Shorter's Separation of Anxiety and Depressive Disorders-Blind Alley in Psychopharmacology and Class

Shorter's Separation of Anxiety and Depressive Disorders-Blind Alley in Psychopharmacology and Class

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Separation of anxiety and depressive disorders: blind alley in psychopharmacology and classification of disease Edward Shorter, Peter 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 commu- nity, most mood disorders present as a combination of depression and anxiety. Yet the Food and Drug Admin- istration 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 com- pelled 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 x The concept of “major depression” is far too hetero- geneous to be useful 3 x The subdivision of anxiety into separate micro- diagnoses of panic, social anxiety disorder, etc, is questionable 4 x 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 adjust- ment 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 exclu- sively 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
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Shorter's Separation of Anxiety and Depressive Disorders-Blind Alley in Psychopharmacology and Class

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