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Introduction

Every psychiatrist and general practitioner diagnoses mixed anxiety and depression readily. The condition is so common that about one in ten of the population is suffering from this disorder at any given time.

Recognition of anxiety and depressive disorder in primary care setting is now considered to be extremely important in health care delivery. It has been suggested that there may be a group of patients who fail to fulfill conventional diagnostic criteria for either anxiety or depressive disorder but when the total constellation of anxiety and depressive symptom is considered in aggregate, seem to warrant a psychiatric diagnosis i.e. mixed anxiety depressive disorder.

Mixed anxiety depressive disorder is characterized by dysphoria combined with other depressive and anxiety symptoms that are subthreshold for a diagnosis of primary depressive or anxiety disorder. Anxiety and depression frequently co-occur and neither of them fit completely into the diagnostic categories, such as major depressive disorder (MDD) and generalized anxiety disorder (GAD), and subsyndromal symptoms may be clinically significant.

Depression and anxiety are common comorbid presentation in clinical practice. It is estimated that more than two third of patients with major depressive disorder 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.

Despite somewhat successful attempts to separate a variety of anxiety and depressive syndrome the distinction between GAD and MDD has never been clear cut, and genetic evidence suggests that these two disorders are outcome of the same underlying diathesis (Kendler 1996)1. It is unclear whether this syndrome is in fact a stable disorder or whether under stress, it can be exacerbated, leading to an overt anxiety or depressive disorder.

Epidemiology

Major depressive disorder and panic disorder co-exist quite commonly. About two third of depressed patients have prominent anxiety symptoms. 20-90% patients with panic disorder have episodes of depressive disorder.

The prevalence of mixed anxiety depressive disorder in the general population is as high as 10% and in primary care clinics as high as 50%.

Etiology

• Hyperactivity of the noradrenergic system
• GABA
• Serotonergic system
• Genetic basis
• Psychological factors
• Social factors

Clinical Features

• Some of the symptoms of anxiety disorder
• Some of the symptoms of depressive disorder
• Symptom of autonomic nervous system hyperactivity such as gastro-intestinal complaints
• Psychological are more common than somatic symptoms of anxiety

The dysphoric mood is accompanied by the presence of at least four or more the following symptoms (DSM IV)2,3

• Difficulty in concentration
• Disturbed sleep
• Fatigue
• Irritability
• Worry
• Crying easily
• Hypervigilance
• Anticipating the worst
• Sense of hopelessness
• Low self esteem
• Feeling of worthlessness

Management

There are no conclusive findings on treatment of Mixed Anxiety Depressive Disorder; following is the tentative recommendation for treatment (Boulenger et al. 1997)4

• All major groups of antidepressants as they have some degree of antidepressant and anxiolytic effect
• Buspirone as it may have antidepressant effect in higher doses (more effective with the psychological than the somatic symptoms of anxiety)
• Benzodiazepines, these are not appropriate if depressive symptoms are more prominent. Rebound and withdrawal effect should also be considered.
• Tricyclic anti depressant like dothiepin can also be used
• Combination treatment

Pharmacotherapy with cognitive behavior therapy, including

• Anxiety management
• Relaxation therapy
• Cognitive restructuring

References

• Kendler KS: Major depression and generalized anxiety disorder: Same genes, (partly) different environment-revisited. Br J Psychiatry 168 (Suppl 30): 68-75, 1996.
• American Psychiatric Association; Diagnostic and Statistical Manual IV of Mental Disorder.
• ICD 10.
• Boulenger J P, Fournier M, Rosales D, et al: Mixed Anxiety and Depression: From theory to practice J Clin Psychiatry 58(suppl 8): 27-34, 1997.