Diagnosis, Clinical Features, and Therapeutic Implications of Agitated Depression

Key points

The problem of classification of agitated “unipolar” depression

In the modern classification systems, the diagnosis of agitated depression is unclear and misleading. In 1978, with the approval of Research Diagnostic Criteria, agitated depression was considered a subtype of depressive episode, which could be present either during a major depressive disorder or during a bipolar disorder.¹⁰ In the third edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-III),¹⁴ the category of MDD included several depressive states, such as melancholic

What is agitated “unipolar” depression?

The original definitions of agitated “unipolar” depression described an affective state in which mood and ideation were in the negative polarity and activity in the opposite polarity.¹¹ It has also been called “excited depression” or “depression with excitatory symptoms,” pointing out the presence of symptoms of excitement (ie, restlessness, talkativeness, flight of ideas, irritability) together with a depressed mood within the same affective episode.

Koukopoulos and Koukopoulos⁹ proposed that

Suicidality in agitated depression

Suicidal behaviors are due to the interaction between biological, psychosocial, and sociocultural factors. People suffering from agitated depression are at high risk of suicide, especially for the presence of racing thoughts and general restlessness. Because of flight of ideas and high levels of impulsivity, patients can take life-threatening decisions and risky behaviors. Other elements concurring to the high suicidal risk include the rapid cycling course, the predominant depressive polarity,

Therapeutic implications

Agitated depression is a severe clinical condition that requires a specific management and treatment plan. The main challenge is represented by its adequate identification and appropriate diagnosis.^50,64 In case of patients with treatment-resistant depression, who failed to respond to treatment with 4 or 5 sequential trials of antidepressants over a period of years, a diagnosis of agitated depression should always be considered.⁶⁵ Moreover, many patients with this disorder—even if they are on a

Summary

Agitated “unipolar” depression represents a potentially dangerous clinical entity, given the high associated risk of suicide. It is extremely relevant for clinicians, mental health professionals, patients, carers, and all mental health stakeholders to adequately identify, diagnose, and treat it. This clinical condition has been neglected for many years, and therefore, there is still an open and ongoing debate about the correct classification of this disorder. In particular, it should be

Acknowledgments

The authors would like to acknowledge Carmela Palummo, Benedetta Pocai, Luca Steardo Jr, Arcangelo Di Cerbo, and Francesca Zinno, all from the Department of Psychiatry of the University of Campania “L. Vanvitelli”, Naples, Italy.