Major depressive disorder (MDD) frequently appears with other disorders and comorbidities; experts say it’s more the rule than the exception. But before the Diagnostic and Statistical Manual for Mental Health Disorders, Fifth Edition (DSM-5) was published in 2013, the presence of anxiety in some patients may have been missed.
The addition of the anxiety distress specifier in the DSM-5 has simplified the task of identifying those patients whose anxiety must be considered in their treatment plan, said Mark Zimmerman, MD, director of outpatient psychiatry and the Partial Hospital Program at Rhode Island Hospital, and a professor of psychiatry at Brown Medical School.
During a presentation at the US Psychiatric and Mental Health Congress in New Orleans, Louisiana, Zimmerman said studies show that the presence of a comorbid disorder or specific symptom were the most important factors driving treatment decisions when clinicians picked an antidepressant, and anxiety was the symptom they cited most frequently (19.9%).1
For patients to meet the criteria of the anxious distress specifier, they must have 2 of the following 5 symptoms across an episode: 1) feeling keyed up or tense, 2) feeling unusually restless, 3) difficulty concentrating because of worry, 4) fear that something awful might happen, and 5) a feeling that one might lose control of himself/herself.2
In reality, anxiety affects about 50% of patients with depression, Zimmerman said. That covers a lot ground: he led a study of 373 depressed patients that found 17.1% had panic disorder, 33% had social phobia, 13.4% had posttraumatic stress disorder (PTSD), and 15% had general anxiety disorder.3 Despite the numbers, social phobia was frequently overlooked, he said. This means that many patients with anxiety are missed. “It’s just the reality of a busy clinical practice,” Zimmerman said.
But finding better ways to screen patients for anxiety is important, because Zimmerman said studies show more than three-fourths of patients with anxiety say they want to be treated. “When we ask patients do they want treatment, they say ‘yes,’” he said.
Zimmerman took the audience through a 2-stage screening process; the first stage screens for general distress, and if the patient tests positive, a second, more in-depth stage hones in on the precise diagnosis.
Next, he reviewed clinical trial data involving patients with anxious depression. Zimmerman explained there have been fewer studies involving patients with depression and anxiety, because they have often been excluded from trials. These patients have greater psychosocial impairment, and poorer, slower response to treatment. A literature review involving 31 studies concluded that:
· Selective serotonin reuptake inhibitors (SSRIs), serotonin–norepinephrine reuptake inhibitors, and tricyclic antidepressants are effective in treating anxious depression.
· Patients with anxious depression have poorer outcomes and greater side effects.
· Patients with anxious depression often do not have sustained outcomes after initial success with a new drug.4
Guidelines from different countries have varied on which antidepressants are recommended. British guidelines did not find much difference among different antidepressants, but the American Psychiatric Association made several specific recommendations for SSRIs (good for social anxiety disorder with depression, PTSD, and obsessive compulsive disorder [OCD]), bupropion (comparable to SSRIs for low to moderate levels of anxiety), and clomipramine (effective for OCD with depression).
Testing the Anxious Distress Specifier
So far, some studies of the anxious distress specifier don’t actually measure all 5 criteria because databases didn’t have information on all 5 measures. Zimmerman’s research group came up with ways to measure all 5. His group tested a scale for the new anxious distress specifier, called CUDOS (Clinically Useful Depression Outcome Scale); the study with 793 depressed outpatients found the scale to have high retest reliability, and good discriminant and convergent validity.5 Because the specifier is supposed to measure symptoms across an episode, Zimmerman’s group also came up with an interview measure; once again, the specifier held up to clinician and self-reported assessments of anxiety and depression.
Some of their work suggests that the new specifier may produce different results than older scales that measured anxiety; this is an area for future research, Zimmerman said. “Hopefully the anxious distress specifier is as good if not better at [assessing] impairment, functioning, and predicting outcomes,” because it’s so much easier to administer. “Hopefully, it’s a more clinically useful way of assessing anxiety.”
Clinical guidelines, however, say there is no best or worst antidepressant for highly anxious depressed patients, which can leave much to the individual prescribing practices of the psychiatrist.
The DSM-5 anxious distress specifier does represent a step forward, Zimmerman said. “Screening can improve detection. It can improve the efficiency of the diagnostic process.”
1. Zimmerman M, Posternak M, Friedman M, et al. Which factors influence psychiatrists’ selection of antidepressants? Am J Psychiatry. 2004;161(7):1285-1289. DOI: 10.1176/appi.ajp.161.7.1285.
2. American Psychiatric Association. Diagnostics and Statistical Manual, Fifth Edition. Arlington, VA: American Psychiatric Association; 2013.
3. Zimmerman M, McDermut W, Mattia JI. Frequency of anxiety disorders in psychiatric outpatients with major depressive disorder. Am J Psychiatry. 2000;157(8):1337-1340. https://doi.org/10.1176/appi.ajp.157.8.1337 .
4. Ionescu DF, Niciu MJ, Richards EM, Zarate CA. Pharmacological treatment of dimensional anxious depression: a review. Prim Care Companion CNS Disord. 2014;16(3). doi: 10.4088/PCC.13r01621.
5. Zimmerman M, Chelminski I, Young D, Dalyrymple K, Walsh E, Rosenstein L. A clinically useful self-report measures of the DSM-5 anxious distress specifier for major depressive disorder. J Clin Psychiatry. 2014;75(6):601-607.