Agitated depression as a mixed state and the problem of melancholia

The extensive use of antidepressant drugs in the treatment of all forms of depression makes the question of the real nature of agitated depression a crucial issue because many patients have adverse outcomes, including increased agitation, increased insomnia, increased risk of suicide, and sometimes the onset of psychotic symptoms. Agitated depression is no longer considered a mixed state in the DSM system. After a review of the literature on melancholia agitata as a mixed state and on the introduction of the concept of mixed states, this article has examined the psychopathology of agitated depression. The main symptoms are depressive mood with marked anxiety, restlessness, and often delusions. In other cases, psychic agitation and racing or crowded thoughts prevail alongside anxiety and depressed mood. The mixed nature of these symptoms has been discussed and new diagnostic criteria proposed, including those syndromes without marked restlessness but with evident psychic agitation and racing or crowded thoughts. It is suggested that all the varieties of agitated depression be called mixed depression, with the following diagnostic criteria: A. Major depressive episode B. At least two of the following symptoms: 1. Motor agitation 2. Psychic agitation or intense inner tension 3. Racing or crowded thoughts.