Mixed anxiety depression. For and against

The subject of mixed anxiety depression has been the topic of a somewhat confused discussion. At one point, it was held that anxiety and depression were both manifestations of an underlying affective disorder, but systematic work by Martin Roth and others clearly demonstrated that anxiety disorders could be separated from depressive disorders via a multivariate scale. Interestingly, spontaneous panic attacks were among the highest loading items on this scale. Nonetheless, it was plain that many patients were simultaneously anxious and depressed. Interest then grew in understanding the evolution of these syndromes over time. In general, anxiety syndromes antecede depressive syndromes, although there are many exceptions. For instance, some people only develop panic attacks when in the midst of a depressive episode. To attempt to understand these complexities, detailed family studies have been attempted with often contradictory results. We shall present family study data indicating that patients with comorbid panic disorder and depression have different familial patterns from those with panic disorder alone. In addition, a practical question is whether there exist patients, primarily in private settings, who present with symptoms of anxiety and depression but do not meet full criteria for any of the currently defined syndromes. Such patients are often referred to as subsyndromal or subthreshold patients. Epidemiological data indicates that such patients exist and that their symptomatology is associated with social and functional impairment. Recently the DSM IV field trial has specifically addressed this issue by clinical investigations of primary care and psychiatric facilities. These results will be reported.