Disease Course

Both anxiety and depressive disorders tend to run a chronic course, with waxing and waning symptomatology. Illness severity typically worsens the longer the illness remains untreated. The age of onset for anxiety disorders varies greatly, depending on the specific condition. Specific phobias and separation anxiety, for example, often begin in childhood (median age of onset, 7 years), while panic disorder (median age, 21) and GAD (median age, 31) are typically seen in early to mid-adulthood (Kessler et al., 2005b). In elderly persons (>65 years) the prevalence of all anxiety disorders appears to decline, except for GAD, which is maintained at 4% prevalence and may increase over time (Krasucki et al., 1998). GAD is often a recurring illness in which patients may experience periods of residual symptoms and occasional interepisode remissions (Angst et al., 2009). More than one third of patients with panic disorder have full remission with treatment, but about 20% have an unremitting and chronic course despite treatment (Katschnig and Amering, 1998).

The onset of major depression can occur at any age, although the median age of onset is 30 (Kessler et al., 2005b). Depression is a highly recurrent illness, and each episode increases the likelihood of future episodes. Patients with a single episode have a 50% lifetime chance of recurrence, whereas those with three or more episodes have an almost 100% chance of recurrence without treatment (Eaton et al., 2008). Untreated depressive episodes can last 6 months or longer (Kessler et al., 2003).The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study found that a substantial number of patients receiving first-line treatment may require 8 weeks or more of treatment to achieve response or remission (Trivedi et al., 2006). Although most patients will recover from their depressive episode and return to normal functioning with treatment, approximately 15% of patients will continue to have an unremitting course, with worsening psychosocial functioning and higher risk for suicide (Eaton et al., 2008).

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