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29.01.2015

Mixed anxiety depressive disorder dsm, pulsatile tinnitus most common cause - For Begninners

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The diagnostic category of adjustment disorder (AD) made its first appearance in DSM-III in 1968, replacing the previous “transient situational disturbance” of DSM-II, and shortly after was included in ICD-9.
This definition excludes the diagnosis if there is another Axis I or II disorder to which the symptoms may be attributed or if the symptoms are due to bereavement (Table). ICD-10 limits the time frame of onset to within 1 month of the causative stressor and, as with DSM-IV, categorizes it as one of exclusion, specifying that the criteria for an affective disorder must not be met. While DSM-IV states that the symptoms should resolve within 6 months, it also recognizes a chronic form if exposure to the stressor is long-term or the consequences of exposure to the stressor are prolonged. Symptoms caused by mood fluctuations in response to day-to-day stressful events that occur in persons with borderline (emotionally unstable) personality disorder are not classified as AD. The second dilemma is the differentiation of AD from other Axis I disorders, such as generalized anxiety disorder (GAD) and major depression disorder (MDD). This suggests that the current diagnostic system based on symptom thresholds is limited and that in DSM-5 more emphasis should be placed on the specific symptom clusters and their quality. It is increasingly accepted that anxiety in depression is associated with increased morbidity, that anxiety disorders typically precede the development of major depression, and that patients with major depression and anxiety respond to efficacious treatments and so deserve early and robust intervention. Here, I will briefly review some of the clinically important lessons that the literature has provided on anxiety in major depression, but also address some of the more complex conceptual issues in this area in an attempt to outline some clinically relevant approaches to these debates. It is important to also consider the overlap between anxiety disorders and major depression. On the other hand, it is also important to recognize that anxiety disorders are the most prevalent psychiatric disorders, and that they are underdiagnosed and undertreated.
A potential compromise here is to recognize the importance of both categorical and dimensional approaches to psychiatric disorders in general, and to depression and anxiety in particular.12,13 Separate diagnostic categories for different mood and anxiety disorders have been useful in ensuring efficient clinical communication, and also in preliminary neurobiological research. It is also important to emphasize that anxiety disorders typically precede the onset of major depression.
Indeed, it is far from clear that anxious depression is characterized by specific neurocircuitry alterations, or by a particular neurochemical or neurogenetic signature. One useful approach to the psychobiology of anxious depression may be to pay greater attention to the effects of anxiety on key psychological processes in depression. It seems clear that patients with major depression and anxiety symptoms deserve early and robust intervention. While it is very difficult to demonstrate conclusively that early treatment of anxiety disorders is effective for decreasing the development of subsequent comorbid depression, there are some data which point in this direction.29 It would seem entirely reasonable to encourage the early detection and management of anxiety disorders in order to help prevent the subsequent onset of comorbid major depression, substance use disorders, and other negative outcomes. Work on the management of anxious depression raises the key question of why anxiety is so often overlooked in the management of depression.
Perhaps a second clinical lesson emerges from literature which emphasizes the heterogeneity of anxious depression, and the importance of understanding the context of the relevant symptoms. On the other hand, the psychobiology of “neurotic depression” may well differ from other forms of depression with anxiety, such as depression with panic attacks or agitated depression. Depression and anxiety disorders are the most prevalent psychiatric disorders seen in the primary care setting.
Mood and anxiety disorders are the most common psychiatric disorders in the community and in primary care settings.1 This educational review is designed to be an evidence-based reference for primary care clinicians using psychiatric medication to treat patients with these conditions. There are many good reasons for the recent proliferation of evidence-based guidelines for psychiatric disorders.
Depression should be diagnosed using specific diagnostic criteria, such as those outlined in the Diagnostic and Statisical Manual of Mental Disorders, Fourth Edition, Text-Revision, (DSM-IV-TR) (Table 1). The differential diagnosis of depression includes not only other psychiatric disorders, but also mood disorders due to general medical conditions and substance-induced mood disorders.
Depression may be complicated in several ways, impacting decisions about pharmacotherapy and other interventions. Melancholic features of depression include loss of pleasure in activities, lack of reactivity to pleasurable stimuli, and various neurovegetative symptoms such as exacerbation of depression in the morning, early-morning awakening, and significant weight loss.
Clinicians should be alert for psychotic symptoms in depression, as these are sometimes subtle. Atypical features of depression include mood reactivity, as well as neurovegetative symptoms of reversed polarity (ie, increased rather than decreased sleep and appetite), severe lack of energy or leaden feelings in the limbs (leaden paralysis), and pathologic sensitivity to interpersonal rejection. A detailed history of substance abuse is essential in patients with depression because of the frequent comorbidity of these disorders. Depression during pregnancy should be treated with nonpharmacotherapeutic interventions when possible. Depression during lactation should be treated with nonpharmacotherapeutic interventions when possible.
Although antidepressants may be useful,88 additional interventions, such as psychotherapy, may be crucial in patients with depression and comorbid personality disorders. Depressed patients who fail to respond to medication should be thoroughly reassessed for an underlying medical disorder.
Some medications may be particularly useful in cases of depression that do not respond to one or more antidepressants. Particular attention should be paid to the evaluation of symptoms that are chosen as targets for pharmacotherapy and to symptoms that may point to the presence of other psychiatric disorders. It is also necessary to rule out the presence of comorbid psychiatric and medical disorders.
Research indicates that GAD in the elderly is not uncommon and is often accompanied by depression.101 Given the possibility of accumulation of the drug and consequent adverse effects, such as motor vehicle accidents, falls, and fractures, benzodiazepines (particularly in high doses or those with long half-lives) should be prescribed only with great caution in this population.
As noted earlier, there is a high rate of comorbidity among GAD, other anxiety disorders, and mood disorders. Clinicians need to be aware of the multiple interactions between medications used in the treatment of GAD and the treatment of other disorders, as well as of the impact of the medication’s adverse effects on medical disorders. Although β-blockers are often prescribed by general practitioners for anxiety symptoms, there is not sufficient evidence to include them as a first-line medication for GAD.
It is important to establish whether comorbid mood or other anxiety disorders are present.
Many patients with GAD suffer from extreme anxiety and are in fact compliant with their medication.
In the presence of active alcohol or substance use, it may be necessary to shift the emphasis of treatment toward a substance use disorder as the primary diagnosis, with the anxiety as a secondary problem. Although antidepressants may be useful, additional interventions, such as psychotherapy, may be helpful in patients with chronic anxiety and comorbid personality disorder.
In some cases, a diagnosis of an adjustment disorder with anxious features may be more accurate than that of GAD, and a psychotherapeutic approach therefore indicated.
In such cases, following some of the strategies that have proven useful in the treatment of resistant depression is suggested. Panic disorder, social anxiety disorder (social phobia), and PTSD are all anxiety disorders and are among the most common of the psychiatric disorders.1 Each is characterized by panic attacks or hyperarousal and by underdiagnosis or misdiagnosis as physical illness in primary care settings. The role of psychotherapy in the treatment of panic disorder, social anxiety disorder, and PTSD must be emphasized.119 Cognitive-behavioral therapy can augment the anxiolytic effects of medication, is essential in reducing avoidance behaviors (eg, agoraphobia, avoidance of social situations), and may be important in ultimately allowing medication discontinuation.
Panic attacks in panic disorder and PTSD (Tables 5, 6) may be spontaneous or may be cued by exposure to stimuli previously associated with a panic attack (eg, a confined space), while panic attacks in social phobia (Table 7) are cued by feared social situations (eg, public speaking). Panic attacks may occur in other psychiatric disorders, such as depression, specific phobias, OCD, and substance use disorders.
Panic disorder, social anxiety disorder, and PTSD may be complicated in several ways, impacting decisions about pharmacotherapy. Patients with anxiety disorders often have comorbid depression, but this usually also responds to first-line anti-anxiety treatments such as the SSRIs.
Alcohol and other substance use disorders are associated with exacerbation of anxiety disorders. Clinicians need to be aware of the multiple interactions between medications used in the treatment of the anxiety disorders and other medications, as well as of the impact of medication adverse effects on medical disorders. In Algorithm 3, SSRIs or venlafaxine are suggested as the first-line treatment of panic disorder, social anxiety disorder, and PTSD.
Panic disorder also responds to the TCAs and to certain other antidepressants (but not all).


Social anxiety disorder does not respond to the TCAs (with the possible exception of clomipramine, a predominantly serotonergic TCA), and these agents should not be used as first-line treatments of this disorder.
There are few studies showing that any one SSRI is superior to another in the treatment of anxiety disorders. Important aspects of psychoeducation regarding the SSRIs and SNRIs include the fact that these are not addictive, that despite being termed antidepressants they are highly effective in anxiety disorders, that side effects are typically transient, that therapeutic response is relatively slow in onset, and that if one agent does not work another should be tried. High-potency benzodiazepines (alprazolam, clonazepam) have also been shown to be effective in the treatment of panic disorder and social anxiety disorder.
Although β-blockers are often prescribed by primary care practitioners for anxiety symptoms, there is not sufficient evidence to include them as a first-line medication for panic disorder, generalized social anxiety disorder, or PTSD.
In panic disorder, high-potency benzodiazepines have been anecdotally described as useful in treatment-resistant panic disorder,136 and these agents (particularly slow-release agents or those with a longer half-life) may be expected to reduce anxiety secondary to antidepressants and to combat the primary disorder. In social anxiety disorder, given its efficacy as monotherapy, augmentation with clonazepam is a theoretical consideration.141 Nevertheless, this again runs the risk of benzodiazepine dependence.
When anxiety disorders do not respond to a clinical trial of optimal dose and duration, it is useful to reassess a number of factors. AD is classified as either acute or chronic, and within each form there are subtypes with depressed mood, with anxiety, with mixed anxiety and depressed mood, with disturbance of conduct, with mixed disturbance of emotions and conduct, and not otherwise specified.
The categories in ICD-10 are brief depressive reaction, prolonged depressive reaction, mixed anxiety and depressive reaction, with predominant disturbance of other emotions, with predominant disturbance of conduct, with mixed disturbance of emotions and conduct, and with other specified predominant symptoms.
Instruments such as the Structured Clinical Interview for DSM (SCID) and the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) include the criteria for AD, albeit in a cursory manner.
I will briefly address in turn the phenomenology, psychobiology, and management of anxiety in major depression. Several symptoms of generalized anxiety disorder (GAD), eg, anxiety and insomnia, are core features both of major depression and GAD (Table I), and psychological models indicate that major depression and GAD share negative affect.4 Panic attacks are found in both depression and several anxiety disorders.
Thus, a contrary view is that epidemiological data on mixed anxiety depressive disorder have significant methodological limitations, and that in patients with both depressive and anxiety symptoms, it is crucial to determine if a particular anxiety disorder is currently present or will develop over time.11 There are important differences in the management of different anxiety disorders, so these need carefully tailored assessment and intervention. At the same time, the use of dimensional assessments of anxiety in major depression may be useful in emphasizing the spectrum of anxiety symptoms seen in depression, and in encouraging researchers and clinicians to evaluate this set of symptoms more rigorously. There has been increased attention recently, for example, to disturbances in emotion regulation in several psychiatric disorders, including mood and anxiety disorders.23-25 Anxious depression may be associated with particular kinds of cognitive distortion and with increased avoidance strategies. Multiple studies with multiple antidepressants have indicated that these agents are efficacious and well tolerated in the treatment of patients with major depression with co-occurring anxiety symptoms.28 Given that anxiety symptoms in depression are an important prognostic indicator, patients with such symptoms need to be evaluated carefully and treated appropriately. A key clinical lesson may emerge from a deeper consideration of the experience of depression; we have a tendency to think of depression as a “down,” and to use language consistent with this metaphor (eg, low mood, low energy). Some psychopathology is best understood using a model of “defect” rather than “defense,” and these kinds of anxious depression may represent maladaptive responses with significant disruptions in the underlying functional systems. The algorithms included here cover the major mood and anxiety disorders, namely major depressive disorder (MDD), generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), panic disorder, posttraumatic stress disorder (PTSD), and social anxiety disorder. Nevertheless, there is increasing recognition that dysthymia also responds to standard antidepressant treatments.21,22 This disorder, which is characterized by chronic depressive symptoms, has significant associated morbidity when left untreated. A range of practical questionnaires that incorporate these criteria are available to help clinicians identify and diagnose patients with major depression.27,28 Particular attention should be paid to symptoms that are chosen as targets for pharmacotherapy, which include mood symptoms, associated symptoms (such as pain), and disability. There is some evidence that TCAs and venlafaxine may be more effective than selective serotonin reuptake inhibitors (SSRIs) in patients with depression accompanied by melancholic features34 and in possibly related subgroups, such as in-patients with depression,35,36 although not all data is consistent.37 Certainly the presence of melancholic features in depression predicts a poor response to nonsomatic interventions. Depression with psychotic features is associated with increased risk for suicide and recurrent depression.
Depressed patients with comorbid substance use disorders are more likely to require hospitalization, more likely to attempt suicide, and less likely to comply with treatment. Increasingly, the literature is emphasizing not only significant reduction in depressive symptoms, but also the value of aiming for near-complete remission of symptoms. Guidelines for maintenance therapy of depression have become increasingly conservative, favoring longer courses of medication, in view of the safety of modern antidepressants and the likelihood of additional episodes of depression in patients with repeated episodes.77,78 It is reasonable to continue medication for at least 1 year before gradual tapering, and to continue for even longer in patients with a risk of recurrence. Even among responders, residual symptoms of depression are common, and, as noted earlier, are associated with greater likelihood of relapse. While improvement in depressive symptoms may reduce maladaptive behavior in patients with comorbid personality disorder, there are other patients (eg, those with borderline personality disorder) in whom the personality disorder itself may need to be a major target of treatment. Apathy has been reported as an adverse event of some antidepressants, and may masquerade as depression.
In particular, there is increasing evidence that patients with GAD and mixed anxiety-depression frequently present in primary care settings,100 and the DSM-IV-TR now provides fairly user-friendly criteria for the diagnosis of GAD (Table 3).
It is also useful to determine the severity of GAD symptoms using a scale, such as the Hamilton Rating Scale for Anxiety. Mood disorders, such as depression and dysthymia, and other anxiety disorders are common in patients with GAD.
However, when symptoms of anxiety have their onset during substance abuse or withdrawal, it is likely that a longer period of abstinence is indicated prior to re-evaluation of the need for treatment.
GAD will often respond to the antidepressants that are used as first-line medication in these disorders and these agents should therefore be initially prescribed. Nevertheless, the high comorbidity of symptoms of depression in GAD, and the significant difficulties experienced by many patients during benzodiazepine withdrawal, constitute a strong argument against their use. Disadvantages include a lack of efficacy against the depressive symptoms often found in GAD and a lack of efficacy in some trials.
Indeed, guidelines for maintenance therapy of GAD emphasize the safety of modern agents, the likelihood of additional episodes of illness in patients with repeated past episodes, and the theoretical possibility that appropriate treatment may prevent the onset of secondary disorders.106 Such guidelines have become increasingly conservative, favoring longer courses of medication. Augmentation offers the advantage of retaining any possible gains from the first agent, but the potential disadvantages of polypharmacy (more side effects and drug interactions).81 Given the literature on combining SSRIs with buspirone in the treatment of refractory depression, this strategy perhaps deserves consideration in GAD patients with partial response.
For example, comorbid dysthymia may not respond to buspirone alone, comorbid social anxiety disorder is unlikely to respond to a TCA (other than clomipramine), and comorbid hypochondriasis may require high doses of serotonin reuptake inhibitors. While improvement in anxiety symptoms may reduce maladaptive behavior in patients with comorbid personality disorder, there are other patients (eg, those with borderline personality disorder) in whom the personality disorder itself may need to be a major target of treatment.
A range of different medical disorders may lead to chronic anxiety, including endocrine disorders (eg, hyperthyroidism), respiratory disorders (eg, chronic obstructive pulmonary disorders), cardiac disorders (eg, congestive heart failure) and others. In addition, psychoeducation of both patient and family is crucial in the treatment of anxiety disorders.
Although there is less data on the treatment of children and adolescents with these disorders, what does exist suggests that a similar approach may be useful in some younger patients.120,121 Specialist consultation may, however, be indicated in such cases. Panic disorder, social anxiety disorder, and PTSD may all be associated with other psychiatric symptoms, particularly depressive and substance abuse symptoms, which therefore also deserve particular attention. The possible association between panic disorder and increased risk of suicide, for example, needs to be taken seriously. However, there is some evidence (albeit controversial) that TCAs and venlafaxine may be more effective than SSRIs in patients with depression accompanied by melancholic features34 and in possibly related subgroups, such as in-patients with depression,35,36 although not all data is consistent.37 Interestingly, clomipramine is a TCA with properties that overlap with the SSRIs in that it is relatively selective for the serotonin system. Anxiety disorders may lead to use of alcohol and other substances in order to self-medicate anxiety. Fortunately, certain SSRIs have relatively few interactions with other medications, and the SSRIs as a class are well tolerated in most medical disorders. Similarly, given their disadvantageous side-effect profiles (including tardive dyskinesia), one should be extremely cautious about the use of low-dose antipsychotic medications in the treatment of anxiety symptoms, despite the anecdotal impression of many clinicians that these agents can be useful for this indication. Dose-response relationship of the SSRIs has not been as well studied in the anxiety disorders as in depression.
Guidelines for maintenance therapy of anxiety disorders have become increasingly conservative, favoring longer courses of medication, in view of the safety of modern antidepressants and the likelihood of relapse in patients with an untreated chronic illness.
There is nothing to assist the clinician in making this distinction except that ICD-10 requires both functional impairment and symptoms to make the diagnosis, while DSM requires symptoms or impairment. So it is not possible to achieve a gold standard measure based on the current criteria in DSM-IV and ICD-10.
Furthermore, many individuals with depression have obsessive-compulsive and related disorder symptomatology, and many individuals either with depression or trauma and stress-related disorders have been exposed to stressors. This in turn may make it hard to recognize such conditions as bipolar disorder (with its phases of mania) and more agitated depressions (where anxiety plays a key role). Although the neurobiology of agitated depression is poorly understood, there is some evidence that this lies on the bipolar spectrum.35 Thus, some forms of anxious depression should be viewed as indicators of rather serious forms of psychopathology, and clinical interventions should be targeted appropriately.


This review emphasizes that both categorical and dimensional approaches to co-occurring depression and anxiety are needed, that anxiety in depression is a heterogeneous construct, and that variants of anxious depression, such as stressor-related depression and agitated depression, likely require quite different approaches. Anxiety Disorders Comorbid with Depression: Social Anxiety Disorder, Post-Traumatic Stress Disorder, Generalized Anxiety Disorder and Obsessive-Compulsive Disorder. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of anxiety, obsessive-compulsive and post-traumatic stress disorders—first revision.
Dimensional or categorical: different classifications andmeasures of anxiety and depression.
Clinical and psychobiological characteristics of simultaneous panic disorder and major depression. Difference in treatment outcome in outpatients with anxious versus nonanxious depression: a STAR*D report. Towards DSM-V: the relationship between generalized anxiety disorder and major depressive episode. The evolutionary significance of depressive symptoms: different adverse situations lead to different depressive symptom patterns.
Proximate and evolutionary studies of anxiety, stress and depression: synergy at the interface. The CANMAT task force recommendations for the management of patients with mood disorders and comorbid anxiety disorders.
Psychopharmacologic treatment of generalized anxiety disorder and the risk of major depression. Efficacy of bupropion and the selective serotonin reuptake inhibitors in the treatment of major depressive disorder with high levels of anxiety (anxious depression): a pooled analysis of 10 studies.
Agitated “unipolar” depression reconceptualized as a depressive mixed state: implications for the antidepressant- suicide controversy. It aims to provide a concise, logical, and user-friendly approach to the pharmacotherapy of depression and anxiety disorders in the primary care context. Classical monoamine oxidase inhibitors (MAOIs) are more effective than TCAs in atypical depression.40 However, in view of the inconvenience caused by dietary and other restrictions when using these MAOIs, SSRIs may be considered a first-line class of medication41 (despite the fact that not all studies of these agents in this subgroup have been positive).
A depressed patient with a history of any cardiac disorder should be monitored for the emergence of cardiac symptoms, electrocardiogram (EG) changes, and orthostatic blood-pressure decrements. It may be useful to have the patient complete a rating scale of depression (Table 2) to help quantify response to medication.
Risk factors for recurrence include history of multiple episodes, persistent dysthymic symptoms after recovery from MDD, and comorbid psychiatric and medical disorders.
Given that GAD often presents with somatic symptoms and comorbid psychiatric disorders, the diagnosis is frequently overlooked. It is possible that the situation in GAD mirrors that in depression, where less severe forms of the disorder respond equally well to pharmacotherapy and to psychotherapy. In addition, attention should be paid to the possibility of comorbid somatization disorder or substance abuse, dependence, or withdrawal.
Similarly, in patients with chronic anxiety and comorbid personality disorder (eg, borderline personality disorder), antidepressants may be particularly useful.
All too frequently, patients on short-acting compounds have intermittent increases of anxiety before the next dose of medication is to be taken. Excluding important comorbid psychiatric disorders is perhaps the most important step in the evaluation and management of refractory GAD. In other cases of chronic anxiety, psychosocial factors may be enduring and therefore continuously complicate treatment of GAD until given independent attention. Melancholic features of depression include loss of pleasure in activities, lack of reactivity to pleasurable stimuli, and various neurovegetative symptoms, such as exacerbation of depression in the morning, early-morning awakening, and significant weight loss. Thus, although it is generally advisable to detoxify patients prior to beginning pharmacotherapy, in some cases such pharmacotherapy is an integral part of the treatment of the secondary substance use disorder.102 There is some evidence that the SSRIs in particular may be useful as a primary treatment of alcohol dependence.
No matter which antidepressant is used in the treatment of panic disorder, however, it is crucial to initiate treatment with very low doses (eg, fluoxetine 5 mg or imipramine 10 mg) in order to prevent early exacerbation of panic attacks. Some authors have suggested that high-potency benzodiazepines qualify as first-line monotherapies in panic disorder and social anxiety disorder, but others have emphasized the potential problems of long-term treatment. In panic disorder, social anxiety disorder, and PTSD it is not unreasonable to continue medication for at least a year before gradual tapering.126-128,133 Cognitive-behavioral therapy may be useful prior to beginning and during medication withdrawal in order to maintain gains, although more research on the optimal combination and sequencing of pharmacotherapy and psychotherapy in these disorders is needed.
The anticonvulsant gabapentin has shown some efficacy as monotherapy in panic disorder,137 does not have dependence potential, and is another theoretical possibility for use as an augmenting agent.
The anticonvulsant gabapentin also showed some efficacy as monotherapy in social anxiety disorder,142 does not have dependence potential, and is another theoretical possibility for use as an augmenting agent. ICD-10 is silent on the knock-on effect of stressors but allows a 2-year period of symptoms in the prolonged depressive subtype.
In general, normal reactions to events resolve quickly and do not persist, hence, the time frames specified in DSM-IV and ICD-10. This failure to recognize the full spectrum of the experience of depression can have significant negative consequences; in particular, clinicians may underestimate the severity of anxious depression and its clear link with negative outcomes such as suicide. Clinical, family history, and naturalistic outcome—comparisons with panic and major depressive disorders.
It is particularly important to exclude a history of mania or hypomania in patients with a family history of bipolar disorder. ECT may be used in selected cases, or in patients in whom depression is complicated by psychotic features, as it is both safe and effective in depression during pregnancy. In addition to monitoring depression symptoms, it is important to ascertain overall change in objective disability and subject well-being (ie, quality of life). In addition, psychoeducation is of the utmost importance, particularly in the initial stages of treatment, and should address the direct effects of anxiety on the life of the patient, as well as possible effects on family members. On the other hand, improvements in the nosology and treatment of GAD now make it useful to establish whether diagnostic criteria for this disorder are met.
In particular, excessive alcohol or caffeine use may contribute to chronic anxiety symptoms and should be excluded. Slow-release preparations or benzodiazepines with longer half-lives (eg, clonazepam) have the advantage of avoiding rebound anxiety between doses.
A compromise position is that short-term augmentation of antidepressant agents with benzodiazepines may be useful in rapidly stabilizing symptoms, and should therefore be considered in panic disorder132 and perhaps social anxiety disorder, particularly when high levels of anxiety threaten to disrupt ongoing pharmacotherapy. Nevertheless, there is a paucity of research on augmentation strategies in social anxiety disorder.
Management of anxiety or insomnia symptoms, or brief psychological treatments are sometimes used to shorten the duration or reduce the intensity of AD episodes.
A further reason for monitoring is that the symptoms may represent a disorder, such as evolving MDD that emerges more clearly over time. Diagnostic Issues in Depression and Generalized Anxiety Disorder: Refining the Research Agenda for DSM-V. On the other hand, a positive family history of depression, a history of depression preceding alcohol or other substance use, or a history of major depression during periods of sobriety raises the possibility that early intervention with antidepressants may be useful. Children with pervasive anxiety likely deserve evaluation by a specialist before a diagnosis of GAD is made.
Certainly, the lowest effective antidepressant dose of an SSRI may not be sufficient for some patients with panic disorder, social anxiety disorder, and PTSD. In patients with AD, both emotional and behavioral disturbances are present and include low mood, tearfulness, anxiety, self-harm, withdrawal, anger, and irritability. In patients with depression and comorbid OCD, it is advisable to use a serotonergic medication (ie, clomipramine or an SSRI).
In patients with depression and comorbid social anxiety disorder, SSRIs and venlafaxine, rather than TCAs, would be favored as first-line agents.



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