Broadening the definition of generalized anxiety disorder: effects on prevalence and associations with other disorders in the National Comorbidity Survey Replication

The case for eliminating excessive worry as a requirement for generalized anxiety disorder: a cross-national investigation

BACKGROUND

Around the world, people living in objectively difficult circumstances who experience symptoms of generalized anxiety disorder (GAD) do not qualify for a diagnosis because their worry is not 'excessive' relative to the context. We carried out the first large-scale, cross-national study to explore the implications of removing this excessiveness requirement.

METHODS

Data come from the World Health Organization World Mental Health Survey Initiative. A total of 133 614 adults from 12 surveys in Low- or Middle-Income Countries (LMICs) and 16 surveys in High-Income Countries (HICs) were assessed with the Composite International Diagnostic Interview. Non-excessive worriers meeting all other DSM-5 criteria for GAD were compared to respondents meeting all criteria for GAD, and to respondents without GAD, on clinically-relevant correlates.

RESULTS

Removing the excessiveness requirement increases the global lifetime prevalence of GAD from 2.6% to 4.0%, with larger increases in LMICs than HICs. Non-excessive and excessive GAD cases worry about many of the same things, although non-excessive cases worry more about health/welfare of loved ones, and less about personal or non-specific concerns, than excessive cases. Non-excessive cases closely resemble excessive cases in socio-demographic characteristics, family history of GAD, and risk of temporally secondary comorbidity and suicidality. Although non-excessive cases are less severe on average, they report impairment comparable to excessive cases and often seek treatment for GAD symptoms.

CONCLUSIONS

Individuals with non-excessive worry who meet all other DSM-5 criteria for GAD are clinically significant cases. Eliminating the excessiveness requirement would lead to a more defensible GAD diagnosis.

Psychometric properties of the generalized anxiety disorder questionnaire (GAD-7) in a polish postpartum women sample

OBJECTIVE

Generalized Anxiety Disorder is an international mental health problem. Prevalence for anxiety disorders reported in perinatal period is high and related with adverse parental and child outcomes. Thus, the objective of this study was to investigate the psychometric properties and factorial validity of General Anxiety Disorder-7 questionnaire (GAD-7) in the context of postpartum mothers.

METHODS

In this cross-sectional study, 278 mothers (mean age 31.09; SD = 4.42) were recruited at the Neonatology, Gynecology, and Obstetrics Ward. Generalized Anxiety Disorder was assessed with GAD-7, stress with Parental Stress Scale (PSS), while risk of depression with Edinburgh Postpartum Depression Scale (EPDS). Confirmatory factor analysis (CFA) was used to verify factor structure of GAD-7 and the internal consistency was evaluated using reliability coefficients: Cronbach's Alpha and McDonald's Omega.

RESULTS

The internal consistency of the GAD-7 was high (Cronbach's Alpha = 0.90 and MacDonald's Omega = 0.91). GAD-7 had significant correlations with the variables examined for construct validity, stress (PSS; r = 0.35, p < 0.01) and risk of depression (EPDS; r = 0.76, p < 0.01). The Confirmatory Factor Analysis results supported a good fit of the data to the model: χ²(df) = 14.19 (14), p = 0.44; Comparative Fit Index (CFI) = 0.99; Tucker-Lewis Index (TLI) = 0.99; Root Mean Square Error of Approximation (RMSEA) = 0.007 (90% C.I. 0.000; 0.059).

CONCLUSION

GAD-7 has satisfactory psychometric properties. GAD-7 had significant correlations with the variables examined for construct validity with PSS and EPDS. GAD-7 is a reliable instrument for screening anxiety symptoms in perinatal period in research and clinical setting.

Disability terminology: the use of "disability," "disorder," and "illness" in academic writing

PURPOSE

The ways in which words are used to describe and discuss people with disabilities has long been an area of social concern. Previous research has demonstrated that language can overtly and subtly influence cognitions and perceptions of individuals, but there is less research on how language relates to perceptions of individuals with disabilities.

MATERIALS AND METHODS

A content analysis of 236 peer-reviewed articles was performed to explore differences in the frequency of the use of "disability," "disorder," and "illness" in academic articles related to eight common conditions: deafness, blindness, multiple sclerosis, quadriplegia, anxiety, depression, schizophrenia, and addiction.

RESULTS

Results indicated that there were differences in how disability language was used by academic writers. Specifically, "disability" appeared in the writing more frequently in articles related to physical disabilities, "disorder" appeared most frequently in articles related to anxiety and depression, and "illness" appeared most frequently in articles related to schizophrenia.

CONCLUSIONS

This observed difference in frequency use could reflect differences in the context and meaning of the use of these conditions. Suggestions for future research are discussed.

The structure of mood and anxiety disorder symptoms in the perinatal period

BACKGROUND

The perinatal period is increasingly recognized as a vulnerable time for the development and exacerbation of psychiatric symptoms. Research has often focused on perinatal depression, with much less information on perinatal anxiety. This study examined the psychometric structure of all internalizing (anxiety and mood disorder symptoms) in the perinatal period.

METHODS

Participants were primarily community adults receiving prenatal care from an academic medical center (N = 246). Participants completed a structured clinical interview using the Interview for Mood and Anxiety Symptoms (IMAS) during pregnancy (28-32 weeks gestation) and the postpartum (6-8 weeks). Clinical interviews dimensionally assessed all current anxiety, mood, and obsessive-compulsive symptoms as well as lifetime psychiatric diagnoses.

RESULTS

Confirmatory factor analyses identified three latent factors onto which psychiatric symptoms loaded: Distress (depression, generalized anxiety, irritability, and panic symptoms), Fear (social anxiety, agoraphobia, specific phobia, and obsessive-compulsive symptoms), and Bipolar (mania and obsessive-compulsive symptoms) in both pregnancy and the postpartum. The fit statistics of the models indicated adequate to good fit in both models.

LIMITATIONS

The IMAS is validated against the DSM-IV-TR rather than the DSM-5 and assessments of psychiatric symptoms were focused only on the current pregnancy.

CONCLUSIONS

A three-factor model consisting of Distress, Fear and Bipolar latent factors was the best-fitting model in pregnancy and the postpartum period and showed stability across time. The structure of internalizing symptoms has important implications for future perinatal research and can be utilized to guide treatment by highlighting which psychiatric symptoms may be most similar during the perinatal period.

Profanity as a Self-Defense Mechanism and an Outlet for Emotional Catharsis in Stress, Anxiety, and Depression

Background

Swearing is an increasing trend among men and women worldwide. Earlier studies on the positive aspects of profanity mostly relate to pain management and the release of negative emotions. The uniqueness of the current study is its analysis for a possible constructive role of profanity in stress, anxiety, and depression.

Method

The current survey involved 253 conveniently selected participants from Pakistan. The study analyzed the role of profanity in connection to stress, anxiety, and depression. Profanity Scale and the Urdu version of Depression, Anxiety, and Stress Scale were used along with a structured interview schedule. Descriptive statistics, Pearson's correlation coefficient, and t-test were implied to obtain results.

Results

The study revealed that the usage of profane language had significantly inverse correlations with stress (r = -0.250; p < 0.01), anxiety (r = -0.161; p < 0.05), and depression (r = -0.182; p < 0.01). Higher profaners also revealed significantly lower levels of depression (M = 29.91, SD = 10.80 vs. M = 33.48, SD = 10.40; p = 0.009; Cohen's d = 0.338) and stress (M = 30.83, SD = 11.41 vs. M = 35.16, SD = 11.31; p = 0.003; Cohen's d = 0.381) as compared to lower profaners. Profanity had no significant correlations with age (r = 0.031; p > 0.05) and education (r = 0.016; p > 0.05). Men projected significantly higher levels of profanity as compared to women.

Conclusion

The current study viewed profanity similar to the self-defense mechanisms and emphasized on its cathartic role in stress, anxiety, and depression.

Subsyndromal generalised anxiety disorder: operationalisation and epidemiology - a systematic literature survey

The diagnosis of anxiety disorders, like other psychiatric disorders also, is operationalised since the introduction of diagnostic manuals. The diagnostic criteria of Generalised Anxiety Disorder (GAD) have been tightened in the last decades. This leads to the exclusion of patients with a high level of anxiety, but not fulfilling certain of the GAD-criteria, from effective treatment. Such so-called subsyndromal, subthreshold or subclinical GAD-states, however, often exhibit a comparable burden of disease like the full syndromal disorder and often tend to develop into the full syndromal disorder. The purpose of this review is - beside systematically reporting the papers found in respective data bases from 2013 onwards - to summarise the relevant data regarding definitions, epidemiology and consequences of subsyndromal anxiety states in order to give a comprehensive review.

The prevalence of subthreshold psychiatric symptoms and associations with alcohol and substance use disorders: from a nationally representative survey of 36,309 adults

BACKGROUND

Our aim was to describe a broad number of subthreshold psychiatric symptoms (SPS) in a nationally representative population and evaluate associations with substance use. SPS describe groups of symptoms with significant pathology, but that do not quite meet full psychiatric diagnostic criteria. They have been associated with significant impairment and cost.

METHODS

The National Epidemiologic Survey on Alcohol and Related Conditions-III was a multistage, weighted, cross-sectional survey completed in the United States in 2013 comprising 36,309 noninstitutionalized adults. We report lifetime prevalence rates of 14 SPS related to mood, anxiety, trauma, eating, and personality disorders. We then evaluate associations with lifetime alcohol use disorders (AUD) and all substance use disorders (SUD) using logistic regression and adjusted odds ratios. SPS and psychiatric diagnoses were mutually exclusive (could not co-occur).

RESULTS

Lifetime prevalence of having at least one of 14 SPS was 57% compared with 37% for the related psychiatric disorders. This was similar for males and females, in contrast to psychiatric disorders in which prevalence was 42% in females and 31% in males. Otherwise, overall SPS and disorders had similar prevalence patterns across sociodemographic characteristics. Subthreshold personality symptoms had the highest prevalence rates (schizotypal 21.3%, antisocial 18.3%, and borderline 17.6%), followed by posttraumatic stress (13.1%). Subthreshold bipolar and depression had lifetime prevalence rates of 2.7 and 8.5%, respectively. Prevalence rates of subthreshold anxiety symptoms ranged from 2.2% (agoraphobia) to 9.8% (specific phobia). Subthreshold eating disorder related symptoms had the lowest prevalence rates (anorexia 1.5% and bulimia 1.7%). Half (seven) of the SPS had significantly increased odds of lifetime AUD. This number increased to 12 for all SUD. Subthreshold antisocial personality symptoms had the highest odds of AUD (2.2; 95% CI 2.00-2.37) and SUD (3.5; 95% CI 3.22-3.81).

CONCLUSIONS

We found high lifetime SPS prevalence rates and significant associations with AUD and SUD. To our knowledge, this is the first published study evaluating a broad number of SPS. This indicates possible opportunities for early intervention and prevention but requires additional research and development of infrastructure and guidelines to better understand and manage patients who experience SPS.

Subthreshold lifetime depression and anxiety are associated with increased lifetime suicide attempts: A Korean nationwide study

BACKGROUND

Subthreshold depression and anxiety are highly prevalent and known to be associated with functional limitations and future onset of major depression or anxiety disorders. However, studies regarding suicidality at subthreshold levels of depression and anxiety are limited.

METHODS

A total of 17,639 Koreans aged from 18 to 64 responded to the Korean version of the WHO-composite international diagnostic interview (K-CIDI) version 2.1 between 2006 and 2016. Prevalence of subthreshold depression and anxiety, and information on lifetime suicide attempt (SA) were assessed. Multivariable logistic regression was performed to calculate the risk of SA by the level of depression or anxiety.

RESULTS

The risk of lifetime SA increased incrementally according to the level of depression and anxiety. In the subthreshold depression group, individuals with subthreshold anxiety increased the odds about threefold (OR = 3.15, 95% CI 3.12-3.18) and the threshold anxiety disorder group increased the odds about fivefold (OR = 5.33, 95% CI 5.27-5.38) for SA, compared to the group without any level of anxiety. In threshold depressive disorder, the subthreshold anxiety group showed about 1.8-fold higher odds (OR = 1.76, 95% CI 1.75-1.77) and the threshold anxiety disorder group showed threefold higher odds (OR = 2.93, 95% CI 2.92-2.95) for SA compared to the group without any level of anxiety.

CONCLUSIONS

Subthreshold levels of depression and anxiety were prevalent among Koreans and were associated with an increased prevalence of lifetime SA. A detailed assessment of depression and anxiety symptoms according to their level should be performed on a diagnostic continuum to prevent suicide.

Validity and reliability of the Generalized Anxiety Disorder-7 (GAD-7) among university students of Bangladesh

This study investigated the reliability and factorial validity of General Anxiety Disorder-7 (GAD-7) in the context of university students in Bangladesh. The research aimed to assess whether the original one-dimensional model or a model containing both somatic and cognitive-emotional factors is appropriate. A repeated cross-sectional survey design based on convenience sampling was used to collect data from 677 university students. The factor structure of the GAD-7 was assessed by exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), and its convergent validity was determined by investigating its correlations with Patient Health Questionnaire-9 (PHQ-9) and Patient Health Questionnaire Anxiety-Depression Scale (PHQ-ADS). Results showed excellent reliability of GAD-7 as measured by Cronbach's α. CFA suggested that a modified one-factor model is appropriate for the sample. This model provided high values of comparative fit index (CFI), goodness of fit index (GFI), and Tucker Lewis Index (TLI), low value of standardized root mean square residual (SRMR) and a non-significant root mean square error of approximation (RMSEA). Correlation between GAD-7 and PHQ-9 was 0.751 and 0.934 between GAD-7 and PHQ-ADS. Overall, the study provided support for modified unidimensional structure for GAD-7 and showed high internal consistency along with good convergent validity.

Perceived helpfulness of treatment for generalized anxiety disorder: a World Mental Health Surveys report

BACKGROUND

Treatment guidelines for generalized anxiety disorder (GAD) are based on a relatively small number of randomized controlled trials and do not consider patient-centered perceptions of treatment helpfulness. We investigated the prevalence and predictors of patient-reported treatment helpfulness for DSM-5 GAD and its two main treatment pathways: encounter-level treatment helpfulness and persistence in help-seeking after prior unhelpful treatment.

METHODS

Data came from community epidemiologic surveys in 23 countries in the WHO World Mental Health surveys. DSM-5 GAD was assessed with the fully structured WHO Composite International Diagnostic Interview Version 3.0. Respondents with a history of GAD were asked whether they ever received treatment and, if so, whether they ever considered this treatment helpful. Number of professionals seen before obtaining helpful treatment was also assessed. Parallel survival models estimated probability and predictors of a given treatment being perceived as helpful and of persisting in help-seeking after prior unhelpful treatment.

RESULTS

The overall prevalence rate of GAD was 4.5%, with lower prevalence in low/middle-income countries (2.8%) than high-income countries (5.3%); 34.6% of respondents with lifetime GAD reported ever obtaining treatment for their GAD, with lower proportions in low/middle-income countries (19.2%) than high-income countries (38.4%); 3) 70% of those who received treatment perceived the treatment to be helpful, with prevalence comparable in low/middle-income countries and high-income countries. Survival analysis suggested that virtually all patients would have obtained helpful treatment if they had persisted in help-seeking with up to 10 professionals. However, we estimated that only 29.7% of patients would have persisted that long. Obtaining helpful treatment at the person-level was associated with treatment type, comorbid panic/agoraphobia, and childhood adversities, but most of these predictors were important because they predicted persistence rather than encounter-level treatment helpfulness.

CONCLUSIONS

The majority of individuals with GAD do not receive treatment. Most of those who receive treatment regard it as helpful, but receiving helpful treatment typically requires persistence in help-seeking. Future research should focus on ensuring that helpfulness is included as part of the evaluation. Clinicians need to emphasize the importance of persistence to patients beginning treatment.

Is clinical, musculoskeletal pain associated with poorer logical reasoning?

Clinical pain does not seem to be considerably related to logical reasoning ability, which seems consistent with the effect of experimental pain on logical reasoning.

Introduction:

It has been hypothesized that pain disrupts system 2 processes (eg, working memory) presumed to underlie logical reasoning. A recent study examining the impact of experimentally induced pain on logical reasoning found no evidence of an effect.

Objectives:

The aim of this study was to examine whether clinical pain, which is qualitatively different from experimental pain, would lower the ability to reason logically.

Methods:

Ninety-six participants completed a questionnaire containing 3 different logical reasoning tasks (the cognitive reflection test, the belief bias syllogisms task, and the conditional inference task), questions about pain variables (present pain intensity, pain intensity during the last 24 hours, the influence of pain on daily activities, pain duration, and pain persistence), questions about other pain-related states (anxiety, depression, and fatigue), and pain-relieving medication. Correlations between the logical reasoning tasks and the pain variables were calculated.

Results:

For 2 of the 3 logical reasoning tasks (the cognitive reflection test and the belief bias syllogisms task), clinical pain was unrelated to logical reasoning. Performance on context-free logical reasoning showed a significant negative correlation with present pain intensity, but not with the other pain variables.

Conclusion:

This finding that logical reasoning ability is largely unrelated to clinical pain is highly consistent with previous research on experimentally induced pain. Pain should probably not constitute a significant barrier to logical reasoning in everyday life.

Rapid screening for generalized anxiety disorder in patients with migraine

Background: Generalized anxiety disorder (GAD) often remains undiagnosed in patients with migraine, while comorbidity of GAD with migraine is associated with increased dysfunction and risk of chronic migraine. Generalized Anxiety Disorder Scale 7-item (GAD-7) and Generalized Anxiety Disorder Scale 2-item (GAD-2) are the commonly employed screening measures for generalized anxiety symptoms in different patient groups. The present study aimed to evaluate psychometric properties of the Persian version of GAD-7 and GAD-2 in migraine. Methods: In this cross-sectional study, patients were diagnosed with migraine headaches according to the International Classification of Headache Disorders, 3rd edition (ICHD-3); then they participated in the psychiatric diagnostic interview, and filled out GAD-7, GAD-2, Beck Anxiety Inventory (BAI), Headache Impact Test-6 (HIT-6), and Migraine-Specific Quality of Life Questionnaire version 2.1 (MSQv2.1). The psychometric properties of GAD-7 and GAD-2 were examined using SPSS and LISREL. Results: Final samples were 186 patients with migraine that 83 patients received a diagnosis of GAD. Confirmatory factor analysis (CFA) indicated that the one-factor model of GAD-7 fit the data well. Internal consistency, test-retest, and Guttman split-half reliability of GAD-7 and GAD-2 were good. Significant correlation results, average variance extracted (AVE), and composite reliability (CR) supported the construct validity of the GAD-7. A score of ≥ 10 in GAD-7 and ≥ 3 in GAD-2 achieved satisfactory sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) (GAD-7: 92%, 90%, 88%, and 93%, respectively; GAD-2: 79%, 88%, 71%, and 91%, respectively). Conclusion: Our findings supported GAD-7 and GAD-2 for assessing GAD in patients with migraine. It seems that GAD-7 and GAD-2 accurately diagnosed GAD in this group of patients.

Disruption of functional and structural networks in first-episode, drug-naïve adolescents with generalized anxiety disorder

BACKGROUND

Individuals with generalized anxiety disorder (GAD) tend to worry exaggeratedly and uncontrollably about various daily routines. Previous studies have demonstrated that the GAD patients exhibited widespread alternations in both functional networks (FN) and structural networks (SN). However, the simultaneous alternations of the topological organization of FN, SN, as well as their couplings in GAD still remain unknown.

METHODS

Using multimodal approach, we constructed FN from resting-state functional magnetic imaging (R-fMRI) data and SN from diffusion magnetic resonance imaging (dMRI) data of 32 adolescent GAD patients and 25 healthy controls (HC). Graph theory analysis was employed to investigate the topological properties of FN, SN, and FN-SN coupling.

RESULTS

Compared to HC, the GAD patients showed disruptions in global (i.e., decreased clustering coefficient, global, and local efficiency) and subnetwork (i.e., reduced intermodular connections, rich club, and feeder connections) levels in FN. Abnormal global level properties (i.e., increased characteristic path length and reduced global efficiency) were also observed in SN. Altered FN-SN couplings in normalized characteristic path length and feeder connections were identified in the GAD patients. The identified network measures were correlated with anxiety severity in the GAD patients.

LIMITATIONS

The sample size of the current study is small and the cross-sectional nature can not infer causal relationship.

CONCLUSIONS

Our findings identified GAD-related topological alternations in both FN and SN, together with the couplings between FN and SN, providing us with a novel perspective for understanding the pathophysiological mechanisms of GAD.

Resistance exercise training among young adults with analogue generalized anxiety disorder

INTRODUCTION

The objective of this randomized controlled trial (RCT) was to quantify the effects of eight weeks of World Health Organization and American College of Sports Medicine guidelines-based resistance exercise training (RET) among participants meeting criteria for subclinical, or analogue-GAD (AGAD) METHODS: Forty-four participants (mean age (y): 25.4.6±4.9.2) were randomized to either an eight-week, fully-supervised, one-on-one RET intervention or wait-list control. AGAD status was determined using validated cut-scores for both the Psychiatric Diagnostic Screening Questionnaire-GAD subscale (≥6) and Penn State Worry Questionnaire (≥45). Remission, based on change in AGAD status, was assessed post-intervention, and quantified with number needed to treat (NNT). Primary analyses focused on participants missing outcome data at ≤1 time point (RET: n=12, Wait-list: n=15). RM-ANCOVA examined differences between RET and wait-list across time. Simple effects analysis decomposed significant interactions. Hedges' d quantified magnitude of differences in change between conditions over time.

RESULTS

Attendance was 81% and compliance to the RET was 77%. Participants significantly increased strength (all d≥1.24, p≤0.006) with no adverse events. RET improved AGAD status (NNT=3, 95%CI: 2 to 7). Significant group X time interactions were found for worry (F_(3,66) = 3.12, p≤0.043; d=0.93, 95%CI: 0.13 to 1.73) and anxiety symptoms (F_(3,57.84)=2.91, ε=0.88, p≤0.045; d=0.71, 95%CI: -0.08 to 1.49). RET significantly reduced worry (mean difference=-6.49, p≤0.045) and anxiety symptoms (mean difference=-10.50, p≤0.001).

LIMITATIONS

Limitations include a small sample size, and lack of attention-matched control condition.

CONCLUSION

RET significantly improved AGAD severity, and elicited large, clinically meaningful improvements in worry and anxiety symptoms among young adults with AGAD.

Different pain variables could independently predict anxiety and depression in subjects with chronic musculoskeletal pain

OBJECTIVES

Chronic, clinical pain states are often accompanied by distress such as anxiety and depression. The aim of this study was to determine if certain clinical pain variables could predict the level of anxiety and depression in subjects with musculoskeletal pain.

METHODS

Two multiple linear regression analyses were conducted on a sample consisting of 189 subjects with clinical pain with the independent pain variables of pain intensity, the influence of pain on daily activities, pain persistence, pain duration, and the number of pain locations. The dependent variables measured anxiety and depression, respectively.

RESULT

Two statistically significant models were found, where the predicted variables accounted for 37.0% of the variability in the anxiety levels and 43.7% of the variability in the depression levels. The independent variable, the influence of pain on daily activities, significantly predicted the level of anxiety. The variables, the influence of pain on daily activities and the number of pain locations, significantly predicted the levels of anxiety and depression.

CONCLUSIONS

This study showed that two different independent variables, the influence of pain on daily activities and the number of pain locations, significantly predicted the levels of depression. The predictor, the influence of pain on daily activities, significantly predicted the levels of anxiety. The knowledge gained about which specific pain variables are more likely to coexist with anxiety and depression in clinical pain states could be important in implementing holistic treatment plans for chronic pain.

Framing the process in the implementation of care for people with generalized anxiety disorder in primary care: a qualitative evidence synthesis

Background

Generalized anxiety disorder (GAD) is one of the most common mental disorders in primary care (PC). GAD has low remission and high relapse rates over long follow-up periods. Qualitative evidence was synthesized to understand the implementation of care and treatment options for people with GAD in PC.

Methods

Research published from 2008 to September 2020 was searched in five databases (MEDLINE, EMBASE, CINAHL, WOS and PsycArticles). Studies that used qualitative methods for data collection and analysis to investigate the implementation of care and treatment options for people with GAD in PC and outpatient settings were included. Non-qualitative studies, mixed methods studies that did not separately report qualitative findings and studies in languages other than English or Spanish were excluded. We used the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) framework to assess the overall confidence in the findings.

Results

The results with a moderate level of confidence showed that the trajectory of care for people with GAD in PC and outpatient settings is long and fluctuates over time, involving multiple difficulties in accessing and maintaining initial treatment or successive treatment options. In addition, there are wide variations in the preferences for and acceptability of different treatment options. The results with a high level of confidence indicated that more information on GAD and its treatment options is needed for PC practitioners, GAD patients and their carers. The results with a low level of confidence suggested that patients use antidepressants for longer than recommended and that the interruption of treatment is not usually planned.

Conclusions

Initial resistance to new treatments among people with GAD can make access and adherence to treatment difficult. Improving care may require patients to be informed of possible trajectories in stepped care pathways before the initiation of treatment so they are aware that they may need to try a number of options until the most effective treatment for them is found. Increased awareness of and information materials on GAD may facilitate both appropriate diagnosis and long-term care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-020-01307-6.

Effects of mindfulness-based stress reduction on anxiety symptoms in young people: A systematic review and meta-analysis

In this study, we evaluated the efficacy of mindfulness-based stress reduction (MBSR) for young people with anxiety symptoms. We used many databases, including PubMed, PsycINFO, Web of Science, EMBASE, CINAHL and Cochrane Library (from inception to May 2019). We included randomized controlled trials (RCTs) comparing MBSR with various control conditions, including didactic lecture course, health education, treatment as usual, didactic seminar and cognitive behavioral program in young people with anxiety symptoms. Finally, we selected fourteen studies comprising 1489 participants comparing with control conditions. The meta-analysis suggested that MBSR significantly reduced anxiety symptoms compared to control conditions at post-treatment (Standardized Mean Difference, SMD = -0.14, 95% CI -0.24 to -0.04). However, the effect of MBSR on anxiety symptoms in young people may be affected by different intervention duration, especially the significance in a short-term intervention (less than 8 weeks). In addition, the meta-analysis indicated publication bias for anxiety symptoms. Using the trim-and-fill method, we found the adjusted standardized mean difference, which indicated that MBSR was still significantly superior to the other control conditions. The sensitivity analysis showed that the result was reliable. Current evidence indicates MBSR has superior efficacy compared with control conditions in treating young people with anxiety symptoms. Based on this, we suggest there is a significant effect of MBSR on young people with anxiety symptoms, especially the effects of long-term intervention for future studies.

Normal Versus Pathological Mood: Implications for Diagnosis

Is there a clear line between normal and abnormal mood? Studies of manifest and latent structure provide strong support for a continuum that extends from asymptomatic to subsyndromal to syndromal cases of increasing severity. Subsyndromal symptoms are impairing, predict syndrome onset and relapse, and account for more doctor's visits and suicide attempts than the full syndromes, yet they are not recognized in the current classification. For most research and some clinical activities, dimensional diagnoses are recommended, and examples are offered for how such diagnoses could be made. For clinical activities requiring decisions, a multithreshold model is proposed in which both lower (e.g., mild depression, capturing subsyndromal cases) and upper (e.g., major depression, capturing clinically significant cases) diagnostic categories are used to inform clinical care. Beyond its implications for diagnosis, the dimensionality of depression and anxiety has implications for etiology and for research aimed at understanding how emotions become disrupted in psychopathology.

The paradox of relaxation training: Relaxation induced anxiety and mediation effects of negative contrast sensitivity in generalized anxiety disorder and major depressive disorder

BACKGROUND

The Contrast Avoidance Model postulates that individuals with generalized anxiety disorder (GAD) fear a sharp spike in negative emotion, and thus, prefer to worry to maintain their negative affect rather than being in a more euthymic state, such as relaxation. Relaxation induced anxiety (RIA) is a paradoxical phenomenon wherein people experience a spike in their anxiety during relaxation training. Because these phenomena may be related and may also operate among individuals with major depressive disorder (MDD), we attempted to test whether negative contrast sensitivity was a mediator of GAD or MDD in the prediction of RIA.

METHODS

Individuals with GAD (n = 32), MDD (n = 34), and healthy controls (n = 30) were exposed to a negative emotional contrast by engaging with relaxation practice and then watching a negative emotional video. This was followed by the assessment of their negative contrast sensitivity. After this, participants engaged again with relaxation and RIA was measured. We examined mediation effects of negative contrast on the relationship between diagnostic status and RIA.

RESULTS

Negative contrast sensitivity fully mediated GAD and partially mediated MDD in predicting RIA.

CONCLUSIONS

Our findings support the hypotheses that negative contrast sensitivity is the mediator of both GAD and MDD in predicting RIA. This may have implications for assessment and treatment of GAD and MDD.

Beneficial effects of Silexan on sleep are mediated by its anxiolytic effect

Disturbed sleep is among the most prevalent hyperarousal symptoms in anxiety disorders. Most drugs recommended for anxiety and insomnia have a sedating effect which is related to their beneficial effect on disturbed sleep. Silexan is a proprietary essential oil from Lavandula angustifolia. This drug has significant anxiolytic and sleep improving properties. Interestingly, these effects are not associated with sedation. Here we asked whether the positive effects on sleep are due to primary pharmacodynamic or secondary, disease related effects. We used the data from a double-blind, randomized study in which 212 patients were analyzed for efficacy after ten weeks' treatment with 80 mg/day Silexan or placebo. Anxiety and disturbed sleep were assessed using the Hamilton Anxiety Scale (HAMA) and the Pittsburgh Sleep Quality Index (PSQI), respectively. Regression-based mediation analysis was employed to estimate direct treatment effects and indirect effects mediated by anxiety control separately for each study group. Sobel's test was used to investigate the extent to which the mediator (HAMA change) contributes to the total effect of the independent variable (treatment) on the dependent variable (PSQI change). Compared to placebo, Silexan significantly reduced the total scores of the HAMA (p < 0.001) and of the PSQI (p = 0.002) after ten weeks, with clinically meaningful treatment group differences that were observed already after two and six weeks for HAMA and PSQI, respectively. Silexan had a statistically meaningful indirect effect on sleep (mediated by the effect on anxiety; p < 0.001) but no appreciable direct effect (p = 0.958). The ratio between the indirect and the total effect was determined to be 0.984, i. e., 98.4% of the total effect of Silexan on disturbed sleep were explained by the effect of Silexan on the symptoms of anxiety whereas 1.6% were attributable to a direct effect. The results indicate that Silexan exerts a secondary sleep improving effect almost exclusively through its anxiolytic action rather than by sedation. Findings are consistent with the drug's assumed mechanism of action.

Common mental disorders within chronic inflammatory disorders: a primary care database prospective investigation

OBJECTIVE

There is inconsistent evidence about the association between inflammatory disorders and depression and anxiety onset in a primary care context. The study aimed to evaluate the risk of depression and anxiety within multisystem and organ-specific inflammatory disorders.

METHODS

This is a prospective cohort study with primary care patients from the UK Clinical Practice Research Datalink diagnosed with an inflammatory disorder between 1 January 2001 and 31 December 2016. These patients were matched on age, gender, practice and index date with patients without an inflammatory disorder. The study exposures were seven chronic inflammatory disorders. Clinical diagnosis of depression and anxiety represented the outcome measures of interest.

RESULTS

Among 538 707 participants, the incidence of depression ranged from 14 per 1000 person-years (severe psoriasis) to 9 per 1000 person-years (systemic vasculitis), substantively higher compared with their comparison group (5-7 per 1000 person-years). HRs of multiple depression and anxiety events were 16% higher within inflammatory disorders (HR, 1.16, 95% CI 1.12 to 1.21, p<0.001) compared with the matched comparison group. The incidence of depression and anxiety was strongly associated with the age at inflammatory disorder onset. The overall HR estimate for depression was 1.90 (95% CI 1.66 to 2.17, p<0.001) within early-onset disorder (<40 years of age) and 0.93 (95% CI 0.90 to 1.09, p=0.80) within late-onset disorder (≥60 years of age).

CONCLUSIONS

Primary care patients with inflammatory disorders have elevated rates of depression and anxiety incidence, particularly those patients with early-onset inflammatory disorders. This finding may reflect the impact of the underlying disease on patients' quality of life, although the precise mechanisms require further investigation.

Prevalence and course of subthreshold anxiety disorder in the general population: A three-year follow-up study

BACKGROUND

This study examined the prevalence, course and risk indicators of subthreshold anxiety disorder to determine the necessity and possible risk indicators for interventions.

METHODS

Data were derived from the 'Netherlands Mental Health Survey and Incidence Study-2' (NEMESIS-2), a psychiatric epidemiological cohort study among the general population (n = 4528). This study assessed prevalence, characteristics, and three-year course of subthreshold anxiety disorder (n = 521) in adults, and compared them to a no anxiety group (n = 3832) and an anxiety disorder group (n = 175). Risk indicators for persistent and progressive subthreshold anxiety disorder were also explored, including socio-demographics, vulnerability factors, psychopathology, physical health and functioning.

RESULTS

The three-year prevalence of subthreshold anxiety disorder was 11.4%. At three-year follow-up, 57.3% had improved, 29.0% had persistent subthreshold anxiety disorder and 13.8% had progressed to a full-blown anxiety disorder. Prevalence, characteristics and course of subthreshold anxiety disorder were in between both comparison groups. Risk indicators for persistent course partly overlapped with those for progressive course and included vulnerability and psychopathological factors, and diminished functioning.

LIMITATIONS

Course analysis were restricted to the development of anxiety disorders, other mental disorders were not assessed. Moreover, due to the naturalistic design of the study the impact of treatment on course cannot be assessed.

CONCLUSIONS

Subthreshold anxiety disorder is relatively prevalent and at three-year follow-up a substantial part of respondents experienced persistent symptoms or had progressed into an anxiety disorder. Risk indicators like reduced functioning may help to identify these persons for (preventative) treatment and hence reduce functional limitations and disease burden.

Diagnostic consequences of a new category of anxious depression and a reduced duration requirement for anxiety symptoms in the ICD-11 PHC

BACKGROUND

A new diagnosis of anxious depression (AD), characterized by both depressive and anxious symptoms at case level, has been proposed for the classification of mental disorders for primary care for ICD-11 (ICD-11 PHC). The ICD-11 PHC proposes a duration requirement for anxiety symptoms of 2 weeks, in line with the requirement for depressive symptoms. This study examined diagnostic assignment under ICD-11 PHC as compared to the previous classification, the ICD-10 PHC, and the relationship of anxiety duration to disability and suicidal ideation.

METHODS

Primary care physicians in five countries referred patients based on either perceived psychological distress or distressing somatic symptoms to a research assistant who administered a computer-guided diagnostic interview. Complete data were obtained for 2279 participants.

RESULTS

Under ICD-11 PHC 47.7% participants received a diagnosis of AD and had greater disability than other diagnostic groups. Under ICD-10 PHC, in addition to meeting requirements for depressive episode, most of these patients met requirements for either generalized anxiety disorder (41.5%) or mixed anxiety and depressive disorder (45.4%). One third of individuals diagnosed with AD had anxiety durations between 2 weeks and 3 months and presented as much disability and suicidal ideation as individuals with longer anxiety durations.

LIMITATIONS

The study was not designed to establish prevalence of these conditions.

CONCLUSION

The proposed ICD-11 PHC encourages early identification and management of significant anxiety symptoms in primary care, particularly when these co-occur with depression. This study provides support for the clinical relevance of these symptoms and the importance of early identification.

The Effects of Resistance Exercise Training on Anxiety: A Meta-Analysis and Meta-Regression Analysis of Randomized Controlled Trials

BACKGROUND

The salutary effects of resistance exercise training (RET) are well established, including increased strength and function; however, less is known regarding the effects of RET on mental health outcomes. Aerobic exercise has well-documented positive effects on anxiety, but a quantitative synthesis of RET effects on anxiety is needed.

OBJECTIVES

To estimate the population effect size for resistance exercise training (RET) effects on anxiety and to determine whether variables of logical, theoretical, and/or prior empirical relation to anxiety moderate the overall effect.

METHODS

Thirty-one effects were derived from 16 articles published before February 2017, located using Google Scholar, MEDLINE, PsycINFO, PubMed, and Web of Science. Trials involved 922 participants (mean age = 43 ± 21 years, 68% female/32% male) and included both randomization to RET (n = 486) or a non-active control condition (n = 436), and a validated anxiety outcome measured at baseline, mid-, and/or post-intervention. Hedges' d effect sizes were computed and random effects models were used for all analyses. Meta-regression quantified the extent to which participant and trial characteristics moderated the mean effect.

RESULTS

RET significantly reduced anxiety symptoms (Δ = 0.31, 95% CI 0.17-0.44; z = 4.43; p < 0.001). Significant heterogeneity was not indicated (Q _T(30) = 40.5, p > 0.09; I ² = 28.3%, 95% CI 10.17-42.81); sampling error accounted for 77.7% of observed variance. Larger effects were found among healthy participants (Δ = 0.50, 95% CI 0.22-0.78) compared to participants with a physical or mental illness (Δ = 0.19, 95% CI 0.06-0.31, z = 2.16, p < 0.04). Effect sizes did not significantly vary according to sex (β = -0.31), age (β = -0.10), control condition (β = 0.08), program length (β = 0.07), session duration (β = 0.08), frequency (β = -0.10), intensity (β = -0.18), anxiety recall time frame (β = 0.21), or whether strength significantly improved (β = 0.19) (all p ≥ 0.06).

CONCLUSIONS

RET significantly improves anxiety symptoms among both healthy participants and participants with a physical or mental illness. Improvements were not moderated by sex, or based on features of RET. Future trials should compare RET to other empirically-supported therapies for anxiety.

The WHO World Mental Health (WMH) Surveys

The paper presents an overview of the WHO World Mental Health (WMH) Survey Initiative and summarizes recent WMH results regarding the prevalence and societal costs of mental disorders. The WMH surveys are representative community surveys that were carried out in 28 countries throughout the world aimed at providing information to mental health policy makers about the prevalence, burden, and unmet need for treatment of common mental disorders. Results show that mental disorders are commonly occurring in all participating countries. The inter-quartile range (IQR: 25(th)-75(th) percentiles) of lifetime DSM-IV disorder prevalence estimates (combining anxiety, mood, disruptive behavior, and substance disorders) is 18.1-36.1%. The IQR of 12-month prevalence estimates is 9.8-19.1%. Analysis of age-of-onset reports shows that many mental disorders begin in childhood-adolescence and have significant adverse effects on subsequent role transitions. Adult mental disorders are found in the WMH data to be associated with high levels of role impairment. Despite this burden, the majority of mental disorders go untreated. Although these results suggest that expansion of treatment could be cost-effective from both the employer perspective and the societal perspective, treatment effectiveness trials are needed to confirm this suspicion. The WMH results regarding impairments are being used to target several such interventions.

The increase in interest in GAD: Commentary on Asmundson & Asmundson

Generalized Anxiety Disorder (GAD) is one of the most common anxiety disorders. It is associated with functional impairment and is unlikely to spontaneously remit. As identified by Asmundson and Asmundson (2018), published research studies on GAD have increased in number over the last decade. We propose that this is due to the high prevalence of the diagnosis and symptoms, interest in transdiagnostic processes, such as worry, increased interest in emotion dysregulation as a principle underlying diagnoses, and new methods of treating and disseminating treatment that may be particularly well suited to GAD. Despite the increase in research articles on GAD, GAD still remains one of the least studied anxiety disorders. We propose that this is due to the misconception that GAD does not lead to severe impairment, despite data showing otherwise. Future research should continue to examine the phenomenology, mechanisms, and treatment of GAD in order to better understand this common anxiety disorder.

Epidemiology of anxiety disorders: from surveys to nosology and back

On the basis of epidemiological survey findings, anxiety disorders are the most prevalent mental disorders around the world and are associated with significant comorbidity and morbidity. Such surveys rely on advances in psychiatric nosology and may also contribute usefully to revisions of the nosology. There are a number of questions at the intersection of psychiatric epidemiology and nosology. This review addresses the following: What is the prevalence of anxiety disorders and how do we best explain cross-national differences in prevalence estimates? What are the optimal diagnostic criteria for anxiety disorders, and how can epidemiological data shed light on this question? What are the comorbidities of anxiety disorders, and how do we best understand the high comorbidities seen in these conditions? What is the current treatment gap for anxiety disorders, and what are the implications of current understandings of psychiatric epidemiology and nosology for policy-making relevant to anxiety disorders? Here, we emphasize that anxiety disorders are the most prevalent of the psychiatric conditions, and that rather than merely contrasting cross-national prevalence in anxiety disorders, it is more productive to delineate cross-national themes that emerge about the epidemiology of these conditions. We discuss that optimizing diagnostic criteria for anxiety disorders is an iterative process to which epidemiological data can make a crucial contribution. Additionally, high comorbidity in anxiety disorders is not merely artefactual; it provides key opportunities to explore pathways to mental disorders and to intervene accordingly. Finally, work on the epidemiology and nosology of anxiety disorders has provided a number of important targets for mental health policy and for future integrative work to move between bench and bedside, as well as between clinic and community.

Factor structure and construct validity of the Generalized Anxiety Disorder 7-item (GAD-7) among Portuguese college students

: The Generalized Anxiety Disorder 7-item (GAD-7) scale has been presented as a reliable and valid measure to assess generalized anxiety symptoms in several clinical settings and among the general population. However, some researches did not support the original one-dimensional structure of the GAD-7 tool. Our main aim was to examine the factor structure of GAD-7 comparing the one-factor model fit with a two-factor model (3 somatic nature symptoms and 4 cognitive-emotional nature symptoms) in a sample of college students. This validation study with data collected cross-sectionally included 1,031 Portuguese college students attending courses in the six schools of the Polytechnic Institute of Coimbra, Coimbra, Portugal. Measures included the GAD-7, Hospital Anxiety and Depression Scale (HADS) and the University Student Risk Behaviors Questionnaire. Confirmatory factor analysis (CFA) procedures confirmed that neither factor structure was well fitting. Thus, a modified single factor model allowing the error terms of items associated with relaxing difficulties and irritability to covary was an appropriate solution. Additionally, this factor structure revealed configural and metric invariance across gender. A good convergent validity was found by correlating global anxiety and depression. However, this measure showed a weak association with consumption behaviors. Our results are relevant to clinical practice, since the comprehensive approach to GAD-7 contributes to knowing generalized anxiety symptoms trajectory and their correlates within the university setting.

Cross-sectional Comparison of the Epidemiology of DSM-5 Generalized Anxiety Disorder Across the Globe

IMPORTANCE

Generalized anxiety disorder (GAD) is poorly understood compared with other anxiety disorders, and debates persist about the seriousness of this disorder. Few data exist on GAD outside a small number of affluent, industrialized nations. No population-based data exist on GAD as it is currently defined in DSM-5.

OBJECTIVE

To provide the first epidemiologic data on DSM-5 GAD and explore cross-national differences in its prevalence, course, correlates, and impact.

DESIGN, SETTING, AND PARTICIPANTS

Data come from the World Health Organization World Mental Health Survey Initiative. Cross-sectional general population surveys were carried out in 26 countries using a consistent research protocol and assessment instrument. A total of 147 261 adults from representative household samples were interviewed face-to-face in the community. The surveys were conducted between 2001 and 2012. Data analysis was performed from July 22, 2015, to December 12, 2016.

MAIN OUTCOMES AND MEASURES

The Composite International Diagnostic Interview was used to assess GAD along with comorbid disorders, role impairment, and help seeking.

RESULTS

Respondents were 147 261 adults aged 18 to 99 years. The surveys had a weighted mean response rate of 69.5%. Across surveys, DSM-5 GAD had a combined lifetime prevalence (SE) of 3.7% (0.1%), 12-month prevalence of 1.8% (0.1%), and 30-day prevalence of 0.8% (0). Prevalence estimates varied widely across countries, with lifetime prevalence highest in high-income countries (5.0% [0.1%]), lower in middle-income countries (2.8% [0.1%]), and lowest in low-income countries (1.6% [0.1%]). Generalized anxiety disorder typically begins in adulthood and persists over time, although onset is later and clinical course is more persistent in lower-income countries. Lifetime comorbidity is high (81.9% [0.7%]), particularly with mood (63.0% [0.9%]) and other anxiety (51.7% [0.9%]) disorders. Severe role impairment is common across life domains (50.6% [1.2%]), particularly in high-income countries. Treatment is sought by approximately half of affected individuals (49.2% [1.2%]), especially those with severe role impairment (59.4% [1.8%]) or comorbid disorders (55.8% [1.4%]) and those living in high-income countries (59.0% [1.3%]).

CONCLUSIONS AND RELEVANCE

The findings of this study show that DSM-5 GAD is more prevalent than DSM-IV GAD and is associated with substantial role impairment. The disorder is especially common and impairing in high-income countries despite a negative association between GAD and socioeconomic status within countries. These results underscore the public health significance of GAD across the globe while uncovering cross-national differences in prevalence, course, and impairment that require further investigation.

Screening for anxiety, depression, and anxious depression in primary care: A field study for ICD-11 PHC

BACKGROUND

In this field study of WHO's revised classification of mental disorders for primary care settings, the ICD-11 PHC, we tested the usefulness of two five-item screening scales for anxiety and depression to be administered in primary care settings.

METHODS

The study was conducted in primary care settings in four large middle-income countries. Primary care physicians (PCPs) referred individuals who they suspected might be psychologically distressed to the study. Screening scales as well as a structured diagnostic interview, the revised Clinical Interview Schedule (CIS-R), adapted for proposed decision rules in ICD-11 PHC, were administered to 1488 participants.

RESULTS

A score of 3 or more on one or both screening scale predicted 89.6% of above-threshold mood or anxiety disorder diagnoses on the CIS-R. Anxious depression was the most common CIS-R diagnosis among referred patients. However, there was an exact diagnostic match between the screening scales and the CIS-R in only 62.9% of those with high scores.

LIMITATIONS

This study was confined to those in whom the PCP suspected psychological distress, so does not provide information about the prevalence of mental disorders in primary care settings.

CONCLUSIONS

The two five-item screening scales for anxiety and depression provide a practical way for PCPs to evaluate the likelihood of mood and anxiety disorders without paper and pencil measures that are not feasible in many settings. These scales may provide substantially improved case detection as compared to current primary care practice and a realistic alternative to complex diagnostic algorithms used by specialist mental health professionals.

Social Epidemiology of Depression and Anxiety by Gender Identity

PURPOSE

This study investigates depression and anxiety in gender minority (i.e., transgender and/or gender nonconforming) compared with nongender minority (cisgender) young adults.

METHODS

Data were from the Growing Up Today Study, a national cohort of U.S. young adults. A two-step method (maternal-reported natal sex in 1996 cross-classified with participant-reported current gender identity in 2010) was used to identify gender minority and nongender minority respondents (n = 7,831; mean age = 26 years). Differences in past week depressive symptoms and anxious symptoms were examined cross-sectionally by gender identity. Gender minority and nongender minority respondents were compared using age-adjusted logistic regression models.

RESULTS

In gender minorities, the prevalence of depressive and anxious symptoms meeting clinical cutoffs was 52% and 38%, respectively, compared with nongender minorities (27% and 30% in females and 25% and 14% in males; p < .01).

CONCLUSIONS

Gender identity is an understudied social determinant of mental health. Surveillance efforts to monitor mental health disparities should include survey questions to assess gender identity in epidemiologic research. Research and interventions to understand and ameliorate mental health disparities by gender identity are needed.

Factor mixture modeling of the Penn State Worry Questionnaire: Evidence for distinct classes of worry

Worry, the anticipation of future threat, is a common feature of anxiety and mood psychopathology. Considerable research has examined the latent structure of worry to determine whether this construct reflects a dimensional or taxonic structure. Recent taxometric investigations have provided support for a unidimensional structure of worry; however, the results of these studies are limited in that taxometric approaches are unable to assess for the presence of more than two classes of a given construct. Given the complex nature of worry, it is possible that worry may actually reflect a latent structure comprised of multiple classes that cannot be assessed through taxometric approaches. Thus, it is important to utilize newer statistical techniques, such as factor-mixture modeling (FMM), which allow for a more nuanced assessment of the latent structure of a given psychological construct. The aim of the current study was to examine the latent structure of worry using FMM. It was predicted that worry would reflect a three-class structure comprised of (1) a class of low, normative levels of worry, (2) a class of moderate, subclinical worry, and (3) a class of high, pervasive worry. The latent class structure of worry was assessed using FMM in a sample of 1337 participants recruited from the community through a research clinic. Results revealed a three-class structure of the PSWQ comprising low, moderate-high, and high classes of worry. We also provided convergent and discriminant validity of the worry classes by demonstrating that the high worry class was most associated with GAD and that the low worry class was the least associated with GAD. The clinical utility of the worry classes, including the creation of empirically based cut-scores, and the implications for future research are discussed.

The Feasibility, Acceptability, and Efficacy of Delivering Internet-Based Self-Help and Guided Self-Help Interventions for Generalized Anxiety Disorder to Indian University Students: Design of a Randomized Controlled Trial

BACKGROUND

Generalized anxiety disorder (GAD) is one of the most common mental disorders among university students; however, many students go untreated due to treatment costs, stigma concerns, and limited access to trained mental health professionals. These barriers are heightened in universities in India, where there are scant mental health care services and severe stigma surrounding help seeking.

OBJECTIVE

To evaluate the feasibility, acceptability, and efficacy of Internet-based, or "online," cognitive behavioral therapy (CBT)-based unguided and guided self-help interventions (using the programs GAD Online and Lantern, respectively) to reduce GAD symptoms in students with clinical and subthreshold GAD and, ultimately, reduce the prevalence and incidence of GAD among the student population.

METHODS

Students will be recruited via 3 colleges in Hyderabad, India, and referred for a campus-wide online screening. Self-report data will be collected entirely online. A total of 300 qualifying students will be randomized in a 1:1:1 ratio to receive GAD Online, Lantern, or to be in a wait-list control condition, stratified by clinical and subthreshold GAD symptomatology. Students will complete a postintervention assessment after 3 months and a follow-up assessment 6 months later, at which point students in the wait-list control condition will receive one of the programs. The primary outcome is GAD symptom severity at 3 months postintervention. Secondary outcomes include GAD caseness at 9 months, other anxiety and depression symptoms, self-efficacy, and functional measures (eg, sleep, social functioning) at 3 and 9 months, respectively. Primary analyses will be differences between each of the intervention groups and the wait-list control group, analyzed on an intention-to-treat (ITT) basis using mixed-design ANOVA.

RESULTS

The study commenced in February 2015. The sample was recruited over a 3-week period at each college. The trial is expected to end in December 2015.

CONCLUSIONS

This trial will be the first to evaluate the use of Internet-based CBT programs compared with a wait-list control group for the treatment of GAD among students in Indian universities. If effective, these programs have the potential to reduce the mental health care treatment gap by providing readily accessible, private, and cost-effective evidence-based care to students with GAD who do not currently receive the treatment they need.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02410265 http://clinicaltrials.gov/ct2/show/NCT02410265 (Archived by WebCite at http://www.webcitation.org/6ddqH6Rbt).

Classification models for subthreshold generalized anxiety disorder in a college population: Implications for prevention

Generalized anxiety disorder (GAD) is one of the most common psychiatric disorders on college campuses and often goes unidentified and untreated. We propose a combined prevention and treatment model composed of evidence-based self-help (SH) and guided self-help (GSH) interventions to address this issue. To inform the development of this stepped-care model of intervention delivery, we evaluated results from a population-based anxiety screening of college students. A primary model was developed to illustrate how increasing levels of symptomatology could be linked to prevention/treatment interventions. We used screening data to propose four models of classification for populations at risk for GAD. We then explored the cost considerations of implementing this prevention/treatment stepped-care model. Among 2489 college students (mean age 19.1 years; 67% female), 8.0% (198/2489) met DSM-5 clinical criteria for GAD, in line with expected clinical rates for this population. At-risk Model 1 (subthreshold, but considerable symptoms of anxiety) identified 13.7% of students as potentially at risk for developing GAD. Model 2 (subthreshold, but high GAD symptom severity) identified 13.7%. Model 3 (subthreshold, but symptoms were distressing) identified 12.3%. Model 4 (subthreshold, but considerable worry) identified 17.4%. There was little overlap among these models, with a combined at-risk population of 39.4%. The efficiency of these models in identifying those truly at risk and the cost and efficacy of preventive interventions will determine if prevention is viable. Using Model 1 data and conservative cost estimates, we found that a preventive intervention effect size of even 0.2 could make a prevention/treatment model more cost-effective than existing models of "wait-and-treat."

Threshold and subthreshold generalized anxiety disorder in later life

OBJECTIVE

Symptoms and disorders of anxiety are highly prevalent among older adults; however, late-life anxiety disorders remain underdiagnosed. The objective of this study was to (1) estimate the prevalence of late-life threshold and subthreshold generalized anxiety disorder (GAD), (2) examine sociodemographic and health correlates associated with membership in these groups, (3) assess 3-year conversion rates of these groups, and (4) explore characteristics associated with 3-year conversion to GAD.

METHODS

Using Waves 1 and 2 of the National Epidemiological Survey of Alcohol and Related Conditions, 13,420 participants aged 55-98 years were included in this study.

RESULTS

Subthreshold GAD was more highly prevalent than threshold GAD and was interposed between asymptomatic and GAD groups in terms of severity of health characteristics. Although most participants with subthreshold and threshold GAD were asymptomatic by Wave 2, differences in disability persisted. Subthreshold GAD at baseline was not a predictor of threshold GAD at follow-up.

CONCLUSION

These findings suggest that late-life GAD should be conceptualized as a dimensional rather than categorical construct. The temporal stability of anxiety-associated disability further suggests that subthreshold GAD bears clinical significance. However, the suitability and efficacy of interventions for minimizing negative sequelae in this group remain to be determined.

Advancing understanding of executive function impairments and psychopathology: bridging the gap between clinical and cognitive approaches

Executive function (EF) is essential for successfully navigating nearly all of our daily activities. Of critical importance for clinical psychological science, EF impairments are associated with most forms of psychopathology. However, despite the proliferation of research on EF in clinical populations, with notable exceptions clinical and cognitive approaches to EF have remained largely independent, leading to failures to apply theoretical and methodological advances in one field to the other field and hindering progress. First, we review the current state of knowledge of EF impairments associated with psychopathology and limitations to the previous research in light of recent advances in understanding and measuring EF. Next, we offer concrete suggestions for improving EF assessment. Last, we suggest future directions, including integrating modern models of EF with state of the art, hierarchical models of dimensional psychopathology as well as translational implications of EF-informed research on clinical science.

Profile of agomelatine and its potential in the treatment of generalized anxiety disorder

BACKGROUND

Although many generalized anxiety disorder (GAD) patients respond to the available pharmacological treatments, nearly half of them do not present the expected results. Besides, the side effects associated to some drugs have a negative impact on treatment adherence. Therefore, the aim of this review was to report the clinical profile of agomelatine, a selective melatonergic MT1/MT2 receptor agonist with serotonin 5-HT2c receptor antagonist activities, as a potential pharmacological option in the treatment of GAD.

METHODS

We performed a literature review regarding studies that evaluated the use of agomelatine in GAD treatment.

RESULTS

Two short-term, double-blinded studies and one prevention-treatment trial evaluated the efficacy of agomelatine in the treatment of GAD. Agomelatine was associated with higher rates of clinical response and remission, when compared to placebo. In addition, the long-term use of agomelatine decreased the risk of relapse of anxiety symptoms, even for the severely ill patients. Besides, the tolerability was satisfactory with the absence of discontinuation symptoms, as observed in previous studies.

CONCLUSION

The efficacy and tolerability profiles of agomelatine in the treatment of GAD were good. However, the scarce number of trials, the small sample sizes, and the use of patients without any comorbid conditions were some limitations that impaired the generalization of the results in the general population. Nevertheless, agomelatine is an attractive off-label option in the treatment of GAD that needs more conclusive evidences to establish its role in future guidelines.

Threshold and subthreshold generalized anxiety disorder among US adolescents: prevalence, sociodemographic, and clinical characteristics

BACKGROUND

Threshold and subthreshold forms of generalized anxiety disorder (GAD) are highly prevalent and impairing conditions among adults. However, there are few general population studies that have examined these conditions during the early life course. The primary objectives of this study were to: (1) examine the prevalence, and sociodemographic and clinical characteristics of threshold and subthreshold forms of GAD in a nationally representative sample of US youth; and (2) test differences in sociodemographic and clinical characteristics between threshold and subthreshold forms of the disorder.

METHOD

The National Comorbidity Survey-Adolescent Supplement is a nationally representative face-to-face survey of 10,123 adolescents 13 to 18 years of age in the continental USA.

RESULTS

Approximately 3% of adolescents met criteria for threshold GAD. Reducing the required duration from 6 months to 3 months resulted in a 65.7% increase in prevalence (5.0%); further relaxing the uncontrollability criterion led to an additional 20.7% increase in prevalence (6.1%). Adolescents with all forms of GAD displayed a recurrent clinical course marked by substantial impairment and co-morbidity with other psychiatric disorders. There were few significant differences in sociodemographic and clinical characteristics between threshold and subthreshold cases of GAD. Results also revealed age-related differences in the associated symptoms and clinical course of GAD.

CONCLUSIONS

Findings demonstrate the clinical significance of subthreshold forms of GAD among adolescent youth, highlighting the continuous nature of the GAD construct. Age-related differences in the associated symptoms and clinical course of GAD provide further support for criteria that capture variation in clinical features across development.

The prevalence and burden of subthreshold generalized anxiety disorder: a systematic review

BACKGROUND

To review the prevalence and impact of generalized anxiety disorder (GAD) below the diagnostic threshold and explore its treatment needs in times of scarce healthcare resources.

METHODS

A systematic literature search was conducted until January 2013 using PUBMED/MEDLINE, PSYCINFO, EMBASE and reference lists to identify epidemiological studies of subthreshold GAD, i.e. GAD symptoms that do not reach the current thresholds of DSM-III-R, DSM-IV or ICD-10. Quality of all included studies was assessed and median prevalences of subthreshold GAD were calculated for different subpopulations.

RESULTS

Inclusion criteria led to 15 high-quality and 3 low-quality epidemiological studies with a total of 48,214 participants being reviewed. Whilst GAD proved to be a common mental health disorder, the prevalence for subthreshold GAD was twice that for the full syndrome. Subthreshold GAD is typically persistent, causing considerably more suffering and impairment in psychosocial and work functioning, benzodiazepine and primary health care use, than in non-anxious individuals. Subthreshold GAD can also increase the risk of onset and worsen the course of a range of comorbid mental health, pain and somatic disorders; further increasing costs. Results are robust against bias due to low study quality.

CONCLUSIONS

Subthreshold GAD is a common, recurrent and impairing disease with verifiable morbidity that claims significant healthcare resources. As such, it should receive additional research and clinical attention.

Anxious and non-anxious forms of major depression: familial, personality and symptom characteristics

BACKGROUND

Earlier clinical studies have suggested consistent differences between anxious and non-anxious depression. The aim of this study was to compare parental pathology, personality and symptom characteristics in three groups of probands from the general population: depression with and without generalized anxiety disorder (GAD) and with other anxiety disorders. Because patients without GAD may have experienced anxious symptoms for up to 5 months, we also considered GAD with a duration of only 1 month to produce a group of depressions largely unaffected by anxiety.

METHOD

Depressive and anxiety disorders were assessed in a 10-year prospective longitudinal community and family study using the DSM-IV/M-CIDI. Regression analyses were used to reveal associations between these variables and with personality using two durations of GAD: 6 months (GAD-6) and 1 month (GAD-1).

RESULTS

Non-anxious depressives had fewer and less severe depressive symptoms, and higher odds for parents with depression alone, whereas those with anxious depression were associated with higher harm avoidance and had parents with a wider range of disorders, including mania.

CONCLUSIONS

Anxious depression is a more severe form of depression than the non-anxious form; this is true even when the symptoms required for an anxiety diagnosis are ignored. Patients with non-anxious depression are different from those with anxious depression in terms of illness severity, family pathology and personality. The association between major depression and bipolar disorder is seen only in anxious forms of depression. Improved knowledge on different forms of depression may provide clues to their differential aetiology, and guide research into the types of treatment that are best suited to each form.

Worry and generalized anxiety disorder: a review and theoretical synthesis of evidence on nature, etiology, mechanisms, and treatment

Generalized anxiety disorder (GAD) is associated with substantial personal and societal cost yet is the least successfully treated of the anxiety disorders. In this review, research on clinical features, boundary issues, and naturalistic course, as well as risk factors and maintaining mechanisms (cognitive, biological, neural, interpersonal, and developmental), are presented. A synthesis of these data points to a central role of emotional hyperreactivity, sensitivity to contrasting emotions, and dysfunctional attempts to cope with strong emotional shifts via worry. Consistent with the Contrast Avoidance model, evidence shows that worry evokes and sustains negative affect, thereby precluding sharp increases in negative emotion. We also review current treatment paradigms and suggest how the Contrast Avoidance model may help to target key fears and avoidance tendencies that serve to maintain pathology in GAD.

National trends of psychotropic medication use among patients diagnosed with anxiety disorders: results from medical expenditure panel survey 2004-2009

Data from the 2004 to 2009 Medical Expenditure Panel Survey (MEPS) were used to: (1) characterize changes in utilization and (2) identify factors associated with the use of psychotropic medication among patients with anxiety disorders. We calculated the prevalence, compared the use patterns for each year and drug class, and used logistic regression to identify the factors associated with psychotropic medication use. Patients ever using a psychotropic medication for anxiety grew from 57.4% in 2004 to 63.8% in 2009 (p<0.01). From 2004 to 2009, use of benzodiazepines (22.7-30.5%, p<0.01) and atypical antipsychotics (2.3-3.9%, p<0.01) increased. A high prevalence in the use of benzodiazepines (41.8% in 2004 to 48.8% in 2009) was observed among older adults. Older age, having insurance coverage, and poor health status were significantly associated with self-reported psychotropic medication use. An increase of psychotropic medication use from 2004 to 2009 was observed. A high prevalence and increasing trend in the use of benzodiazepines may warrant further attention given safety concerns in older adults.