Let's Talk About the Link Between Depression and Anxiety
Depression and anxiety are a notorious duo, often striking at the same time. Being depressed can make us more anxious, and anxiety can make us more depressed. Here’s what you need to know to break the cycle.
Depression and anxiety are like that toxic couple we all know who bring out the worst in each other. We (in this case, researchers) don’t get the attraction, but it’s definitely there. Even though they ratchet up stress levels, aggravate each other’s symptoms, and suck the joy out of life in general, they’re determined to stick together. Think of depression and anxiety as this couple. You’d avoid them at a dinner party, but now they live in your head and they never shut up. Here, we’ll explain why they’re so intertwined, how they manifest differently, and how understanding these factors can help you treat them when they show up together, uninvited.
Our Pro Panel
We asked some of the nation's top depression and anxiety experts to bring you the most up-to-date information possible.
James B. Potash, M.D., M.P.H.
Henry Phipps Professor of Psychiatry and Behavioral Sciences, Department Director and Psychiatrist-in-Chief
Johns Hopkins School of Medicine
Carol A. Bernstein, M.D.
Psychiatrist, Vice Chair for Faculty Development and Well-Being in the Departments of Psychiatry and Obstetrics and Gynecology
Montefiore Medical Center/Albert Einstein College of Medicine
The Bronx, NY
Jennifer L. Payne, M.D.
Director of the Women's Mood Disorders Center and Associate Professor of Psychiatry
Johns Hopkins School of Medicine
More common than you think! Nearly one in five Americans has an anxiety disorder, so if you do too, you’re definitely not alone. That equates to 40 million people every year—more of the XX chromosome variety. Specifically, women are affected nearly twice as much as their male counterparts. This could be because of differences in brain chemistry, fluctuations of reproductive hormones, or how men and women tend to cope with stress differently (women tend to ruminate more while men are more problem-solvers, according to research).
That’s a valid concern…and it’s also exactly what someone with Generalized Anxiety Disorder would ask. It’s true that sweating, racing heart, headaches, stomach problems, lightheadedness, and shortness of breath can all be signs of underlying medical conditions, so it’s not unreasonable to see your physician for a routine workup. The most common physical health issues that can be confused with an anxiety disorder are thyroid problems, B12 deficiency, and Irritable Bowel Syndrome (IBS), which can trigger anxiety. If your doc clears you but you’re still excessively worried that they missed something, don’t insist on undergoing more and more exploratory tests. Discuss those fears with a therapist first (particularly if you might have a touch of hypochondriasis—a.k.a. health-focused anxiety).
Depression and an anxiety are so closely related that any therapist worth their degree (and please, please check that they are licensed) will be able to create a treatment plan that can help you with both, since therapeutic approaches for both conditions are similar. If your depression is so severe that you don’t have the motivation to give therapy your best go, they might focus on lifting the black cloud of depression more aggressively at first. Since depression and anxiety can exacerbate one another, it’s important to treat both disorders to stop their self-perpetuating cycle.
It does. And while motivating to suit up and go for a jog may take every ounce of determination you’ve got, it’ll likely be worth it. Working out releases feel-good chemicals called endorphins, revs your circulation, and boosts your self-confidence. You don’t have to go full-on HIIT for an hour to get the benefits. A recent review in the Journal of Happiness Studies found that even as little as 10 minutes of physical activity per week can increase your level of happiness.
What Is Anxiety, Exactly?
Before we jump into the relationship between depression and anxiety, let’s define some terms. Everybody experiences some anxiety (i.e. worries, stuff that stresses them out or makes them nervous). It’s normal and appropriate to feel anxious if you’re, say, taking an important exam, being unexpectedly summoned to your boss’s office, or about to sing your first hit single in front of an arena full of fans.
That type of anxiety is actually a pretty beneficial response, even though it feels uncomfortable at the time. Back in the caveman days, anxiety turned on our fight-or-flight stress response in times of imminent physical danger, which helped us survive things like woolly mammoth attacks. Today, that type of anxiety mostly helps us pay attention to our surroundings, prepare for challenges, and think on our feet.
An anxiety disorder is different from normal anxiety. For people with clinical anxiety, these worries don’t go away—in fact, they keep growing until they begin to take over your life. Over time, trying to escape these uncontrollable anxious feelings can make your world smaller as you find yourself avoiding work obligations, social events, even friendships. We’re not talking about staying home on a Saturday night to decompress from a trying week. Your fears and worries must be totally out of proportion and affect your ability to function.
Feeling this way is, unfortunately, not uncommon: Anxiety disorders are the number-one mental illness in the United States, with 18% of adults—approximately 40 million people—experiencing one every year. Women are affected nearly twice as much as men. (Even kids aren’t immune, with 8% of children between 6–17 years old diagnosed with either anxiety or depression. ) Among adults, 7% to 9% have a specific phobia, 7% have social anxiety disorder, 2-3% have panic disorder, 2% have agoraphobia, 2% have generalized anxiety disorder, and 1 to 2% percent have separation anxiety disorder.
Do I Have the Symptoms of an Anxiety Disorder?
Well, it depends which type of anxiety you have, or may have. This disorder comes in several varieties. Here are some of the most common ones.
Generalized Anxiety Disorder (GAD). You’re forever anticipating disaster, which involves constant, intense worry and rumination about pretty much anything. Symptoms also include:
Muscle soreness, from tensing up all the time
Shortness of breath
Social Anxiety Disorder (SAD). With SAD, anxiety revolves around social situations where other people might judge you: meeting new people, public speaking, parties, eating in public. Avoiding social interactions can erode your friendships, love life, and career.
Mental symptoms: high levels of anxiety and fear, dreading social events, fear of embarrassment and humiliation
Physical symptoms: blushing, shaky hands, nausea, stumbling over words, situationally pre-disposed anxiety attacks
Panic Disorder. Your fight-or-flight response should have an “out of order” sign on it. You experience recurrent, unexpected panic attacks. Though the attacks peak within 10 minutes and then ease up, they’re so terrible that you’re constantly worried about when you’ll have your next one. You may experience:
Feelings of unreality, like you’re in a movie
Racing heart, sweating, shaking
Feeling like you’re having a heart attack
Shortness of breath
Agoraphobia. In the movies, agoraphobic people can’t leave their home at all, but that’s only true for the most severe cases. You might avoid subways and buses, elevators or tight spaces, open spaces, or crowds. For obvious reasons (feeling stuck at home, unable to participate in life), agoraphobia and panic disorder often occur together. Usually, fears are focused on situations that you predict could cause a panic attack or make you feel:
Separation Anxiety Disorder. Your anxiety is fixated on being separated from a caretaker, parent, spouse or other loved one, or even a pet. You might fear being left alone or think something bad will happen to them if you’re apart. Children are more likely to get this (4% of them), but some adults experience it, too (1.2%). In adults, this dependence eats away at your self-esteem and sense of agency. You may feel like a burden to the other person.
Children, who are less able to express their emotions, are more likely to show physical symptoms including:
Specific Phobias. An irrational, intense fear of a specific object or situation. There’s a phobia for everything—snakes, heights, blood, clowns—but the commonality is that you’re so scared of The Thing that you’ll do just about anything to avoid it. Sometimes, even a depiction or passing mention of The Thing can send you into an anxiety spiral.
What Are the Symptoms of Depression (a.k.a. Major Depressive Disorder or MDD)?
Having depression can mean a lot of things (anxiety, fear, and uncertainty may play a role), but the main element, without a doubt, is a hopelessness. But if an anxiety disorder has been controlling your life, it’s not unheard of to feel depressed as a result.
Symptoms of depression include:
Feeling sad, despairing, or apathetic nearly every day
Things that used to make you happy no longer bring you joy
Increased hunger (or gaining weight) or decreased hunger (or losing weight)
Feeling exhausted and drained of energy
Sleeping too much or too little
Slowed-down thinking and movement (a.k.a. psychomotor retardation) or the opposite, nervous energy (a.k.a. psychomotor agitation)
Feeling guilty or worthless
Having a hard time concentrating and making decisions
Recurring thoughts of death or suicide
Can I Have Both Depression and Anxiety?
Not only is it possible to have both at the same time, it’s actually pretty common. One study found that half of people with depression or an anxiety disorder also have the other condition!
Someone struggling with clinical depression might show symptoms of an anxiety disorder, and vice versa. Anxiety might be a symptom of depression, or it might trigger depression. Or they could be separate problems that show up at the same time. This is called comorbidity, and it means that two chronic conditions (in this case, depression and anxiety) are working together to make things super sucky for you.
Depression and anxiety are often confused for one another because, at times, they look and feel very similar. Many symptoms of anxiety mirror depressive ones, like irritability and restlessness, sleep problems, fatigue, and difficulty concentrating. Both conditions can cause distress and result in avoidance behaviors like withdrawing from friends and family.
So How Can I Tell Depression and Anxiety Apart?
People with anxiety disorders are typically stressed out about all the ways that future events can and will go wrong. People with depression dwell on past failures, are unable to find joy in the present, and have no hope that the future will be better. When avoidant behaviors pop up, the best way to determine if it’s due to depression or anxiety is to ask yourself, What’s my motivation?
Say you’re invited to a party. Instead of attending, you stay in and spend the evening curled in the fetal position, crying into a box of wine. If you’re home because you’re exhausted and you already know you won’t have fun since you never have fun anymore, so what’s the point—that’s depression. If you’re home because all your party clothes look terrible on you, your car’s making a weird noise so you’ll probably get into an accident on the way, and even if you do make it to the party, you’ll look stupid when you can’t pronounce the hostess’s last name properly—that’s anxiety.
Why Are Depression and Anxiety So Obsessed With Each Other?
There are a few reasons why this duo shows up together so often. First off, they’re easily recognizable. People use the terms “depressed” and “anxious” in a non-clinical way to express their feelings about the typical ups and downs of life. Brief periods of feeling depressed and anxious are common and super-relatable
Even clinically recognized symptoms of an anxiety disorder can look like depression. That overlap of symptoms could mean they share a biological or chemical pathway in the brain. On the other hand, the current diagnostic criteria in the DSM-5—the official guidebook for mental health conditions—could just be making it look that way.
Both conditions commonly present with these overlapping symptoms:
Psychomotor retardation or agitation
Difficulty concentrating and indecisiveness
Scientists don’t yet know why depression and anxiety have this peanut butter and jelly relationship. There’s no single easy-to-point-to gene responsible for them. Actually, a recent large-scale genetic study from The University of Edinburgh identified a whopping 269 genes linked to depression. Some scientists point to [low serotonin levels and changes in brain chemicals like dopamine and epinephrine](https://www.healthcentral.com/condition/depression-causes), while others think that a neurotransmitter called GABA plays a large role.
Depression and anxiety have also been linked to a part of the brain called the amygdala, which helps process emotions, actions, and cognition. Needless to say, researchers are still working it all out.
One condition can also trigger the other. Maybe you’re anxious because you haven’t experienced a positive mood in forever, because you’re depressed. Or maybe you’re depressed because your anxiety isolates you from the people, things, and activities you used to love. Luckily, it doesn’t really matter so much which disorder came first or exactly what the underlying biological mechanism is, since they have similar treatments.
Targeted therapy that focuses on problem-solving and changing negative thinking patterns, such as Cognitive Behavioral Therapy (CBT), and antidepressants are effective ways of dealing with both anxiety and depression. For severe anxiety, benzodiazepines (also called “benzos”) like Xanax (alprazolam), Klonopin (clonazepam), Ativan (lorazepam) may be used for short-term relief or as needed as a part of your treatment program.
How Can I Cope With Depression and Anxiety?
Don’t go at it alone! A professional therapist can help formulate a plan to treat your anxiety and depression at the same time, with therapy, medication, or a combination of both. Resist the urge to withdraw from the world. Socializing with friends and family can lift your mood by taking you out of your own head for a while. Here, some other steps you can take to keep depression and anxiety from spiraling out of control.
Opt out of coffee culture. Caffeine can aggravate anxiety and trigger panic attacks, so ditch the espresso stress-o. Same goes for other high-caffeine items like tea, energy drinks, chocolate, and diet pills.
Get some exercise. Unfortunately, when you’re mired in depression and anxiety, the last thing you want to do is change into wicking fabric and work up a sweat. (Life would be a lot easier if stress-eating potato chips helped, right?) Real talk: You’re not going to just wake up one day motivated to exercise. The secret is to do it anyway. If you’re tired, start with a 10-minute walk. After that, see if you can keep going. If you’re feeling worried, work out and worry at the same time. Regular exercise calms your depressive and anxious symptoms by getting your circulation going, releasing endorphins (feel-good chemicals), and focusing your mind on something other than negative self-talk. Over time, your confidence and mood will improve as you build momentum.
Practice mindfulness meditation. It might seem impossible for a jittery, restless person with anxiety issues to close their eyes, sit on a pillow, and focus on breathing for 20 minutes a day, but studies show it reduces stress. Focused, deep breathing is the antidote to anxious hyperventilation. Mindfulness meditation, in particular, trains your attention on the present moment, not on your internal monologue, predicting the future, or ruminating over the past.
Relax from head to toe. Progressive muscle relaxation is a stress-relief exercise that involves slowly and systematically tensing, then relaxing, each of the body’s muscle groups. For a similar guided meditation technique, you can download a body scan meditation, in which you focus attention on bodily sensations in a gradual sequence from the feet to the head.
Depression and Anxiety Comorbidity (1): European Psychiatry. (1998). “The role of serotonin in depression and anxiety.” europsy-journal.com/article/S0924-9338(98)80015-1/pdf
Depression and Anxiety Comorbidity (2): Primary Care Companion For CNS Disorders. (2001). “The Comorbidity of Major Depression and Anxiety Disorders: Recognition and Management in Primary Care.” psychiatrist.com/PCC/article/Pages/2001/v03n06/v03n0609.aspx
GABA & Anxiety Disorders: Journal of Clinical Psychology. (2003). “The role of GABA in anxiety disorders.” ncbi.nlm.nih.gov/pubmed/12662130
Overlapping Symptoms: Journal of Clinical Psychiatry. (1997). “Symptom Overlap in GAD and Depression.” adaa.org/sites/default/files/GAD_depression_symptoms%20overlap.pdf
Social Anxiety Disorder: International Journal of Psychiatric Research. (2012). “Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States.” ncbi.nlm.nih.gov/pmc/articles/PMC4005415/
Panic Disorder: The National Institute of Mental Health (NIMH). (n.d.). “Panic Disorder: When Fear Overwhelms.” nimh.nih.gov/health/publications/panic-disorder-when-fear-overwhelms/index.shtml
Diagnostic Overlap: Depression and Anxiety. (2012). “Diagnostic Overlap of Generalized Anxiety Disorder and Major Depressive Disorder in a Primary Care Sample.” ncbi.nlm.nih.gov/pmc/articles/PMC3629816/#R13
Biological Link: Nature Neuroscience. (2010). “CRF receptor 1 regulates anxiety behavior via sensitization of 5-HT2 receptor signaling.” nature.com/articles/nn.2529
Treatments (1): PLoS One. (2018). “Cognitive behaviour treatment of co-occurring depression and generalised anxiety in routine clinical practice.” ncbi.nlm.nih.gov/pmc/articles/PMC6062076/
Treatments (2): The Anxiety and Depression Association of America. (2019). “Medication.” adaa.org/finding-help/treatment/medication