The relationship of anxiety and depression continues to be an active topic of discussion in psychiatry. Primary care clinicians are bombarded with information on various anxiety disorders from companies claiming efficacy for their particular antidepressant in panic disorder, social anxiety disorder, generalized anxiety disorder, etc. If most anxious patients are depressed, or at risk of developing depression, and most depressed patients are anxious, or at risk of developing anxiety disorders, why do we separate anxiety disorders and mood disorders into 2 distinct nosologic categories? Aren't antidepressants—especially SSRIs—effective for both? Isn't this evidence of shared biological underpinnings? When antidepressants are used to treat anxiety, do the principles of care, including dose and duration of therapy, differ from the treatment of mood disorders?
In this supplemental reading for our audience, Dr. Richard C. Shelton of the Vanderbilt Department of Psychiatry leads a panel of experts in the consideration of these important questions. Dr. James C. Ballenger of the Medical University of South Carolina, Dr. Laurel L. Brown of Vanderbilt, Dr. Alan Frazer of the University of Texas San Antonio, Dr. P. Murali Doraiswamy of the Duke University Department of Psychiatry, and Dr. Mark H. Pollack of the Harvard Department of Psychiatry join Dr. Shelton for the discussion. Information on neurobiology, comorbidity, pharmacology, and clinical practice sheds light on the controversies mentioned. I found the discussion of nosologic models of the anxiety-depression continuum presented by Drs. Shelton and Brown to be well presented and useful as I thought about the material. I also found Dr. Pollack's discussion of social anxiety to be quite elucidating, and would like to add my own emphasis from clinical experience and investigation to the comorbidity of social anxiety and bipolar disorder. Social anxiety was found to be associated with bipolar outcomes in the large NIMH prospective study documented by Akiskal and others.1 Dr. Pollack references the National Comorbidity Survey of Kessler et al.2 in which the odds ratio of bipolar/social anxiety comorbidity was 5.9—more than twice that of major depressive disorder or dysthymia. Antidepressant use in the treatment of some patients with social anxiety disorder may uncover bipolarity. Careful patient assessment is always apropos.
J. Sloan Manning, M.D.
Editor in Chief
The Primary Care Companion to the Journal of Clinical Psychiatry
- Akiskal HS, Maser JD, Zeller PM, et al. Switching from "unipolar" to bipolar II. Arch Gen Psychiatry 1995;52:114–123
- Kessler RC, Stang P, Wittchen HU, et al. Lifetime comorbidities between social phobia and mood disorders in the US National Comorbidity Survey. Psychol Med 1999;29:555–567