Anxiety and depression change together during treatment

doi:10.1016/S0005-7894(03)80010-2

Behavior Therapy

Volume 34, Issue 2, Spring 2003, Pages 149-163

https://doi.org/10.1016/S0005-7894(03)80010-2 Get rights and content

Anxiety and depression frequently co-occur and are viewed by many theorists as aspects of a unitary disorder. In contrast, the diagnostic nomenclature views anxiety and depression as discrete disorders, and current protocols for anxiety and depression treat the disorders separately. To test the hypothesis (based on the unitary view) that anxiety and depression are tightly related and change together over the course of treatment, we monitored week-by-week changes in symptoms of anxiety and depression in 58 outpatients treated naturalistically in private practice with cognitive-behavior therapy. Results were more supportive of a unitary than a discrete view, and showed that anxiety and depression were highly predictive of one another over the course of treatment. These findings lend support to a view of anxiety and depression as more unitary than discrete, and suggest the need to consider changes in the diagnostic nomenclature and in treatment strategies for anxious depressed patients.

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The medial habenula (mHb), a subregion of the habenula, is involved in diverse brain functions, such as nicotine addiction, anxiety, and anhedonia. We recently reported that TMEM16A deficiency, a calcium-activated chloride channel, decreased the activity of mHb cholinergic neurons. Since downregulated activity in cholinergic neurons of the mHb is involved in anhedonia-like behavior, we here investigated whether conditional deletion of TMEM16A in mHb cholinergic neurons also displays anhedonia-like behavior. The conditional deletion of TMEM16A in the mHb cholinergic neurons of mice (TMEM16A cKO mice) was generated by crossing ChaT-Cre (+) with floxed TMEM16A f/f mice. TMEM16A cKO mice displayed significantly reduced social interaction, sucrose preference, female urine sniffing, and increased marble burying. These behavioral data suggest the potential role of TMEM16A in anhedonic-like behavior in mice. Taken together, the presented data suggest that TMEM16A-mediated mHb activity might be a therapeutic target for anhedonia-related symptoms.
Course of symptom change during anxiety treatment: REDUCTIONS in anxiety and depression in patients completing the Coordinated Anxiety Learning and Management program
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Empirical data suggest that both depression and anxiety typically respond to evidence-based treatment. Although individuals with comorbid depression and anxiety may initially present with greater symptom severity, both cognitive behavioral therapy (CBT) and pharmacotherapy appear to decrease distress broadly, including reductions in disorder-specific symptoms and comorbid symptoms (e.g., Rudolph et al., 1998; Mennin and Heimberg, 2000; Russell et al., 2001; Persons et al., 2003; Norton et al., 2004; Joormann et al., 2005; Kring et al., 2007; Allen et al., 2010; Tourian et al., 2010). The reason for this broad response, however, is unknown.
When treating anxious patients with co-occurring depression, research demonstrates that both types of symptoms independently improve. The current analyses examined how reductions in anxiety and depression may be interrelated both during treatment, as well as over time following treatment. Participants were 503 individuals with one or more DSM-IV anxiety disorders who completed a collaborative care anxiety management program. Anxiety and depression were assessed at each treatment session (i.e., session by session data) and also at 6, 12, and 18-month post-baseline assessments (i.e., long-term outcomes data). Mediation analyses examined changes in symptoms in session by session data and long-term outcomes data. Anxiety and depression changed reciprocally in session by session data; change in anxiety mediated change in depression to a greater extent than vice versa. In the long-term outcomes data, change in anxiety mediated change in depression. However, the reverse mediation model of the long-term outcomes period revealed that accounting for changes in depression altered the effect of time on anxiety. Thus, temporal change during active treatment may share similarities with those related to maintaining gains after treatment, although differences arose in the reverse mediation models. Limitations of the methodology and implications of anxiety treatment for depression outcomes are discussed.
Change in obsessive-compulsive symptoms mediates subsequent change in depressive symptoms during exposure and response prevention
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The current study examines the temporal relationship between changes in obsessive-compulsive symptoms and changes in depressive symptoms during exposure and response prevention (EX/RP) therapy for obsessive-compulsive disorder (OCD).
Participants were 40 adults (53% female) who received EX/RP in a randomized controlled trial comparing serotonin reuptake inhibitor (SRI) augmentation strategies. Participants completed clinician-administered assessments of OCD (Yale-Brown Obsessive Compulsive Scale) and depressive symptoms (Hamilton Depression Rating Scale) every four weeks from baseline to 32-week follow-up.
Lagged multilevel mediational analyses indicated that change in OCD symptoms accounted for 65% of subsequent change in depressive symptoms. In contrast, change in depressive symptoms only partially mediated subsequent change in OCD symptoms, accounting for 20% of the variance in outcome.
These data indicate that reductions in co-morbid depressive symptoms during EX/RP for OCD are largely driven by reductions in obsessive-compulsive symptoms.
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Many emotion-related responses observed in patients with PNES, such as heightened vigilance, greater attention to threatening stimuli, greater avoidance behavior, and lower RSA, have also been observed in other clinical disorders, such as depression, borderline personality disorder, and PTSD [8,20–26]. This is perhaps not surprising, given that common affective processes or vulnerabilities may underlie many disorders [27,28]. In particular, trauma is often a shared characteristic among these disorders, including PNES.
We examined emotional responses to standard affective pictures in 18 psychogenic nonepileptic seizure (PNES) patients. Given reports of trauma and posttraumatic stress symptoms (PTS) in many PNES patients, comparison groups were seizure-free individuals high and low in PTS (PTS-high, PTS-low; n = 18 per group). Patients with psychogenic nonepileptic seizures (1) reported more emotional intensity to neutral and pleasant pictures than PTS-low and more intensity to neutral pictures than PTS-high, and (2) showed less positive emotional behavior to pleasant pictures than PTS-high. Groups did not differ in pleasantness/unpleasantness ratings, negative emotional behavior, cardiac interbeat interval, or respiratory sinus arrhythmia (RSA) reactivity to the pictures. Patients with psychogenic nonepileptic seizures reported more general emotion regulation difficulties and showed lower baseline RSA than PTS-low but not PTS-high. In sum, intense emotional experience and diminished positive emotional behavior characterized PNES patients' emotional responses.
Changes in affect during treatment for depression and anxiety
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A subscale of eight items from the Burns AI was used to assess AA. Persons et al. (2003) developed this measure of AA by selecting items from the Burns AI that approximated the AA symptom list presented by Watson, Weber et al. (1995). The eight items included fear of physical illness/dying; pain/tightness in chest; tingling in toes/fingers; sweating; trembling/shaking; dizziness/lightheadedness; choking sensations; and hot flashes/cold chills.
We tested the hypothesis that the tripartite model [Clark, L. A., & Watson, D. (1991). Tripartite model of anxiety and depression: Psychometric evidence and psychometric implications. Journal of Abnormal Psychology, 100, 316–336] can be extended to account for change during treatment for anxiety and depression. Forty-one patients treated naturalistically in private practice with cognitive behavior therapy completed weekly measures of depression, anxiety, negative affect (NA), positive affect (PA), and anxious arousal (AA). Consistent with the model, NA was associated with anxiety and depression during treatment, PA was more strongly related to depression than to anxiety, and AA was more strongly related to anxiety than to depression. As predicted, symptoms of depression and anxiety and NA all decreased during treatment. As predicted, AA also decreased, particularly for patients with panic disorder. PA increased during treatment, but only for patients who showed a significant decline in depression and only over an extended period of treatment. Nearly two-thirds of the variance in anxiety change was accounted for by changes in depression and NA, and just over three-fourths of the variance in depression change was accounted for by changes in anxiety and NA, indicating that much of the change in anxiety and depression across the course of treatment is shared in common.
Naturalistic outcome of case formulation-driven cognitive-behavior therapy for anxious depressed outpatients
2006, Behaviour Research and Therapy
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Another limitation is that the selection bias may have influenced the findings. One of the selection criteria that excluded the largest number of subjects was the requirement that subjects provide a minimum of four scores on both the measures of anxiety and depression; this criterion was set because we originally collected these data as part of a study of change in anxiety and depression during treatment (Persons, Roberts, & Zalecki, 2003). The fact that only patients who provided four sessions of data on the outcome measures were studied may have biased the study in favor of patients who complied with and persisted in therapy.
This article describes a case formulation-driven approach to the treatment of anxious depressed outpatients and presents naturalistic outcome data evaluating its effectiveness. Fifty-eight patients who received case formulation-driven cognitive-behavior therapy (CBT) in a private practice setting were studied. All received individual CBT guided by a case formulation and weekly outcome monitoring; in addition, 40 patients received adjunct therapies, including pharmacotherapy, which were added as indicated by the case formulation and the results of weekly outcome monitoring. Patients treated with case formulation-driven CBT showed statistically and clinically significant changes in anxiety and depression that were generally comparable to those reported in published randomized controlled trials of empirically supported therapies (ESTs) for single mood and anxiety disorders. Findings support the proposal that anxious depressed patients who have multiple comorbidities and require multiple therapies can benefit from empirically supported treatments guided by a case formulation and weekly outcome monitoring.

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^*: These findings were presented in part at the meetings of the Association for Advancement of Behavior Therapy in New Orleans, November 2000; at the World Congress of Behavioral and Cognitive Therapies in Vancouver, British Columbia, July 2001; and at the Clinical Science Colloquium in the Psychology Department at the University of California-Berkeley in October 2001.

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Original ResearchAnxiety and depression change together during treatment*

Clinical Psychology Review

Journal of Affective Disorders

Clinical Psychology Review

Comorbidity of anxiety and depressive disorders: A helplessness-hopelessness perspective

Diagnostic and statistical manual of mental disorders

Diagnostic and statistical manual of mental disorders

The nature of anxiety: Anxiety, depression, and emotional disorders

The introduction of “Empirically validated/supported treatment criteria: A rationale for enhancing treatment authority”

Cognitive therapy of the emotional disorders

Differentiating anxiety and depression: A test of the cognitive content specificity hypothesis

Journal of Abnormal Psychology

Anxiety disorders and phobias: A cognitive perspective

An inventory for measuring clinical anxiety: Psychometric properties

Journal of Consulting and Clinical Psychology

Cognitive therapy of personality disorders

Cognitive therapy of depression

Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large clinical sample

Journal of Abnormal Psychology

Therapist's toolkit

Why are depression and anxiety correlated? A test of the tripartite model

Journal of Consulting and Clinical Psychology

Tripartite model of anxiety and depression: Evidence and taxonomic implications

Journal of Abnormal Psychology

Mastery of your anxiety and panic: Therapist guide for anxiety, panic, and agoraphobia (MAP-3)

The SCL-90 and the MMPI: A step in the validation of a new self-report scale

British Journal of Psychiatry

Original Research
Anxiety and depression change together during treatment*