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Education And Debate

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

BMJ 2003; 327 doi: (Published 17 July 2003) Cite this as: BMJ 2003;327:158
  1. Edward Shorter, professor of the history of medicine1,
  2. Peter Tyrer, head of department (
  1. 1History of Medicine Program, Faculty of Medicine, University of Toronto, Toronto ON, Canada M5G 1VJ
  2. 2Department of Psychological Medicine, Imperial College Faculty of Medicine, St Mary's Campus, London W2 1PD
  1. Correspondence to: P Tyrer

    No new drugs for mood and anxiety disorders have reached the market for over a decade. Why is there so little innovation in a sector that accounts for the largest proportion by far of sales of psychiatric drugs?

    The current division between anxiety and depression is increasingly recognised as inadequate. In the community, most mood disorders present as a combination of depression and anxiety. Yet the Food and Drug Administration in the United States, which has become the world bellwether of drug approval, indicates drugs either for major depression or for the various forms of anxiety recognised by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM). As a result, the pharmaceutical industry is compelled to develop drugs for diagnoses that are of questionable clinical relevance. This is one reason for the big slowdown in drug discovery in psychiatric drugs. A return to the former unitary classification of mood and anxiety disorders as nervousness or cothymia might represent a way out of this blind alley.

    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 …

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