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Anxiety Disorders --- Anxiety disorders

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PURPOSE: To review the evidence on screening benefits and harms of screening, accuracy of screening, benefits and harms of treatment for suicide risk, anxiety, and depression in children and adolescents in settings relevant to primary care in the United States for the U.S. Preventive Services Task Force. DATA SOURCES: PubMed, the Cochrane Library, PsycINFO, CINAHL and trial registries through July 19, 2021; bibliographies from retrieved articles, outside experts, and surveillance of the literature through June 1, 2022. STUDY SELECTION: Two investigators independently selected English-language studies using a priori defined criteria. We included trials that evaluated the benefits or harms of screening for suicide risk, anxiety, or depression compared with no screening or usual care. We included studies of screening with instruments feasible in primary care settings. For treatment benefits and harms, we included drugs approved for pediatric use by the Food and Drug Administration. For suicide and depression treatment studies, we included any eligible psychotherapy or collaborative care interventions. For anxiety, we restricted nonpharmacological interventions to cognitive behavioral therapy CBT. Eligible outcomes included test accuracy, symptoms, response, remission, loss of diagnosis, all-cause mortality, functioning, suicide-related symptoms or events, withdrawal due to adverse events, serious adverse events, and harms from screening. We also included systematic reviews reporting on harms of treatment. We excluded studies with poor methodological quality. DATA EXTRACTION AND ANALYSIS: One investigator extracted data and a second checked accuracy. Two reviewers independently rated methodological quality for all included studies. When at least three similar studies were available, we conducted meta-analyses. DATA SYNTHESIS: We included 80 studies in 106 publications. No studies evaluated the direct benefits of screening compared with no screening or usual care. Seventeen studies reported on accuracy of screening instruments for one or more conditions; of these, one reported on suicide N=580, 10 on anxiety N=3,260, seven on depression N=3,316, and two on anxiety or depression N=695. Studies reported a wide range for sensitivity and specificity across a variety of instruments, with no more than one or two studies on each instrument. For suicide, sensitivity ranged from 0.87 to 0.91, and specificity was 0.60. For anxiety, sensitivity generally ranged from 0.34 to 1.00, and specificity from 0.47 to 0.98. For depression, sensitivity ranged from 0.59 to 0.94, and specificity from 0.38 to 0.96. Two RCTs N=2,675 compared short-term distress from screening for suicide risk and reported no significant differences between those screened and those who were not screened. Sixty randomized, controlled trials RCTs addressed benefits of treatment; of these, 16 reported on suicide risk interventions N=3,034, 29 on anxiety treatment N=2,970, 13 on depression treatment N=2,156, and two on depression or anxiety treatment N=236. Interventions addressing suicide risk or self-harm reported lower scores for the Beck Hopelessness Scale pooled mean difference: −2.35 95% confidence interval CI, −4.06 to −0.65; N=644; k=4 for intervention arms when compared with control arms. Findings for other measures were mixed or not statistically significantly different. Of the 29 RCTs on anxiety treatment, 22 were on CBT; six were on pharmacotherapy; and one had multiple arms evaluating CBT, sertraline, and CBT plus sertraline. The evidence suggests CBT was associated with gains on several pooled measures of symptom improvement magnitude of change varies by outcome measure, response pooled relative risk RR: 1.89 95% CI, 1.17 to 3.05; N=606; k=6; I2=64%, remission RR: 2.68 95% CI, 1.48 to 4.88; N=321; k=4, and loss of diagnosis RRs range from 3.02 to 3.09, when compared with usual care or wait-list. The evidence on functioning for CBT was mixed. The evidence suggests pharmacotherapy, when compared with placebo, was associated with gains on two pooled measures of symptom improvement mean difference Pediatric Anxiety Rating Scale: −4.0 95% CI, −5.5 to −2.5, N=726, k=5 and mean difference Clinical Global Impressions-Severity: −0.84 95% CI, −1.13 to −0.55; N=550, k=4 and response RR: 2.11 95% CI, 1.58 to 2.98; N=370; k=5 but was mixed on measures of functioning. Of the 13 RCTs on depression treatment, eight were on psychotherapy; two on pharmacotherapy; one on CBT, fluoxetine, and their combination; and one on collaborative care. Results for psychotherapy varied by measure. Two pooled estimates suggested that psychotherapy is associated with improved symptoms Beck Depression Inventory BDI or BDI-II standardized mean difference: −0.58 95% CI, −0.83 to −0.34; N=471; k=4 and Hamilton Depression Scale mean difference: −2.25 95% CI,−4.09 to −0.41; N=262; k=3, clinical response 3 studies with statistically significant results using varying thresholds, and loss of diagnosis RR: 1.73 95% CI, 1.00 to 3.00; N=395; k=4 but no statistically significant differences for other measures. The evidence suggested statistically pharmacotherapy was associated with improvement for one measure of symptoms Children's Depression Rating Scale-Revised CDRS-R mean difference −3.76 95% CI, −5.95 to −1.57, N=793; k=3, and pharmacotherapy was associated with improvement for remission, but the pooled differences were not statistically significant. The single collaborative care trial N=101 found that collaborative care was associated with improved symptoms at 6 months CDRS-R change: 8.5 95% CI, 13.4 to −3.6, response by 12 months odds ratio OR for ≥50% reduction in CDRS-R score: 3.3 95% CI, 1.4 to 8.2, and remission OR for Patient Health Questionnaire-9 <5 at 6 months: 5.2 95% CI, 1.6 to 17.3. The study reported no statistically significant benefits on measures of functioning. Twenty studies 19 randomized controlled trials and 1 meta-analysis addressed harms. Of these, two reported on suicide risk interventions N=885, 11 on anxiety treatment N=1,293, and seven on depression treatment N=1,352. Two RCTs of interventions to reduce suicide risk or self-harm reported no statistically significant differences in adverse events. Of the 11 RCTs reporting harms of anxiety treatments, four evaluated CBT; six evaluated pharmacotherapy; and one evaluated CBT, sertraline, and their combination. The evidence from CBT studies yielded inconsistent results on suicide-related events; these studies also suggested lower rates of withdrawal due to adverse events and serious adverse events in the CBT arms. Suicide-related events and withdrawals due to adverse events in pharmacotherapy studies were rare and not statistically significant; however, they were more commonly reported in pharmacotherapy arms when compared with placebo arms. Of the seven studies reporting harms of depression treatment, three evaluated pharmacotherapy; two evaluated psychotherapy; one evaluated CBT, fluoxetine, and their combination; and one evaluated collaborative care 1,276 from trials. Suicide-related outcomes, withdrawal as a result of adverse events, and serious adverse events were not statistically significant between study arms but were more frequent for pharmacotherapy when compared with placebo; inconsistencies in the evidence further reduced certainty. The evidence from the collaborative care study was inconsistent. LIMITATIONS: No studies were available that reported benefits of screening compared with no screening. Limited evidence was available on harms of screening, long-term outcomes, test accuracy, and suicide risk and depression treatment in children. Treatment-as-usual comparators for suicide risk interventions included active treatments. The review was limited to drugs approved for pediatric use by the Food and Drug Administration FDA. For anxiety, psychotherapy was limited to CBT. CONCLUSIONS: We found no eligible studies that reported on benefits directly arising from screening when compared with usual care or no screening. Limited direct evidence suggests no short-term harms from screening for suicide risk. The evidence for screening for suicide risk, anxiety, and depression in children and adolescents relied on indirect evidence on the accuracy of screening and the benefits and harms of treatment. The evidence suggests that some screening instruments are reasonably accurate for anxiety and depression, but the evidence is limited for suicide risk screening instruments. Both pharmacotherapy and psychotherapy treatments have some benefit for some depression and anxiety outcomes (specifically, CBT for anxiety alone was reviewed); the evidence is limited for suicide risk interventions. Harms are rare in treatment studies but more frequent in pharmacotherapy arms when compared with placebo. Evidence gaps persist in children younger than age 11 years for test accuracy; depression and suicide risk interventions; and screening and treatment differences by sex, race/ethnicity, sexual orientation, and gender identity.

Anxiety disorders.

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Anxiety disorders are amongst the most common of all mental health problems. Research in this field has exploded over recent years, yielding a wealth of new information in domains ranging from neurobiology to cultural anthropology to evidence-based treatment of specific disorders. This book offers a variety of perspectives on new developments and important controversies relevant to the theory, research, and clinical treatment of this class of disorders. Clinicians will find reviews of state-of-the-art treatments for panic disorder, social anxiety disorder, phobias, obsessive-compulsive disorder, generalized anxiety disorder, and post-traumatic stress disorder, as well as controversies over diagnostic and treatment issues. Researchers will find in-depth consideration of important selected topics, including genetics, neuroimaging, animal models, contemporary psychoanalytic theory, and the impact of stressors. This book illustrates the enormous advances that have occurred in anxiety research and describes the evolving multi-disciplinary efforts that will shape the future of the field.

Anxiety disorders.

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Anxiety disorders.

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Since the 1880s neurasthenia - a term popularised by New York-physician George Beard - was discussed an a phenomenon of modernity, but over a long period of debate, psychiatry were not able to define what this "modern malady" exactly meant nor was it able to find any discernible causes for the epidemic disease. Neurasthenia was not simply a diagnostic term, which was often applied by fin de siècle-physicians to their workaday routine, but a kind of lifestyle, a sign of a certain emotional sensitivity in modern times. In the last decade historical research on neurasthenia has focused on Britain, Germany and the Netherlands. But what happened in Austria-Hungary, especially in Vienna? Focusing on Viennese psychiatry, part one of the book analyses the "invention" of Neurasthenia and the adoption of Beards thesis in Austrian medicine, bringing out various figures and alternative methods of explanations of the disease that was identified as a central, yet unwanted feature of modern manliness. Based on this the outcome of war could be seen as an instance of 'nerve-corrections'. Like many medical professionals in Austria-Hungary, psychiatrists had reacted to the war with nearly unanimous support: patriotic habits went hand in hand with high psychiatric expectations of the powerful mental effects of war. These hopes were badly disappointed. In the more recent literature on the medical and cultural history of the Great War, the phenomenon of the epidemic mental breakdowns of soldiers has been given a prominent place. 'Shellshock' and 'war neurosis' are now key words and frequent metaphors for the shattering effects of an industrialized war. In a sense these psychiatric labels symbolically represent the destructive impact of mechanized weapons on body and soul, the loss of narrative structures and the traumatic after-effects of modern warfare. How can Viennese-centred Austrian psychiatry in the First World War be characterized? With regard to new studies on the history of trauma, war and psychiatry I intend to emphasize two interpretations. Firstly, as in German and other European psychiatric war communities, models of rationalisation and modernisation are of significance when focusing on this topic. Viennese psychiatrists were neither particularly brutal nor especially tolerant in the way they dealt with the situation. Instead, as in other European countries in the Great War, they acted in keeping with military requirements and standards. Secondly, the specific political and cultural context of the Austro-Hungarian situation is of utmost importance as well. Shell-shock was a phenomenon that affected all nations, but reactions differed according to different national traditions and different medical ways of understanding, representing and acting. In a comparative cultural history of World War One, Austria-Hungary is a model of a shattered society, paralysed by ethnic conflicts and cultural differences. In this context, the therapeutic response to war neurosis was affected by language confusion, national stereotypes and malingering. The German-Austrian psychiatrists not only emerged as a group of experts who had taken responsibility for the efficient treatment of war neurosis, but also as a pressure group that intended to keep centrifugal forces of the multinational empire under control. Das Unbehagen an der Moderne hatte um 1900 einen Namen: Neurasthenie. Dieses Buch führt in die unruhigen mentalen Landschaften Kakaniens und thematisiert als zentrale Fragen: Wie wurde die Neurasthenie in den österreichischen Ärztemilieus debattiert? Was hiess es für Patienten, mit dieser Diagnose konfrontiert zu sein? Neurasthenie stand für die Erschöpfung der modernen städtischen Gesellschaft, die sich durch eine rastlose Lebensführung überfordert sah, und machte ihre emotionalen Sensibilitäten und Sicherheitsbedürfnisse transparent. Insbesondere Männer des Bürgertums griffen auf das neue psychiatrische Deutungsangebot zurück. Die Diagnose der Neurasthenie konnte "unmännliche" Verhaltensweisen sinnstiftend erklären. Zugleich liess sie aber auch Bedürfnisse nach deren Überwindung entstehen. Im Spiegel dieser Nervendiskurse lässt sich besser verstehen, warum 1914 der Krieg als "therapeutisches Erlebnis" und männliches Erneuerungsprojekt angepriesen wurde. Die Realitäten des modernen Maschinenkrieges setzten diesen Vorstellungen ein rasches Ende: Der Zitterer wurde zu einer massenhaft auftretenden Erscheinung, zum umstrittenen Patienten und zur Krisenfigur der Abhärtungsutopisten, die aus dem Krieg den "neuen Menschen" hervorgehen sahen. Da die Militärs in den Kriegsneurosen eine gefährliche Schwächung der Schlagkraft der Armee sahen, wurden wissenschaftliche Experten gebraucht, die rasch und effizient mit diesem Problem umgehen konnten. Die Psychiatrie befand sich dadurch in einer völlig neuen Situation, da sie nicht nur Kritik an einer gesellschaftlichen Krisensituation formulieren konnte, sondern auch Ressourcen und Instrumentarien zu deren Bewältigung bereitzustellen hatte. Welche Akzentverschiebungen ergaben sich in der psychiatrischen Wahrnehmung und Deutung sowie im Umgang mit Nervenkrankheiten? Wie lässt sich die österreichische Psychiatrie des Ersten Weltkriegs in historischer Perspektive charakterisieren? Mit Bezug auf die neuere medizinhistorische und kulturwissenschaftliche Forschung wird die Kriegspsychiatrie auf der Folie der Herausbildung der Medizin als Schlüsselwissenschaft des modernen Krieges analysiert. Dies bedeutete, dass die therapeutische Arbeit der Psychiater an den Vorgaben und Zielvorstellungen des Krieg führenden Staates ausgerichtet war. Darüber hinaus wird auf einige Problemkonstellationen des Vielvölkerstaates und deren Auswirkungen auf psychiatrisches Handeln im Krieg eingegangen. Die elektrischen Behandlungsmethoden der Psychiater werden auf der Folie der ethnisch-sprachlichen Pluralität der österreichisch-ungarischen Armee diskutiert. Der zweite Teil der Arbeit bietet solcherart eine differenzierte Analyse und Neubewertung des Phänomens der "Kriegsneurosen" wie auch der Rolle der österreichischen Psychiatrie im Ersten Weltkrieg.

Anxiety disorders.