Separation of anxiety and depressive disorders: blind alley in psychopharmacology and classification of disease

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Abstract
Origins of the new system In 1980, the American Psychiatric Association revised its standard system of diagnoses in the third edition of its diagnostic manual (DSM-III).1 This document erected a firewall between depression and anxiety. Indeed, in drafting this edition the association appointed separate committees to study depression and anxiety and stated that any overlap between the two disorders would henceforth be considered mainly as comorbidity. Although this division was controversial at the time, DSM-III became the accepted psychiatric nosology worldwide, and its successors dominate the picture today.2 Recent observers, however, suggest that The concept of “major depression” is far too heterogeneous to be useful3 The subdivision of anxiety into separate micro-diagnoses of panic, social anxiety disorder, etc, is questionable4 The firewall between anxiety and depression ignores the fact that the commonest form of affective disorder is mixed anxiety-depression.5 Admittedly, the manual allows for diagnoses such as dysthymic disorder, a chronic form of depression that merges closely with major depression, and adjustment disorder, a lost diagnosis originally offered as a political sop to the large American psychotherapeutic community.6 However, neither diagnosis has proved particularly helpful. The crucial point is that the Food and Drug Administration accepts psychiatric drugs almost exclusively for DSM-style indications; European regulators seem to be headed in the same direction. For example, the European Agency for the Evaluation of Medicinal Products has decided to “re-evaluate the existing requirements” for the treatment of anxiety by focusing on generalised anxiety disorder.7 So the name of the disease determines how it is treated: depression is treated with antidepressants, anxiety with anxiolytics. Footnotes Contributors and sources ES has carried out research on historical aspects of psychiatry over many years, wherever possible studying documents that are key to the making of decisions by policy makers and psychiatric bodies. Most recently, he has worked in the archives of the US Food And Drug Administration and the American Psychiatric Association. PT has carried out clinical trials into the drug and psychological treatment of anxiety and depression since 1969 and has been involved in field trials for the 10th revision of the International Classification of Diseases (ICD-10). Competing Interests PT has received support from the Mental Health Foundation to evaluate the outcome of anxiety and depressive disorders.