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.These patients were more likely to have other psychiatric disorders and tobe functionally impaired.However, they made far fewer primary care visitsper year when compared with patients with other psychiatric disorders orwith controls.Their mental health utilization was at the same low level ofthe other psychiatric patients.Patients with social phobias had high rates ofsubstance abuse but seemed to be avoiding going to their primary carephysician for medical or for psychiatric care.Finally, using a systematic sample of over 1000 primary care attenders inthe same clinic, we found high rates of suicidal ideation in patients withpanic disorder, or panic attacks, with and without agoraphobia.If thepatient had both major depression and panic disorder, there was a 15-foldincreased risk of having suicidal ideation.Again, neither the panic attacks,the agoraphobia nor the suicidal ideation was diagnosed and most of thesepeople did not receive any psychiatric treatment [3].Major depression has been a focus of most physician education andscreening in primary care.Few studies have looked at the range ofpsychiatric disorders in patients coming to primary care.Few haveconcentrated on the phobias.These studies point out the need to broaden1New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, USA SOCIAL AND ECONOMIC BURDEN OF PHOBIAS: COMMENTARIES __________ 343both the screening and the physician education in primary care to includethe anxiety disorders and suggest that the presence of an anxiety disorderhas both mental and physical health consequences.The social cost and burden of the phobias is also evident in studies ofprepubertal children.There are now several epidemiologic [4 6] as well asclinical studies [6] showing that anxiety disorders, particularly phobias,before puberty are an early precursor of major depression.We have beenfollowing a group of depressed parents and normal controls and theiroffspring over 20 years.Now the third generation, the grandchildren, havebeen assessed.The major findings are strong familial aggregation of majordepression across three generations (mood disorders in the grandparentwere associated with mood disorder in the grandchildren, irrespective ofthe parental mood disorder), and the stability of the sequence of disordersspread across generations (specific phobias in childhood were followed bythe emergence of major depression in adolescence).This increased risk ofmajor depression, preceded by anxiety, was stable across three generationsin the high-risk sample.Few prepubertal children who are phobic, shy andfearful ever receive treatment.The symptoms are often interpreted as beingpart of one s character and not a treatable state.As more treatment, bothbehavioural and pharmacological, becomes available for these disorders inchildren, possibly intervention studies will be developed.These findingssuggest that the treatment of the phobic disorders in prepubertaladolescents could lead to the prevention of secondary depression.This isa hypothesis that has never been clinically tested.Demyttenaere et al.note quite correctly that the majority of research of thephobias is on the social phobia, also known as social anxiety disorder.Inaddition to the epidemiological and clinical studies, data showing the highfamilial loading of the social phobias over a three-fold increased risk infamilial aggregation [7] are also relevant to a discussion of burden.Themore generalized social phobias characterized by fear and avoidance in awide variety of social situations are specifically found in families.Based onthe evidence for familial loading as well as evidence for moderateheritability from twin studies [8], there has been increased interest inattempting to determine the role of genetics.However, this work is still inits infancy [9].REFERENCES1.Gross R., Gameroff M.J., Olfson M., Feder A., Weissman M.M.(2002) Bloodinjection injury phobia in primary care.Presented at the American PsychiatricAssociation Annual Meeting, Philadelphia, 18 23 May. 344 __________________________________________________________________________________________ PHOBIAS2.Gross R., Olfson M., Gameroff M.J., Feder A., Weissman M.M.(2001) Socialanxiety disorder in primary care.Presented at the American PsychiatricAssociation Annual Meeting, New Orleans, 5 10 May.3.Goodwin R., Olfson M., Feder A., Fuentes M., Pilowsky D.J., Weissman M.M.(2001) Panic and suicidal ideation in primary care.Depress.Anxiety, 14: 244 246.4.Kessler R.C., Nelson C.B., McGonagle K.A., Edlund M.J., Frank R.G., Leaf P.J.(1996) The epidemiology of co-occurring addictive and mental disorders:implications for prevention and service utilization.Am.J.Orthopsychiatry, 66:17 31.5.Pine D.S., Cohen P., Gurley D., Brook J., Ma Y.(1998) The risk for early-adulthood anxiety and depressive disorders in adolescents with anxiety anddepressive disorders.Arch.Gen.Psychiatry, 55: 56 64.6.Weissman M.M., Warner V., Wickramaratne P.J., Nomura Y., Merikangas K.,Bruder G., Tenke C.E., Grillon C.(2003) Offspring at high risk for anxiety anddepression: preliminary findings from a three generation study.In Fear andAnxiety: Benefits of Translational Research (Ed.J.Gorman).American PsychiatricAssociation Press, Washington, DC.7.Stein M.B., Chartier M.J., Hazen A.L., Kozak M.A., Tancer M.E., Lander S., FurerP., Chubaty D., Walker J.R.(1998) A direct interview family study of generalizedsocial phobia.Am.J.Psychiatry, 155: 90 97.8.Kendler K.S., Neale M.C., Kessler R.C., Heath A.C., Eaves L.J.(1992) The geneticepidemiology of phobias in women: the interrelationship of agoraphobia, socialphobia, situational phobia, and simple phobia.Arch.Gen.Psychiatry, 49: 273 281.9.Stein M.B., Chartier M.J., Kozak M.V., King N., Kennedy J.L.(1998) Geneticlinkage to the serotonin transporter protein and 5HT2A receptor genes excludedin generalized social phobia.Psychiatry Res., 81: 282 291.6.7Treatments Are Needed to Reduce the Burden of Phobic IllnessPeter P.Roy-Byrne and Wayne Katon1Demyttenaere et al. s review of the social and economic burden of phobiasdescribes the health service use and determinants of use, barriers toobtaining treatment, prevalence and type of functional disability, types andamounts of associated costs, and impairment in quality of life, across arange of phobic disorders.The conclusions of this review are strikinglysimilar to those described by previous authors for depression: phobias arecommon, disabling, costly and associated with multiple impairments inquality of life
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