Mixed Depressive Syndromes

Among the Mixed States, forms of Depression with severe agitation and excitatory symptoms of Hypomania are extremely common. These forms are often called Anxious or Agitated Depression. Their importance lies in the severity of these conditions due to:
 a great risk of suicidal behavior, and in
 the frequent worsening of symptoms with antidepressant agents.

We found the most common symptoms reported in these forms include:
 racing, crowded thoughts;
 restlessness, pacing, agitation;
 increased speech with continuous complaining;
 suicidal ideation with plan and often intent;
 extreme mood lability;
 dramatic, vivacious expression of suffering;
 reversed diurnal mood variations (worsening in p.m. hours);
 sleep disturbances, decreased sleep;
 anxiety and panic symptoms -- nervousness, tension.

The rapid worsening of these symptoms in response to treatment with antidepressant or exposure to stimulants confirms the presence of an excitatory process underlying these presentations.

As suggested by Koukopoulos, these forms require treatment of the hypomanic symptoms with sedatives and antimanic agents, and only later, if necessary, treatment of depressive symptoms. It is not unusual to see complete remission of symptoms with antimanic agents or sedatives.