Arun V. Ravindran, MB, PhD and Lakshmi N. Ravindran, MD
Dr A. V. Ravindran is professor of psychiatry and psychology at the University of Toronto and clinical director of the Mood and Anxiety Disorders Program at the Centre for Addiction and Mental Health in Toronto. Dr L. N. Ravindran was until recently a research fellow in the department of psychiatry at the VA San Diego Health Center and the University of California–San Diego, and is now an assistant professor at the Univer-
sity of Toronto and staff psychiatrist in the Mood and Anxiety Disorders Program at the Centre for Addiction and Mental Health.
Acknowledgments: The authors would like to thank Tricia da Silva, MA, for her assistance in the preparation of this article.
Dr A. V. Ravindran reports that he is not a major stockholder with any pharmaceutical company but has received grant and research support from Cephalon, Eli Lilly, GlaxoSmithKline, Janssen-Ortho, Pfizer, Roche, Servier, Wyeth, AstraZeneca, and Lundbeck. In addition, he serves as a consultant for the above-named companies and on their advisory boards, and he has participated in CME programs sponsored by these companies. Dr L. N. Ravindran reports no conflicts of interest concerning the subject matter of this article.
Psychiatric Times - Category 1 Credit
To earn AMA PRA Category 1 Credit(s)™:
Read the article "Depression and Comorbid Anxiety: An Overview of Pharmacological Options" from the June 2009 issue of Psychiatric Times, complete the posttest and the evaluation. (Note: A score of at least 70% must be achieved in order to be awarded credit.)
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Educational Objectives
After reading this article, you will be familiar with:
• Ways to recognize and assess comorbid depression and anxiety
• Pharmacological treatment approaches
• Treatment for comorbidity of depression and specific anxiety disorders
Who will benefit from reading this article?
Psychiatrists, psychologists, primary care physicians, nurse practitioners, and other health care professionals. To determine whether this article meets the continuing education requirements of your specialty, please contact your state licensing and certification boards.
Although depressive and anxiety disorders are classified as distinct groups of illnesses, studies document their frequent co-occurrence and provide evidence of a common biological substrate and a shared vulnerability.1 Comorbid depression and anxiety disorders are most frequently seen in primary care and in the general community, and the prevalence of comorbidity has been estimated to be as high as 10% to 20%.1 The comorbidity of depression and anxiety tends to have an earlier age of onset, increased severity of illness, more functional impairment, and poorer outcome (including greater risk of suicide) than does depression or anxiety alone.2 Research data and clinical experience suggest that depression comorbid with anxiety disorders may show less robust response to both pharmacotherapy and psychosocial interventions and may lead to more residual symptoms and increased vulnerability to relapse.3,4
General guidelines
Early recognition is an important first step in the management of depression with comorbid anxiety. Co-occurrence may take several forms. Depression may be present comorbidly with one or more anxiety disorders. Alternatively, the depression may be primary, with significant anxiety symptoms that do not meet criteria for a disorder (subsyndromal anxiety). Many patients may also present with an equal admixture of depressive and anxiety symptoms, neither of which meets criteria for full disorders (mixed depression-anxiety). Thus, the assessment of patients with depression should explore the presence of subsyndromal anxiety symptoms and mixed depression-anxiety, as well as specific anxiety disorders.
Several easy-to-use self-rated scales are available for monitoring symptoms:
• Depression Anxiety Stress Scale (42-item or shorter 21-item)
• Beck Depression Inventory
• Beck Anxiety Inventory
• Yale-Brown Obsessive Compulsive Scale
