COMMENTARY

Anxiety Symptoms and Treating Depression

Michael R. Liebowitz, MD

Disclosures

March 25, 2004

In This Article

Depression Plus Anxiety

Many unipolar depressed patients present with considerable anxiety symptomatology, and data exist to suggest that these patients are harder to treat successfully and have higher suicide rates than depressed patients who are not highly anxious as well.[4] In terms of evaluating the anxiety symptoms, it is useful to distinguish between an earlier-onset anxiety condition such as panic, posttraumatic stress, social anxiety, generalized anxiety, or obsessive compulsive disorder and anxiety symptoms stemming directly from the depression. In either case, selection of an antidepressant with proven antianxiety efficacy is sensible. The proven efficacy of SNRIs like venlafaxine and several of the SSRIs for one or more anxiety disorders adds, I believe, to their usefulness in unipolar depression with prominent anxiety symptomatology. For depressed patients who are highly anxious, it is useful to add a benzodiazepine as initial adjunctive therapy to provide symptom relief for the first several weeks until the antidepressant begins to have significant effects.

The time course of response of the various symptom constellations in patients with depression and a comorbid anxiety disorder is interesting to consider, and has not, in my estimation, been studied sufficiently. My colleagues and I conducted one open trial of patients with social anxiety disorder with comorbid major depression using an SSRI.[5] We considered the major depressions to be secondary to the more longstanding social phobias in these patients. Therefore, we expected that the social anxiety disorder would improve first, followed by the depressive symptoms. However, contrary to our expectations, the patient group showed a very significant drop in depression ratings over the first 4 weeks, while a meaningful drop in social anxiety symptoms took about 8 weeks to emerge. Thus, in these comorbid states, each condition responded in a manner similar to what is seen when it occurs alone. The clinical lessons we learned were twofold: first, depression comorbid with even a chronic anxiety disorder can respond even before the anxiety disorder is significantly improved. Second: longer medication treatment is required for amelioration of some of the anxiety disorders that are frequently comorbid with major depression. While our study illustrated this for social anxiety disorder, it is probably true for obsessive-compulsive disorder and posttraumatic stress disorder as well, since these conditions have also been shown to typically require longer treatment periods than major depression before showing significant improvement.

Some unipolar depressed patients present with agitated depression, a very serious and fairly common clinical picture colloquially known as a "nervous breakdown." These patients are almost always melancholic. In addition to their anhedonia, insomnia, and loss of appetite, they show psychomotor activation in the form of pacing, rubbing their hands together, and/or a feeling that they are "jumping out of their skin." SNRIs are the treatment of choice for such patients, augmented initially with antianxiety drugs like a benzodiazepine, or even more usefully, low doses of atypical neuroleptics. The augmenting agents help bring about quick relief of the extreme agitation, and can usually be tapered after several weeks when the antidepressant begins to have significant effects. It is very important to recognize and effectively treat agitated depressions because of the extreme distress and incapacitation they engender.

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