Are anxiety disorders publications continuing on a trajectory of growth? A look at Boschen's (2008) predictions and beyond

Development of decision rules for an adaptive aftercare intervention based on individual symptom courses for agoraphobia patients

As other mental illnesses, agoraphobia is associated with a significant risk for relapse after the end of treatment. Personalized and adaptive approaches appear promising to improve maintenance treatment and aftercare as they acknowledge patients' varying individual needs with respect to intensity of care over time. Currently, there is a deficit of knowledge about the detailed symptom course after discharge from acute treatment, which is a prerequisite for the empirical development of rules to decide if and when aftercare should be intensified. Therefore, this study aimed firstly at the investigation of the naturalistic symptom course of agoraphobia after discharge from initial treatment and secondly at the development and evaluation of a data-driven algorithm for a digital adaptive aftercare intervention. A total of 56 agoraphobia patients were recruited in 3 hospitals. Following discharge, participants completed a weekly online monitoring assessment for three months. While symptom severity remained stable at the group level, individual courses were highly heterogeneous. Approximately two-thirds of the patients (70%) reported considerable symptoms at some time, indicating a need for medium or high-intense therapeutic support. Simulating the application of the algorithm to the data set resulted in an early (86% before week six) and relatively even allocation of patients to three groups (need for no, medium, and high-intense support respectively). Overall, findings confirm the need for adaptive aftercare strategies in agoraphobia. Digital, adaptive approaches may provide immediate support to patients who experience symptom deterioration and thus promise to contribute to an optimized allocation of therapeutic resources and overall improvement of care.

Current prevalence and determinants of generalized anxiety disorder from a nationally representative, population-based survey of India

Introduction

Generalized anxiety disorder (GAD) is one of the common anxiety disorders leading to impairment and burden. However, GAD remains the least studied anxiety disorder. There is a need for nationally representative epidemiological data of GAD to understand the current burden and plan the mental health policies and programs to attain their unmet needs. Hence, this study focuses on epidemiology, socio-demographic correlates, disability, and treatment gap of GAD from India's National Mental Health Survey (NMHS) 2016.

Materials and Methods

NMHS 2016 was a nationally representative epidemiological survey of adult respondents from 12 states of India. NMHS is a multi-stage, stratified, random cluster sampling with random selection based on probability proportional to size at each stage. The Mini-International Neuropsychiatric Interview 6.0.0 used to diagnose psychiatric disorders. Sheehan disability scale was used to assess the disability. The current weighted prevalence of GAD was estimated. Association between GAD and socio-demographic factors was done using Firth's penalized logistic regression. The treatment gap and disability in GAD also calculated.

Results

The current weighted prevalence of GAD is 0.57%. The male gender and higher education groups have significantly lesser odds with current GAD. Urban metro and the married group have significantly higher odds with current GAD. The most common comorbid psychiatric disorders are depression (15.8%) followed by agoraphobia (9.4%). Among respondents with current GAD in the past 6 months across three domains, around 2/5th has mild and moderate disability, 1/10th has a severe disability, and 1/20th has an extreme disability. The overall treatment gap of current GAD is 75.7%.

Conclusion

NMHS 2016 has provided valuable insights into the epidemiology and burden of GAD among the general population. The available findings provide a glimpse of the current scenario in GAD to aid policymakers in targeting interventions.

Community-Based Participatory Research (CBPR) to Enhance Participation of Racial/Ethnic Minorities in Clinical Trials: A 10-Year Systematic Review

There has not been a significant improvement in the rate of clinical trial accrual in more than 20 years. Worse, the challenge of inadequate representation among racial and ethnic minorities also persists, deepening disparities in health. Community-Based Participatory Research (CBPR) is a participatory communication method that centers on effective dialogue between researchers and community stakeholders with the goal of creating an equitable partnership for health and social change. The objective of the current study was to provide an update since a systematic review in 2012, on the current status of the empirical research, with a particular focus on the elements of CBPR methods used to improve the rate of accrual of members of racial and ethnic minority communities for clinical trials. Our systematic review found a large increase in the number of CBPR related studies and studies related to racial and ethnic representation in research. More than 85% of studies employing CBPR methods saw statistically positive outcomes. Specifically, the elements of CBPR that are associated with these positive outcomes include community partner participation in (1) a study advisory committee, (2) data collection, (3) the development of interventions, and (4) participant recruitment. However, the results of our study indicate that researchers need to be more transparent about the extent of community participation as well as more thoroughly and accurately describe the nature of the partnership with members of minority communities in order to build upon the scientific literature on community-engaged methods.

Invisible Hands and Fine Calipers: A Call to Use Formal Theory as a Toolkit for Theory Construction

In recent years, a growing chorus of researchers has argued that psychological theory is in a state of crisis: Theories are rarely developed in a way that indicates an accumulation of knowledge. Paul Meehl raised this very concern more than 40 years ago. Yet in the ensuing decades, little has improved. We aim to chart a better path forward for psychological theory by revisiting Meehl's criticisms, his proposed solution, and the reasons his solution failed to meaningfully change the status of psychological theory. We argue that Meehl identified serious shortcomings in our evaluation of psychological theories and that his proposed solution would substantially strengthen theory testing. However, we also argue that Meehl failed to provide researchers with the tools necessary to construct the kinds of rigorous theories his approach required. To advance psychological theory, we must equip researchers with tools that allow them to better generate, evaluate, and develop their theories. We argue that formal theories provide this much-needed set of tools, equipping researchers with tools for thinking, evaluating explanation, enhancing measurement, informing theory development, and promoting the collaborative construction of psychological theories.

Adverse childhood experiences (ACEs) research: A bibliometric analysis of publication trends over the first 20 years

BACKGROUND

The relative health and robustness of a field of research can be approximated by assessing peer reviewed journal publication trends for articles pertinent to the field. To date, there have been no such assessments of the burgeoning research on adverse childhood experiences (ACEs).

OBJECTIVE

The overall goal of this study was to examine ACEs research trends using bibliometric methods. More specifically, we sought to describe observed publication trends of the ACEs literature from its inception in the late 1990s. We also analyzed the nature of ACEs publications with regard to key characteristics of main outcomes, levels of analysis, and populations of primary focus.

METHODS

A search was conducted using Scopus to identify English language papers on ACEs published in peer-reviewed journals between 1998 and 2018. The primary field of research was determined by having independent raters code the title of the publishing journal into distinct categories. Main research outcomes were similarly coded.

RESULTS

A total of 789 articles on ACEs appearing in 351 different academic journals were published between 1998 and 2018. There was considerable growth in the number of ACEs papers published over the past several years. General medicine and multidisciplinary research were the most frequent of 12 primary fields of research characterizing ACEs research. Of 16 primary outcomes on which ACEs research focused, the most common were mental health and physical health.

CONCLUSION

Significant growth in ACEs research over the past several years suggest the field is thriving. Observed publication trends and publication characteristics are discussed briefly.

Association of Recognized and Unrecognized Myocardial Infarction With Depressive and Anxiety Disorders in 125,988 Individuals: A Report of the Lifelines Cohort Study

OBJECTIVE

No previous study has focused on recognition of myocardial infarction (MI) and the presence of both depressive and anxiety disorders in a large population-based sample. The aim of this study was to investigate the association of recognized MI (RMI) and unrecognized MI (UMI) with depressive and anxiety disorders.

METHODS

Analyses included 125,988 individuals enrolled in the Lifelines study. Current mental disorders according to the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) were assessed with the Mini-International Neuropsychiatric Interview. UMI was detected using electrocardiogram in participants who did not report a history of MI. The classification of RMI was based on self-reported MI history together with the use of either antithrombotic medications or electrocardiogram signs of MI. Analyses were adjusted for age, sex, smoking, somatic comorbidities, and physical health-related quality of life as measured by the RAND 36-Item Health Survey in different models.

RESULTS

Participants with RMI had significantly higher odds of having any depressive and any anxiety disorder as compared with participants without MI (depressive disorder: odds ratio [OR] = 1.86, 95% confidence interval [CI] = 1.38-2.52; anxiety disorder: OR = 1.60, 95% CI = 1.32-1.94) after adjustment for age and sex. Participants with UMI did not differ from participants without MI (depressive disorder: OR = 1.60, 95% CI = 0.96-2.64; anxiety disorder: OR = 0.73, 95% CI = 0.48-1.11). After additional adjustment for somatic comorbidities and low physical health-related quality of life, the association between RMI with any depressive disorder was no longer statistically significant (OR = 1.18; 95% CI =0.84-1.65), but the association with any anxiety disorder remained (OR = 1.27, 95% CI = 1.03-1.57).

CONCLUSIONS

Recognition of MI seems to play a major role in the occurrence of anxiety, but not depressive, disorders.

Mental health disorders research in Europe, 2001-2018

BACKGROUND

The burden of mental health disorders in Europe is well above the world average and has increased from 11.5% to 13.9% of the total disease burden in 2000 and 2015. That from dementia has increased rapidly, and overtaken that from depression as the leading component. There have been no analyses of the research activity in Europe to combat this burden.

METHODOLOGY

We identified research papers in the Web of Science (WoS) with a complex mental health disorders filter based on title words and journal names in the years 2001-18, and downloaded their details for analysis.

RESULTS

European mental health disorders research represented less than 6% of the total biomedical research. We estimate that research expenditure in Europe on mental health disorders amounted to about €5.4 billion in 2018. The Scandinavian countries, with Croatia and Estonia, published the most relative to their wealth, but the outputs of France and Romania were less than half the amounts expected.

DISCUSSION AND CONCLUSIONS

The burden from mental health disorders is increasing rapidly in Europe, but research was only half what would have been proportional. Suicide & self-harm, and alcohol misuse, were also neglected by researchers, particularly since the latter also causes many physical burdens, such as foetal alcohol syndrome, interpersonal violence, and road traffic accidents. Other relatively neglected subjects are sexual disorders, obsessive compulsive disorder, post-traumatic stress disorder, attention-deficit hyperactivity and sleep disorders. There is an increasing volume of research on alternative (non-drug) therapies, particularly for post-traumatic stress and eating disorders, notably in Germany.

The efficacy and safety of 'antianxiety granule' for anxiety disorder: a multicentre, randomized, double-blind, placebo-controlled, parallel-group trial

BACKGROUND

Anxiety disorders are the most prevalent class of lifetime disorders in China, and generalized anxiety disorder (GAD) is one of the most common but frequently overlooked anxiety disorders. Conventional pharmacological treatments for GAD have varying degrees of side effects, dependency, and/or withdrawal syndromes. Traditional Chinese medicine (TCM) is considered a valuable therapeutic option for anxiety disorders and a potentially effective technique to reduce the side effects associated with antipsychotic drugs. This trial aimed to evaluate the clinical efficacy and safety of Antianxiety Granule, a granular Chinese medicine compound, for treatment of GAD.

METHODS/DESIGN

The current work is a multicentre, randomized, double-blind, placebo-controlled, parallel-group clinical trial with a 6-week treatment schedule. The study consists of three periods: a 1-7-day screening period, a 6-week primary treatment period, and a 1-week follow-up period. Follow-up assessments will be conducted 1 week after the last visit with a face-to-face interview or by telephone. The clinical efficacy of Antianxiety Granule for the treatment of GAD will be evaluated by examining the change in the Hamilton anxiety scale (HAMA) score, state-trait anxiety inventory (STAI) score, and TCM symptom scale in patients with GAD who receive daily TCM treatment. Moreover, an intention-to-treat (ITT) analysis will also be used in this randomized controlled trial (RCT).

DISCUSSION

Our study is a multicentre, randomized, double-blind, placebo-controlled, parallel-group trial to evaluate the safety and efficacy of Antianxiety Granule for the treatment of GAD. The results of this trial will provide valuable clinical evidence for the treatment of GAD.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR1800016039. Registered on 8 May 2018.

Prevalence and correlates of generalized anxiety disorder in Singapore: Results from the second Singapore Mental Health Study

The aim of this paper is to report findings on the epidemiology of generalized anxiety disorder (GAD) using data from the Singapore Mental Health Study (SMHS) 2016, and draw comparisons with results from the first SMHS in 2010. Singapore residents aged 18 years and above participated in the household survey where the WHO Composite International Diagnostic Interview 3.0 was administered to assess the prevalence of GAD and other mental health conditions. The findings revealed that the lifetime prevalence of GAD was 1.6% among the Singapore general population in 2016, an increase from the 0.9% in 2010. More lifetime GAD cases were reported across several sociodemographic groups including age and employment status. Lifetime GAD was significantly associated with higher odds of several comorbid psychiatric conditions (OR = 3.8-9.3, p < 0.05). Treatment seeking behavior did not differ significantly when compared to SMHS 2010 and there was still a considerable treatment gap among individuals with GAD. Future intervention programs to reduce anxiety and encourage help-seeking behavior could be implemented at institutes of higher learning and workplace settings to reach the targeted audience.

A comparison of DSM-5 and DSM-IV agoraphobia in the World Mental Health Surveys

BACKGROUND

The Diagnostic and Statistical Manual of Mental Disorders, version 5 (DSM-5) definition of agoraphobia (AG) as an independent diagnostic entity makes it timely to re-examine the epidemiology of AG. Study objective was to present representative data on the characteristics of individuals who meet DSM-IV criteria for AG (AG without a history of panic disorder [PD] and PD with AG) but not DSM-5 criteria, DSM-5 but not DSM-IV criteria, or both sets of criteria.

METHODS

Population-based surveys from the World Mental Health Survey Initiative including adult respondents (n = 136,357) from 27 countries across the world. The Composite International Diagnostic Interview was used to assess AG and other disorders.

RESULTS

Lifetime and 12-month prevalence estimates of DSM-5 AG (1.5% and 1.0%) were comparable to DSM-IV (1.4% and 0.9%). Of respondents meeting criteria in either system, 57.1% met criteria in both, while 24.2% met criteria for DSM-5 only and 18.8% for DSM-IV only. Severe role impairment due to AG was reported by a lower proportion of respondents who met criteria only for DSM-IV AG (30.4%) than those with both DSM-5 and DSM-IV AG (44.0%; χ ²₁  = 4.7; P = 0.031). The proportion of cases with any comorbidity was lower among respondents who met criteria only for DSM-IV AG (78.7%) than those who met both sets (92.9%; χ ²₁ = 14.5; P < 0.001).

CONCLUSIONS

This first large survey shows that, compared to the DSM-IV, the DSM-5 identifies a substantial group of new cases with AG, while the prevalence rate remains stable at 1.5%. Severity and comorbidity are higher in individuals meeting DSM-5 AG criteria compared with individuals meeting DSM-IV AG criteria only.

Enhanced cognitive control over task-irrelevant emotional distractors in generalized anxiety disorder versus obsessive-compulsive disorder

Generalized anxiety disorder (GAD) is defined in part by excessive and uncontrollable worry. However, little is known about cognitive control abilities in adults with GAD. The present study examined cognitive control over negative and neutral material in a mixed clinical sample of adults with GAD and/or obsessive-compulsive disorder and a comparison healthy control sample. Participants completed a novel emotional variant of the AX-CPT (eAX-CPT) to index proactive and reactive cognitive control in the presence of negative and neutral distractor stimuli. Participants with GAD demonstrated enhanced cognitive control specifically over negative emotional distractors, relative to neutral distractors (within-subjects) and relative to OCD and controls (between-subjects). Findings were specific to GAD versus trait worry; however, higher trait worry predicted better cognitive control in GAD only. These findings are inconsistent with deficit-based cognitive models of GAD and may be better accounted for by models that conceptualize worry as an intentional (albeit maladaptive) cognitive control or emotion regulation strategy that is actively maintained by individuals with GAD in order to avoid engaging with more distressing emotional information.

A meta-analytic review of cognitive processing therapy for adults with posttraumatic stress disorder

Numerous studies have demonstrated the efficacy of cognitive processing therapy (CPT) for treating posttraumatic stress disorder (PTSD). Two prior meta-analyses of studies are available but used approaches that limit conclusions that can be drawn regarding the impact of CPT on PTSD outcomes. The current meta-analysis reviewed outcomes of trials that tested the efficacy of CPT for PTSD in adults and evaluated potential moderators of outcomes. All published trials comparing CPT against an inactive control condition (i.e. psychological placebo or wait-list) or other active treatment for PTSD in adults were included, resulting in 11 studies with a total of 1130 participants. CPT outperformed inactive control conditions on PTSD outcome measures at posttreatment (mean Hedges' g = 1.24) and follow-up (mean Hedges' g = 0.90). The average CPT-treated participant fared better than 89% of those in inactive control conditions at posttreatment and 82% at follow-up. Results also showed that CPT outperformed inactive control conditions on non-PTSD outcome measures at posttreatment and follow-up and that CPT outperformed other active treatments at posttreatment but not at follow-up. Effect sizes of CPT on PTSD symptoms were not significantly moderated by participant age, number of treatment sessions, total sample size, length of follow-up, or group versus individual treatment; but, older studies had larger effect sizes and percent female sex moderated the effect of CPT on non-PTSD outcomes. These meta-analytic findings indicate that CPT is an effective PTSD treatment with lasting benefits across a range of outcomes.

Posttraumatic stress disorder as a growth industry: Comment on Asmundson and Asmundson (2018)

Asmundson and Asmundson's (2018) bibliometric study demonstrates that the anxiety disorders remain a major focus of clinical research. Yet striking differences emerged among these syndromes. For example, in contrast to panic disorder, posttraumatic stress disorder has increasingly flourished as a major focus of publications. The purpose of my commentary is to discuss the basis for the remarkable success of traumatology relative to other areas (e.g., panic disorder research).

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.

Obsessive-compulsive disorder research: Growing in scope, advances unclear

There has been impressive growth in scholarly research on obsessive-compulsive disorder (OCD). As a general rule, this can be construed as a sign of health in the subspecialty within anxiety disorder research. One factor that likely contributed to the growth in research on OCD was the observation that obsessional experiences can be placed on a dimension from normal to abnormal (or non-clinical to clinical) (Rachman and de Silva, 1978). While the dramatic growth in OCD research has led to increased sophistication in clinical conceptualization of various presentations of this heterogeneous condition, it has not led to a commensurate increase in the availability of efficacious treatment. This gap, between awareness of the disorder and delivery of evidence-based treatment, serves as a limiting factor in enthusiasm regarding the growth in research productivity on OCD as a sign of health in the subspecialty.

Research on social anxiety disorder continues to escalate: A commentary on Asmundson and Asmundson's analysis of publication trends in the anxiety disorders

Asmundson and Asmundson (2018) reported that publication of research on anxiety disorders, including social anxiety disorder (SAD), has seen rapid growth in the period between 2006 and 2016. In fact, the uptick in publication rate of SAD research was unexpectedly high given previous predictions by Boschen (2008), who reviewed publication trends from 1980 to 2005. In this commentary, we consider potential factors involved in the continued increase in publication of research on SAD. We examine the roles that empathy and evolutionary factors may play in our ability to relate to those with SAD and in our motivation to research it. Further, we consider whether the relatively high prevalence of SAD, the visibility of experiences of social anxiety in the general population, and the availability of viable theoretical models of SAD and its treatment have played a significant role in the high publication rate. Other factors affecting research on SAD such as changes in the definition of SAD in various editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), comorbidity which other psychiatric disorders, and the role of pharmaceutical company research are also discussed.