Olantunji et al. (2010) – A meta-analysis of the influence of comorbidity on
treatment outcome in anxiety disorders
Comorbidity in the anxiety disorders may result in greater psychopathology and more dysfunction
resulting in a lower quality of life. This is an important concern given that rates of comorbidity between
anxiety and other mental disorders are substantial.
Prior research has shown that anxiety disorders tend to be highly comorbid with mood, substance, and
personality disorders, and presence of specific patterns of comorbidity (e.g., personality disorders) has
been shown to be associated with more severe pathology among patients with anxiety disorders.
Comorbidity may also influence treatment outcome in the anxiety disorders. Concern has namely been
raised about the utility of CBT, and other evidence-based treatments that are very specific and manual-
driven. The specificity and problem-focused nature of CBT has been the basis of arguments that such a
treatment may not generalize to real-life “patients” who are heterogeneous and frequently present with
comorbid disorders. Consistent with this notion, research has shown that comorbidity is associated with
higher anxiety disorder symptom levels after CBT.
Aim of the study
Address inconsistent findings as to the relationship between psychiatric comorbidity and treatment
outcome in anxiety disorders. Also, examine whether the impact of comorbidity on treatment outcome
differs according to the type of treatment provided. Lastly, examine the extent to which treatment
outcome for different anxiety disorder diagnosis are influenced by comorbidity.
Results
The study suggests that the degree of comorbidity in RCTs of anxiety disorders is substantial
and pervasive. To the extent that frequent comorbidity with other disorders is representative of
real-life patients with anxiety disorders, these findings suggest that treatments deemed
efficacious based on RCTs are suitable for real world patients.
The findings revealed that comorbidity was generally unrelated to anxiety disorder treatment
effect sizes at post-treatment and follow-up. This pattern of findings was consistent for both
active and inactive interventions, suggesting that the presence of comorbidity does not
influence treatment outcome for the anxiety disorders, and this appears to be the case for
treatments with specific and nonspecific mechanisms of action.
Efforts to develop strategies to address the potential negative impact of various comorbid
conditions during treatment of anxiety disorders may be premature and, in some cases, even
unnecessary. Rather than modifying treatments to address the influences of comorbid
conditions, focusing specifically on core symptoms in some anxiety disorders may maximize
outcome for the anxiety disorder as well as comorbid conditions.
A significant positive association was observed between comorbidity and effect size for panic
disorder and/or agoraphobia, PTSD/sexual abuse survivors, and OCD to a degree. However,
no relationship was found between comorbidity and effect size for social and specific phobia.
No significant difference in comorbidity rates across the anxiety disorder diagnostic categories
was found suggesting that there may be some unique features of panic disorder, PTSD, and
, OCD (relative to other anxiety disorders) that accounts for the positive association between
comorbidity and treatment effect.
Some personality disorders may have an adverse impact upon treatment outcome in anxiety
disorders.
The presence of more comorbidity may not always translate into worse outcomes. And thus, the
study suggests that comorbidity does not necessarily influence anxiety disorder treatment
outcome. Furthermore, in specific anxiety disorders where a relationship between treatment
outcome and comorbidity is observed, the relationship is not always in the anticipated direction
(more comorbidity=worse outcome).
Three ways to conceptualize co-occurrence of multiple disorders
1. Chronological: In which if multiple diagnoses are observed, the primary diagnosis developed
first.
2. Causal: in which secondary diagnosis are caused by another co-existing disorder.
3. Symptomatic predominance: in which the primary diagnosis is associated with the greatest
distress and dysfunction.
The common observation that comorbidity is associated with poorer treatment outcomes can reflect
either a prognostic or prescriptive view:
Prognostic: One that predicts outcome irrespective of the treatment
Prescriptive: Predicts a different pattern of outcomes between two, or more, treatment
modalities.
From a prognostic view, these findings suggest that overall comorbidity is significantly positively
associated with treatment outcome for panic disorder, PTSD, and perhaps OCD when holding type of
treatment constant. However, the prescriptive implications of these finders are less clear.
Topper et al. (2017) – Prevention of anxiety disorders and depression by targeting
excessive worry and rumination in adolescents and young adults
Although evidence-based treatments for anxiety disorders and depression are available, large numbers
of people do not seek treatment, do not respond to treatment, or experience a new episode over time.
Therefore, it is increasingly being argued that treatment alone is not sufficient to alleviate the individual
and societal burden associated with these disorders, but that this needs to be complemented by
prevention.
Universal prevention programs: interventions offered to all individuals without pre-selection.
Selective prevention programs: provided for individuals at risk for psychopathology
Indicated prevention programs: offered to individuals showing early symptoms of a disorder.
The provision of prevention programs for depression and anxiety disorders appears generally promising.
For depression, results are mixed. One study found 34% reduction of the risk of developing a
depressive disorder, while another study did not find significant differences in the reduction of incidence
rate of depression between the 3 prevention programs.
For anxiety disorders: the incidence of anxiety disorders was significantly reduced when compared to
control groups at postintervention, but this effect was only maintained at longer-term follow-up for
indicated prevention. The preventive interventions are efficacious in reducing both symptom clusters
(depression and anxiety). Importantly, however, these effects were not maintained at the 12 months
assessment.
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