3 May 2021

Seven signs that anxiety may become chronic

Clinical Mental Health

Roughly four in five patients with anxiety disorders achieve remission within six years, according to research described as “reassuring” for affected patients.

While anxiety trajectories have been studied in clinical populations, less was known about the general population, said the authors, from the Amsterdam Public Health Institute in the Netherlands.

They used survey results from randomly selected respondents aged between 18 and 64 from each Dutch household.

More than 4,500 people were re-interviewed at three and six years, of whom 243 had an anxiety disorder including panic disorder, agoraphobia, social phobia and generalised anxiety disorder at baseline.

Almost 80% achieved remission after six years: over half were completely free of symptoms at six years and 47% had subthreshold anxiety symptoms.

A small group took an intermittent course – being anxiety-free but transitioning to a new mood or substance use disorder.

One in 12 developed chronic anxiety. But the authors found predictors that “may contribute to the timely identification of people with an increased risk” of chronicity, including: not living with a partner, number of negative life events, neuroticism, disorder severity, medication use, lower mental functioning and use of mental health care.

“Our findings corroborate the view that the course of anxiety disorders is more favourable in the general population as compared with clinical-based populations, which generally report lower remission rates,” they wrote in Australian and New Zealand Journal of Psychiatry.

Melbourne GP Dr Caroline Johnson, who was not involved in the study, said it was reassuring that anxiety passed for many respondents but said patients presenting to GPs may differ from the general population.

“GPs need to be careful not to minimise a person’s self-report of symptoms on this basis. Those presenting for care warrant a more thorough assessment, particularly to rule out more complex conditions, e.g., PTSD or OCD,” said Dr Johnson, a medical educator at the University of Melbourne.

She added the unfavourable course for one-fifth of the cohort emphasised the crucial role of GPs in proactive monitoring of patients with anxiety symptoms.

The predictors of chronicity raised “chicken and the egg questions” but GPs might focus on building a patient’s social connections and preventing ongoing negative life events where possible, Dr Johnson said.

Clinical psychologist Elisabeth Shaw told TMR the findings were important as patients with anxiety often saw it as defining their personality rather than a condition to be overcome.

But regarding the predictors, she said it was crucial for clinicians to understand why patients didn’t live with a partner – for example whether relationship trauma contributed to anxiety or whether the disorder fuelled social isolation – and to refer to a couple or family therapist if there were risks of relationship breakdown.

“As others in the family may also experience anxiety to different degrees, working together on emotional and behavioural strategies together can be hugely beneficial as it has greater impetus for change that will last,” said Ms Shaw, CEO of Relationships Australia NSW.

“Loneliness plays a significant part in the development of mental health disorders … it fits with other clinical indicators that people without the support of loving and supportive caregivers will struggle more than those with positive relationships.”

Black Dog Institute clinical psychologist Associate Professor Jill Newby added the sample size was too small to detect factors influencing intermittent or chronic paths and that the Dutch research may not be generalisable to Australia.

She emphasised cognitive behavioural therapy was the first-line treatment for anxiety disorders and medication may also be required for severe anxiety.

“People in this study may have been treated between the assessments which may have contributed to the strong recovery rates.”

Australian and New Zealand Journal of Psychiatry 2021, 22 April