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Full depressive syndrome and inner unrest are both essential elements of this syndrome. The presence of motor agitation is sufficient to make the diagnosis, as in the RDC criteria, because it also confirms the presence of psychic agitation. The absence of motor agitation creates the diagnostic problem of distinguishing anxiety from the particular inner unrest of agitated depression. In order to clarify the differential diagnosis between anxiety and inner agitation, pending more systematically validated criteria, we used a set of criteria different from that proposed in our previous paper (Koukopoulos, 1999). Along with major depression and inner agitation, at least three of the following symptoms must be present: (1) Racing or crowded thoughts; (2) irritability or unprovoked feelings of rage; (3) absence of signs of motor retardation; (4) talkativeness; (5) dramatic descriptions of suffering or frequent spells of weeping; (6) mood lability and marked emotional reactivity; and (7) early insomnia. Such symptoms are of excitatory, not depressive, nature and indicate the absence of inhibition. Early insomnia is often sustained by racing or crowded thoughts. These criteria were, however, validated by the external criterion of the effect of antidepressant treatments. A total of 53% of cases in a previous study (Koukopoulos et al., 2004) had simple depressions that became agitated (with at least three of the above symptoms) when treated with antidepressants.
Spontaneous and induced agitated depression
Among our 212 agitated depressions, 68 (47 women and 21 men) also had psychotic symptoms. As psychotic symptoms we considered hallucinations, delusions, both congruent and non-congruent (true delusions and not mere fears or doubts), and the presence of a state of mental confusion and grossly disturbed behavior. Of these patients, 22 (32%) were spontaneous, that is, the psychotic symptoms emerged spontaneously and not in association with pharmacological treatment. In the other 46 patients, the psychotic symptoms emerged in association with antidepressant treatment. Of these 46 patients, 30 patients had a BPI course (54% of all BPI patients), 14 had a course of BPII (21% of all BPII patients), 19 had a previous course of recurrent depression (28% of all unipolar patients), and five were first affective episodes of psychotic depression. It should be underlined that all the 14 BPII patients who had a psychotic agitated depression were all induced by antidepressants.
Latent agitated depression and the issue of antidepressant-induced
We propose the term latent agitated depression for these depressions prone to agitation. How can they be identified or at least suspected? According to our observations, the most reliable signs are: 1. Total lack of inhibition in speech and movement; 2. A certain mental vivacity unusual to inhibited depression; 3. Rich description of their depressive suffering; 4. Early or middle insomnia rather than late insomnia. These signs are not of absolute value but may suffice to suspect a latent agitated depression and make the clinician more cautious with treatment. Treatment should commence with an anti-manic (small doses of anti-psychotics, anti-epileptics or lithium) and/or anxiolytic. If antidepressants are used from the beginning, one of the above-mentioned agents should be added. Indeed, sedating treatments are the best protection against suicide (Fawcett, Clark & Busch, 1993).
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