سن شروع اختلال اضطراب اجتماعی در بیماران سرپایی افسرده

Abstract Onset of social anxiety disorder (SAD) often precedes that of major depressive disorder (MDD) in patients with this comorbidity pattern. The current study examined the association between three SAD onset groups (childhood, adolescent, adulthood) and clinical characteristics of 412 psychiatric outpatients diagnosed with MDD and SAD based on a semi-structured diagnostic interview. Childhood and adolescent SAD onset groups were more likely to report an onset of MDD prior to age 18 and have made at least one prior suicide attempt compared to the adulthood onset group. The childhood SAD onset group also was more likely to have chronic MDD, poorer past social functioning, and an increased hazard of MDD onset compared to the adulthood onset group. Findings suggest that patients with an onset of SAD in childhood or adolescence may be particularly at risk for a more severe and chronic course of depressive illness.

2. Results Mean age of onset of MDD was 22.0 years of age (SD = 12.0), and mean age of onset of SAD was 11.7 years (SD = 8.6). The majority of patients reported an onset of SAD before MDD (n = 299; 72.6%). Sixty patients (14.6%) reported an onset of MDD before SAD, and 52 patients (12.6%) reported a simultaneous onset of SAD and MDD (the MDD age of onset was missing for one participant). Two thirds of the patients (n = 272) reported an onset of SAD in childhood, while 74 (18.0%) reported an onset in adolescence and 66 (16.0%) in adulthood. As shown in Table 1, the three onset groups differed on current age with both the childhood and adulthood onset groups being older than the adolescent onset group (childhood vs. adolescent p = 0.04; adulthood vs. adolescent p = 0.01). This comparison remained significant when examining the FDR (q-value = 0.03). There was no significant difference between the childhood and adulthood onset groups on age. There were no other differences between onset groups on demographic variables. A greater percentage of childhood and adolescent SAD onset patients reported onset of MDD before age 18 compared to the patients with an onset of SAD in adulthood (childhood vs. adulthood onset χ2 = 13.22, p < 0.001; adolescent vs. adulthood onset χ2 = 6.05, p = 0.01). This remained significant after examining the FDR (q-value = 0.004). A greater percentage of patients with an onset of SAD in childhood also had chronic MDD compared to patients with an adolescent and adulthood onset of SAD, which remained significant after the FDR correction (q-value = 0.004; childhood vs. adolescent onset χ2 = 11.45, p = 0.001; childhood vs. adulthood onset χ2 = 5.30, p = 0.02). In addition, a greater percentage of patients with a childhood and adolescent onset of SAD had made at least one prior suicide attempt compared to the adulthood onset group, which remained significant after the FDR correction (q-value = 0.04; childhood vs. adulthood onset χ2 = 8.33, p = 0.004; adolescent vs. adulthood onset χ2 = 4.84, p = 0.03). The initial comparison on CGI scores was significant, but it was no longer significant after the FDR correction (q-value = 0.07). There were no significant differences between groups on occurrence of prior inpatient or partial hospitalizations ( Table 2). Table 2. Clinical characteristics of childhood, adolescent, and adulthood onset comorbid social anxiety disorder in depressed outpatients. Variable Child onset (n = 272) Adolescent onset (n = 74) Adult onset (n = 66) Statistic p MDD onset before 18, n (%) 124 (45.8) 30 (40.5) 14 (21.2) χ2 = 13.23 0.001 b, c Chronic MDD, n (%) 133 (49.1) 20 (27.0) 22 (33.3) χ2 = 14.31 0.001 a, b Suicide attempt, n (%) 80 (29.5) 20 (27.0) 8 (12.1) χ2 = 8.32 0.02 b, c Past social functioning, n (%) χ2 = 15.60 <0.001 a, b Fair or worse 138 (50.7) 27 (36.5) 17 (25.8) Good or better 134 (49.3) 47 (63.5) 49 (74.2) Additional diagnoses, M (SD) 1.79 (1.40) 2.05 (1.29) 1.76 (1.59) F = 1.14 0.32 Number of episodesd, M (SD) 6.85 (16.95) 9.77 (22.99) 5.86 (16.85) F = 0.97 0.38 CGI, M (SD) 3.21 (0.67) 3.01 (0.56) 3.08 (0.51) F = 3.68 e 0.04* GAF, M (SD) 48.40 (7.51) 49.70 (7.25) 49.06 (6.33) F = 1.00 0.37 Number of social fearsf, M (SD) 5.88 (2.52) 5.52 (2.45) 5.05 (2.58) F = 1.78 0.17 Desire treatment for SAD, n (%) 212 (77.9) 56 (75.7) 57 (86.4) χ2 = 2.82 0.24 Inpatient hospitalization, n (%) 73 (26.8) 24 (32.4) 17 (25.8) χ2 = 1.05 0.59 Partial hospitalization, n (%) 15 (16.1) 6 (24.0) 3 (15.0) χ2 = 0.94 0.62 Current social functioningg, n (%) χ2 = 2.30 0.32 Fair or worse 75 (80.6) 18 (72.0) 18 (90.0) Good or better 18 (19.4) 7 (28.0) 2 (10.0) Time out of workh, n (%) χ2 = 0.25 0.88 Virtually none 57 (22.8) 16 (22.9) 13 (20.0) 1 month or more 193 (77.2) 54 (77.1) 52 (80.0) Note: Additional diagnoses = number of additional Axis I diagnoses; number of episodes = total number of depressive episodes; CGI, Clinical Global Impression Scale; GAF, Global Assessment of Functioning Scale; SAD, social anxiety disorder; MDD, major depressive disorder; chronic MDD = current episode duration greater than 2 years; suicide attempt = presence of at least one prior suicide attempt; inpatient hospitalization = presence of at least one prior inpatient hospitalization; partial hospitalization = at least one prior partial hospitalization. Variables with significant findings are bold italicized. * This comparison was not significant after the false discovery rate correction. a Significant difference on post hoc comparisons between childhood and adolescent onset of SAD. b Significant difference on post hoc comparisons between childhood and adulthood onset of SAD. c Significant difference on post hoc comparisons between adolescent and adulthood onset of SAD. d Missing data from one childhood onset participant (n = 271). e Welch's variance weighted F statistic is reported due to unequal variances. f Total sample size reduced to 229 (childhood onset n = 147; adolescent onset n = 42; adulthood onset n = 40). g Total sample size reduced to 138 (childhood onset n = 93; adolescent onset n = 25; adulthood onset n = 20). h Total sample size reduced to 385 (childhood onset n = 250; adolescent onset n = 70; adulthood onset n = 65). Table options A greater percentage of patients with a childhood onset of SAD were rated as having fair or worse social functioning as an adolescent compared to patients with an onset of SAD in either adolescence or adulthood (childhood vs. adolescent onset χ2 = 4.73, p = 0.03; childhood vs. adulthood onset χ2 = 13.35, p < 0.001), and this also remained significant after the FDR adjustment (q-value = 0.004). The three groups did not differ on current social functioning or time out of work in the past 5 years due to psychopathology. Regarding comorbidity, a greater percentage of patients with a SAD onset in adolescence met current criteria for an impulse control disorder compared to patients with a SAD onset in childhood (χ2 = 6.25, p = 0.01), but this did not remain significant after the FDR correction (q-value = 0.07). There were no differences for other specific Axis I disorders ( Table 3). Table 3. Current comorbidity of childhood, adolescent, and adulthood onset comorbid social anxiety disorder in depressed outpatients. Variable Overall sample (n = 412) Freq. (%) Child onset (n = 272) Freq. (%) Adolescent onset (n = 74) Freq. (%) Adult onset (n = 66) Freq. (%) χ2 p Alcohol use disorder 39 (9.5) 21 (7.7) 12 (16.2) 6 (9.1) 4.91 0.09 Drug use disorder 21 (5.1) 11 (4.0) 6 (8.1) 4 (6.1) 2.14 0.34 Dysthymia 55 (13.3) 39 (14.3) 11 (14.9) 5 (7.6) 2.28 0.32 Any anxiety disorder 271 (65.8) 179 (65.8) 50 (67.6) 42 (63.6) 0.24 0.89 Any impulse control 66 (16.0) 37 (13.6) 19 (25.7) 10 (15.2) 6.35 0.04* Any somatoform 55 (13.3) 34 (12.5) 13 (17.6) 8 (12.1) 1.39 0.50 Eating disorder 21 (5.1) 17 (6.2) 2 (2.7) 2 (3.0) 2.21 0.33 ADHD 16 (3.9) 7 (2.6) 6 (8.1) 3 (4.5) 4.87 0.09 Note: ADHD, attention deficit/hyperactivity disorder. * This comparison was no longer significant after the false discovery rate correction. Table options For the Cox regression analysis (Table 4 and Fig. 1), age was entered in the first block and the SAD onset group variable in the second block. The adulthood SAD onset group was the reference category. This overall model was significant (χ2 = 95.71, p < 0.001). Results showed that as age increased by 1 year, the hazard of MDD onset decreased (i.e., there was a longer time to MDD onset). However, being in the childhood SAD onset group increased the hazard of MDD onset relative to the adulthood onset group (i.e., there was a shorter time to MDD onset). Table 4. Hazard of major depressive disorder onset in patients with a prior onset of social anxiety disorder. Variable B Wald p Exp(B) 95%CI Age −0.07 84.04 <0.001 0.93 0.92–0.95 SAD onset (overall) – 10.36 0.006 – – Childhood SAD onseta 0.62 8.40 0.004 1.85 1.22–2.81 Adolescent SAD onseta 0.34 1.84 0.18 1.40 0.86–2.28 Note: SAD, social anxiety disorder. Sample size reduced to 299 (childhood onset n = 225; adolescent onset n = 49; adulthood onset n = 25). Variables with significant findings are bold italicized. a Reference category is adulthood onset of SAD. Table options Hazard function of major depressive disorder onset in patients with a childhood, ... Fig. 1. Hazard function of major depressive disorder onset in patients with a childhood, adolescent, and adulthood onset of social anxiety disorder. Note: Top line represents the childhood SAD onset group; middle line represents the adolescent SAD onset group; bottom line represents the adult SAD onset group.