Beyond signs and symptoms: the case against a mixed anxiety and depression category

Both primary care physicians and psychiatrists report frequent difficulty in distinguishing between major depression and generalized anxiety disorder. This fact has suggested the need for a new diagnostic category of mixed anxiety and depression. The solution, however, does not address the fundamental issues and creates additional problems. While there are multiple factors contributing to the difficulty in distinguishing between these categories, two are of paramount importance. First, pivotal cross-sectional criteria for the two disorders as enumerated in DSM-III-R are virtually identical. Second, the crux of the distinction between these two disorders involves factors other than the immediate cross-sectional presentation in the office such as the longitudinal course of the patient's complaints. Obtaining such a history takes time and training. For a variety of reasons (e.g., time allocated for patient evaluation, physician training), such a longitudinal history may not be elicited in a primary care office. To respond to these problems by establishing a mixed diagnostic category does not address the primary problems, may encourage cursory evaluations of patients, and will likely hinder research.