Stressed, Depressed and Anxious in America

Frequently, when a person experiences depression, it’s often – though not always – accompanied by anxiety. That can complicate recovery, as research finds that people who experience high levels of anxiety, like persistent or excessive worry, respond less well to treatment for depression.

“So that makes it harder to get over the depression,” says Dr. Jesse Wright, director of the University of Louisville Depression Center.

Pile on top of that the rising level of stress that many in the U.S. are experiencing – as reported in the American Psychological Association’s latest annual Stress in America survey – and you have an even rockier road to mental wellness.

“Not every person with an anxiety disorder is depressed, and not every person with depression is full of anxiety, and similarly not every person with either of those conditions has a lot of stress in their life,” Wright says. It may be that genetics has more to do with a person’s depression than what’s happening at work or home, for example. “But it’s more common to see these three problems all interwoven, and to try to treat somebody you have to address all three,” he says.

[See: Am I Just Sad – or Actually Depressed?]

Though the relationship is complex, there are a number of reasons why stress may be associated with mental illness.

“A first episode of depression or anxiety often accompanies a stressor,” explains Dr. Dolores Malaspina, a professor of psychiatry and child psychiatry at NYU Langone Medical Center in New York City. For example, serious childhood adversity, such as emotional or sexual abuse or the loss of a family member, can set the stage for future depression, she says.

Future episodes of depression – marked by everything from low or depressed mood to feeling worthless – or anxiety may not necessarily be related to stress. However, chronic stress can induce a person’s so-called fight-or-flight response (as the body prepares to take on or run from a perceived threat) with not only physiologic consequences, such as raising blood pressure and disrupting sleep, but mental health effects as well, like worsening anxiety.

Conversely, struggling with anxiety or being depressed can be a significant source of stress in a person’s life. “If you have depression, that problem in and of itself is stressful, and it tends to lead to things that create more stress in your life,” Wright says.

You can see a vicious cycle at play out on the job. “If you have depression, and you have such low energy that you’re having difficulty getting to work, and when you get to work, you’re having trouble concentrating – your mind’s wandering all over the place, and your mind’s full of all these self-condemning and hopeless thoughts – it makes it hard for you to function at work,” Wright explains.

The same sort of troubles can follow a person home, dragging down intrapersonal interactions and affecting a relationship with a partner or others close to a person struggling with mental illness. All of that fallout can heap added stress on the person with depression and anxiety, experts say.

Though the exact number of Americans struggling with anxiety and depression who may also be overwhelmed by stress isn't known, another national snapshot of those who face serious psychological distress may offer clues regarding the scale of the problem in the U.S.

Those experiencing serious psychological distress are likely to have a mental health issue severe enough to impair their ability to function socially or on the job, and which requires treatment. SPD is measured by looking at negative emotional states that people report experiencing recently: Nothing can cheer them up, they're nervous, they feel hopeless and worthless. “When you talk about [people with] anxiety, depression and stress, you’re likely talking about the same group of people who have serious psychological distress," says Judith Weissman, research manager for the department of general internal medicine at NYU Langone Medical Center.

[See: What Only Your Partner Knows About Your Health.]

Among adults 18 and over, 3.4 percent had serious psychological distress, according to a study that Weissman led – for which Malaspina was a co-author – published in April in the journal Psychiatric Services. That’s in excess of 8 million adults with SPD nationally. “These are the kind of negative emotional states that people also experience when they have depression [and] anxiety, when they feel under emotional stress,” Weissman says.

Complicating any efforts to seek treatment, researchers found that compared with adults who didn’t experience serious psychological distress, those with SPD were more likely to be uninsured, report delays in receiving care and lack sufficient funds to pay for medications and health care. Hispanics, blacks and individuals who had lower income and less education were disproportionately affected by SPD. The research also found – paradoxically – that those with SPD were more likely to visit a doctor 10 or more times in the past 12 months, and change their usual place of health care, compared with those without SPD. “They seem to be sort of spinning through the health care system, yet they have poorer outcomes,” Weissman says – as many with serious psychological distress don’t get the care they need.

In addition to proposed systemic solutions – like better coordinating mental health care with a patient’s normal medical care – experts say it’s important that those struggling with serious psychological distress persist in their efforts to see a mental health professional.

Cognitive behavior therapy can be a very useful treatment for tackling stress, anxiety and depression together, Wright says. “CBT teaches people specific skills to manage stress and to reduce anxiety and depression. For example, if you have worrisome thoughts – how to tap into those thoughts and revise them, so they’re less troubling to you,” he says. The therapy also focuses on changing behaviors that may make the anxiety, stress or depression worse. Medications including the class of antidepressants known as selective serotonin uptake inhibitors, or SSRIs – such as sertraline, escitalopram, and fluoxetine – may also be helpful to treat depression and anxiety together, Wright says. Often, a combination of medication and therapy is recommended.

In place of harmful coping mechanisms, such as alcohol abuse or smoking, experts advise minding the basic pillars of wellness: getting adequate sleep, exercising and eating well – lifestyle changes that have been shown to reduce depressive symptoms and improve overall mental health.

Of course, taking care of oneself can be more challenging if a person is psychologically distressed. “Mental distress interferes with your ability to organize your behavior, and even to show up at appointments,” Malaspina says. So it may be that a family member could advocate for a loved one who is mentally ill, she notes. Or another caregiver or friend may be able to provide support – the reason it’s important to persist, despite the stigma some still associate with mental illness, in being open about struggles, experts say.

Given the potentially disabling and even deadly consequences of untreated SPD – from raising a person’s suicide risk to their blood pressure – some experts say not doing more to tackle the issue and improve mental health coverage would only perpetuate a downward spiral for many individuals struggling with all three, plus increase associated health care costs. But if or how that might be addressed, as many in Congress seek to repeal and replace the Affordable Care Act, is unclear.

[See: 11 Simple, Proven Ways to Optimize Your Mental Health.]

“The leading cause of disability-adjusted life years in the U.S. is psychiatric diseases – depression principally. So it is our biggest health care burden,” Malaspina says. “It’s the psychologically distressed that have higher rates of diabetes, hypertension and congestive heart failure,” and she adds, who are more likely to die earlier from these diseases.

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