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Anxiety: Behavioral and Cognitive Strategies for Treating Anxiety - 10 CEUs

Section 19
Work, Social, and Family Disabilities
of Subjects With Anxiety and Depression 

CEU Question 19 | CEU Answer Booklet | Table of Contents | Anxiety
Psychologist CEs, Social Worker CEUs, Counselor CEUs, MFT CEUs

In the 1990s, researchers increasingly assessed the functional impairment and disabilities of patients with mental disorders in a variety of ways and with a number of scales. In brief, they found a relationship between the severity of illness and the degree of functional impairment; generally, with improvement of the illness, function improved. The common disabilities associated with the illnesses were more missed days at work, reduced work performance, and increased financial assistance. Also, in the McDonnell-Douglas study, it was estimated that 23% of employees with psychiatric conditions lost their jobs within a 5-year period. Despite the magnitude of disability and job loss, Rupp estimated that 70% of those with affective disorders do not get mental health treatment, often because inadequate insurance coverage makes treatment unavailable.

Based on the review by Weissman et al of the limitations and merits of available functional-impairment scales and on the need for both a short, self-rated and a clinician-rated scale, Sheehan et al developed an analog (Likert) scale to assess disability across 3 domains: work, social, and family life. This disability scale (DISS) has been used in various studies to measure the overall disability of patients with some anxiety and depressive disorders in primary care clinics; in the Cross-National Collaborative Panic Study; in a panic disorder clinical trial; and in those receiving treatment for SP. Inasmuch as the DISS has been used in some clinical trials and also to assess the possible presence of psychopathology in primary care clinics, we evaluated the work, social, and family disabilities of 228 subjects with 6 common mental disorders. We compared the data with the scores of a comparison group (control subjects) and also with the results of the few available reports of work, social, and family disability scores in the literature.

Methods
We recruited 228 men and women, aged 18 to 65 years, by advertising for participation in clinical drug trials of common depression and anxiety disorders. Among them, 77 had an Axis I diagnosis of major depression (MD); 21 had a diagnosis of panic disorder (PD); 65 had a diagnosis of generalized anxiety disorder (GAD); 30 had a diagnosis of social phobia (SP); 14 had a diagnosis of obsessive-compulsive disorder (OCD); and 21 had a diagnosis of mixed anxiety disorder (MAD). The comparison (control) group (CC) consisted of 29 healthy male and female theology graduate students. On the symptom checklist SCL-90, our control group scores were in line with those of other control groups.

The research subjects were diagnosed according to DSM-III-R criteria by a complete psychiatric clinical evaluation; they also met the diagnostic criteria on disorder-specific scales as defined by the specific clinical trials. Thus, the Structured Clinical Interview for Diagnosis (SCID) was given to only those with GAD and PD. Physical examination and laboratory studies, including urine drug screening, were unremarkable for all subjects. Substance abusers and those with serious suicidal ideation were excluded. Patients who met criteria for major psychiatric comorbidity disorders were not included. All subjects gave written, informed consent (approved by the university's Human Studies Committee), and completed the Sheehan Disability Scale before treatment. The mean scores with standard deviations are reported. Statistical analyses were performed by analysis of variance (ANOVA) and Tukey post hoc test.

Results
Subjects in the 6 diagnostic groups (MD, PD, GAD, SP, OCD, and MAD) had significantly higher work disability scores than control subjects (Table 1). Those with OCD and MAD had the highest work disability scores and those with SP the lowest, but there were no significant differences among diagnostic groups. Also, for social disability, the subjects in all 6 diagnostic groups had significantly higher scores than the controls. Subjects with MD had the highest scores, and those with GAD the lowest scores, but the differences among the 6 diagnostic groups' scores were not statistically significant. For family disability, the subjects with MD, GAD, OCD, or MAD had significantly higher scores than the controls, but those with PD or SP did not. Those with MAD had the highest family disability scores and those with SP the lowest. Those with the depressive disorders tended to have significantly higher family disability scores than subjects with the anxiety disorders.

Table 2 presents comparisons of our SP and PD data with those of Sheehan et al, Davidson et al/7 and Leon et al. All of our SP subjects' mean disability scores were lower than those of the SP subjects of Sheehan et al and Davidson et al. Sheehan et al ascribed the higher disability scores of the subjects in the international study to the patients being more severely ill. In the 3 studies presented, subjects with SP had less impairment at work and within the family than in social situations. The other investigators' data indicate that SP subjects had a higher level of work and social disability than PD subjects; we found the opposite (ie, our PD subjects had higher levels of work and social disability than our SP subjects). In all studies shown in Table 2, family disability scores were definitely lower for both SP and PD subjects than those scores for work and social disability. In both SP and PD subjects, social disability scores were the highest.

Discussion
Our first question was whether subjects with the different anxiety and depressive disorders had distinct patterns of disability. All of our subjects with the disorders had significantly increased work, social, and family disability compared with the control group, with the exception of the family disability scores of the SP and PD subjects. Also, Sheehan et al reported that the family disability scores were lower than the work and social disability scores for their subjects with SP and PD. Those findings are not surprising; generally, SP patients have little discomfort when speaking with family members, and PD patients relate that they are more comfortable when with a family member both at home or "in the mall."

The relatively large standard deviations in our disability scores and those of other investigators indicate considerable overlap in the scores of subjects with various disorders, and thus identification of specific differences in work, social, and family disability is limited. Sheehan et al reported that increased age, higher education, greater severity of illness, psychiatric hospitalization, and being divorced, separated, or widowed with no family support are factors that increase disability scores. Sex and age of onset of the disorder do not appear to affect scores. Mintz et al reported that both severity and duration of illness and relapses affect work disability. Also, the degree of social impairment may depend on the persons' social situations.

Leon et al found increased risks of psychiatric impairment in primary care clinics when subjects' DISS scores were 5.00 or greater. In our study, the MD, OCD, and MAD subjects had mean work, social, and family scores of 5.0 or above. In most of the data from Sheehan et al, PD and SP subjects' scores in the 3 domains were also 5.0 or above. Perhaps of greater importance was the finding by Sheehan et al that symptoms account for only about 30% of the variance in disability, and that there may be desynchrony of symptom severity and disability-scale scores over time that requires measurements of both in tracking treatment outcomes.

In our studies, most subjects had a moderate degree of illness, and many were employed, as would be expected of subjects in most clinical drug trials. Studies with the DISS subscales in primary care clinics have been done, and there appears to be a range of mental disorders with significant disabilities in these populations. We concur with Sheehan et althat "the disability scale may be useful as a very brief, simple, cost-effective and sensitive measure that can easily be included in treatment outcome studies in psychiatric and chronic medical illness."

Table 1. Disability Mean Scores in Anxiety and Depressive Disorders
Legend for Chart:  B - No.   C - Work Score (± SD)   D - Social Score (± SD)  E - Family Score (± SD)
    A                                                   B              C
                                                           D              E
Major depression                              77         4.96 ± 2.46
                                                6.42 ± 2.21     5.63 ± 2.04
Panic disorder                                  21         4.29 ± 2.10
                                              5.88 ± 2.09     3.76 ± 2.67
Generalized anxiety disorder           65         3.97 ± 2.44
                                              4.41 ± 2.42      4.40 ± 2.39
Social phobia                                   30          3.83 ± 2.10
                                              5.67 ± 2.54      2.93 ± 2.26
Obsessive-compulsive disorder      14         5.29 ± 2.16
                                               5.58 ± 2.83    5.16 ± 2.61
Mixed anxiety disorder                   21         5.00 ± 2.41
                                               5.82 ± 2.32    5.95 ± 1.94
Comparison group                          29         0.86 ± 0.99
                                             1.97 ± 2.14     2.17 ± 2.18

All diagnostic groups differed significantly from the comparison group in work and social disability scores. All diagnostic groups except panic disorder and social phobia differed significantly from the comparison group in the family disability score. Social phobia was significantly different from major depression, obsessive-compulsive disorder, and mixed anxiety disorder; panic disorder was significantly different from major depression and mixed anxiety disorder; generalized anxiety disorder was significantly different from major depression.
SD = Standard deviation.

Table 2. Disabiliy Mean Score Across Studies for Subjects With Social Phobia and Panic Disorder
Legend for Chart:  B - Sheehan el al(n14) (International)   C - Davidson et al(n17)  D - Leon et al(n16) (CNCPS)
E - Kennedy et al (Current Study)

      A                     B       C        D       E
Social phobia
Work score         6.67    5.05     -       3.83
Social score       7.17    6.62     -       5.67
Family score       4.57    3.77     -       2.93

Panic disorder
Work score         5.42    -        4.83    4.29
Social score       6.14    -        6.13    5.88
Family score       5.18    -        4.32    3.76

CNCPS = Cross-National Collaborative Panic Study.
- Kennedy, Barbara L., Schwab, John J., Southern Medical Journal, Dec2002.
The article above contains foundational information. Articles below contain optional updates.

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Personal Reflection Exercise #5
The preceding section contained information about work, social, and family disabilities of subjects with anxiety and depression.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 19
What diagnostic group had the highest family disability score? Record the letter of the correct answer in the CEU Answer Booklet.

 
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The article above contains foundational information. Articles below contain optional updates.
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