Millions of people experience episodes of depression every year, making it one of our most common mental disorders. Although its symptoms may look similar, clinical depression differs in its intensity and duration from the ordinary sadness that we all experience from time to time. Sadness triggered by a loss, disappointment, or a major life change is typically short-lived, fading over time as we adjust to new situations. Clinical depression, also known as major depressive disorder, can be precipitated by a specific event but can also result from a change in brain chemistry that makes it difficult to maintain mood stability. Depression is a long-lasting, serious medical condition that must be diagnosed and treated by a medical professional.
In my practice, I often use a swimming analogy to understand depression. Having worked as a lifeguard, I will often look at patients with depressive symptoms and ask the question, “are you swimming well?” While we all may get upset and let down, there are healthy behaviors which trend towards improvement. On the other hand, patients with depression will often have trouble “staying afloat,” or carrying on with daily activities, or steps towards recovery. Sleep, work, relationships, and self-care can begin to shut down, and this is the point where I believe people need “saving.”
Not everyone experiences clinical depression in the same way. In some people, the characteristic listlessness and lethargy of depression may be overshadowed by agitation, restlessness, and impulsive activity. Those with “agitated depression” feel as hopeless and worthless as those who are more passive but they are moved to act – to do something, anything, even engage in self-destructive behaviors – to dispel the pain. Symptoms of agitated depression include angry outbursts and extreme irritability; panic attacks, pacing, and fidgeting; racing thoughts, excessive talking; and insomnia. While episodes of agitation are not unusual in people with depression, in those with agitated depression the agitation is more severe and more persistent. Agitated depression is often indicative of a more severe manifestation of depression, and sufferers may be at increased risk of self-harm or suicidal thoughts.
A challenge in diagnosing agitated depression is to distinguish it from bipolar disorder, which also includes symptoms of high energy, sleeplessness, and restlessness. The primary difference is that bipolar disorder is characterized by swings between high (manic) and low (depressive) states – typically lasting at least 4 days, while agitated depression presents as a single, persistent set of symptoms. To diagnose agitated depression, a psychiatrist will take a comprehensive history, observe the individual carefully, and examine family history to rule out other causes of irritability and other types of depression.
Patients with bipolar presentations often carry some soft markers of bipolarity. Family history may reveal a close relative with a significant psychiatric history, including hospitalizations, suicide attempts, and substance abuse. Individuals will often experience significant mood symptoms as a teenager – which may include panic attacks or depression, and may have had acts of self-injury. In women, hormonal sensitivity, in the form of severe PMS/PMDD, post-partum depression, or significant mood decline around menopause may also indicate a need to investigate bipolar disorder as a possibility. More globally speaking, bipolar patients will often exhibit what I call, “rockstar histories.” By this, I refer to episodes of seemingly intense and overly active behavior. Periods of intense mood shifts, panic, and significant substance use (and or rehab). Patterns of significant life change in a period of time are seen as well, with people changing jobs frequently, switching partners, or entering into affairs. Insomnia that comes and goes is often a common thread through these episodes. It is essential to also realize that not all the mania in bipolar disorder is the energized giddy high we often think of. Too much energy can easily get mis-diverted. Agitation, anxiety, panic attacks, and insomnia may often present over a period of time as the “manic” state of bipolar disorder.
Treatment for agitated depression, as for other types of depression, generally includes both medication and therapy but medication must be used carefully since common antidepressant medications often produce a different response in patients with agitated depression. For example, selective serotonin reuptake inhibitors (SSRIs) such as Prozac, Zoloft, Lexapro, Celexa, and Paxil, which are among the most commonly described drugs for depression, may be dangerous for people with agitated depression. These medications, which elevate mood, cause suicidal ideation in some patients and since those suffering from agitated depression may already be at higher risk for suicidal thoughts, the medication may trigger increased energy and an impulse to act. Indeed, antidepressants used in a bipolar patient, may amplify mood swings, and intensify agitation and insomnia. In some cases, antidepressants in combination with antipsychotics may be cautiously used to treat agitated depression – though careful monitoring is essential. As with all drug regimens for depression, it often takes a period of trial and error to determine the most effective medication and dosage for a particular patient.
A wide range of psychotherapies is used in treating depression. Cognitive behavioral therapy (CBT) has been particularly effective in helping people with agitated depression manage their condition. CBT is based on the idea that thoughts and perceptions influence behavior and that if we can identify the harmful thoughts that are producing a distorted perception of reality, we can work to change those thoughts and behaviors. CBT aims to help develop coping and problem-solving strategies that can be employed to reduce agitation and impulsive behavior. I often repeatedly counsel my patients that “an ounce of prevention is worth a ton of cure,” and indeed knowing the early warning signs, and intervening early, is essential to smooth outcomes. Additional facets of a personalized treatment plan may include peer support, general wellness strategies such as following a nutritional diet and exercise regimen, and stress-reduction techniques such as yoga and meditation,
Agitated depression is a serious mental disorder that has no specific cure but those who are committed to diligently seeking the most effective treatment and sticking with it can manage the condition and lead a happy, productive life.
Alex Dimitriu, MD, is the founder of Menlo Park Psychiatry & Sleep Medicine in Menlo Park, CA. He is dual board-certified in psychiatry and sleep medicine. If you’re interested in learning more about agitated depression and how it affects you, please call (650) 326-5888 or contact us online.