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Anxiety depression disorder treatment, chronic fatigue help me - Review

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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.
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. 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. 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. Diagnostic Issues in Depression and Generalized Anxiety Disorder: Refining the Research Agenda for DSM-V.

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