Clinician recognition of anxiety disorders in depressed outpatients

Clinician recognition of anxiety disorders in depressed outpatients

Mark Zimmerman*, Iwona Chelminski

Department of Psychiatry and Human Behavior, Brown University School of Medicine, Rhode Island Hospital, Providence, RI 02905, USA

Received 5 September 2002; received in revised form 7 January 2003; accepted 23 January 2003

Abstract

The recognition of anxiety disorders in depressed patients has potential clinical significance because their presence predictspoorer outcome and may influence treatment selection. In routine clinical settings, an unstructured diagnostic interview istypically used to assess patients at the initiation of treatment. Unstructured interviews, however, may result in missed diag-

noses, with potential negative clinical consequences. The goals of the present study were to examine whether anxiety disordersare less frequently identified using a routine unstructured clinical evaluation than a semi-structured diagnostic interview inpatients with a principal diagnosis of major depressive disorder (MDD), and to determine patients’ desire for treatment for

comorbid anxiety disorders. Psychiatric outpatients with MDD were evaluated with either a semi-structured or an unstructureddiagnostic interview. Current DSM-IV anxiety disorder diagnoses were compared in the two, nonoverlapping, groups of depressedpsychiatric outpatients seen in the same practice setting. Patients with comorbid anxiety disorders who were interviewed with

the semi-structured interview were asked if they wanted treatment to address their anxiety symptoms. Individuals interviewedwith the semi-structured interview were diagnosed with significantly more current anxiety disorders than individuals who wereassessed with an unstructured interview. There was variability in patients’ desire for treatment of the different anxiety dis-orders, though for each disorder the majority of patients wanted treatment to address the anxiety symptoms. In psychiatric

outpatients with a principal diagnosis of MDD psychiatrists underrecognize anxiety disorder comorbidity for which patients wanttreatment.# 2003 Elsevier Science Ltd. All rights reserved.

Keywords: Anxiety disorders; Depression; Comorbidity; Semi-structured interview; Desire for treatment

1. Introduction

Anxiety is frequent in depressed patients, thoughmost studies of this relationship have been of symptomsof anxiety rather than diagnosable anxiety disorders(Clayton et al., 1991; Joffe et al., 1993; Van Valkenburget al., 1984). Five studies of the full range of DSM-defined anxiety disorders in depressed psychiatric out-patients each found that when diagnoses are based onsemi-structured diagnostic interviews more than 40% ofthe patients had a comorbid anxiety disorder (Fava etal., 2000; Melartin et al., 2002; Pini et al., 1997; San-derson et al., 1990; Zimmerman et al., 2000).During the last 2 years three reports have questioned

the adequacy of the unstructured clinical diagnosticinterview. In an earlier report from the Rhode Island

Methods to Improve Diagnostic Assessment and Ser-vices (MIDAS) project, we found much lower comor-bidity rates in psychiatric outpatients diagnosedaccording to unstructured clinical interviews than astandardized research interview (Zimmerman and Mat-tia, 1999). Shear and colleagues in Pittsburgh (Shear etal., 2000) and Basco and colleagues in Texas (Basco etal., 2000) reported similar results.Previously we examined diagnostic underdetection in

a broad cross-section of psychiatric outpatients bycomparing diagnostic frequencies in two separatecohorts of patients, one evaluated with an unstructuredclinical interview and the other evaluated with a semi-structured research diagnostic interview (Zimmermanand Mattia, 1999). In the present report we narrow ourfocus to the detection of anxiety disorders in depressedpatients because of the high frequency of this comor-bidity, and the potential impact this comorbidity mighthave on treatment planning. As an indicator of thepotential importance of anxiety disorder comorbidity

0022-3956/03/$ - see front matter # 2003 Elsevier Science Ltd. All rights reserved.

doi:10.1016/S0022-3956(03)00020-7

Journal of Psychiatric Research 37 (2003) 325–333

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* Corresponding author. Tel.: +1-401-277-0724; fax: +1-401-277-

0726.

E-mail address: [email protected] (M. Zimmerman).

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on treatment planning with depressed patients we askedpatients whether they were interested in having treat-ment directed towards the comorbid anxiety disorder.Thus, in the present report from the Rhode Island

MIDAS project we examined the following three ques-tions: (1) In psychiatric outpatients diagnosed withmajor depressive disorder (MDD), how well do psy-chiatrists do in detecting the presence of comorbidanxiety disorders? (2) Are there differences between theanxiety disorders regarding patients’ desire for treat-ment? (3) Do psychiatrists underrecognize anxiety dis-order comorbidity for which patients want treatment?

2. Methods

More than two thousand patients were evaluatedupon presentation for outpatient treatment to theRhode Island Hospital Department of Psychiatry out-patient practice. This private practice group pre-dominantly treats individuals with medical insurance(including Medicare but not Medicaid) on a fee-for-ser-vice basis, and it is distinct from the hospital’s out-patient residency training clinic that predominantlyserves lower income, uninsured, and medical assistancepatients.We examined psychiatric diagnoses made during the

initial intake evaluation in two nonoverlapping cohortsof patients—in one group patients were interviewed byattending psychiatrists with an unstructured clinicalinterview (n=1352), and in the other group patientsinterviewed with the Structured Clinical Interview forDSM-IV (n=800). The diagnostic procedures employedin each group are described further below. Not allpatients were interviewed with the SCID because of thelack of availability of diagnostic raters and patients’preference for the briefer unstructured evaluation. Itshould be noted that in our earlier report comparing thediagnostic practices of clinicians and researchers thesamples were ascertained sequentially (Zimmerman andMattia, 1999). That is, 500 patients were evaluated byclinicians, and subsequent to this 500 patients wereinterviewed with the SCID. That was not the case in thepresent study in which the two groups of patients wereascertained during the same time period, though groupassignment was not based on random assignment. Thepatients in our prior report are not included in the pre-sent analyses.Before the initial evaluation all patients completed the

Psychiatric Diagnostic Screening Questionnaire (PDSQ,Zimmerman and Mattia, 2001a,b) as part of their initialpaperwork. The PDSQ is a broad-based screeningquestionnaire assessing the symptoms of DSM-IVmood, eating, anxiety, substance use, and somatoformdisorders. Because the validity of the PDSQ was underinvestigation, the clinicians were kept blind to the

patients’ responses on the questionnaire. The institu-tional review board reviewed and approved the eval-uation protocol, and all participants provided writteninformed consent.All patients were presenting for their initial diagnostic

evaluation in a community based, hospital affiliated,outpatient psychiatric practice. For convenience, werefer to the patients interviewed with the SCID (whichwas followed by an unstructured interview by theirtreating psychiatrist) as the SCID sample, and thepatients interviewed only with the psychiatrist’sunstructured clinical interview as the nonSCID sample.In the non SCID sample, unstructured diagnostic eval-

uations were conducted by board certified or board eli-gible attending psychiatrists. Diagnoses were based onDSM-IV criteria. Clinicians completed a standardizedintake form modeled on the Intake Evaluation Form ofMezzich and colleagues (1981). The intake form inclu-ded space for a narrative description of the chief com-plaint, history of present illness, and past psychiatrichistory. In addition, there was a checklist to record thepresence or absence of substance use problems, a his-tory of sexual or physical abuse, psychotic symptoms,panic attacks, phobias, obsessions, compulsive beha-vior, and all of the symptoms of major depression. Onthe last page of the five-page form clinicians recordedpatients’ DSM-IV multiaxial diagnoses. Research assis-tants recorded the results of the clinician’s diagnosticevaluation written on the last page of the intake form,and collected demographic information from the narra-tive. When estimating disorder prevalence rates forclinical diagnoses, we included as cases patients whomthe clinicians diagnosed with a ‘‘ruleout’’ disorder.When patients called to schedule their initial

appointment they were offered the opportunity toreceive a more comprehensive evaluation than the usualunstructured clinical evaluation. The patients were toldthat they would be interviewed by two people—first bya diagnostic rater who would conduct a comprehensiveevaluation, and then by a psychiatrist. After the SCID,the rater presented the case to a psychiatrist whoreviewed the findings of the evaluation with the patient.If the psychiatrist obtained additional information tomodify the diagnosis this was discussed with the SCIDrater. Although not systematically recorded, it was rarefor a diagnosis to be added after the psychiatrist’sreview of the case.The core of the diagnostic evaluation was the January

1995 DSM-IV patient version of the SCID (First et al.,1995). During the course of the study, joint-interviewdiagnostic reliability information has been collected on47 patients. For mood and anxiety disorders the Kappacoefficients were: MDD (k=0.91), dysthymic disorder(k=0.88), bipolar disorder (k=0.85), panic disorder(k=1.0), social phobia (k=0.84), obsessive-compulsivedisorder (OCD; k=1.0), specific phobia (k=0.91), gen-

326 M. Zimmerman, I. Chelminski / Journal of Psychiatric Research 37 (2003) 325–333

eralized anxiety disorder (GAD; k=0.93), and post-traumatic stress disorder (PTSD; k=0.91). Detailsregarding interviewer training and supervision are avail-able in other reports from the MIDAS project (Zimmer-man and Mattia, 1999, 2001a,b; Zimmerman et al., 2000).Two questions about reasons for seeking treatment

were asked: ‘‘Was (symptoms of disorder) one of themain reasons you decided to seek treatment now?’’ Ifthe patient responded ‘‘no’’ to this question, they wereasked: ‘‘Now that we’ve talked about (symptoms ofdisorder), would you like your treatment here to addressthese symptoms?’’ When asking these questions theinterviewer reviewed the features of the disorder thathad just been described so the patient understood towhat the question referred.In our analyses, first we compared the frequency of

current DSM-IV anxiety disorders in the SCID andnonSCID samples. Then, we determined the percentageof patients in the SCID sample who indicated that theywanted treatment for each of the comorbid diagnoses.Finally, we recomputed the prevalence of anxiety dis-orders in the SCID sample by requiring both disorderpresence and desire for treatment, and compared this tothe prevalence rate in the nonSCID sample. Thisaddresses the question of whether psychiatrists under-recognize anxiety disorder comorbidity for whichpatients want treatment. t-Tests were used to comparethe samples on continuously distributed variables.Categorical variables were compared by the chi-squarestatistic, or by Fisher’s Exact test if the expected valuein any cell of a 2�2 table was less than 5. The degree ofinequality between the rates of diagnoses in the twosamples was tested using odds ratios (OR) calculatedwith 95% confidence intervals (CI).

3. Results

3.1. Comparability of the samples

A principal diagnosis of current nonbipolar MDDwas given to 610 patients in the nonSCID sample and300 patients in the SCID sample. Patients diagnosedwith bipolar depression are not included in this report.The depressed patients in the nonSCID sample weresignificantly older than the depressed patients in theSCID sample (Table 1). In addition, patients in thenonSCID sample were significantly less likely to haveattended some college and to be white. There was nodifference in gender or marital status.Patients in the clinical and SCID samples were com-

pared on the PDSQ self-report symptom scale, control-ling for age. There were no significant differencesbetween the groups on each of the 13 PDSQ subscalescores. Thus, despite significant, albeit modest, differ-ences in demographic characteristics, the SCID and

clinical patient samples were clinically similar as asses-sed by a self-report measure of DSM-IV symptoms.

3.2. Anxiety disorder comorbidity rates in depressedoutpatients diagnosed clinically or by a semistructureddiagnostic interview

More current anxiety disorders were diagnosed in theSCID than the nonSCID sample (1.0�1.1 vs. 0.3�0.6,t=10.4, P<0.001). The data in Table 2 shows that eachanxiety disorder except PTSD was significantly morefrequently diagnosed in the SCID sample. Social phobiaand specific phobia were more than 15 times more fre-quently diagnosed in the SCID sample.To determine whether the difference in diagnostic

frequencies between the SCID and clinical interview wasa general phenomenon or specific to anxiety disorderswe compared the two groups on the second most fre-quently diagnosed class of disorders—substance usedisorders. There was no difference between SCID andclinically diagnosed patients in rates of current alcoholabuse/dependence [6.0% vs. 4.9%, w2=0.5, n.s.;OR=1.2 (95% C.I. 0.7–2.2)] or drug abuse/dependence[4.7% vs. 3.4%, w2=0.8, n.s.; OR=1.4 (95% C.I. 0.7–2.7)].The effect of demographic factors on anxiety disorder

comorbidity detection was determined by examining thestudy group by demographic variable interaction termin an analysis of variance model that included sex, edu-cation, marital status, age, and assessment method asvariables. None of the interaction terms was significant.The mean number of anxiety disorder diagnoses washigher in the SCID than the nonSCID samples forwomen (1.1�1.1 vs. 0.3�0.5, t=9.36, P<0.001) andmen (0.9�1.1 vs. 0.3�0.6, t=4.79, P<0.001), currentlymarried (0.9�1.1 vs. 0.3�0.6, t=5.59, P<0.001) andnot married patients (1.1�1.1 vs. 0.3�0.6, t=8.75,P<0.001), patients above and below the median age of39 years (age 539: 0.9�1.1 vs. 0.3�0.5, t=6.55,P<0.001; age 438: 1.1�1.2 vs. 0.3�0.6, t=8.14,P<0.001), and patients who did or did not go beyond ahigh school education (some college: 0.9�1.1 vs. 0.3�0.5,t=8.48, P<0.001; high school graduate or less: 1.2�1.1vs. 0.3�0.6, t=6.60, P<0.001).

3.3. Patients desire for treatment of their comorbidanxiety disorders

Table 3 shows that the depressed patients evaluatedwith the SCID most often wanted treatment of theirsymptoms of GAD, panic disorder, and PTSD. One-half to two-thirds of patients wanted treatment of socialphobia, OCD, and specific phobia. Overall, 86% of thedepressed patients with at least one anxiety disorderwanted their treatment to address a comorbid anxietydisorder.

M. Zimmerman, I. Chelminski / Journal of Psychiatric Research 37 (2003) 325–333 327

We re-computed the prevalence of anxiety disordersin the SCID sample by raising the diagnostic thresh-old by requiring both the presence of the disorder aswell as the patients’ desire for treatment of the dis-

order. The data in Table 4 shows that the rate of eachanxiety disorder (except PTSD) remained significantlyhigher in the SCID sample than in the nonSCIDsample.

Table 1

Demographic characteristics of patients with a principal diagnosis of DSM-IV major depressive disorder in clinical and SCID samples

Clinical (n=610)
SCID (n=300) w2 P
N
% N %
Female gender
424 69.6 203 67.7 0.4 n.s.
Caucasian
484 79.3 264 88.0 10.3 <0.01
Education
10.9 <0.05
Less than 12th grade
84 14.0 27 9.0
HS graduation or equivalency
170 28.2 74 24.7
Some college
190 31.6 125 41.6
Four year college or more
158 26.2 74 24.7
Marital status
10.7 n.s.
Married
254 42.8 122 40.7
Living together
35 5.9 17 5.7
Widowed
24 4.0 4 1.3
Separated
48 8.1 20 6.7
Divorced
108 18.2 51 17.0
Never married
124 20.9 86 28.7
Mean
S.D. Mean S.D. t P
Age
40.8 14.3 38.8 11.8 2.3 P<0.05
Table 2

Frequency of current DSM-IV anxiety disorders in patients with a principal diagnosis of major depressive disorder in clinical and SCID samples

Anxiety disorders
Clinical (n=610) SCID (n=300) OR 95% CI w2 P
N
% N %
Panic disorder
49 8.1 47 15.7 2.1 1.4–3.2 12.4 <0.001
Specific phobia
5 0.8 37 12.3 17.0 6.6–43.8 60.6 <0.001
Social phobia
13 2.1 98 32.7 22.3 12.2–40.6 175.0 <0.001
Obsessive compulsive disorder
20 3.3 26 8.7 2.8 1.5–5.1 12.2 <0.001
Posttraumatic stress disorder
47 7.7 34 11.3 1.5 1.0–2.4 3.3 0.07
Generalized anxiety disorder
41 6.7 60 20.0 3.5 2.3–5.3 35.9 <0.001
Any anxiety disorder
144 23.6 172 57.3 4.3 3.2–5.8 100.9 <0.001
Table 3

Desire for treatment for current DSM-IV comorbid anxiety disorders in SCID patients with a principal diagnosis of major depressive disorder

Anxiety disorders
Frequency of the disorder Desire for treatment
N
N %
Panic disorder
47 46 97.9
Specific phobia
37 21 56.8
Social phobia
98 72 73.5
26 21 80.8
34 30 88.2
60 55 91.7
172 149 86.6

4. Discussion

Our results suggest that in psychiatric outpatientswith a principal diagnosis of MDD psychiatrists under-recognize anxiety disorder comorbidity, and when ananxiety disorder is present patients usually want theirtreatment to address the comorbid anxiety disorders.There are several alternative explanations for the lowerrate of anxiety disorders in the nonSCID than the SCIDsample. First, it is possible that the difference incomorbidity rates reflects true sample differences, andthe nonSCID sample was a less severely ill group. Thisis, however, extremely unlikely because patients in thetwo samples scored similarly on the PDSQ anxiety dis-order subscales. This makes it less likely that the diag-nostic differences between the samples reflect a realinter-sample difference in level of pathology. Sig-nificantly more patients in the nonSCID than the SCIDsample received a principal diagnosis of MDD, thoughthe two groups scored similarly on the PDSQ depres-sion subscale. Because nondepressive disorders weremore frequently diagnosed when the SCID was used, itis likely that some of the SCID patients received aprincipal diagnosis of a nondepressive disorder withcomorbid MDD, and this accounts for the differencebetween groups in diagnosing principal MDD.Second, it is possible that the lower anxiety disorder

rates in the nonSCID sample are the result of clinicians’deliberate underdocumentation of psychopathology. Ifclinicians censor from their records diagnostic informa-tion that patients are most embarrassed, ashamed, orstigmatized by, then it would be inappropriate to con-clude that comorbidity was not being detected. How-ever, post hoc conversations with the clinicians in thepractice indicated that they did not deliberately omitdiagnostic information from the patients’ charts. Inaddition, the drug and alcohol use disorders were diag-nosed with equal frequency in the SCID and nonSCIDsamples. This, too, is inconsistent with the censoringhypothesis.Third, underdiagnosis may be a local rather than a

widespread problem. Perhaps the clinicians in our prac-

tice are poor diagnosticians who failed to detectcomorbidity. While it is not possible to rule out thispossibility, elswhere we reported that the likelihood ofdetecting a comorbid disorder by the clinicians in ourpractice is higher than the rates found in other reportsof comorbidity based on clinical evaluations (Zimmermanand Mattia, 1999). Moreover, our findings are con-sistent with those of other studies comparing unstruc-tured clinical evaluations with the results of semi-structured diagnostic interviews (Basco et al., 2000;Shear et al., 2000). Thus, it does not appear that thepsychiatrists in this study were more likely than otherpsychiatrists to underrecognize diagnostic comorbidity.Fourth, perhaps the problem is not with clinician

underdiagnosis but with semi-structured research inter-view overdiagnosis. Interviews such as the SCID areviewed as diagnostic ‘‘gold standards,’’ but it is possiblethat they are too sensitive and result in false positivediagnoses. Or perhaps we were biased to overdiagnoseon the SCID. Inconsistent with this is the comparabilityof the anxiety disorder rates in our study with those ofother studies that used research diagnostic interviewsfor assessing anxiety disorders in depressed patients(Fava et al., 2000; Melartin et al., 2002; Pini et al., 1997;Sanderson et al., 1990). Also inconsistent with theSCID-overdiagnosis hypothesis is that when the resultsof the SCID evaluations were presented to the clin-icians, the clinicians made more diagnoses in thepatients’ clinical charts (data available upon request).Because clinicians confirmed the SCID diagnoses, andrecorded more diagnoses in their patients’ charts com-pared to when they conducted unstructured clinicalevaluations, it is less likely that diagnostic bias accountsfor our findings.

4.1. Implications of anxiety disorders in depressedpatients

The recognition of comorbidity is not simply ofacademic interest—it has important clinical signi-ficance. Epidemiological studies such as the NationalComorbidity Study have demonstrated that depressed

Table 4

Frequency of current DSM-IV anxiety disorders in patients with a principal diagnosis of major depressive disorder in clinical and SCID samples

Anxiety disorders
Clinical (n=610) SCID (n=300)+ desire for treatmenta w2 P
N
% N %
Panic disorder
49 8.1 46 15.3 11.5 <0.001
Specific phobia
5 0.8 21 7.0 27.7 <0.001
Social phobia
13 2.1 72 24.0 113.6 <0.001
20 3.3 21 7.0 6.5 <0.05
47 7.7 30 10.0 1.4 n.s.
41 6.7 55 18.3 28.7 <0.001
144 23.6 149 49.7 62.6 <0.001
a Indicates patients with the disorder who wanted treatment for it.


individuals with a history of anxiety disorders are atincreased risk for hospitalization, suicide attempt, andgreater impairment from the depression (Kessler et al.,1994, 1996). The co-occurrence of anxiety disorders indepressed patients has been associated with a morechronic course of depression in psychiatric patients,primary care patients, and epidemiological samples.Van Valkenberg et al. (1984) reported that depressedpatients with anxiety neurosis (diagnosed according tothe Washington University criteria) had poorer out-come and greater psychosocial impairment thandepressed patients without an anxiety disorder. In theNIMH Collaborative Depression Study, the presence ofpanic attacks predicted a lower recovery during the first2 years of the follow-up interval (Coryell et al., 1988).Grunhaus and colleagues (Grunhaus, 1988) similarlyfound poorer outcome in depressed patients withcomorbid panic disorder than depressed patients with-out panic. In an 8-month follow-up of depressed pri-mary care patients treated with nortriptyline orinterpersonal therapy, patients with a history of GADor panic disorder were less likely to have recovered fromtheir depressive episode (Brown et al., 2000). In theMedical Outcomes Study, panic or phobic disorder, butnot GAD, coexisting with MDD predicted a lowerremission rate 1 year after the initial evaluation, though2 years after the evaluation only panic disorder wassignificantly associated with a lower remission rate(Sherbourne and Wells, 1997). Gaynes and colleagues(Gaynes et al., 1999) prospectively followed 68 primarycare patients with MDD every 3 months for 1 year afterthe initial diagnostic evaluation. Half of the patientshad a coexisting anxiety disorder, the most frequentbeing social phobia. Twelve months after intake thepatients with a comorbid anxiety disorder were sig-nificantly more likely to still be in an episode of depres-sion, and they experienced more disability days duringthe course of the 12 months than the depressed patientswithout an anxiety disorder.There are few controlled treatment studies of the

prognostic or treatment implications of anxiety dis-orders in depressed patients because many of thesestudies exclude patients with clinically significantcomorbid anxiety disorders (Bennie et al., 1995; New-house et al., 2000; Rapaport et al., 1996; Tollefson et al.,1994a). We are not aware of any effectiveness studies, inwhich exclusion criteria are minimal, that have exam-ined the prognostic significance of comorbid anxietydisorders. Nor are there studies of the influence ofcomorbid anxiety disorders on treatment selection forpatients seen in routine clinical practice. While there areseveral controlled studies of the prognostic significanceof anxious features in depressed patients (Joffe et al.,1993; Tollefson et al., 1994b), we do not consider thesestudies here because of the uncertain relationshipbetween the severity of anxiety features and a diagnosis

of a comorbid anxiety disorder (Fava et al., 2000).However, at least three controlled studies of the prog-nostic significance of anxiety disorders in depressedpatients have been conducted.Fava and colleagues (Fava et al., 1997) treated nearly

300 depressed outpatients with fluoxetine and foundthat patients with a comorbid anxiety disorder were lesslikely to respond than depressed patients without acomorbid anxiety disorder. In Brown, Schulberg andcolleagues’ (1996) primary care study of nortriptylineand interpersonal therapy, the presence of a comorbidanxiety disorder was associated with a nonsignificantlyhigher rate of premature discontinuation from treat-ment, and patients with a lifetime history of panic dis-order had a lower recovery rate than patients withoutpanic. Levitt et al., (1993) treated 31 depressed out-patients with seasonal affective disorder (SAD) withlight therapy and 25 patients without SAD with desi-pramine or imipramine. The presence of a comorbidanxiety disorder did not predict response to light ther-apy in the patients with SAD. In the patients withoutSAD who were treated with a TCA, the presence of acomorbid anxiety disorder was associated with a sig-nificantly lower response rate. None of these studiesincluded a placebo group.The poorer outcome of anxious depressed patients

compared to nonanxious depressed patients, particu-larly in naturalistic longitudinal studies of the course ofdepression, raises the question of whether improving thedetection of anxiety disorders would result in improvedoutcome. The clinical implications of underdiagnosinganxiety disorders in depressed patients depend on twofactors—(1) whether or not anxiety disorders have animpact on the longitudinal course of depression, and (2)the availability of effective treatment that is specific foranxiety disorders. As reviewed above, the literaturesuggests that the presence of a comorbid anxiety dis-order is associated with a poorer outcome. The secondquestion is whether or not appropriate intervention willimprove outcome. It is logical to speculate thatimproved diagnostic practice, resulting in improveddetection of anxiety disorders and treatment directed tothe additional concerns related to anxiety disorders, willresult in improved treatment outcome. However, it isalso possible that the presence of a comorbid anxietydisorder will be associated with poorer outcome evenwhen the diagnosis is known. In studies finding that thepresence of a comorbid anxiety disorder was associatedwith a greater likelihood of depression chronicity, it isnot clear whether the health care providers were awareof the researchers’ anxiety disorder diagnoses. It istherefore unknown if the greater chronicity of depres-sion in patients with high anxiety was due to the failureof appropriate treatment or the failure to provideappropriate treatment. There are no studies that haveexamined the important question of whether the treat-


ment of depressed patients with and without comorbidanxiety disorders should differ; though clinical experi-ence and inference from the extant literature suggeststhat the presence of a comorbid anxiety disorderimpacts upon case formulation and treatment planning.

4.2. Treatment planning in depressed patients withcomorbid anxiety disorders

Experts in the treatment of depression with comorbidanxiety disorders have described how knowledge of acomorbid anxiety disorder might impact upon thetreatment of MDD (Nutt, 1999; Pollack and Marzol,2000; Roy-Byrne, 1999). For example, treatment plan-ning for depressed patients with a comorbid anxietydisorder could include referral for CBT for the anxietydisorder. Choice and dosing of pharmacologic agentsmight also vary. Depressed patients with a comorbidpanic disorder might have a benzodiazepine prescribedas well as an antidepressant at treatment onset in orderto achieve more rapid relief from the panic attacks. If anSSRI is prescribed, dosage titration might be more gra-dual (Gorman et al., 1987). The best empirically sup-ported treatment decision is the preferential selection ofan SSRI over a TCA in the treatment of depressedpatients with comorbid OCD (Hoehn-Saric et al., 2000).Depression comorbid with social phobia might also bepreferentially prescribed an SSRI. The addition of abenzodiazepine might be considered in depressedpatients with comorbid GAD.In the recently revised APA Practice Guideline for the

treatment of MDD (2000), four suggestions were maderegarding the treatment of depression comorbid with ananxiety disorder: initiate antidepressant medication atlower than usual dosages and slowly titrate upwards;SSRIs and clomipramine are effective for OCD andtherefore should be considered when treating depressedpatients with comorbid obsessive features; buproprionhas not been found to be effective in the treatment ofpanic disorder (and although the guidelines do not spe-cifically state this, the inference is that this medicationshould not be considered a first line treatment fordepressed patients with this comorbidity); and benzo-diazepines may be beneficial augmenting agents in theshort term. Except for the single OCD study, none onthe treatment suggestions described above have beensubjected to empirical testing.

4.3. Future directions

The literature is consistent concerning the prevalenceand impact of anxiety disorder comorbidity in depressedpatients. Substantial rates of comorbid disorders havebeen found in epidemiological and clinical populationsusing structured research diagnostic interviews. How-ever, much lower comorbidity rates have been found in

clinical populations using unstructured clinical inter-views. Given that the structured interview is consideredthe diagnostic gold standard, this suggests that comor-bidity is underdiagnosed in routine clinical settings.Structured interviews such as the SCID are too long

and unwieldy for use in routine outpatient mentalhealth settings. A less time consuming semi-structuredinterview, such as the Mini International Neu-ropsychiatric Interview (MINI, Sheehan et al., 1998) isbrief enough to be incorporated into clinical practice;however, this would require a significant change in howclinicians conduct their diagnostic evaluations. It islikely that clinicians already in practice will resist such achange. The difficulty of convincing clinicians to use abrief semi-structured interview in clinical practice, evenwhen underrecognition of psychopathology has beenwell established, was reported by Spitzer and colleagues(1999) in their research on the PRIME-MD in primarycare settings. It is well known that changing physicianbehavior is difficult, and we believe that there will besignificant obstacles to overcome in getting clinicians toroutinely use a measure such as the MINI. It is morelikely that clinicians would use an inexpensive, screeninginstrument that does not intrude on the clinician’s usualpractice but provides clinically relevant diagnosticinformation. Potentially, a reliable and valid self-reportscreening questionnaire would enhance and not inter-fere with usual clinical practice. Elsewhere we describedthe reliability and validity of a broad-based screeningquestionnaire for Axis I disorders (Zimmerman andMattia, 2001a,b), and in a separate report we examine theability of the scale to detect comorbid anxiety disordersin patients with a principal diagnosis of MDD (sub-mitted for publication). The completion of paperworkbefore an initial evaluation is common in physicians’offices. The advantage of the empirically developedmeasures such as the PDSQ over home-grown forms isthat the psychometric and diagnostic properties of thescientifically studied instruments have been establishedthereby guiding the interpretation of the results.Finally, our review of the treatment literature indi-

cates that there are few placebo-controlled studies thathave examined the effectiveness of treatments forpatients with comorbid depression and anxiety dis-orders. Because of the high frequency of this comorbid-ity, this area of treatment research warrants furtherstudy. Also sparse are studies examining differencesbetween active treatment and placebo in patients withand without an anxiety disorder. For example, Smith,Londborg and colleagues recently found that depressedpatients treated with fluoxetine and clonazepamresponded more rapidly than patients treated withfluoxetine plus placebo (Londborg et al., 2000; Smith etal., 1998). Unfortunately, they did not examine whetherthis difference was true of patients with and without ananxiety disorder. Future treatment studies should


examine whether the presence or absence of a comorbidanxiety disorder in depressed patients warrants differenttreatment approaches.

Acknowledgements

This research was supported, in part, by grantsMH48732 and MH56404 from the National Institute ofMental Health.

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Clinician recognition of anxiety disorders in depressed outpatients