Anxiety disorders are common in depressed patients. Several studies of the full range of Diagnostic and Statistical Manual of Mental Disorders-defined anxiety disorders in depressed psychiatric outpatients each found that when diagnoses are based on semi-structured diagnostic interviews >40% of the patients had a comorbid anxiety disorder. The recognition of comorbidity is not simply of academic interest, but it has important clinical significance. Epidemiological studies, such as the National Comorbidity Study, have demonstrated that depressed individuals with a history of anxiety disorders are at increased risk for hospitalization, suicide attempt, and greater impairment from the depression. The co-occurrence of anxiety disorders in depressed patients has been associated with a more chronic course of depression in psychiatric patients, primary care patients, and epidemiological samples. Recent research has suggested that clinicians underrecognize anxiety disorder comorbidity in depressed patients. The clinical significance of this underrecognition is highlighted by the finding that patients often want treatment to address their anxiety disorder comorbidity. When anxiety disorders are detected they often influence clinicians' selection of antidepressant medication, though some of clinicians' prescribing biases are not supported by empirical data.

In this monograph, Iwona Chelminski, PhD, reviews the significance of anxiety in patients with depression as well as diagnostic instruments for recognizing this comorbidity. Next, Mark Zimmerman, MD, addresses the factors that affect the clinician's choice of antidepressant, focusing on the influence of comorbid anxiety. Finally, Sidney Zisook, MD, discusses the differential efficacy of antidepressants as well as the role of psychotherapy in patients with comorbid anxiety and depression.

Patients in psychiatric settings may present with medical conditions, such as brain tumors, which may or may not be associated with neurological symptoms. In some cases, patients may only have psychiatric symptoms, such as mood changes (depression or mania), psychotic symptoms, panic attacks, changes in personality, or memory difficulties. Brain tumors may be detected in patients at their first presentation to mental health services or sometimes in patients with well-established psychiatric diagnoses.This article presents the case of a 29-year-old woman who was treated for >4 years for posttraumatic stress disorder and borderline personality traits, who developed depressive symptoms and memory difficulties. However, she did not develop any major neurological signs or symptoms. Brain imaging showed the presence of a left thalamic tumor, later confirmed as glioblastoma multiforme. She underwent surgical treatment and radiation therapy. With this we show that in some cases, brain tumors can be neurologically silent and only present atypical psychiatric symptoms.

Treatment and rehabilitation of the cognitive, psychological, and motor sequelae of central nervous system dysfunction often relies on assessment instruments to inform diagnosis and to track changes in clinical status. Typically, these assessments employ paper-and-pencil psychometrics, hands-on analog/computer tests, and rating of behavior within the context of real-world functional environments. Virtual reality offers the option to produce and distribute identical “standard” simulation environments in which performance can be measured and rehabilitated. Within such digital scenarios, normative data can be accumulated for performance comparisons needed for assessment/diagnosis and for treatment/rehabilitation purposes. In this manner, reusable archetypic virtual environments constructed for one purpose can also be applied for applications addressing other clinical targets. This article will provide a review of such a retooling approach using a virtual classroom simulation that was originally developed as a controlled stimulus environment in which attention processes could be systematically assessed in children with attention-deficit/hyperactivity disorder. This system is now being applied to other clinical targets including the development of tests that address other cognitive functions, eye movement under distraction conditions, social anxiety disorder, and the creation of an earthquake safety training application for children with developmental and learning disabilities.

Excessive pain during medical procedures, such as burn wound dressing changes, is a widespread medical problem and is especially challenging for children. This article describes the rationale behind virtual reality (VR) pain distraction, a new non-pharmacologic adjunctive analgesia, and gives a brief summary of empirical studies exploring whether VR reduces clinical procedural pain. Results indicate that patients using VR during painful medical procedures report large reductions in subjective pain. A neuroimaging study measuring the neural correlates of VR analgesia is described in detail. This functional magnetic resonance imaging pain study in healthy volunteers shows that the large drops in subjective pain ratings during VR are accompanied by large drops in pain-related brain activity. Together the clinical and laboratory studies provide converging evidence that VR distraction is a promising new non-pharmacologic pain control technique.