Agitated vs Vegetative Depressions - Why the Distinction Is Important

Patient Expert

Back in June 2001, I attended my first psychiatric conference - The Fourth International Conference on Bipolar Disorder. I had been writing about mood disorders for exactly two years. My lack of knowledge intimidated me. Here I was, among the top mood disorders experts in the world, pretending to be a mental health journalist..

One of the speakers, Athanasios Koukopoulos MD of the University of Rome, presented a seminar that would have the long-term effect of changing how I looked at depression. In the short term, however, I was rather confused. Fortunately, I took good notes.

Agitated depression, Dr Koukopoulos told us, has been relegated to a symptom of depression in the DSM-IV ("psychomotor agitation or retardation"). This meant that "major depressive episodes with or without agitation are treated in the same way, and the result is disastrous in many cases of agitated depression."

If the patient is agitated, Dr Koukopoulos went on to say, then the first course of treatment is "anything that calms him down." This would probably not be an antidepressant. If the depression appears pure and simple, then an antidepressant may be employed. I recall Dr Koukopoulos urging the clinicians in the audience to very carefully probe for signs of agitation before reaching for the prescription pad. "It is better," he concluded, "that things go slowly than trying to get well all at once."

Over time, I was able to make sense of Dr Koukopoulos. Not all depressions are the same, he was telling us in effect. The DSM may make some distinctions, but the overall impression is that there is but one type of depression. If that is so, then an antidepressant is the obvious treatment.

Not so fast, said Dr Koukopoulos in no uncertain terms.

Agitated depression, of course, implies its opposite, a vegetative type of depression. Most likely you have experienced one or the other, perhaps both. Imagine yourself pacing up and down, a fearful nervous wreck, not able to eat or sleep. Now imagine yourself with all the energy sucked out of you, barely able to think or feel or move. Clearly we are talking about two very different clinical conditions, with virtually opposite symptoms. Does it make sense to refer to both of these conditions as "depression?" Or, if we must, can we not distinguish them in a way that puts our doctors on notice?

Depression is infinitely complex, but I would submit that agitated-vegetative offers us a good starting point. Consider:

Are you dealing with too much emotion or too little? Sad? Angry? Or perhaps you are feeling the very opposite - beyond sad and angry. Maybe you're numb to the point of not caring.

What's going on in the thinking part of your brain? Over-ruminating? Runaway thoughts? Or, to the contrary, does it feel as if your brain is not booting up?

What's going on physically? Are you like a cranked up wind-up toy? Or do you feel like your battery has gone dead?

What about your behavior? Unable to engage? Overly cautious? Or is it the other way around - overly engaged and reckless?

Why don't we put these conditions side-by-side?



  • Too much emotion (sad, angry, etc).
  • Too much thinking (eg over-ruminating).
  • Excess physical activity (eg pacing up and down).
  • Excessive behavior (eg recklessness).
  • Not enough emotion (psychic numbness).
  • Difficulty thinking (as if your brain is off-line).
  • Deficit of physical activity (eg as if weighted down).
  • Deficit of behavior (eg overly cautious).

Do both describe depression? My answer would be yes. But at the same time, no one would regard both sets of symptoms as the same.

Now I will ask you to forget about depression. Forget antidepressants had ever been invented. Simply focus on the two sets of symptoms. Would you agree that the first set of symptoms might call for something to slow down the brain? Would you agree that the second set of symptoms might call for something to boot up the brain?

I am not proposing any easy answers here - depression hardly lends itself to that. But I do encourage you to consider how your depressions tend to manifest - agitated or vegetative. Chances are your symptoms are not about to gather into one neat category. But depressive symptoms do have a very binary nature about them - too much or too little, excess or deficit, and so on. Chances are you will find your symptoms leaning one way or the other. If nothing else, this will help you strip away the depression label to find out what is really going on with you, and that's a start.

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