Anxiety and Depression Together?

By R. Morgan Griffin

Originally published on Advocate.com October 20 2010 5:00 AM ET

 Depression and anxiety might seem like opposites. We think: Depression saps you of energy; anxiety makes you keyed up and afraid. Depression makes it near impossible to get out of bed; anxiety leaves you sleepless, pacing all night.

But the truth is not so simple. In fact, depression and anxiety often go together. Mental health experts estimate that more than half of the people diagnosed with depression also have anxiety.

"We know that many of the symptoms of depression and anxiety disorders overlap," says Ian A. Cook, MD, the director of the Depression Research Program at the University of California, Los Angeles. "And we're learning from studies that there also appears to be a lot of overlap in the underlying brain mechanisms involved in these two conditions."

Unfortunately, the combination of depression and anxiety can be particularly severe, and many people don't get the correct diagnosis. The good news is that doctors have good treatments for tackling both conditions.

"When you're in the grip of depression and anxiety, it can feel like the misery will never end, that you'll never recover," says Dean F. MacKinnon, MD, an associate professor at the Johns Hopkins Hospital in Baltimore. "But people do recover. You just need to find the right treatment."

Understanding Depression and Anxiety

Although either depression or anxiety can be a disabling condition on its own, the combination can be particularly hard. "If you're already depressed, anxiety is a multiplier of suffering," MacKinnon says.

Depression can make feel people profoundly discouraged, helpless, and hopeless. Anxiety can make them agitated and besieged by physical symptoms -- a pounding heart, tightness in the chest, and difficulty breathing.

"People who have both depression and anxiety feel low, down in the dumps, and unmotivated," says Jerilyn Ross, MA, LICSW, president and chief executive of the Anxiety Disorders Association of America. "But their minds are also racing. They can't concentrate. They can't sit still. It's a very tough combination."

It's also tough to control. "It's important for people to recognize that when they have both depression and anxiety, it may be more difficult for them to get all the way well," Cook says. That's not to say they won't recover fully, but that it may take more work.

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Some people who are depressed have a distinct anxiety disorder, like panic disorder, social anxiety disorder, or generalized anxiety disorder, Ross says. Many others don't have full-fledged anxiety disorders but more general anxiety symptoms that accompany their depression.

The fact that depression and anxiety so often occur together has led some researchers to speculate -- controversially -- that they may not always be different conditions. "It's possible that in time, we'll come to see anxiety and depression together as representing a distinct illness separate from either condition by itself," Cook says.


Treating Depression and Anxiety

Different experts take different approaches to treating depression with anxiety. Some try to work out which condition is causing the major problems -- the primary condition -- and try to resolve that first. Others try to deal with both at the same time. Fortunately, many treatments are good for either individual condition. They just might be used in different ways.

Here's a rundown of five ways to treat depression and anxiety:

(1) Antidepressants. Despite the name, these drugs aren't just for depression anymore. "We've learned that a lot of the medications originally approved as antidepressants also relieve anxiety symptoms," says David I. Sommers, Ph.D., the scientific review officer at the National Institute of Mental Health in Bethesda, Md. However, it's key that you get the right medication. Some antidepressants have a reputation for being activating, which could worsen anxiety symptoms.

For depression and anxiety, many doctors first turn to an SSRI antidepressant -- like Lexapro, Paxil, and Zoloft. "I think they're some of the safest and easiest to use," MacKinnon says. Cymbalta and Effexor -- newer antidepressants known as SNRIs -- are other first-line anxiety and depression treatments. If those medications don't work, your doctor may try other antidepressants like the older tricyclic medications.

(2) Therapy. Although many types of talk therapy may help, the approach with the best evidence for depression and anxiety is cognitive behavioral therapy. CBT is a technique that helps people identify and then change the thought and behavior patterns that add to their distress. "When you're anxious and depressed, you've come to believe that the world is a much more negative and frightening place than it is," MacKinnon says. "CBT helps expose those ways of thinking and teaches you ways to develop new ones."

(3) Antianxiety medicines. Although some antidepressants can help both depression and anxiety, they take some time to work. Other drugs like benzodiazepines -- Ativan or Xanax, for example -- can quickly control the symptoms of anxiety. However, many doctors are reluctant to prescribe them in the long term because of a potential risk of abuse or addiction.

(4) Other medications. Depending on how a person responds to treatment, other medications might help. MacKinnon says that some people with depression and anxiety benefit from mood stabilizers like lithium, antipsychotic drugs, and antiepileptic drugs on top of their antidepressants. Medications that help with sleep - like the antidepressant trazodone - may allow people with anxiety to get the rest they need.

(5) Lifestyle changes. Experts stress that you can do a lot to support your treatment for depression and anxiety. Try to eat well and get enough sleep. Don't rely on alcohol or illicit drugs. Physical activity is key, since there's good evidence that it can help with mood and may help people bounce back from depression. Breathing exercises, muscle relaxation, and disciplines like yoga can help too.

"Most people already know this stuff," Sommers says. "Telling people that eating well or exercising is a good idea is often just preaching to the choir." The key, he says, is to figure out ways of integrating better habits into your life. That's something else that you can work on with your therapist.

Which approach is best to treat depression and anxiety symptoms? There's no right answer; it all depends on the person. Sometimes, just one approach -- like therapy or an antidepressant -- is enough. In some people, it isn't.

"There's evidence that people who have both depression and anxiety tend not to do as well with just the standard treatments," Cook says. "They may need more aggressive treatment at the outset, with more frequent appointments and closer monitoring." People with depression and anxiety might do best with a combination of therapy and medication, he says, or a pairing of different medications at the same time.Recovery and Feeling Better

There are lots of different ways to treat depression and anxiety effectively. But experts say that they all hinge on one thing: a good relationship with your health care provider. Whether you see a general doctor, psychiatrist, psychologist, or social worker -- or a combination -- you need to work well together. Recovery will be a collaborative project.

"Really, the first treatment people with depression and anxiety need is education," MacKinnon says. "When they come in for treatment, they're often bewildered. But just talking to an expert who takes the time to explain the basics -- to define what depression and anxiety are and how they are treated -- can reduce a lot of the suffering right away."

So find someone whom you trust and can work with. And stick with it.

"Depression and anxiety together can be hard to treat," Cook says. "But the odds are very good that people with these conditions can get their lives back and feel well again. They just need to hang in there while we find the treatment that works."