Anxious depression: clinical features and treatment.

Anxious depression has been conceptualized in at least two related but separate ways: 1) major depressive disorder with at least one comorbid Axis I anxiety disorder and 2) major depressive disorder with a high level of anxiety with or without one or more comorbid Axis I anxiety disorders. Using either definition, patients with anxious depression seem to have a more chronic course of illness, an increased incidence of suicidal thoughts and behavior, greater functional and occupational impairment, and poorer response to treatment. Multiple classes of medications are used to treat anxious depression, most commonly first- and second-generation antidepressants, atypical antipsychotics, and benzodiazepines. Certain patients with anxious depression may require lower starting doses, more gradual dose escalations, higher end point doses, longer duration of treatment, and/or early augmentation with other agents. Nonpharmacologic treatments such as targeted psychotherapy and preventative stepped-care approaches also may be effective. Well-conceived, randomized controlled treatment trials are necessary to make further gains in the management of patients with anxious depression.