Treatment Considerations for Patients with both Anxiety and Depression

Although cognitive-behavioral therapy has proven effective for both anxiety and depression, when individuals present with particularly high levels of both disorders, treating them with psychiatric medication as well as therapy frequently leads to the most favorable result.

In many instances, patients suffering from anxiety begin to experience significant depression when their anxiety worsens--just as patients afflicted with serious depression tend to become painfully anxious when their thoughts increasingly focus on fears about their future. Becoming sad or despairing about one's anxiety is a natural progression, just as depressed individuals are likely to worry about, or even anguish over, their negative mood state the longer they're "consumed" by it. Here, schematically, is how one might, for example, "evolve" from anxiety to depression:

Anxiety → Avoidance → Isolation → Loneliness → Feeling Abandoned & Alienated → Depression

One important research finding (supported, incidentally, by the experience of virtually all therapists--including myself) is that anxiety and depression are commonly present when a patient's primary diagnosis involves some other disorder--such as substance abuse, an eating disorder, somatoform disorder [a mental disturbance characterized by physical symptoms that lack any organic basis], or one of the personality disorders. And such "co-morbidity" suggests that medications useful for anxiety and depression might also be helpful for these other disorders, which in fact is frequently the case.

Although at times anti-depressant medications have been used in conjunction with the so-called "anxiolytics," to treat patients with both anxiety and depression, they have also been employed with some success independent of any added anti-anxiety medication. By themselves, they're frequently able to reduce the patient's anxiety symptoms and help them to regulate their mood. The class of anti-depressants known as the SSRIs (Selective Serotonin Reuptake Inhibitors)--such as Paxil, Zoloft, and Lexapro--have demonstrated efficacy in treating both anxiety and depression, as have the even more recent SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)--such as Cymbalta, Effexor, and Pristiq. Consequently, these formulations are prescribed fairly regularly to treat patients who complain of both disorders.

Further, as R. Morgan Griffin cites Dean F. MacKinnon, MD, as suggesting, when administering an SSRI or SNRI isn't in itself sufficient to alleviate the suffering of someone suffering both from anxiety and depression, they may also benefit from adding a mood stabilizer (such as lithium, an anti-psychotic drug, or even an anti-epileptic) to their anti-depressant regimen. And if sleep is a major concern (because of a racing, restless, obsessing mind), the practitioner might even want to try one of the much older tricyclic class of anti-depressants (in particular, Trazodone) to help patients get the rest and bodily restoration they so desperately need.

Since it's now clear that certain medications work well with combined anxiety and depression because of the brain chemistry affinities between these two disorders, as scientists learn even more about their related chemistry further advances in psycho-pharmacological treatments can be expected. Specifically, the small molecule inhibitor developed by Stephen Ferguson and associates (cited earlier) has already been shown in studies with mice to block a pathway responsible for the link between stress, anxiety, and depression.

To put some of the above more in layperson's terms, it's hardly coincidental that many anti-depressants are touted as also having substantial anxiety-alleviating effects. For a medication that can appropriately sedate you so that you experience less depression is also likely to dampen your anxiety. I say "sedate" because anti-depressant medications by themselves can't alter the underlying assumptions and beliefs that typically have created your emotional or mood disturbance in the first place. Mainly, it's your disturbed thinking about your situation--or rather, about your ability to summon up the necessary resources to effectively deal with it--that most often gives rise to your emotional distress.

As regards talk therapy treatments for co-occurring anxiety and depression, what does everything I've written up to this point suggest? In reviewing the literature on the subject, I think many points are worth emphasizing (and, indeed, some I already have). They are, in no particular order:

• Because of their many similarities (cognitive and chemical), therapy centering on either anxiety or depression can lead to a reduction in the symptoms of the disorder less focused upon--and a single therapy may at times be effective in addressing both disorders;
• If serious depression is to be successfully treated, any significant anxiety also present must be recognized and attended to;
• When pronounced anxiety and depression co-occur, successful treatment can be expected to be more difficult and take longer to achieve (and therapists need to be aware of such patients' increased suicide risk);
• In terms of "evidence-based treatments," cognitive-behavioral therapy (CBT) seems to have the edge over other treatments, although many types of talk therapy can effectively deal with these disorders. CBT, however, focuses more on identifying, and altering, dysfunctional thought patterns and behaviors that have culminated in feelings of helplessness and hopelessness--which, in turn, have led to the patient's serious symptoms of anxiety and depression;
• Making lifestyle changes--such as expanding one's support system, improving one's diet; learning breathing and relaxation procedures; getting more sleep; discontinuing or cutting down on tobacco, alcohol, caffeine, and any illicit substances; adding to one's daily regimen physical exercise, yoga, Pilates, etc.--can all significantly accelerate progress in therapy. Exercise, especially, has repeatedly been shown to improve the mood of depressives, and to "loosen up" the brains and bodies of those who are anxious and up-tight.

But perhaps the most important point to make here is that if you're in the throes of severe anxiety and depression, therapy alone is much less likely to be helpful than the combination of therapy and the most suitable psychiatric medication(s). That is, if your negative mind has been working overtime to keep you in a state of restless despondency, it may be impossible to get therapy off the ground until you're properly medicated. Only then may you be able to fully appreciate just how much your maladaptive beliefs and behaviors have gotten you into such a bad place . . . and how, at last, you can get yourself out of it.

Note 1: For those readers "tuning in" late for this multi-part post, here are links to and brief descriptions of its earlier parts. Part 1 described the broad distinctions between the syndromes of anxiety and depression, while Part 2 discussed the many crucial similarities between the two syndromes. Part 3 elaborated upon the various negative beliefs about self and one's place in the world that can be seen as giving rise to both these distressful mental/emotional states. And Part 4 covered the research findings and current theory on combined anxiety and depression.

Note 2: If you have any interest in following my ongoing posts on PT, please consider subscribing to my RSS feed (click on orange radio signal icon at top right corner of page, below my image).

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