Prospective studies of cothymia (mixed anxiety-depression): how do they inform clinical practice?

Abstract

We suggest that the diagnosis of mixed anxiety depression at syndromal level (i.e. both anxiety and depressive diagnoses present in the same person and given equal status) is valuable clinically and should be introduced into the formal classification of neurotic and mood disorders. Evidence is given from a systematic review that cothymia has a significantly worse outcome than either an anxiety or a depressive diagnosis alone (p < 0.0001). Long-term follow-up data in a 12-year outcome study of neurotic disorder reinforce this finding both with regard to social functioning and the clinical course of anxiety and depressive disorders; these were significantly worse (P < 0.001 and P < 0.02 respectively) in those with cothymia compared with single anxiety disorders. These outcome differences are much greater than those between anxiety and depressive disorders alone.:1

The Core Elements of Neurosis: Mixed Anxiety-Depression (Cothymia) and Personality Disorder

“…After 12 years, the influence of initial neurotic diagnosis remained insignificant in determining outcome (measured by the Neurotic Disorder Outcome Scale [NDOS; Tyrer et al, 2001]) but both cothymia and the general neurotic syndrome each contributed to the significantly worse outcome of those with mixed diagnoses, in which the outcome scores were 30% to 70% worse for those with cothymia and the general neurotic syndrome than for those with single neurotic diagnoses (Table 3). However, the effect of the general neurotic syndrome did not lead to a significant interaction and most of the poor outcome can be attributed to the cothymic diagnosis.…”

“…Such information can be the selection of treatment, the prediction of prognosis, genetic risk of transmission, or assessment of risk of relapse or some other event. The reason why the diagnosis of cothymia showed clinical utility and clinical validity is that it successfully predicted a significantly worse long-term outcome than single mood diagnoses with regard to social functioning and the clinical course of anxiety and depressive disorders after 12 years (Tyrer, Seivewright, Simmonds, & Johnson, 2001). This finding is supported by other evidence showing a poorer response to initial treatment and a different family history (Van Valkenberg, Akiskal, Puzantian, & Rosenthal, 1984), and a recent systematic review (Emmanuel, Simmonds, & Tyrer, 1997).…”

The Management of Anxiety and Depressive Disorders: A Review

“…They suggested four models of association: (a) distinct but sometimes co-existent syndromes; (b) symptoms of anxiety and depression denote external manifestations of a single underlying cause; (c) anxiety predisposing to depression; and (d) the converse, depression predisposing to anxiety. Tyrer (2001) argued that, on the basis of their long-term (12-year) outcome study, in which these patients performed nearly 50% worse than those with single mood disorders with regard to clinical symptoms, service contact and social function, (Tyrer, Seivewright, Simmonds, & Johnson, 2001), persisting in regarding this association as yet another example of co-morbidity, would retard progress in the treatment of a distinct disorder (cothymia), which they regarded as a very morbid condition.…”

Associations between anxiety disorders and physical illness

“…In contrast to the accumulating literature on the association of depression with medical illness [3,15,17,20,21,23,26], less is known about the comorbidity of anxiety disorders and somatic disorders or mixed anxietydepression states [29]. Nonetheless, many investigators have reported an association between anxiety disorders and medical illnesses [8,12,27,36].…”