Mixed anxiety depression

Roy-Byrne PP (1996). Generalized anxiety and mixed anxiety-depression association with disability and health care utilization. J Clin Psychiatry 57 (suppl. 7), 86-91. 

A typical example of diagnostic splintering provides the group of mood disorders. One reads about major depression, minor depression, double depression, dysthymia, unipolar and bipolar depression, depressive personality, depression not otherwise specified, brief recurrent depression, subsyndromal symptomatic depression, mixed anxiety depression disorder, seasonal depression, and adjustment disorder with depressive mood. 

Comorbid anxiety and depressive features are common in clinical practice, and DSM-IV has included mixed anxiety-depression in its appendix of conditions needing nosological refinement. The presence of comorbid anxiety has prognostic implications. For example, prospective studies of patients with depression have found that the co-occurrence of panic attacks was correlated with a poor outcome (Coryell et al. 1988 van Valkenburg et al. 1984). Some evidence suggests that such patients do better with MAOls. Likewise, patients with depression and obsessive-compulsive disorder may be more resistant to treatment, even with SSRls (Hollander et al. 1991)... 

The anxiolytic activity of several compounds in some, but not all, animal models of anxiety in fact suggests that different receptor subtypes may modulate different types of anxiety as discussed below. It would not be surprising if the specific serotonin links to disorders of anxiety also differ among the various disorders of anxiety such as generalized anxiety versus obsessive-compulsive disorder versus panic disorder versus social phobia versus mixed anxiety depression. Such studies are in progress, and much further research is necessary to clarify the potential links between subtypes of anxiety and subtypes of serotonin receptors. 

Beta-adrenoceptor antagonists, particularly propranolol, have been shown to be effective for anxiety symptoms particularly in situational anxiety and GAD. Buspirone, an azaspirodecanedione, is an agonist at 5-HTlA receptors and seems to have anxiolytic effects, though it is less potent than the BDZs and the effects take up to three weeks to become evident. There is high first pass metabolism and a considerable proportion of the effect is due to a metabolite (1-PP). The principal adverse effects of buspirone are nausea, gastrointestinal upset and headache. Antidepressant drugs, both the older tricyclic antidepressants and the newer drugs, have been demonstrated to have anxiolytic effects in mixed anxiety-depressive patients, GAD and panic disorder. 

FIGURE 8-1. Anxiety and depression can be combined in a wide variety of syndromes. Generalized anxiety disorder (GAD) can overlap with major depressive disorder (MDD) to form mixed anxiety depression (MAD). Subsyndromal anxiety overlapping with subsyndromal depression to form subsyn-dromal mixed anxiety depression, sometimes also called anxious dysthymia. Major depressive disorder can also overlap with subsyndromal symptoms of anxiety to create anxious depression GAD can also overlap with symptoms of depression such as dysthymia to create GAD with depressive features. Thus, a spectrum of symptoms and disorders is possible, ranging from pure anxiety without depression, to various mixtures of each in varying intensities, to pure depression without anxiety. 

FIGURE 8—6. Subsyndromal mixed anxiety depression (MAD) may be an unstable psychological state, characterized by vulnerability under stress to decompensation to more severe psychiatric disorders, such as generalized anxiety disorder (GAD), full-syndrome MAD, or major depressive disorder (MDD). 

F43.2 Adjustment disorders. 20 Brief depressive reaction. 21 Prolonged depressive reaction. 22 Mixed anxiety and depressive reaction. 23 With predominant disturbance of other emotions. 24 With predominant disturbance of conduct. 25 With mixed disturbance of emotions and conduct. 28 With other specified predominant symptoms... 

The usually accepted prevalences for generalized anxiety disorder (GAD) are around 1.6% for current, 3.1% for 1 year and 5.1% lifetime (Roy-Byrne, 1996). The condition is twice as common in women as in men (Pigott, 1999). A small minority (10%) have GAD alone, and about the same proportion suffer from mixed anxiety and depression. Morbidity is high. About a half of those with uncomplicated GAD seek professional help, but two-thirds of those with comorbid GAD do so. Up to a half take medication at some point. The condition may coexist with other anxiety disorders such as phobias, with affective disorders, or with medical conditions such as unexplained chest pain and irritable bowel syndrome. 

Stabel S, Parker PJ Protein kinase C. Pharmacol Ther 51 71-95, 1991 Stagno SJ, Smith ML, Hassenbusch SJ Reconsidering psychosurgery issues of informed consent and physician responsibility. J Clin Ethics 5 217-223, 1994 Stahl SM Is serotonin receptor down regulation linked to the mechanism of action of antidepressant drugs Psychopharmacol Bull 30 39-43, 1994 Stahl SM Mixed anxiety and depression serotonin 1A receptors as a common pharmacological link. J Chn Psychiatry (in press)... 

Given this context, it is not surprising that general physicians find psychiatric differential diagnosis difficult. Whether there is a unique condition consisting of mixed anxiety and depression is not known, but before it is added to our nomenclature, there should be evidence supporting its construct validity. The following are the standard tests of such validity ... 

Whereas such data exist for MDD and the various anxiety-related disorders, such data do not exist for the proposed mixed anxiety and depression category. 

Boulenger JP, Lavallee YJ. Mixed anxiety and depression. Diagnostic issues. J din Psychiatry 1993 54[Suppl 1] 3-8. 

Preskorn SH, Fast G. Beyond signs and symptoms the case against a mixed anxiety and depression category. J din Psychiatry 1993 54 24-32. 

Other bad news in the treatment of depression is that many responders never remit (Table 5 — 17). In feet, some studies suggest that up to half of patients who respond nevertheless fail to attain remission, including those with either apathetic responses" or anxious responses (Table 5 — 18). The apathetic responder is one who experiences improved mood with treatment, but has continuing lack of pleasure (anhedonia), decreased libido, lack of energy, and no zest. The anxious responder, on the other hand, is one who had anxiety mixed with depression and who experiences improved mood with treatment but has continuing anxiety, especially generalized anxiety characterized by excessive worry, plus insomnia and somatic symptoms. Both types of responders are better, but neither is well. 

Katon W, Roy-Byrne PP (1991) Mixed anxiety and depression. J Abnorm Psychol 100 337-345... 

In general, anxiety disorders are a group of heterogeneous illnesses that develop before age 30 and are more common in women, individuals with social issues, and those with a family history of anxiety and depression. Patients often develop another anxiety disorder, major depression, or substance abuse. The clinical picture of mixed anxiety and depression is much more common than an isolated anxiety disorder. ... 

Phenelzine, a monoamine oxidase (MAO) A inhibitor (15 mg t.i.d.), is indicated in treatment of depressed patients clinically characterized as atypical, nonendogenous, or neurotic. These patients often have mixed anxiety and depression and phobic or hypochondriacal features (see also Tables 5 through 7). 

The drug exerts its therapentie aetion to eombat various types of anxiety disorders viz., generalized anxiety disorders, panie attaeks, phobie disorders, obsessive-compulsive disorder, post-tranmatic stress disorder, and mixed anxiety and depressive disorders. Perhaps the drug acts as a atypical antisychotic agent by virtue of its reduced tendency to produce the extrapyramidal effects. 

Differential includes rapid cycling (pi64) mixed anxiety and depression, and mood lability in EUPD... 

When we began using reserpine at the Maudsley Hospital less than two years ago there were very few reliable accounts of its use in the treatment of neuropsychiatric conditions and almost no controlled clinical studies. Dr D. L. Davies and I therefore conducted a clinical trial on a mixed group of out-patients, the majority of whom were suffering from anxiety and depressive reactions. The patients were given either reserpine, prescribed as Serpasil in a dose of 0.5 mg. by mouth twice daily, or a seemingly identical placebo, for a period of six weeks. The two substances... 

In this chapter we reviewed taxometric studies in domains of psychopathology that only recently attracted the attention of taxometricians eating disorders, depression, anxiety, personality disorder, and issues surrounding comorbidity. In all these areas the findings are mixed, and it is impossible to offer a verdict about the taxonic status of any of these forms of psychopathol-... 

Depression, generalized anxiety disorder (GAD) PO 10 mg/day Uniabeied Uses Mixed anxiefy and depressive disorder Contraindications Usewifhin 14 days of MAOIs... 

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