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Diagnosing Depressive Disorders
 

MIXED ANXIETY AND DEPRESSION

Depression and anxiety are common comorbid presentations in clinical practice. It is estimated that more than two-thirds of patients with major depression also suffer from some level of anxiety. Depression with concomitant anxiety is associated with a more chronic course, a poorer outcome, and a higher incidence of suicide.

Mixed anxiety-depressive disorder has been under a great deal of debate with respect to whether or not this comorbid state represents a distinct condition. It is included in the appendix of DSM-IV.

Categories of Comorbidity & Treatment Options
[Adapted from Stahl SM. Mixed anxiety and depression: clinical implications. J Clin Psychiatry 1993;54:(suppl)33-8.]

Patients presenting with comorbid depression and anxiety may be classified under one of four possible categories:

 

1.

Meets the full criteria for both depression and anxiety disorder. For this group of patients, SSRIs and newer agents are increasingly being used to treat both depression and anxiety.

 
2.

Meets the criteria for sub-threshold anxiety disorder and sub-threshold depression (Mixed anxiety-depressive disorder) Benzodiazepines, although useful, do not provide effective treatment for depressive symptoms. Increasingly, the SSRIs and newer agents are being used with good results in both sets of symptoms.

 
3.

Meets the full criteria for an anxiety disorder, accompanied by sub-threshold depressive symptoms. These patients have been found to respond favorably to treatment with low-dose antidepressants, particularly the SSRIs and newer agents. Studies indicate that for all major anxiety disorders, antidepressants rather than traditional anti-anxiety agents should be first-line treatment.

 
4.

Meets the full criteria for depression, accompanied by sub-threshold anxiety symptoms. This final category would appear to be the most common comorbid situation. The SSRIs and newer agents again are accepted as first-line treatment for this group of patients.

 

There is increasing recognition that depression and anxiety are commonly comorbid, complicating both diagnosis and treatment. It should be noted that anxiolytics can actually worsen depression, while antidepressants can treat both conditions. The SSRIs and newer agents constitute current treatment recommendations for the patient with comorbid depression and anxiety.

 

Differentiating Anxiety and Depression

Differentiating Anxiety and Depression
Anxiety Depression
Adaptive Debilitating
Future-oriented Past-oriented
Helplessness Hopelessness
Worse in the p.m. Worse in the a.m.
Blames external factors Blames internal factors (self)
Trouble falling asleep Early morning awakening
Potential suicide risk Definite suicide risk

Please see:

Section II: "Managing Major Depression Disorder"
CANMAT – Guidelines for the Diagnosis and Pharmacological Treatment of Depression
(1st Edition Rev., 1999)
P. 20

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Over one million Canadians suffer from some form of depressive illness.