Brief report
Mixed anxiety–depression in a 1 year follow-up study: shift to other diagnoses or remission?

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Abstract

Background: In 1992, the ICD-10 introduced the concept of mixed anxiety–depression disorder (MAD). However, a study examining the stability of this ICD-10-diagnosis is lacking. Our objective was to examine the 12 month outcome of MAD in comparison to the outcome of depression, anxiety, and comorbid depression and anxiety. Methods: 85 MAD patients, 496 patients with major depression, 296 patients with anxiety disorders, and 306 comorbid patients were reassessed after 12 months. Rates of depression, anxiety, and MAD were compared using χ2-tests. Results: While depressive disorders and anxiety disorders showed relatively high stability, MAD Patients had no higher rates of MAD at follow-up than patients with depression, anxiety or both. Limitations: Detailed information regarding treatment and disorders during the follow-up interval was lacking. Prevalence rates of MAD in single centres were too small for contrasting centres. Conclusions: MAD cannot be seen as a stable diagnosis: Most of MAD patients remit; many of them shift to other diagnoses than depression or anxiety. The ICD-10 criteria have to be specified more exactly.

Introduction

A substantial number of patients suffer from depressive and anxiety symptoms without meeting official criteria of either ICD-10 or DSM-IV depressive and/or anxiety disorders (Zinbarg et al., 1994, Stein et al., 1995; see Katon and Roy-Byrne, 1991, Wittchen and Essau, 1993, Boulenger et al., 1997 for reviews). These patients are frequent in primary care (Barrett et al., 1988, Wittchen and Essau, 1993, Barlow and Campbell, 2000). To provide a clinical definition for those patients the ICD-10 (WHO, 1992) introduced the concept of mixed anxiety–depression disorder (MAD). The criteria for MAD are as follows:

  • 1.

    Presence of mild or moderate anxiety and depression, without prevailing of anxiety or depression,

  • 2.

    at least temporary occurrence of vegetative symptoms,

  • 3.

    the symptoms do not fulfil the criteria of an anxiety disorder or a depressive episode.

The status of the ICD-10-MAD diagnosis — in relation to depressive and anxiety disorders — needs further research. There is a need for follow-up studies — explicitly applying the specified diagnostic criteria of the ICD-10 — to determine the temporal stability of a given ICD-10-MAD diagnosis and the possible shift to depressive and/or anxiety disorders (see also Katon and Roy-Byrne, 1991, Wittchen and Essau, 1993, Stein et al., 1995). This study examines the outcome of a given ICD-10-MAD diagnosis as compared to depression and anxiety after one year in a primary care sample in terms of the diagnostic status. Data were collected within the scope of the World Health Organization (WHO) Collaborative Study on ‘Psychological Problems in General Health Care’, which is a cross-sectional and prospective-longitudinal international study (Sartorius et al., 1993, Üstün and Sartorius, 1995).

Section snippets

Methods

From the sample of the WHO Collaborative Study1 patients meeting ICD-10 criteria for a depressive episode, dysthymia, agoraphobia, panic disorder, generalised anxiety disorder (GAD), comorbid depressive and anxiety disorder, and MAD at the baseline assessment were identified and reassessed after 12 months. Additional ICD-10 psychiatric diagnoses were

Sample characteristics

A total of 1856 patients were identified to meet ICD-10 criteria for a depressive episode, dysthymia, agoraphobia, panic disorder, GAD, comorbid anxiety and depressive disorder, and MAD at the baseline diagnostic assessment. 1183 subjects (63.7%) could be re-examined at the follow-up. A total of 673 (36.3%) did not participate in the follow-up examination because they had moved and were not found anymore, because of refusal or because of death. Exact proportions were not recorded. There was no

Discussion

The data presented herein did not show temporal stability of MAD as compared to depressive and anxiety disorders. Our results are in contrast to the findings of Usall and Marquez (1999) who concluded that MAD is a stable diagnosis. These authors applied DSM-IV research criteria so that their results cannot be directly compared with our findings.

References (19)

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