Treat Anxiety in Patients With Depressive, Bipolar Disorders

SANTA FE, N.M. — Anxiety disorders are a common comorbidity that lead to worse outcomes for patients with major depressive and bipolar disorders, speakers warned at a psychiatric symposium sponsored by the University of Arizona.

Dr. A. John Rush reported that more than half, 53%, of 2,876 depressed patients in the first phase of the STAR*D trial had anxious depression (Am. J. Psychiatry 2006;163:28–40).

Anxious patients were significantly less likely to achieve remission on their first medication for depression (odds ratio 0.77), according to Dr. Rush, principal investigator of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial.

Each of the comorbid anxiety disorders was associated with a lower remission rate. Posttraumatic stress disorder (PTSD) had the most negative effect (OR 0.6). Only social phobia did not have a significant impact, though it also reduced the odds of remission (OR 0.87).

“A person coming in with anxiety disorder takes longer and is less likely to remit,” said Dr. Rush, a distinguished professor in mental health at the University of Texas Southwestern Medical Center in Dallas.

About half of bipolar depression patients also had an anxiety disorder, according to an analysis of the first 500 patients in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) trial, another large multicenter study supported by the National Institute of Mental Health. Lifetime prevalence was 51%, and 31% had a current anxiety disorder when they entered the study.

Bipolar patients with comorbid anxiety were significantly more likely to have a history of suicide attempts, said Dr. Gary Sachs, principal investigator of STEP-BD and director of the Bipolar Clinic and Research Program at Massachusetts General Hospital in Boston.

The rate of suicide attempts was 52% in patients with lifetime anxiety disorder, compared with 22% in patients who did not have a history of anxiety disorder. The highest rate, 65%, was in patients with a history of posttraumatic stress disorder (Am. J. Psychiatry 2004;161:2222–9).

Bipolar patients with lifetime anxiety disorders also had an earlier age of bipolar onset, 15.6 years vs. 19.4 years in patients who did not have a history of anxiety disorder, Dr. Sachs said at the meeting, which also was sponsored by the University of Texas Southwestern Medical Center at Dallas and the University of New Mexico.

Length of recovery was shorter as well in patients with a history of anxiety disorder. Their longest mean period of euthymia was 183 days, compared with 254 days for patients without lifetime anxiety.

Dr. Murray B. Stein called for greater efforts to treat comorbid anxiety in patients with mood disorders. About 50%–60% of people with mood disorders also have an anxiety disorder, according to Dr. Stein, director of the Anxiety and Traumatic Stress Disorders Program at the University of California, San Diego. Conversely, he estimated that 80%–90% of people with general anxiety disorder will also have major depression at some point, and most had the anxiety disorder first.

Though anxiety is an early-onset disorder, he noted that it is rarely studied in children. In one of the few studies that did so, he said, nearly two-thirds of children with social anxiety disorder responded to a selective serotonin reuptake inhibitor (SSRI), and nearly as many went into remission.

Most antidepressants relieve symptoms in adult patients with anxiety disorders, Dr. Stein said, possibly because they treat both syndromes. “You get some benefit, but you don't get a really robust response,” he said of SSRIs used in PTSD. Though SSRIs have been shown to be better than placebo for general anxiety disorder, he said the benefit likewise was not robust.

As benzodiazepines are effective for anxiety disorders, he suggested they might also treat depression. “We were taught it is important to separate anxiety and depression because benzodiazepines could make people worse. I don't think there are any data that benzodiazepines make people worse.”

Other classes of medication, including anticonvulsants, are sometimes used for resistant anxiety disorders, but Dr. Stein said more information is needed about their safety and effectiveness.

Cognitive-behavioral therapy should be considered as an adjunct or an alternative to medication for anxiety disorders, he added. “The best cognitive-behavioral therapy is as good as the best medication we can provide.”

SANTA FE, N.M. — Anxiety disorders are a common comorbidity that lead to worse outcomes for patients with major depressive and bipolar disorders, speakers warned at a psychiatric symposium sponsored by the University of Arizona.

Dr. A. John Rush reported that more than half, 53%, of 2,876 depressed patients in the first phase of the STAR*D trial had anxious depression (Am. J. Psychiatry 2006;163:28–40).

Anxious patients were significantly less likely to achieve remission on their first medication for depression (odds ratio 0.77), according to Dr. Rush, principal investigator of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial.

Each of the comorbid anxiety disorders was associated with a lower remission rate. Posttraumatic stress disorder (PTSD) had the most negative effect (OR 0.6). Only social phobia did not have a significant impact, though it also reduced the odds of remission (OR 0.87).

“A person coming in with anxiety disorder takes longer and is less likely to remit,” said Dr. Rush, a distinguished professor in mental health at the University of Texas Southwestern Medical Center in Dallas.

About half of bipolar depression patients also had an anxiety disorder, according to an analysis of the first 500 patients in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) trial, another large multicenter study supported by the National Institute of Mental Health. Lifetime prevalence was 51%, and 31% had a current anxiety disorder when they entered the study.

Bipolar patients with comorbid anxiety were significantly more likely to have a history of suicide attempts, said Dr. Gary Sachs, principal investigator of STEP-BD and director of the Bipolar Clinic and Research Program at Massachusetts General Hospital in Boston.

The rate of suicide attempts was 52% in patients with lifetime anxiety disorder, compared with 22% in patients who did not have a history of anxiety disorder. The highest rate, 65%, was in patients with a history of posttraumatic stress disorder (Am. J. Psychiatry 2004;161:2222–9).

Bipolar patients with lifetime anxiety disorders also had an earlier age of bipolar onset, 15.6 years vs. 19.4 years in patients who did not have a history of anxiety disorder, Dr. Sachs said at the meeting, which also was sponsored by the University of Texas Southwestern Medical Center at Dallas and the University of New Mexico.

Length of recovery was shorter as well in patients with a history of anxiety disorder. Their longest mean period of euthymia was 183 days, compared with 254 days for patients without lifetime anxiety.

Dr. Murray B. Stein called for greater efforts to treat comorbid anxiety in patients with mood disorders. About 50%–60% of people with mood disorders also have an anxiety disorder, according to Dr. Stein, director of the Anxiety and Traumatic Stress Disorders Program at the University of California, San Diego. Conversely, he estimated that 80%–90% of people with general anxiety disorder will also have major depression at some point, and most had the anxiety disorder first.

Though anxiety is an early-onset disorder, he noted that it is rarely studied in children. In one of the few studies that did so, he said, nearly two-thirds of children with social anxiety disorder responded to a selective serotonin reuptake inhibitor (SSRI), and nearly as many went into remission.

Most antidepressants relieve symptoms in adult patients with anxiety disorders, Dr. Stein said, possibly because they treat both syndromes. “You get some benefit, but you don't get a really robust response,” he said of SSRIs used in PTSD. Though SSRIs have been shown to be better than placebo for general anxiety disorder, he said the benefit likewise was not robust.

As benzodiazepines are effective for anxiety disorders, he suggested they might also treat depression. “We were taught it is important to separate anxiety and depression because benzodiazepines could make people worse. I don't think there are any data that benzodiazepines make people worse.”

Other classes of medication, including anticonvulsants, are sometimes used for resistant anxiety disorders, but Dr. Stein said more information is needed about their safety and effectiveness.

Cognitive-behavioral therapy should be considered as an adjunct or an alternative to medication for anxiety disorders, he added. “The best cognitive-behavioral therapy is as good as the best medication we can provide.”

SANTA FE, N.M. — Anxiety disorders are a common comorbidity that lead to worse outcomes for patients with major depressive and bipolar disorders, speakers warned at a psychiatric symposium sponsored by the University of Arizona.

Dr. A. John Rush reported that more than half, 53%, of 2,876 depressed patients in the first phase of the STAR*D trial had anxious depression (Am. J. Psychiatry 2006;163:28–40).

Anxious patients were significantly less likely to achieve remission on their first medication for depression (odds ratio 0.77), according to Dr. Rush, principal investigator of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial.

Each of the comorbid anxiety disorders was associated with a lower remission rate. Posttraumatic stress disorder (PTSD) had the most negative effect (OR 0.6). Only social phobia did not have a significant impact, though it also reduced the odds of remission (OR 0.87).

“A person coming in with anxiety disorder takes longer and is less likely to remit,” said Dr. Rush, a distinguished professor in mental health at the University of Texas Southwestern Medical Center in Dallas.

About half of bipolar depression patients also had an anxiety disorder, according to an analysis of the first 500 patients in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) trial, another large multicenter study supported by the National Institute of Mental Health. Lifetime prevalence was 51%, and 31% had a current anxiety disorder when they entered the study.

Bipolar patients with comorbid anxiety were significantly more likely to have a history of suicide attempts, said Dr. Gary Sachs, principal investigator of STEP-BD and director of the Bipolar Clinic and Research Program at Massachusetts General Hospital in Boston.

The rate of suicide attempts was 52% in patients with lifetime anxiety disorder, compared with 22% in patients who did not have a history of anxiety disorder. The highest rate, 65%, was in patients with a history of posttraumatic stress disorder (Am. J. Psychiatry 2004;161:2222–9).

Bipolar patients with lifetime anxiety disorders also had an earlier age of bipolar onset, 15.6 years vs. 19.4 years in patients who did not have a history of anxiety disorder, Dr. Sachs said at the meeting, which also was sponsored by the University of Texas Southwestern Medical Center at Dallas and the University of New Mexico.

Length of recovery was shorter as well in patients with a history of anxiety disorder. Their longest mean period of euthymia was 183 days, compared with 254 days for patients without lifetime anxiety.

Dr. Murray B. Stein called for greater efforts to treat comorbid anxiety in patients with mood disorders. About 50%–60% of people with mood disorders also have an anxiety disorder, according to Dr. Stein, director of the Anxiety and Traumatic Stress Disorders Program at the University of California, San Diego. Conversely, he estimated that 80%–90% of people with general anxiety disorder will also have major depression at some point, and most had the anxiety disorder first.

Though anxiety is an early-onset disorder, he noted that it is rarely studied in children. In one of the few studies that did so, he said, nearly two-thirds of children with social anxiety disorder responded to a selective serotonin reuptake inhibitor (SSRI), and nearly as many went into remission.

Most antidepressants relieve symptoms in adult patients with anxiety disorders, Dr. Stein said, possibly because they treat both syndromes. “You get some benefit, but you don't get a really robust response,” he said of SSRIs used in PTSD. Though SSRIs have been shown to be better than placebo for general anxiety disorder, he said the benefit likewise was not robust.

As benzodiazepines are effective for anxiety disorders, he suggested they might also treat depression. “We were taught it is important to separate anxiety and depression because benzodiazepines could make people worse. I don't think there are any data that benzodiazepines make people worse.”

Other classes of medication, including anticonvulsants, are sometimes used for resistant anxiety disorders, but Dr. Stein said more information is needed about their safety and effectiveness.

Cognitive-behavioral therapy should be considered as an adjunct or an alternative to medication for anxiety disorders, he added. “The best cognitive-behavioral therapy is as good as the best medication we can provide.”