¶ … Successful Are Clinicians in the Treatment of Comorbid Depression and Anxiety in Adult Patients, With DBT Skills Application? Depression and anxiety are two of the most common mental health problems in the United States. These two conditions affect a significant percentage of the United States population, meaning that billions of dollars are spent every year to care for the conditions and related problems. Additionally, depression and anxiety are behind the significant declines in patient social functioning and well-being. The two disorders have also been found to cause great suffering and pain to both patients and their close friends and family. In spite of the fact that proven treatments exist, both conditions remain undertreated (Rizvi, 2011 -- ). The diagnosis and subsequent treatment of the disorders are made even more difficult by the fact that the two disorders share many signs and symptoms. For instance, data from the National Comorbidity Survey shows that at least 58% of individuals who were found to have lifetime depression have a minimum of one anxiety disorder. Patients with comorbid anxiety and depression were also found to have significantly lower levels of productivity and use of healthcare resources (Ballenger, 2000).

Depression and anxiety have been found to frequently co-occur, both sequentially and concurrently, in both children and adults. It has also been found that the presence of one of the disorders increases the risk of getting the other, as time goes by. The most prevalent anxiety disorder among adults is GAD (Generalized Anxiety Disorder), while the most prevalent depression disorder is MDD (Major Depressive Disorder). GAD and MDD frequently appear together in many patients, through family lines (Garber & Weersing, 2010). One of the most frequently used type of psychotherapy today, is CBT (Cognitive Behavioral Therapy). The focus of this therapy is to help individuals learn their thought process so that they can eventually change how they feel and behave, at the end of therapy. The majority of American psychotherapists who practice CBT use a version of it that is more goal-oriented and time-limited (Garber & Weersing, 2010). A version of CBT that is gaining prominence among therapists is DBT (Dialectical Behavioral Therapy). DBT is based on the principles of CBT, which it uses to increase the effectiveness of treatment and focus on specific issues. The founder of dialectical behavioral therapy, Dr. Marsha Linehan, came up with this version of CBT after seeing the deficits in Cognitive Behavioral Therapy (Matusiewicz, Hopwood, Banducci&Lejuez, 2010). This study would therefore help in the understanding and delivery of best practices in psychological therapy.

Psychiatrists have recognized the relationship between anxiety and depression; detailed studies into the phenomenon have just begun. According to various researches and data, both conditions have been known to occur collectively more often than as singular clinical illnesses. Many researchers believe that both or either of these conditions occur when a prolonged illness has persisted, for example, chronic anxiety can transform into depression over time. In short, anxiety can be considered a prodrome for depression. Having these two conditions present in a single patient can greatly damage his/her clinical outcome as a combination is lethal and slows down the effect of drugs and/or clinical treatment. Luckily, the new variety of antidepressants are doing a good job of targeting both mood and anxiety issues.

There are so many diagnostic overlaps that the reoccurrence or prevalence of these conditions as a duo in a single individual are hard to monitor, and to what extent the population is affected by the combination of depression and anxiety. From acquired data, it is clear that as many as 10% patients have exhibited comorbid anxiety and depression in primary care settings. However, almost 60% MDD patients exhibited moderate levels of anxiety, 20-25%; the rest, on the other hand, exhibited severe anxiety. There is no set criterion here (Ballenger 2000)

Under primary care settings, it is difficult to diagnose patients with comorbid anxiety and depression because they don't really fall in a specific criterion for either issue fully. Therefore, this condition has been named "Mixed anxiety-depressive disorder." To better identify diagnostic basis for such patients, the APA has integrated the condition in the DSM-IV under a provisional category. The symptoms of this disorder are incomplete forms or low intensity symptoms of both anxiety and depression. Usually this disorder can be recognized by:

Difficulty in concentration

Memory loss

Lack of sleep

Reoccurring dysphoric moods

Fatigue

Irritability

Low energy and prone to worrying

While these symptoms are congruent with both anxiety and depression, the evidence is limited and not enough for a full diagnosis of either an anxiety disorder...

However, even while coexisting, one condition will be more dominant than the other. For example, if the coexisting depression is dominant, the patient will show hopelessness and the absence of positivity while dominant anxiety will most likely show motor tension and/or hyperactivity (Ballenger 2000)
Even if the diagnosis is not easy to make, the resolution process should always initiate with controlling the anxiety issues of such a patient. Once one aspect is managed, the other can be controlled with a regime of antidepressants. Medication and therapy is required for a full remission of depression. One such combination of drugs that is highly recommended for comorbid anxiety and depression is BZD or buspirone with an antidepressant. Since traditional anxiolytics will have little to no effect on depression, it is essential that treatment be coupled with antidepressants to manage this disorder (Koons et al., 2001). However, doctors have to be very careful with this particular combination of drugs and taper off the patient steadily and carefully. The withdrawal effects, especially from drugs like BZD, are not to be taken lightly.

2. Method

2.1. Data Sources

The purpose of this review is to evaluate evidence of the efficacy of various psychological interventions used in the treatment or management of comorbid anxiety and depression.

Three databases were used in conducting this literature review and they include: MEDLINE -- A database of the United States Library of Medicine (www.nlm.nih.gov/); PsycINFO -- A database for storing psychology articles, reports and other literature (www.apa.org/psycinfo); and the Cochrane Library - an evidence-based database for health care literature (www.cochrane.org).

As the search was being conducted in each of these databases, only literature published between 2011 and 2014 were considered. Considering the little time and money available for the review, only literature published in English were considered. Previous reviews done show that this kind of restriction has little impact on the outcome. Given the specifications of this study, the search was also restricted by the age i.e. only adults were considered. Further restrictions were made based on study design, intervention settings and ways in which the interventions were evaluated. To get only the most relevant data, the following criteria was used to "fine tune" the search process, and only empirical studies were considered (Valentine et al., 2015).

Drawbacks of the "systematic review approach" are repeatedly brought to light in this paper. They are as follows:

Long time scale

Narrow focus

Lack of cost-effectiveness

Wasteful approach to data retrieval

No actual clinical relevance (Leitner et al., 2006).

2.2. Sample Unit Description

In the search done on the three databases, the following keywords were used "depress*" OR "depression" OR "dysthymic disorder" OR "depressive disorder" OR "intent*" OR "Depression and anxiety" OR "DBT compared with CBT" OR "DBT Effectiveness" OR "Success" (The asterisk indicates a wildcard search, which retrieves all data that include the phrase preceded by the asterisk). By removing all duplicated searches and then applying the restriction criteria highlighted above, the number of individual texts found was thirty-six. The intervention restriction criteria further reduced this number to 18 texts. Random selection searches on the excluded texts revealed that the majority of those texts were purely discursive. However, it was also clear that there was an imbalance in the texts with many of them focusing on risk rather than intervention (Farrell, Shaw & Webber, 2009). The abstracts of the remaining texts were each individually read so as to further exclude any that did not meet the review criteria. Those which were ambiguous or did not have enough information were read by other reviewers. At the end of the process, only 12 papers out of the initial 36 were found to be potentially worth reading, and were purchased in full-text format. Each of these was then read to the end, after which a final decision was made to consider all of them for the review (Valentine et al., 2015; Kvarstein et al., 2015).

2.3. Summary of the Collected Data

The review recognized a variety of methodological problems pertinent to the current research evidence, which must to be dealt with if future researches are to work successfully and be based around an "evidence-based practice." The review also pointed out a number of issues with respect to the limitations, outreach and focus of the existing evidence bank. Due to the "Scatter gun" approach that has been adopted towards the study, research and treatment of comorbid anxiety and depression, neither doctors nor policy makers have been able to benefit from this poor evidence base collected from small studies addressing a much larger issue (Campbell, 2000). In the intervention…