Comorbid Anxiety

and Depression and

its Management

Md. Golam Kibria

DSM-Inspira
 Objectives:

•Identify the DSM V criteria for anxiety and depression disorders.

•Describe the presentation of a patient with anxiety and depression.

•Outline the treatment and management options available for anxiety and
depression

•Discuss interprofessional team strategies for improving care

• Coordination and outcomes for patients with anxiety and depression.

 Psychiatric Illness

Psychosis Neurosis

Anxiety
Schizophrenia Affective (Mood) Disorder

DA, 5-HT, NA

Mania Depression Bipolar Disorder

NA, 5-HT NA, 5-HT

 Anxiety Disorder

 According to the American Psychiatric Association, anxiety disorders are

the most common type of psychiatric disorders.  Many patients with
anxiety disorders experience physical symptoms related to anxiety and
subsequently visit their primary care providers. Despite the high
prevalence rates of these anxiety disorders, they often are
underrecognized and undertreated clinical problems.

 According to the Diagnostic and Statistical Manual of Mental Disorders,

Fifth Edition (DSM-5), anxiety disorders include disorders that share
features of excessive fear and anxiety and related behavioral disturbances.
 Symptoms of Anxiety Disorder

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth

Edition (DSM-5), the criteria for an anxiety disorder vary depending on the specific
disorder. However, I can provide you with a general overview of the symptoms of
anxiety based on the DSM-5.
1.Excessive worry or apprehension: Feeling restless, on edge, or experiencing a sense of impending
doom.

2.Restlessness or feeling keyed up or on edge: Being easily fatigued, having difficulty concentrating, or
experiencing irritability.

3.Muscle tension: Feeling muscle tension or experiencing muscle aches.

4.Sleep disturbances: Having difficulty falling asleep, staying asleep, or having restless, unsatisfying
sleep.

5.Difficulty controlling worry: Finding it challenging to control the worry or the associated symptoms.

6.Cognitive symptoms: Experiencing excessive or irrational fears or concerns, recurrent intrusive

 Symptoms of Anxiety Disorder

7.Physical symptoms: Having physical symptoms such as increased heart rate,

sweating, trembling or shaking, shortness of breath, chest pain, dizziness, nausea, or
other gastrointestinal distress.

8.Avoidance behaviors: Avoiding certain situations, places, or activities due to fear

or anxiety.

9.Panic attacks: Sudden and intense periods of fear or discomfort that may include
palpitations, sweating, trembling or shaking, shortness of breath, chest pain or
discomfort, feeling dizzy or lightheaded, fear of losing control or going crazy, and
fear of dying.

10.Social anxiety symptoms: Avoidance of social situations or extreme fear or

anxiety in social situations where one may be exposed to scrutiny or potential
embarrassment.
 Types of Anxiety Disorder

Anxiety disorder list from the DSM-5 Of the 11 anxiety disorders in the
DSM-5, approximately 7.3%Trusted Source of individuals globally live
with one of these disorders.

 Separation anxiety disorder

 Selective mutism
 Specific phobia
 Social anxiety disorder (social phobia)
 Panic disorder
 Generalized anxiety disorder (GAD)
 Agoraphobia
 Substance/medication-induced anxiety disorder
 Anxiety disorder due to another medical condition
 Other specified anxiety disorder
 Unspecified anxiety disorder
 Etiology- Anxiety Disorder

Anxiety disorders appear to be caused by an interaction of biopsychosocial

factors. Genetic vulnerability interacts with situations that are stressful or
traumatic to produce clinically significant syndromes.

Anxiety can be caused by the following conditions:

•Medications
•Herbal medications
•Substance abuse
•Trauma
•Childhood experiences
•Panic disorders
https://www.ncbi.nlm.nih.gov/books/NBK470361/#:~:text=Etiology,to%20produce%20clinically%20significant
%20syndromes.
 Epidemiology- Anxiety Disorder

 Anxiety is one of the most common psychiatric disorders in the general population.

 Specific phobia is the most common with a 12-month prevalence rate of 12.1%.

 Social anxiety disorder is the next most common, with a 12-month prevalence rate of
7.4%.

 The least common anxiety disorder is agoraphobia with a 12-month prevalence rate
of 2.5%.

 Anxiety disorders occur more frequently in females than in males with an

approximate 2:1 ratio.

https://www.ncbi.nlm.nih.gov/books/NBK470361/#:~:text=Etiology,to%20produce%20clinically%20significant
%20syndromes.
 Pathophysiology- Anxiety Disorder

 The significant mediators of anxiety in the central nervous system are

thought to be norepinephrine, serotonin, dopamine, and gamma-
aminobutyric acid (GABA). The autonomic nervous system, especially
the sympathetic nervous system, mediates most of the symptoms.

 The amygdala plays an important role in tempering fear and anxiety.

Patients with anxiety disorders have been found to show heightened
amygdala response to anxiety cues. The amygdala and limbic system
structures are connected to prefrontal cortex regions, and prefrontal-
limbic activation abnormalities may be reversed with psychological or
pharmacologic interventions.

https://www.ncbi.nlm.nih.gov/books/NBK470361/#:~:text=Etiology,to%20produce%20clinically%20significant
%20syndromes.
 Depression

 Depression (major depressive disorder)

is a common and serious medical
illness that negatively affects how you
feel, the way you think and how you act.
Fortunately, it is also treatable.
Depression causes feelings of sadness
and/or a loss of interest in activities you
once enjoyed. It can lead to a variety of
emotional and physical problems and
can decrease your ability to function at
work and at home.

https://www.psychiatry.org/patients-families/depression/what-is-depression
 Symptoms of Depression

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the
criteria for a major depressive episode include the presence of at least five of the following
symptoms, which must be present for at least two weeks and represent a change from previous
functioning. These symptoms should be associated with distress or impairment in social,
occupational, or other important areas of functioning
.
1.Depressed mood: Feeling sad, empty, or having a depressed
mood most of the day, nearly every day.

2.Anhedonia: Markedly diminished interest or pleasure in almost

all activities most of the day, nearly every day.

3.Weight or appetite changes: Significant weight loss or gain or a

decrease or increase in appetite nearly every day.
 Symptoms of Depression

4.Sleep disturbances: Insomnia (difficulty sleeping) or hypersomnia (excessive sleep) nearly every day.

5.Psychomotor agitation or retardation: Observable restlessness or sluggishness nearly every day.

6.Fatigue or loss of energy: Feeling tired, fatigued, or having a lack of energy nearly every day.

7.Feelings of worthlessness or excessive guilt: Feeling worthless or excessively guilty nearly every day.

8.Diminished ability to think or concentrate: Trouble thinking, concentrating, or making decisions nearly
every day.

9.Recurrent thoughts of death or suicidal ideation: Recurrent thoughts of death, recurrent suicidal ideation
without a specific plan, or a suicide attempt or a specific plan for committing suicide.
 Types of depressive disorders

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

(DSM-5), recognizes several different types of depressive disorders. Here
are some of the major types:
 Major Depressive Disorder (MDD)

 Persistent Depressive Disorder (PDD)

 Disruptive Mood Dysregulation Disorder (DMDD)

 Premenstrual Dysphoric Disorder (PMDD)

 Other Specified Depressive Disorder (OSDD) and Unspecified

Depressive Disorder (UDD)
 Etiology- Depressive Disorder
According to the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition), the
etiology of depression, also known as major depressive disorder (MDD), is multifactorial and involves a
combination of biological, psychological, and social factors. The DSM-5 does not provide an exhaustive
list of potential causes but highlights some key factors that may contribute to the development of
depression. These factors include:

 Biological Factors: Genetic and biological factors play a role in the etiology of depression. Family
history of depression and certain genetic variations are associated with an increased risk of developing
the disorder. Imbalances in neurotransmitters, such as serotonin, norepinephrine, and dopamine, are
also thought to contribute to depressive symptoms.

 Psychological Factors: Certain psychological factors can increase the vulnerability to depression.
Individuals with low self-esteem, a negative outlook, or a history of childhood trauma or abuse may be
more prone to developing depression. Additionally, individuals with certain personality traits, such as
high levels of neuroticism, may have a greater risk of experiencing depressive symptoms.

 Social Factors: Social and environmental factors can influence the onset and severity of depression.
Stressful life events, such as the loss of a loved one, divorce, financial difficulties, or interpersonal
conflicts, can trigger or exacerbate depressive episodes. Lack of social support, social isolation, and
difficulties in interpersonal relationships can also contribute to the development of depression.
 Epidemiology- Depressive Disorder

 Prevalence: Depression is a common mental health disorder worldwide.

According to the World Health Organization (WHO), more than 264
million people of all ages suffer from depression globally. The prevalence
rates can vary across countries and populations, but on average, around
4.4% of the global population experiences a depressive episode in a given
year.

 Gender Differences: Depression is more prevalent in women compared to

men. Women tend to experience depression at roughly twice the rate of
men. This difference becomes evident during adolescence and continues
throughout adulthood. Various factors, including hormonal, genetic, and
psychosocial influences, may contribute to this disparity.
 Epidemiology- Depressive Disorder

 Age of Onset: Depression can occur at any age, from childhood to late
adulthood. However, it often emerges in adolescence or early adulthood.
Major life transitions, such as puberty, academic pressures, and social
challenges, can contribute to the onset of depression during this period.
The risk of depression also increases in older adults, particularly those
facing health issues, social isolation, or bereavement

 Comorbidity: Depression frequently co-occurs with other mental health

disorders and physical conditions. Anxiety disorders, substance use
disorders, and chronic medical conditions like diabetes, cardiovascular
disease, and chronic pain often coexist with depression. The presence of
comorbidities can complicate the diagnosis, treatment, and overall
management of depression.
 Pathophysiology- Depressive Disorder

 Neurotransmitter Imbalance: One prominent theory suggests that an

imbalance in certain neurotransmitters, particularly serotonin,
norepinephrine, and dopamine, plays a role in depression. These
neurotransmitters are involved in regulating mood, emotions, and the
brain's reward system. Low levels of these neurotransmitters or impaired
signaling between them may contribute to depressive symptoms.

 Neuroendocrine Dysregulation: The hypothalamic-pituitary-adrenal

(HPA) axis is a crucial component of the body's stress response. In
individuals with depression, there is evidence of dysregulation in the
HPA axis, leading to abnormalities in the release of stress hormones like
cortisol. Elevated cortisol levels and impaired stress response may
influence mood and contribute to the development of depression.
 Pathophysiology- Depressive Disorder

 Inflammation and Immune System Dysfunction: Chronic

inflammation and immune system dysfunction have been associated with
depression. Increased levels of pro-inflammatory cytokines, such as
interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha), have
been observed in individuals with depression. Inflammation may disrupt
the functioning of neurotransmitters, neuroplasticity, and neurogenesis,
contributing to depressive symptoms.
 Structural and Functional Brain Changes: Brain imaging studies have
revealed structural and functional alterations in specific brain regions
implicated in mood regulation and emotional processing. Areas such as
the prefrontal cortex, hippocampus, amygdala, and the anterior cingulate
cortex may show reduced volume, abnormal activity, or connectivity
patterns in individuals with depression. These changes may underlie the
cognitive and emotional symptoms observed in depression.
 Pathophysiology- Depressive Disorder

 Genetic and Epigenetic Factors: There is evidence that genetic factors

contribute to the risk of developing depression. Certain gene variants
involved in neurotransmitter regulation, stress response, and
neuroplasticity have been associated with an increased susceptibility to
depression. Epigenetic mechanisms, which can modulate gene
expression without altering the DNA sequence, may also influence the
development and progression of depression.
Antidepressants
 Anti-anxiety Drug

Anti-anxiety Drug

BZDs AZAPIRONS ANTIDEPRESSANTS SEDATIVES BETA-BLOCKERS

Diazepam Buspiron SSRI Hydroxyzine Propanolol

Chlordiazepoxide Gepiron TCA
Oxazepam Ispapiron
Lorazepam
Alprazolam
Nitrazepam
Clonazepam-Long T 1/2,
Highly potent
 Anxiety and Depression

 Depression often accompanies anxiety

disorders and when it does, it needs to be
treated as well
 Symptoms of depression include feelings
of sadness, hopelessness, changes in
appetite or sleep, low energy, and difficulty
concentrating.
 Most people with depression can be
effectively treated with antidepressant
medications, psychotherapy, or a
combination of both.
 Comorbid depression with anxiety

 It is recommended that anxiety symptoms should be taken into account

when assessing the most appropriate antidepressant agent for treating
someone with depression, to optimize treatment outcome and recovery
rate.
 Escitalopram/ Paroxetine/ Desvenlafaxine is extensively prescribed
medication for major depression.
 Clonazepam is a highly potency, Long-acting benzodiazepine with
anxiolytic property.
 Clonazepam’s long half-life of 20 to 80 hours render this compound
especially promising for augmenting therapy in major depression,
because inter-dose fluctuation in mood state is less.
 Hence it is rational to combine it with SSRI for comorbid depression
with anxiety