of women and between 2 and 3% of men meet the diagnostic criteria for major depression at any time 10-25% of all women suffer major depression sometime in their lives, while 5-10% of men will develop major depressive disorder (American Psychiatric Association, 1994). The anxiety disorders obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), panic disorder, and generalized anxiety disorder (GAD) show lifetime prevalence rates of approximately 2.5%, 7%, 2.5%, and 5% respectively. Between 3 and 13% of individuals in community samples are regarded to meet the diagnostic criteria for social phobia. Mood and anxiety disorders are common comorbidities (American Psychiatric Association, 1994) and the most common antidepressant medications including the serotonin reuptake inhibitors, the mixed serotonin-catecholamine reuptake inhibitors, the tricyclic antidepressants, and the monoamine oxidase inhibitors, are all effective treatments for anxiety and panic attacks. 

Generalized anxiety disorder (GAD) (6) is defined as excessive anxiety and worry occurring more days than not for a period of at least 6 months. The anxiety is accompanied by at least three of the following symptoms restlessness, fatigue, impaired concentration, irritability, muscle tension, and sleep disturbance. The anxiety is uncontrollable and causes clinically significant distress. GAD has a lifetime prevalence of 6-10% (7), and the NCS study (3) indicates a high comorbidity with other psychiatric disorders, especially depression and panic disorder. 

Antidepressants tend to provide a more sustained and continuous improvement of the symptoms of attention-deficit/hyperactivity disorder than do the stimulants and do not induce tics or other abnormal movements sometimes associated with stimulants. Indeed, desipramine and nortriptyhne may effectively treat tic disorders, either in association with the use of stimulants or in patients with both attention deficit disorder and Tourette s syndrome. Antidepressants also are leading choices in the treatment of severe anxiety disorders, including panic disorder with agoraphobia, generalized anxiety disorder, social phobia, and obsessive-compulsive disorder, as weU as for the common comorbidity of anxiety in depressive illness. Antidepressants, especially SSRIs, also are employed in the management of posttraumatic stress disorder, which is marked by anxiety, startle, painful recollection of the traumatic events, and disturbed sleep. Initially, anxious patients often tolerate nonsedating antidepressants poorly (Table 17-1), requiring slowly increased doses. Their beneficial actions typically are delayed for several weeks in anxiety disorders, just as they are in major depression. 

Generalized Sociai Anxiety Disorder, Treatment Resistance. A significant minority of patients will not experience a satisfactory treatment response to antidepressant therapy, even after a trial of adequate duration at full strength doses. For those with comorbid depression who are experiencing no benefit from SSRI treatment for either the anxiety or depression, then switching treatment is advisable. The options include switching to another SSRI, a SNRI (venlafaxine or perhaps dulox-etine), or, when other alternatives fail, phenelzine. 

PTSD is highly comorbid with depression (Kessler et al. 1995) and substance use disorders, and is associated with a previous exposure to trauma and a previous history of anxiety disorders. PTSD probably carries the highest risk of suicide among the anxiety disorders (Davidson et al. 1991). Without effective treatment the disorder generally runs a chronic, unremitting course. 

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