Diagnostic Comorbidity in Adults With Generalized Anxiety Disorder: Impact of Comorbidity on Psychotherapy Outcome and Impact of Psychotherapy on Comorbid Diagnoses
Open accessAbstract
The current study examined the impact of comorbidity on cognitive and behavioral therapies for generalized anxiety disorder (GAD) as well as the impact of these therapies on diagnoses comorbid to GAD. Seventy-six treatment-seeking adults with principal diagnoses of GAD received 14 sessions of therapy. Most (n=46; 60.5%) of the sample had at least one comorbid diagnosis. Although the presence of comorbid diagnoses was associated with greater severity of GAD symptoms at pretreatment, greater severity of comorbid major depression, simple phobia, and social phobia was associated with greater change in symptoms of GAD in response to treatment, with no effect on maintenance of gains during a 2-year follow-up. Further, psychotherapy for principal GAD led to a reduction in number of comorbid diagnoses and in severity of social phobia, simple phobia, and major depression at posttreatment. At 2-year follow-up severity of social and simple phobia remained below pretreatment levels, whereas severity of depression was no longer significantly below pretreatment levels. These results suggest that although people with comorbid disorders enter treatment with more severe GAD symptomatology, they demonstrate greater change, and therefore such comorbidity does not diminish the efficacy of cognitive and behavioral therapies for GAD. In addition, the impact of these treatments for GAD may generalize to reduced severity of simple phobia, social phobia, and major depression; however, gains in severity of major depression are not maintained.
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When generalized anxiety disorder and major depressive disorder co-occur, subjective distress and functional impairment may be greater and treatment response may be worse.
“When co-occurring, the subjective distress and functional impairment may be even larger, and the treatment response worse (Farabaugh et al., 2012; Newman, Przeworski, Fisher, & Borkovec, 2010; Olatunji, Cisler, & Deacon, 2010).”
From Changes in Decentering and Reappraisal Temporally Precede Symptom Reduction During Emotion Regulation Therapy for Generalized Anxiety Disorder With and Without Co-Occurring Depression. (2019) · cites this paper as Newman et al., 2010
The Abstract links GAD comorbidity generally to greater severity and disability, but the paper's psychotherapy findings contradict the claim of worse treatment response. The Discussion reports that participants with comorbid MDD showed greater improvement in GAD symptoms and reached comparable posttreatment symptom levels to those without comorbidity. (LLM, conf=0.88)
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Experimental — accuracy not yet measuredThe presence of comorbidity between GAD and depression predicts poorer therapeutic outcomes.
“Unfortunately, the presence of this comorbidity predicts poorer therapeutic outcomes (Van Balkom et al., 2008; Newman et al., 2010; Coplan et al., 2015).”
From A Multiple-Baseline Evaluation of Acceptance and Commitment Therapy Focused on Repetitive Negative Thinking for Comorbid Generalized Anxiety Disorder and Depression (2020) · cites this paper as Newman et al., 2010
The Discussion (page unavailable) reports that pretreatment comorbidity, including major depressive disorder, did not worsen GAD psychotherapy outcomes: those clients improved more and reached comparable symptom levels. Although the paper recounts an earlier study finding poorer responsiveness with comorbid depression, it describes the prior evidence as equivocal and its own results point the other way. (LLM, conf=0.89)
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Experimental — accuracy not yet measuredCBT for generalized anxiety disorder also shows strong efficacy for comorbid anxiety and depressive disorders.
“CBT for GAD also has shown strong efficacy for comorbid anxiety and depressive disorders [10,12].”
From Psychotherapeutic treatments for generalized anxiety disorder: cognitive and behavioral therapies, enhancement strategies, and emerging efforts (2022) · cites this paper as [12]
The Abstract and Discussion report posttreatment reductions in comorbid social phobia, simple phobia, and major depression after cognitive and behavioral therapies for GAD. Calling this strong efficacy for comorbid anxiety and depressive disorders is broader than the findings: the study excluded clinical panic disorder and very severe depression, and depression gains were not maintained at two years. (LLM, conf=0.86)
Experimental — accuracy not yet measuredGAD and conceptually related conditions lag behind in treatment efficacy compared to other anxiety and mood disorders, make otherwise efficacious interventions for MDD refractory, and are associated with difficulties maintaining durability of comorbid MDD gains over the long term.
“GAD, and conceptually related conditions (e.g., MDD with anxious apprehensive features) lag behind in treatment efficacy compared to other anxiety and mood disorders6, makes otherwise efficacious interventions for MDD refractory7, and are associated with notable difficulties in maintaining durability of comorbid MDD gains over the long term8.”
From AN OPEN TRIAL OF EMOTION REGULATION THERAPY FOR GENERALIZED ANXIETY DISORDER AND COOCCURRING DEPRESSION. (2015) · cites this paper as [8]
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Experimental — accuracy not yet measuredGAD and MDD, particularly when comorbid, respond less well to long-term treatment than other anxiety and mood disorders and have worse long-term outcomes.
“GAD and MDD, especially when comorbid, are significantly less responsive to treatment in the long term than other anxiety and mood disorders and overall have inferior long-term treatment outcomes (e.g., Newman, Przeworski, Fisher, & Borkovec, 2010).”
From A Pilot Study of Emotion Regulation Therapy for Generalized Anxiety and Depression: Findings From a Diverse Sample of Young Adults. (2018) · cites this paper as Newman, Przeworski, Fisher, & Borkovec, 2010
The Discussion reports that improvement in comorbid MDD was not maintained at the two-year follow-up, whereas improvements in simple and social phobia remained below baseline. But the Results found no significant difference between participants with and without pretreatment comorbidity in maintaining GAD treatment gains. The paper does not establish that comorbid GAD and MDD are generally less responsive than other anxiety and mood disorders. (LLM, conf=0.88)
Experimental — accuracy not yet measured
The presence of comorbid GAD and depression has predicted poorer therapeutic outcomes using psychotropic medication and psychological therapy.
“Importantly, the presence of comorbid GAD and depression has predicted poorer therapeutic outcomes using psychotropic medication (Van Balkom et al., 2008) and psychological therapy (Newman et al., 2010; Coplan et al., 2015).”
From A Multiple-Baseline Evaluation of Acceptance and Commitment Therapy Focused on Repetitive Negative Thinking for Comorbid Generalized Anxiety Disorder and Depression (2020) · cites this paper as Newman et al., 2010
The paper reports that comorbid major depression predicted reduced responsiveness to brief psychodynamic or supportive therapy in an earlier study (background passage labelled Abstract; page unavailable). But it calls the psychotherapy evidence equivocal, and its own Discussion reports greater improvement in GAD symptoms among patients with comorbidity, including depression. Newman et al. therefore supports the narrower observation that poorer outcomes have been reported for some therapies, not an unqualified claim about psychological therapy generally. The medication finding is cited to Van Balkom et al., not Newman et al. (LLM, conf=0.86)
Experimental — accuracy not yet measuredGAD trials that used patient samples without prominent depression have tended to report that effect sizes for depressive outcomes were small or diminished to pre-treatment levels in follow-up.
“many of these trials utilized samples of GAD patients without prominent MDD or depression68–70 and, in some instances, found that effect sizes for depression outcomes were small or diminished to pre-treatment levels in the follow-up period8.”
From AN OPEN TRIAL OF EMOTION REGULATION THERAPY FOR GENERALIZED ANXIETY DISORDER AND COOCCURRING DEPRESSION. (2015) · cites this paper as [8]
There is less evidence that associated symptoms and conditions such as MDD are fully ameliorated by traditional CBT for GAD, especially in the longer term.
“there is less evidence that associated symptoms and conditions such as MDD are fully ameliorated, especially in the longer term (Newman et al., 2010).”
From A Pilot Study of Emotion Regulation Therapy for Generalized Anxiety and Depression: Findings From a Diverse Sample of Young Adults. (2018) · cites this paper as Newman et al., 2010
Distress disorders, particularly when they co-occur, often fail to make sufficient treatment gains, prolonging deficits in life functioning and satisfaction.
“These disorders, particularly when they co-occur, often fail to make sufficient treatment gains thereby prolonging their deficits in life functioning and satisfaction.”
From Emotion Regulation Therapy: A Mechanism-Targeted Treatment for Disorders of Distress (2017) · cites this paper as Newman et al., 2010
When GAD is comorbid with MDD, patients demonstrate suboptimal durability of their depression treatment gains.
“Also, when GAD is comorbid with MDD, patients demonstrate suboptimal durability of their depression treatment gains (Newman et al., 2010).”
From Emotion Regulation Therapy: A Mechanism-Targeted Treatment for Disorders of Distress (2017) · cites this paper as Newman et al., 2010
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References 56 · Cited by 112
Research works printed but not linked: 2
- Clarke P O’Campo P Wheaton B Data sparseness in contextual population health research: Effects of small group size and cluster analysis on linear and nonlinear multilevel models Proceedings of Statistics Canada Symposium: Methodological Issues in Measuring Population Health Ottawa: Canada 2006, March Retrieved July 21, 2008, from http://www.statcan.ca/english/freepub/11-522-XIE/11-522-XIE2006001.htm
- Crits-Christoph P Gibbons MBC Losardo D Narducci J Schamberger M Gallop R Who benefits from brief psychodynamic therapy for generalized anxiety disorder? Canadian Journal of Psychoanalysis 2004 12 301 324
- Authors
- Newman, M. G., Przeworski, A., Fisher, A. J., & Borkovec, T. D.
- Affiliations
- Pennsylvania State University (US)
- Corresponding author
- Newman, Michelle G.
- Venue
- Behavior Therapy
- Publisher
- Elsevier BV
- Published
- 2010-03
- Volume
- 41
- Issue
- 1
- Pages
- 59-72
- ISSN
- 0005-7894 (ISSN-L)
- PMC
- PMC2827339
- OpenAlex
- W2056849293
- Cited by
- 112
- References
- 56
- Citations by year
- 2026: 3 · 2025: 4 · 2024: 4 · 2023: 5 · 2022: 5 · 2021: 8 · 2020: 9 · 2019: 5 · 2018: 2 · 2017: 8 · 2016: 6 · 2015: 11 · 2014: 9 · 2013: 13 · 2012: 6
- FWCI
- 8.46
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Behavior Therapy (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- ScholarSphere (Penn State Libraries) (submittedVersion, cc-by)
- SSRN Electronic Journal (submittedVersion)
- Funders
- National Institute of Mental Health (R01MH039172)
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Social Sciences › Psychology › Clinical Psychology › Psychological Treatments and Assessments
- Keywords
- generalized anxiety disorder, comorbidities, psychotherapy outcome, cognitive behavioral therapy, major depressive disorder, specific phobia, social anxiety disorder, symptom severity, maintenance of treatment gains, adults
- MeSH terms
- Adult, Anxiety Disorders, Mental Disorders, Depressive Disorder, Major, Major Depressive Disorder, Female, Follow-Up Studies, Humans, Male, Phobic Disorders, Psychiatric Status Rating Scales, Psychotherapy, Time Factors, Comorbidity
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