Anxiety And Depression In The General Population

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The general psychiatric literature provides additional insight and findings related to the discussion of depression, anxiety and the co-occurrence of the two disorders. As clinicians and researchers in epilepsy, we can utilize the knowledge gleaned from the general population about depression and anxiety in order to gain an understanding of the similarities and differences in the presentation of these disorders in epilepsy.

Based on the National Comorbidity Survey-Replication in the United States, lifetime prevalence rates for depressive disorders is 20.8% with major depression being the most prevalent (16.6%), and lifetime anxiety disorders identified in 28.8% with specific phobia (12.5%) and social phobia (12.1%) as the most commonly occurring anxiety disorders (Kessler et al., 2005a, b). Additionally, the European Study of the Epidemiology of Mental Disorders (ESEMeD) project included representative samples from six European countries (Belgium, France, Germany, Italy, The Netherlands, Spain). This project reported lower prevalence rates of depressive disorders (14.0%), major depression (12.8%), anxiety disorders (13.6%), specific phobia (7.7%), and social phobia (2.4%) (Alonso et al., 2004b) . These studies confirm what is considered common knowledge: individuals with epilepsy likely have higher prevalence rates of depression and anxiety disorders compared to the general population.

In 1934, Sir Aubrey Lewis described symptoms of anxiety and depression on the same continuum. In contrast, depression and anxiety are currently viewed as separate and distinct disorders in the DSM, fourth edition (DSM-IV) and ICD, tenth edition (ICD-10). However, the possibility that anxiety and depression could be placed on a continuum continues to be studied (Angst, 1997 ) Boulenger et al.) 1997 ) Levine et al., 2001) Zimmerman and Chelminski, 2003) . In tandem with this idea is the significant debate in the literature regarding the extent and impact of subthreshold anxiety and depression (Angst, 1997 ) Boulenger et al.) 1997 ) Stahl, 1997). The term subsyndromal alludes to a cluster of symptoms that do not reach diagnostic criteria. Subsyndromal symptoms may cause distress and impairment and may require treatment (Ninan and Berger, 2001) . In response to the concern that individuals with subthreshold depression and anxiety were presenting to primary care physicians with significant levels of distress and impairment, the ICD-10 and DSM-IV introduced the concept of mixed anxiety and depression. In general clinical practice world wide it appears that 13% have a combined anxiety and depressive disorder (Stein et al.) 1995 ) Sartorius et al.) 1996).

There are three major theories or ideas describing the relationship between anxiety and depression (Stahl, 1997 ) Levine et al.) 2001). The first is the traditional theory which essentially states that anxiety and depression are distinct disorders in and of themselves including their treatments (i.e., antidepressants and anxiolytics) (Figure 7.1). This is further amplified by the subcategorization of both anxiety (e.g., generalized anxiety disorder, panic disorder, social phobia, obsessive compulsive disorder) and depression (e.g., major depression, dysthymia, brief intermittent depression). The second is the comorbid theory, which capitalizes on the sheer fact that anxiety and depression often co-exist (Figure 7.1) (Stahl, 1997). The individual presents with two illnesses and will require treatment for both. For example, there is an increased incidence of current or past depressive disorders among individuals with panic disorder. The third is the subsyndromal theory which asserts that some individuals have symptoms of depression and anxiety that are chronic in nature, and these symptoms may or may not always be severe enough to meet criteria for a diagnosis of an anxiety or depressive disorder (Figure 7.1) . These subsyndromal symptoms ebb and flow depending on stressors and may escalate over time to meet criteria for a depressive and/or anxiety disorder. Two of the three theories reflect the idea that depression and anxiety are related and may be entangled with one another.

The co-occurrence of anxiety and depression is very commonly recognized in general clinical practice. International epidemiological and clinical studies revealed that comorbid depression and anxiety results in increased distress, impairment, and symptoms resulting in a longer course than either of these disorders alone (Angst, 1997 ) Kessler et al.) 1999 ) Kessler, 2007). Major depression is often comorbid with other psychiatric conditions, and most commonly co-occurs with symptoms of anxiety. In the Epidemiological Catchment Area program (ECA), 43% of individuals in the community with a depressive disorder also had a comorbid lifetime diagnosis of an anxiety disorder, and 25% with a primary anxiety disorder had a lifetime mood disorder (Regier et al.) 1990). Fava et al. (2000) reported that

Traditional

FIGURE 7.1 Three theories on symptoms of anxiety and depression. Syndromal disorders are represented by depressive disorder (D), anxiety disorder (A), and co-occurring depressive and anxiety disorder (DA). Subsyndromal presentation of symptoms include depression (d), anxiety (a), and mixed depression and anxiety (da). Subsyndromal and syndromal mixtures can occur (dA and Da). Source : Obtaining permission from author Stahl (1997).

Traditional

Subsyndromal

FIGURE 7.1 Three theories on symptoms of anxiety and depression. Syndromal disorders are represented by depressive disorder (D), anxiety disorder (A), and co-occurring depressive and anxiety disorder (DA). Subsyndromal presentation of symptoms include depression (d), anxiety (a), and mixed depression and anxiety (da). Subsyndromal and syndromal mixtures can occur (dA and Da). Source : Obtaining permission from author Stahl (1997).

among adults with major depression, anxiety disorders were present in half the sample (50.6%), and the anxiety disorder preceded the onset of depression in 31.4% of the sample. The ESEMeD project analyzed the co-occurrence of psychiatric disorders based on 12-month prevalence rates (Alonso et al., 2004a). They found high pairwise associations between any depressive disorder and any anxiety disorder.

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