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Anxiety Disorders in Old Age: Psychiatric Comorbidities, Quality of Life, and Prevalence According to Age, Gender, and Country
Accepted Manuscript Title: Anxiety Disorders in Old Age: Psychiatric Comorbidities, Quality of Life and Prevalence According to Age, Gender and Country. Author: Aartjan T.F. Beekman PII: DOI: Reference:
S1064-7481(17)30493-1 https://doi.org/doi:10.1016/j.jagp.2017.10.004 AMGP 946
To appear in:
The American Journal of Geriatric Psychiatry
Received date: Accepted date:
1-10-2017 2-10-2017
Please cite this article as: Aartjan T.F. Beekman, Anxiety Disorders in Old Age: Psychiatric Comorbidities, Quality of Life and Prevalence According to Age, Gender and Country., The American Journal of Geriatric Psychiatry (2017), https://doi.org/doi:10.1016/j.jagp.2017.10.004. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Invited Perspective for the American Journal of Geriatric Psychiatry (764 words) Anxiety disorders in old age: Psychiatric comorbidities, quality of life and prevalence according to age, gender and country. Aartjan TF Beekman
Although anxiety is a core human experience, science has been long at exploring the effects of age and aging on the occurrence, expression and consequences of anxiety disorders. Alessandra Canuto and colleagues in this issue present the results of a large EU funded project, comparing the prevalence, co-morbidity patterns and association with quality of life of the full range of anxiety disorders among older people (Canuto et al, 2017). In so doing, they have taken on the challenge of using an age-appropriate measure for anxiety disorders. Mohlman et al (2012) have indicated a series of reasons why the diagnostic criteria that were developed for younger patients, may not be appropriate for older patients. The result is that we may quite severely underestimate the prevalence and thereby the importance of anxiety disorders among older people. Given this problem, one would expect higher prevalence rates when using age appropriate measures, which was indeed what Canuto et have found. About one in six older adults was diagnosed with an anxiety disorder. There is an ongoing debate about the high levels of comorbidity found among psychiatric disorders when using fine-grained classification systems like ICD and DSM. Anxiety and depression are a classic example, exhibiting extremely high levels of comorbidity (Kessler et al 1994). Most patients with one anxiety disorder also have at least one other anxiety disorder and the correlations between symptoms of anxiety and depression are very high. Moreover, comorbidity between anxiety and depression is a marker for severity, persistence and treatment resistance, which adds to the co-occurrence of disorders (Penninx et al 2011). It is striking that, in this study, the authors found very little comorbidity among anxiety disorders, very little comorbidity between anxiety and major depression and very little comorbidity among anxiety disorders and alcohol use disorders. What does that mean? It may be that the use of age-specific measures for anxiety has uncovered the existence of a large group of older people who have stand-alone anxiety problems, that have a different etiology and consequently a different comorbidity when compared with their younger peers. Another striking finding is that although anxiety disorders were found to be common, the prevalence declined sharply after 75. The age specific criteria that were used seem to pick up symptoms that are especially common among the younger old and their occurrence declines among the older old. A third finding was that the correlation with impaired quality of life was much weaker than what is often found. This is worrying because, in order to qualify as a disorder, symptoms need to significantly impair the functioning and quality of life of patients. It might therefore be that the age-specific criteria used, pick up anxiety signals that are age appropriate and common, especially among the younger old. However, given the
Page 1 of 3
weak associations with quality of life, they may be deemed less clinically relevant. The blurring of clear diagnostic boundaries for psychiatric morbidity in later life is a recurrent theme. When devising new, age appropriate criteria for mental disorders, this is a difficult issue to tackle. Anxiety disorders often emerge at an early age and tend to wax and wane over the life cycle. As was described by the authors, the weak association with quality of life may show that people learn to live and cope with their anxieties. It is worrying to see that less than 20% of those with anxiety disorders were not using psychotropic medication. It seems likely that many were long term benzodiazepine users. This may have masked the severity of symptoms and may have dampened the impact on quality of life. Although access to effective psychotherapeutic treatment is increasing rapidly for older people in Europe, it is likely that very few of the participants of the study had access to such treatment. The use of age-sensitive criteria to diagnose psychiatric disorders has long been advocated and opens up new areas and questions. It is encouraging to see that such criteria have now been operationalised for anxiety disorders and that they have been tested in a large, multinational study. The results seem to confirm the idea that anxiety and anxiety related problems are extremely common among older people and that, indeed, age specific criteria are more sensitive at picking them up. However, sensitivity goes at a price of specificity. Assigning the label of ‘anxiety disorder’ to one in six older adults seems premature, given the unusual comorbidity patterns and lack of associations with quality of life that were found.
Page 2 of 3
References Canuto A, Weber K, Baertschi M, Andreas S, Volkert J et al. Anxiety disorders in old age: Psychiatric comorbidities, quality of life, and prevalence according to age, gender, and country. Am J Ger Psychiatry this issue Kendler KS, Aggen SH, Knudsen GP, Røysamb E, Neale MC, Reichborn-Kjennerud T et al. The Structure of Genetic and Environmental Risk Factors for Syndromal and Subsyndromal Common DSM-IV Axis I and All Axis II Disorders. Am J Psychiatry. 2011;168(1):29–39. Kessler, R.C., McGonagle, K.A., Zhao, S., Nelson, C.B., Hughes, M., Eshleman, S., Wittchen, H.U., and Kendler, K.S. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch. Gen. Psychiatry. 1994; 51: 8–19 Mohlman J, Bryant C, Lenze EJ, et al. Improving recognition of late life anxiety disorders in Diagnostic and Statistical Manual of Mental Disorders: observations and recommendations of the Advisory Committee to the Lifespan Disorders Work Group. Int J Geriatr Psychiatry. 2012;27(6):549–56. Penninx BW, Nolen WA, Lamers F, Zitman FG, Smit JH, Spinhoven P, Cuijpers P, de Jong PJ, van Marwijk HW, van der Meer K, Verhaak P, Laurant MG, de Graaf R, Hoogendijk WJ, van der Wee N, Ormel J, van Dyck R, Beekman AT. Two-year course of depressive and anxiety disorders: results from the Netherlands Study of Depression and Anxiety (NESDA). J Affect Disord. 2011 Sep;133(1-2):76-85.
Page 3 of 3
S1064-7481(17)30493-1 https://doi.org/doi:10.1016/j.jagp.2017.10.004 AMGP 946
To appear in:
The American Journal of Geriatric Psychiatry
Received date: Accepted date:
1-10-2017 2-10-2017
Please cite this article as: Aartjan T.F. Beekman, Anxiety Disorders in Old Age: Psychiatric Comorbidities, Quality of Life and Prevalence According to Age, Gender and Country., The American Journal of Geriatric Psychiatry (2017), https://doi.org/doi:10.1016/j.jagp.2017.10.004. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Invited Perspective for the American Journal of Geriatric Psychiatry (764 words) Anxiety disorders in old age: Psychiatric comorbidities, quality of life and prevalence according to age, gender and country. Aartjan TF Beekman
Although anxiety is a core human experience, science has been long at exploring the effects of age and aging on the occurrence, expression and consequences of anxiety disorders. Alessandra Canuto and colleagues in this issue present the results of a large EU funded project, comparing the prevalence, co-morbidity patterns and association with quality of life of the full range of anxiety disorders among older people (Canuto et al, 2017). In so doing, they have taken on the challenge of using an age-appropriate measure for anxiety disorders. Mohlman et al (2012) have indicated a series of reasons why the diagnostic criteria that were developed for younger patients, may not be appropriate for older patients. The result is that we may quite severely underestimate the prevalence and thereby the importance of anxiety disorders among older people. Given this problem, one would expect higher prevalence rates when using age appropriate measures, which was indeed what Canuto et have found. About one in six older adults was diagnosed with an anxiety disorder. There is an ongoing debate about the high levels of comorbidity found among psychiatric disorders when using fine-grained classification systems like ICD and DSM. Anxiety and depression are a classic example, exhibiting extremely high levels of comorbidity (Kessler et al 1994). Most patients with one anxiety disorder also have at least one other anxiety disorder and the correlations between symptoms of anxiety and depression are very high. Moreover, comorbidity between anxiety and depression is a marker for severity, persistence and treatment resistance, which adds to the co-occurrence of disorders (Penninx et al 2011). It is striking that, in this study, the authors found very little comorbidity among anxiety disorders, very little comorbidity between anxiety and major depression and very little comorbidity among anxiety disorders and alcohol use disorders. What does that mean? It may be that the use of age-specific measures for anxiety has uncovered the existence of a large group of older people who have stand-alone anxiety problems, that have a different etiology and consequently a different comorbidity when compared with their younger peers. Another striking finding is that although anxiety disorders were found to be common, the prevalence declined sharply after 75. The age specific criteria that were used seem to pick up symptoms that are especially common among the younger old and their occurrence declines among the older old. A third finding was that the correlation with impaired quality of life was much weaker than what is often found. This is worrying because, in order to qualify as a disorder, symptoms need to significantly impair the functioning and quality of life of patients. It might therefore be that the age-specific criteria used, pick up anxiety signals that are age appropriate and common, especially among the younger old. However, given the
Page 1 of 3
weak associations with quality of life, they may be deemed less clinically relevant. The blurring of clear diagnostic boundaries for psychiatric morbidity in later life is a recurrent theme. When devising new, age appropriate criteria for mental disorders, this is a difficult issue to tackle. Anxiety disorders often emerge at an early age and tend to wax and wane over the life cycle. As was described by the authors, the weak association with quality of life may show that people learn to live and cope with their anxieties. It is worrying to see that less than 20% of those with anxiety disorders were not using psychotropic medication. It seems likely that many were long term benzodiazepine users. This may have masked the severity of symptoms and may have dampened the impact on quality of life. Although access to effective psychotherapeutic treatment is increasing rapidly for older people in Europe, it is likely that very few of the participants of the study had access to such treatment. The use of age-sensitive criteria to diagnose psychiatric disorders has long been advocated and opens up new areas and questions. It is encouraging to see that such criteria have now been operationalised for anxiety disorders and that they have been tested in a large, multinational study. The results seem to confirm the idea that anxiety and anxiety related problems are extremely common among older people and that, indeed, age specific criteria are more sensitive at picking them up. However, sensitivity goes at a price of specificity. Assigning the label of ‘anxiety disorder’ to one in six older adults seems premature, given the unusual comorbidity patterns and lack of associations with quality of life that were found.
Page 2 of 3
References Canuto A, Weber K, Baertschi M, Andreas S, Volkert J et al. Anxiety disorders in old age: Psychiatric comorbidities, quality of life, and prevalence according to age, gender, and country. Am J Ger Psychiatry this issue Kendler KS, Aggen SH, Knudsen GP, Røysamb E, Neale MC, Reichborn-Kjennerud T et al. The Structure of Genetic and Environmental Risk Factors for Syndromal and Subsyndromal Common DSM-IV Axis I and All Axis II Disorders. Am J Psychiatry. 2011;168(1):29–39. Kessler, R.C., McGonagle, K.A., Zhao, S., Nelson, C.B., Hughes, M., Eshleman, S., Wittchen, H.U., and Kendler, K.S. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch. Gen. Psychiatry. 1994; 51: 8–19 Mohlman J, Bryant C, Lenze EJ, et al. Improving recognition of late life anxiety disorders in Diagnostic and Statistical Manual of Mental Disorders: observations and recommendations of the Advisory Committee to the Lifespan Disorders Work Group. Int J Geriatr Psychiatry. 2012;27(6):549–56. Penninx BW, Nolen WA, Lamers F, Zitman FG, Smit JH, Spinhoven P, Cuijpers P, de Jong PJ, van Marwijk HW, van der Meer K, Verhaak P, Laurant MG, de Graaf R, Hoogendijk WJ, van der Wee N, Ormel J, van Dyck R, Beekman AT. Two-year course of depressive and anxiety disorders: results from the Netherlands Study of Depression and Anxiety (NESDA). J Affect Disord. 2011 Sep;133(1-2):76-85.
Page 3 of 3