Treating comorbid anxiety and depression: Psychosocial and pharmacological approaches

Abstract

Comorbid anxiety with depression predicts poor outcomes with a higher percentage of treatment resistance than either disorder occurring alone. Overlap of anxiety and depression complicates diagnosis and renders treatment challenging. A vital step in treatment of such comorbidity is careful and comprehensive diagnostic assessment. We attempt to explain various psychosocial and pharmacological approaches for treatment of comorbid anxiety and depression. For the psychosocial component, we focus only on generalized anxiety disorder based on the following theoretical models: (1) "the avoidance model"; (2) "the intolerance of uncertainty model"; (3) "the meta-cognitive model"; (4) "the emotion dysregulation model"; and (5) "the acceptance based model". For depression, the following theoretical models are explicated: (1) "the cognitive model"; (2) "the behavioral activation model"; and (3) "the interpersonal model". Integration of these approaches is suggested. The treatment of comorbid anxiety and depression necessitates specific psychopharmacological adjustments as compared to treating either condition alone. Serotonin reuptake inhibitors are considered first-line treatment in uncomplicated depression comorbid with a spectrum of anxiety disorders. Short-acting benzodiazepines (BZDs) are an important "bridging strategy" to address an acute anxiety component. In patients with comorbid substance abuse, avoidance of BZDs is recommended and we advise using an atypical antipsychotic in lieu of BZDs. For mixed anxiety and depression comorbid with bipolar disorder, we recommend augmentation of an antidepressant with either lamotrigine or an atypical agent. Combination and augmentation therapies in the treatment of comorbid conditions vis-à-vis monotherapy may be necessary for positive outcomes. Combination therapy with tricyclic antidepressants, gabapentin and selective serotonin/norepinephrine reuptake inhibitors (e.g., duloxetine) are specifically useful for comorbid chronic pain syndromes. Aripiprazole, quetiapine, risperidone and other novel atypical agents may be effective as augmentations. For treatment-resistant patients, we recommend a "stacking approach" not dissimilar from treatment of hypertension In conclusion, we delineate a comprehensive approach comprising integration of various psychosocial approaches and incremental pharmacological interventions entailing bridging strategies, augmentation therapies and ultimately stacking approaches towards effectively treating comorbid anxiety and depression.

A Multiple-Baseline Evaluation of Acceptance and Commitment Therapy Focused on Repetitive Negative Thinking for Comorbid Generalized Anxiety Disorder and Depression

“…The average annual cost of comorbid GAD and depression is about 4,235 USD per person and, when other somatoform disorders are developed, such as pain disorders, it increases to 12,624 USD (Zhu et al, 2009). Importantly, the presence of comorbid GAD and depression has predicted poorer therapeutic outcomes using psychotropic medication (Van Balkom et al, 2008) and psychological therapy (Newman et al, 2010;Coplan et al, 2015).…”

Latent variable analysis of positive and negative valence processing focused on symptom and behavioral units of analysis in mood and anxiety disorders

“…Moreover, these findings lend support to the notion that positive valence processing in mood and anxiety disorder is an independent contributor to the psychopathology with a distinct genetic (Hess et al, 2015) and neural circuit (Liu et al, 2011) signature. Finally, it will be important to determine whether treatments that are specifically aimed at improving positive valence processing (Coplan et al, 2015) may work best for those individuals who have deficits in positive valence processing or that individuals with positive valence dysfunction are most in need of PVS-targeted interventions. If confirmed, such a finding could contribute to a precision medicine approach to treatment (Zbozinek and Craske, 2016).…”

Depresión adulta y experiencias infantiles adversas: evidencia de un subtipo depresivo complejo en consultantes de la atención primaria en Chile

“…La evidencia señala que los cuadros ansiosos se inician a menor edad y suelen preceder a los cuadros depresivos 48 . En base a esto, planteamos que existiría un subtipo de pacientes depresivos, actualmente ingresando a la GES depresión de la APS, cuya patología depresiva se inició más temprano, probablemente precedida por un trastorno de ansiedad y asociada a la presencia de estrés biográfico temprano, dado lo cual, la pesquisa de la patología ansiosa en pacientes con depresión adquiere relevancia y requeriría de tratamientos diferenciados 49 .…”