Psychodynamic profiles of major depressive disorder and generalized anxiety disorder in China

Traditional clinical diagnoses relying on symptoms may overlook latent factors that illuminate mechanisms and potentially guide treatment. The Operationalized Psychodynamic Diagnosis (OPD) system may compensate for symptom-based diagnosis by measuring psychodynamic profiles underlying mental disorders through conflicts and structure axes. However, OPD has not been widely adopted in China, and it remains unclear whether OPD can be used as an effective approach to distinguish between depression and anxiety. The current study aims to adopt the OPD system to investigate the psychodynamic profiles of major depressive disorder (MDD) and generalized anxiety disorder (GAD) in China, targeting patients with "pure" symptoms without comorbidity. We recruited 42 MDD patients, 32 GAD patients, and 31 healthy controls (HC), and assessed their self-report depression and anxiety symptoms, along with their underlying psychodynamic profiles through OPD interviews. Overall, both MDD and GAD patients showed more prominent conflict issues and lower levels of structure than HC. The MDD and GAD groups yielded different conflict profiles and conflict processing modes when processing their second conflicts. Importantly, the multi-dimensional psychodynamic profiles achieved machine learning classification of clinical groups with an accuracy of 0.84, supporting successful distinction of MDD and GAD patients. In conclusion, the OPD demonstrated sensitivity in revealing distinct psychodynamic profiles underlying "pure" depression and anxiety clinical populations in China. This work calls for future incorporation of OPD as a tool to investigate psychodynamic formulations underlying mental disorders, compensating for traditional symptom-based diagnostic approaches to guide precise individualized interventions.

Knowledge and Behavior of Primary Care Physicians Regarding Utilization of Standardized Tools in Screening and Assessment of Anxiety, Depression, and Mood Disorders at a Large Integrated Health System

INTRODUCTION

Standardized screening, objective evaluation, and management of behavioral health conditions are major challenges in primary care. The Generalized Anxiety Disorder Scale (GAD-7), Patient Health Questionnaire (PHQ-9), and Mood Disorder Questionnaire (MDQ) provide standardized screening and symptom management tools for generalized anxiety disorder (GAD), major depressive disorder (MDD), and Mood Disorders (MD), respectively. This study explores family physicians' knowledge, attitudes, and practices regarding the utilization of GAD-7, PHQ-9, and MDQ in outpatient primary care offices.

METHODS

The study method was a cross-sectional electronic and paper survey utilizing a self-administered questionnaire that assessed primary care physicians' demographics, knowledge, attitudes, and practices in rural and urban outpatient clinical settings regarding GAD-7, PHQ-9, and MDQ. Statistical software SAS 9.4 was used for descriptive and Chi-Square statistics.

RESULTS

Out of 320 total participants,145 responded (45.3%). Responding family physicians demonstrated a high level of familiarity with the GAD-7 (97.9%), PHQ-9 (97.9%), and MDQ (81.3%) assessment tools. However, the reported utilization rates were relatively lower than knowledge, with 62.7%, 73.1%, and 31.9% extremely likely or likely to utilize the GAD-7, PHQ-9, and MDQ as screening and monitoring tools, respectively. Less than a quarter of the total respondents use the objective score for the future management of GAD, with significantly more residents utilizing the score for GAD-7 compared to attendings (P < .05). There was no statistical significance difference between residents and attendings for the objective evaluation of Major Depressive Disorder (P = .26) and Mood Disorders (P = .05).

CONCLUSIONS

Despite being knowledgeable of the utility of GAD-7, PHQ-9, and MDQ, the primary care physicians in a large integrated health system in Central Pennsylvania and Northern Maryland report inconsistent utilization in their practice. Further studies are needed to determine the underlying factors contributing to the suboptimal usage of these screening tools and ways to increase it.

Enhancing generalized anxiety disorder diagnosis precision: MSTCNN model utilizing high-frequency EEG signals

Generalized Anxiety Disorder (GAD) is a prevalent mental disorder on the rise in modern society. It is crucial to achieve precise diagnosis of GAD for improving the treatments and averting exacerbation. Although a growing number of researchers beginning to explore the deep learning algorithms for detecting mental disorders, there is a dearth of reports concerning precise GAD diagnosis. This study proposes a multi-scale spatial-temporal local sequential and global parallel convolutional model, named MSTCNN, which designed to achieve highly accurate GAD diagnosis using high-frequency electroencephalogram (EEG) signals. To this end, 10-min resting EEG data were collected from 45 GAD patients and 36 healthy controls (HC). Various frequency bands were extracted from the EEG data as the inputs of the MSTCNN. The results demonstrate that the proposed MSTCNN, combined with the attention mechanism of Squeeze-and-Excitation Networks, achieves outstanding classification performance for GAD detection, with an accuracy of 99.48% within the 4-30 Hz EEG data, which is competitively related to state-of-art methods in terms of GAD classification. Furthermore, our research unveils an intriguing revelation regarding the pivotal role of high-frequency band in GAD diagnosis. As the frequency band increases, diagnostic accuracy improves. Notably, high-frequency EEG data ranging from 10-30 Hz exhibited an accuracy rate of 99.47%, paralleling the performance of the broader 4-30 Hz band. In summary, these findings move a step forward towards the practical application of automatic diagnosis of GAD and provide basic theory and technical support for the development of future clinical diagnosis system.

Cardioautonomic lability assessed by heart rate variability changes in Royal Canadian Mounted Police cadets during the cadet training program

Objective

The current study examined variations in cardioautonomic lability during the Royal Canadian Mounted Police (RCMP) Cadet Training Program (CTP) between cadets starting their training who did or did not screen positive for one or more mental health disorders (i.e., posttraumatic stress disorder [PTSD], major depressive disorder [MDD], social anxiety disorder [SAD], generalized anxiety disorder [GAD], panic disorder [PD], alcohol use disorder [AUD]).

Methods

Electrocardiogram (ECG) signals integrated into Hexoskin garments were used to record ECG and heart rate Over the 26-week CTP. There were 31 heart rate variability (HRV) parameters calculated using Kubios Premium HRV analysis software. Mann-Whitney U-tests were used to perform groupwise comparisons of participant raw values and HRV during the CTP.

Results

A total of 157 cadets (79% male) were screened for any mental disorder using self-report surveys and then grouped by positive and negative screening. Analyses indicated a statistically significant (p < 0.05) decrease in low frequency (LF): High Frequency (HF) variability during CTP, but only for cadets who endorsed clinically significant anxiety symptoms on the GAD-7 at the start of their training. There were no other statistically significant groupwise differences.

Conclusion

The results indicate the participants have excellent cardiac health overall and suggest potentially important differences between groups, such that cadets who endorsed clinically significant anxiety symptoms on the GAD-7 showed less variability in the LF:HF ratio over the course of the CTP. The relatively lower variability suggests decreased parasympathetic tone in those without clinically significant anxiety symptoms. The results also have important implications for future investigations of cardioautonomic dysfunction and chronic hypothalamic pituitary adrenal (HPA) axis deviations in policing populations with anxiety disorders; specifically, cardioautonomic inflexibility related to cardiovascular morbidity and mortality. In any case, the current results provide an important baseline for future cardiac research with cadets and serving officers.

Neuroimaging Study of Brain Functional Differences in Generalized Anxiety Disorder and Depressive Disorder

Generalized anxiety disorder (GAD) and depressive disorder (DD) are distinct mental disorders, which are characterized by complex and unique neuroelectrophysiological mechanisms in psychiatric neurosciences. The understanding of the brain functional differences between GAD and DD is crucial for the accurate diagnosis and clinical efficacy evaluation. The aim of this study was to reveal the differences in functional brain imaging between GAD and DD based on multidimensional electroencephalogram (EEG) characteristics. To this end, 10 min resting-state EEG signals were recorded from 38 GAD and 34 DD individuals. Multidimensional EEG features were subsequently extracted, which include power spectrum density (PSD), fuzzy entropy (FE), and phase lag index (PLI). Then, a direct statistical analysis (i.e., ANOVA) and three ensemble learning models (i.e., Random Forest (RF), Light Gradient Boosting Machine (LightGBM), eXtreme Gradient Boosting (XGBoost)) were used on these EEG features for the differential recognitions. Our results showed that DD has significantly higher PSD values in the alpha1 and beta band, and a higher FE in the beta band, in comparison with GAD, along with the aberrant functional connections in all four bands between GAD and DD. Moreover, machine learning analysis further revealed that the distinct features predominantly occurred in the beta band and functional connections. Here, we show that DD has higher power and more complex brain activity patterns in the beta band and reorganized brain functional network structures in all bands compared to GAD. In sum, these findings move towards the practical identification of brain functional differences between GAD and DD.

Examining Associations Between Metacognitive Beliefs and Type II Worry: The Specificity of Negative Metacognitive Beliefs to State Type II Worry During a Worry Episode

The metacognitive model of generalized anxiety disorder (GAD) considers Type II worry, which represents one's tendency to negatively appraise worry, as a defining feature of GAD, and negative metacognitive beliefs are central to eliciting Type II worry during worry episodes. Extant research has found that individuals experiencing GAD report elevated Type II worry, and that negative metacognitive beliefs correlate with Type II worry. However, because of how Type II worry was assessed in existing studies, it remains unclear if negative metacognitive beliefs relate to state Type II worry specifically during a worry episode. This study sought to fill that gap in the existing literature among a sample of individuals experiencing elevated GAD symptom severity (N = 106). Participants completed an assessment of GAD symptom severity and metacognitive beliefs, while later attending an in-person study session where they completed a worry induction and state Type II worry, as conceptualized as the strength of negative appraisals of worry, which was then assessed. Metacognitive beliefs generally positively correlated with state Type II worry, with negative metacognitive beliefs being the only metacognitive belief domain that correlated with state Type II worry in multivariate analyses. Implications for how these results support the metacognitive model of GAD and treatment implications are discussed.

Child Tax Credit, Spending Patterns, and Mental Health: Mediation Analyses of Data from the U.S. Census Bureau's Household Pulse Survey during COVID-19

This study examined the relationship between the receipt of COVID-19 child tax credit and adult mental health problems in the United States, and we explored whether and the extent to which a wide range of spending patterns of the credit-15 patterns regarding basic necessities, child education, and household expenditure-mediated the relationship. We used COVID-19-specialized data from the U.S. Census Bureau's Household Pulse Survey, a representative population sample (N = 98,026) of adult respondents (18 and older) who participated between 21 July 2021 and 11 July 2022. By conducting mediation analyses with logistic regression, we found relationships between the credit and lower levels of anxiety (odds ratio [OR] = 0.914; 95% confidence interval [CI] = 0.879, 0.952). The OR was substantially mediated by spending on basic necessities such as food and housing costs (proportion mediated = 46% and 44%, respectively). The mediating role was relatively moderate in the case of spending on child education and household expenditure. We also found that spending the credit on savings or investments reduces the effect of the child tax credit on anxiety (-40%) while donations or giving to family were not a significant mediator. Findings on depression were consistent with anxiety. The child tax credit-depression relationships were substantially mediated by spending on food and housing (proportion mediated = 53% and 70%). These mediation analyses suggested that different patterns of credit spending are important mediators of the relationship between the receipt of the child tax credit and mental illnesses. Public health approaches to improve adult mental health during and after the COVID-19 pandemic need to consider the notable mediating role of spending patterns.

Rate and Predictors of Intractable Status Migrainosus among Patients Aged 13-18 Years

Purpose

To assess associations for intractable status migrainosus in the pediatric inpatient setting.

Methods

A retrospective cohort study of 1,805 patients presenting to the pediatric hospital in Dayton, Ohio with status migrainosus from 2017 to 2022, was performed. Among 1,805 patients, 159 received 3 lines of sequentially more aggressive abortive migraine treatment and were included in this analysis. Responders and non-responders were categorized based on a visual analogue scale (VAS) of pain scores from time of admission to discharge with responders having a reduction of 50% or greater in VAS. Patient demographic information, migraine history, headache type, medication history, self-reported pain, anxiety level and co-morbidities were assessed.

Results

Out of 159 patients, 125 (78.6%) achieved the target pain control with decrease in VAS pain score by ≥ 50% from the baseline. The remaining 34/159 (21.4%) patients remained refractory to treatment. Non-responder patients had a longer hospital stay (6.1 days) and greater readmission rate within 7 days (17.6%) compared to responders (4.7 days and .8% respectively). Among the non-responder patients, 14/34 (41.2%) had attention-deficit/hyperactivity disorder (ADHD) compared to the responder group in which 17/125 (13.6%) had ADHD. Among patients who had comorbidity of anxiety, non-responders had greater severe generalized anxiety disorder (GAD-7 ≥15) (6/14, 42.9%) than responders (2/39, 5.1%).

Conclusion

ADHD and severe GAD are associated with poorer response to treatment in pediatric patients with refractory migraine admitted for inpatient therapy. This study highlights the prolonged hospital stay and modest clinical outcomes seen with intractable migraine in 13-18-year-old pediatric patients.

Difference analysis of multidimensional electroencephalogram characteristics between young and old patients with generalized anxiety disorder

Growing evidences indicate that age plays an important role in the development of mental disorders, but few studies focus on the neuro mechanisms of generalized anxiety disorder (GAD) in different age groups. Therefore, this study attempts to reveal the neurodynamics of Young_GAD (patients with GAD under the age of 50) and Old_GAD (patients with GAD over 50 years old) through statistical analysis of multidimensional electroencephalogram (EEG) features and machine learning models. In this study, 10-min resting-state EEG data were collected from 45 Old_GAD and 33 Young_GAD. And multidimensional EEG features were extracted, including absolute power (AP), fuzzy entropy (FE), and phase-lag-index (PLI), on which comparison and analyses were performed later. The results showed that Old_GAD exhibited higher power spectral density (PSD) value and FE value in beta rhythm compared to theta, alpha1, and alpha2 rhythms, and functional connectivity (FC) also demonstrated significant reorganization of brain function in beta rhythm. In addition, the accuracy of machine learning classification between Old_GAD and Young_GAD was 99.67%, further proving the feasibility of classifying GAD patients by age. The above findings provide an objective basis in the field of EEG for the age-specific diagnosis and treatment of GAD.

Mental Health and Quality of Life among Dental Students during COVID-19 Pandemic: A Cross-Sectional Study

Students are particularly vulnerable from the mental health aspect, which was especially recognized during the COVID-19 pandemic. This study aimed to reveal the impact of COVID-19 on quality of life (QoL) and mental health among dental students. The study was conducted on a sample of 797 students (207 male and 592 female) with an average age of 21.7 ± 2.4, from the School of Dental Medicine, University of Belgrade. The measurements used in the study were the Demographic and Academic Questionnaire, Questionnaire about exposure to COVID-19, COVID-19-Impact on QoL Questionnaire (COV19-QoL), Generalized Anxiety Disorder 7-item (GAD-7) scale, and Patient Health Questionnaire (PHQ-9). The mean total score for COV19-QoL was 2.9 ± 0.9, while the diagnostic criteria of GAD-7 and depression met 19.9% and 31.4% of students, respectively. There was a positive and strong correlation between QoL, anxiety, and depression. During COVID-19, predictors for lower perceptions of QoL were female gender and death of close relatives (p = 0.049, p = 0.005, respectively). At the same time, predictors for GAD were female gender, living in dormitories, and death of close relatives (p = 0.019, p = 0.011, p = 0.028, respectively), while for depression they were year of study, living with parents, and death of close relatives due to COVID-19 (p = 0.012, p = 0.008, p = 0.029, respectively). The study showed that students' QoL and mental health during the pandemic were at high risk.

Aberrated Multidimensional EEG Characteristics in Patients with Generalized Anxiety Disorder: A Machine-Learning Based Analysis Framework

Although increasing evidences support the notion that psychiatric disorders are associated with abnormal communication between brain regions, scattered studies have investigated brain electrophysiological disconnectivity of patients with generalized anxiety disorder (GAD). To this end, this study intends to develop an analysis framework for automatic GAD detection through incorporating multidimensional EEG feature extraction and machine learning techniques. Specifically, resting-state EEG signals with a duration of 10 min were obtained from 45 patients with GAD and 36 healthy controls (HC). Then, an analysis framework of multidimensional EEG characteristics (including univariate power spectral density (PSD) and fuzzy entropy (FE), and multivariate functional connectivity (FC), which can decode the EEG information from three different dimensions) were introduced for extracting aberrated multidimensional EEG features via statistical inter-group comparisons. These aberrated features were subsequently fused and fed into three previously validated machine learning methods to evaluate classification performance for automatic patient detection. We showed that patients exhibited a significant increase in beta rhythm and decrease in alpha1 rhythm of PSD, together with the reduced long-range FC between frontal and other brain areas in all frequency bands. Moreover, these aberrated features contributed to a very good classification performance with 97.83 ± 0.40% of accuracy, 97.55 ± 0.31% of sensitivity, 97.78 ± 0.36% of specificity, and 97.95 ± 0.17% of F1. These findings corroborate previous hypothesis of disconnectivity in psychiatric disorders and further shed light on distribution patterns of aberrant spatio-spectral EEG characteristics, which may lead to potential application of automatic diagnosis of GAD.

Validation of the generalized anxiety disorder scales (GAD-7 and GAD-2) in primary care settings in Latvia

BACKGROUND

Anxiety disorders are the most prevalent mental disorders in the world and have an important impact on the global burden of disease. Generalized anxiety disorder (GAD) is the most prevalent anxiety disorder encountered in primary care. There are no available validated anxiety screening tools in primary care in Latvia. We aimed to validate both a seven-item and a two-item generalized anxiety disorder scale (GAD-7 and GAD-2) in the Latvian and Russian languages, to detect generalized anxiety disorder (GAD) in primary care settings in Latvia.

METHODS

During a 1-week period, all patients aged 18 years or older visiting their GP (general practitioners) with any health concern at 24 primary care settings throughout Latvia were invited to complete the GAD-7 in their native language (Latvian or Russian). Criterion validity was assessed against the Mini International Neuropsychiatric Interview (MINI).

RESULTS

The study sample included 1,459 participants who completed the GAD-7 and the MINI. The GAD-7 items showed good internal reliability [Cronbach's alpha 0.87 for Latvian version and 0.85 for Russian version (for Latvia) of the GAD-7]. A cut-off score for detecting GAD of 5 or above was estimated for Latvian version of the GAD-7 (sensitivity 75.4%, specificity 68.9%, respectively) and 7 or above for Russian version of the GAD-7 (sensitivity 73.3%, specificity 84.1%, respectively). The internal reliability of the GAD-2 was lower for both languages (Cronbach's alpha 0.75 for Latvian version and 0.68 for Russian version of the GAD-2). A cut-off score of 2 or above was established for both the Latvian, and Russian versions of the GAD-2 (sensitivity 78.9 and 83.3%; specificity 63.7 and 69.1% for the Latvian and Russian versions of the GAD-2, accordingly) for detecting GAD.

CONCLUSIONS

This is the first study to report criterion validity of the Latvian and Russian (for Latvia) versions of the GAD-7 and GAD-2, assessed in a nationwide study conducted at the primary care level.

Increased Intra-Individual Variability as a Marker of Executive Dysfunction in Generalized Anxiety Disorder

Recent studies suggest that individual difference in intra-individual variability (IIV) of reaction times is an important indicator of attentional executive control. However, there are few existing studies on the executive control of high trait-anxious individuals assessed by using reaction time variability. This study assessed whether executive functions are impaired among clinical and non-clinical trait-anxious individuals indicated by IIV. The cross-reliability and discriminative power of three IIV parameters (raw intra-individual standard deviation, SD; reaction time coefficient of variation, RTCV; and mean absolute deviation, MAD) were compared. Twenty-five non-clinical individuals with low trait anxiety (LTA), 31 non-clinical individuals with high trait anxiety (HTA), and 19 clinical patients diagnosed with generalized anxiety disorder (GAD) finished self-reported measures, an emotional spatial-cuing task, and a non-emotional arrow flanker task. In the emotional task, GAD patients had significantly slower response speed, lower accuracy, and greater IIV parameters than the LTA and HTA groups. In the non-emotional task, the GAD group exhibited poorer processing efficiency, greater SD and RTCV, and intact performance effectiveness. RTCV is suggested to be a better marker of executive dysfunction than SD and MAD due to its good discriminative power and reliability as well as less affected by reaction times.

Pharmacogenetically Guided Escitalopram Treatment for Pediatric Anxiety Disorders: Protocol for a Double-Blind Randomized Trial

Current pharmacologic treatments for pediatric anxiety disorders (e.g., selective serotonin reuptake inhibitors (SSRIs)) frequently use "one size fits all" dosing strategies based on average responses in clinical trials. However, for some SSRIs, including escitalopram, variation in CYP2C19 activity produces substantial variation in medication exposure (i.e., blood medication concentrations). This raises an important question: would refining current SSRI dosing strategies based on CYP2C19 phenotypes increase response and reduce side effect burden? To answer this question, we designed a randomized, double-blind trial of adolescents 12-17 years of age with generalized, separation, and/or social anxiety disorders (N = 132). Patients are randomized (1:1) to standard escitalopram dosing or dosing based on validated CYP2C19 phenotypes for escitalopram metabolism. Using this approach, we will determine whether pharmacogenetically-guided treatment-compared to standard dosing-produces faster and greater reduction in anxiety symptoms (i.e., response) and improves tolerability (e.g., decreased risk of treatment-related activation and weight gain). Secondarily, we will examine pharmacodynamic variants associated with treatment outcomes, thus enhancing clinicians' ability to predict response and tolerability. Ultimately, developing a strategy to optimize dosing for individual patients could accelerate response while decreasing side effects-an immediate benefit to patients and their families. ClinicalTrials.gov Identifier: NCT04623099.

A cross-sectional study on generalized anxiety disorder and its socio-demographic correlates among the general population in Saudi Arabia

BACKGROUND

Generalized anxiety disorder (GAD) is often described than define as a psychological illness that is characterized by excessive worry. Little attention has been given to anxiety disorders by the medical community in Saudi Arabia. This study was carried out to screen for GAD among adults and determine the correlation of anxiety disorder with other comorbidities.

METHODOLOGY

This study was a cross-sectional observational study carried out among adults aged 18 years and above in the general population in Saudi Arabia. The people were screened by using an Arabic validated version of General Anxiety Disorder-7 (GAD-7) questionnaire that was sent as a Google link via emails or different social media (Twitter, Facebook, WhatsApp, and Telegram groups) of the general population. The study was approved by the hospital research committee and the Institutional Review Board (HlRI-05-Apr21-01).

RESULTS

We collected 338 participants in response to our questionnaire where 60.7% of them were females and 54.5% were aged between 25 and 34 years old. hypersensitivity, rheumatoid arthritis (RA), hypertension and diabetes mellitus (DM) were the main medical conditions represented by 7.6%, 4.8%, 3.7%, and 3.4%. According to GAD-7 questionnaire, prevalence of any degree of anxiety was 62.1% where 33.1% of the total sample had mild anxiety, 15.7% had a moderate degree of anxiety and 13.3% had severe anxiety. Anxiety was related to age, residency, occupation, and some medical conditions.

CONCLUSION

We found high prevalence of anxiety among our population which was the highest among younger participants, and students. Moreover, we found that prevalence and severity of anxiety were higher in patients with chronic conditions and depressed patients.

Comorbid anxiety and depression: Opposing effects on the electrocortical processing of negative imagery in a focal fear sample

BACKGROUND

Anxiety and depression are highly comorbid and share clinical characteristics, such as high levels of negative emotion. Attention toward negative stimuli in anxiety and depression has been studied primarily using negative pictures. Yet, negative mental imagery-that is, mental representations of imagined negative events or stimuli-might more closely mirror patient experience.

METHODS

The current study presents the first examination of neural response to negative imagery in 57 adults (39 female) who all shared a common "focal fear" diagnosis (i.e., specific phobia or performance-only social anxiety disorder), but varied in levels of comorbid anxiety and depression. After listening to standardized descriptions of negative and neutral scenes, participants imagined these scenes as vividly as possible. Associations between categorical and continuous measures of depression, generalized anxiety disorder (GAD), and social anxiety disorder with electrocortical and subjective responses to negative imagery were assessed.

RESULTS

Individuals who were more depressed showed reduced electrocortical processing of negative imagery, whereas those with GAD showed increased electrocortical processing of negative imagery-but only when controlling for depression. Furthermore, participants with higher levels of depression rated negative imagery as less negative and those with greater social anxiety symptoms rated negative imagery more negatively.

CONCLUSIONS

Depression and GAD are characterized by opposing electrocortical response to negative imagery; moreover, depression may suppress GAD-related increases in the electrocortical processing of negative imagery. Results highlight distinctions between different dimensions of distress-based psychopathology, and reveal the unique and complex contribution of comorbid depression to affective response in anxiety.

Case Report: Neuropsychiatric Symptoms in PKU Disease

Phenylketonuria is a rare inborn error of metabolism. The build-up of phenylalanine in the blood and body tissues can have significant impact on the brain's development. High phenylalanine levels have been shown to be associated with an increase in neuropsychiatric symptoms, including mood, anxiety, and attention problems; decreased social competence; and low self-esteem. This case report highlights such a presentation in an adolescent with phenylketonuria.

Six-month prevalence and correlates of generalized anxiety disorder among primary care patients aged 70 years and above: Results from the ESA-services study

OBJECTIVES

To estimate the 6-month prevalence of generalized anxiety disorder (GAD) in primary care patients aged 70 years and above and to describe their clinical profile, including types of worries.

METHODS/DESIGN

Participants (N = 1193) came from the Étude sur la Santé des Aînés (ESA) services study conducted in Quebec, Canada. An in-person structured interview was used to identify GAD and other anxiety/depressive disorders as well as to identify types of worries. Three groups were created (ie, patients with GAD, patients with another anxiety disorder, and patients without anxiety disorders) and compared on several sociodemographic and clinical characteristics using multinomial logistic regression analyses.

RESULTS

The 6-month prevalence of GAD was 2.7%. Findings also indicated that the most common types of worries were about health, being a burden for loved ones, and losing autonomy. Compared with respondents without anxiety disorders, older patients with GAD were more likely to be women, be more educated, suffer from depression, use antidepressants, be unsatisfied with their lives, and use health services. In comparison with respondents with another anxiety disorder, those with GAD were 4.5 times more likely to suffer from minor depression.

CONCLUSIONS

GAD has a high prevalence in primary care patients aged 70 years and above. Clinicians working in primary care settings should screen for GAD, since it remains underdiagnosed. In addition, it may be associated with depression and life dissatisfaction. Screening tools for late-life GAD should include worry themes that are specific to aging.

The Impact of Antidepressant Dose and Class on Treatment Response in Pediatric Anxiety Disorders: A Meta-Analysis

OBJECTIVE

To determine the trajectory and magnitude of antidepressant response as well as the effect of antidepressant class and dose on symptomatic improvement in pediatric anxiety disorders.

METHOD

Weekly symptom severity data were extracted from randomized, parallel group, placebo-controlled trials of selective serotonin reuptake inhibitors (SSRIs) and selective serotonin-norepinephrine reuptake inhibitors (SNRIs) in pediatric anxiety disorders. Treatment response was modeled for the standardized change in continuous measures of anxiety using Bayesian updating. Posterior distributions for each study served as informative conjugate prior to distributions update subsequent study posteriors. Change in symptom severity was evaluated as a function of time, class and, for SSRIs, standardized dose.

RESULTS

Data from 9 trials (SSRIs: n = 5; SNRIs, n = 4) evaluating 7 medications in 1,673 youth were included. In the logarithmic model of treatment response, statistically, but not clinically, significant treatment effects emerged within 2 weeks of beginning treatment (standardized medication-placebo difference = -0.054, credible interval [CI] = -0.076 to -0.032, p = .005, approximate Cohen's d ≤ 0.2) and by week 6, clinically significant differences emerged (standardized medication-placebo difference = -0.120, CI = -0.142 to -0.097, p = .001, approximate Cohen's d = 0.44). Compared to SNRIs, SSRIs resulted in significantly greater improvement by the second week of treatment (p = .0268), and this advantage remained statistically significant through week 12 (all p values <.03). Improvement occurred earlier with high-dose SSRI treatment (week 2, p = .002) compared to low-dose treatment (week 10, p = .025), but SSRI dose did not have an impact on overall response trajectory (p > .18 for weeks 1-12).

CONCLUSIONS

In pediatric patients with generalized, separation, and/or social anxiety disorders, antidepressant-related improvement occurred early in the course of treatment, and SSRIs were associated with more rapid and greater improvement compared to SNRIs.

Buspirone in Children and Adolescents with Anxiety: A Review and Bayesian Analysis of Abandoned Randomized Controlled Trials

OBJECTIVES

An increasing number of abandoned clinical trials have forestalled efforts to advance the evidence base for the treatment of mood and anxiety disorders in children and adolescents. With this in mind, we sought to present and validate a Bayesian approach for the reanalysis of summary data in abandoned clinical trials and to review and re-evaluate available pharmacokinetic, tolerability, and efficacy data from two large, randomized controlled trials of buspirone in pediatric patients with generalized anxiety disorder (GAD).

METHODS

Prospective, randomized, parallel-group controlled trials of buspirone in pediatric patients with GAD as well as associated pharmacokinetic studies were identified and data were extracted. In addition to descriptive statistics, marginal posterior densities for each variable of interest were determined and a Monte Carlo pseudosample was generated with random draws obtained from the Student's t-distribution to assess, with inferential statistics, differences in variables of interest.

RESULTS

Buspirone was evaluated in one flexibly dosed (N = 227) and one fixed-dose (N = 341) trial in children and adolescents aged 6-17 years with a primary diagnosis of GAD. With regard to improvement in the sum of the Columbia Schedule for Affective Disorders and Schizophrenia GAD items, buspirone did not separate from placebo in the fixed-dose trial at low (95% CI: -0.78 to 2.39, p = 0.32) or high dose (95% CI: -0.87 to 1.87, p = 0.47) nor did it separate from placebo in the flexibly dosed study (95% CI: -0.3 to 1.9, p = 0.15). Drop out as a result of a treatment-emergent adverse event was significantly greater in buspirone-treated patients compared to placebo (p = 0.011). Side effects were consistent with the known profile of buspirone with lightheadedness occurring more frequently in buspirone-treated patients (p < 0.001).

CONCLUSIONS

Buspirone is well tolerated in pediatric patients with GAD, although two randomized controlled trials were underpowered to detect small effect sizes (Cohen's d < 0.15). Finally, Bayesian approaches may facilitate re-examination of data from abandoned clinical trials.

Treatment-emergent sexual dysfunction in randomized trials of vortioxetine for major depressive disorder or generalized anxiety disorder: a pooled analysis

OBJECTIVE

Antidepressants are frequently associated with treatment-emergent sexual dysfunction (TESD). Vortioxetine, which was approved for patients with major depressive disorder (MDD), has a receptor profile that suggests limited impact on sexual functioning.

METHODS

Arizona Sexual Experiences Scale (ASEX) patient-level data were pooled from 7 short-term vortioxetine trials (6 in MDD, 1 in generalized anxiety disorder) and analyzed for incidence of TESD at any post-baseline visit in patients without sexual dysfunction at baseline (defined as ASEX total score ≥19; individual ASEX item score ≥5; or a score ≥4 on any 3 ASEX items). The primary objective was to confirm the non-inferiority of vortioxetine 5-20 mg/day to placebo on the incidence of TESD. Comparisons were based on the common risk difference (95% confidence interval). Additional analyses compared vortioxetine to duloxetine and duloxetine to placebo. A sensitivity analysis, defined as TESD at 2 consecutive post-baseline visits, was conducted.

RESULTS

TESD incidence, relative to placebo, generally increased with vortioxetine dose with vortioxetine 5 mg non-inferior to placebo. Vortioxetine 10, 15, and 20 mg did not meet the non-inferiority criterion, but no dose had a significantly higher risk of developing TESD versus placebo. Changes in ASEX individual item scores supported the similarity of vortioxetine doses to placebo. Significantly higher TESD risk occurred with duloxetine 60 mg/day versus placebo and versus vortioxetine 5 or 10 mg. The sensitivity analysis was generally consistent with the primary analysis. Rates of spontaneously reported sexual adverse events were low.

CONCLUSIONS

Vortioxetine was associated with rates of TESD that were not significantly different from placebo in short-term clinical trials.

Clinical experiences in conducting empirically supported treatments for generalized anxiety disorder

Knowledge of the efficacy of cognitive-behavioral therapy (CBT) for generalized anxiety disorder (GAD) predominantly derives from randomized controlled trials (RCTs). However, there may be unique or complex issues encountered in practice, but not necessarily in the context of a controlled clinical trial. Therefore, launching a systematic dialogue between researcher and practicing clinician can be instrumental in augmenting evidence-based therapies through identification of variables that promote and interfere with clinical effectiveness. Through an initiative sponsored by the American Psychological Association's Divisions 12 (Society for Clinical Psychology) and 29 (Psychotherapy), this study aimed to examine clinical experiences conducting CBT for GAD. The participants were 260 psychotherapists who completed an online survey on assessment and therapeutic intervention utilization and their experience of factors that limit successful GAD treatment and symptom reduction. The majority of respondents reported 20 years or less experience using ESTs for GAD, typically treating clients in outpatient clinics, treatment centers, and private practice. Some of the most commonly used interventions address clients' maladaptive cognitions and elevated anxiety and muscle tension typical of GAD. Approximately one half of respondents reported incorporating integrative techniques into treatment. Factors perceived as limiting effective GAD treatment included severity and chronicity of GAD, presence of comorbid conditions, stressful home and work environments, client motivation and resistance to treatment, and issues encountered when executing therapy techniques. This study provides researchers with clinically derived directions for future empirical investigation into enhancing efficacy of GAD treatment.