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    Sn Social Anxiety Disorder and the Risk of Depression A Prospective Community Study of Adolescents and Young Adults Murray B. Stein, MD; Martina Fuetsch, MagRerNat; Nina Miller, DiplPsych; Michael Hofler, Diplstat; Roselind Lieb, PhD; Hans-Ulrich Wittchen, PhD Background: Social anxiety disorder (SAD) (also known, as “social phobia’) is frequently comorbid with major de- pression, and in such eases, almost always precedes it This has led to interest in SAD as a possible modifier of the risk and/or course of mood disorders. ‘Methods: Data come from a prospective, longitudinal epi- demiologic study of adolescents and young adults (aged 14-24 years) in Munich, Germany. Respondent diagnoses (N=2548) at baseline and follow-up (34-50 months later) are considered. The influence of SAD at baseline on the risk, ‘course, and characteristics of depressive disorders (ie, ma- jor depression or dysthymia) at follow-up is examined, Results: The baseline prevalence of SAD was 7.2% (05% confidence interval [CI], 6.19-8.4%). Social anxiety dis- order in nondepressed persons at baseline was associ- ‘ted with an increased likelihood (odds ratio [OR] =3.55, 95% Cl, 2.0-6.0) of depressive disorder onset during the follow-up period. Furthermore, comorbid SAD and de- pressive disorder at baseline was associated with a worse prognosis (compared with depressive disorder without comorbid SAD at baseline). This is exemplified by the greater likelihood of depressive disorder persistence oF recurrence (OR=2.3; 95% Cl, 1.2-+.6) and attempted sui- cide (OR=6.1; 95% Cl, 1.2-32.2) Conclusions: Social anxiety disorder during adoles- cence or young adulthood is an important predictor of subsequent depressive disorders. Moreover, the pres ence of comorbid SAD in adolescents who are already de- pressed is associated with a more malignant course and character of subsequent depressive illness. These find- {ings may inform targeted intervention efforts Arch Gen Psychiatry. 2001;58:251-256 From the Department of Psychiatry, University of ‘California San Diego, ad the Veterans Administration San Diego Healthcare System, Lalla, Calif (Dr Stein) and the Department of Clinical Paychology and Epidemiology ‘Max Planch Istitate of Psychiatry, Munich, Germany (ss Fuetsch and Mle, ‘Mr Hfler, and Drs Lich and Witchen), OCIAL ANSIETY disorder (SAD) (also known as “so cial phobia”) is a prevalent disorder with its onset al- most universally in child hood or adolescence." Recent estimates indicate that between 4% and 8% of adults in the general population suffer from SAD in a given year, with even higher rates when lifetime prevalence is consid- cred In a community study of adoles- centsand youngadults aged 14 to 24 years, from which the current report is derived, wwe found a lifetime prevalence of DSM-IV SAD of 9.5% in females and 4.9% in rmales."* Another characteristic feature of the longitudinal course of SAD, in addition to its early onset, sits frequent co-oceur- rence with depressive illness" Socialanxi- cy disorder s reported tobe the most com- monly occurring comorbid anxiety disor- der among patients with depressive disorders." Furthermore, when comorbid- ity does occur, SAD almost always tarts irs, often many years prior to the onset of de- pression." This consistent finding has (©2001 American Med jamanetwork.com/ on 12/19/2019 spurred interest inthe study of SAD asa pos- sible risk factor for major depression. ‘A possible link between social anxi- ety and earlier onset of major depression hasbeen reported in several studies." In a longitudinal study, anxiety disorders in early adolescence predicted clinically si nificant depressive and anxiety disorders (especially SAD) in early adulthood.** Fur- thermore, the association between eatly- onset (eg, prepubertal) anxiety and depres- sion in young adulthood is evident when looking at family patterns of transmission in depressive high-risk families" These observations have sparked interest in the possibilty that early identification of and intervention with socially anxious chil- dren or adolescents might reduce their risk for depressive disorders in later life" In this report, we examined data from the Early Developmental Stages of Psy- chopathology (EDSP) Study,* focusing on the longitudinal relationship between SAD and depressive disorders. We hypoth- esized that SAD at baseline would pr dict onset and severity of subsequent de pressive disorders, Association, All rights reserved. SUBJECTS AND METHODS SAMPLE Data were collected as part ofthe EDSP study. The EDSP tea prospective longitulinal study designed to collec data on the prevalence, sk factors, comorby and course of mental and substance use dsorders in a tepresentaive "simple which constted of 3021 subjects aged 14 24 yets baseline. The study consists of baseline (TO) survey, 2 follow-up surveys (1 and 72), and family history com- pnehe baseline sample was drawn in 1994 from govern- sent registries in metropolitan Munich, Germany ofr ‘rans expected tobe aged U4 to 24 years atthe ime of the baseline interview in 1995, Because the sty was de- Signed aa longltadnal panel with special ermpass om sty developmental tages of peychopathology, 14-10 13-yea- old individuals were sampled at twice the probablity of cope aged 16 to 21 yeas, and 22- to 24-year-old people {rere sampled at hall the probabiliy ofthe Loto 21-year old peopl individuals were contacted frst by letr, and then by telephone lo arrange a meting, Most interviews took place in the respondents homes of, in some instances, at an- other location preferred by the respondent, Approxt- tmately one third of the sample received «financial incen- tive (US $10-820) to participate. Pariipante provided informed consent; parental consent was provided for respondents aged 18 years and younger “The demographic disibution of the sampled popu- lation and the respondents has been reported clse- where" Briefly, among the sampled subject, a total of 3021 interviews were completed, resulting in a response rate of 70.8% At haseline, refusal to participate inthe st ‘ey (18.2%) was by far the most frequent reason for non- response, followed bya reported lack of tine (3%), all trewocontct anyone in the ented household 021%), ‘nd fallre to contact the sampled individual in the house™ iald (3.0%). “hers fllow-upsurvey was conducted only for sub- jects aged 14 to 17 yeas at baslin, whereas the second {ellowsup survey vas conducted foralloubjets. At the fest follow-up survey 141025 months alter baseline (tnean in- terval, 20 months; SD, 3 months), aot of 1228 interviews were completed, resuling in response rate of 88%, From the 3021 subjects ofthe baseline stuvey, a oa of 2548 tervews were completed a the second olow-up survey 34 {o30months afer baseline (ean duration 42 months SD, months), eulling in a response rte of 64%. A more de: ialed description of the study s presented elsewhere." or thove probands aged 14 to 17 years at baseline, the follow-up satus is asessed from the aggregation of formation obtained from the first an second follow-up i terviews For the probands older than 17 yearsal baseline, the follow-up stats is asesed from the the second st of follow-up qtestions, which refer tothe time between bas Tine and the second follow-up. DIAGNOSTIC ASSESSMENT The survey staff throughout the entire study period (In cluding the family history component ofthe stud) con- Sted 657 linia interviewer most of whom were clini Gal psychologists with extensive experience in daghostic imiervewing including the Munich-Composte Interna: tional Diagnostic Interview (M-CIDI) "At baseline, 23 professional health research interviewers recruited frm a urvey company were azo involved. Formal raining with the M-CIDI took place for 2 weck followed by at least 10 tlosely monitored practice interviews and additional 1-day booster sessions throughout the study “The M-CIDI allows forthe assessment of symptoms, syndromes, and diagnoses of 48 mental disorders, lon ‘with information about onset, dation, severity, and pay Chosocial impairment, Diagstlc ndings repored in this stele were obtained by using the M-CIDVBSMEIV dag- hostc algorithms, Test-retet reliability and validity for the fll M-CIDI have been reported elsewhere" song ‘with descriptions of the M-CIDI format and coding con- ‘Social ansetydlsorder defined here as one mesting DSM eneria pr the M-CIDI diagnose algorithm: De pressive donde is defined as one mestng DSM-IV eitera Torone or more epzodesofmajr depreseon or dythymia One-week test-retest reality of hese diagnostic catego- fies was aceplable al values, > 0.04," ae was thir a iniy (ec values ange, 0-54 for dysthymia to 096 for single depressive episodes). Descriptors ofthe course of depres sion (ep, nutmber of depresve episodes), which was aso —_ i dy (CHARACTERISTICS OF THE SAMPLE |AT BASELINE AND THE SECOND. FOLLOW-UP PERIOD Sociodemographic characteristics of the sample at base: line ate summarized in Fable 1. A total of 3021 cases ‘were available at baseline, with data from the second fol- low-up available for 2548 cases. PREVALENCE RATES AT BASELINE Baseline prevalence rates (lifetime and past 12 months) ‘of SAD and depressive disorder are presented in Table 2: 27.3% of eases with lifetime social phobia were ofthe gen cralized subtype. These disorders are categorized into 3 (©2001 American Med jamanetwork.com/ on 12/19/2019 mutually exclusive combinations (le, SAD without de- pressive disorder, depressive disorder without SAD, dé pressive disorder with SAD) to permit comparison oftheir longitudinal outcomes at follow-up. Depressive disor- ders (OR= 1.9; 95% Cl, 1.5-2.5) and SAD (OR=2.0; 05% Cl, 1.42.0) were more common in women than men; associations were therefore adjusted for sex. LIKELIHOOD OF DEPRESSION AT FOLLOW-UP Rates of depression during the period between baseline and the second follow-up are presented in Fable 3. Per- sons with SAD but no depression (current or previous) atbaseline were significantly more likely (OR=3.5; 05% 1, 20-60) than persons with no mental disorder to have experienced a depressive disorder during the follow-up period. This effect, however, could be detected only for Association, All rights reserved. derived from the M-CIDI, refer to the time between baseline and follow-up. Severity desriptors (ep, num ber of depressive symptoms) refer to the sell- ‘identified worst episode of depression during this in terval, The variable total duration of depression” was estimated in weeks by multiplying the number of de- pressive episodes by the duration of the longest de- pressive episode. The variable “suicidal ideas” refers {othe number of endorsed stems from a total of 4 pos- sibilities: (1) frequent thoughts of death, (2) desire fordeath, (3) suicidal thoughts, and (4) concrete sui- cidal plans of attempts STATISTICAL ANALYSES Data were weighted to conser diferent sampling prob Sli ested ar spc nonespone at nace The Stata Soltware=palage was used to comput o- bus confidence intra ey applying the Haber White sandvch matin th case of repression mod- cl) required whens analysesonvseighted snp sis, Logistic regressions wi ods ratio (OR) were ted to describe ssotations with onset and tabty ofespressive disorders, eeagnizing confounding it sbles such subjects ag, se, or bance abe dcpendence”" Wealso condaccd most amass ting the subsets (0600) who siflered fom alohol thie a tt drag sles or dopesonce aan tine point Thereslisof hese analyses didnot ilr mean Engl from those in ic the fll mp asi chided we have therefore eeced to eepot only re Suls for the fall sample- The quantitative outcomes of teeny odcpene oc conte ere (om ber of deprenive episodes) consti out variables witha strongly postvely skewed distribution. For this togules Baal premises vere ued wih ma Pllaive elect described by socalled incidence ac Fats IRR) Ge, the tr by which the mes dies from the onc inthe comparson group). Negative bi ttomalegresons db br ene Pekien vrai or verdispersion that likely to be awing to uncb- served hterogencitin the outcome between subjects ssvellascorelted eventsthator counted eg 3 toms)" and 9595 confidence intervals (C1) ate aed throughout ths are the older (ie, aged 18-24 years at baseline) (OR=5.3; 05% Cl, 1.6-3.8), but not the younger (ie, aged 14-17 years at baseline) subsample (OR=0.6; 95% Cl, 0.1-2.7). ‘A similar significant increase in odds (OR=3.8; 95% 1, 2.6-5.5) was seen for persons with depression but no SAD at baseline. Persons with depression and SAD (cur- rent or previous) at baseline were also at significantly am- plified odds for subsequent depression (OR=8.7;95% Cl, 4.5-16.8) compared with persons with no mental disor der at baseline. In persons with depressive disorder at base- line, SAD (current or previous) at baseline approxi- mately doubled the odds for subsequent (or persistent, as this might reflect a continuous episode from baseline to follow-up) depressive disorder (OR=2.3; 95% Cl, 12-46) ‘Among persons with SAD, age at onset of social anxi- ty symptoms (not disorder, which was unavailable)” was Table 1. Sociodemographic Characteristics of the Sample* Fgwatbasotne,y 1et7 921 (3048) 767 (80.11) 767 (20.11) 1e24 2100 (6252) 1780 (6089), 1780 (6.89) ga olon-upy W721 net 23.82) 961 (2282) 2m 1685 (65.18), 1685 (65.18) Sex Male 1493 (40.41) 1262 4057) 1262 (4057) Female 1528 (60.50) 284 (60.4) 1284 (0.43) Nara status Ward 103.40) 76,300) 1924758) Single 2577 (85.30) 2200 (86.41) 1826(71.71) With pare ‘ti (11.20) 270 (1060) 520 2076) igs educational eel mena school 428 (1415) 295 (1150) 280 (10.98) idle choo! 732 (2425) 600(23.00) 8653397) High school ooher 1861 (1.0) 16436451) 1402 (85.05) Professoral statis Unampojes 34(ia3) 140057) 30(117) Homarater eo(1t) 37 (148) 83,325) Suecolarworker 74/248) 60,235) 84,331) Prolssionlor white $24(1735) 429(1687)790(31.36) ‘alr Set-amployed or 205 (676) 171(665) 280 (10.08) coher Intvapprentie/ 1043 (3453) 990(35.08) 945 (37.11) susent 1002 (96.15) 944 (37.06) 326 1282) Ling situation With prots 1804 (6271) 1623,63.72) 1028 40.38) Withers than 442 (1462) 355 (1307) 065 (22.05), pares lone 635 2267) 568,221) 684 2567) Dat are presented as number (percentage 4, netes weighted Nave Standard oe ase sample Values have een rounded tthe newest whole umber Elipses inate ‘ot appabl Table 2. Baseline Lifetime and 12-Month Prevalence of Social Anulely Disorder and Depressive Disorder Inthe EDSP° Baseline Prevlenes = 2547) et eon ‘Asoc anesty 183 (7.17) (600-802) 195 6.2 [4255630] dearer depress 368 14d) (1253-1570) 189 (7.17 [6.11-8.40), deorder Sov amiety 110 (465) (382567) 97 (380 (308-474) ‘deorde nou depressive ‘deorder Depressive disorder 204 (1158) [10.16 1806 145 (5.69) [47-678 “iho eae nt sort Depressive disorder 64 (251) (1.86897) 38 1.49 [099.210] "ith sci any ‘dearer ~ Data are resened as weighted number (weg percentage) 35% condence eral Depress dare inca 4 major depressive episode ‘rym: EDSP Fay Development Stages of Pjchopaolay tua. lation, All rights reserved. found to predict neither depressive disorder onset (OR=1L.1 (95% C1, 0.9-1.2) nor persistence or recurrence (OR= 1.0; 95% CL, 0.9-1.1), OTHER ANXIETY DISORDERS Specificity ofthe elfects attributable to SAD (vis-t-vis other anxiety disorders) in predicting onset and recurrence or persistence of depressive disorder was not high. Other anxi- ‘ety disorders (specific phobias and generalized anxiety dis- ‘order in particular) at baseline were also associated with, similarly increased odds (data not shown). We therefore ‘examined the possibility that the associations we had linked, LoSAD might be due to comorbidity with other anxiety dis- ‘orders. Analyses were repeated where SAD groups were stratified for the presence or absence of at least one other ‘comorbid anxiety disorderat baseline, The association with, the onset of depressive disorder was somewhat higher in ‘eases with SAD plus another comorbid anxiety disorder (OR=6.0; 95% Cl, 2.6-13.3) than in eases with SAD alone (OR=2.4;05% Cl, 12-49), though not significantly so. No, appreciable difference in association was found forthe per- sistence of recurrence of depressive disorder in cases with SAD alone (OR=7.7; 95% Cl, 2.5-23.7) compared with SAD plusanother comorbid anxiety disorder (OR=9.2;05% Cl, 42-199) CLINICAL CHARACTERISTICS AND COURSE OF DEPRESSIVE DISORDER AT FOLLOW-UP. Several clinical characteristics and descriptors ofthe course ‘of depressive illness during the follow-up period were com- pared between groups (fable 4). Compared with pet sons with no mental disorder at baseline, there were few significant differences in these parameters for persons with either a depressive disorder alone or SAD alone at base- line. The sole exception was a small but statistically sig- nificant increase in the severity of depression (as in ‘Table 3, Depressive Disorder Status at Follow-up by Mo Depressive iso Baseline Dlagnste status Ho.) onesent Tomer order Tee 01.) Socal aly disorder witht depressive ort 90 7621) 2312370) 352080) Depressive dearer without ol arty ort 220 7489) 7402511) 48/2685) Depressive dearer with eo anit deader 36 (6507) 28 (48.93) a7asiea) Depress corer with social alt esorder 231240) "ve dares order wiou oll antl esarger lintel and elipses, ot potable {Logit egesions and odd rales were aduste or sex and age eet congusons. “Munber and percentage of nial were weghed. Depressive soa aetes a major depressive epsodeordstymi OR, adds aa, Cl, conaence ‘omental sore indetes an ads Ring no agra at ase, ot considering noe dependence. Tish elerence group used for ‘Table 4, Solectod Description of Course of Depression During Follow-up lod by Baseline Diagnostic Status” sutanyt sultat Atty Depressive symplomss leauaea mmemen PT Baseline Dlagnoste status Kreanonmy oxen P| Two.e) onooncy Peon cmmpisocn omental disorder oa ae18) 1020 Socal sncety disorder without dpreseve 008 (1.1)(0619) <8 34025) | 26 (04182) s214(12) (10-15) ‘ieorder™ Depressive sore witout socal anviey 0.96 (1.0)(07-15] <8 34487) 11(03.40) 1265(12) [11-14] ‘ieorder Depressive dearer with coclamsiety 1.9822) (14-24) <001 6(1076) 7.0(15222) 1455(14 (1247) <001 ‘herder ennss

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