Article

Prevalence of Generalized Anxiety Disorder in General Practice in Denmark, Finland, Norway, and Sweden

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Abstract

This study assessed the prevalence rate of generalized anxiety disorder among patients of general practitioners in Denmark, Finland, Norway, and Sweden and determined whether general practitioners recognize the condition and its correlates. Data were gathered in September 2001. Participating patients received a questionnaire that included the Generalized Anxiety Questionnaire and the Depression Screening Questionnaire. The scale used DSM-IV criteria to identify generalized anxiety disorder and major depressive episode. General practitioners filled in a questionnaire about their patients' mental and physical illnesses, including generalized anxiety and major depressive episode. General practitioners' basic sociodemographic data and professional career information were also gathered. A total of 648 general practitioners and 8,879 patients participated in the study. The age-standardized rates for generalized anxiety disorder ranged from 4.1 to 6.0 percent for males and from 3.7 to 7.1 percent for females; for major depressive episode the rates ranged from 7.2 to 11.5 percent for males and from 9.9 to 14.2 percent for females. The proportion of generalized anxiety disorder cases recognized by general practitioners varied from 33 percent in Denmark to 53 percent in Norway. Recognition of generalized anxiety disorder by general practitioners was associated with presentation of anxiety problems by the patients. Physical symptoms as a reason for a consultation was associated with lowered recognition of generalized anxiety disorder. Previous diagnoses of generalized anxiety disorder or anxiety neurosis were associated with increased recognition of generalized anxiety disorder. Of the total percentage of cases of generalized anxiety disorder in general practice (4.8 percent for males and 6.0 percent for females), only one-third to one-half of the cases were identified by the general practitioners.

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... Наиболее отчетливо эти отличия прослеживаются при сравнении эффективности терапии СИОЗС и ТЦА (p=0,02, c 2 =4,75). В группе больных с генотипом LS прослеживается тенденция к достоверно худшей эффективности СИОЗС по сравнению с АДП других классов (p=0,08, Всего (n=100) 37 (37) 43 (43) 20 (20) СИОЗС (n=37) 14 (37,8) 18 (48,7) 5 (13,6) ТЦА (n=45) 15 (33,3) 19 (42,2) 11 (24,5) НССА (n=18) 8 (44,5) 6 (33,3) 4 (22,2) Генотипы по полиморфному маркеру STin2, абс. (%) ...
... It was found that the level of BDNF in schizophrenic patients with depressive symptoms was significantly lower than that of non-depressed patients, and the level of cortisol in patients with depression was significantly higher. жает потери тирозингидроксилазы, маркера дофаминергических нейронов, в культурах клеток эмбриональных крыс и вентральной части среднего мозга человека, а также защищает дофаминергические нейроны от нейротоксических агентов, таких как 6-гидроксидофамин (6-OHDA) и 1-метил-4-фенилперидин (MPPb) [43,44]. BDNF также улучшает выживаемость нейронов дофамина в культуре [16,36] и регулирует высвобождение мРНК рецепторов D 1 -и белка [24] и экспрессию D 5 -рецептора в развивающихся стриарных астроцитах [4]. ...
... Представленные в табл. 2 данные подтверждаются результатами ряда исследований, выполненных на выборках гериатрических и/или соматически отягощенных больных [24,25,29,31,33,[42][43][44]. ...
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The article presents a linguistic analysis of the scientific edition «Clinic of psychopathies, their statics, dynamics, systematic» authored byP.B.Gannushkin (1933). The aim of the study was to compare the author’s writing style in the texts «Statics of psychopathies» and «Dynamics of psychopathies». The variables of lexical, stylistic, morphological and syntactical levels were studied with the expert methods of linguistic analysis and the authorial invariant analysis in order tо evaluate the author’s writing style. Statistical analysis was performed using programs MS Excel and Resampling Stats. The resampling method of statistical analysis was used. For description of the data, mean and 95% confidential interval of the mean (1000 iteration) were used, hypotheses testing was done with pair-wise comparison. The results of the test were significant if p-value was less than 0.05. Results showed no difference between the texts «Statics of psychopathies» and «Dynamics of psychopathies» in 22 out of 26 variables characterising the author’s writing style, while the four remaining variables deviated due to the typical context meanings of the text rather than due to the author’s affiliation issues. The study concluded that both of the texts were written by the same author.
... [1,2] Studies in primary care show that general practitioners correctly recognise only about one-third of them. [1,3] Still, GAD significantly impairs the quality of life and functioning of sufferers and entails considerable economic costs to the society. [4] GAD is fairly common in the society with a current prevalence of 2-3% and lifetime prevalence of 5%. ...
... In Finland, the prevalence of GAD in general practice has been reported to be 4.1% in men and 7.1% in women. [3] Similarly, an international study in 15 countries showed a one month prevalence of 7.9% in primary care. [6] Moreover, the highest prevalence rates for GAD have been reported among health care high utilisers, the prevalence of GAD rising to 21.8% among distressed health care high utilisers in an American study. ...
... [1] These findings may reflect the poor detection of GAD, as earlier studies indicate that primary care physicians detect only about one-third of cases. [1,3] An earlier study suggested that higher utilisation of non-mental health care services among patients with an anxiety disorder is explained by greater co-morbid illness but not anxiety symptoms. [33] However, the results in this study showed that people who tested positive for GAD had higher health care utilisation also when controlled for somatic co-morbidities. ...
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Objective: To analyse the utilization of health care services of people who tested positive for GAD compared to those who tested negative. Setting: A cross-sectional study from the Northern Finland 1966 Birth Cohort. Subjects: A total of 10,282 members followed from birth in a longitudinal study were asked to participate in a follow-up survey at the age of 46. As part of this survey they filled in questionnaries concerning health care utilization and their illness history as well as the GAD-7 screening tool. Althogether 5,480 cohort members responded to the questionnaries. Main outcome measures: Number of visits in different health care services among people who tested positive for GAD with the GAD-7 screening tool compared to those who tested negative. Results: People who tested positive for GAD had 112% more total health care visits, 74% more total physician visits, 115% more visits to health centres, 133% more health centre physician visits, 160% more visits to secondary care, and 775% more mental health care visits than those who tested negative. Conclusion: People with GAD symptoms utilize health care services more than other people. Key Points Generalised anxiety disorder (GAD) is a common but poorly identified mental health problem in primary care. People who tested positive for GAD utilise more health care services than those who tested negative. About 58% of people who tested positive for GAD had visited their primary care physician during the past year. Only 29% of people who tested positive for GAD had used mental health services during the past year.
... For general practitioners (GPs), people with anxiety disorders represent a significant part of their patient population as they use health care services more frequently compared to patients without anxiety disorders [9][10][11]. It is estimated that 1-7% of the patients in general practice have panic disorder [12][13][14], 4-12% have generalised anxiety disorder [3,12,13,15] and 4-6% have social phobia [3,13]. ...
... Patients with non-psychotic disorders, such as anxiety disorders, are poorly recognised and often not treated sufficiently [3,[15][16][17][18][19][20][21][22]. The main obstacles for adequate treatment are poor coordination between sectors and a lack of competent treatment availability in general practice [23]. ...
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Background People with anxiety disorders represent a significant part of a general practitioner’s patient population. However, there are organisational obstacles for optimal treatment, such as a lack of coordination of illness management and limited access to evidence-based treatment such as cognitive behavioral therapy. A limited number of studies suggest that collaborative care has a positive effect on symptoms for people with anxiety disorders. However, most studies are carried out in the USA and none have reported results for social phobia or generalised anxiety disorder separately. Thus, there is a need for studies carried out in different settings for specific anxiety populations.A Danish model for collaborative care (the Collabri model) has been developed for people diagnosed with depression or anxiety disorders. The model is evaluated through four trials, of which three will be outlined in this protocol and focus on panic disorder, generalised anxiety disorder and social phobia. The aim is to investigate whether treatment according to the Collabri model has a better effect than usual treatment on symptoms when provided to people with anxiety disorders. Methods Three cluster-randomised, clinical superiority trials are set up to investigate treatment according to the Collabri model for collaborative care compared to treatment-as-usual for 364 patients diagnosed with panic disorder, generalised anxiety disorder and social phobia, respectively (total n = 1092). Patients are recruited from general practices located in the Capital Region of Denmark. For all trials, the primary outcome is anxiety symptoms (Beck Anxiety Inventory (BAI)) 6 months after baseline. Secondary outcomes include BAI after 15 months, depression symptoms (Beck Depression Inventory) after 6 months, level of psychosocial functioning (Global Assessment of Functioning) and general psychological symptoms (Symptom Checklist-90-R) after 6 and 15 months. DiscussionResults will add to the limited pool of information about collaborative care for patients with anxiety disorders. To our knowledge, these will be the first carried out in a Danish context and the first to report results for generalised anxiety and social phobia separately. If the trials show positive results, they could contribute to the improvement of future treatment of anxiety disorders. Trial registrationClinicalTrials.gov, ID: NCT02678624. Retrospectively registered 7 February 2016; last updated 15 August 2016
... According to international studies, GAD is especially frequent among primary care attenders with an 8% prevalence [3,4]. In Finland, the age-standardized prevalence rate of GAD among primary health care patients has been reported to be 4.1% for males and 7.1% for females [5]. Patients with GAD often present with somatic and sleeping problems and only rarely complain of anxiety symptoms directly, which makes detecting of this disease challenging [1]. ...
... Earlier studies indicated a higher prevalence of GAD than that observed in this investigation because in a European study primary care attenders have been reported to have a prevalence of 8% [3,4]. In Finland, the prevalence of current GAD among primary care attenders was 4.1% for males and 7.1% for females in an earlier study based on self-questionnaires [5]. In a population study, the 12-month prevalence of GAD in Finland was 1.3% based on CIDI interview [17]. ...
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Objective: To analyse the prevalence of GAD and other anxiety disorders, as well as sensitivity and specificity of GAD-7 among high utilizers of health care. Setting: Four municipal health centres in Northern Finland. Subjects: A psychiatric interview was conducted for 150 high utilizers of health care. Main outcome measures: Prevalence of GAD as well as sensitivity and specificity of GAD-7. Results: The prevalence of GAD was 4% in this study group of Finnish high utilizers of health care. The sensitivity of GAD-7 was 100.0% (95% CI 54.1-100.0) and the specificity of GAD-7 was 82.6% (95% CI 75.4-88.4) with a cut-off point of 7 or more. Conclusion: GAD is rather common among high utilizers of primary care, although the prevalence of 4% is lower than that previously reported. GAD-7 is a valid and useful tool for detecting GAD among primary health care patients.
... Calleo et al. (2009) reported that only 28% of all elderly GAD patients presenting in specialty medical clinics received a diagnosis of any anxiety or mood disorder and only 1.5% were correctly diagnosed with GAD. In other primary care studies, between 30% and 55% of GAD patients were recognized and correctly diagnosed (Munk-Jorgensen et al., 2006;Vermani, Marcus, & Katzman, 2011). GAD is particularly difficult to separate from MD: Calleo et al. (2009) report that the number of GAD patients receiving a diagnosis of a depressive disorder is more than twice the number of GAD patients receiving a diagnosis of an anxiety disorder. ...
... Hence, the IUS-12 most prominently contributed to the disorder-classification. This is in line with the hypotheses derived from studies reporting that GAD is difficult to diagnose in primary care settings (Calleo et al., 2009;Munk-Jorgensen et al., 2006;Vermani et al., 2011;Wittchen et al., 2002). We are not aware of studies in more specialized settings or in settings using more standardized diagnostic instruments, where diagnostic classification may be more accurate. ...
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Background Generalized anxiety disorder (GAD) is difficult to recognize and hard to separate from major depression (MD) in clinical settings. Biomarkers might support diagnostic decisions. This study used machine learning on multimodal biobehavioral data from a sample of GAD, MD and healthy subjects to differentiate subjects with a disorder from healthy subjects (case‐classification) and to differentiate GAD from MD (disorder‐classification). Methods Subjects with GAD (n = 19), MD without GAD (n = 14), and healthy comparison subjects (n = 24) were included. The sample was matched regarding age, sex, handedness and education and free of psychopharmacological medication. Binary support vector machines were used within a nested leave‐one‐out cross‐validation framework. Clinical questionnaires, cortisol release, gray matter (GM), and white matter (WM) volumes were used as input data separately and in combination. Results Questionnaire data were well‐suited for case‐classification but not disorder‐classification (accuracies: 96.40%, p < .001; 56.58%, p > .22). The opposite pattern was found for imaging data (case‐classification GM/WM: 58.71%, p = .09/43.18%, p > .66; disorder‐classification GM/WM: 68.05%, p = .034/58.27%, p > .15) and for cortisol data (38.02%, p = .84; 74.60%, p = .009). All data combined achieved 90.10% accuracy (p < .001) for case‐classification and 67.46% accuracy (p = .0268) for disorder‐classification. Conclusions In line with previous evidence, classification of GAD was difficult using clinical questionnaire data alone. Particularly cortisol and GM volume data were able to provide incremental value for the classification of GAD. Findings suggest that neurobiological biomarkers are a useful target for further research to delineate their potential contribution to diagnostic processes.
... Generalized Anxiety Disorder (GAD) is a common mental disorder marked by persistent anxiety and worries, which are excessive and difficult to control, as well as multiple psychological and physical symptoms [1]. GAD often has a chronic course [2][3][4][5][6] with a lifetime prevalence rate for DSM-IV criteria estimated at approximately 6 % [7][8][9][10]. Persons suffering from GAD present significant impairments in work, social and family functioning, and healthrelated quality of life [11][12][13][14][15][16]. ...
... Previous research has exposed the challenges to the detection and treatment of mental disorders in primary care [23]. Research has typically shown low rates of recognition of GAD by primary care providers [8][9][10][24][25][26][27][28]. For GAD in particular, it has been suggested that underrecognition may be due to vague somatic symptoms, to patient's attribution of symptoms to physical problems, to an ill-defined diagnosis [2] and to the variety of clinical presentations [5], which may depend on the symptom overlap with comorbid psychiatric disorders and somatic diseases [2,[29][30][31][32]. ...
Article
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Purpose: Generalized Anxiety Disorder (GAD) is a common mental disorder in the primary care setting, marked by persistent anxiety and worries. The aims of this study were to: 1) examine mental health services utilisation in a large sample of primary care patients; 2) explore detection of GAD and minimal standards for pharmacological and psychological treatment adequacy based on recommendation from clinical practice guidelines; 3) examine correlates of treatment adequacy, i.e. predisposing, enabling and needs factors according to the Behavioural Model of Health Care Use. Methods: A sample of 373 adults meeting DSM-IV criteria for Generalized Anxiety Disorder in the past 12 months took part in this study. Data were drawn from the "Dialogue" project, a large primary care study conducted in 67 primary care clinics in Quebec, Canada. Following a mental health screening in medical clinics (n = 14833), patients at risk of anxiety or depression completed the Composite International Diagnostic Interview-Simplified (CIDIS). Multilevel logistic regression models were developed to examine correlates of treatment adequacy for pharmacological and psychological treatments. Results: Results indicate that 52.5 % of participants were recognized as having GAD by a healthcare professional in the past 12 months, and 36.2 % of the sample received a pharmacological (24.4 %) and/or psychological treatment (19.2 %) meeting indicators based on clinical practice guidelines recommendations. The detection of GAD by a health professional and the presence of comorbid depression were associated with overall treatment adequacy. Conclusions: This study suggests that further efforts towards GAD detection could lead to an increase in the delivery of evidence-based treatments. Key targets for improvement in treatment adequacy include regular follow up of patients with a GAD medication and access to psychotherapy from the primary care setting.
... Up to a quarter of patients annually seen in primary care have mental health disorders [12]. Two major contributors to this increasing problem area are anxiety and depression, which together affect about 5-15% of primary care patients [1,8,12,19,21,23]. ...
Article
The mental health burden on primary care is substantial and increasing. Anxiety is a major contributor. Stepped collaborative care (SCC) is implemented worldwide to improve patient outcomes, but long term real-world evaluations of SCC do not exist. Using routinely used electronic medical records from more than a decade, we investigated changes in anxiety prevalences, whether physicians made distinction between non-severe and severe anxiety, and whether these groups were referred and treated differently, both non-pharmacologically and pharmacologically. Retrospective assessment of anxiety care parameters recorded by 54 general practitioners between 2003 and 2014, in the electronic medical records of a dynamic population of 49,841-69,413 primary care patients. Substantial shifts in anxiety care parameters have occurred. The prevalence of anxiety symptoms doubled to 0.9% and of anxiety disorders almost tripled to 1.1%. Use of ICPC codes seemed comprehensive and use of instruments to support in anxiety level differentiation increased to 13% of anxiety symptom and 7% of anxiety disorder patients in 2014. Minimal interventions were used more frequently, especially for anxiety symptoms (OR 21 [95% CI 5.1-85]). The antidepressant prescription rates decreased significantly for anxiety symptoms (OR 0.5 [95% CI 0.4-0.8]) and anxiety disorders (OR 0.6 [95% CI 0.4-0.8]). More patients were referred to psychologists and psychiatrists. We found shifts in anxiety care parameters that follow the principles of SCC. Future primary care research should comprehensively assess the use of the SCC range of therapeutic options, tailored to patients with all different anxiety severity levels. Copyright © 2015 Elsevier Masson SAS. All rights reserved.
... In a screening of 14000 patients seeking primary health care in Belgium and Luxemburg, 8.3 % were given a GAD diagnosis (Ansseau, Fischler, Dierick, Mignon & Leyman, 2005). In a Scandinavian study, the prevalence of GAD in patients consulting their general practitioner was studied (Munk-Jørgensen et al., 2006). Among the Swedish 1300 patients in that study, 5% were diagnosed with pure GAD and an additional 1.5 % of the males, and 3% of the women had comorbid GAD and major depression. ...
... The DSQ assessed ten symptoms of depression with three-point scaled items labelled 0 = never, 1 = on some days and 2 = on the majority of days; in GAD-P, however, a slightly modified response format was used (0 = seldom/never, 1 = often and 2 = on the majority of days). The DSQ is well established and has been used in epidemiological studies in primary care in various countries (Munk-Jorgenson et al. 2006). Test-retest reliability and convergent validity [diagnosis of major depression based on the DSQ as compared with the Composite International Diagnostic Interview (Wittchen & Pfister, 1997)] have been shown to be high (Wittchen & Perkonigg, 1997). ...
Article
Aims Although associations between various somatic diseases and depression are well established, findings concerning the role of gender and anxiety disorders for these associations remain fragmented and partly inconsistent. Combining data from three large-scaled epidemiological studies in primary care, we aim to investigate interactions of somatic diseases with gender and anxiety disorders in the association with depression. Methods Self-reported depression according to the International Classification of Diseases, Tenth Edition (ICD-10) was assessed in n = 83 737 patients from three independent studies [DETECT (Diabetes Cardiovascular Risk Evaluation: Targets and Essential Data for Commitment of Treatment), Depression-2000 and Generalized Anxiety and Depression in Primary Care (GAD-P)] using the Depression Screening Questionnaire (DSQ). Diagnoses of depression, anxiety disorders and somatic diseases were obtained from treating physicians via standardised clinical appraisal forms. Results In logistic regressions, adjusted for gender, age group and study, each somatic disease except for arterial hypertension and endocrine diseases was associated with self-reported depression (odds ratio, OR 1.3–2.6) and each somatic disease was associated with physician-diagnosed depression (OR 1.1–2.4). Most of these associations remained significant after additional adjustment for anxiety disorders and other somatic diseases. The associations with depression increased with a higher number of somatic diseases. Cardiovascular diseases (OR 0.8), diabetes mellitus (OR 0.8) and neurological diseases (OR 0.8) interacted with gender in the association with self-reported depression, while endocrine diseases (OR 0.8) interacted with gender in the association with physician-diagnosed depression. That is, the associations between respective somatic diseases and depression were less pronounced in females v. males. Moreover, cardiovascular diseases (OR 0.7), arterial hypertension (OR 0.8), gastrointestinal diseases (OR 0.7) and neurological diseases (OR 0.6) interacted with anxiety disorders in the association with self-reported depression, and each somatic disease interacted with anxiety disorders in the association with physician-diagnosed depression (OR 0.6–0.8). That is, the associations between respective somatic diseases and depression were less pronounced in patients with v. without anxiety disorders; arterial hypertension was negatively associated with self-reported depression only in patients with anxiety disorders, but not in patients without anxiety disorders. Conclusions A range of somatic diseases as well as anxiety disorders are linked to depression – and especially patients with co-/multi-morbidity are affected. However, interactions with gender and anxiety disorders are noteworthy and of relevance to potentially improve recognition and treatment of depression by physicians. Somatic diseases are associated more strongly with depression in males v. females as well as in patients without v. with anxiety disorders, primarily because women and patients with anxiety disorders per se are characterised by considerably increased depression prevalence that only marginally changes in the presence of somatic comorbidity.
... The remaining four items are filler items. Depression was measured with the Depression-Screening Questionnaire [DSQ; 33], a self-report questionnaire developed by Wittchen and Perkonigg [34] which is a well-established and frequently used instrument in largescale studies in primary care [35]. The DSQ consists of ten items with a three-point scale ranging from 0 (never) through 1 (on some days) to 2 (on the majority of days) referring to the preceding 2 weeks. ...
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Purpose: To examine whether optimism/pessimism reliably predicts depression and whether such function is stable also in older age. Method: In a prospective study, we observed a representative sample of n = 4,046 primary care patients over 5 years. The Life Orientation Test (LOT-R, measuring optimism/pessimism) and the Depression-Screening Questionnaire were applied. Medical diagnoses were recorded by the treating physician in a structured medical interview. Results: Depression could only be predicted by LOT-R scores in younger-age cohorts. In older adults, test stability and predictive accuracy of optimism/pessimism were markedly reduced, while somatic comorbidity gained importance as a predictor. Conclusions: Predictive value of screening measures for mental disorders may be specific in older age due to lower trait stability and age-specific psychometric limitations as well as age-related changes in relevant predictors.
... In a general Swedish community, the annual incidence of first time depression in women was reported as 7.6 per 1000 person years (208). Among female patients in primary healthcare in the Nordic countries, the reported prevalence of depression was 9.9 14.2% (158). Although it is not clear which comes first, depression or LBP, it has been shown that a depressed mood increases the risk for pain problems and that psychosocial variables are clearly linked to the transition from acute to persistent pain disability (129). ...
... Generalized anxiety disorder (GAD) is a disabling psychiatric illness characterized by excessive worry, without specific cause, for a period of at least 6 months. 1 GAD is often a chronic condition and is associated with reduced health-related quality of life (HRQoL) and psychosocial functioning, low overall life satisfaction, and impairment in the ability to fulfill roles and social tasks. 2 GAD is twice as common in women as in men 3,4 and is often comorbid with other psychiatric disorders and/or medical conditions. [5][6][7][8][9] Considerable variability in prevalence has been observed between European countries; 10,11 however, in Europe overall, the 12-month prevalence of GAD is estimated to be approximately 2% of the adult population, 12 with higher rates (5.3%) reported for patients receiving treatment in the primary care setting. 13 submit your manuscript | www.dovepress.com ...
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Whilst studies suggest that generalized anxiety disorder (GAD) represents a considerable health care burden in Europe, there is a paucity of published evidence. This study investigated the burden of illness associated with GAD across five European countries (France, Germany, Italy, Spain, and the UK). Information from the 2008 European National Health and Wellness Survey database was analyzed. Bivariate, multivariate, and cost analyses were used to compare patients with GAD and propensity-matched controls. Compared with non-GAD controls, patients with GAD had more comorbidities and were more likely to smoke but less likely to be employed, use alcohol, or take exercise. They also had significantly worse health-related quality of life, and significantly greater work impairment and resource use, which increased as GAD severity increased. Within-country analyses demonstrated results similar to those for the five European countries overall, with the largest differences in resource use between patients with GAD and non-GAD controls documented in France and Germany. The average mean differences in direct costs were relatively small between the GAD groups and controls; however, indirect costs differed substantially. Costs were particularly high in Germany, mainly due to higher salaries leading to higher costs associated with absence from work. The limitation of this study was that the data were from a self-reported Internet survey, making them subject to reporting bias and possibly sample bias. Across all five European countries, GAD had a significant impact on work impairment, resource use, and economic costs, representing a considerable individual and financial burden that increased with severity of disease. These data may help us to understand better the burden and costs associated with GAD.
... In most countries general practitioners (GPs) mediate access to secondary services, i.e. specialist care. Unfortunately GPs often struggle to identify mental health problems [15,18]. Fear of stigmatisation is another obstacle to timely treatment [19]. ...
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Background This study compares the effectiveness of psychotherapeutic consultation in the workplace (PSIW) with psychotherapeutic outpatient care (PSOC) in Germany. Methods Work ability (WAI), quality of life (SF-12), clinical symptoms (PHQ) and work-related stress (MBI, IS) were assessed in 367 patients seeking mental health care via two routes (PSIW n = 174; PSOC n = 193) before consultation and 12 weeks later. Changes in outcome variables were assessed using covariance analysis with repeated measures (ANCOVA) with sociodemographic variables (propensity score method), therapy dose, setting and symptom severity as covariates. ResultsThe PSIW and PSOC groups included 122 and 66 men respectively. There were 102 first-time users of mental healthcare in the PSIW group and 83 in the PSOC group. There were group differences in outcome variables at baseline (p < 0.05); PSIW patients were less impaired overall.There were no group difference in sociodemographic variables, number of sessions within the offer or symptom severity. There was no main effect of group on outcome variables and no group*time interaction. Work-related stress indicators did not change during the intervention, but work ability improved in both groups (F = 10.149, p = 0.002; baseline M = 27.2, SD = 8.85); follow-up M = 28.6, SD = 9.02), as did perceived mental health (SF-12 MCS), depression (PHQ-9) and anxiety (PHQ-7). Effect sizes were between η2 = 0.028 and η2 = 0.040. Conclusions Psychotherapeutic consultation is similarly effective in improving patients’ functional and clinical status whether delivered in the workplace or in an outpatient clinic. Offering mental health services in the workplace makes it easier to reach patients at an earlier stage in their illness and thus enables provision of early and effective mental health care. Trial registrationDRKS00003184, retrospectively registered 13 January 2012.
... Generalised anxiety disorder is amongst the most common of mental disorders in primary medical care, and is associated with increased use of health services. However it is often not recognised, possibly because only a minority of patients present with anxiety symptoms (most present with physical symptoms), and doctors tend to overlook anxiety unless it is a presenting complaint [I] (Munk-Jorgensen et al., 2006). The degree of functional impairment associated with generalised anxiety disorder is similar to that with major depression [I] . ...
Article
This revision of the 2005 British Association for Psychopharmacology guidelines for the evidence-based pharmacological treatment of anxiety disorders provides an update on key steps in diagnosis and clinical management, including recognition, acute treatment, longer-term treatment, combination treatment, and further approaches for patients who have not responded to first-line interventions. A consensus meeting involving international experts in anxiety disorders reviewed the main subject areas and considered the strength of supporting evidence and its clinical implications. The guidelines are based on available evidence, were constructed after extensive feedback from participants, and are presented as recommendations to aid clinical decision-making in primary, secondary and tertiary medical care. They may also serve as a source of information for patients, their carers, and medicines management and formulary committees.
... GAD is one of the most common mental disorders in primary medical care (general practice). A study of adult primary care patients in four Nordic countries found the prevalence of GAD to be 4.1 -6.0% among men and 3.7 -7.1% in women: however, only a minority of patients with GAD were recognized as having the condition, possibly because few patients presented with characteristic symptoms (Munk Jorgensen et al. 2006). Previous studies indicate that those with co-morbid depression are more likely to be recognised as having a mental health problem, though not necessarily as having GAD (Weiller 1998;Wittchen et al. 2002). ...
... In most countries general practitioners (GPs) mediate access to secondary services, i.e. specialist care. Unfortunately GPs often struggle to identify mental health problems [15,18]. Fear of stigmatisation is another obstacle to timely treatment [19]. ...
... Despite its pervasiveness in primary care (Calleo et al., 2009;Wittchen, 2002) and its associated disability, GAD still remains a poorly recognized disorder. Moreover, while the disorder has been well documented in Western psychiatric literature (Munk-Jorgensen et al., 2006), there has been a relative lack of data from countries in South East Asia (Lee et al., 2007a,b;Lim et al., 2005). The current study thus aims to explore the prevalence, correlates, and co-morbidity of GAD in the multi-ethnic population of Singapore in an attempt to further understand this chronic and disabling condition. ...
Article
Despite its pervasiveness and associated impairment, generalized anxiety disorder (GAD) remains a poorly recognized disorder. Furthermore, given that GAD has been relatively understudied in Asia, the current study examined the prevalence, correlates and co-morbid conditions of this disorder in a multi-ethnic population of Singapore. Data was utilized from the Singapore Mental Health Study (SMHS), a cross-sectional epidemiological survey conducted among the adult population (n = 6616) aged 18 years and above. The Composite International Diagnostic Interview version 3.0 (CIDI v3.0) was used to assess co-morbidity as well as the life-time and 12-month prevalence of disorders. Functional impairment and treatment-seeking behavior were also assessed. The life-time (0.9%) and 12-month (0.4%) prevalence estimates in the current study were found to be lower than those reported in Western populations but comparable to the prevalence estimates found in Asian countries. The relatively lower prevalence rate of GAD in this study suggests the possible role of culture in reporting and manifestation of anxiety symptomatology. The failure of a substantial proportion of individuals to seek treatment despite self-reported impairment was also identified as an area of concern.
... Patients suffering from anxiety disorders are more likely to seek treatment from primary care provider than from mental health specialist [5]. However, only up to one third of anxiety cases are recognized by primary care providers [3,6,7] and only a small proportion of patients receive treatment for anxiety disorders [4,8,9]. Generalized anxiety disorder (GAD) is characterized by persistent anxiety and worry, and is the most common anxiety disorder with reported prevalence rates ranging between 2.8% and 8.5% [6,10]. ...
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Background: Depressive and anxiety disorders are common in primary care setting but often remain undiagnosed. Metabolic syndrome (MetS) is also prevalent in the general population and can impair recognition of common mental disorders due to significant co-morbidity and overlap with psychiatric symptoms included in self-reported depression/anxiety screening tools. We investigated if MetS has an impact on the accuracy of current major depressive disorder (MDD) and generalized anxiety disorder (GAD) screening results using the Hospital Anxiety and Depression scale (HADS). Methods: A total of 1115 (562 men; mean age 62.0 ± 9.6 years) individuals of 45+ years of age were randomly selected from the general population and evaluated for current MetS; depressive and anxiety symptoms (HADS); and current MDD and GAD (Mini International Neuropsychiatric Interview [MINI]). Results: The MetS was diagnosed in 34.4% of the study participants. Current MDD and GAD were more common in individuals with MetS relative to individuals without MetS (25.3% vs 14.2%, respectively, p < 0.001; and 30.2% vs 20.9%, respectively, p < 0.001). The ROC analyses demonstrated that optimal thresholds of the HADS-Depression subscale for current MDE were ≥9 in individuals with MetS (sensitivity = 87%, specificity = 73% and PPV = 52%) and ≥8 in individuals without MetS (sensitivity = 81%, specificity = 78% and PPV = 38%). At threshold of ≥9 the HADS-Anxiety subscale demonstrated optimal psychometric properties for current GAD screening in individuals with MetS (sensitivity = 91%, specificity = 85% and PPV = 72%) and without MetS (sensitivity = 84%, specificity = 83% and PPV = 56%). Conclusions: The HADS is a reliable screening tool for current MDE and GAD in middle aged and elderly population with and without MetS. Optimal thresholds of the HADS-Depression subscale for current MDD is ≥9 for individuals with MetS and ≥8 - without MetS. Optimal threshold of the HADS-Anxiety subscale is ≥9 for current GAD in individuals with and without MetS. The presence of MetS should be considered when interpreting depression screening results.
... In a study of adult primary-care patients in Norway, Sweden, Denmark and Finland, the rates of GAD were 4.1–6.0 % among men, and 3.7–7.1 among women (Munk-Jorgensen et al. 2006). The proportion of GAD patients recognized by a general practitioner varied from 33 % in Denmark to 53 % in Norway. ...
Article
Generalized anxiety disorder (GAD) is chiefly characterized by a cognitive focus on threats and risks towards the individual and/or the immediate family. It is accompanied by a sense of tension, worry, muscle pain, disturbed sleep and irritability. The condition impairs work capacity, relations, and leisure activities, and aggravates concurrent somatic diseases. Due to its chronic course, GAD increases costs for the individual, the family, and health care services, and reduces work and educational performance. In cardiovascular or cerebrovascular disease, pulmonary disease, diabetes and neurological diseases, GAD is a risk factor for somatic complications and for lowered adherence to somatic treatments. There is evidence that GAD can be treated with cognitive behavioural therapy (CBT), and/or with medications. First-line pharmacotherapies are selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs) and pregabalin. If such therapies fail, one may reconsider the diagnosis, question adherence with the prescribed schedule, and determine the adverse influence of comorbidity (such as depression, substance use, and physical ill-health) as well as the influence of social stressors. Second-line pharmacotherapies are largely not supported by controlled trials, and so leave much to clinical judgment and careful monitoring. One may attempt treatments with benzodiazepine anxiolytics, with quetiapine, or with pregabalin as an adjunct therapy in patients with partial response to SSRI or SNRI treatment. CBT is a valid alternative to pharmacotherapy, depending on patient preference.
... Results showed that the health care cost for patients with GAD treated with antidepressants was substantial, with a 9-month cost of £984, which corresponds to £1313 per patient per year. In the perspective of evaluation of burden of disease and because GAD is largely underdiagnosed (only one third to half the patients are recognized by GPs), it would be informative to determine the total health care costs in patients with GAD treated with treatments other than ADs, including psychotherapy, as well as in undiagnosed patients with GAD [27]. In addition, GAD is associated with a high impact on daily life and occupation [11], and underdiagnosis is most likely the cause of increased costs, especially of indirect costs such as work productivity (e.g., absenteeism and presenteeism). ...
Article
To describe real-life prescription patterns, health care resource use, and costs in adults with generalized anxiety disorder (GAD) initiating antidepressant (AD) treatment in the United Kingdom. A retrospective longitudinal cohort study using data from Clinical Research Practice Datalink was conducted. Adults with incident prescription of an AD (index date) between January 1, 2006, and June 30, 2010, and with a diagnosis of GAD within the 2 months preceding or following the index date were included. Patients with a diagnosis of schizophrenia or bipolar disorder were excluded. A total of 29,131 patients with GAD were included in the analysis. Their mean age was 48.5 ± 15.5 years, and two thirds were women. GAD-licensed ADs (i.e., escitalopram, paroxetine, venlafaxine XR, and duloxetine) represented only 12.5% of the index AD prescriptions. At least one anxiolytic was prescribed for 23.5% of the patients. Only 33.2% of the patients continued index AD treatment over the study period. Discontinuation occurred for 46.0% of the patients, after a mean of 3.7 months of treatment. The health care costs were £338.4 per patient in the 6 months before the index date and £984.6 in the 9 months after the index date. Psychiatric hospitalization (relative risk = 4.18; 95% CI 3.53-4.96; P < 0.001) and duloxetine as index treatment (relative risk = 1.85; 95% CI 1.30-2.63; P < 0.001) were the main determinants of increased costs for these patients. The significant rate of AD discontinuation and associated treatment duration indicate unmet needs among patients with GAD. As described in American studies, substantial health care costs were also observed in this study.
... While the end of the lockdown period was associated with improved psychological well-being [51], the practicalities of easing lockdown restrictions and returning to work, returning children to school, etc., could increase stress and anxiety. This is particularly true among women with depression (prevalence of 14.2% among Danish women) or anxiety (prevalence of 6.8% among Danish women) [52], both of which have been associated with PTB [53]. We cannot exclude that the psychosocial and behavioural changes during the lockdown, i.e. more people working from home, could have affected the risk of xPTB in specific groups of pregnant women. ...
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Using provisional or opportunistic data, three nationwide studies (The Netherlands, the USA and Denmark) have identified a reduction in preterm or extremely preterm births during periods of COVID-19 restrictions. However, none of the studies accounted for perinatal deaths. To determine whether the reduction in extremely preterm births, observed in Denmark during the COVID-19 lockdown, could be the result of an increase in perinatal deaths and to assess the impact of extended COVID-19 restrictions, we performed a nationwide Danish register-based prevalence proportion study. We examined all singleton pregnancies delivered in Denmark during the COVID-19 strict lockdown calendar periods (March 12–April 14, 2015-2020, N = 31,164 births) and the extended calendar periods of COVID-19 restrictions (February 27–September 30, 2015-2020, N = 214,862 births). The extremely preterm birth rate was reduced (OR 0.27, 95% CI 0.07 to 0.86) during the strict lockdown period in 2020, while perinatal mortality was not significantly different. During the extended period of restrictions in 2020, the extremely preterm birth rate was marginally reduced, and a significant reduction in the stillbirth rate (OR 0.69, 0.50 to 0.95) was observed. No changes in early neonatal mortality rates were found. Conclusion : Stillbirth and extremely preterm birth rates were reduced in Denmark during the period of COVID-19 restrictions and lockdown, respectively, suggesting that aspects of these containment and control measures confer an element of protection. The present observational study does not allow for causal inference; however, the results support the design of studies to ascertain whether behavioural or social changes for pregnant women may improve pregnancy outcomes. What is Known: • The aetiologies of preterm birth and stillbirth are multifaceted and linked to a wide range of socio-demographic, medical, obstetric, foetal, psychosocial and environmental factors. • The COVID-19 lockdown saw a reduction in extremely preterm births in Denmark and other high-income countries. An urgent question is whether this reduction can be explained by increased perinatal mortality. What is New: • The reduction in extremely preterm births during the Danish COVID-19 lockdown was not a consequence of increased perinatal mortality, which remained unchanged during this period. • The stillbirth rate was reduced throughout the extended period of COVID-19 restrictions.
... A review of epidemiological studies in europe (eU) estimates that 38.2% of the eU population suffers from a mental disorder each year. The most common disorders are anxiety disorders (14.0%), insomnia (7.0%), major depression (6.9%) (31). in a study of patients in primary adult care in four nordic countries, gAd rates ranged from 4.1 to 6.0% among men and from 3.7 to 7.1% among women (32). Anxiety disorder is about twice as common in women (28,29) and probably the most common mental disorder in the elderly population (31,33). ...
Article
Introduction. Two-thirds of primary care patients with depression also have somatic symptoms present, making detection of depression more difficult. Primary health care is the first level of screening for depression, and early detection is key to treatment success. Anxiety also has a high comorbidity rate with chronic pain conditions. Generalized anxiety disorder (GAD) is common among patients with “medically unexplained” chronic pain and chronic physical illness and is also a predictor of chronic musculoskeletal pain after trauma. Belonging to different ethnic groups and ignorance of these differences by primary care physicians can be an obstacle to good health care, especially early recognition of depressive symptoms. Aim. The aim of this proposed, systematic work was to draw conclusions from empirical research dealing with the processes involved in the examination of depression, anxiety, and chronic non malignant pain. The research question for this review paper was to examine the correlation of depression and anxiety with chronic non-malignant pain. The aim was to examine the role of primary health care in recognizing, preventing, and treating depression and anxiety in patients with chronic non-malignant pain, and whether there is a difference in the correlation between depression, anxiety, and chronic non-malignant pain according to ethnicity. Methods. Methods for identifying the study were derived from the Medline database (via PubMed). The analysis included all scientific papers in English, regardless of methodology, published since 2011. The papers dealt with the correlation between depression, anxiety, and chronic non-malignant pain, and included the population of primary care patients over 18 years of age who suffer from chronic nonmalignant pain and at the same time have symptoms of depression and anxiety present or are members of ethnic groups. 403 articles were found, original and review papers, of which, after a detailed reading, 10 were selected that meet the inclusion criteria for the purposes of this review. Results. Depression and anxiety are significantly more present in people with chronic pain (23%), compared to those who do not have chronic pain (12%). The most common is chronic musculoskeletal pain, with one-third of patients having depression. Depression and anxiety are significantly associated with the intensity and duration of pain. Chronic pain and depression also differ according to ethnic groups, with cultural differences and language barriers being a barrier to early detection of depression. Conclusion. Depression is the most common mental health disorder associated with chronic pain. It is extremely important to treat both depression and pain, in order to prevent the development of severe depression and chronic pain at an early stage. The integrated program at the level of primary health care is expected to have positive effects on both the physical and mental condition of patients. Cultural differences and ethnicity, which can significantly reduce the detection of depressive symptoms at the primary health care level, should certainly be taken into account.
... En studie av i den generelle praksis i Danmark, Finland, Norge og Danmark fant at kun 37 % av pasientene med GAD ble identifisert av de allmennpraktiserende legene. Manglende identifisering i primaerhelsetjenesten utgjør et problem, da det kreves henvisning fra leger i primaerhelsetjenesten for å bli henvist til spesialisthelsetjenesten (Munk-Jørgensen et al., 2006). ...
Thesis
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During the last two decades a number of therapies, under the name of the third wave of cognitive behavior therapy have been developed. One disorder that has gained attention from the third wave is Generalized Anxiety Disorder (GAD), a disorder cognitive behavior therapy finds difficult to treat. Four of these models for GAD are Metacognitive Therapy, Integrative Therapy, Acceptance Based Behavior Therapy, and Emotion Regulation Therapy. The purposes of this review of these third wave treatments were: 1. To describe these models, 2. To evaluate if they currently fulfill the criteria for empirically supported treatments (EST), 3. To discuss whether it is reasonably to assess the treatment models with the EST criteria, and 4: To give some recommendations to research and practice. The result demonstrates that none of the treatment models fulfilled the EST criteria. The review recommends psychologists in research and practice to implement the Policy Statement on evidence based practice in psychology of APA (2005), and broaden the view on evidence based practice.
... National studies done in the United States observe that the prevalence of anxiety disorders is 5.1 to 11.9 percent (Kessler et al., 2009;Wittchen and Jacobi, 2005). Anxiety is also probably the most common psychiatric disorder among the elderly population (Munk-Jørgensen et al., 2006). In a nationally demonstrative study, 66 percent of individuals with current anxiety had at least one concurrent disorder (Wittchen et al., 1994). ...
Article
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Anxiety disorders are the most common form of psychiatric disorders and start at an early age. The homeopathic system of complementary treatment is increasingly used by the general population. Ultra-diluted Aconite and Ignatia are homeopathic medicines used by clinicians for the treatment of anxiety. The objective of this study is to test the efficacy of Aconite 12CH and Ignatia 12CH on experimental anxiety models of Wistar rats subjected to chronic unpredictable stress. 30 Wistar rats were divided into 5 groups of Control, Stress, Vehicle, Aconite and Ignatia group with 6 animals in each group. All the groups were subjected to chronic unpredictable stress except the control group. The last two groups were fed Aconite and Ignatia through oral gavage daily for 5 weeks. Following this, a behavioral and biochemical assessment was done. It was observed that the Aconite and Ignatia treated animals showed better weight gain, but the behavioral and biochemical assessment did not show any significant change. Hence it was inferred that ultra-diluted Aconite and Ignatia though an anxiolytic used clinically, did not decrease anxiety in Wistar rats which were subjected to chronic unpredictable stress.
... A study examining the point prevalence of GAD in Sweden's general population found a prevalence of 8.8% when using a standard cut of value on the screening measure used, and 4.7% when using a stricter cut of value (Johansson, Carlbring, Heedman, Paxling, & Andersson, 2013). In Swedish primary care patients, the lifetime prevalence has been estimated to range from 4.1 to 6.0% for men and 3.7 to 7.1% for women (Munk-Jørgensen et al., 2006). ...
... Die diagnostischen Kriterien der Erkrankungen überlappen zudem deutlich [Zbozinek et al., 2012] und beide Störungen sind hochgradig komorbid [Carter et al., 2001;Kessler et al., 2005]. Für die primärärztliche Versorgung liegen zudem empirische Daten vor, die zeigen, dass die GAS häufig nicht erkannt oder fehldiagnostiziert wird [Wittchen et al., 2002;Munk-Jørgensen et al., 2006;Calleo et al., 2009;Vermani et al., 2011]. In einer Untersuchung an gesunden Kontrollprobanden, GAS Probanden mit und ohne komorbide depressive Störung sowie Probanden mit einer depressiven Störung ohne komorbide GAS wandten wir ein zweistufiges Vorgehen an: in einem ersten Schritt sollten Patienten mit einer Störung von den gesunden Kontrollprobanden unterschieden werden, im zweiten Schritt dann diejenigen Patienten mit einer GAS (mit und ohne komorbide Depression) von denjenigen ohne GAS [Hilbert et al., 2017] Koutsouleris et al., 2009;Mechelli et al., 2011;Foland-Ross et al., 2015]. ...
Article
Während in der somatischen Medizin mittlerweile eine Vielzahl von biologischen Markern für die Diagnostik und Therapieplanung vorliegen, gibt es keine vergleichbaren bio­logischen oder psychologischen Marker für psychische Störungen. Hier sind die Pathogenese und Wirkung psychotherapeutischer Interventionen durch eine Vielzahl mitei­nander interagierender Faktoren determiniert. Die prädiktive Analytik verfügt mit dem maschinellen Lernen über eine aussichtsreiche Methode, komplexe Muster und Interaktionen zwischen verschiedenen Variablen in Aussagen für den individuellen Patienten zu übersetzen. Diese Methoden bestimmen (“lernen”) aus bereits vorhandenen Daten die Beziehung zwischen Prädiktoren und Ergebnissen und können anschließend das entwickelte Modell auf neue Daten, bei denen das Ergebnis noch offen ist, anwenden. Zuvor muss aber zwingend geprüft werden, ob das Gelernte tatsächlich bedeutungsvoll ist. Zur Illustration des Ansatzes stellen wir eine Reihe von Studien vor, die das Paradigma der prädiktiven Analytik für diagnostische Fragestellungen, Vorhersage von Risikoverläufen sowie zur Prognose von Psychotherapieergebnissen genutzt haben. Die Ergebnisse sind vielversprechend; vor einem Einsatz in der klinischen Praxis muss die Vorhersagegenauigkeit jedoch weiter gesteigert und in verschiedenen Settings und Populationen überprüft werden. Zur Verbesserung der Vorhersagegüte scheinen insbesondere die Berücksichtigung unterschiedlicher Datenmodalitäten wie klinische Maße, (f)MRT-Daten und genetische Daten sowie der Fokus auf Variablen, die Mechanismen von Psychopathologie und Veränderungsmechanismen gut abbilden, sinnvoll. Darüber hinaus sollte eine enge Zusammenarbeit mit Vertretern von Praktikern und Betroffenen stattfinden, um die Akzeptanz solcher Marker zu gewährleisten. Wenn dies gelingt, bieten derartige Marker das Potenzial, die Diagnosesicherheit insbesondere in ­schwierigen Fällen deutlich zu erhöhen, mögliche Risikoverläufe früh zu identifizieren und die Zuweisung von Patienten zu den für sie bestmöglichen Behandlungen zu unterstützen.
... According to the World Health Organization, management of these conditions should be integrated into primary care [7]. Nevertheless, it is recognized that this group of patients is both underdiagnosed and undertreated in primary care [1,[8][9][10][11]. Lack of coordination between sectors and limited availability of evidence-based treatment, such as psychotherapy, are some of the explanations for these deficiencies in Denmark [12]. ...
Article
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Background: Models of collaborative care and consultation liaison propose organizational changes to improve the quality of care for people with common mental disorders, such as anxiety and depression. Some literature suggests only short-term positive effects of consultation liaison on patient-related outcomes, whereas collaborative care demonstrates both short-term and long-term positive effects. To our knowledge, only one randomized trial has compared the effects of these models. Collaborative care was superior to consultation liaison in reducing symptoms of depression for up to 3 months, but the authors found no difference at 9-months' follow-up. The Collabri Flex Trial for Depression and the Collabri Flex Trial for Anxiety aim to compare the effects of collaborative care with those of a form of consultation liaison that contains potential contaminating elements from collaborative care. The trials build on knowledge from the previous cluster-randomized Collabri trials. Methods: Two randomized, investigator-initiated, parallel-group, superiority trials have been established: one investigating the effects of collaborative care vs consultation liaison for depression and one investigating the effects of collaborative care vs consultation liaison for generalized anxiety, panic disorder and social anxiety disorder at 6-months' follow-up. Participants are recruited from general practices in the Capital Region of Denmark: 240 in the depression trial and 284 in the anxiety trial. The primary outcome is self-reported depression symptoms (Beck Depression Inventory (BDI-II)) in the depression trial and self-reported anxiety symptoms (Beck Anxiety Inventory (BAI)) in the anxiety trial. In both trials, the self-reported secondary outcomes are general psychological problems and symptoms (Symptom Checklist 90-Revised), functional impairment (Sheehan Disability Scale) and general well-being (World Health Organization-Five Well-Being Index). In the depression trial, BAI is an additional secondary outcome, and BDI-II is an additional secondary outcome in the anxiety trial. Explorative outcomes will also be collected. Discussion: The results will supplement those of the cluster-randomized Collabri trials and provide pivotal information about the effects of collaborative care in Denmark. Trial registration: ClinicalTrials.gov, NCT03113175 and NCT03113201 . Registered on 13 April 2017.
... The prevalence of common mental disorders among patients in general practice is high ( King et al., 2008;Munk-Jorgensen et al., 2006). ...
Article
In a collaborative care model in Denmark, general practitioners (GPs) were trained in cognitive behavioural therapy (CBT) of their patients with common mental disorders through supervision by psychiatric nurses and a psychiatrist. We explored the feasibility of implementing CBT as a treatment into routine general practice through this supervision. A qualitative interview study as part of a larger implementation study of collaborative care between general practice and psychiatry in Denmark. Interviews with all three professional groups involved in the intervention were analysed using interpretative phenomenological analysis. The participants experienced several cultural and organizational challenges with implementing CBT in general practice. The GPs were used to carrying out talking therapy with methods integrated into the treatment culture in general practice, and it was difficult for them to supplant existing therapeutic skills and approaches. The specific CBT approach was not compatible with the work conditions and work culture in general practice regarding patient relations, time frames and workload; and the inter‐professional training relations between GPs and psychiatric nurses were often challenging. There was an overall agreement among the professionals that general practice of talking therapy could not be changed in the image of psychiatry. The results suggest that wide‐scale implementation of CBT delivered by GPs to patients with common mental disorders is not feasible. Nevertheless, there are many psychotherapeutic elements in routine consultations in general practice, and GPs could possibly gain from improving their ways of questioning, and their use of non‐specific therapeutic, relational and psychodynamic factors.
... Thus, patients suffering from CMD are part of their daily routine. On the other hand, studies show low recognition rates, i.e., of maximum 50% in generalized anxiety disorder [57]. Rates were even lower if patients presented physical symptoms. ...
Article
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The rising burden of common mental disorders (CMDs) in employees requires strategies for prevention. No systematic data exist about how those involved perceive their roles, responsibilities, and interactions with other professional groups. Therefore, we performed a multi-professional standardized survey with health professionals in Germany. A self-administered questionnaire was completed by 133 occupational health physicians (OHPs), 136 primary care physicians (PCPs), 186 psychotherapists (PTs), and 172 human resource managers (HRMs). Inter alia, they were asked which health professionals working in the company health service and in the outpatient care or in the sector of statutory insurance agents should play a key role in the primary, secondary, and tertiary prevention of CMDs in employees. The McNemar test was used in order to compare the attributed roles among the professionals involved. With regard to CMDs, all the professional groups involved in this study declared OHPs as the most relevant pillar in the field of prevention. In primary prevention, HRMs regarded themselves, OHPs, and health insurance agents as equally relevant in terms of prevention. PTs indicated an important role for employee representatives in this field. In secondary prevention, PCPs were regarded as important as OHPs. HRMs indicated themselves as equally important as OHPs and PCPs. In tertiary prevention, only OHPs identified themselves as main protagonists. The other groups marked a variety of several professions. There is a common acceptance from the parties involved that might help the first steps be taken toward overcoming barriers, e.g., by developing a common framework for quality-assured intersectional cooperation in the field of CMD prevention in employees.
... However, it has been largely neglected in the health services literature, with the exception of some studies showing GAD to contribute to higher use of primary care services in primary care samples. [24][25][26][27][28] Clinical samples, however, have the potential for self-selection bias. Further research is needed to determine whether GAD leads to hospital admissions. ...
Article
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Objective Generalised anxiety disorder (GAD) is the most common anxiety disorder in the general population and has been associated with high economic and human burden. However, it has been neglected in the health services literature. The objective of this study is to assess whether GAD leads to hospital admissions using data from the European Prospective Investigation of Cancer-Norfolk. Other aims include determining whether early-onset or late-onset forms of the disorder, episode chronicity and frequency, and comorbidity with major depressive disorder (MDD) contribute to hospital admissions. Design Large, population study. Setting UK population-based cohort. Participants 30 445 British participants were recruited through general practice registers in England. Of these, 20 919 completed a structured psychosocial questionnaire used to identify presence of GAD. Anxiety was assessed in 1996–2000, and health service use was captured between 1999/2000 and 2009 through record linkage with large, administrative health databases. 17 939 participants had complete data on covariates. Main outcome measure Past-year GAD defined according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Results In this study, there were 2.2% (393/17 939) of respondents with GAD. Anxiety was not independently associated with hospital admissions (incidence rate ratio (IRR)=1.04, 95% CI 0.90 to 1.20) over 9 years. However, those whose anxiety was comorbid with depression showed a statistically significantly increased risk for hospital admissions (IRR=1.23, 95% CI 1.02 to 1.49). Conclusion People with GAD and MDD comorbidity were at an increased risk for hospital admissions. Clinicians should consider that meeting criteria for a pure or individual disorder at one point in time, such as past-year GAD, does not necessarily predict deleterious health outcomes; rather different forms of the disorder, such as comorbid cases, might be of greater importance.
... For example, in a large-scale study in the general Scandinavian population, general medical care practitioners identified only one-third to one-half of the cases of generalized anxiety disorder. 46 In another study in the Danish population, only 13% of people identified as having a major depressive disorder were receiving treatment by a physician. 47 Taken together, these results illustrate that standardized screening of the psychological domain as part of evaluating patients' pain in a general dental practice is far from being unnecessary. ...
Article
Background: Evidence in the field of dentistry has demonstrated the importance of pain-related disability and psychological assessment in the development of chronic symptoms. The Diagnostic Criteria for Temporomandibular Disorders offer a brief assessment for the diagnostic process in patients with orofacial pain (Axis II). The authors describe relevant outcomes that may guide general oral health care practitioners toward tailored treatment decisions and improved treatment outcomes and provide recommendations for the primary care setting. Methods: The authors conducted a review of the literature to provide an overview of knowledge about Axis II assessment relevant for the general oral health care practitioner. Results: The authors propose 3 domains of the Axis II assessment to be used in general oral health care: pain location (pain drawing), pain intensity and related disability (Graded Chronic Pain Scale [GCPS]), and psychological distress (Patient Health Questionnaire-4 [PHQ-4]). In the case of localized pain, low GCPS scores (0-II), and low PHQ-4 scores (0-5), patients preferably receive treatment in primary care. In the case of widespread pain, high GCPS scores (III-IV), and high PHQ-4 scores (6-12), the authors recommend referral to a multidisciplinary team, especially for patients with temporomandibular disorder (TMD) pain. Conclusions: The authors recommend psychological assessment at first intake of a new adult patient or for patients with persistent TMD pain. The authors recommend the pain-related disability screening tools for all TMD pain symptoms and for dental pain symptoms that persist beyond the normal healing period. Practical implications: A brief psychological and pain-related disability assessment for patients in primary care may help the general oral health care practitioner make tailored treatment decisions.
... [1][2][3] Despite its high prevalence, GAD frequently goes undiagnosed. 3,4 Over more than a decade of follow-up, GAD has been shown to have a lower recovery rate than major depressive disorder (58% vs. 73%), 5 and among patients who do recover, the rate of recurrence is high (45%). 5 GAD is also associated with work and social impairment at levels comparable with those observed among MDD patients. ...
Article
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Generalized anxiety disorder (GAD) is a common disorder that is chronic, disabling, and often goes undiagnosed. Currently, four distinct classes of medications have demonstrated efficacy in the treatment of GAD: benzodiazepines, serotonin and/or norepinephrine reuptake inhibitors (SSRIs/SNRIs), histamine H1 receptor blockers (hydroxyzine), and pregabalin. Pregabalin acts via binding to an α2-δ subunit presynaptic membrane protein that inhibits neurotransmitter release in excited neurons. Pregabalin is renally excreted and undergoes minimal (<2%) hepatic metabolism, thus limiting the risk of drug–drug interactions. The efficacy of pregabalin for the treatment of GAD has been established based on the results of 8 double-blind, placebo-controlled, short-term led trials, and one 6-month relapse prevention study. The current review summarizes data showing that pregabalin has a significantly different safety profile from the benzodiazepines (eg, less sedation, less cognitive and psychomotor impairment, less risk of dependence and withdrawal), and SSRI/ SNRI anxiolytics (eg, less gastrointestinal side effects and sexual dysfunction). The review also summarizes efficacy data showing that pregabalin is a broad spectrum anxiolytic that with a speed of onset similar to the benzodiazepines.
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Background. Depression and anxiety disorders are major world-wide problems. There are no or few epidemiological studies investigating the prevalence of depression, generalized anxiety disorder and anxiety disorders in general in the Swedish population. Methods. Data were obtained by means of a postal survey administered to 3001 randomly selected adults. After two reminders response rate was 44.3%. Measures of depression and general anxiety were the 9-item Patient Health Questionnaire Depression Scale (PHQ-9) and the 7-item Generalized Anxiety Disorder Scale (GAD-7). The PHQ-9 identified participants who had experienced clinically significant depression (PHQ-9 ≥ 10), and who had a diagnosis of major depression (defined by using a PHQ-9 scoring algorithm). Clinically significant anxiety was defined as having a GAD-7 score ≥ 8. To specifically measure generalized anxiety disorder, the Generalized Anxiety Disorder Questionnaire-IV (GAD-Q-IV) was used with an established cut-off. Health-related quality of life was measured using the EuroQol (EQ-5D). Experiences of treatments for psychiatric disorders were also assessed. Results. Around 17.2% (95% CI: 15.1–19.4) of the participants were experiencing clinically significant depression (10.8%; 95% CI: 9.1–12.5) and clinically significant anxiety (14.7%; 95% CI: 12.7–16.6). Among participants with either clinically significant depression or anxiety, nearly 50% had comorbid disorders. The point prevalence of major depression was 5.2% (95% CI: 4.0–6.5), and 8.8% (95% CI: 7.3–10.4) had GAD. Among those with either of these disorders, 28.2% had comorbid depression and GAD. There were, generally, significant gender differences, with more women having a disorder compared to men. Among those with depression or anxiety, only between half and two thirds had any treatment experience. Comorbidity was associated with higher symptom severity and lower health-related quality of life. Conclusions. Epidemiological data from the Swedish community collected in this study provide point prevalence rates of depression, anxiety disorders and their comorbidity. These conditions were shown in this study to be undertreated and associated with lower quality of life, that need further efforts regarding preventive and treatment interventions.
Article
Background and Objectives: To describe patterns of healthcare utilization among patients with generalized anxiety disorder (GAD) in general practitioner (GP) settings in Germany. Methods: Using a large computerized database with information from GP practices across Germany, we identified all patients, aged > 18 years, with diagnoses of, or prescriptions for, GAD (ICD-10 diagnosis code F41.1) between October 1, 2003 and September 30, 2004 ("GAD patients"). We also constituted an age- and sex-matched comparison group, consisting of randomly selected patients without any GP encounters or prescriptions for anxiety or depression (a common comorbidity in GAD) during the same period. GAD patients were then compared to those in the matched comparison group over the one-year study period. Results: The study sample consisted of 3340 GAD patients and an equal number of matched comparators. Mean age was 53.2 years; 66.3% were women. Over the 12-month study period, GAD patients were more likely than matched comparators to have encounters for various comorbidities, including sleep disorders (odds ratio [OR] = 6.75 [95% CI = 5.31, 8.57]), substance abuse disorders (3.91 [2.89, 5.28]), and digestive system disorders (2.62 [2.36, 2.91]) (all p Conclusions: Patients with GAD in GP practices in Germany have more clinically recognized comorbidities and higher levels of healthcare utilization than patients without anxiety or depression.
Article
Generalized anxiety disorder (GAD) is characterized by a pervasive cognitive dysfunction with a focus on threats and risks toward the individual or his/her immediate family. It goes with tension, worry, muscle pain, disturbed sleep, and irritability that all together impair work capacity, relations, and leisure activities. By its chronic course, GAD increases direct and indirect costs for the individual, the family, the health care services, and at work or in education. Among patients with cardiovascular or cerebrovascular disease, pulmonary disease, diabetes, and neurological diseases, GAD is a risk factor for somatic complications and for lowered adherence to somatic treatments. GAD can be treated with cognitive behavioral therapy, and/or with medications.
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Background The ongoing COVID-19 pandemic has had an unprecedented impact on the lives of people globally and is expected to have profound effects on mental health. Here we aim to describe the mental health burden experienced in Sweden using baseline data of the Omtanke2020 Study. Method We analysed self-reported, cross-sectional baseline data collected over a 12-month period (June 9, 2020–June 8, 2021) from the Omtanke2020 Study including 27,950 adults in Sweden. Participants were volunteers or actively recruited through existing cohorts and, after providing informed consent, responded to online questionnaires on socio-demographics, mental and physical health, as well as COVID-19 infection and impact. Poisson regression was fitted to assess the relative risk of demonstrating high level symptoms of depression, anxiety, and COVID-19 related distress. Result The proportion of persons with high level of symptoms was 15.6 %, 9.5 % and 24.5 % for depression, anxiety, and COVID-19 specific post-traumatic stress disorder (PTSD), respectively. Overall, 43.4 % of the participants had significant, clinically relevant symptoms for at least one of the three mental health outcomes and 7.3 % had significant symptoms for all three outcomes. We also observed differences in the prevalence of these outcomes across strata of sex, age, recruitment type, COVID-19 status, region, and seasonality. Conclusion While the proportion of persons with high mental health burden remains higher than the ones reported in pre-pandemic publications, our estimates are lower than previously reported levels of depression, anxiety, and PTSD during the pandemic in Sweden and elsewhere.
Article
Generalized Anxiety Disorder (GAD) is the second most common anxiety disorder (after phobias) with a lifetime prevalence of approximately 5–10% and a point prevalence in the general population of approximately 2%, depending on gender. Despite its prevalence, only one-third of patients with GAD are diagnosed by their primary care physician even though they are frequent attenders of primary care clinics. Patients with GAD constitute a diagnostic challenge because they often present with disturbed sleep or medically unexplained symptoms such as pain rather than with anxiety per se. GAD is usually comorbid with other disorders, particularly other psychiatric disorders, and with medical disorders, which presents further diagnostic challenges. GAD itself is a risk factor for the development of subsequent Major Depressive Disorder and may also contribute to an increased risk of or poorer outcomes from medical disorders such as diabetes and cardiovascular disease. GAD exacts a substantial personal, societal and economic burden. Based on a thorough review of the evidence, the World Federation of Societies of Biological Psychiatry has recommended pregabalin, SSRIs and SNRIs as first-line treatments for GAD. Benzodiazepines are reserved as a second-line treatment for short-term use due to concerns about the potential for abuse and dependence. Experts in the management of GAD regard it as an important psychiatric and public health problem that has been somewhat neglected and for which better physician education is needed.
Chapter
Generalized anxiety disorder (GAD) is one of the more prevalent anxiety disorders. However, many questions still remain regarding its etiopathogenesis and optimal treatment, including possible effects of gender. This chapter provides an overview about the prevalence of GAD, its diagnosis, psychological and (neuro-)biological models as well as treatment options, highlighting any gender differences as reported so far. As for most anxiety disorders, gender differences have been most consistently revealed for prevalence, with females being approximately 1.5-2 times as likely as males to meet criteria for GAD. However, the cause for this female preponderance is largely unknown to date. While some first evidence points towards an important role of different emotion regulation strategies in women and men, almost no information is available on possible gender effects on the genetic or neurobiological underpinning of the disorder. With regard to the diagnosis and treatment of GAD, gender appears not to play a major role except for health care utilization.
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Generalized anxiety disorder is a complex psychiatric syndrome. Current understanding on the epidemiological risk factors, genetic vulnerability and neurobiology of the GAD is beginning to unfold the complexities behind this disorder. This narrative review has attempted to put together the recent advances in the area of GAD research with intent to identify the gaps requiring further research.
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Background: Therapist-supported, internet-delivered cognitive behavioral therapy (iCBT) is efficacious for generalized anxiety disorder (GAD), but few studies are yet to report its effectiveness in routine care. Objective: In this study, we aim to examine whether a new 12-session iCBT program for GAD is effective in nationwide routine care. Methods: We administered a specialized, clinic-delivered, therapist-supported iCBT for GAD in 1099 physician-referred patients. The program was free of charge for patients, and the completion time was not predetermined. We measured symptoms with web-based questionnaires. The primary measure of anxiety was the GAD 7-item scale (GAD-7); secondary measures were, for pathological worry, the Penn State Worry Questionnaire and, for anxiety and impairment, the Overall Anxiety Severity and Impairment Scale. Results: Patients completed a mean 7.8 (SD 4.2; 65.1%) of 12 sessions, and 44.1% (485/1099) of patients completed all sessions. The effect size in the whole sample for GAD-7 was large (Cohen d=0.97, 95% CI 0.88-1.06). For completers, effect sizes were very large (Cohen d=1.34, 95% CI 1.25-1.53 for GAD-7; Cohen d=1.14, 95% CI 1.00-1.27 for Penn State Worry Questionnaire; and Cohen d=1.23, 95% CI 1.09-1.37 for Overall Anxiety Severity and Impairment Scale). Noncompleters also benefited from the treatment. Greater symptomatic GAD-7-measured relief was associated with more completed sessions, older age, and being referred from private or occupational care. Of the 894 patients with a baseline GAD-7 score ≥10, approximately 421 (47.1%) achieved reliable recovery. Conclusions: This nationwide, free-of-charge, therapist-supported HUS Helsinki University Hospital-iCBT for GAD was effective in routine care, but further research must establish effectiveness against other treatments and optimize the design of iCBT for GAD for different patient groups and individual patients.
Article
Background: Generalized anxiety disorder (GAD) is common. It accounts for about one out of four anxiety related clinic consultations. The prevalence of this common disorder and the associated factors in Ugandan students are unknown. The objectives of this study were to determine the prevalence of GAD symptoms, and to evaluate its association with intolerance of uncertainty and parental attachment among fresh undergraduates in Uganda. Methods: The research utilized a cross-sectional approach. Non-clinical participants from 8 colleges (mean age 21.24; 59.7% males, 40.3% females) completed self-report inventories measuring intolerance of uncertainty, parental attachment and GAD symptoms. Pearson’s correlations were run to test relationship between the independent and dependent variables, a stepwise regression analysis was used to identify predictors of GAD, while controlling for age. Results: A total of 401 students were involved in the study. The prevalence of GAD symptoms was 28.9%. There was a significant positive relationship between GAD symptoms and intolerance of uncertainty (r = 0.30, p = 0.001) and with parental attachment (r = 0.21, p = 0.001). Intolerance of uncertainty and parental attachment, predicted GAD symptoms (r = 0.30, 95% CI = 0.30 to 6.16, p = 0.001; r = 0.21, 95% CI = 0.21 to 4.19, p = 0.001, respectively). Conclusion: The present research suggests that GAD symptoms are prevalent among fresh undergraduates and are associated with both intolerances of uncertainty and parental attachment. Psychological interventions for undergraduate students may be needed to target these factors. © 2017, National Institute for Medical Research. All rights reserved.
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Collaboration among occupational health physicians, primary care physicians and psychotherapists in the prevention and treatment of common mental disorders in employees has been scarcely researched. To identify potential for improvement, these professions were surveyed in Baden-Württemberg (Germany). Four hundred and fifty occupational health physicians, 1000 primary care physicians and 700 resident medical and psychological psychotherapists received a standardized questionnaire about their experiences, attitudes and wishes regarding activities for primary, secondary and tertiary prevention of common mental disorders in employees. The response rate of the questionnaire was 30% (n = 133) among occupational health physicians, 14% (n = 136) among primary care physicians and 27% (n = 186) among psychotherapists. Forty percent of primary care physicians and 33% of psychotherapists had never had contact with an occupational health physician. Psychotherapists indicated more frequent contact with primary care physicians than vice versa (73% and 49%, respectively). Better cooperation and profession-specific training on mental disorders and better knowledge about work-related stress were endorsed. For potentially involved stakeholders, the importance of interdisciplinary collaboration for better prevention and care of employees with common mental disorders is very high. Nevertheless, there is only little collaboration in practice. To establish quality-assured cooperation structures in practice, participants need applicable frameworks on an organizational and legal level.
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Generalized anxiety disorder is a common mental health in general practice. The aims of this study are to determine the prevalence of generalized anxiety disorder (GAD) among patients attending family practice clinics and its relation to socio-demographic factors and chronic diseases. A cross-sectional design was used on 811 patients over a twomonth period in family medicine clinics at a large teaching hospital in Jordan. This study utilized a self -administered questionnaire that included questions about socio-demographic factors, chronic diseases, and GAD 7-item (GAD7). Patients who were positively diagnosed to have anxiety were then interviewed using DSM-IV criteria to confirm the diagnosis. The prevalence of generalized anxiety disorder was 23.7%. Patients aged 36-45 were five times more likely to have anxiety than other age groups. Women were twice as likely to have GAD as compared to men. Illiterate patients were more likely to have this disorder than others. Patients with a positive family history of anxiety were more diagnosed with GAD than patients with a negative family history, and patients with asthma or arthritis were more likely to develop GAD than other chronic conditions. The prevalence of GAD among patients attending family medicine clinics is relatively high and is associated with socio-demographic factors and chronic diseases, which necessitate enhancing awareness of the prevalence, diagnosis and management of generalized anxiety disorders among family practitioners.
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Background: Premenstrual dysphoric disorder (PMDD) demonstrates predictable, cyclic, affective and somatic symptoms that are aggravated in the late luteal phase and are resolved by menstruation. Generalized anxiety disorder (GAD) is characterized by excessive and persistant worry. The present study aims to evaluate the association between PMDD and GAD. The fluctuations of behavior inhibition, anxiety, depression, and irritability were also evaluated during the menstrual cycle among women with PMDD and healthy women. Methods: There were 100 women diagnosed with PMDD based on a psychiatric interview and on a prospective evaluation in three menstrual cycles. A total of 96 healthy women were recruited as controls. Each individual's GAD diagnosis, behavior inhibition, behavior activation, depression, anxiety, and irritability were assessed in both luteal and follicular phases. Results: The odds ratio of women with GAD having PMDD was 7.65 (95% CI: 1.69-34.63) in relation to those without it. This association was partially mediated by behavior inhibition and irritability and was completely mediated by depression. Women with PMDD and GAD had higher anxiety during the luteal phase and higher PMDD severity, depression, and irritability than those without GAD in the follicular phase. There is no difference in anxiety, depression, or irritability between the luteal and follicular phases among women with PMDD and GAD. Conclusions: Women with GAD were more likely to have PMDD. Anxiety, depression, and irritability symptoms in women with PMDD and GAD were not relieved in the follicular phase. Thus, GAD should be assessed for women with PMDD. Their anxiety, depression, and irritability should be intervened not only in the luteal phase, but also in the follicular phase. Depression, irritability and behavior inhibition mediated the association between PMDD and GAD. Intervening with these mediators to attenuate GAD and PMDD comorbidity should be researched in the future.
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A meta‐analysis was performed to examine therapeutic effects of Silexan on somatic symptoms, including insomnia/fatigue, and physical health in patients with anxiety disorders. Five randomized, placebo‐controlled trials were included in this analysis: The efficacy of Silexan (80 mg/day) was investigated in patients with subthreshold anxiety disorders (three trials) and in patients with generalized anxiety disorder (two trials). Silexan was superior to placebo in terms of the mean change from baseline in the Hamilton Anxiety Rating Scale (HAMA) subscore somatic anxiety at week 10 with a standardized mean difference of −0.31 [95% Cl: −0.52 to −0.10, p = .004]. Treatment effects of silexan on somatic anxiety were independent of gender and age. Statistically significant differences were also shown for single HAMA items somatic muscular, cardiovascular, respiratory, and genitourinary symptoms, indicating clinical relevance with small to medium effects of Silexan. Similar clinically meaningful effects of Silexan on SF‐36 physical health, including reduced bodily pain and improved general health, and on insomnia complaints and fatigue, were demonstrated. In this meta‐analysis including all placebo‐controlled clinical trials in patients with anxiety disorders to date, statistically significant and clinically meaningful advantages of Silexan over placebo treatment were found in improving somatic symptoms and physical health.
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The diagnostic ability of general practitioners (GPs) concerning mental disorders is not optimal, and could be improved by structured diagnostic interviews. Various aspects of the Structured Psychiatric Interview for General Practice (SPIFA) are examined. The inter-rater reliability of the SPIFA, the time used by GPs and specialists and the GPs satisfaction are examined. The properties of the SPIFA are compared with those of the Prime-MD and the MINI schedules. Inter-rater reliability of the SPIFA was tested in 336 patients in general practice. The patients were randomized to two interview strategies. Either both GPs and psychiatrists used the SPIFA, or GPs used the SPIFA and psychiatrists a modified version of the SCID for Axis I disorders. The satisfaction was investigated by a questionnaire sent to 1000 GPs who had SPIFA training. The SPIFA showed adequate inter-rater reliability for depression, anxiety disorders and increased suicidal risk for both interview strategies. In patients with more than two co-morbid disorders, the inter-rater reliability was poor. The mean duration of SPIFA was 21 min for SPIFA screening and 22 min for SPIFA manual. The 192 GPs responding to the questionnaire were mostly satisfied with the SPIFA. The SPIFA seems to be a reliable, valid and helpful instrument for GPs making diagnoses of mental disorders in their patients. Compared with the Prime MD and the MINI, the SPIFA seemed to have comparable psychometric properties but better feasibility in primary care.
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To describe the 12-month and lifetime prevalence rates of mood, anxiety and alcohol disorders in six European countries. A representative random sample of non-institutionalized inhabitants from Belgium, France, Germany, Italy, the Netherlands and Spain aged 18 or older (n = 21425) were interviewed between January 2001 and August 2003. DSM-IV disorders were assessed by lay interviewers using a revised version of the Composite International Diagnostic Interview (WMH-CIDI). Fourteen per cent reported a lifetime history of any mood disorder, 13.6% any anxiety disorder and 5.2% a lifetime history of any alcohol disorder. More than 6% reported any anxiety disorder, 4.2% any mood disorder, and 1.0% any alcohol disorder in the last year. Major depression and specific phobia were the most common single mental disorders. Women were twice as likely to suffer 12-month mood and anxiety disorders as men, while men were more likely to suffer alcohol abuse disorders. ESEMeD is the first study to highlight the magnitude of mental disorders in the six European countries studied. Mental disorders were frequent, more common in female, unemployed, disabled persons, or persons who were never married or previously married. Younger persons were also more likely to have mental disorders, indicating an early age of onset for mood, anxiety and alcohol disorders.
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Little is known about the general population prevalence or severity of DSM-IV mental disorders. To estimate 12-month prevalence, severity, and comorbidity of DSM-IV anxiety, mood, impulse control, and substance disorders in the recently completed US National Comorbidity Survey Replication. Nationally representative face-to-face household survey conducted between February 2001 and April 2003 using a fully structured diagnostic interview, the World Health Organization World Mental Health Survey Initiative version of the Composite International Diagnostic Interview. Nine thousand two hundred eighty-two English-speaking respondents 18 years and older. Twelve-month DSM-IV disorders. Twelve-month prevalence estimates were anxiety, 18.1%; mood, 9.5%; impulse control, 8.9%; substance, 3.8%; and any disorder, 26.2%. Of 12-month cases, 22.3% were classified as serious; 37.3%, moderate; and 40.4%, mild. Fifty-five percent carried only a single diagnosis; 22%, 2 diagnoses; and 23%, 3 or more diagnoses. Latent class analysis detected 7 multivariate disorder classes, including 3 highly comorbid classes representing 7% of the population. Although mental disorders are widespread, serious cases are concentrated among a relatively small proportion of cases with high comorbidity.
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General practitioners (GPs) can be provided with effective training in the skills to manage depression. However, it remains uncertain whether such training achieves health gain for their patients. The study aimed to measure the health gain from training GPs in skills for the assessment and management of depression. The study design was a cluster randomized controlled trial. GP participants were assessed for recognition of psychological disorders, attitudes to depression, prescribing patterns and experience of psychiatry and communication skills training. They were then randomized to receive training at baseline or the end of the study. Patients selected by GPs were assessed at baseline, 3 and 12 months. The primary outcome was depression status, measured by HAM-D. Secondary outcomes were psychiatric symptoms (GHQ-12) quality of life (SF-36), satisfaction with consultations, and health service use and costs. Thirty-eight GPs were recruited and 36 (95%) completed the study. They selected 318 patients, of whom 189 (59%) were successfully recruited. At 3 months there were no significant differences between intervention and control patients on HAM-D, GHQ-12 or SF-36. At 12 months there was a positive training effect in two domains of the SF-36, but no differences in HAM-D, GHQ-12 or health care costs. Patients reported trained GPs as somewhat better at listening and understanding but not in the other aspects of satisfaction. Although training programmes may improve GPs' skills in managing depression, this does not appear to translate into health gain for depressed patients or the health service.
Article
Errors in Byline, Author Affiliations, and Acknowledgment. In the Original Article titled “Prevalence, Severity, and Comorbidity of 12-Month DSM-IV Disorders in the National Comorbidity Survey Replication,” published in the June issue of the ARCHIVES (2005;62:617-627), an author’s name was inadvertently omitted from the byline on page 617. The byline should have appeared as follows: “Ronald C. Kessler, PhD; Wai Tat Chiu, AM; Olga Demler, MA, MS; Kathleen R. Merikangas, PhD; Ellen E. Walters, MS.” Also on that page, the affiliations paragraph should have appeared as follows: Department of Health Care Policy, Harvard Medical School, Boston, Mass (Drs Kessler, Chiu, Demler, and Walters); Section on Developmental Genetic Epidemiology, National Institute of Mental Health, Bethesda, Md (Dr Merikangas). On page 626, the acknowledgment paragraph should have appeared as follows: We thank Jerry Garcia, BA, Sara Belopavlovich, BA, Eric Bourke, BA, and Todd Strauss, MAT, for assistance with manuscript preparation and the staff of the WMH Data Collection and Data Analysis Coordination Centres for assistance with instrumentation, fieldwork, and consultation on the data analysis. We appreciate the helpful comments of William Eaton, PhD, Michael Von Korff, ScD, and Hans-Ulrich Wittchen, PhD, on earlier manuscripts. Online versions of this article on the Archives of General Psychiatry Web site were corrected on June 10, 2005.
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Ed T B Ustun, N Sartorius Wiley for WHO, £50, pp 398 ISBN 0 471 95491 8 How do mental disorders in primary care vary in terms of frequency, nature, and treatment across the world? Mental Illness in General Health Care describes a prospective study, sponsored by the World Health Organisation, of cultural differences in mental disorders in primary care involving 15 centres in five continents. The topic should interest general practitioners, psychiatrists, and public health doctors. The book itself is clearly written and easy to follow. After …
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This study examines predictors of false positive depression diagnoses by primary care doctors in a sample of primary care attendees, taking the patients' diagnostic status from a self-report measure (Depression Screening Questionnaire, DSQ) as a yardstick against which to measure doctors' correct and false positive recognition rates. In a nationwide study, primary care patients aged 15–99 in 633 doctors' offices completed a self-report packet that included the DSQ, a questionnaire that assesses depression symptoms on a three-point scale to provide diagnoses of depression according to the criteria of DSM-IV and ICD-10. Doctors completed an evaluation form for each patient seen, reporting the patient's depression status, clinical severity, and treatment choices. Predictor analyses are based on 16,909 patient-doctor records. Covariates examined included depression symptoms, the total DSQ score, number and persistence of depression items endorsed, patient's prior treatment, history of depression, age and gender. According to the DSQ, 11.3% of patients received a diagnosis of ICD-10 depression, 58.9% of which were correctly identified by the doctor as definite threshold, and 26.2% as definite subthreshold cases. However, an additional 11.7% of patients not meeting the minimum DSQ threshold were rated by their doctors as definitely having depression (the false positive rate). Specific DSQ depression items endorsed, a higher DSQ total score, more two-week depression symptoms endorsed, female gender, higher age, and patient's prior treatment were all associated with an elevated rate of false positive diagnoses. The probability of false positive diagnoses was shown to be affected more by doctors ignoring the ‘duration of symptoms’ criterion than by doctors not following the ‘number of symptoms’ criterion for an ICD or DSM diagnosis of depression. A model selection procedure revealed that it is sufficient to regress the ‘false positive diagnoses’ on the DSQ-total score, symptoms of depressed mood, loss of interest, and suicidal ideation; higher age; and patient's prior treatment. Further, the total DSQ score was less important in prediction if there was a prior treatment. The predictive value of this model was quite good, with area under the ROC-curve = 0.86. When primary care doctors use depression screening instruments they are oversensitive to the diagnosis of depression. This is due to not strictly obeying the two weeks duration required by the diagnostic criteria of ICD-10 and DSM-IV. False positive rates are further increased in particular by the doctor's knowledge of a patient's prior treatment history as well as the presence of a few specific depression symptoms. Copyright
Article
The prevalence of mental illness in five different Scandinavian primary care populations was investigated in this study. Patients consecutively consulting their general practitioner a particular week-day were included in the study. Initially the SCL-25 was applied and next the high scores and a sample of the low scores were interviewed by the PSE. In the analysis the screening procedure was first validated. The internal validity of the SCL was tested by means of Rasch latent structure analysis and the external validity tested by ROC/QROC analysis. Based on this, a short 8–item version of the SCL was developed. The prevalence of mental illness in all centres was 0.26 with a minimum of 0.14 in Nacka and a maximum of 0.34 in Turku.
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A total of 1281 patients were examined during consultation with their GP in a Nordic multicentre study focusing on the prevalence of psychiatric illness, hidden psychiatric morbidity, treatment and pathways to specialized care. The methodology and prevalence were reported in an accompanying paper. The present paper presents results concerning the variables hidden psychiatric morbidity, treatment and pathways to specialized care. The GPs detected 44% of the psychiatric cases compared with the result of a diagnostic interview (PSE). The distinction between psychosis and non-psychosis did not influence the GPs' ability to detect a mental illness. According to the GPs' assessment the majority of patients suffering from a mental disorder consulted their GP about physical complaints. The GPs treated the patients themselves, and only a limited number of cases were referred to psychiatrists or psychologists.
Chapter
IntroductionDiagnosisEpidemiologyDifferential diagnosisSocial impact of GADPathogenesisConclusions
Article
Nationally representative general population data are presented on the current, 12-month, and lifetime prevalence of DSM-III-R generalized anxiety disorder (GAD) as well as on risk factors, comorbidity, and related impairments. The data are from the National Comorbidity Survey, a large general population survey of persons aged 15 to 54 years in the noninstitutionalized civilian population of the United States. DSM-III-R GAD was assessed by lay interviewers using a revised version of the Composite International Diagnostic Interview. Generalized anxiety disorder was found to be a relatively rare current disorder with a current prevalence of 1.6% but was found to be a more frequent lifetime disorder affecting 5.1% of the US population aged 15 to 45 years. Generalized anxiety disorder was twice as common among women as among men. Multivariate logistic regression analysis showed that being older than 24 years, separated, widowed, divorced, unemployed, and a homemaker are significant correlates of GAD. Consistent with studies in treatment samples, we found that GAD was frequently associated with a wide spectrum of other mental disorders, with a lifetime comorbidity among 90.4% of the people who had a history of GAD. Contrary to the traditional view that GAD is a mild disorder, we found that the majority of people with GAD, whether they were comorbid or not, reported substantial interference with their life, a high degree of professional help seeking, and a high use of medication because of their GAD symptoms. Although lifetime GAD is highly comorbid, the proportion of current GAD that is not accompanied by any other current diagnosis is high enough to indicate that GAD should be considered an independent disorder rather than exclusively a residual or prodrome of other disorders.
Article
A total of 1,281 patients were examined during consultation with their GP in a Nordic multicentre study focusing on the prevalence of psychiatric illness, hidden psychiatric morbidity, treatment and pathways to specialized care. The methodology and prevalence were reported in an accompanying paper. The present paper presents results concerning the variables hidden psychiatric morbidity, treatment and pathways to specialized care. The GPs detected 44% of the psychiatric cases compared with the result of a diagnostic interview (PSE). The distinction between psychosis and non-psychosis did not influence the GPs' ability to detect a mental illness. According to the GPs' assessment the majority of patients suffering from a mental disorder consulted their GP about physical complaints. The GPs treated the patients themselves, and only a limited number of cases were referred to psychiatrists or psychologists.
Article
The paper describes the rationale, sensitivity and specificity of the Anxiety Screening Questionnaire (ASQ), a disorder-specific screening instrument for use in primary care. Two hundred and fifty subjects sampled from psychiatric, primary care settings and the community, participated in a test-retest reliability as well as a procedural validity study, using the M-CIDI with DSM-IV algorithms as a diagnostic yardstick. The ASQ was found to be easy to administer and acceptable and efficient in terms of sensitivity and specificity for generalised anxiety syndromes. The test-retest item reliability was good to excellent with kappa values of 0.6 or above. As compared with the validity standard, the DSM-IV/CIDI diagnoses caseness sensitivity was generally high (above 82%) for all diagnostic domains covered, whereas the specificity was only high for DSM-IV threshold and subthreshold generalised anxiety disorder. These preliminary findings demonstrate the usefulness of this anxiety screening questionnaire, constructed closely following the guidelines of specific diagnostic criteria.
Article
The study examines the prevalence of depressive syndromes among unselected primary care attenders, as well as doctors' recognition and treatment rates, in order to examine patient and doctor-related factors associated with poor recognition. This nationwide study included a total of 20421 patients (aged 15-99 years) attending their primary care doctors (n = 633) on the study's target day in April 1999. Patients received a self-report questionnaire, including the Depression Screening Questionnaire (DSQ), to provide diagnoses of depressive disorders according to the criteria of DSM-IV and ICD-10. Doctors completed: (1) a pre-study questionnaire assessing data on doctors' psychosocial, professional and training background, as well as current practices in patients with depression and (2) an evaluation form for each patient seen to assess his diagnostic decision, clinical severity and treatment choices. Taking the DSQ as a yardstick, 4.2% of all primary care attenders fulfilled criteria for a major depressive episode according to DSM-IV; considerably higher rates of 11.3% were obtained using the ICD-10 criteria for mild depressive episodes. Rates of depression were higher in females, increased by age, and were also elevated in those retired, unemployed as well as non-working housemen/wives. Taking the doctors' decision of definite or probable depression, 75% of all DSM and 59% of all ICD-10 diagnoses were recognized by the treating physician. However, doctors also assigned diagnoses of definite depression in an additional 11.7% of patients not meeting either ICD-10 nor DSM-IV criteria. Among correctly identified depression cases doctors decided to prescribe drug treatments in 72.7% (DSM) and 60.8% (ICD). Some 16.2% of DSM and 10.1% of ICD-cases were referred to mental health specialists; non-drug interventions were prescribed for 19.8% (DSM) and 24.9% (ICD), respectively. Multiple logistic regression analyses revealed that recognition is associated with prior treatment episodes, increasing number of depression symptoms, patients higher age, practice experience of treating physician greater 5 years and psychomotor retardation. These findings confirm the high prevalence of depressive syndromes in primary care settings and underline the particular challenge posed by a high proportion of with near-threshold symptomology patients. Although recognition rates among more severe major depressive patients as well as treatments prescribed appear to be more favourable than in previous studies, the situation in less severe cases, and the high proportion of doctors' definite depression diagnoses in patients with depression symptoms that are clearly below even the subthreshold level, raises significant concerns.
Article
This study reports results of a large-scale epidemiological investigation of the prevalence of mental disorder in Oslo. A random sample of Oslo residents age 18-65 years was drawn from the Norwegian National Population Register. A total of 2,066 subjects, 57.5% of the original sample, were interviewed with the Composite International Diagnostic Interview in 1994-1997. The mean age of the interviewed subjects was 39.3 years. The 12-month prevalence of all mental disorders was 32.8%, and the lifetime prevalence was 52.4%. Alcohol abuse/dependence and major depression had the highest lifetime prevalence and 12-month prevalences. All mental disorders were more prevalent in women than in men, with the exception of alcohol and drug abuse/dependence. Severe psychopathology (e.g., three or more diagnoses) was found in 14%-15% of the respondents. The lifetime and 12-month prevalences for all diagnostic categories except drug abuse/dependence were similar to those found in the United States Comorbidity Survey. Epidemiological data for Oslo show that the lifetime and 12-month prevalences of mental disorder are quite high, with alcohol abuse/dependence and major depression particularly frequent. The rates for women are higher than those for men for all diagnostic categories, except for alcohol and drug abuse/dependence.
Article
The authors reviewed the literature on mental health education for primary care physicians and made recommendations for the design of educational programs and research. They searched the MEDLINE and PsycLIT databases from 1950 to 2000 by using a variety of key words and subjects. More than 400 articles were identified, ranging from empirical studies to philosophical articles. Many identified a perceptual gap between primary care and psychiatry as the basis for problems of contextual relevance in psychiatric education for primary care practitioners. There were few empirical studies; most reported only results of satisfaction surveys or simple tests of knowledge. Long-term outcomes were less positive; there were important negative findings. An extensive literature published over five decades identified a strong need for ongoing mental health training for primary care physicians. Helpful recommendations exist related to objectives, methods, and evaluation. However, there are organizational and attitudinal issues that may be equally or more important for educators to consider than the selection of educational methods.
Article
Most studies of the recognition of depression in primary care have used a categorical definition of depression. This may overstate the extent of the problem. Our objective was to investigate the relationship between severity and recognition of depression, and its modification by patient and practitioner characteristics. An association study in multiple consecutive adult cohorts of 18 414 primary care consultations drawn from a representative sample of 156 general practitioners in Hampshire, UK. There was a curvilinear relationship between the severity of depression and practitioners' ratings of depression. One case of probable depression was missed in every 28.6 consultations. Anxiety and unemployment altered the chances of recognition, but age, gender and deprivation scores did not. A dimensional approach to severity of depression shows that general practitioners may be better able to recognise depression than previous categorical studies have suggested. Efforts to improve the care of depression should therefore focus on doctors who have been shown to have difficulty making the diagnosis and on improving the treatment of identified patients.
Article
The aim of the study is to develop a comprehensive clinical-epidemiological description of the prevalence of generalized anxiety disorders and depression among primary care patients along with an assessment of physicians recognition rates and prescription behaviour. The paper describes methods and design of the study and provides background information on the sampling process and instruments used as well as characteristics of doctors and patients. The study is based on a nationally representative sample of 558 primary care physicians and over 20,000 patients, who attended physicians' offices on the target day. The first stage of study involved a comprehensive description of the physicians characteristics in terms of psychosocial qualification, and provider aspects as well as attitudes towards GAD and depression. In the second stage, all the patients completed a diagnostic screening questionnaire for GAD and depression. In the third stage all patients were characterized by their physicians in terms of their diagnostic status and their past and current interventions.
Article
Determine attitudes toward patients with generalized anxiety disorder (GAD) and major depressive episodes (MDE) in primary care; determine prevalence of GAD, MDE, and comorbid GAD/MDE among primary care patients; assess physician recognition of GAD and MDE; and describe primary care interventions for these patients. 558 primary care physicians participated in a 1-day survey. Over 20,000 patients completed a diagnostic-screening questionnaire for GAD and MDE. Physician questionnaires included a standardized clinical appraisal of somatic and psychosocial symptoms and information on past and current treatments and a prestudy questionnaire assessing experience with and attitudes toward patients with GAD and MDE. 56.9% of physicians viewed GAD as a genuine mental disorder with clinical management problems and considerable patient burden; 27.4% treated GAD patients differently from MDE patients. 5.3% of patients met criteria for GAD, 6.0% for MDE, 3.8% for pure GAD, 4.4% for pure MDE, and 1.6% for comorbid GAD/MDE. Pure GAD and MDE were associated with disability, high utilization of health care resources, and suicidality, which were even higher with comorbid GAD/MDE. Physicians recognized clinically significant emotional problems in 72.5% of patients with pure GAD, 76.5% with pure MDE, and 85.4% with comorbid GAD/MDE. However, correct diagnosis was much lower (64.3% for MDE and 34.4% for GAD). Although the majority of patients with recognized GAD or MDE were treated, only a small minority with GAD were prescribed medications or referred to specialists. The high proportion of respondents with pure GAD is inconsistent with previous reports that GAD is usually comorbid with depression. GAD remains poorly recognized and inadequately treated. Improving the recognition and treatment of GAD in primary care patients is discussed relative to new treatments.
Article
Anxiety disorders are prevalent and associated with increased morbidity and mortality. Some chronic anxiety disorders, including generalized anxiety disorder (GAD), may be characterized by an underlying high level of anxiety on which exacerbations of symptoms are superimposed. Effective treatment of anxiety disorders should therefore strive to attain both an acute reduction in the symptoms of anxiety (a response) and sustained resolution of the symptoms of any underlying chronic anxiety (remission). This strategy may necessitate long-term treatment of these disorders by pharmacotherapy and/or psychotherapy. Studies using the serotonin and norepinephrine reuptake inhibitor (SNRI), venlafaxine extended release (XR), suggest that these aims may be achieved using this newer class of drugs. Studies with venlafaxine XR in patients with GAD have demonstrated robust anxiolytic efficacy over placebo, particularly regarding worry, cognitive dysfunction, and muscular tension, which are specific to GAD. Administration of venlafaxine XR over both short- (8-week) and long-term (6-month) periods resulted in a significantly greater number of patients achieving response and remission than obtained with placebo. Long-term treatment with venlafaxine XR in patients with GAD showed greater efficacy than that observed in short-term studies. This was achieved without any loss of short-term efficacy and patients' social functioning was also restored. While available data indicate that venlafaxine XR is an appropriate choice of agent in the long-term treatment of GAD, more studies are needed to determine how to further increase remission rates and to maintain remission beyond 6 months.
Article
Anxiety and depression in Swedish primary care has rarely been studied. A national sample of 131 primary care physicians and their 1,348 patients during one day in September 2001 responded to questionnaires on somatic disease, social conditions, treatments, and symptoms of anxiety and depression. A total of 23% of the patients had generalized anxiety and/or depression with or without receiving treatment, i.e. the most common category following musculoskeletal conditions. The appointment was caused by anxiety in 7.1% of the patients, depression in 8.5%, and insomnia in 11%. This group of patients did not deviate much in terms of somatic and social conditions, except being younger. Doctors were confident in diagnosing and treating them. Five key questions can be used in primary care to screen for these common psychiatric conditions.
Article
The objective of this paper is to provide a review on available data to date on the epidemiology of GAD in Europe, and to highlight areas for future research. MEDLINE searches were performed and supplemented by consultations with experts across Europe to identify non-published reports. Despite variations in the design of studies, available data suggest that (a) about 2% of the adult population in the community is affected (12-month prevalence), (b) GAD is one of the most frequent (up to 10%) of all mental disorders seen in primary care, (c) GAD is a highly impairing condition often comorbid with other mental disorders, (d) GAD patients are high utilizers of healthcare resources, and (e) despite the high prevalence of GAD in primary care, its recognition in general practice is relatively low. Marked data deficits are: lack of data from eastern European countries, lack of information about the natural course of GAD in unselected samples, the vulnerability and risk factors involved in the aetiology of GAD and lack of data about adequate and inappropriate treatments in GAD patients as well as the associated and societal costs of GAD.
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