Agitated Depression: What You Need To Know

If you haven’t heard of agitated depression, or if you have come across the term because you or a loved one has been diagnosed with it, it can be overwhelming and frightening to sift through all the information available.

Agitated depression is still a highly debated disorder, but it tends to be diagnosed when people with depression experience a physical manifestation of their anxious symptoms called psychomotor agitation.¹

What is agitating depression?

Agitated depression (AD) is a subtype of depression that is distinct from what we think of as the classic presentation of depression. However, this is a debated diagnosis among clinicians.

How is agitated depression different from typical depression?

Agitated depression was originally described as a depressive state in which the patient’s mood was low, and they experienced negative thoughts, but they didn’t have the typical depressive symptoms of low activity levels and lethargy.

Agitation isn’t usually a symptom of major depression. In “typical” major depression, the person who is depressed can struggle to get out of bed, complete usual household tasks, or find the motivation to fulfill the requirements of everyday life.

In agitated depression, the person with depression can still have a depressed mood and feel just as bad, but they are more likely to experience:

• Restlessness

• Talkativeness

• Irritability

What does agitated depression look like?

Agitated depression can look like several other disorders, which is why it is so difficult to separate and diagnose. Some people don’t agree that agitated depression is a valid diagnosis, as it stems from attempting to rectify a mixed depression condition that is clinically difficult to diagnose.

The exact composition of agitated depression historically has a lack of consensus. Generally, agitated depression has been categorized under mixed depression or manic depressive reactions.

Part of the confusion is that the condition is similar to bipolar disorder, another mental illness where patients present with excitatory symptoms and depressive symptoms. Historically, it has been difficult for clinicians to distinguish between bipolar disorder and mixed depression.

In its fifth edition, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)² still does not define a method for diagnosing agitated depression that suits patients, clinicians, and governing bodies. In recent years, clinicians have become disenchanted with the current DSM-5 method of diagnosing people with both manic and depressive symptoms.

As a result, they have proposed agitated depression as a mixed form of bipolar and depressive disorders.

Agitated depression requires that at least two of the following manifestations of psychomotor agitation are present for several days in the current episode of psychological distress:

• Pacing

• Hand-wringing

• Unable to sit still

• Rubbing on hair, skin, clothing, or other objects

• Outbursts

• Can’t stop talking

This is a specific type of depression where the person exhibits a physical manifestation of their anxiety called psychomotor agitation, which is also mixed with a depressive mood. This can then be separated from other mixed emotional states, which is important because some medications may work better for one but not the other.

The main factor that separates bipolar states from agitated depression is that the psychomotor agitation in AD is completely pointless. In mania, the person often experiences restlessness that leads to an ability to complete various tasks very quickly. This can result in burnout and a depressive state. However, in agitated depression, the same restlessness ends up as a purposeless, unpleasant movement, like being unable to sit still.

Symptoms

An agitated depression diagnosis occurs when a patient presents excitatory and depressive symptoms in the same episode, along with a psychomotor response. This can be difficult to diagnose.

The symptoms include:

Excitatory

• Psychomotor agitation

• Irritability

• Racing and crowded thoughts

• Logorrhea (talking a lot)

Depressive

• Depressed mood

• Anxiety

• Profound despair

• Anguish

• High risk of suicide

There has been controversy over how to classify these symptoms, as some people can present with some but not all of them. Clinicians are often concerned that if patients present with fewer of these symptoms than required to make the diagnosis, they will miss out on the most effective treatments.

Causes and triggers of agitated depression

The cause of agitated depression isn’t well known. Some key factors that make people more likely to experience agitated depression include:

• Premorbid temperament (the state of their emotional regulation before becoming depressed)

• The course of illness (how their disease has affected them)

• Family history

• Worsening of the clinical status with antidepressants

• Female gender

• More lifetime mixed episodes

• Suicide attempts

These are factors that tend to be associated more with agitated depression but don’t explain what is happening in the brain to cause this condition. Unfortunately, we don’t yet know exactly why depression in some patients presents differently.

Some studies have found that patients with agitated depression are more likely to have a dependence on alcohol, cocaine, opioids, sedatives, or other drugs. This type of depression can be associated with certain types of opioid addiction.

Given the limited research into agitated depression, and because we don’t yet understand how to diagnose this condition, we can’t rule out the idea that the mechanisms underlying this association with drugs and alcohol aren’t uni-directional.

This means that the reasons why people who have agitated depression are more likely to be addicted to opioids and other drugs may also be the reasons that they have agitated depression in the first place. We simply don’t know enough about the condition to make any definitive conclusions.

Prevalence and incidence

It is difficult to know the prevalence and incidence of agitated depression because there isn’t a consensus on the exact definition of agitated depression. In other words, many clinicians (the diagnosing bodies) disagree with the governing body (the DSM-5) that sets the diagnostic criteria. As a result, the clinical usage of agitated depression might be less than it should be.

One study looked into the prevalence of agitated depression in unipolar (not bipolar) depressives. The study found that agitated depression was present in 19.7% of patients. This is highly significant because it indicates a gap in treatment for many unipolar patients.

However, other studies have found that between 7% and 60% of patients with major depressive disorder have agitated depression. So we have no idea how many patients in the general populace might have this condition.

Who’s at risk?

People who already experience high levels of activity or mania without being diagnosed with a manic condition like bipolar disorder are most at risk of developing agitated depression. These people could develop depression, which may then present as agitated depression.

However, we don’t know the exact causes or triggers of agitated depression, so it is impossible to determine who is most at risk. What is known is that patients with agitated depression are more likely to have a family history of agitated depression and a premorbid personality.

Links with other conditions

Agitated depression is its own condition but is often confused with other conditions like bipolar disorder.

Is agitated depression the same as mixed-state bipolar?

Some clinicians and studies³ believe that the DSM has the diagnostic criteria for agitated depression wrong. They think it makes diagnosing mixed depression and bipolar disorder too difficult to distinguish from agitated depression.

Historically, depression has been kept separate from bipolar disorder. Even the name “bipolar disorder” comes from the idea that patients swing wildly from one “polarity” to the other — from a depressed state to a manic state. So, there is a lot of difficulty in determining whether a patient who experiences a combination of the two states has bipolar disorder, major depressive disorder, or some combination of the two.

This is made even more complex by the wide variability in symptoms that can be seen in patients with any of these disorders.

To add even more difficulty, clinicians often diagnose a patient based on their recollections of their symptoms. This can be a problem because people with mood disorders, such as agitated depression, can be unreliable in how they present their symptoms, particularly if they are anxious about their diagnosis.

In a nutshell, mixed depression is the official guideline diagnosis for conditions with excitatory and depressive states mixed together, whereas agitated depression is a specific diagnosis that clinicians have defined to encapsulate all the patients who don’t fit the diagnostic criteria for mixed depression.

The two conditions are very similar, or the same disease, that can be diagnosed differently based on the individual symptoms and the diagnosing body.

How agitated depression is diagnosed

Agitated depression isn’t a formal diagnosis yet. It is a term that has been adopted by a group of clinicians to fill a diagnostic gap in the people they are treating. These clinicians diagnose agitated depression in those who have most of the following features:

• Psychomotor agitation

• Dysphoric mood

• Talkativeness or racing thoughts

• Initial or middle insomnia

• Impulsive suicide attempts

• Verbal outbursts

Agitated depression treatment

Treatment of agitated depression comes with some risks. Patients with this type of depression often have suicidal thoughts, which need to be diagnosed with the appropriate care to make sure no one is at risk of harm.

Medications

Regular antidepressants don’t work as well for patients with agitated depression. In some patients, antidepressants can increase the risk of suicidal ideation. This is already a risk for patients with agitated depression, so we want to ensure not to exacerbate this problem.

Some new medications, such as quetiapine⁴, are being tested to help alleviate depression and manic symptoms that often trouble these patients.

Therapy

Because some of the core complaints of agitated depression are racing thoughts, anxiety, and unmanageable behaviors, therapy could help alleviate the burden imposed by these symptoms. However, therapy alone may not be enough to completely treat the person.

Avoid triggers or sources of conflict

It is difficult to tell what triggers an agitated depressive episode, but there is some evidence that it can be linked to opioid use. Recreational opioid use should always be avoided, and those susceptible to depression should especially avoid it, as using opioids could potentially trigger an agitated depressive episode.

The lowdown

Agitated depression is a form of depression in which a person has psychomotor symptoms. These are symptoms that present as a physical manifestation of internal anxiety alongside a depressed mood and more typical depressive symptoms.

However, agitated depression is not a formal subset of major depressive disorder. More research into the topic is needed before treatments and therapies specific to this condition can be developed.