We examined whether a self-report measure of the DSM-5 anxious distress specifier, the Clinically Useful Depression Outcome Scale Anxious Distress Specifier Subscale (CUDOS-A), was as valid as a broader measure of the severity of anxiety, the Clinically Useful Anxiety Outcome Scale (CUXOS), in patients with depression.
Methods
Two hundred ninety-four patients with major depressive disorder were administered a semi-structured interview. The patients completed self-report measures of depression, anxiety, and irritability. Sensitivity to change was examined in a subset of patients.
Results
Both the CUDOS-A and CUXOS were more highly correlated with measures of anxiety than with measures of the other symptom domains. Patients with anxiety disorders scored significantly higher on both measures than did patients with no current anxiety disorder. Both measures were equally correlated with measures of coping, general well-being, and functioning. A large effect size of treatment was found for both measures (CUDOS-A: d = 1.2; CUXOS: d = 1.3).
Conclusions
Both the CUDOS-A and CUXOS were valid self-report measures of anxiety symptom severity in patients with depression. Because anxiety is common in patients with depression, the addition of a small number of items assessing the DSM-5 anxious distress criteria should be added to depression measures and used in measurement-based care efforts.
Get full access to this article
View all access options for this article.
References
1.
ChanHNRushAJNierenbergAA. Correlates and outcomes of depressed out-patients with greater and fewer anxious symptoms: a CO-MED report. Int J Neuropsychopharmacol. 2012; 15: 1387–1399.
2.
FavaMRankinMAWrightE. Anxiety disorders in major depression. Compr Psychiatry. 2000; 41: 97–102.
3.
ZimmermanMMcDermutWMattiaJ.The frequency of anxiety disorders in psychiatric outpatients with major depressive disorder. Am J Psychiatry. 2000; 157: 1337–1400.
4.
GoesFSMcCuskerMGBienvenuOJ; National Institute of Mental Health Genetics Initiative Bipolar Disorder Consortium. Co-morbid anxiety disorders in bipolar disorder and major depression: familial aggregation and clinical characteristics of co-morbid panic disorder, social phobia, specific phobia and obsessive-compulsive disorder. Psychol Med.2010; 42: 1449–1459.
5.
HowlandRHRushAJWisniewskiSR. Concurrent anxiety and substance use disorders among outpatients with major depression: clinical features and effect on treatment outcome. Drug Alcohol Depend. 2009; 99: 248–260.
6.
GoldbergDPWittchenHUZimmermanP. Anxious and non-anxious forms of major depression: familial, personality and symptom characteristics. Psychol Med.2014; 44: 1223–1234.
7.
LinCHWangFCLinSC. A comparison of inpatients with anxious depression to those with nonanxious depression. Psychiatry Res.2014; 220: 855–860.
8.
RhebergenDBatelaanNMde GraafR, . The 7-year course of depression and anxiety in the general population. Acta Psychiatr Scand.2011; 123: 297–306.
9.
FichterMMQuadfliegNFischerUC. Twenty-five-year course and outcome in anxiety and depression in the Upper Bavarian Longitudinal Community Study. Acta Psychiatr Scand.2010; 122: 75–85.
10.
FavaMRushAJAlpertJE. What clinical and symptom features and comorbid disorders characterize outpatients with anxious major depressive disorder: a replication and extension. Can J Psychiatry. 2006; 51: 823–835.
11.
SareenJCoxBJAfifiTO. Anxiety disorders and risk for suicidal ideation and suicide attempts: a population-based longitudinal study for adults. Arch Gen Psychiatry. 2005; 62: 1249–1257.
12.
SeoHJJungYEKimTS. Distinctive clinical characteristics and suicidal tendencies of patients with anxious depression. J Nerv Ment Dis.2011; 199: 42–48.
13.
BandelowBAndersenHFDolbergOT. Escitalopram in the treatment of anxiety symptoms associated with depression. Depress Anxiety. 2007; 24: 53–61.
14.
SteinDJPicarel-BlanchotFKennedySH. Efficacy of the novel antidepressant agomelatine for anxiety symptoms in major depression. Human Psychopharmacol.2013; 28: 151–159.
15.
ThaseMEChenDEdwardsJ. Efficacy of vilazodone on anxiety symptoms in patients with major depressive disorder. Int Clin Psychopharmacol. 2014; 29: 351–356.
16.
AlpertJEFranznickDAHollanderSB. Gepirone extended-release treatment of anxious depression: evidence from a retrospective subgroup analysis in patients with major depressive disorder. J Clin Psychiatry. 2004; 65: 1069–1075.
17.
BaldwinDSFloreaIJacobsenPL. A meta-analysis of the efficacy of vortioxetine in patients with major depressive disorder (MDD) and high levels of anxiety symptoms. J Affect Disord. 2016; 206: 140–150.
18.
FavaMRosenbaumJHoogS. Fluoxetine versus sertraline and paroxetine in major depression: tolerability and efficacy in anxious depression. J Affect Disord. 2000; 59: 119–126.
19.
FawcettJBarkinR.A meta-analysis of eight randomized, double-blind, controlled clinical trials of mirtazapine for the treatment of patients with major depression and symptoms of anxiety. J Clin Psychiatry. 1998; 59: 123–127.
20.
IonescuD FSheltonRCBaerL. Ziprasidone augmentation for anxious depression. Int Clin Psychopharmacol. 2016; 31: 341–346.
21.
KornsteinSGGuico-PabiaCJFayyadRS. The effect of desvenlafaxine 50 mg/day on a subpopulation of anxious/depressed patients: a pooled analysis of seven randomized, placebo-controlled studies. Human Psychopharmacol. 2014; 29: 492–501.
22.
PapakostasGStahlSKrishenA. Efficacy of bupropion and the selective serotonin reuptake inhibitors in the treatment of major depressive disorder with high levels of anxiety (anxious depression): a pooled analysis of 10 studies. J Clin Psychiatry. 2008; 69: 1287–1292.
23.
PapakostasGIClainAAmeralVE. Fluoxetine-clonazepam cotherapy for anxious depression: an exploratory, post-hoc analysis of a randomized, double blind study. Int Clin Psychopharmacol. 2010; 25: 17–21.
24.
ThaseMEDemyttenaereKEarleyWR. Extended release quetiapine fumarate in major depressive disorder: analysis in patients with anxious depression. Depress Anxiety. 2012; 29: 574–586.
25.
DavidsonJMeoniPHaudiquetV. Achieving remission with venlafaxine and fluoxetine in major depression: its relationship to anxiety symptoms. Depress Anxiety. 2002; 16: 4–13.
26.
FavaMRushAJAlpertJE. Difference in treatment outcome in outpatients with anxious versus nonanxious depression: a STAR*D report. Am J Psychiatry. 2008; 165: 342–351.
27.
NelsonJ.Anxiety does not predict response to duloxetine in major depression: results of a pooled analysis of individual patient data from 11 placebo-controlled trials. Depress Anxiety. 2010; 27: 12–18.
28.
TollefsonGDHolmanSLSaylerME. Fluoxetine, placebo, and tricyclic antidepressants in major depression with and without anxious features. J Clin Psychiatry. 1994; 55: 50–59.
29.
ZimmermanMPosternakMFriedmanM. Which factors influence psychiatrists’ selection of an antidepressant?Am J Psychiatry. 2004; 161: 1285–1289.
30.
HamiltonM.The assessment of anxiety states by rating. Br J Med Psychol. 1959; 23: 50–55.
31.
BeckATEpsteinNBrownG. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol. 1988; 56: 893–897.
ZimmermanMClarkHMcGonigalP. Relationship between the DSM-5 anxious distress specifier and the Hamilton Depression Rating Scale Anxiety/Somatization factor. J Nerv Ment Dis.2018; 206: 152–154.
34.
HardingKJRushAJArbuckleM. Measurement-based care in psychiatric practice: a policy framework for implementation. J Clin Psychiatry. 2011; 72: 1136–1143.
35.
ZimmermanMYoungDChelminskiI. Overcoming the problem of diagnostic heterogeneity in applying measurement-based care in clinical practice: the concept of psychiatric vital signs. Compr Psychiatry. 2012; 53: 117–124.
36.
FortneyJCUnutzerJWrennG. A tipping point for measurement-based care. Psychiatr Serv.2017; 68: 179–188.
37.
ZimmermanMChelminskiIYoungD. A clinically useful self-report measure of the DSM-5 anxious distress specifier for major depressive disorder. J Clin Psychiatry. 2014; 75: 601–607.
38.
ZimmermanM.A review of 20 years of research on overdiagnosis and underdiagnosis in the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) Project. Can J Psychiatry. 2016; 61: 71–79.
39.
FirstMBSpitzerRLWilliamsJBW. Structured Clinical Interview for DSM-IV (SCID). Washington, DC: American Psychiatric Association; 1997.
40.
EndicottJSpitzerRL. A diagnostic interview: the Schedule for Affective Disorders and Schizophrenia. Arch Gen Psychiatry. 1978; 35: 837–844.
41.
ZimmermanMMattiaJI. Psychiatric diagnosis in clinical practice: is comorbidity being missed?Compr Psychiatry. 1999; 40: 182–191.
42.
ZimmermanMGalioneJAttiullahN. Depressed patients’ perspectives of 2 measures of outcome: the Quick Inventory of Depressive Symptomatology (QIDS) and the Remission from Depression Questionnaire (RDQ). Ann Clin Psychiatry. 2011; 23: 208–212.
43.
ZimmermanMMartinezJAttiullahN. A new type of scale for determining remission from depression: the Remission from Depression Questionnaire. J Psychiatr Res.2013; 47: 78–82.
44.
ZimmermanMMcGlincheyJPosternakM. How should remission from depression be defined? The depressed patient's perspective. Am J Psychiatry. 2006; 163: 148–150.
45.
CampbellDTFiskeDW. Convergent and discriminant validation by the multitrait-multimethod matrix. Psychol Bul.1959; 56: 81–105.
46.
SteigerJH. Tests for comparing elements of a correlation matrix. Psychol Bul.1980; 87: 245–251.
47.
GasperszRLamersFKentJM. Anxious distress predicts subsequent treatment outcome and side effects in depressed patients starting antidepressant treatment. J Psychiatr Res.2017; 84: 41–48.
48.
GasperszRLamersFKentJM. Longitudinal predictive validity of the DSM-5 anxious distress specifier for clinical outcomes in a large cohort of patients with major depressive disorder. J Clin Psychiatry. 2017; 78: 207–213.
49.
RoselliniAJBourgeoisMLCorreaJ. Anxious distress in depressed outpatients: prevalence, comorbidity, and incremental validity. J Psychiatr Res.2018; 103: 54–60.
50.
SimonGHeiligensteinJGrothausL. Should anxiety and insomnia influence antidepressant selection: a randomized comparison of fluoxetine and imipramine. J Clin Psychiatry. 1998; 59: 49–55.
51.
SonawallaSSpillmannMKolskyA. Efficacy of fluvoxamine in the treatment of major depression with comorbid anxiety disorders. J Clin Psychiatry. 1999; 60: 580–583.
52.
SilverstonePRavindranA.Once-daily venlafaxine extended release (XR) compared with fluoxetine in outpatients with depression and anxiety. J Clin Psychiatry. 1999; 60: 22–28.
53.
UherRDernovsekMZMorsO. Melancholic, atypical and anxious depression subtypes and outcome of treatment with escitalopram and nortriptyline. J Affect Disord. 2011; 132: 112–120.
54.
LauxGFriedeMMullerWE. Treatment of comorbid anxiety and depression with escitalopram: results of a post-marketing surveillance study. Pharmacopsychiatry. 2013; 46: 16–22.
55.
ZimmermanMMcGlincheyJBChelminskiI.An inadequate community standard of care: lack of measurement of outcome when treating depression in clinical practice. Prim Psychiatry. 2008; 15: 67–75.
56.
TrivediMRushAWisniewskiS; STAR*D Study Team. Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D implications for clinical practice. Am J Psychiatry. 2006; 163: 28–40.
57.
GilbodySMHouseAOSheldonTA. Psychiatrists in the UK do not use outcomes measures. National survey. Br J Psychiatry. 2002; 180: 101–103.
58.
ZimmermanMMcGlincheyJB. Why don't psychiatrists use scales to measure outcome when treating depressed patients?J Clin Psychiatry. 2008; 69: 1916-1919.
