Treatment of patients with major depression and anxiety - Tips from Other Journals

Author: Linz Audain
Date: Feb 15, 1997

Depression that occurs with anxiety is associated with a poorer therapeutic outcome than depression alone. Brown and colleagues conducted a randomized, controlled eight-month trial of treatments for major depression to examine the clinical outcomes of patients with psychiatric comorbidity within the primary care setting.

Patients in four primary care settings were recruited and screened for depression by interview and testing. A total of 276 patients who met the criteria for depression were randomized to three treatment groups: usual care by their physician, interpersonal psychotherapy and pharmacotherapy with nortriptyline. All of the 276 patients were then subjected to further testing. A total of 157 of the 276 patients were diagnosed with either current major depression alone or current major depression with a lifetime anxiety disorder. These 157 patients were then assigned to one of three categories: major depression alone (no comorbidity); major depression with generalized anxiety disorder, or major depression with panic disorder.

For patients with comorbidities, psychotherapy and pharmacotherapy were found to be equally effective. Depressed patients with a lifetime comorbid anxiety disorder had a significantly greater severity of depression on presentation, slower and less improvement with treatment, and a higher dropout rate from both psychotherapy and pharmacotherapy than did patients with major depression alone.

The authors caution that their findings are based on small group sizes that may have diminished the statistical power of their analysis. They also caution that although all of the patients with comorbidity were determined to have a lifetime anxiety disorder by testing and interview on entry into the study, the procedure used did not determine which patients met diagnostic criteria for panic disorder in the past month or generalized anxiety disorder in the past six months; thus, an unknown number of those assigned to the group with comorbidity were likely not to be clinically anxious on entering the study.

The authors conclude that primary care physicians should assess the anxiety status of their depressed patients. If a physician determines that a panic disorder exists concurrently with major depression, a therapeutic modality can be selected that will address both the patient's depression and his or her anxiety.

Brown C, et al. Treatment outcomes for primary care patients with major depression and lifetime anxiety disorders. Am J Psychiatry 1996;153:1293-1300.

EDITOR'S NOTE: A point in this article worth emphasizing is that the comorbid depression that is observed in the primary care setting is just as severe and refractory to treatment as the comorbid depression observed elsewhere (e.g., psychiatric inpatient, psychiatric referrals). It is unclear from the study whether the patients with comorbidity or their physicians were aware of the concomitant anxious state. The challenge for clinicians will be in recognizing the presence of comorbid depression and anxiety and providing effective treatment for both.

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