Mixed anxiety-depressive disorder

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Mixed anxiety-depressive disorder (MADD) is a diagnostic category defining patients who suffer from both anxiety and depressive symptoms of limited and equal intensity accompanied by at least some autonomic features. The World Health Organization's ICD-10 describes Mixed anxiety and depressive disorder : "...when symptoms of anxiety and depression are both present, but neither is clearly predominant, and neither type of symptom is present to the extent that justifies a diagnosis if considered separately. When both anxiety and depressive symptoms are present and severe enough to justify individual diagnoses, both diagnoses should be recorded and this category should not be used."[1]


The symptoms of anxiety and depression disorders can be very similar. A diagnosis of mixed anxiety-depressive disorder as opposed to a diagnosis of depression or an anxiety disorder can be difficult. The Diagnostic and Statistical Manual of Mental Health Disorders IV has defined certain requirements for diagnosing mixed anxiety-depressive disorder:

  • A dysphoric mood is chronic or recurring for a minimum of four weeks and has at least four of the following symptoms: troubles concentrating or with memory, disturbed sleep, tiredness or lack of energy, feeling irritable, worrying, crying easily, enhanced sensory state, expecting the worst, feeling hopeless or pessimistic, or having low self-esteem/feeling worthless.
  • The symptoms presented are not caused by medications, drugs, or a health condition.
  • The symptoms cause significant impairments or distresses in aspects of daily life.
  • The symptoms do not meet the criteria for different and separate mental health disorders. Many people experience depression and anxiety symptoms at the same time, often of sufficient severity for both to be diagnosed. Between 10% and 65% of individuals with Panic Disorder also experience Major Depressive Disorder, with approximately a third of such individuals experiencing depression prior to the onset of panic. For others, the restrictions to lifestyle and erosion of social and emotional well-being caused by ongoing anxiety can result in depression.

Risk factors[edit]

Risk factors for mixed anxiety-depressive disorder include risk factors for either depression or anxiety disorders. These risk factors often overlap and may include:

  • History of mental health disorders in the family, including substance addictions
  • Living in poverty
  • Lack of social or familial support
  • Having a serious or chronic illness
  • Low self-esteem
  • Childhood trauma
  • Stress


The priority is to treat the most disabling of either the anxiety or depression first and then consider treatments such as SSRI antidepressants and/or CBT which are effective for both anxiety and depression. Further treatment may point to symptoms that require a diagnosis of either an anxiety disorder and a depressive disorder.[2][3][4]


Throughout studies of anxiety disorders and depressive disorders, scientists have come to multiple conclusions about the cause. This disorder is caused by a combination of biological, psychological, and environmental factors. These factors include imbalances to neurotransmitters in the brain, traumas, stresses, and an unstable home environment. Since the possible causes of anxiety disorders and depressive disorders are so similar, it is not surprising that these disorders occur so frequently together: approximately 58% of patients with major depression also have an anxiety disorder, and approximately 17.2% of patients with generalized anxiety disorder also have depression.[5]


  1. ^ "ICD-10". Retrieved 2010-07-10. 
  2. ^ The Maudsley Prescribing Guidelines in Psychiatry, 12th Edition. 
  3. ^ David Semple, Roger Smyth-Oxford Handbook of Psychiatry-Oxford University Press (2013). 
  4. ^ "NICE | The National Institute for Health and Care Excellence". www.nice.org.uk. 
  5. ^ Ballenger, J. C. (2000). "Anxiety and Depression: Optimizing Treatments". Primary Care Companion to the Journal of Clinical Psychiatry. 2 (3): 71–79. PMC 181112Freely accessible. PMID 15014652. 
  • American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (Revised 4th ed.). Washington, DC: Author.
  • Howland, Robert H, MD and Michael E. Thase, MD. “Comorbid Depression and Anxiety: When and How to Treat.” Journal of Psychiatry, 329, 11: 891-1047 (2006). Web. <www.ccspublishing.com/j_psych/depression_and_anxiety.htm>
  • Tyrer, Peter. “The case for cothymia: mixed anxiety and depression as a single diagnosis.” British Journal of Psychiatry, 179: 191-193 (2001). Web. <http://bjp.rcpsych.org/content/179/3/191>