Academic journal article General Psychiatry

Comorbidity of Depressive and Anxiety Disorders: Challenges in Diagnosis and Assessment

Academic journal article General Psychiatry

Comorbidity of Depressive and Anxiety Disorders: Challenges in Diagnosis and Assessment

Article excerpt

The concurrent presence of a depressive disorder with prominent anxiety symptoms or with an anxiety disorder is common in clinical practice. Studies have shown that more than 70% of individuals with depressive disorders also have anxiety symptoms and 40 to 70% simultaneously met criteria for at least one type of anxiety disorder. [1-4] In China, 69% of patients with depressive disorders [5] have a current anxiety disorder and 60% [6] have had a history of prior anxiety disorder(s). A study of 8487 patients treated in non-psychiatric outpatient clinics of general hospitals in urban China found that 8.6% of them met the diagnostic criteria of at least one type of anxiety disorder; and among those with anxiety disorders, 49% had a comorbid depressive disorder. [7] And a community-based epidemiological survey in mainland China reported that 63% of individuals with mood disorders had at least one type of anxiety disorder. [8]

The concurrent presence of anxiety symptoms or anxiety disorders often complicates the treatment of depressive disorders. These individuals are more dysfunctional and disabled than individuals with depression in the absence of anxiety symptoms, and they are more likely to be resistant to standard treatment with antidepressant medication. Therefore, to improve the clinical characterization of depression and the effectiveness of treatments for depressive disorders treating clinicians must simultaneously assess the severity of both depressive and anxiety symptoms and, if both types of symptoms are prominent, revise their standard treatment regimens accordingly.

1. Challenges in diagnosing comorbid depressive and anxiety disorders in China

Despite its high prevalence, the diagnosis of comorbid depressive and anxiety disorders in Chinese clinical settings is quite uncommon. There are several reasons for the failure to identify this common comorbid condition in clinical practice in China.

(a) The clinical presentations of comorbid disorders are more complex than those of 'pure' disorders.

(b) Anxiety symptoms can fluctuate over time. A follow-up study of individuals with uncomplicated generalized anxiety disorder (GAD) at baseline found that at the end of three years the diagnosis of 24% of the participants had changed to depressive disorders and that of a further 16% had changed to depressive disorders comorbid with GAD. [9]

(c) The 'diagnostic hierarchy' approach adopted in 1980 with publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), shifted the clinical decision making paradigm in psychiatry. According to this principle, severe mental disorders were prioritized and coexisting 'minor' mental disorders were not diagnosed. This principle has been widely used in psychiatry and in psychiatric training ever since. Therefore, when the diagnosis of a depressive disorder is evident, there is no need to determine whether or not comorbid anxiety disorders are present.

(d) In the two most commonly used diagnostic systems in clinical practice in China, the Chinese Classification of Mental Disorders (CCMD) and the 10th edition of the International Classification of Disease (ICD-10), standardized diagnostic evaluation using structured questionnaires is not emphasized and the diagnosis of comorbid conditions is not encouraged.

(e) In the busy, and often hectic, environment of many psychiatric outpatient departments in China, clinicians do not have the time needed to conduct the type of detailed examination needed to identify comorbid psychiatric disorders. In these settings they tend to take the time-saving 'diagnostic hierarchy' approach, so individuals with depressive disorders are not questioned further about anxiety symptoms. At best, the clinician may identify the concurrent presence of anxiety symptoms (without determining whether or not an anxiety disorder is present) by labeling the condition 'depression accompanied with anxious symptoms' or 'depression accompanied with anxiety'. …

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