quick LESSON Anxiety and Depression: Comorbidity

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Description/Etiology
Anxiety and depressive disorders occur in combination more often than either condition occurs alone, and have
overlapping symptoms that can complicate diagnosis and treatment. Anxiety and depression are often debilitating,
chronic, and costly to affected individuals. (For more information, see Quick Lesson AboutDepression: an Overview
and series of Quick Lessons on anxiety disorders, including Quick Lesson AboutGeneralized Anxiety Disorder , and
Quick Lesson AboutPost-Traumatic Stress Disorder .)
Symptoms of an anxiety disorder often precede symptoms of a depressive disorder, with anxiety symptoms typically
appearing in early childhood to adolescence. Patients may be diagnosed with comorbid anxiety and depression if
they present with increased impairment in daily life (e.g., work and interpersonal relationships), decreased quality of
life (QOL), and suicidal ideation and a history of suicide attempts . The coexistence of anxiety and depression
often leads to symptoms that are more severe than when either disorder occurs independently, and is associated
with a more severe course of illness and less favorable prognosis, including substantially higher risk for suicide
attempts. When a patient complains of or is diagnosed with an anxiety disorder they should be assessed for signs and
symptoms of depression. The differential diagnosis includes bipolar disorder (i.e., a condition that is characterized
by alternating periods of mania and depression), which is not diagnosed unless cyclical depressive symptoms are
present. Other conditions can cause signs and symptoms that imitate those of comorbid depression and anxiety,
including diabetes mellitus, cancer, attention deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder
(OCD), ulcerative colitis, and bereavement.
Treatment of patients with comorbid anxiety and depression includes pharmacology and referral to a mental health
clinician for cognitive-behavioral therapy (CBT). Pharmacologic treatment options include antidepressants (e.g.,
selective serotonin reuptake inhibitors [SSRIs]), antianxiety agents (e.g., benzodiazepines), and sedatives. Patient
education regarding the diagnosis and the importance of regularly performing relaxation techniques is important.
Comorbid anxiety and depression are associated with greater persistence of related manifestations, poorer response
to treatment, and lower health-related QOL compared with either condition alone.

Facts and Figures

A high rate of comorbidity exists between depression and anxiety disorder. More than 60% of patients with an
ICD-9 anxiety disorder, including 39% of those with a diagnosis of generalized anxiety disorder, also meet the diagnostic
300.4 criteria for depression. Social anxiety disorder is associated with a two-fold increased risk of developing depression.
About 85% of patients with major depression experience significant anxiety. Cormorbid anxiety and depression are
present in up to 25% of patients in the primary care setting. Forty percent of patients with comorbid anxiety and
depression do not seek treatment. In children and adolescents, 1015% of those with an anxiety disorder also have
Authors
a depressive disorder and 2050% of those with a depressive disorder also have an anxiety disorder; children and
Penny March, PsyD
Cinahl Information Systems, Glendale, CA
adolescents with comorbid anxiety and depression tend to be older and more severely affected.
Tanja Schub, BS
Cinahl Information Systems, Glendale, CA Risk Factors
Risk factors for comorbid anxiety and depression include female gender, poor self-perception of personal health,
Reviewers lower socioeconomic status, and high levels of pain and disability. Patients who have PTSD related to a history of
Eliza Schub, RN, BSN early traumatic experiences and childhood abuse frequently develop severe anxiety and depression. Family history of
Cinahl Information Systems, Glendale, CA either anxiety or depression can increase the risk for developing comorbid disorders.
Rosalyn McFarland, DNP, RN, APNP,
FNP-BC Signs and Symptoms/Clinical Presentation
Nursing Practice Council
Signs and symptoms of depression include daily depressed mood for most of the day, diminished interest in
Glendale Adventist Medical Center,
previously pleasurable activities, weight fluctuations, fatigue, a feeling of worthlessness, sleep disturbances,
Glendale, CA
listlessness, restlessness, concentration difficulties, and recurrent thoughts of death or suicide . Symptoms of
anxiety include shakiness, muscle aches, sweatiness or clammy hands, fatigue, racing heart, irritability, feelings of
Editor apprehension and a persistent worry that something negative may occur, ruminations, phobias, somatic complaints,
Diane Pravikoff, RN, PhD, FAAN and panic attacks.
Cinahl Information Systems, Glendale, CA

Assessment
Patient History
December 6, 2013

Published by Cinahl Information Systems, a division of EBSCO Publishing. Copyright2014, Cinahl Information Systems. All rights reserved. No
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given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional.
Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
 Ask about medical and mental health history to determine if the symptoms are psychologically based or related to a medical condition; ask about medication
history to evaluate adverse reactions to medications as a cause of depression and/or anxiety
Assess for psychosis , which can be present in patients with depression
Assess for suicidal ideation and level of threat to self and others
Laboratory Tests That May Be Ordered
UA may be ordered to assess for underlying medical conditions as a cause of depression, anxiety, or both
Drug testing may be ordered to assess for drug levels that can cause anxiety or depression
CBC may be ordered to assess for anemia, which can cause symptoms of anxiety and depression
Thyroid function tests may be ordered to evaluate for hyper- and hypothyroidism as a cause of anxiety and depression
Blood glucose level may be ordered to evaluate for hypoglycemia as a cause of anxiety
Other Diagnostic Tests/Studies
EKG may be performed to assess for cardiovascular disease, which is common in persons who have anxiety and depression
Pulmonary function testing may be performed to assess for asthma as a cause of anxiety
CAGE questionnaire may be administered to assess for substance abuse as a cause of anxiety and depression (for details, seehttp://jama.jamanetwork.com/
article.aspx?articleid=182810)
Psychological assessment tools such as the Hamilton Rating Scale for Depression (HAM-D), the Hamilton Anxiety Scale (HAS), the Penn State Worry
Questionnaire (PSWQ), and the Beck Anxiety Inventory (BAI) are often ordered to assess for depression and anxiety

Treatment Goals
Promote Optimum Physiologic and Mental Health Status
Monitor vital signs and assess level of depression and anxiety; administer prescribed benzodiazepines (e.g., ALPRAZolam, LORazepam, diazepam,
clonazePAM) for immediate reduction of severe anxiety and reduce environmental stimulation
Monitor for suicidal ideation and maintain patient safety (e.g., airway, circulation, and prevention of injury); follow facility protocols for requesting
patient surveillance by facility security officers and 1:1 staffing, as appropriate
Request referral to a mental health clinician and/or request transfer to a mental health unit/facility, as appropriate
Administer prescribed antidepressants (e.g., SSRIs, e.g., sertraline, FLUoxetine)
A common treatment regimen for comorbid anxiety and depression includes prescribing a benzodiazepine in combination with an SSRI, with tapering of
the benzodiazepine as the SSRI begins to exert its effect
Regulate patients caffeine intake (e.g., soft drinks, chocolate, coffee) and educate that caffeine intensifies anxiety; demonstrate relaxation techniques (e.g.,
deep breathing exercises, visualization, stretching and physical activity to relax muscles) and educate that regularly performing these will increase the patients
sense of self-control
Provide Emotional Support and Educate
Assess patient/family for knowledge deficits regarding the diagnosis; provide emotional support, educate, and encourage discussion regarding the diagnosis,
potential complications, underlying or comorbid conditions if appropriate, the importance of adherence to the prescribed treatment regimen of therapy and
medication, treatment risks and benefits, and individualized prognosis
Request referral to a social worker for identification of local and Internet resources for support groups and information regarding the diagnosis

Food for Thought

Patients with anxiety and depression receive more prescriptions for psychotropic drugs than patients who have either condition alone
Anxiety and depression are both commonly found in patients with heart disease, and the presence of either anxiety or depression in cardiac patients is
associated with poor prognosis

Red Flags
Benzodiazepines, which are associated with physical dependence, memory impairment, and drowsiness, can cause severe withdrawal symptoms if discontinued
abruptly
Patients who receive SSRIs can have adverse effects (e.g., jitteriness) that worsen anxiety; SSRI dosage should be increased slowly to avoid adverse effects that
could intensify anxiety
Unlike either condition alone, comorbid depression and anxiety during pregnancy are associated with elevated maternal level of cortisol, which is associated
with adverse birth outcomes and subsequent health compromise of the child when he/she reaches adulthood

What Do I Need to Tell the Patient/Patients Family?

Provide written information such as a booklet from the Anxiety Disorder Association of America available through the U.S. National Institute of Mental
Health Web site at http://www.nimh.nih.gov/), to educate about anxiety and depression symptoms and treatment options
Educate patient and/or family members about prescribed medications and when to contact the treating clinician should side effects develop
Encourage joining a support group for contact with others who have similar health challenges

References
1. DynaMed. (2013, October 31). Depression. Ipswich, MA: EBSCO Publishing. Retrieved November 19, 2013, from
http://search.ebscohost.com/login.aspx?direct=true&db=dme&AN=116638&site=dynamed-live&scope=site
2. Flynn, M. K., & Kaplan-Gill, M. L. (2013). Anxiety. In F. J. Domino (Ed.), The 5-minute clinical consult 2013 (21st ed., pp. 88-89). Philadelphia, PA: Wolters Kluwer Health/
Lippincott Williams & Wilkins.
3. Johnson, L. E., & Greenberg, M. T. (2013). Parenting and early adolescent internalizing: The importance of teasing apart anxiety and depressive symptoms. Journal of Early
Adolescence, 33(2), 201-226. doi:10.1177/0272431611435261
4. Johansson, R., Carlbring, P., Heedman, , Paxling, B., & Andersson, G. (2013). Depression, anxiety and their comorbidity in the Swedish general population: Point prevalence
and the effect on health-related quality of life. Peer J, 1, e98. doi:10.7717/peerj.98
5. McIntyre, R. S., Rosenbluth, M., Ramasubbu, R., Bond, D. J., Taylor, V. H., Beaulieu, S., & Schaffer, A. (n.d.). Managing medical and psychiatric comorbidity in individuals with
major depressive disorder and bipolar disorder. Annals of Clinical Psychiatry, 24(2), 163-169.
6. Tiller, J. W. G. (2012). Depression and anxiety. MJA Open, 1(Suppl 4), 28-31. doi:10.5694/mjao12.10628