Psychiatric-Medical ComorbidityAnxiety disorders and comorbid medical illness☆,☆☆,
Introduction
Mental disorders occur with chronic medical conditions in many patients, causing significant role impairment, work loss and work cut-back [1], [2]. Depression increases symptom burden and functional impairment and worsens prognosis for heart disease, stroke, diabetes mellitus, HIV/AIDS, cancer and other chronic illnesses [3], [4], [5]. One nationally representative survey of over 130,000 Canadian adults demonstrated that depression independently increased role impairment by 21% compared to healthy controls. However, when depression occurred along with chronic lung disease, diabetes mellitus or heart disease, the rate of disability increased by over 50% [5]. A more complete understanding of the adverse effect of depression on biological and self-care (e.g., adherence to diet, smoking cessation, exercise, medications) mechanisms and findings from treatment studies is emerging to guide patient care [6], [7], [8], [9], [10], [11], [12], [13], [14]. These data paint a compelling picture of the importance of depression in medical illness.
Much less is known about the impact of anxiety disorders on function and outcome in persons with chronic medical illness. There is convincing evidence that anxiety is associated with high rates of medically unexplained symptoms and increased utilization of healthcare resources [4], [15], [15], [16], [17], [18], [19]. Moreover, anxiety disorders are strongly and independently associated with chronic medical illness [20], [21], low levels of physical health-related quality of life, and physical disability [21], [22], [23], [24]. Indeed, the disability and related poor physical and economic outcomes associated with anxiety disorders may be as great as with depression. In a sample of 480 primary care patients, the probability of missing time from work in the prior month for persons with an anxiety disorder (OR: 2.22) was as great as for persons with major depression (OR: 2.15) [25]. In patients with diabetes, comorbid panic disorder had a significant adverse effect on symptom burden, functional impairment and HbA1c levels after controlling for depression [23]. In the National Comorbidity Survey–Replication (NCS-R), Kessler et al. [1] reported that various anxiety disorders had equal or greater association than depression with four chronic physical disorders (i.e., hypertension, arthritis, asthma, ulcers) (Fig. 1). Similarly, the number of 30-day role impairment days associated with anxiety disorders among respondents with these four chronic medical disorders was similar or greater to that seen in association with depression and dysthymia (Fig. 2) [1].
In recognition of the need to better understand and illustrate the effect of anxiety disorders on persons with chronic medical illnesses and with the hope of developing treatment strategies, the Anxiety Disorders Association of America (ADDA) convened a multidisciplinary conference on January 30–31, 2006, to review current data on the relationship between anxiety disorders and specific medical illnesses. Presenters and discussants included clinicians and researchers in psychiatry, psychology, primary care, healthcare systems, epidemiology, public health, healthcare policy and advocacy. The proceedings of the conference are summarized in this paper, which reviews anxiety disorders in the context of functional gastrointestinal disorders, asthma, heart disease, cancer and chronic pain. These selective reviews mainly focused on anxiety disorders per se and did not investigate numerous studies focused on “stress”. In addition, specific recommendations are made for furthering the basic science and clinical research agenda to better understand the impact of anxiety disorders on medical illness and improve clinical outcomes and patient care.
Section snippets
Epidemiology
Irritable bowel syndrome (IBS) is characterized by chronic, unexplained abdominal pain or discomfort associated with diarrhea, constipation, or both [26]. It is one of the most common and well studied of the 28 functional gastrointestinal disorders (FGIDs) [27], affecting an estimated 10% to 25% of the population and occurring in women twice as frequently as in men. A key feature of IBS is visceral hyperalgesia, defined as abnormally exaggerated visceral pain responses from gut events (e.g.,
Research priorities
Conference participants outlined research needs to advance understanding of anxiety disorders and comorbid medical illness and improve patient care. No attempt was made at the conference to rank order these priorities, but all were felt to be of substantial importance to the field.
Conclusions
The clinical importance of the bidirectional relationship between psychiatric and physical illness is beginning to be appreciated by the medical, clinical and research communities. Extant studies primarily focus on comorbid depression. However, emerging evidence suggests that anxiety and the anxiety disorders, which have received relatively less attention, may be as important as depression. In addition, many patients have comorbid anxiety and depressive symptoms, which are associated with
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Based on a multidisciplinary conference sponsored by the Anxiety Disorders Association of America on January 30–31, 2006.
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Financial disclosure/COI statements: Dr Roy-Byrne discloses the following: Grants/research support (NIMH #2R01MH057858; NIMH #K24MH065324), consultant/advisor (Jazz; Solvay; Alexza), speaker honoraria via CME company only (Wyeth-Ayerst; Forrest), speaker's bureau (none), stock holder (none), other financial or material support (none). Dr Davidson discloses the following: Grants/research support (HC-25197, HL-76857, HL-80665, and HL-84034 from the National Heart, Lung, and Blood Institute and UL1 RR024156 from the National Center for Research Resources). Dr Kessler discloses the following: Consultant (Astra Zeneca; BristolMyersSquibb; Eli Lilly and Co; GlaxoSmithKline; Pfizer, Inc.; Sanofi-Aventis; Wyeth), research support for epidemiological studies (Bristol-MyersSquibb; Eli Lilly and Co; Ortho-McNeil; Pfizer, Inc; the Pfizer Foundation). Dr Asmundson has no financial or conflict of interest information to disclose. Dr Goodwin has no financial or conflict of interest information to disclose. Dr Kubzansky has no financial or conflict of interest information to disclose. Dr Lydiard discloses the following: Grants/research support [Pfizer, Inc., Sanofi-Aventis, Eli Lilly and Co (also spouse); Cephalon; UCB Pharma; Neurocrine; AstraZeneca; Jazz Pharmaceuticals; Medicinova; Wyeth Pharmaceuticals; Bristol-Myers Squibb; Forest Pharmaceuticals; GlaxoSmithKline; Somaxon Pharmaceuticals]; consultant [Eli Lilly and Co; Pfizer, Inc.; AstraZeneca; Sanofi-Aventis; Novartis; Roche; Medicinova; Abbott (spouse); Forest Pharmaceuticals (spouse)]; shareholder (none). Dr Massie has no financial or conflict of interest information to disclose. Dr Katon discloses the following: Advisory board (Eli Lilly and Co); honoraria for lectures (Eli Lilly and Co; Pfizer, Inc; Forest Pharmaceuticals; Wyeth-Ayerst). Ms. Laden discloses that the Anxiety Disorders Association of America (ADAA) funded her collaboration with the co-authors in the writing and editing of an initial draft of the paper, which was based on their presentations at a meeting sponsored by the ADAA. Dr Stein discloses the following: Grants/research support (NIMH #K24MH064122), research support (Eli Lilly and Company; Forest Laboratories; GlaxoSmithKline), consultant (AstraZeneca; Bristol-Myers Squibb; Cephalon; Eli Lilly and Co; Forest Laboratories; GlaxoSmithKline; Hoffmann-La Roche Pharmaceuticals; Jazz Pharmaceuticals; Johnson & Johnson; Pfizer; UCB Pharma; Wyeth), speaking honoraria (none), major stock shareholder (not applicable).
The Psychiatric-Medical Comorbidity section will focus on the prevalence and impact of psychiatric disorders in patients with chronic medical illness as well as the prevalence and impact of medical disorders in patients with chronic psychiatric illness.