Tips for Treating Comorbid Depression and Anxiety

Comorbid depressive and anxiety disorders are commonly seen in both primary care and the specialty setting. Such comorbidity can present as major depression with subsyndromal anxiety symptoms or unipolar/bipolar depression comorbid with an anxiety disorder. The following Tipsheets offer general guidelines and are adapted from a previously published article in Psychiatric Times, “Depression and Comorbid Anxiety: An Overview of Pharmacological Options.”

TIPSHEET 1. Self-Rated Scales

Several easy-to-use self-rated scales are available for monitoring symptoms:

• Depression Anxiety Stress Scale (42-item or shorter 21-item)

• Beck Depression Inventory

• Beck Anxiety Inventory

• Yale-Brown Obsessive Compulsive Scale

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TIPSHEET 2. Clinical Tips for Treating Comorbid Depression and Anxiety

• Rule out general medical conditions that may cause/worsen or mimic anxiety symptoms

• Initiate treatment with an antidepressant agent shown to be effective for the comorbid anxiety disorder

• Start with a low dosage (to minimize worsening of anxiety) and increase gradually to reach the optimal dosage range

• Watch for antidepressant-induced increase in anxiety symptoms in the initial phase of treatment

• Use benzodiazepines for a short period as adjunct to antidepressants at treatment initiation when anxiety symptoms are relatively severe

• Be aware that depressed patients with comorbid anxiety are often more sensitive to adverse effects

• Treatment resistance is common in depressed patients with comorbid anxiety disorders and these patients often need higher doses, longer time to reach remission, and long-term maintenance; consider specific pharmacological and psychological adjunctive treatment if one condition persists while the other resolves

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TIPSHEET 3. Antidepressant Treatment Plan

• Initiate therapy with a low-dose antidepressant

• Assess tolerability in 1 week

• Gradually increase dosage at 1- to 2-week intervals

• Target to reach optimal dose by 6 weeks

• The treatment goal is remission of both depression and anxiety symptoms

• Continue medications for at least 12 months, but preferably for 24 months (except in patients with social anxiety disorder, for whom 12 months may suffice)

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TIPSHEET 4. Pros and Cons of Adjunctive Benzodiazepine
Therapy in Comorbid Depression and Anxiety

Pros

• Rapid reduction in anxiety during antidepressant lag

• Reduces agitation associated with antidepressants in early phase of treatment

• May reduce residual anxiety

Cons

• Cognitive adverse effects

• Psychomotor impairment

• Potential drug interactions

• Potential for tolerance, dependency, and withdrawal effects
 

For further reading, see “Depression and Comorbid Anxiety: An Overview of Pharmacological Options,” by Arun V. Ravindran, MB, PhD and Lakshmi N. Ravindran, MD.