When Anxiety and Depression Coexist: The Role of Differential Diagnosis Using Clinimetric Criteria

Abstract

Depressive and anxiety disorders are frequently associated. Depression may be a complication of anxiety and anxiety can complicate depression. The nature of their relationship has been a source of controversy. Reviews generally base their conclusions on randomized controlled trials and meta-analyses that refer to the average patient and often clash with the variety of clinical presentations that may occur when anxiety and depression coexist. The aim of this review was to examine the literature according to profiling of subgroups of patients based on clinimetric criteria, in line with the recently developed concept of medicine-based evidence. We critically reviewed the literature pertaining to the specific presentations of anxiety and depression, outlining the advantages and disadvantages of each treatment approach. The following prototypic cases were presented: depression secondary to an active anxiety disorder, depression in patients with anxiety disorders under treatment, anxious depression, anxiety as a residual component of depression, and demoralization secondary to anxiety disorder. We argue that the selection of treatment when anxiety and depression coexist should take into account the modalities of presentation and be filtered by clinical judgment. Very different indications may ensue when the literature is examined according to this perspective.

What Is a Review Article and What Are Its Purpose, Attributes, and Goal(s)

“…Thus, in my opinion, out of three articles dealing with a similar topic, only one seems to be useful to clinicians [2]. Two of these articles [2, 3] would probably not fulfill usual journals’ criteria for a review article (see below), and one is not really clinically useful [1]. The utility of another one [3] is also doubtful.…”

“…Three recent articles [1][2][3] on the seemingly very similar topic of coexistence of anxiety and depression are a case in point of the lack of clarity of what a review article is and what its attributes and goals are The first one by Saha et al [1] is a systematic review and meta-analysis which "found robust and consistent evidence of comorbidity between broadly defined mood and anxiety disorders. Clinicians should be vigilant for the prompt identi-fication and treatment of this common type of comorbidity."…”

“…Three recent articles [1-3] on the seemingly very similar topic of coexistence of anxiety and depression are a case in point of the lack of clarity of what a review article is and what its attributes and goals are The first one by Saha et al [1] is a systematic review and meta-analysis which “found robust and consistent evidence of comorbidity between broadly defined mood and anxiety disorders. Clinicians should be vigilant for the prompt identification and treatment of this common type of comorbidity.” The second article by Cosci and Fava [2] (Editor and Associate Editor of this journal, where I am member of the Editorial Board) also states that depressive and anxiety disorders are frequently associated, and that depression may be a complication of anxiety and vice versa. They argue that the selection of treatment of coexisting anxiety and depression “should take into account the modalities of presentation and be filtered by clinical judgment.” The third review by Goodwin [3] states that: “Many antidepressant agents are also effective for symptoms of GAD [generalized anxiety disorder], including selective serotonin reuptake inhibitors (SSRIs)” and “Likewise, drug classes used to treat GAD are also effective in the treatment of depression with anxious symptoms (e.g., SSRIs, serotonin-noradrenaline reuptake inhibitors, tricyclic antidepressants, and agomelatine).”…”

“…This article also lists only one antidepressant – agomelatine - by its name among key words and in Key Summary Points, which considered together with the funding sources for the article may raise question about the article purpose. Cosci and Fava [2], in their “Innovation,” remind us of the complexity of clinical psychiatry and point out that: “Reviews generally base their conclusions on randomized controlled trials that refer to the average [italics mine] patient and may thus clash with the variety of clinical presentation.” They emphasize that diagnostic criteria “do not include patterns of symptoms, severity of illness, effects of comorbid conditions, timing of phenomena, rate of progression of illness, response to previous treatments that demarcate major prognostic and therapeutic differences among patients who otherwise seem to be deceptively similar since they share the same psychiatric diagnosis” (p. 309). They apply this discussion to coexisting anxiety and depression symptomatology.…”

“…This article is based on a new model of reviewing literature which integrates details of both biology and biography with the ultimate goal of “precision medicine” [5]. Yet their article [2] feels more as an “opinion piece” rather than solid review article.…”