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Depression and Anxiety: Overview and Risk Factors

Mood and anxiety symptoms occur normally in the course of any eventful life and likely have important evolutionary functions. However, they become pathologic when they interfere with daily functioning, maintenance of relationships, work or school performance, and other important activities of life.

Depressive and anxiety disorders are distinct conditions, but their biological underpinnings and clinical presentations frequently overlap. Because the nutritional considerations related to these disorders are similar, the conditions are described in a single chapter.

Depression is a common syndrome marked by sadness, hopelessness, and apathy. Associated symptoms may include poor concentration, excessive guilt, sleep disturbance, appetite disturbance, sexual dysfunction, delusions, and psychomotor changes (eg, slowed thoughts and movements, slurred speech, slumped posture). The pathophysiology of depression is believed to involve a combination of abnormal neurotransmitter (eg, serotonin and norepinephrine) activity, hormonal (eg, cortisol) abnormalities, genetic traits, and environmental and psychological factors.

Anxiety is marked by physiological arousal (motor tension, autonomic hyperactivity) and psychological arousal (excessive worry, increased vigilance). Norepinephrine, serotonin, and gamma-aminobutyric acid (GABA) may be involved in its pathophysiology, and both genetic predispositions and environmental factors are believed to play a role.

Risk Factors

Significant depressive symptoms are present in up to 40% of primary care patients in the United States. Major depression occurs in up to 10% of primary care patients and up to 15% of medical inpatients. The following factors are associated with increased risk:

Gender. Females are more likely to be diagnosed with a depressive disorder.

Family history. It is important to consider both diagnosed and undiagnosed indicators of mood disorder, especially in first-degree relatives.

Inadequate social supports. Examples include living alone or having few friends.

Stressful life events. These might include retirement or the death of a loved one.

Coexisting illness. Some studies show that up to 30% of patients who present to physicians with a physical symptom had either a depressive or anxiety disorder.1 Common coexisting illnesses associated with depression include coronary disease, cancer, neurologic disease, and endocrine disease (eg, hypothyroidism). Common coexisting illnesses associated with anxiety include angina, myocardial infarction, arrhythmias, congestive heart failure, mitral valve prolapse, asthma, chronic obstructive pulmonary disease (COPD), hyperthyroidism, hypoglycemia, Cushing's syndrome, Parkinson's disease, and cancer.

Medications. Drugs associated with anxiety include bronchodilators, antidepressants (anxiety symptoms associated with starting an antidepressant usually abate after several weeks of use), various antihypertensive medications (although beta-blockers are sometimes used to decrease the physical symptoms of anxiety), steroids, psychostimulants (eg, Ritalin), over-the-counter medications that contain caffeine, and pseudoephedrine.

Drug intoxication or withdrawal. Drugs that may contribute to anxiety include caffeine, alcohol, cannabis, cocaine, methamphetamine, and nicotine. Some medications that are used to treat anxiety, notably benzodiazepines, can cause rebound anxiety, in which individuals feel more anxious after the medication wears off than they did before taking it. This often leads to a cycle of escalating use.

Suicide is a risk in depressive illnesses, as in other psychiatric conditions. Among the risk factors for suicide are:

  • A history of suicide attempts.
  • Suicidal ideation.
  • Family history of suicide or attempts.
  • Access to weapons.
  • Substance abuse.
  • Underlying medical illness.
  • Male gender.
  • Increasing age.


Depression and Anxiety: Diagnosis >>