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An examination of the bidirectional relationship between functioning and symptom levels in patients with anxiety disorders in the CALM study

  • L. A. Brown (a1), J. L. Krull (a1), P. Roy-Byrne (a2), C. D. Sherbourne (a3), M. B. Stein (a4), G. Sullivan (a5) (a6), R. D. Rose (a1), A. Bystritsky (a7) and M. G. Craske (a1)...

Abstract

Background

Patients with anxiety disorders suffer marked functional impairment in their activities of daily living. Many studies have documented that improvements in anxiety symptom severity predict functioning improvements. However, no studies have investigated how improvements in functioning simultaneously predict symptom reduction. We hypothesized that symptom levels at a given time point will predict functioning at the subsequent time point, and simultaneously that functioning at a given time point will predict symptom levels at a subsequent time point.

Method

Patients were recruited from primary-care centers for the Coordinated Anxiety Learning and Management (CALM) study and were randomized to receive either computer-assisted cognitive-behavioral therapy and/or medication management (ITV) or usual care (UC). A cross-lagged panel design examined the relationship between functional impairment and anxiety and depression symptom severity at baseline, 6-, 12-, and 18-month follow-up assessments.

Results

Prospective prediction of functioning from symptoms and symptoms from functioning were both important in modeling these associations. Anxiety and depression predicted functioning as strongly as functioning predicted anxiety and depression. There were some differences in these associations between UC and ITV. Where differences emerged, the UC group was best modeled with prospective paths predicting functioning from symptoms, whereas symptoms and functioning were both important predictors in the ITV group.

Conclusions

Treatment outcome is best captured by measures of functional impairment as well as symptom severity. Implications for treatment are discussed, as well as future directions of research.

Copyright

Corresponding author

* Address for correspondence: M. G. Craske, Ph.D., Department of Psychology, UCLA, 405 Hilgard Avenue, Los Angeles, CA 90095-1563, USA. (Email: craske@psych.ucla.edu)

References

Hide All
Akaike, H (1976). An information criterion (AIC). Math Science 14, 59.
APA (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th edn. American Psychiatric Publishing: Arlington, VA.
Arch, JJ, Ayers, CR (2013). Which treatment worked better for whom? Moderators of group cognitive behavioral therapy versus adapted mindfulness based stress reduction for anxiety disorders. Behaviour Research and Therapy 51, 434442.
Arch, JJ, Eifert, GH, Davies, C, Plumb, JC, Rose, RD, Craske, MG (2012). Randomized trial of cognitive behavioral therapy versus acceptance and commitment therapy for the treatment of mixed anxiety disorders. Journal of Consulting and Clinical Psychology 80, 750765.
Bentler, PM (1995). EQS: Structural Equations Program Manual. Multivariate Software: Encino, CA.
Bentler, PM, Bonett, DG (1980). Significance tests and goodness of fit in the analysis of covariance structures. Psychological Bulletin 88, 588606.
Chan, S, Jia, S, Chiu, H, Chien, W, Thompson, DR, Hu, Y, Lam, L (2009). Subjective health-related quality of life in Chinese older persons with depression in Shanghai and Hong Kong: relationship to clinical factors, level of functioning, and social support. International Journal of Geriatric Psychiatry 24, 355362.
Craske, MG, Rose, RD, Lang, AJ, Welch, SS, Campbell-Sills, L, Sullivan, G, Sherbourne, CD, Bystritsky, A, Stein, MB, Roy-Byrne, P (2009). Computer-assisted delivery of cognitive behavioral therapy for anxiety disorders in primary-care settings. Depression and Anxiety 26, 235242.
Craske, MG, Stein, MB, Sullivan, G, Sherbourne, C, Bystritsky, A, Rose, RD, Lang, AJ, Welch, S, Campbell-Sills, L, Golinelli, D, Roy-Byrne, P (2011). Disorder-specific impact of coordinated anxiety learning and management treatment for anxiety disorders in primary care. Archives of General Psychiatry 68, 378388.
Derogatis, LR (1994). Symptom Checklist-90-R (SCL-90-R): Administration, Scoring, and Procedures Manual. NCS: Minneapolis, MN.
Derogatis, LR, Melisaratos, N (1983). The Brief Symptom Inventory: an introductory report. Psychological Medicine 13, 595605.
DuPont, RL, Rice, DP, Miller, LS (1996). Economic costs of anxiety disorders. Anxiety 2, 167172.
Fleishman, J, Selim, A, Kazis, L (2010). Deriving SF-12v2 physical and mental health summary scores: a comparison of different scoring algorithms. Quality of Life Research 19, 231241.
Hayes, SC, Strosahl, K, Wilson, KG (1999). Acceptance and Commitment Therapy: an Experiential Approach to Behavior Change. Guilford Press: New York.
Hoehn-Saric, R, McLeod, DR, Hipsley, PA (1993). Effect of fluvoxamine on panic disorder. Journal of Clinical Psychopharmacology 13, 321326.
Hox, JJ, Maas, CJM, Brinkhuis, MJS (2010). The effect of estimation method and sampling size in multileve structural equation modeling. Statistica Neerlandica 64, 157170.
Hu, L, Bentler, PM (1999). Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Structural Equation Modeling 6, 155.
Jacobs, RJ, Davidson, JR, Gupta, S, Meyerhoff, AS (1997). The effects of clonazepam on quality of life and work productivity in panic disorder. American Journal of Managed Care 3, 11871196.
Katerndahl, DA, Realini, JP (1997). Quality of life and panic-related work disability in subjects with infrequent panic and panic disorder. Journal of Clinical Psychiatry 58, 153158.
Kiliç, C, Noshirvani, H, BaşoĞlu, S, Marks, I, (1997). Agoraphobia and panic disorder: 3.5 years after alprazolam and/or exposure treatment. Psychotherapy and Psychosomatics 66, 175178.
Kroenke, K, Spitzer, RL, Williams, JBW (2001). The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine 16, 601613.
Lecrubier, Y, Judge, R (1997). Long-term evaluation of paroxetine, clomipramine and placebo in panic disorder. Collaborative paroxetine panic study investigators. Acta Psychiatrica Scandinavica 95, 153160.
Leon, AC, Olfson, M, Portera, L, Farber, L, Sheehan, DV (1997). Assessing psychiatric impairment in primary care with the sheehan disability scale. International Journal of Psychiatry in Medicine 27, 93105.
Leon, AC, Shear, MK, Portera, L, Klerman, GL (1992). Assessing impairment in patients with panic disorder: the Sheehan Disability Scale. Social Psychiatry and Psychiatric Epidemiology 27, 7882.
Lochner, C, Mogotsi, M, du Toit, PL, Kaminer, D, Niehaus, DJ, Stein, DJ (2003). Quality of life in anxiety disorders: a comparison of obsessive-compulsive disorder, social anxiety disorder, and panic disorder. Psychopathology 36, 255262.
Maas, CJM, Hox, JJ (2004). The influence of violations of assumptions on multilevel parameter estimates and their standard error. Computational Statistics & Data Analysis 46, 427440.
Malik, ML, Connor, KM, Sutherland, SM, Smith, RD, Davison, RM, Davidson, JR (1999). Quality of life and posttraumatic stress disorder: a pilot study assessing changes in SF-36 scores before and after treatment in a placebo-controlled trial of fluoxetine. Journal of Traumatic Stress 12, 387393.
Maor, Y, Olmer, L, Mozes, B (2001). The relation between objective and subjective impairment in cognitive function among multiple sclerosis patients – the role of depression. Multiple Sclerosis 7, 131135.
Mardia, KV (1970). Measures of multivariate skewness and kurtosis with applications. Biometrika 57, 519530.
Markowitz, JS, Weissman, MM, Ouellette, R, Lish, JD, Klerman, GL (1989). Quality of life in panic disorder. Archives of General Psychiatry 46, 984992.
Martens, MP, Haase, RH (2006). Advanced applications of structural equation modeling in counseling psychology research. The Counseling Psychologist 34, 806838.
Mavissakalian, M, Perel, J, Talbott-Green, M, Sloan, C (1998). Gauging the effectiveness of extended imipramine treatment for panic disorder with agoraphobia. Biological Psychiatry 43, 848854.
Michelson, D, Lydiard, RB, Pollack, MH, Tamura, RN, Hoog, SL, Tepner, R, Demitrack, MA, Tollefson, GD (1998). Outcome assessment and clinical improvement in panic disorder: evidence from a randomized controlled trial of fluoxetine and placebo. American Journal of Psychiatry 155, 15701577.
Monson, CM, Schnurr, PP, Resick, PA, Friedman, MJ, Young-Xu, Y, Stevens, SP (2006). Cognitive processing therapy for veterans with military-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology 74, 898907.
Moritz, S, Rufer, M, Fricke, S, Karow, A, Morfeld, M, Jelinek, L, Jacobsen, D (2005). Quality of life in obsessive-compulsive disorder before and after treatment. Comprehensive Psychiatry 46, 453459.
Muthén, LK, Muthén, BO (2011). Mplus User's Guide, 6th edn. Muthén & Muthén: Los Angeles, CA.
Peterson, RA, Heilbronner, RL (1987). The anxiety sensitivity index: construct validity and factor analytic structure. Journal of Anxiety Disorders 1, 117121.
Rapaport, MH, Clary, C, Fayyad, R, Endicott, J (2005). Quality-of-life impairment in depressive and anxiety disorders. The American Journal of Psychiatry 162, 11711178.
Reiss, S, Peterson, RA, Gursky, DM, McNally, RJ (1986). Anxiety sensitivity, anxiety frequency, and the prediction of fearfulness. Behavior Research and Therapy 24, 18.
Revelle, W (2013). psych (version 1.3.2). Evanston, Illinois (http://personality-project.org/revelle.html). Accessed 15 July 2014.
Rose, RD, Lang, AJ, Welch, SS, Campbell-Sills, L, Chavira, DA, Sullivan, G, Sherbourne, CD, Bystritsky, A, Stein, MB, Roy-Byrne, P, Craske, MG (2011). Training primary care staff to deliver a computer-assisted cognitive-behavioral therapy program for anxiety disorders. General Hospital Psychiatry 33, 336342.
Roy-Byrne, P, Craske, MG, Sullivan, G, Rose, RD, Edlund, MJ, Lang, AJ, Bystritsky, A, Welch, SS, Chavira, DA, Golinelli, D, Campbell-Sills, L, Sherbourne, CD, Stein, MB (2010). Delivery of evidence-based treatment for multiple anxiety disorders in primary care. Journal of the American Medical Association 303, 19211928.
Rubin, HC, Rapaport, MH, Levine, B, Gladsjo, JK, Rabin, A, Auerbach, M, Judd, LL, Kaplan, R (2000). Quality of well being in panic disorder: the assessment of psychiatric and general disability. Journal of Affective Disorders 57, 217221.
Safren, SA, Heimberg, RG, Brown, EJ, Holle, C (1996). Quality of life in social phobia. Depression and Anxiety 4, 126133.
Satorra, A, Bentler, PM (2001). A scaled difference chi-square test statistic for moment structure analysis. Psychometrika 66, 507514.
Sheehan, DV (1983). The Anxiety Disease. Scribner: New York.
Spitzer, RL, Kroenke, K, Williams, JBW (1999). Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary care evaluation of Mental Disorders. Patient Health Questionnaire. Journal of the American Medical Association 282, 17371744.
Steiger, JH, Lind, JC (1980). Statistically based tests for the number of common factors. Paper presented at the Annual meeting of the Psychometric Society, Iowa City, IA.
Stein, MB, Fyer, AJ, Davidson, JRT, Pollac, MH, Wiita, B (1999). Fluvoxamine treatment of social phobia (social anxiety disorder): a double-blind, placebo-controlled study. American Journal of Psychiatry 156, 756760.
Stein, MB, Walker, JR, Hazen, AL, Forde, DR (1997). Full and partial posttraumatic stress disorder: findings from a community survey. American Journal of Psychiatry 154, 11141119.
Telch, MJ, Schmidt, NB, Jaimez, TL, Jacquin, KM, Harrington, PJ (1995). Impact of cognitive-behavioral treatment on quality of life in panic disorder patients. Journal of Consulting and Clinical Psychology 63, 823830.
Tenney, NH, Denys, DAJP, van Megen, HJGM, Glas, G, Westenberg, HGM (2003). Effect of a pharmacological intervention on quality of life in patients with obsessive-compulsive disorder. International Clinical Psychopharmacology 18, 2933.
Ware, JE, Kosinski, M, Keller, SD (1996). A 12-item short-form Health Survey: construction of scales and preliminary tests of reliability and validity. Medical Care 34, 220233.
West, SG, Finch, JF, Curran, PJ (1995). Structural equation models with non-normal variables: problems and remedies. In Structural Equation Modeling: Concepts, Issues, and Applications (ed. Hoyle, R.), pp. 5675. Sage: Thousand Oaks, CA.
Wittchen, HU, Fuetsch, M, Sonntag, H, Muller, N, Liebowitz, M (2000). Disability and quality of life in pure and comorbid social phobia. Findings from a controlled study. European Psychiatry 15, 4658.
Wolitzky-Taylor, KB, Arch, JJ, Rosenfield, D, Craske, MG (2012). Moderators and non-specific predictors of treatment outcome for anxiety disorders: a comparison of cognitive behavioral therapy to acceptance and commitment therapy. Journal of Consulting and Clinical Psychology 80, 786799.

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An examination of the bidirectional relationship between functioning and symptom levels in patients with anxiety disorders in the CALM study

  • L. A. Brown (a1), J. L. Krull (a1), P. Roy-Byrne (a2), C. D. Sherbourne (a3), M. B. Stein (a4), G. Sullivan (a5) (a6), R. D. Rose (a1), A. Bystritsky (a7) and M. G. Craske (a1)...

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