Recognizing the Anxious Face of Depression GIN S. MALHI, B.SC. (HONS.) M.R.C.PSYCH. F.R.A.N.Z.C.P., 1 GORDON B. PARKER, D.SC., M.D., PH.D., F.R.A.N.Z.C.P., 1 GEMMA GLADSTONE, B.A. (HONS). M.A.P.S., 1 KAY WILHELM, M.D., F.R.A.N.Z.C.P., 1 and PHILIP B. MITCHELL, M.D., F.R.C.PSYCH., F.R.A.N.Z.C.P. 1 “Anxious depression” is used variably both by researchers and clinicians to describe admixtures of anxiety and depressive symptoms. The authors sought to determine the best model for conceptualizing anxious depression by studying a sample of depressed patients referred to a tertiary referral unit. Anxiety and de- pression were assessed using a comprehensive set of mixed symptoms that were subsequently refined to provide separate anxiety and depressive factors, and pa- tients were trichotomized into groups of low, medium, and high anxiety on the basis of their total anxiety factor scores. Associations between the constructs of anxiety and depression in different depressive subgroups were explored, and the severity of depressive symptoms and other clinical variables across the three anxiety groupings was assessed. Depression variables were not linearly associated in a consistent pattern with anxiety-defined groups, arguing against a simple interdependence model driven by a higher-order variable such as depression severity. By contrast, the state anxiety categories were linked strongly with lifetime anxiety disorder preva- lence, with some associations linear and with others evidencing a trend break association. The authors found support for a model of anxious depression, whereby anxiety both predisposes to nonmelancholic depression and contributes to its presentation by shaping its clinical features. Such a model and its definition assist in clarifying the cause of anxious depression and its treatment. —J Nerv Ment Dis 190:366 –373, 2002 Both depression and anxiety disorders are com- mon, with 1-year prevalence rates of 10% and 17%, respectively, in the US National Comorbidity Survey general population study (Kessler et al., 1994). Indi- vidual depressive and anxiety disorders have dis- tinct symptomatology and diagnostic criteria; how- ever, community presentations usually comprise an admixture of anxiety and depressive symptoms, and often fail to meet criteria for either group of condi- tions (Katon and Roy-Byrne, 1991). This is particu- larly an issue in community and primary care in which combinations of anxiety and depressive symptoms are distinctly more common (Goldberg and Huxley, 1992) than separate expressions, per- haps contributing to both poor detection and low rates of referral to mental health care professionals (Ustun and Sartorius, 1995)). Furthermore, in psy- chiatric settings, the prevalence rates of major de- pression with comorbid panic or generalized anxiety disorder are high, ranging up to 60% (Di Nardo and Barlow, 1990; Sanderson et al., 1990). Consequently, ascertaining diagnostic lineage is difficult in each of these clinical settings, and this in turn complicates clinical management. In this article, we seek to clarify the nature of links between anxiety and depression in those with “anxious depression,” a clinically relevant objective because depressed patients with concurrent anxiety are more likely to be severely and chronically inca- pacitated (Fawcett and Cravitz, 1988; Garvey et al., 1987), have a poorer response to treatment (Coryell et al., 1988; Van Valkenburg et al., 1984), and attempt suicide (Fawcett, 1990; Fawcett and Cravitz, 1988) perhaps as a consequence of biological differences (Kara et al., 2000; Meller et al., 1995). However, despite the high prevalence of comorbid anxiety and depressive disorders, anxious depression is yet to be accurately modeled and defined, leading to difficul- ties in detection and diagnosis (Goldberg, 1999). A DSM-IV Task Force suggested four models for associations between anxiety and depression: a) dis- tinct but sometimes coexistent syndromes, b) symp- toms of anxiety and depression denoting dissimilar external manifestations of a single underlying cause, 1 School of Psychiatry, University of New South Wales, Sydney, Australia. Reprint requests should be sent to: Dr. Malhi, The Mood Disorders Unit, The Prince of Wales Hospital, Randwick, NSW 2031, Australia. This work was supported by a National Health and Medical Research Council Program Grant (NHMRC–993208). 0022-3018/02/1906 –366 Vol. 190, No. 6 THE JOURNAL OF NERVOUS AND MENTAL DISEASE Printed in U.S.A. Copyright © 2002 by Lippincott Williams & Wilkins DOI: 10.1097/01.NMD.0000018961.74539.A2 366