International Journal of Psychiatry in Clinical Practice, 2010; 14: 244–247
REVIEW ARTICLE
Anxiety disorders as a risk factor for subsequent depression
PAMELA J. HORN & LISA A. WUYEK Int J Psych Clin Pract Downloaded from informahealthcare.com by University of Melbourne on 10/28/14 For personal use only.
Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD, USA
Abstract Introduction. Patients with comorbid depression and anxiety disorders have a higher suicide risk, increased social and vocational dysfunction and more severe and refractory illness. Methods. This paper reviews the studies examining the temporal relationship between onset of anxiety disorders and depression. Results. The highest rates of subsequent depression have been found in generalized anxiety disorder, followed by panic disorder and social anxiety disorder. The largest numbers of studies have been done on social anxiety disorder. Panic attacks, separation anxiety disorder and specific phobia also have an association with higher rates of subsequent depression in a limited number of studies. Conclusion. Further studies are needed to investigate whether treatment and treatment outcomes in anxiety disorders has an effect on the risk for developing subsequent depression. Key Words: Anxiety, depression, epidemiology
Introduction Patients with comorbid anxiety disorders and depression have increased severity and chronicity of illness, increased social and vocational impairment and increased risk of suicide [1]. Comorbidity of anxiety and depressive disorders has been estimated to be as high as 19.2% in a primary care setting and the US National Comorbidity Survey found that 58% of subjects with major depressive disorder had a comorbid anxiety disorder [2,3].This high rate of comorbidity has raised questions about the nature of the relationship between anxiety and depressive disorders as they are defined in the current DSM-IV model. The reason for co-occurrence of depression and anxiety can be potentially explained by: (1) comorbidity which is due to the randomly distributed incidence of two distinct conditions; (2) interaction in which the presence of one disorder increases the likelihood of the other; (3) a continuum of presentations of a gradually evolving illness that may be diagnosed differently depending on when the patient is evaluated; or (4) a unique syndrome separate from pure anxiety or depressive states which is a single more complex disorder [4]. There are data to support the theory that depression and anxiety are phenomenologically distinct and that it is useful to think of anxiety disorders and
depressive disorders as separate [5–7]. There are also data to support the theory that neuroticism, the measure of an enduring tendency to experience negative emotions, provides the framework for a continuum of anxiety and depressive disorders [4]. While studies in the fields of genetics, neurobiology and epidemiology inform our understanding of this issue, they have not conclusively shown that one theory is superior to the other in terms of understanding the relationship [4]. However, by doing research within the framework of the current DSM, the epidemiological studies available for review have by necessity looked at depression and anxiety disorders as two separate sets of disorders. There are individual studies looking at the temporal relationship between the onset of anxiety disorders and major depression, many of which focus on panic disorder and social anxiety disorder [8,9]. It has been hypothesized that anxiety disorders are a risk factor for subsequent development of major depression [10,11]. Formulating this hypothesis assumes that anxiety disorders and depression are not different presentations of the same illness, but are separate disorders [4]. This hypothesis seeks to test the degree to which the presence of one disorder increases the likelihood of the other. From a purely practical clinical perspective, these studies inform treatment providers and patients
Correspondence: Lisa A. Wuyek, Ph.D., Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, School of Medicine, 600 N. Wolfe St., Meyer 123, Baltimore, MD 21287. Tel.: 410-614-1869. Email: [email protected] (Received 17 December 2009 ; accepted 19 April 2010 ) ISSN 1365-1501 print/ISSN 1471-1788 online © 2010 Informa Healthcare DOI: 10.3109/13651501.2010.487979
Anxiety disorders and subsequent depression
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of Melbourne on 10/28/14 For personal use only.
of what course their illness may take over their lifetime. In this review, we discuss and synthesize the available literature that has examined the temporal relationship between anxiety disorders and depression, in an attempt to evaluate the epidemiological evidence that anxiety disorders are indeed a risk factor for subsequent development of depression. The studies were identified using Medline search keywords: comorbid, depression, anxiety. Studies were included if they contained data on the risk the presence of an anxiety disorder conferred to developing a depressive disorder (Table I).
Social anxiety disorder Multiple studies have examined the relationship between social anxiety disorder (social phobia) and major depression. In one prospective study people with social anxiety disorder were at 3.5 times higher risk than those without to have a subsequent depressive disorder. They were also 6 times more likely to have a depressive disorder when they had social anxiety disorder and another anxiety disorder [9]. In another study of the incidence of social anxiety disorder and secondary depression, 59% of people with both diagnoses had onset of social anxiety disorder preceding first onset of depression [10]. They also found a 3 times higher risk of depression in people with social anxiety disorder [10]. Kessler et al. found people with social phobia to have a 2.9 times higher
245
lifetime risk of major depressive disorder [12]. They noted that 71.9% retrospectively reported onset of social phobia prior to major depressive disorder. In a 10-year prospective longitudinal study, Beesdo and colleagues used the Munich-Composite International Diagnostic Interview to diagnose SAD and depression and assess factors like severity and psychosocial impairment at several time points [10]. They concluded that people with social anxiety disorder who have more severe impairment, more persistent symptoms, more social fears and more anxiety cognitions have a higher risk of subsequent depression. An analysis of data collected in the US National Comorbidity Survey using the Composite International Diagnostic Interview revealed that people with three or more social fears have a two to three time higher risk of ha ving ten or more major depressive episodes [12]. A number of factors also increases the risk for subsequent depression, including: (1) a history of an anxiety disorder; (2) major depressive episode in a parent; (3) female gender; (4) behavioral inhibition in childhood; and (5) three or more anxiety disorders, and panic attacks in particular [10,13]. Of these factors, behavioral inhibition (which refers to a temperament characteristic marked by wary, fearful and restrained responses in young children to novel stimuli), was significant in an overall model of predicting subsequent depression [14]. It was also shown to be predictive of depression if there was evidence of clinically significant social anxiety in childhood [10,13].
Table I. Summary of reviewed studies.
Source
Anxiety disorder
Odds ratio for developing depression
Stein et al. [9] 2001 Beesdo et al. [10] 2007 Kessler et al. [12] 1999 Kessler et al. [16] 1998
Social anxiety disorder Social anxiety disorder Social anxiety disorder Panic disorder
Goodwin [17] 2002 Ball et al. [8] 1994
Panic disorder Panic disorder
Bittner et al. [15] 2004
3.4 4.5 2.9 1.9 1.5–7.8 at the subsequent longitudinal assessments
Lenze et al. [21] 2005
Panic disorder Generalized anxiety disorder Social anxiety disorder Simple phobia Panic disorder, generalized anxiety disorder Generalized anxiety disorder
Lewinsohn et al. [11] 2008
Separation anxiety disorder
3
Merikangas et al. [20] 2003
3.5 3 2.9 16.5
% subjects with subsequent depression
Panic disorder precedes depression in 21% of the study sample.
1.9 24% of people with panic disorder went on to develop a depressive episode over the subsequent 2 year period
Retrospectively 43% of subjects has onset of GAD prior to MDD
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of Melbourne on 10/28/14 For personal use only.
246
P. J. Horn & L. A. Wuyek
Panic attacks and panic disorder
Conclusion
Panic disorder has been shown to increase the risk of subsequent depression by 3.1–3.4 times [15,16]. Ball conducted a study in which 55% of the sample had a history of depression and current panic disorder, 24% developed a depressive episode over a 2-year prospective period [8]. Panic attacks preceded onset of major depression in 43%, and panic disorder preceded major depression in 21% of another sample [16]. Kessler found that the risk for development of depression is 16.5 within the first year of onset of panic attacks [16]. On average, the risk of subsequent depression after having a panic attack is estimated to be between 1.9 and 4.8 [15–17]. In Kessler’s study, he concludes that the absence of a dose response relationship indicates that panic attacks are a marker, rather than a causal risk factor, for depression [16]. He also concludes that panic is a severity marker for depression. In patients with another anxiety disorder, comorbid panic attacks increase the risk of depression from 2 to 6.4 times [15]. Risk factors associated with increased risk of a depression in subjects with panic disorder include: (1) comorbid generalized anxiety disorder; (2) dysfunctional cognitions (assessed by the DAS; and CQ with items like “If others dislike you, you cannot be happy”); and (3) low assertiveness [8,18,19].
Presence of any of the anxiety disorders reviewed is associated with higher rates of development of a subsequent major depression. The highest rates of subsequent depression have been found in generalized anxiety disorder, followed by panic disorder and social anxiety disorder. The largest numbers of studies have been done on social anxiety disorder. Panic attacks, separation anxiety disorder and specific phobia also have an association with higher rates of subsequent depression in a limited number of studies. Social anxiety disorder was most likely to precede the onset of depression. Major depression was more likely to precede panic disorder, while panic attacks and generalized anxiety disorder are more likely to precede depression. It is plausible that panic attacks may be seen when individuals experience increased anxiety in the context of depression, and that having panic attacks during a depressive episode increases the risk of development of the maladaptive patterns of avoidance and fear of subsequent panic attacks seen in panic disorder. Despite the ongoing controversy on how to understand the relationship between anxiety disorders and depression there is sufficient evidence to state that anxiety disorders are a risk factor for depression to more or lesser degrees. Now that a correlational relationship has evidence in the literature it may be useful to investigate whether treatment and treatment outcomes in anxiety disorders has an effect on the risk for developing subsequent depression.
Other anxiety disorders The Zurich Cohort Study followed a group of subjects over 15 years and found that those with an anxiety disorder (defined as meeting DSM-III criteria for either generalized anxiety disorder or panic disorder) had an odds ratio of 1.5–6.5 of having a depressive disorder alone at the next assessment [20]. The risk of developing depression was found to be elevated by 4.5 times in people with generalized anxiety disorder and in a retrospective study 43% of subjects had onset of GAD prior to MDD and 22% had onset of MDD prior to the onset of GAD [15,21]. Separation anxiety disorder has also been examined for a relationship to subsequent depression. One study found that females have an approximately 2.5-fold increased risk for developing depression than males with separation anxiety disorder and subjects with sep aration anxiety disorder were 3 times more likely to develop depression than subjects with no psychiatric disorder or another anxiety disorder [11]. Specific phobia has been shown to increase the risk of subsequent depression by a factor of 1.9 and increases risk by 4 times when combined with another anxiety disorder [15].
Key points • Presence of an anxiety disorder is associated with higher rates of development of a subsequent major depression • The highest rates of subsequent depression have been found in generalized anxiety disorder, followed by panic disorder and social anxiety disorder • The largest numbers of studies have been done on social anxiety disorder and it is the most likely to precede depression • There is sufficient evidence to state that anxiety disorders are a risk factor for depression • Further studies are needed to investigate whether treatment and treatment outcomes in anxiety disorders has an effect on the risk for developing subsequent depression
Acknowledgements None.
Anxiety disorders and subsequent depression Statement of interest None.
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of Melbourne on 10/28/14 For personal use only.
References [1] Kaufman J, Charney D. Comorbidity of mood and anxiety disorders. Depress Anxiety 2000;12(Suppl 1):69–76. [2] Stein MB, Kirk P, Prabhu V, Grott M, Terepa, M. Mixed anxiety-depression in a primary care clinic. J Affect Disord 1995;34:79–84. [3] Kessler RC, Nelson CB, McGonagle KA, Liu J, Swartz M, Blazer DG. Comorbidity of DSM-III-R major depressive disorder in the general population: results from the US National Comorbidity Survey. Br J Psychiatry Suppl 1996;30: 17–30. [4] Hranov LG. Comorbid Anxiety and depression: illumination of a controversy. Int J Psychiatry Clin Pract 2007;11(3): 171–89. [5] Barlow DH, Campbell LA. Mixed anxiety-depression and its implications for models of mood and anxiety disorders. Compr Psychiatry 2000;41(Suppl):55–60. [6] Bystritsky A, Waikar SV, Vapnik T. Four-dimensional anxiety and depression scale: a preliminary psychometric report. Anxiety 1996;2:47–50. [7] Brown TA, Chorpita BF, Barlow DH. Structural relationships among dimensions of DSM-IV anxiety and mood disorders and dimensions of negative affect, positive affect and autonomic arousal. J Abnorm Psychol 1998;107: 179–92. [8] Ball SG, Otto MW, Pollack MH, Rosenbaum JF. Predicting prospective episodes of depression in patients with panic disorder. J Consult Clin Psychol 1994;62:359–65. [9] Stein MB, Fuetsch M, Muller N, Hofler M, Lieb R, Wittchen H-U. Social anxiety disorder and the risk of depression. Arch Gen Psychiatry 2001;58:251–6. [10] Beesdo K, Bittner A, Pine DS, Stein MB, Hofler M, Lieb R, Wittchen H-U. Incidence of social anxiety disorder and the
[11]
[12]
[13] [14] [15]
[16]
[17]
[18]
[19]
[20]
[21]
247
consistent risk for secondary depression in the first three decades of life. Arch Gen Psychiatry 2007;64(8):903–12. Lewinsohn PM, Holm-Denoma JM, Small JW, Seeley JR, Joiner TE. Separation anxiety disorder in childhood as a risk factor for future mental illness. J Am Acad Child Adolesc Psychiatry 2008;47:548–55. Kessler RC, Stang P, Wittchen H-U, Stein M, Walters EE. Lifetime co-morbidities between social phobia and mood disorders in the US National Comorbidity Survey. Psychol Med 1999;29:555–67. Gladstone GL, Parker GB. Is behavioral inhibition a risk factor for depression? J Affect Disord 2006;95:85–94. Garcia-Coll CG. Behavioral inhibition in young children. Child Dev 1984;55:1005–19. Bittner A, Goodwin RD, Wittchen H-U, Beesdo K, Hofler M, Lieb R. What characteristics of primary anxiety disorders predict subsequent major depressive disorder? J Clin Psychiatry 2004;65(5):618–26. Kessler RC, Stang PE, Wittchen, H-U, Ustun TB, Roy-Burne PP, Walters EE. Lifetime panic-depression comorbidity in the National Comorbidity Survey. Arch Gen Psychiatry 1998;55:801–8. Goodwin RD. Anxiety disorders and the onset of depression among adults in the community. Psychol Med 2002;32: 1121–4. Weissman AN. The Dysfunctional Attitude Scale: A validation study (Doctoral dissertation, University of Pennsylvania). Dissertation Abstr Int 1979;40:1389–90B. Fennell M, Campbell E. The Cognitions Questionnaire: Specific thinking errors in depression. Br J Clin Psychol 1984;1: 81–92. Merikangas KR, Zhang H, Avenevoli S, Acharyya S, Neuenschwander M, Angst J. Longitudinal trajectories of depression and anxiety in a prospective community study. Arch Gen Psychiatry 2003;60:993–1000. Lenze EJ, Mulsant BH, Mohlman J, Shear MK, Dew MA, Schulz R, et al. Generalized anxiety disorder in late life: lifetime course and comorbidity with major depressive disorder. Am J Geriatr Psychiatry 2005;13(1):77–80.
REVIEW ARTICLE
Anxiety disorders as a risk factor for subsequent depression
PAMELA J. HORN & LISA A. WUYEK Int J Psych Clin Pract Downloaded from informahealthcare.com by University of Melbourne on 10/28/14 For personal use only.
Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD, USA
Abstract Introduction. Patients with comorbid depression and anxiety disorders have a higher suicide risk, increased social and vocational dysfunction and more severe and refractory illness. Methods. This paper reviews the studies examining the temporal relationship between onset of anxiety disorders and depression. Results. The highest rates of subsequent depression have been found in generalized anxiety disorder, followed by panic disorder and social anxiety disorder. The largest numbers of studies have been done on social anxiety disorder. Panic attacks, separation anxiety disorder and specific phobia also have an association with higher rates of subsequent depression in a limited number of studies. Conclusion. Further studies are needed to investigate whether treatment and treatment outcomes in anxiety disorders has an effect on the risk for developing subsequent depression. Key Words: Anxiety, depression, epidemiology
Introduction Patients with comorbid anxiety disorders and depression have increased severity and chronicity of illness, increased social and vocational impairment and increased risk of suicide [1]. Comorbidity of anxiety and depressive disorders has been estimated to be as high as 19.2% in a primary care setting and the US National Comorbidity Survey found that 58% of subjects with major depressive disorder had a comorbid anxiety disorder [2,3].This high rate of comorbidity has raised questions about the nature of the relationship between anxiety and depressive disorders as they are defined in the current DSM-IV model. The reason for co-occurrence of depression and anxiety can be potentially explained by: (1) comorbidity which is due to the randomly distributed incidence of two distinct conditions; (2) interaction in which the presence of one disorder increases the likelihood of the other; (3) a continuum of presentations of a gradually evolving illness that may be diagnosed differently depending on when the patient is evaluated; or (4) a unique syndrome separate from pure anxiety or depressive states which is a single more complex disorder [4]. There are data to support the theory that depression and anxiety are phenomenologically distinct and that it is useful to think of anxiety disorders and
depressive disorders as separate [5–7]. There are also data to support the theory that neuroticism, the measure of an enduring tendency to experience negative emotions, provides the framework for a continuum of anxiety and depressive disorders [4]. While studies in the fields of genetics, neurobiology and epidemiology inform our understanding of this issue, they have not conclusively shown that one theory is superior to the other in terms of understanding the relationship [4]. However, by doing research within the framework of the current DSM, the epidemiological studies available for review have by necessity looked at depression and anxiety disorders as two separate sets of disorders. There are individual studies looking at the temporal relationship between the onset of anxiety disorders and major depression, many of which focus on panic disorder and social anxiety disorder [8,9]. It has been hypothesized that anxiety disorders are a risk factor for subsequent development of major depression [10,11]. Formulating this hypothesis assumes that anxiety disorders and depression are not different presentations of the same illness, but are separate disorders [4]. This hypothesis seeks to test the degree to which the presence of one disorder increases the likelihood of the other. From a purely practical clinical perspective, these studies inform treatment providers and patients
Correspondence: Lisa A. Wuyek, Ph.D., Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, School of Medicine, 600 N. Wolfe St., Meyer 123, Baltimore, MD 21287. Tel.: 410-614-1869. Email: [email protected] (Received 17 December 2009 ; accepted 19 April 2010 ) ISSN 1365-1501 print/ISSN 1471-1788 online © 2010 Informa Healthcare DOI: 10.3109/13651501.2010.487979
Anxiety disorders and subsequent depression
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of Melbourne on 10/28/14 For personal use only.
of what course their illness may take over their lifetime. In this review, we discuss and synthesize the available literature that has examined the temporal relationship between anxiety disorders and depression, in an attempt to evaluate the epidemiological evidence that anxiety disorders are indeed a risk factor for subsequent development of depression. The studies were identified using Medline search keywords: comorbid, depression, anxiety. Studies were included if they contained data on the risk the presence of an anxiety disorder conferred to developing a depressive disorder (Table I).
Social anxiety disorder Multiple studies have examined the relationship between social anxiety disorder (social phobia) and major depression. In one prospective study people with social anxiety disorder were at 3.5 times higher risk than those without to have a subsequent depressive disorder. They were also 6 times more likely to have a depressive disorder when they had social anxiety disorder and another anxiety disorder [9]. In another study of the incidence of social anxiety disorder and secondary depression, 59% of people with both diagnoses had onset of social anxiety disorder preceding first onset of depression [10]. They also found a 3 times higher risk of depression in people with social anxiety disorder [10]. Kessler et al. found people with social phobia to have a 2.9 times higher
245
lifetime risk of major depressive disorder [12]. They noted that 71.9% retrospectively reported onset of social phobia prior to major depressive disorder. In a 10-year prospective longitudinal study, Beesdo and colleagues used the Munich-Composite International Diagnostic Interview to diagnose SAD and depression and assess factors like severity and psychosocial impairment at several time points [10]. They concluded that people with social anxiety disorder who have more severe impairment, more persistent symptoms, more social fears and more anxiety cognitions have a higher risk of subsequent depression. An analysis of data collected in the US National Comorbidity Survey using the Composite International Diagnostic Interview revealed that people with three or more social fears have a two to three time higher risk of ha ving ten or more major depressive episodes [12]. A number of factors also increases the risk for subsequent depression, including: (1) a history of an anxiety disorder; (2) major depressive episode in a parent; (3) female gender; (4) behavioral inhibition in childhood; and (5) three or more anxiety disorders, and panic attacks in particular [10,13]. Of these factors, behavioral inhibition (which refers to a temperament characteristic marked by wary, fearful and restrained responses in young children to novel stimuli), was significant in an overall model of predicting subsequent depression [14]. It was also shown to be predictive of depression if there was evidence of clinically significant social anxiety in childhood [10,13].
Table I. Summary of reviewed studies.
Source
Anxiety disorder
Odds ratio for developing depression
Stein et al. [9] 2001 Beesdo et al. [10] 2007 Kessler et al. [12] 1999 Kessler et al. [16] 1998
Social anxiety disorder Social anxiety disorder Social anxiety disorder Panic disorder
Goodwin [17] 2002 Ball et al. [8] 1994
Panic disorder Panic disorder
Bittner et al. [15] 2004
3.4 4.5 2.9 1.9 1.5–7.8 at the subsequent longitudinal assessments
Lenze et al. [21] 2005
Panic disorder Generalized anxiety disorder Social anxiety disorder Simple phobia Panic disorder, generalized anxiety disorder Generalized anxiety disorder
Lewinsohn et al. [11] 2008
Separation anxiety disorder
3
Merikangas et al. [20] 2003
3.5 3 2.9 16.5
% subjects with subsequent depression
Panic disorder precedes depression in 21% of the study sample.
1.9 24% of people with panic disorder went on to develop a depressive episode over the subsequent 2 year period
Retrospectively 43% of subjects has onset of GAD prior to MDD
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of Melbourne on 10/28/14 For personal use only.
246
P. J. Horn & L. A. Wuyek
Panic attacks and panic disorder
Conclusion
Panic disorder has been shown to increase the risk of subsequent depression by 3.1–3.4 times [15,16]. Ball conducted a study in which 55% of the sample had a history of depression and current panic disorder, 24% developed a depressive episode over a 2-year prospective period [8]. Panic attacks preceded onset of major depression in 43%, and panic disorder preceded major depression in 21% of another sample [16]. Kessler found that the risk for development of depression is 16.5 within the first year of onset of panic attacks [16]. On average, the risk of subsequent depression after having a panic attack is estimated to be between 1.9 and 4.8 [15–17]. In Kessler’s study, he concludes that the absence of a dose response relationship indicates that panic attacks are a marker, rather than a causal risk factor, for depression [16]. He also concludes that panic is a severity marker for depression. In patients with another anxiety disorder, comorbid panic attacks increase the risk of depression from 2 to 6.4 times [15]. Risk factors associated with increased risk of a depression in subjects with panic disorder include: (1) comorbid generalized anxiety disorder; (2) dysfunctional cognitions (assessed by the DAS; and CQ with items like “If others dislike you, you cannot be happy”); and (3) low assertiveness [8,18,19].
Presence of any of the anxiety disorders reviewed is associated with higher rates of development of a subsequent major depression. The highest rates of subsequent depression have been found in generalized anxiety disorder, followed by panic disorder and social anxiety disorder. The largest numbers of studies have been done on social anxiety disorder. Panic attacks, separation anxiety disorder and specific phobia also have an association with higher rates of subsequent depression in a limited number of studies. Social anxiety disorder was most likely to precede the onset of depression. Major depression was more likely to precede panic disorder, while panic attacks and generalized anxiety disorder are more likely to precede depression. It is plausible that panic attacks may be seen when individuals experience increased anxiety in the context of depression, and that having panic attacks during a depressive episode increases the risk of development of the maladaptive patterns of avoidance and fear of subsequent panic attacks seen in panic disorder. Despite the ongoing controversy on how to understand the relationship between anxiety disorders and depression there is sufficient evidence to state that anxiety disorders are a risk factor for depression to more or lesser degrees. Now that a correlational relationship has evidence in the literature it may be useful to investigate whether treatment and treatment outcomes in anxiety disorders has an effect on the risk for developing subsequent depression.
Other anxiety disorders The Zurich Cohort Study followed a group of subjects over 15 years and found that those with an anxiety disorder (defined as meeting DSM-III criteria for either generalized anxiety disorder or panic disorder) had an odds ratio of 1.5–6.5 of having a depressive disorder alone at the next assessment [20]. The risk of developing depression was found to be elevated by 4.5 times in people with generalized anxiety disorder and in a retrospective study 43% of subjects had onset of GAD prior to MDD and 22% had onset of MDD prior to the onset of GAD [15,21]. Separation anxiety disorder has also been examined for a relationship to subsequent depression. One study found that females have an approximately 2.5-fold increased risk for developing depression than males with separation anxiety disorder and subjects with sep aration anxiety disorder were 3 times more likely to develop depression than subjects with no psychiatric disorder or another anxiety disorder [11]. Specific phobia has been shown to increase the risk of subsequent depression by a factor of 1.9 and increases risk by 4 times when combined with another anxiety disorder [15].
Key points • Presence of an anxiety disorder is associated with higher rates of development of a subsequent major depression • The highest rates of subsequent depression have been found in generalized anxiety disorder, followed by panic disorder and social anxiety disorder • The largest numbers of studies have been done on social anxiety disorder and it is the most likely to precede depression • There is sufficient evidence to state that anxiety disorders are a risk factor for depression • Further studies are needed to investigate whether treatment and treatment outcomes in anxiety disorders has an effect on the risk for developing subsequent depression
Acknowledgements None.
Anxiety disorders and subsequent depression Statement of interest None.
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of Melbourne on 10/28/14 For personal use only.
References [1] Kaufman J, Charney D. Comorbidity of mood and anxiety disorders. Depress Anxiety 2000;12(Suppl 1):69–76. [2] Stein MB, Kirk P, Prabhu V, Grott M, Terepa, M. Mixed anxiety-depression in a primary care clinic. J Affect Disord 1995;34:79–84. [3] Kessler RC, Nelson CB, McGonagle KA, Liu J, Swartz M, Blazer DG. Comorbidity of DSM-III-R major depressive disorder in the general population: results from the US National Comorbidity Survey. Br J Psychiatry Suppl 1996;30: 17–30. [4] Hranov LG. Comorbid Anxiety and depression: illumination of a controversy. Int J Psychiatry Clin Pract 2007;11(3): 171–89. [5] Barlow DH, Campbell LA. Mixed anxiety-depression and its implications for models of mood and anxiety disorders. Compr Psychiatry 2000;41(Suppl):55–60. [6] Bystritsky A, Waikar SV, Vapnik T. Four-dimensional anxiety and depression scale: a preliminary psychometric report. Anxiety 1996;2:47–50. [7] Brown TA, Chorpita BF, Barlow DH. Structural relationships among dimensions of DSM-IV anxiety and mood disorders and dimensions of negative affect, positive affect and autonomic arousal. J Abnorm Psychol 1998;107: 179–92. [8] Ball SG, Otto MW, Pollack MH, Rosenbaum JF. Predicting prospective episodes of depression in patients with panic disorder. J Consult Clin Psychol 1994;62:359–65. [9] Stein MB, Fuetsch M, Muller N, Hofler M, Lieb R, Wittchen H-U. Social anxiety disorder and the risk of depression. Arch Gen Psychiatry 2001;58:251–6. [10] Beesdo K, Bittner A, Pine DS, Stein MB, Hofler M, Lieb R, Wittchen H-U. Incidence of social anxiety disorder and the
[11]
[12]
[13] [14] [15]
[16]
[17]
[18]
[19]
[20]
[21]
247
consistent risk for secondary depression in the first three decades of life. Arch Gen Psychiatry 2007;64(8):903–12. Lewinsohn PM, Holm-Denoma JM, Small JW, Seeley JR, Joiner TE. Separation anxiety disorder in childhood as a risk factor for future mental illness. J Am Acad Child Adolesc Psychiatry 2008;47:548–55. Kessler RC, Stang P, Wittchen H-U, Stein M, Walters EE. Lifetime co-morbidities between social phobia and mood disorders in the US National Comorbidity Survey. Psychol Med 1999;29:555–67. Gladstone GL, Parker GB. Is behavioral inhibition a risk factor for depression? J Affect Disord 2006;95:85–94. Garcia-Coll CG. Behavioral inhibition in young children. Child Dev 1984;55:1005–19. Bittner A, Goodwin RD, Wittchen H-U, Beesdo K, Hofler M, Lieb R. What characteristics of primary anxiety disorders predict subsequent major depressive disorder? J Clin Psychiatry 2004;65(5):618–26. Kessler RC, Stang PE, Wittchen, H-U, Ustun TB, Roy-Burne PP, Walters EE. Lifetime panic-depression comorbidity in the National Comorbidity Survey. Arch Gen Psychiatry 1998;55:801–8. Goodwin RD. Anxiety disorders and the onset of depression among adults in the community. Psychol Med 2002;32: 1121–4. Weissman AN. The Dysfunctional Attitude Scale: A validation study (Doctoral dissertation, University of Pennsylvania). Dissertation Abstr Int 1979;40:1389–90B. Fennell M, Campbell E. The Cognitions Questionnaire: Specific thinking errors in depression. Br J Clin Psychol 1984;1: 81–92. Merikangas KR, Zhang H, Avenevoli S, Acharyya S, Neuenschwander M, Angst J. Longitudinal trajectories of depression and anxiety in a prospective community study. Arch Gen Psychiatry 2003;60:993–1000. Lenze EJ, Mulsant BH, Mohlman J, Shear MK, Dew MA, Schulz R, et al. Generalized anxiety disorder in late life: lifetime course and comorbidity with major depressive disorder. Am J Geriatr Psychiatry 2005;13(1):77–80.
