Agitated depression is characterized by intense psychic conflict, distress, irritability, mood swings, and an increase in risky behavior.1 It is more difficult to treat than regular depression and the complexity of the presentation may result in misdiagnosis. With the right treatment, usually a combination of therapy and medication, relief from symptoms is possible.
What Is Agitated Depression?
Agitated depression includes symptoms like anger and restlessness rather than sadness and hopelessness that are usually more typical of depression. It is often seen in people who experience anxiety and depression together. Agitation itself is a non-specific symptom that can be associated with mania, hypomania, anxiety, depression, schizophrenia, borderline personality disorder, and substance use.2
While the DSM-5 does not list agitated depression as a diagnosis, it seems to best fit under the category of a major depressive episode with mixed features. This means that in addition to depressive symptoms, at least three manic or hypomanic symptoms are present most of the time. A major depressive episode with mixed features may occur as a part of Major Depressive, Bipolar I, or Bipolar II Disorder.
“Agitated depression is not an official DSM diagnosis – in my work I look at agitated depression as something more than depression alone. The immediate consideration is always bipolar disorder. More recently I am also finding that ADHD can lead to quite a lot of intensity and volatility, and so can anxiety. The main difference between all of these is the timing or duration of the ups and downs – anxious and ADHD people tend to experience moods of shorter duration, often less than a day, while bipolar tends to be days or weeks.” – Alex Dimitriu, MD at Menlo Park Psychiatry & Sleep Medicine
Agitated Depression Symptoms
Agitated depression includes more regular symptoms of depression as well as symptoms of hypo/mania, including excited and over-active behavior and increased participation in risky behaviors. These symptoms of hypo/mania, however, are without the euphoria that may be present in a typical hypomanic or manic episode when seen in agitated depression. Someone with agitated depression may experience high levels of distress and is at an increased risk for suicidality. Changes in behavior of the person experiencing symptoms will likely be observable by others.
The most commonly noted symptoms of agitated depression include:3
- Irritability
- Anxiety
- Distractibility
- Psychomotor agitation
- Racing/crowded thoughts
- Initial and middle insomnia
- Indecisiveness
- Anger
- Increased talkativeness
- Emotional lability/tearfulness
- Inner tension
- Rumination
- Impulsivity
- Risky behaviors
What Causes Agitated Depression?
While there is not one clear answer as to what causes agitated depression, there are identifiable factors that are linked to agitation and this type of depression. Agitated depression may be caused by internal elements, external elements, or a combination of both.
Potential causes and triggers of agitated depression include:
- Cultural, environmental, and psychosocial factors4
- Family history of Bipolar Disorder1
- Hormone imbalance
- Use of antidepressants
- Substance use
- Major Depression or bipolar disorder
- Borderline personality disorder, anxiety disorders, or ADHD5
- Toxic stress
Treatment Options for Agitated Depression
Everyone’s experience with depression varies, but agitated depression is notably distressing. It is important to explain all your symptoms to your provider because an accurate diagnosis is important for driving appropriate treatment. Typically, treatment for depression is best managed by a combination of therapy and medication.
Therapy
Therapy for depression is most effective when the client feels comfortable with their therapist. A therapist will be able to assess your symptoms and work with you to determine the best course of treatment, but therapies such as cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT) can be used to address symptoms typical of agitated depression.6
It is important to explore your therapy options and various modalities offered, and it can be helpful to use an online therapist directory to begin your search. Check to see if you can schedule consultations with the few therapists that you are most interested in to find out if working together may be a good fit.
Medication
Medication for depression differs from medication used to treat agitated depression in that antidepressants appear less effective for a depressive episode with mixed features than pure depression. When treating agitated depression, using an antidepressant alone may worsen symptoms of agitation.1 If you notice new or worsening agitation, restlessness, or thoughts of suicide after beginning an antidepressant, talk to your prescriber immediately or reach out to the national suicide prevention lifeline at 800-273-8255.
There is some evidence that mood stabilizers and atypical antipsychotic medications alone or in combination with antidepressants may be beneficial for treating agitated depression.7 Additionally, some research points to the use of small doses of neuroleptics, anticonvulsants, and lithium for treating agitated depression.8
7 Tips to Deal With Agitated Depression
Managing agitated depression can be challenging. Most of the tips below are focused on ways to counter or calm the agitation that you may be experiencing. It will be important for you to try out a few different strategies and then practice the one or two that work best for you. Practicing at least once a day will help you use the skills when you need them most.
Tips for coping with agitated depression include:
1. Follow a Screen-Free Bedtime Routine
Having a consistent sleep schedule is a key factor for improving mental health. One place to start the process is by getting a bedtime routine that prepares your body and mind for rest. This might include things like taking a bath or shower, reading a book, listening to calming music, and drinking decaffeinated tea while the lights are dim prior to getting in bed. Once in bed, you should be ready for sleep and not doing things like checking your phone.
2. Exercise Regularly
Exercise serves many functions related to mental health and overall wellness. It is a great way to manage stress and use up agitated energy. Regular exercise is helpful for improving sleep and mood. Adding 30 minutes of exercise a few days a week is a great goal if you aren’t already active.
3. Cut Out Caffeine & Energy Drinks
This may seem obvious if you’re feeling agitated, but agitated depression can have other symptoms like difficulty concentrating that might result in the use of caffeine or energy drinks. Try cutting these products out for at least a week to see if some of your symptoms subside.
4. Create a Sensory Soothing Toolkit
Identify one thing that is soothing or pleasant for each of your five senses and gather it all in one place so that when you are feeling down or agitated you can engage in self-soothing. Agitated depression can feel very intense, therefore, using a technique that engages all your senses is a good way to ground yourself.
5. Explore Relaxation Techniques
Look into guided imagery, progressive relaxation, meditation for depression, relaxed breathing exercises, and other grounding techniques. Try them out to determine which you like the best. Practice it at least once a day when you’re not feeling agitated so that you’re ready to use it under stress.
6. Practice Anger Management
If you’re experiencing agitated depression, you may struggle with how to control your anger. Some basic tips for anger management are to notice when you’re starting to get angry and remove yourself from the situation if possible. It’s easier to intervene before you reach the peak of your anger so it can be helpful to identify triggers for your anger and signs in your body that you’re getting angry. Once you begin to notice signs of anger, then you can implement a relaxation technique you’ve been practicing.
7. Engage in Mindfulness
We often avoid being present when we are experiencing discomfort. With agitated depression, you may be focused on pain from the past or worry about the future. Mindfulness will guide you to be present in the current moment and you can find exercises on all kinds of topics including mindful eating and mindfulness for chronic pain.
Final Thoughts
Agitated depression is common and you’re not alone in feeling this way. Finding a therapist and a doctor to help you address your symptoms is the best way to get help. Make sure to emphasize all aspects of your experience when speaking with providers so they can make the proper diagnosis and begin appropriate treatment.
Agitated Depression Infographics
