title: Concurrent anxiety and substance use disorders among outpatients with major depression: clinical features and effect on treatment outcome.
abstract: BACKGROUND
  Depressed patients often present with comorbid anxiety and/or substance use disorder. This report compares the four groups defined by the disorders (anxiety disorder, substance use disorder, both, and neither) in terms of baseline clinical and sociodemographic features, and in terms of outcomes following treatment with citalopram (a selective serotonin reuptake inhibitor).
  
  
  METHODS
  The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial enrolled 2838 outpatients with non-psychotic major depressive disorder (MDD) from 18 primary and 23 psychiatric care clinics. Clinical and sociodemographic features were assessed at baseline. These baseline features and the treatment outcomes following treatment with citalopram were compared among the four groups.
  
  
  RESULTS
  Participants with non-psychotic MDD and comorbid anxiety and/or substance use disorder showed several distinctive baseline sociodemographic and clinical features. They also showed greater depression severity; length of illness; likelihood of anxious, atypical or melancholic features; more intolerance/attrition; and worse remission/response outcomes with treatment. Participants with either anxiety or substance use disorder showed outcomes generally intermediate between those with both and those with neither.
  
  
  CONCLUSIONS
  Comorbid anxiety and/or substance use disorder are clinically identifiable, and their presence may define distinct MDD subgroups that have more problems and worse pharmacological treatment outcomes. They may benefit from more aggressive, multi-faceted treatment and psychosocial rehabilitation targeted at reducing their psychological comorbidity and functional impairment.
authors.affiliation: Department of Psychiatry, University of Pittsburgh Medical Center, Western Psychiatric Institute and Clinic, 3811 O'Hara Street, Pittsburgh, PA 15213, United States. HowlandRH@upmc.edu
authors.forename: Robert H
authors.initials: RH
authors.lastname: Howland
authors.forename: A John
authors.initials: AJ
authors.lastname: Rush
authors.forename: Stephen R
authors.initials: SR
authors.lastname: Wisniewski
authors.forename: Madhukar H
authors.initials: MH
authors.lastname: Trivedi
authors.forename: Diane
authors.initials: D
authors.lastname: Warden
authors.forename: Maurizio
authors.initials: M
authors.lastname: Fava
authors.forename: Lori L
authors.initials: LL
authors.lastname: Davis
authors.forename: G K
authors.initials: GK
authors.lastname: Balasubramani
authors.forename: Patrick J
authors.initials: PJ
authors.lastname: McGrath
authors.forename: Susan R
authors.initials: SR
authors.lastname: Berman
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D018687:Antidepressive Agents, Second-Generation / Q000009:adverse effects / Q000627:therapeutic use; D001007:Anxiety / Q000150:complications* / Q000188:drug therapy / Q000523:psychology*; D015283:Citalopram / Q000009:adverse effects / Q000627:therapeutic use; D003865:Major Depressive Disorder / Q000150:complications* / Q000188:drug therapy / Q000523:psychology*; D017831:Diagnosis, Dual (Psychiatry); D004305:Dose-Response Relationship, Drug; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D010045:Outpatients; D010342:Patient Acceptance of Health Care; D011569:Psychiatric Status Rating Scales; D012959:Socioeconomic Factors; D019966:Substance-Related Disorders / Q000150:complications* / Q000188:drug therapy / Q000523:psychology*; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D018687:Antidepressive Agents, Second-Generation; D015283:Citalopram