Mixed anxiety and depression: diagnostic issues.

Mixed anxiety and depression (MAD) is a new diagnostic category introduced in the ICD-10 classification for patients seen mainly in primary care settings. These patients are defined as those suffering from symptoms of anxiety and depression of limited and equal intensity accompanied by at least some autonomic features, who do not qualify for specific diagnosis of anxiety or depressive disorders and are independent of stressful life events. The validity of this clinical entity is presently under investigation in the DSM-IV-MAD field trial. Cases of mixed anxiety and depression, however, are not limited to those meeting the criteria of this new "subsyndromal" category. Many patients fulfilling criteria for either depressive or anxiety disorders may also respectively present symptoms, syndromes, or a diagnosis of anxiety or depression. It is still not known whether anxious and depressive symptoms are two different expressions of the same psychopathologic underlying process. Tyrer's recent description of a "general neurotic syndrome" is an attempt to reunify syndromes separated in our present classifications. In this comprehensive approach, anxiety, depression, or MAD states are associated at different times with specific personality features and considered as expressing different levels of overreactivity to various stressful situations. This hypothesis would explain the close relationship existing between these two categories of symptoms and the common efficacy of some psychopharmacologic agents for both anxiety and depressive disorders.