Depressive illness consists of a series of symptoms, including depressed mood. Depressed mood, however, is not specific to depressive illness; that is, it does not occur only in depression. Therefore, saying that a person suffers “from depression” simply because they are “feeling down” is not a correct way of understanding the situation.
There are inhibited, or slowed, depressions, and excited, or agitated, depressions. There are “calm” depressive forms, in which inactivity and indifference predominate, and “anxious” forms, in which the person complains continuously and remains on edge. There are also depressive forms in which the person appears inactive and blocked, almost as if in hibernation, but under favorable or stimulating circumstances suddenly regains vitality and may even become euphoric and hyperactive.
To varying degrees, depression always involves some degree of anxiety, especially when the depressed person is forced or encouraged to continue dealing with commitments or relationships that cannot be avoided. Sometimes, however, anxiety is accompanied by a genuine state of motor excitement. The person cannot find peace, repeatedly says that they “do not know where to stay” or “do not know where to go,” paces back and forth, or feels the need to move around or get away, for example by driving around in their car. They appear absorbed in thoughts that are distressing in content but rapid, one following another, sometimes repetitive, and which do not leave the person in peace, as though constantly prodding them and keeping them awake. Sleep is typically disrupted, with active insomnia: the person tries to distract themselves without succeeding, cannot concentrate on any activity, and remains restless. The person is deeply involved in the content of their thoughts and may feel an urgent need to find solutions or escape situations that are causing them suffering, while complaining that they cannot do so and cannot conceive of a way out. They believe that everything depends on the problems of the moment, and that those problems provide the key to interpreting their entire life, with a tragic and inevitable ending. Thoughts of suicide may be latent, but above all, impulsivity is increased, so the person may engage in self-harming acts without having planned them or having a clearly defined intention to do so.
Sometimes people with this type of depression try to stimulate themselves in various ways. This is a common presentation among people who abuse alcohol or other substances, but it can also occur outside these circumstances. The person may, for example, seek out sexual encounters, eat voraciously and in a disorganized manner, or attempt to calm themselves by abusing sedatives.
Anxiety is different from agitation because an anxious person tends to complain and feel distressed, but is more passive. They seek reassurance, look to others for security, and avoid commitments that increase their anxiety. They usually move very little, and if they become “agitated,” they tend to do so “in place.”
Anxious depression is not associated with aggression, whereas this can occur in agitated depression. The mood of an agitated person is irritable, reactive, and difficult to control. They are not responsive to reassurance.
With regard to treatment, the distinction is fundamental because antidepressants that often resolve anxious depression may instead worsen the agitation of agitated depression. Agitated depression does not in fact belong to the “family” of depressive disorders, but to the “family” of bipolar disorders. Agitated depression is a state of excitement, albeit with a depressed mood.
Mood stabilizers, as well as certain antipsychotic medications and, not least, electroconvulsive therapy, can be safe and effective methods for treating these disorders. Treatment with antidepressants alone, perhaps initiated during a seemingly “unremarkable” phase of apparent anxious depression, may instead worsen the condition, increase the risk of aggressive behavior toward oneself or others, and generally increase levels of impulsivity.