ANXIOUS DEPRESSION AND THE ENDOGENOUS NEUROTIC DISTINCTION
This paper will summarize data from studies conducted over some years into anxious depressions and their response to tricyclic antidepressants and MAO inhibitors. The studies have gradually led toward the conclusion that, although the MAO inhibitors may to a limited extent produce selectively better response in patients with a mixture of anxiety and depression, the tricyclic antidepressants are relatively broad spectrum drugs producing antidepressant effects over a wide range of depressive pictures. The concept of anxious depression is a somewhat diffuse one, rarely allotted a separate category in official diagnostic schemes or in textbooks. It overlaps with a number of alternative classifications. One of these is the endogenous neurotic distinction. Table 1 summarizes the findings from eight published studies that obtained factors reflecting the contrast between endogenous or psychotic depression and neurotic depression and that included ratings of anxiety. In three studies, anxiety loaded strongly toward the neurotic end of a factor and in two more it loaded weakly in this direction. In two studies it loaded weakly and in one study strongly in the psychotic direction. Two of these (30,32) differed from the remainder in having a unipolar endogenous factor without neurotic loadings rather than a bipolar factor, and one of the studies (31) reported separately a second self-pitying factor on which psychic and somatic anxiety loaded highly. The endogenous first factors in both studies could alternatively be interpreted as general severity factors. Rotation from a bipolar factor structure with anxiety at the neurotic pole can produce a rather similar endogenous factor (23). Overall the findings do suggest some relationship between presence of anxiety and a neurotic symptom pattern. However, the trend is not universal. In our own study, although anxiety loaded in the direction of
neurotic depression on the endogenous neurotic factor, it loaded rather more strongly on a separate factor that contrasted symptoms of anxiety and of depression. In a cluster analytic study undertaken in the United States (18) we found four groups of depressives: psychotic depressives, anxious depressives, hostile depressives, and young depressives with personality disorder. The patients with anxious depression were middle aged and had the highest scores on psychic and somatic anxiety, depersonalization, obsessional symptoms, and fatigue. They were also moderately severely depressed. They were somewhat chronic with the highest number of previous episodes and high scores on the Maudsley Personality Inventory Neuroticism Scale. This classification was consistent with the psychotic neurotic dichotomy, but suggested that neurotic depressives were diverse, comprising three groups. This classification resembled an earlier one reported by Overall et al. (17) using a multivariate procedure that divided inpatient depressives into three groups: retarded depressives, hostile depressives, and anxious depressives, of whom retarded depressives appeared to respond better to tricyclics and the anxious depressives to neuroleptics (7,8). In two successive studies of our own in patients with amitriptyline, anxious depressives responded poorly (19,26). These were uncontrolled studies, and, although analyses of со variance suggested that the poor response was not simply due to the chronicity of anxious depressives, we could not be certain that we were demonstrating drug effects. This warning is an important one. It is really necessary to have placebo comparison to determine whether an antidepressant is of benefit. It is quite possible that anxious depressives, tending to be chronic, might improve only to a limited extent, but that most of the improvement might be drug induced whereas nonanxious depressives were obtaining greater improvement, most of which was not due to the drug.