What is Anxious Depression: Understanding, Diagnosis, and Treatment Challenges

This episode delves into the complex interplay between anxiety and depression, specifically focusing on the condition known as "anxious depression" or, more formally, "depression with anxious distress." Dr. Tracey Marks explains that while anxiety and depression are distinct disorders, they frequently co-occur, presenting in various ways. Sometimes, severe anxiety disorders like OCD or GAD can lead to secondary depression, while in other cases, anxiety symptoms are interwoven with a primary depressive episode, not necessarily rising to the level of a full anxiety disorder but significantly altering the experience of depression.

The podcast details the diagnostic criteria for "anxious distress" as a core specifier from the DSM-5. These criteria include symptoms such as feeling keyed up or tense, unusual restlessness, difficulty concentrating due to worry, fear of impending doom, and the fear of losing control. Dr. Marks clarifies the nuances of "losing control," distinguishing it from extreme cinematic portrayals and explaining its more subtle manifestations. The severity of anxious distress is categorized based on the number of these symptoms, with motor agitation (purposeless physical activity like pacing or leg shaking) indicating a severe level.

Dr. Marks highlights significant differences observed in individuals with anxious depression, including neurobiological findings such as thinning of gray matter (cortical thickness) in specific brain regions and distinct blood work profiles. Crucially, anxious depression is presented as being inherently more challenging to treat than "uncomplicated" depression. Patients often fall into the "treatment-resistant" category, experiencing negative initial reactions to antidepressants, such as increased anxiety or worsening depression, which can be highly discouraging.

For treatment, the episode emphasizes a multi-faceted approach. Patients with anxious depression are likely to require more than one medication, potentially trying several agents before finding an effective combination with minimal side effects. While primary care doctors might manage uncomplicated depression, anxious depression often necessitates consultation with a psychiatrist, who may prescribe off-label medications, including antipsychotics (like aripiprazol or brexpiprazole) or anticonvulsants (like Lamotrigine or Gabapentin), in addition to antidepressants. The importance of combining psychotherapy with medication for superior outcomes is also strongly underscored, preparing patients for a potentially longer and more complex treatment journey.

"Anxiety and depression often come together and there's different ways that they can look."

"Some people's anxiety can be so bad that they wake up every morning and throw up or you can feel like there's this heavy weight pressing on you all day."

"The anxiety doesn't really rise to the level of a full disorder like panic disorder or generalized anxiety disorder. But its presence is enough to make the quality of the depression different."

"Anxious distress is what we call a core specifier. It gives more specific information about how your depression looks and behaves."

"Losing control can be as subtle as not being able to stop yourself from doing something destructive like quitting your job."

"Scientists have seen differences in the brains and blood work of people with anxious depression compared to non- anxious depression."

"Anxious depression tends to be harder to treat than depression without the anxiety mixed in."

"Psychotherapy in combination with medication is more helpful than medication alone."

"If you have depression with anxious distress, be prepared that you may need more than one medication to treat your condition and you may have to try a few before you get one that works well with the least amount of side effects."