Feature Article

Assessing and treating mixed depression and anxiety

Philip B Mitchell, Jillian R Ball
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How can clinicians make sense of patients experiencing both depression and anxiety, and decide on treatment? This article reviews the overlap between depression and the various anxiety disorders and details the various pharmacological and psychological therapeutic options.

Key Points

  • Comorbidity of depression and anxiety is generally associated with more severe illness.
  • The most clinically useful approach to deciding on treatment for patients with mixed depression and anxiety is to determine which disorder was the first to appear.
  • If the depression was the first condition to appear, or was subsequent but is marked or severe, treat the depression. Once the depression is adequately treated, address the anxiety disorder.
  • If the anxiety disorder was the initial presentation and the depression is not severe, the first step should be treatment of the anxiety disorder.
  • Treatment may involve pharmacological therapy, cognitive behavioural therapy, or both.
  • It is a fallacy that depressed patients with anxiety symptoms necessarily require sedative antidepressants such as mirtazepine, nefazodone or the tricyclics.
  • The two main cognitive vulnerabilities that put individuals at heightened risk of depression are interpersonal sensitivity and too much focus on achievement to feel worthwhile.