Anxiety and the Risk of Death in Older Men and Women

BRITISH JOURNAL OF PSYCHIATRY (2004), 185, 399^404

Anxiety and the risk of death in older men sample was pre-stratified by age and gender. The older age strata and men were and women oversampled in anticipation of higher attrition rates during the course of the study. Owing to initial non-response (nn¼698) andand698) HEIN P. J. VAN HOUT, AARTJAN T. F. BEEKMAN, EDWIN DE BEURS, item non-response (nn¼51), 3056 persons HANNIE COMIJS, HARM VAN MARWIJK, MARTEN DE HAAN, were interviewed at baseline. These partici- WILLEM VAN TILBURG and DORLY J. H. DEEG pants gave their informed consent and agreed to be interviewed in their homes. Of the non-responders, 126 had died before approach; 44 could not be contacted, 134 were too ill or cognitively impaired to be Background There are inconsistent Although the elevated mortality risk in interviewed, and 394 were unwilling to reportsastowhetherpeoplewithreports astowhetherpeoplewithanxiety anxiety depression is well established (Cuijpers, participate (Van Exel et aletal, 2000).,2000). 2001), comparable studies of the risks of Participants with anxiety disorders disorders have a higher mortality risk. anxiety are sparse and inconsistent (Coryell were identified using a two-stage screening Aims ToTodetermine determine whether anxiety et aletal, 1986; Johnson et aletal, 1990; Weissman design (Duncan-Jones & Henderson, et aletal, 1990; Allgulander & Lavori, 1991; 1978). The Center for Epidemiological disorders predict mortality in older men HerrmannHerrmann et aletal, 2000; Warshaw et aletal,, Studies Depression Scale (CES–D; Radloff, and womenwomeninthe in the community. 2000; Joukamaa et aletal, 2001). An explana- 1977) was used as the screening instrument, tion for the inconsistency of reported using the generally recommended cut-off MethodMethod Longitudinal data were used mortality risks of patients with anxiety dis- score of 16 or over. This scale was found from a large, community-based random orders may be the failure to control for the to be a good screen for both anxiety and sample ((sample nn¼3107) ofoldermen andwomen effects of comorbid depression, socio- depression (sensitivity 0.79). The second (55^85 years) inThe Netherlands, with a economic status and unhealthy lifestyles in stage of case-finding involved a diagnostic some studies. These variables are related interview, held 2–8 weeks after the first follow-up period of 7.5 years. Anxiety both to anxiety disorders and to subsequent LASA assessment, with everyone who disorders were assessed according to mortality, and may cause spurious relation- screened positive and an equally large DSM ^ III criteria in a two-stage screening ships between anxiety and mortality (Honig random subsample of participants who design.design. et aletal, 1992; Lasser et aletal, 2000).,2000). screened negative. The response at this The main objective of this study was to stage was 86.0% and attrition was related ResultsResults In men, the adjusted mortality determine whether anxiety disorders to age but not to gender, leaving a study risk was1.78 (95% CI1.01^3.13) in cases predict mortality in older people in the sample of 659 persons interviewed, of with diagnosed anxiety disorders at community. Subsidiary objectives were to whom 332 were ‘screen positives’ and 327 filter out the effect of comorbid depression, ‘screen negatives’ (Beekman et aletal, 1995,1995bb).). baseline.In women, no significant to compare men and women, and to Informed consent was obtained from associationwasfoundwithmortality.association was found with mortality. explore the effects of potential explanatory everyone who participated in the study. (lifestyle) and confounding variables. Participants were interviewed in their Conclusions The study revealed a homes by well-trained and intensively gender difference in the association supervised interviewers. These interviewers between anxiety and mortality.For men, METHOD were trained to conduct only the baseline butnotforbut notfor women, anincreasedmortalityanincreased mortality assessment or the diagnostic interview, Design and sample ensuring that no participant was inter- risk was found for anxiety disorders. Data were collected in the context of the viewed by the same person twice. Declaration of interest None.None. Longitudinal Aging Study Amsterdam (LASA). This is an ongoing longitudinal Measurements research effort on determinants and consequences of changes in well-being and Psychopathology autonomy in older people. The analyses Both anxiety disorders and comorbid major were based on the data of 659 indepen- depressive disorder were defined according dently living community residents. Data to DSM–III criteria (American Psychiatric collection procedures and response have Association, 1980) and assessed by means been described in more detail elsewhere of the Diagnostic Interview Schedule (DIS; (Beekman(Beekman et aletal, 1995,1995aa; Geerlings;Geerlings et aletal,, RobinsRobins et aletal, 1981). In this study four 2000). In short, a random sample was anxiety disorders were assessed: phobic, drawn from the population registers of panic, generalised anxiety and obsessive– 11 municipalities in three geographic areas compulsive disorders. The analyses were in The Netherlands. At baseline 3805 based on anxiety disorders and major residents, aged 55–85 years, were depression experienced in the 6 months approached to participate in the study. This prior to interview.

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Death 1000 person-years were calculated and comorbid depression; men suffered Death certificates were traced through the according to anxiety status. When the more from cardiac diseases, stroke and registries of the municipalities in which 95% confidence intervals of the hazard chronic obstructive pulmonary disease; the respondents were registered. Vital ratio did not include the value 1, the associ- considerably more men smoked than status ascertainment was complete. All ation was considered to be statistically women.women. deaths were recorded that occurred significant.significant. Compared with the non-anxious group, between the baseline interview (September Cox proportional hazard regression people with an anxiety disorder were older, 1992 to September 1993) and 1 January models were used to examine the associ- more likely to be female, less likely to be 2000. The average follow-up period lasted ation between anxiety disorders and time married, more often living in urban areas, 7.5 years (s.d.¼0.3).0.3). to death in men and women and with ad- had lower socio-economic status, suffered justment of the explanatory (lifestyle) and more from chronic physical illnesses and confounding variables (age, disease, disabil- were less physically active. The number of Covariates ity, cognition). We explored potential effect anxious persons treated by a psychiatrist Potential explanatory variables included modification of the relation between anxi- or psychotropic medication was low (Table the lifestyle variables smoking, drinking, ety and mortality by the socio-demo- 1). Women with anxiety disorder were body mass index and physical activity graphic, comorbid depression, physical more likely to be treated at follow-up than (walking, cycling, light and heavy house- morbidity, physical disability, cognitive men.men. hold activities, and sports; Visser et aletal,, functioning and lifestyle variables, by inter- After 7.5 years, in total 199 (30.2%) 1997).1997). actions in Cox survival models. For the persons had died. Of the men, 110 Potentially confounding or effect- same variables we checked whether these (39.4%) had died compared with 89 modifying variables, assessed at the study confounded the relation between mortality (23.4%) of the women. Univariate analyses baseline, included demographic characteris- and anxiety. Significant interaction was between mortality and socio-demographic tics (age, gender, socio-economic status, only found between gender, anxiety and characteristics, chronic diseases, lifestyle marital status and urbanisation). As a mortality. The survival curve for men and the anxiety screening score at baseline measure of socio-economic status we used showed a positive association between revealed significant associations on all vari- a weighted score composed of level of anxiety and mortality rate, whereas for ables except for urbanisation and arthritis. education, occupation and income (range women it did not. We therefore present This indicates that the association between 0–100) (van Tilburg et aletal, 1995; Visser etet the outcomes separately for men and anxiety and mortality may be confounded alal, 1997). Psychiatric treatment status was women. Also the confounders were by several variables. measured and concerned contacts with a analysed separately for men and women. Table 2 shows the number of cases of psychiatrist or psychological and appropri- Additional sensitivity analyses were anxiety, the number deceased, the number ate psychotropic medication. An earlier performed to investigate whether the effects of person-years and the mortality rate at account described the treatment rates (de were maintained when controlling for 7.5-year follow-up. The unadjusted mortal- BeursBeurs et aletal, 1999). Functional limitations depression (both for depressive disorder ity rates suggest that the mortality risk is (restrictions in performing daily physical and depressive symptoms) and for ongoing (slightly) elevated in respondents with an activities) were measured using an adap- psychiatric treatment. anxiety disorder. There was a substantial tation of an Organisation for Economic difference between men and women. The Co-operation and Development (OECD) gendergender66anxiety interaction term in the questionnaire (van Sonsbeek, 1988). Cogni- RESULTSRESULTS age-adjusted model was found to be statis- tive functioning was assessed with the tically significant (Wald test 6.3, d.f.¼1,1, Characteristics of the sample Mini-Mental State Examination (Folstein PP¼0.04).0.04). et aletal, 1975). Chronic physical diseases were The mean age of the 659 respondents was assessed in detail, including cardiac 70.6 years; 380 (57.6%) were women. In Anxiety disorder and mortality diseases, arteriosclerosis, stroke (excluding the study sample 112 (17.0%) had an transient ischaemic attacks), diabetes melli- anxiety disorder. Nineteen persons (3.1%) Three (potential) confounders were found, tus, cancer, lung diseases (chronic obstruc- had more than one anxiety disorder and and these were similar for men and women: tive pulmonary disease) and arthritis. 29 (4.4%) had both anxiety and depressive age, functional limitations and the number Other chronic diseases were assessed in less disorders. Generalised anxiety disorder was of chronic diseases. Neither the chronic dis- detail. The validity of the instrument was present in the previous 6 months in 77 eases alone nor cognitive impairment supported in a previous study by cross- persons, panic disorder in 16 persons, affected the relationship between anxiety checking responses with the respondents’ phobia in 36 persons and obsessive– and mortality. In our sample, 26% of general practitioners (Kriegsman et aletal,, compulsive disorder in 9 persons (all 9 were people with an anxiety disorder also met 1996; Visser et aletal, 1997).,1997). women) (Table 1). Extrapolation of the 6- criteria for major depression. In men month prevalence of anxiety disorders to 14.7% of the patients with anxiety disorder the entire LASA study sample yielded an had comorbid depression compared with Statistical analyses estimated prevalence of 10.2% (Beekman 31.2% in women. However, adjustment The socio-demographic, morbidity, treat- et aletal, 1998). The baseline characteristics for baseline depression did not change the ment status and lifestyle characteristics of differed between men and women on mortality risk of anxiety. survivors and deceased were compared by several variables. Notably more women Activity level was the only explanatory means ofmeansof ww22 oror tt-tests. Mortality rates per than men suffered from anxiety disorders variable that substantially changed the

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Ta b l e 11Tab Baseline characteristics and anxiety disorders among men and women (unweighted percentages; magnitude of the relation between anxiety nn¼659)659) and mortality; smoking, drinking and body mass index hardly affected it (Table 3). Adjustment for ongoing treatment status Men (nn¼279)279)Women (nn¼380)Difference had no effect on the hazard ratios. Anxiety disorder, nn (%) Finally, in the fully adjusted model, Any anxiety disorder past 6 months35 (12.5) 77 (20.3)77(20.3) ww22¼6.8** anxiety disorders had a hazard ratio for Generalised anxiety disorder 24 (8.6)(8.6)24 53 (14.1) ww22¼4.2*4.2* subsequent mortality in men of 1.78 (95% Panic disorder 3 (1.1) 13 (3.4)(3.4)13 ww22¼3.73.7 CI 1.01–3.13) and in women of 0.89 Phobia 12 (4.3)24 (6.3) ww22¼1.2 (95% CI 0.51–1.56) (Table 3). The survival curves according to the adjusted Cox model OCDOCD 0 9(2.4)9 (2.4) ww22¼6.6** are shown in Fig. 1 for men and in Fig. 2 for More than one anxiety disorder 3 (1.1) 16 (4.2)(4.2)16 ww22¼8.9, d.f.d.f.8.9, ¼3** women.women. Comorbid depressive disorder, nn (%) 5 (1.8) 24 (6.3)(6.3)24 ww22¼10.2** Psychiatric treatment, nn (%) 8 (2.9)8(2.9) 11 (2.9)(2.9)11 ww22¼0.001 Psychotropic medication, nn (%) 11 (3.9) 26 (6.8)26(6.8) ww22¼5.2* DISCUSSION Sociodemographic factors Age, years: mean (s.d.) 70.9 (8.8)70.5 (8.7) tt¼1,21,2 An association between anxiety disorders Socio-economic status score: mean (s.d.)36.7 (18.8)31.1 (19.2) tt¼8.1*** and subsequent mortality was found for Married, nn (%) 187 (67)165 (43.4) ww22¼201***201*** men only. Older men with diagnosed Urbanised(livedinAmsterdan),Urbanised (lived in Amsterdan), nn (%)83 (29.7)122 (32.1) ww22¼0.4 anxiety disorders had 87% higher risk of Morbidity,Morbidity, nn (%) mortality over 7 years of follow-up. The Any chronic disease 166 (59.5)(59.5)166 260 (68.4)(68.4)260 ww22¼8.7, d.f.¼2* associations between anxiety and mortality Cardiac diseases 84 (30.1) 64 (16.8)64(16.8) ww22¼41***41*** in men remained after adjustment for comorbid depression, the explanatory vari- Peripheral arteriosclerosis 36 (12.8) 45 (11.8)45(11.8) ww22¼0.3 ables (activity, smoking, drinking, body Stroke 21 (7.5)(7.5)21 22 (5.8)22(5.8) ww22¼11.1**11.1** mass index) and confounders (age, psy- Diabetes 18 (6.4) 39 (10.3)(10.3)39 ww22¼1.3 chiatric treatment, functional limitations COPD 46 (16.4) 46 (12.1)46(12.1) ww22¼7.5** and chronic diseases, including heart dis- 22 Cancer 25 (9)25(9)46 (12.1) ww ¼19.7*** ease and stroke). In women with anxiety 22 Osteoarthritis 68 (24.4)68(24.4)179 (47.1) ww ¼133***133*** disorders no association was found with Rheumatoid arthritis 15 (5.3)33 (8.7) ww22¼25***25*** subsequent mortality. MMSEMMSE ScoreScore 5524,24, nn (%) 27 (9.6)44 (11.6) ww22¼1.7 Mean score (s.d.) 26.9 (3) 26.9 (3)(3)26.9 tt¼0.4 Explanations Functional limitations11 Several plausible mechanisms for the link Mean score (s.d.) 1.1 (2)1.8 (2.6) tt¼778.6*** between affective disorders and mortality No difficulties, nn (%) 159 (57.0)175 (46.5) ww22¼65, d.f.¼2*** exist, of which pathophysiological and 1^2 difficulties, nn (%) 52 (18.6)70 (18.6) behavioural explanations are the most 442 difficulties, nn (%) 66 (23.7) 131 (34.8)(34.8)131 important. Physiological alterations have Lifestyle been described which include impairment BMI, kg/mkg/mBMI, 22::mean(s.d.) mean (s.d.) 22.6 (2.9)(2.9)22.6 22.2 (3.7)(3.7)22.2 tt¼772.8** of platelet function and decreased heart Physical activity22 rate variability as a consequence of an imbalance in the autonomic tone (Kawachi Score: mean (s.d.) 3.4 (1.4)3.4 (1.5) tt¼0.3 et aletal, 1995; Musselman et aletal, 1998). Also, Low,Low, nn (%) 31 (11.2)(11.2)31 48 (12.7)48(12.7) ww22¼3, d.f.¼22 immune activation and hypercortisolaemia Moderate,Moderate, nn (%) 106 (38.4)(38.4)106 145 (38.3) as stress responses may result in decreased High, nn (%) 139 (50.4)186 (49.1) insulin resistance and increased steroid pro- Alcohol consumption, nn (%) duction and blood pressure, thereby in- 22 Never 52 (18.7)123 (32.5) ww ¼235***, creasing the risk of cardiac disease Daily 45 (16.2)45(16.2)116 (30.7) d.f.¼33 (Musselman et aletal, 1998). However, these 1^6 days a week 77 (27.7)77(27.7) 76 (20.1)(20.1)76 studies investigated people with affective 551^3 days a month 104 (37.4)63 (16.7) disorders, thus combining anxiety and Currently smoking, nn (%) 103 (39.1)66 (17.4) ww22¼94***94*** depressive disorders. We are not aware of any pathophysiological study on specific BMI, body mass index; COPD, chronic obstructive pulmonary disease; MMSE, Mini-Mental State Examination; OCD, obsessive^compulsive disorder. anxiety disorders. It is likely that anxious 1. Ability to perform basic physical actions used in daily living. people are less compliant with treatment 2. Range 0^50 ^5 sum score of walking, bicycling, household activities (light and heavy), sports; 0^1low,0 ^1 low, 2^3 moderate, 4^5high.4^5high. recommendations and are less willing to **PP550.05, **PP550.01, ***PP550.001.0.001. exercise and eat healthily, which may partly explain our results (DiMatteo et aletal, 2000).,2000).

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Ta b l e 2 Anxiety cases, number of deceased, person-years and mortality rate at 7.5-year follow-up

TotalTotal Cases DeathsDeaths Person-yearsMortality rate per nn nn nn 1000 person-years11 (95% CI)CI)(95%

All participants 659 No anxiety disorder 547164 3170 51.7 (44.1^60.3) Anxiety disorder 11235 626 55.9 (38.9^77.8) Men 279 No anxiety disorder 244 93931350 68.9 (55.6^84.4) Anxiety disorder 3517 161 105.6 (61.5^169.1) Women 380380 No anxiety disorder 303 7171 1820182040.7 (31.9^51.0) Anxiety disorder 7718 465 38.7 (22.9^61.2)

1. (Deaths/person-years)661000.1000. Fig. 11Fig. Cumulative mortality rate for men with an anxiety disorder (grey line) and without an anxiety disorder (black line), based on fully adjusted Cox Ta b l e 3 Mortality risks for men and women with or without anxiety disorders at baseline hazard models.

Total 22 Crude hazard ratio Adjusted hazard ratio11 nn Ratio (95% CI) Ratio (95% CI)

Men 1. No anxiety disorder 222Reference Anxiety disorder 311.65 (0.98^2.78)1.78 (1.01^3.13)* 2. Anxiety or depressive disorder 421.77 (1.10^2.83)*2.41 (1.36^4.25)* 3. Anxiety and depressive disorders4^ 4 ^ 33 ^^ 33 Women 1. No anxiety disorder 297Reference Anxiety disorder 761.00 (0.59^1.71)0.89 (0.51^1.56) 2. Anxiety or depressive disorder 960.95 (0.58^1.56)0.63 (0.31^1.28) 3. Anxiety and depressive disorders24 1.73 (0.84^3.60)2.93 (0.81^10.61)

1. Adjusted for age, physical limitations, physical activity, number of chronic diseases, ever smoked, alcohol, body mass index and comorbid depressive disorder (the last not in 2 and 3). 2. Totals differ betweenTables 2 and 3 owing to missing data on one of the covariates in the model. 3. Number too small for reliable analysis. **PP550.05.

Fig. 22Fig. Cumulative mortality rate for women with A possible explanation for the gender by suicide than their female counterparts. an anxiety disorder (grey line) and without an anxi- difference is that men have more cardio- However, causes of death were studied in ety disorder (black line), based on fully adjusted Cox vascular disorders, the course of which our sample in an earlier account, but hazard models. could be affected more strongly by co- suicide did not explain the excess mortality morbid anxiety. A psychological explana- (Penninx(Penninx et aletal, 1999).,1999). tion might be that men are less capable of dealing with feelings of anxiety and hope- et aletal, 2001), the authors were unable to find lessness than women. Women are more in- Earlier studies significant associations between phobias clined to discuss such feelings with others, The (weighted) prevalence of anxiety dis- and mortality rate. In an earlier study are more open to accepting support from orders in our study is comparable with among in-patients with anxiety disorders others, and may therefore be better able other community-based studies among the excess mortality was reported, of which a to cope with feelings of anxiety (Verbrugge, elderly (Flint, 1994). Mortality figures for third was due to suicide (Allgulander & 1985). Also, men are less inclined than people with anxiety disorders in Lavori, 1991). Studies of out-patients with women to report feelings of anxiety. If they community-based samples are rare and anxiety disorders confirmed the excess nevertheless do report them, their condition conflicting. In a large German cohort study mortality but found a much lower suicide may be worse than that of their female with 5 years of follow-up, anxiety symp- rate (Coryell, 1988; Johnsson Fridell et aletal,, counterparts, which can have a greater im- toms were associated with improved sur- 1996; Warshaw et aletal, 2000). Two small pact on their physical health and may lead vival (Hermann et aletal, 2000). In contrast, US studies among out-patients with panic to earlier death. Another explanation might in a large community-dwelling cohort with disorder reported a doubled mortality rate be that anxious elderly men more often die a follow-up period of 17 years (Joukamaa (Coryell(Coryell et aletal, 1982; Weissman et aletal,,

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1990). However, a confirmation study some years later by Coryell et aletal (1986)(1986) CLINICAL IMPLICATIONS found less evidence for this relationship. && A major consequence of our findings for health policy is that it is important to Strengths and limitations treat anxiety in older people. Our study was the first to combine a long && Toincrease the number of treated patients, better recognition and patient follow-up period (7.5 years) with formal empowerment are key issues. diagnosis of anxiety in a general population && sample and complete mortality data. Also, The next steps for research would be to look into the causes of death associated our extensive biological, psychological and with anxiety and to explore further sociopsychological and pathophysiological sociological baseline measurements enabled differences between men and women. identification and adjustment for confoun- LIMITATIONS ders. A first limitation was that the diagnoses were based on DSM–III nosology; && The diagnoses were based on DSMÎII nosology and therefore our results cannot the results therefore cannot be extrapolated be extrapolated to people meeting current DSMÎV criteria for anxiety disorders. to people meeting DSM–IV criteria for anxiety disorders (American Psychiatric && The sample may underrepresent the frailest individuals and generalisation of our Association, 1994). This is especially rele- findings to this portion of the population is limited. vant since a large portion of the sample were diagnosed with generalised anxiety && Our data make it difficult to disentangle cause and effect; it remains unclear disorder, for which the DSM–IV criteria whether a worse health status leads to anxiety, or conversely whether anxiety leads are more stringent. Second, generalisation to a worse health status and subsequent mortality. of our findings is limited by non-response; this was largely due to oversampling of the ‘older old’, who were more likely to withdraw from the study because of health problems, cognitive problems or death. HEIN P.J.VAN HOUT,PhD,Department of General Practice, AARTJAN T.F.BEEKMAN, MD,PhD, Thus, the sample may underrepresent the Department of Psychiatry,Institute for Research in Extramural Medicine,VU University Medical Centre, frailest group, and generalisation of our Amsterdam; EDWIN DE BEURS, PhD, Department of Psychiatry,Leiden University Medical Centre, Leiden; findings to this section of the population HANNIE COMIJS, PhD, Department of Psychiatry,Psychiatry,HARM HARM VAN MARWIJK, MD, PhD, MARTEN DE HAAN, MD, PhD,Department of General Practice,WILLEM VAN TILBURG,MD,PhD,DORLYJ.H.DEEG,PhD,Department is limited. However, for the study’s purpose of Psychiatry,Institute for Research in Extramural Medicine,VU University Medical Centre, Amsterdam,The of investigating the associations between Netherlands variables, good representation on all variables is far more important. Also, it should Correspondence: Mr Hein van Hout,Department of General Practice,Institute for Research in be noted that selective attrition of the most Extramural Medicine,VU University Medical Centre,Van der Boechorststraat 7,1081BTAmsterdam, frail is more likely to have resulted in too The Netherlands.Tel: +31 20 4448199; fax: +31 20 4448361; e-mail: Hpj.vanhout@@vumc.nlvumc.nl conservative an estimate, rather than exag- (First received 15 September 2003, final revision 16 April 2004, accepted 31May 2004) gerating the impact of anxiety on mortality. Third, with our data it is difficult to disentangle cause and effect: it remains unclear whether a worse health status leads to anxi- people, there is no reason to expect the effi- American Psychiatric Association(19 (1980) 8 0) Diagnostic ety, or conversely whether anxiety leads to cacy of treatment to diminish with age. The and Statistical Manual of Mental Disorders (3rd edn)edn)(3rd (DSMÎII).Washington,(DSM ^ III).Washington, DC: APA. a worse health status and subsequent great- next steps for research are to look into the er mortality. Finally, further analyses causes of death associated with anxiety, to American Psychiatric Association(19 (1994) 94) Diagnostic should take the cause of death into account and Statistical Manual of Mental Disorders (4th edn) explore further the sociopsychological and (DSMÎV).Washington, DC: APA. as well. This might shed more light on the pathophysiological differences between Beekman, A. T., Bremmer, M. A., Deeg, D. J., et aletal mechanism of increased mortality rates men and women, and to test the effect of (19 9 8) Anxiety disorders in later life: a report from the among men. interventions. Longitudinal Aging Study Amsterdam. International Journal of Geriatric Psychiatry,, 13, 717^726.

ACKNOWLEDGEMENT Beekman, A.T., Deeg, D. J., Smit, J. H., et aletal (19 95 aa)) Implications Predicting the course of depression in the older population: results from a community-based study in An important consequence of our findings This research was primarily funded by the Ministry The Netherlands. Journal of Affective Disorders,, 3434,, for health policy is that it is important to of Health Welfare and Sports. 41^49.41^49. treat anxiety in older people. In our study few elderly people with anxiety disorders Beekman, A. T., Deeg, D. J., vanTilburg, T., et aletal REFERENCES (19 95 bb)) Major and minor depression in later life: a study received treatment. There are several treat- of prevalence and risk factors. Journal of Affective ment options available for anxiety disor- DisordersDisorders,, 3636, 65^75.,65^75. Allgulander,C.Allgulander, C. & Lavori, P.W.(19 (1991) 91) Excess mortality ders. Although there are only a few among 3302 patients with‘pure’anxietywith ‘pure’anxiety neurosis. Coryell,W.Coryell,W.(19 (1988) 8 8) Panic disorder and mortality. treatment effect studies among elderly Archives of General Psychiatry,, 48, 599^602.,599^602. Psychiatric Clinics of North America,, 11, 433^404.,433^404.

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