When depression and anxiety co-occur, it can feel like a double blow; but getting treatment for both will help promote a better recovery.
By Robin L. Flanigan
Geoff, from upstate New York, left a teaching job two years ago to become a freelance writer. Instead of celebrating his self-employment, he questions his self-worth because, at 44, he hasn’t yet met two of his long-term goals: being able to buy a house—something he is on track to do—or finding a lasting relationship.
“I get depressed that my life isn’t as good as it should be,” he says, “and that leads to anxiety that I’ve got to get to everything and conquer all these challenges in a day.”
It’s a vicious cycle, ping-ponging between depression and anxiety—it’s an endless loop of feeling distressed that is incredibly common.
The two diagnoses “really exacerbate each other,” says Paige Lynch, a licensed professional counselor in St. Louis, Missouri. “Sometimes people identify more with one or the other, but most of my clients deal with both.”
According to a January 2019 JAMA Psychiatry study, roughly 30 percent of men and 40 percent of women diagnosed with depression before age 20 will be diagnosed with an anxiety disorder within five years. Forty percent of men and 50 percent of women will be diagnosed within 15 years. This strong association between depression and later anxiety was just one of many comorbidities identified in this study—one of the largest and most detailed examinations of comorbidity of mental disorders to date. Other studies have shown that when experienced together, depression and anxiety—considered the fraternal twins of mood disorders—are associated with more chronic symptoms, slower recovery, increased rates of recurrence, and greater medication use.
While more research needs to be done when it comes to the cause of dual-diagnosis depression and anxiety, psychiatric professionals do have some theories. One suggests the dual diagnoses have genetic underpinnings; another posits that a combination of biological and psychological factors is responsible, explains Richa Bhatia, MD, a former faculty member at Harvard Medical School and a member of the Anxiety and Depression Association of America.
Geoff sees his therapist every other week to help him cope with negative feedback loops. It helps him to remember a lesson he learned recently from a self-help book. “The people who are successful and closer to being happy,” he says, “are more compassionate with themselves.”
Reframing your perspective
To demonstrate the interconnection between anxiety and depression, Katharine Bennett, PsyD, a clinical psychologist in Grand Rapids, Michigan, describes an exercise she finds enlightening. She draws a line in the middle of a sheet of paper to make two lists—one for everything that her client says causes depression, and one for everything her client says causes anxiety. More often than not, the two lists wind up looking nearly identical.
“What comes first, the chicken or the egg?” Bennett asks. “Some people get anxious because they’re depressed, and some people get depressed because they’re anxious. Depression and anxiety are different disorders, but they’re often similar in the way they present. So for both, I try to help my clients reframe their perspectives, especially because a lot of people have cognitive distortions which are catastrophizing.”
While external events cause us distress—bills, illnesses, job loss—it is our reaction to them that will or won’t cause pain and suffering, Bennett notes. While she uses cognitive behavioral therapy (CBT), a short-term and practical approach to problem solving, to help her clients change negative patterns of thinking, she often encourages them to make a change in behavior first.
For example, some people are so stressed about their financial situation that they feel paralyzed and avoid paying bills. They feel depressed about not having a comfortable amount of money, and anxious about their growing debt. Being proactive—asking creditors to waive late fees, or starting to pay at least the minimum on credit cards—is always better than reactivity or avoidance. Those simple steps can release endorphins that trigger positive changes in their thoughts.
“Sometimes you just need to start by putting one foot in front of the other,” Bennett says.
Beth S., from Rochester, NY, knows all about catastrophizing. When she is in the midst of a major depressive episode, she has “all these questions pinging in [her] brain about what could go wrong.” The potential for an unfavorable consequence makes her anxious; her chest and stomach tighten, and she occasionally feels short of breath. The symptoms make her feel bad about herself, which inflames her depression.
“It goes round and round, and sometimes I feel like I’m stuck,” she says. She credits dialectical behavioral therapy (DBT), which aims to help people regulate emotions, tolerate distress, be mindful, and communicate effectively with others, with saving her life. The therapy approach provides her the skills she needs to help her catch herself before getting to the worst-case scenario. “It has really kept me out of the hospital.”
While part of her wellness regime includes medication and therapy, Beth explains that the behavioral skills she’s learned from DBT are useful when she’s bouncing between depressive and anxious thoughts and can’t stay focused. “I mentally take a step back and evaluate the situation,” she says, “and ask myself what I can do to change it—or make it more positive.”
This has come in handy with her morning ritual of sitting down with a cup of coffee and pad of paper and writing a daily to-do list. Her trick for preventing a state of being overwhelmed? A pencil to erase when necessary, and an acknowledgment—daily—that there aren’t enough hours in the day to accomplish everything she writes down.
While Beth recognizes this practice is an “ideal set-up,” she says it’s “also a rolling list. I do have some deadlines, but whatever else I don’t accomplish in one day, I can accomplish another day.”
Early intervention is key
While there is no shortage of scientific studies on depression and anxiety presenting separately, there are few studies on the efficacy of treatment options when both conditions are present.
“We do know from research in general that the longer any psychiatric condition goes undiagnosed, the more likelihood of frequent episodes, severe symptoms and treatment resistance,” says Bhatia.
A 2015 World Journal of Psychiatry study, which documented a higher percentage of treatment resistance in comorbid anxiety and depression than when either condition occurs alone, recommended a comprehensive approach to treatment—integrating various psychosocial approaches and incremental pharmacological interventions, among other things.
A timely, in-depth diagnostic assessment is a critical starting point, the study concluded.
“There are many evidence-based options for treatment, and many are effective even with severe anxiety and depressive disorders,” says Bhatia, “but early intervention is key.”
Regardless of the approach, people with a dual diagnosis should work with a professional who assigns homework between sessions, according to Ben Rutt, PhD, a licensed psychologist in Maryland.
“You need to come up with a plan to get you from here to where you want to be, and for this kind of issue, you can’t just go into therapy and talk about the problem of the week,” he says.
To target depression, Rutt may have clients write in a diary once a day and then look for any maladaptive thoughts, as well as take part in three social activities with people they care about—regardless of how they are feeling. For anxiety, he might help clients gradually gain exposure to a situation that in the past has caused panic attacks.
“There is a light at the end of the tunnel,” he says, “if [people] are willing to commit to doing the treatment.”
Sometimes people put off seeking treatment because they don’t realize their symptoms are more than just a normal state of being.
British Columbia’s Johanna R. lived with anxiety and depression for about a year before she sought help. In that time, her symptoms, such as impatience and extreme stress, became more frequent, as did body signals including headaches, gastrointestinal distress, and insomnia. She felt the need to meet her self-imposed high expectations, working harder and harder until she felt completely drained. Eventually she could only sleep two or three hours a night before heading back to work.
It wasn’t until she saw her general practitioner because of the insomnia that she was diagnosed with anxiety, depression and exhaustion. She was shocked.
“The symptoms get incrementally worse, so they sneak up on you,” she says. “It’s so easy to dismiss them and not take a step back to look at the pattern and realize something is wrong.”
These days, she provides individual coaching and management consulting on recognizing, preventing and healing from stress, and creating workplaces where employees are happy, healthy and more productive.
Johanna’s advice to those struggling with anxiety and depression is to learn how to recognize unhealthy reactions and develop new, healthier habits. It’s about “prioritizing, not getting angry at things you can’t control, and not feeling guilty” about helping yourself before you help others.
Adding that therapy should be part of treatment, Johanna sees a bright side to having dual diagnoses: “The things you need to do for anxiety and depression are pretty similar. It’s not twice the work to deal with both.”
Developing healthy habits
For years, Theodora B., a freelance writer who lives in Manhattan, had been more prone to anxiety than depression; that changed course in 2017 after losing her job, her dog, and her mother, all within months.
She says she went from being a social butterfly with a booked calendar “every single night of the week” to someone who canceled plans—or “straight up didn’t show up.” As a triathlete, she went from thinking any high-intensity workout less than a half-hour didn’t count, to pushing herself to get out the door for a 15-minute run.
In addition to therapy and medication, Theodora turns to fitness to manage her major depressive disorder and generalized anxiety disorder.
“Exercise was literally the one thing that was helping me hang on,” she says. “I knew I would feel at least a little better.”
Today, while she still struggles to keep a more regimented workout schedule, she does what feels right for her body in the moment. A leisurely walk or restorative yoga class seems to help when she’s depressed. When feeling anxious, she’ll attend “a slightly harder Vinyasa yoga class that will help me be more present in my body, and not in my mind when it’s not a fun place to be.”
Theodora sees a therapist once a week and is grateful for tasks she is assigned between appointments, such as having a conversation she has been avoiding out of fear, or journaling to springboard discussions later in therapy. She also maintains a blog that explains how she uses running as a stress and anxiety reliever, and to fight depression by getting “to the bottom of these thoughts I have.”
The depression and anxiety don’t always go away completely, says Andrew Buerger, PsyD, who works in private practice in Texas, “but the intensity and the frequency will come down, and you can start to cope and manage better.” He adds: “We all have our stuff. It comes down to our acceptance and relationship with it.”
For Johanna, that relationship is important. She knows she’s susceptible to more episodes, which is why she believes seeking—and sticking with —treatment is important.
“You need to make sure your good new healthy habits stick, and guard against falling back into old unhealthy habits,” she says. “Pay better attention to the warning signs your body will give you and do something much sooner than the last time. Preventing anxiety and depression is a lot easier than recovering from it.”
Co-occurring depression and anxiety can feel like a double whammy. Don’t despair—the sooner you get diagnosed and find the right treatment, the sooner you can go from feeling stuck in the middle to feeling in charge of what’s next. Try these motivators:
Be more aware. We are “wired to remember negative events more often than positive ones, so be more conscious instead of walking around on autopilot,” says Katharine Bennett, PsyD, in Michigan. Notice when you get a good parking spot, or when someone opens the door for you, and feel gratitude. “Gratitude changes your attitude.”
Stay in the present moment. “This is really crucial when you’re dealing with negative thoughts about the future that creep up,” says Beth S. of Rochester. “Tell yourself you’ll deal with those things when the time comes; that they aren’t part of your moment right now.”
Swap your thoughts. When Manhattan’s Theodora B. recognizes her negative thinking patterns, she grabs a pen to set herself straight. “If I’m feeling depressed about the way I look, I write down, ‘I am in shape.’” She does the same when she’s feeling anxious. “If I’m feeling like a guy isn’t going to call me after a date, I write, ‘I had a good time.’I can’t control everything, and that’s OK.’”
Practice compassion. In the mornings, Geoff, from upstate New York, repeats a mantra several times with his hand over his heart: “May I be safe, may I be peaceful, may I be kind to myself, may I accept myself as I am,” he says. “It calms me and makes me focus on what’s important—like the fact that I’m a good person trying to do the right things.”
Don’t settle. You don’t have to feel this way. Find a therapist you are satisfied with; if you’re not satisfied after three or four sessions, start shopping around. “You’re hiring a therapist for a service, and if they’re not delivering the service you need, find a new one,” says Paige Lynch, a licensed professional counselor in Missouri. “I love it when someone calls and asks to sit down with me for 30 minutes to see if we’re a good fit.”
Printed as “Double Diagnosis”, Spring 2019
via Esperanza – Hope To Cope
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