Anxiety and Depression: Two Sides of the Same Coin?

by Mike Nichols – Posted in: Anxiety

Modern psychiatry has long held that Anxiety Disorder and depression are two distinct conditions.

However, in the real world, many suffer from both. Surveys show that half of Anxiety Disorder sufferers also have symptoms of clinical depression. And 60-70 percent of people with major depression also have an Anxiety Disorder.

Evidence is growing that they are really two aspects of one disorder. Looking at them that way, some experts say, could speed the development of therapy and medications that better treat both conditions.

David Barlow, director of the Center for Anxiety and Related Disorders at Boston University, states that:

[Anxiety Disorders and depression are] probably two sides of the same coin. The genetics seem to be the same; the neurobiology seems to overlap.

This post explores several similarities between Anxiety Disorders and depression, along with the risks of getting both disorders, the benefits of early treatment, and a summary of how the disorders are treated together.

Common reactions of people with both Anxiety Disorders and depression

Life stressors: Anxiety and depression reactions

Anxiety Disorders and depression feed on each other, each making the other worse. David Barlow says that, “Some people with the vulnerability react with anxiety to life stressors and some, in addition, go beyond that to become depressed.” He adds,

Depression seems to be a shutdown. Anxiety is a kind of looking to the future, seeing dangerous things that might happen in the next hour, day or weeks. Depression is all that with the addition of “I really don’t think I’m going to be able to cope with this, maybe I’ll just give up.” It’s shutdown marked by mental, cognitive or behavioral slowing.”

In groundbreaking research, Kenneth S. Kendler, a behavioral geneticist from Virginia Commonwealth University in Richmond, offers a new way of looking at psychiatric conditions. He sees a small cluster of genetic risk factors creating “internalizing disorders” such as Anxiety Disorder and depression, which cause sufferers to be miserable. Another set of genetic factors finds expression in “externalizing disorders” such as substance abuse and antisocial behavior — conditions that make others around them miserable.

Avoidant coping style is shared between Anxiety Disorders and depression

Avoiding what you fear

Anxiety Disorders and depression share an avoidant coping style. Sufferers avoid what they fear instead of developing the skills to handle the kinds of situations that make them uncomfortable.

Often, a lack of social skills is at the root of their avoidant behavior. Jerilyn Ross, LICSW, president of the Anxiety Disorders Association of America (ADDA), says,

[The link between Social Phobia and depression is] dramatic. It often affects young people who can’t go out, can’t date, don’t have friends. They’re very isolated, all alone, and feel cut off.

Evidence of shared genetic traits

Brain mechanisms gone awry

At the center of the double disorder are shared brain mechanisms gone awry. Studies have shown that the stress response system is overactive in patients with both Anxiety Disorders and depression, which sends the emotional centers of the brain — including the “fear center” in the amygdala — into hyperactivity. Secretions of the stress hormone cortisol, triggered by repeated trauma, reduce the activity of the gene that produces the 5-HT1A serotonin receptor, which is an important brain messenger implicated in both Anxiety Disorders and depression.

Another study from researchers at the National Institute of Mental Health has found that, in people with both Panic Disorder and depression, there is a significant decrease in a type of receptor (5-HT1A) for the neurotransmitter serotonin.

Early treatment of Anxiety Disorders can prevent depression

Early treatment prevents depression

Anxiety usually precedes depression developmentally, with Anxiety Disorders most commonly beginning in late childhood or adolescence and depression a few years later, in the mid-20s. Psychologist Michael Yapko of San Diego points out a flaw in thinking common in both disorders:

The shared cornerstone of Anxiety and depression is the perceptual process of overestimating the risk in a situation and underestimating personal resources for coping.

Yapko sees a huge opportunity for the prevention of depression, as the average age of first onset is now mid-20s. He says,

A young person is not likely to outgrow anxiety unless treated and taught cognitive skills. But aggressive treatment of the anxiety when it appears can prevent the subsequent development of depression.

Who is at risk for combined Anxiety Disorder and depression?

Risk: Heredity, age, environment

There’s definitely a family heredity component in the risk for developing Anxiety Disorder and depression together. Joseph Himle, Ph.D., Associate Director of the Anxiety Disorders Unit at the University of Michigan, says,

Looking at [what disorders populate] the family history of a person who presents with either primary Anxiety or depression provides a clue to whether he or she will end up with both.

The nature of the Anxiety Disorder also has an influence. Obsessive-Compulsive Disorder, Panic Disorder and Social Phobia are particularly associated with depression. Specific Phobias are less so.

Age plays a role, as well. Himle states,

A person who develops an Anxiety Disorder for the first time after age 40 is likely also to have depression. Someone who develops panic attacks for the first time at age 50 often has a history of depression or is experiencing depression at the same time.

Sometimes a vulnerability to Anxiety Disorders are inherited by a person, and sometimes they are transmitted to children by parental overconcern. Yapko states that:

The largest group of depression/Anxiety sufferers is Baby Boomers. The fastest growing group is their children. They can’t teach kids what they don’t know. Plus their desire to raise perfect children puts tremendous pressures on the kids. They’re creating a bumper crop of anxious/depressed children.

Treatment is similar for Anxiety Disorders and depression

Treatment of Anxiety Disorder and depression together

The treatments that work best for depression also combat Anxiety Disorder. Cognitive-Behavioral Therapy (CBT) is very successful in working with the response patterns central to both conditions. And the drugs most commonly used against depression, the SSRI’s, or selective serotonin reuptake inhibitors, have also been proved effective against an array of Anxiety Disorders, from Social Phobia to Panic Disorder and Post Traumatic Stress Disorder (PTSD). Which drug a patient should get is based more on what can be tolerated rather than on symptoms.

Treatment rarely centers on which disorder, the Anxiety Disorder or the depression, came first. “In many cases,” says Ross of the ADAA, “the depression exists because the anxiety is so draining. Once you treat the anxiety, the depression lifts.”

Treatment usually is targeted at depression and the Anxiety Disorder simultaneously. Himle states,

There’s increasing interest in treating both disorders at the same time. Cognitive Behavioral Therapy is particularly attractive because it has applications to both.

But sometimes the depression is so incapacitating that it has to be overcome first. For example, depression often interferes with exposure therapy for Anxiety, in which people gradually confront situations they avoid because they give rise to overwhelming fear. Himle notes:

Exposure therapy requires substantial effort. That’s effort that depressed people often do not have available to them.

Antidepressants can make a difference with both Anxiety Disorders and depression. Many SSRIs are approved for use in Anxiety Disorders and are the first line of drug therapy. But which drug works best for whom can not be predicted in advance; it may take some trial and error.

Ross finds CBT 80-90 percent successful in getting people functioning well, “provided it’s done correctly.” Not all psychotherapy is CBT, which has a very specific set of procedures, nor is every mental health professional trained in CBT. “Patients have to make sure that is what they are really getting.”

Treatment averages 12 to 15 weeks, and patients can expect to see significant improvement by six weeks. Ross says,

CBT doesn’t involve years and years of talk therapy. There’s homework, practice and development of lifestyle changes. Once patients learn how to identify the trigger thoughts or feelings, or events or people, they need to keep doing that. CBT gives people the tools they need.”

Medication and CBT are equally effective in reducing Anxiety Disorders and depression. But CBT is better at preventing relapse, and it creates greater patient satisfaction. “It’s more empowering,” says Yapko. “Patients like feeling responsible for their own success.” Further, new data suggests that the active coping CBT encourages creates new brain circuits that circumvent the dysfunctional response pathways.

In Summary

DSM first separated Anxiety Disorder and depression

The strong separation of Anxiety Disorders and depression into two disorders was introduced the third (1980) and fourth (1994) editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association.

The DSM is not only used for diagnoses of mental illnesses worldwide, it shapes the mindset of mental health professionals formulating treatments for Anxiety Disorder and depression. With the increasing realization that Anxiety Disorders and depression are closely related, better psychotherapy strategies are being developed to deal with both disorders simultaneously. With all the research being done on the interconnectedness of Anxiety Disorders and depression, it will be interesting to see what how these disorders are handled in the new edition of the DSM, due in 2012. It may very well be that the diagnoses of two decades will be set on their ears by this new information.

In a recent article published in the British Medical Journal, physicians Edward Shorter of Canada and Peter Tyrer of England contend that this separation of Anxiety Disorder and depression, along with several different varieties of Anxiety, is a “wrong classification” that has led the pharmaceutical industry down a “blind alley.” It is also “one reason for the big slowdown in drug discovery in psychiatric drugs,” they say, adding that it is difficult to create effective drugs for marketing-driven disease “niches.”

What do you think?

It has been my experience that Anxiety Disorders and depression went hand in hand. True to Himle’s statement, I had been diagnosed first with depression, then bipolar disorder, before I began having severe problems with Anxiety Disorders in my 50’s. Looking back, I can see the roots of the Anxiety Disorders growing decades before they were diagnosed. I have to wonder how different my life would have been had I had the advantage of modern treatment early on.

Have you had experience with an Anxiety Disorder and depression at the same time?
If you have had CBT therapy, do you agree with the claim for 80-90 percent effectiveness?
Do you think there are other mental illness diagnoses that are artificially separated?

As always, your comments are welcome!

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Resources used in this post:

Hettema, John M. (2008). What is the genetic relationship between anxiety and depression? Retrieved June 25, 2008 from American Journal of Medical Genetics Web site: http://www3.interscience.wiley.com/journal/118635818/abstract

Marano, Hara Estroff. (2007, September 11). Anxiety and Depression. Retrieved June 27, 2008 from Psych Central Web site: http://psychcentral.com/lib/2007/anxiety-and-depression/

Psychology Today. (2007). Anxiety and Depression Together. Retrieved September 23, 2008 from MedicineNet Web site: http://www.medicinenet.com/script/main/art.asp?articlekey=37715