Elsevier

Psychiatry Research

Volume 220, Issue 3, 30 December 2014, Pages 855-860
Psychiatry Research

A comparison of inpatients with anxious depression to those with nonanxious depression

https://doi.org/10.1016/j.psychres.2014.08.048Get rights and content

Highlights

  • Anxious depression is common in hospitalized depressed inpatients.

  • Clinicians should be more vigilant related to suicidality in anxious depression.

  • Anxious depression is a more complex presentation of depression.

Abstract

Anxiety symptoms are common for patients with major depressive disorder (MDD). Anxious depression has been considered MDD with high levels of anxiety symptoms. The objective of this study was to investigate the factors associated with anxious depression for Chinese inpatients with MDD. A total of 174 acutely ill patients were enrolled. Baseline demographic variables, suicide risk, depression severity, quality of life (QOL), and daily functional impairment were assessed. Those MDD patients with a 17-item Hamilton Depression Rating Scale (HAMD-17) anxiety/somatization factor score≥7 were defined as anxious depression. Logistic regression was employed to examine the factors associated with anxious depression. One hundred and forty-one (81.0%) of the subjects reported anxious depression. Patients with anxious depression were more likely to have melancholic features, to be older, to experience more severe depression, to be at greater risk of suicide, to have more pain, poorer quality of life, and more severe functional impairment. Anxious depression is common in inpatients with MDD. These findings suggest that anxious depression significantly differs from nonanxious depression on several clinically relevant variables. These data add to a growing body of evidence that anxious depression is a more complex presentation of depression.

Introduction

Anxiety and depression are the most common coexisting psychological problems (Baldwin et al., 2002). There are several approaches to conceptualize the relationship between major depressive disorder (MDD) and anxiety (i.e., anxious depression) (Fava et al., 2004). A dimensional approach, advocated by DSM-5, would conceptualize anxiety as a single dimension of a multidimensional syndrome categorized together as MDD. Alternatively, anxiety can be conceptualized in MDD as a comorbid disorder. The dimensional approach is commonly regarded to be more applicable to clinical practice, since many depressed patients with prominent anxiety syndromes are not assessed clearly as having a distinct anxiety disorder, or do not fully meet criteria for a DSM-IV or ICD-10 diagnosis (Sanderson et al., 1990, Wiethoff et al., 2010). To date, many studies of anxious depression have used the dimensional approach to define this subtype (Fava et al., 2004, Fava et al., 2006, Fava et al., 2008, Wiethoff et al., 2010, Chan et al., 2012). Moreover, it has been proposed that when compared to the comorbid approach, the dimensional approach has been reported to provide more clinically relevant data on differences between those subjects with anxious depression and those without (Ionescu et al., 2013). In psychosocial theory, feeling of defeat and entrapment is associated with increased anxiety and depression (Griffiths et al., 2014). According to current neurobiological knowledge, anxious depression (dimensional) may have a distinct neurobiological profile compared to non-anxious depression (Ionescu et al., 2013). In STAR*D, anxious depression is considered major depressive disorder (MDD) with high level of anxiety and is defined as depressed patients with a baseline 17-item Hamilton Depression Rating Scale (HAMD-17) (Hamilton, 1960) anxiety/somatization factor score≥7. Results indicate that 46.0–53.2% of patients have anxious depression (Fava et al., 2004, Fava et al., 2008).

Several differences between adults with anxious and non-anxious depression have been reported. For example, individuals with anxious depression have been reported as being more likely to be older (Fava et al., 2004, Fava et al., 2006, Wiethoff et al., 2010), to have lower educational attainment (Fava et al., 2004, Fava et al., 2006, Wiethoff et al., 2010), to manifest melancholic features (Fava et al., 2004, Fava et al., 2006, Wiethoff et al., 2010), to endorse suicidal ideation (Fawcett, 1990, Tollefson et al., 1994, Fava et al., 2004, Fava et al., 2006), to have greater baseline depression severity ratings (Joffe et al., 1993, Wiethoff et al., 2010), to have greater functional impairment (Joffe et al., 1993, Sartorius et al., 1996), and poorer quality of life (QOL) (Fava et al., 2004, Fava et al., 2006). Studies also have found that patients with anxious depression were less likely to respond or remit with antidepressants or to adhere to treatment than patients with nonanxious depression (Fawcett and Kravitz, 1983, Fava et al., 1997, Fava et al., 2008, Wiethoff et al., 2010, Chan et al., 2012, Wu et al., 2013). These findings imply that depression with high levels of anxiety may have important qualitative differences from depression with low levels of anxiety. Therefore, monitoring and treatment of anxiety symptoms could enhance clinical practice by optimizing antidepressant treatment (Zimmerman and McGlinchey, 2008).

A generalizability limitation of the existing studies is that they have almost exclusively been conducted in western countries, and to our knowledge, few studies (Wu et al., 2013) investigate anxious depression in Chinese patients, who have been reported to express depression somatically (Parker et al., 2001). The aim of this study herein was to compare a well characterized group of Chinese adults with MDD with and without high baseline anxiety on demographic, clinical, functional, and quality of life outcomes to provide a comparison with results obtained in western populations.

Section snippets

Subjects

This study, approved by Kai-Syuan Psychiatric Hospital׳s institutional review board, was conducted in accordance with Good Clinical Practice procedures and followed the most recent revision of the Declaration of Helsinki.

Patients were recruited from Kai-Syuan Psychiatric Hospital, a major psychiatric center in Taiwan, from April 2007 to September 2010. The board-certified psychiatrists (1st, 2nd, and 3rd authors) used the Structured Clinical Interview for DSM-IV (SCID) (APA, 1994) to screen and

Results

The participant selection process is shown in Fig. 1. A total of 190 inpatients who met the inclusion criteria agreed to participate in this study. One hundred and seventy-four (91.6%) patients completed all clinician-rated and self-rated assessments and measures. Table 1 shows the antidepressant use during the assessment period. Twenty-seven percent (48/174) of patients were admitted for self-injury or suicide attempt, 3.0% (5/174) admitted for harm to others, 33% (57/174) admitted for suicide

Discussion

Anxious depression is common in Chinese inpatients with MDD. The major finding of this cross-sectional study was that depressed inpatients with anxious depression were more likely to have melancholic features, be older, have higher suicide risk, have more severe baseline self reported and clinician measured scores of depression, experience more pain and functional impairment, and have poorer quality of life.

Two considerations should be mentioned. First, depression is a private, subjective

Acknowledgments

This study was funded by the Kai-Syuan Psychiatric Hospital (KSPH-2007-16) and the Ministry of Science and Technology, Taiwan (MOST-103-2314-B-280-001-MY3). All authors declare that they have no conflicts of interest.

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