When Anxiety and Depression Join Forces
There is no doubt that the chances of suffering depression are higher if you have an anxiety disorder. The greatest risk is if you have panic disorder: You are 6 times more likely to become depressed.(1) Generally, the longer you remain anxious, the more likely you will get depression.
In addition, depression frequently makes anxiety far worse. During a spell of depression (a 'depressive episode' in medical language), anxiety and obsessional states usually become intensified. Even people who have never suffered from anxiety can develop symptoms of anxiety while they are clinically depressed.
The good news is that when the depression goes away, your anxiety is likely to reduce back down to wherever it was before you got depressed.
Until then you need to take into account that your approach to dealing with anxiety (and life) will not be the same as when you are well (or just anxious). So here's how to deal with anxiety AND depression in 6 simple steps.
Step1: Identify if you really have depression
Strange though it may seem, many people who say they are depressed are in reality experiencing something else! So, before reading any further check that you are not simply:
- Unhappy/fed up
- Plain bored
- Just tired
What are the symptoms of depression?
Look at this checklist to determine whether you may have depression:
- Long periods of sadness, dejection and hopelessness
- Reduced energy and motivation
- Inability to gain pleasure from things previously enjoyed
- Feelings of guilt and low self esteem
- Anxiety, panic attacks or obsessive symptoms have intensified
- Insomnia OR oversleeping
- Waking early, with or without anxiety
- Change in appetite - increased OR decreased
- Lowered sex drive
Your doctor can help you discern whether you really do have depression, and also whether you need medication to get well. The great news is that antidepressants also help anxiety, so tend to kill two birds with one stone. For more on when to consider medication go to my article Medication - A Thorny Subject.
Another reason to see a doctor is just in case your depression has a physical cause, unrelated to stress and lifestyle. (This is less likely and won't be addressed within this article)
Step 2: Recognize that depression is a real illness that requires proper care
Okay, now is a good time to clear up some of the misconceptions surrounding depression. Some people believe that depression is all in the mind and not a real illness. They imply that you're being a bit weak, you just have to get on with it. Or if you just think positive thoughts you'll be fine.
When expressed aloud these kinds of thoughts are extremely hurtful to people with depression. You need to recognize without any doubt that depression is a real illness linked to changes in the chemistry AND structure of the brain. It may be triggered by stress or anxiety but once you have it, it's real and it's physical. Positive thinking is unlikely to help, and trying to be stronger could make you more sick. It may become impossible to continue functioning normally.
MRI studies show that the depressed brain loses up to 32% volume in one region of the frontal cortex and 18% volume in the hippocampus.(2,3)
Therefore, stop right now all self criticism and self-berating - either for feeling the way you do or not managing to do everything you would normally do.
You have to realize at this point that you cannot do what you were doing previously... and you should not try. This especially applies to daily responsibilities, keeping others happy, and coping with stress. You are ill precisely because you have overloaded the system (in this case your brain), most likely through a combination of stress, anxiety and your own high standards and expectations.
An analogy would be putting an 18 amp current through a 13 amp fuse. It's blown. For a while you are powered down and will not even be able to manage the normal 13 amps. You must operate at just 3 amps. Tim Cantopher, in his book Depressive Illness: The Curse of the Strong, spells this out very clearly.(4)
All change! Healing the depression should now become the No. 1 priority. Everything else (even fixing your anxiety) comes second.
That's right. You should not try to work on your anxiety in the same way that you might if you were not depressed. Fortunately, as it happens, many of the things you do towards healing depression will help your anxiety too.
Here are some more points:
- You may not have the energy or motivation to carry out the work of therapy or self help just yet... but that's okay (for now).
- You may not have the concentration span to think constructively or work through problems... that's fine, leave that (for now).
- Do all you can to avoid stress. If you don't, it will be like trying to heal a bruise while allowing someone to keep on thumping it; or trying to heal a broken leg while still walking on it.
- You should also avoid counseling or therapy models that involve deep introspection, analysis or recalling painful memories. These could deepen depression.
Step 3: The basic treatment for more severe depression
- Slow down, stop, take a proper break, and at all costs avoid stress. Remember its a 3 amp fuse for the time being.
Minimize responsibilities and all the things you normally do to keep people happy (trust that they will cope). Delegate whatever you can to others who are well. Not all responsibilities can be avoided but even halving your usual quota will pay dividends in terms of speeding your recovery. Whatever you agree to continue, break it down into small steps, punctuated with rest. Give yourself praise for everything you get done.
- Try to ensure that you are eating properly and getting the right amount of sleep (as far as you can).
- If the doctor has prescribed medication, do consider taking it. There is a 60-70% chance it will help you feel better and speed your recovery.
- Do all you can to stop the cycle of ruminating. Do not try to figure out what's wrong with you or why you are depressed. Do whatever you can to break the pattern of dwelling on your problems, the past, or how much you've failed. At least for now, accept that depressed feelings, as well as heightened anxiety are just stressed neurons in the depressed brain firing abnormally. It is only temporary and will improve if you protect the 'stress centers' in your brain.
- Learn to relax deeply on a regular (daily) basis. Some people enjoy meditation, but this requires focus and concentration - which may be thin on the ground when you're depressed. Self hypnosis recordings are better in this respect. You can take a passive role, just following along or drifting off altogether. There are many CDs and downloads available. You can even choose from a variety of issues you would like to deal with.
- Try to engage in pleasant relaxing activity - for short intervals at first. If you no longer enjoy anything, try doing something you used to enjoy. But make sure it's light and in no way taxing to your reduced energy reserves. Make sure you appreciate these small steps towards recovery and give yourself praise.
- Spend as much time as you can in natural daylight. Some people develop depression during the winter months when days are shorter and much time is spent in artificial light.
- Try to exercise for at least 30 minutes 3 to 5 times a week. This has been shown to help depression.(5)
- Do not completely withdraw, but make sure you spend some time with family and friends. Nothing too long or taxing of course. And avoid negative people who tend to make you feel tired or more depressed. Spend time instead with people who are relaxed and fun to be around
Remember that given the right conditions your brain will heal from depression and you will feel better.
Step 4: Sorting out the problems that caused the depression
This comes only after you are feeling quite a bit better. It is not suitable while you are still severely depressed (during which you should stick purely to the advice in Step 3). Assuming you are feeling better or your depression is only mild to moderate, you can now run a 5 amp current through your recovering brain. This means you can begin to work harder at understanding and resolving the issues in your life that triggered the depression.
It could be as simple as talking to a friend and spending a little time each day thinking things through. You might find it helpful to journal your progress. Alternatively you might opt to see a professional counselor. It is important that you talk to somebody and not just try to figure it all out yourself. You need this outside perspective because of the way even mild depression can affect your judgment.
If you choose, you should also be well enough now to undertake a more structured type of therapy. CBT (cognitive behavior therapy) and solution focused therapy are the best and safest ways to address depression.
The great thing is that counseling and psychotherapy are also effective treatments for anxiety. You may find that you're able to kill two birds with one stone (again).
Step 5: Wait a while after you feel better before going back to normal
If you follow my advice to the letter all is likely to change surprisingly quickly - although I won't put an actual time on it because this is highly variable. At this stage you should be feeling much better. You are likely to be sleeping more normally, feeling a lot less depressed, and regaining some interest in life. You feel like your energy is coming back.
The risk now is that you will decide you are completely over it, dive straight back into all you were doing before you got depressed, and possibly stop taking any prescribed medication. Don't do it!
Understand this: Just because you feel better does not mean you are healed. It is equivalent to fixing a broken leg, putting it in a cast and taking painkillers. You feel more comfortable but the leg hasn't healed. It takes time to heal the depressed brain.
This means leaving the 5 amp fuse in place for at least a few months after you feel better, before gradually increasing how much you take on. Continue also with any therapy or self help that you have started.
If taking medication, don't stop until at least 6 months after you feel better, and never without the go ahead from your doctor. It is a fact that the depression is far more likely to come back if you stop too soon. Your doctor is likely to keep you on medication for even longer if this is the second or third time you've been depressed. Do not think you know best about this; the risk of another painful depression is not worth taking.
Very slowly up your level of functioning to 10 amps over the next few months. By 6 months to a year (repeat) after you feel better you may safely resume all normal activities. But taking full account of the following:
Step 6: Future prevention
Put simply, once you've had a run in with depression you must care for yourself more wisely than you did before. You must learn to listen to your mind, body and plain common sense when it comes to how much you take on, how much you do for others, and how much stress you can cope with.
Now you have recovered, your brain has healed, and you can run a 13 amp fuse. You must never again put an 18 amp current through a 13 amp fuse. In fact you should aim to go no higher than 10 amps, except for brief periods during an emergency or when peak performance is necessary. But operating just below - about 80% full capacity should be the norm.
This has to be permanent. If at step 5 you began to feel guilty, as though you ought to be doing more now that you're feeling better, this thought is likely to be even stronger now. You may feel that since you are well there is no longer any excuse to say 'no' to certain requests or find time to relax and care for yourself. But these are the very thoughts that underpin a lifestyle that leads to repeated breakdowns into depression.
Work as hard as you can to undo this type of mindset. Once you recognize that you can and should care first for your health and then everything else, you will become far more resistant to further episodes of depression. If you think about it, this is much fairer on the people around you than risking another depression.
All of the changes you have made through therapy or self help should be continued indefinitely. They should now become part of your way of being to the extent that they are second nature. For example, if you learned through your recovery that it was important for you to take an hour's rest and solitude each day, this should now become a given, an automatic part of your routine that everyone expects.
At this stage your anxiety should be lower than it was originally before you got depressed. This is because all of the changes you have made to recover from depression tend benefit anxiety as well.
Preventing a reoccurrence of depression is not difficult but requires life long attention.
Of course, with the best will in the world, old habits die hard and sometimes resurface. Be vigilant for the early signs of depression and act quickly to re-establish the things that got you well. Whatever you do, don't recycle those toxic self criticisms and accusations, simply revise and act upon what you've learned.
Here are some early signs to watch out for:
- Feeling overtired or exhausted by everyday chores and responsibilities
- Being easily irritated by otherwise reasonable requests
- A feeling that it's all too much
- Trouble sleeping
- Headaches, migraine, non-serious aches and pains
- Increased stress and anxiety
- Feeling that things are meaningless, or wondering what's the point?
Having properly recovered, you also now have an early warning system to help you prevent any future recurrence. Provided you act upon it quickly, you should prevent most depressions before they start.
This has been quite a long article. Congratulations! You got to the end. If you would like to ask any questions, do feel free to email me.
- Boyd JH et al (1984): Exclusion criteria of DSM-III: a study of co-occurance of hierarchy-free syndromes. Arch Gen Psychiatry 41:983-89
- Bremner JD et al (2002): Reduced volume of orbitofrontal cortex in major depression. Biol Psych Feb 15;51(4):273-9
- Videbech P & Ravnkilde B (2004): Hippocampal volume and depression: a meta-analysis of MRI studies. Am J Psych 161(11):1956-66
- Tim Cantopher (2012) Depressive Illness: The Curse of the Strong (3rd Edition). Sheldon Press
- Guszkowska M (2004): Effects of exercise on anxiety, depression and mood. Psychiatry Pol Jul-Aug 38(4):611-20