Comorbid depressive and anxiety disorders in 509 individuals with an at-risk mental state: impact on psychopathology and transition to psychosis

Abstract

Background: The current diagnostic system for subjects at enhanced clinical risk of psychosis allows concurrent comorbid diagnoses of anxiety and depressive disorders. Their impact on the presenting high-risk psychopathology, functioning, and transition outcomes has not been widely researched.

Methods: In a large sample of subjects with an At-Risk Mental State (ARMS, n = 509), we estimated the prevalence of DSM/SCID anxiety or depressive disorders and their impact on psychopathology, functioning, and psychosis transition. A meta-analytical review of the literature complemented the analysis.

Results: About 73% of ARMS subjects had a comorbid axis I diagnosis in addition to the "at-risk" signs and symptoms. About 40% of ARMS subjects had a comorbid diagnosis of depressive disorder while anxiety disorders were less frequent (8%). The meta-analysis conducted in 1683 high-risk subjects confirmed that baseline prevalence of comorbid depressive and anxiety disorders is respectively 41% and 15%. At a psychopathological level, comorbid diagnoses of anxiety or depression were associated with higher suicidality or self-harm behaviors, disorganized/odd/stigmatizing behavior, and avolition/apathy. Comorbid anxiety and depressive diagnoses were also associated with impaired global functioning but had no effect on risk of transition to frank psychosis. Meta-regression analyses confirmed no effect of baseline anxiety and/or depressive comorbid diagnoses on transition to psychosis.

Conclusions: The ARMS patients are characterized by high prevalence of anxiety and depressive disorders in addition to their attenuated psychotic symptoms. These symptoms may reflect core emotional dysregulation processes and delusional mood in prodromal psychosis. Anxiety and depressive symptoms are likely to impact the ongoing psychopathology, the global functioning, and the overall longitudinal outcome of these patients.

Keywords: ARMS; anxiety; attenuated psychosis; depression; prodromal; psychosis; psychosis risk; schizophrenia; ultra high risk.

Fig. 1.

Meta-analysis of comorbid baseline anxiety and depressive diagnoses in subjects at high clinical risk for psychosis. Anxiety 15.3%, 95% CI 8.9%–25%; Depression 40.7%, 95% CI 32.5%–49.4%. Random-effect models applied.

Fig. 2.

Impact of comorbid depressive and/or anxiety disorders on the baseline GAF scores of individuals with an ARMS (Kruskall-Wallis test = 0.004, Jonckheere-Terpstra < 0.001).

Fig. 3.

Kaplan-Meier survival estimates of transition risks stratified for ARMS subgroups (n = 509) over follow-up (mean = 3.65 years). APS, Attenuated Psychosis Syndrome; BLIP, Brief Limited Intermittent Psychotic episode; GRD, Genetic Risk and Deterioration syndrome; Mixed, a mixture of the above subgroups.

Fig. 4.

Hypothesized proportion of each type of attenuated psychotic symptoms (psychotic-like experience, PLE) in different populations.