Depressed or anxious?

Anxiety and depressive disorders are leading causes of disability in the world.1 Anxiety is a large problem on its own, and compounds the problems related to depression. In this workshop, two leading international speakers (Prof Guy Goodwin, UK and Prof Dan Stein, South Africa) discussed these two conditions and the relationships between them. 

Anxiety and its treatment

Generalized Anxiety Disorder (GAD) is obviously associated with excessive anxiety and worries, but also with physical symptoms. Patients therefore often present in primary care with a variety of symptoms such as fatigue or lack of concentration, making the diagnosis less clear. GAD is highly comorbid with depression, as well as other conditions. The onset of GAD also often precedes that of depression, so treating anxiety at an early stage may help prevent the development of depression.2 Common pharmacological interventions are associated with increased quality of life in patients with GAD, as well as symptom reductions. Psychoeducation can also be combined with pharmacotherapy to enhance these results.3 These treatment strategies are reflected in treatment guidelines.4

The hierarchy of diagnosis may mean less attention is paid to anxiety in patients with depression

Anxiety and depression

The association between anxiety and depression has been demonstrated in twin studies, showing a strong association of genetic factors between depression and anxiety.5 However, there has traditionally been a hierarchy in the two diagnoses, in which depression is considered the more important condition. Thus, controversially in the DSM 5, there are no references to anxiety in the diagnostic criteria for major depressive disorder – there is only the specifier of anxious depression. This means there may be little attention to the presence of anxiety in patients with depression, an omission that is reflected in the lack of treatment guidelines specifically for anxious depression.

In patients with depression and anxiety, antidepressant therapy typically also relieves their symptoms of anxiety

Is treatment of depression also treatment of anxiety?

In clinical practice, treatment of depression also produces reductions in patients’ symptoms of anxiety.6 However, in the absence of a formal diagnosis of anxious depression, information is lacking on how patients with symptoms of both anxiety and depression may differ in their response to treatment from those with depression only. In the future, it will be important that clinicians screen for the presence of anxiety in patients with major depressive disorder, both to ascertain the scale of anxious depression and to assess its response to treatment.

Supported by Educational Financial Support from Servier.


1.        Stovner LJ, Nichols E, Steiner TJ, et al. Global, regional, and national burden of migraine and tension-type headache, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2018;17:954–976.

2.        Chowdhury D, Datta D. Managing Migraine in the Times of COVID-19 Pandemic. Ann Indian Acad Neurol [online serial]. Epub 2020.:33–39. Accessed at:

3.        Stark R, Ravishankar K, Chiang Siow H, Soo Lee K, Pepperle R, Wang S. Chronic migraine and chronic daily headache in the Asia-Pacific region: a systematic review. CephalalgiaCephalalgia [online serial]. 2013;33:266–283. Accessed at:

4.        Burch RC, Loder S, Loder E, Smitherman TA. The prevalence and burden of migraine and severe headache in the United States: Updated statistics from government health surveillance studies. Headache. 2015;55:21–34.

5.        Dresler T, Caratozzolo S, Guldolf K, et al. Understanding the nature of psychiatric comorbidity in migraine: A systematic review focused on interactions and treatment implications. J Headache Pain. The Journal of Headache and Pain; 2019;20.

6.        Lin Y-K, Liang C-S, Lee J-T, et al. Association of Suicide Risk With Headache Frequency Among Migraine Patients With and Without Aura. Front Neurol [online serial]. 2019;10. Accessed at:

7.        Bueno-Notivol J, Gracia-García P, Olaya B, Lasheras I, López-Antón R, Santabárbara J. Prevalence of depression during the COVID-19 outbreak: A meta-analysis of community-based studies. Int J Clin Heal Psychol [online serial]. Epub 2020 Aug.:135577. Accessed at:

8.        Neurology A academy of. American academy of neurology position: telemedicine [online]. Accessed at:…. Accessed May 9, 2020.

9.        Müller KI, Alstadhaug KB, Bekkelund SI. A randomized trial of telemedicine efficacy and safety for nonacute headaches. Neurology [online serial]. 2017;89:153–162. Accessed at:

10.      Müller KI, Alstadhaug KB, Bekkelund SI. Telemedicine in the management of non-acute headaches: A prospective, open-labelled non-inferiority, randomised clinical trial. Cephalalgia [online serial]. 2017;37:855–863. Accessed at:

11.      Qubty W, Patniyot I, Gelfand A. Telemedicine in a pediatric headache clinic. Neurology [online serial]. 2018;90:e1702–e1705. Accessed at:

12.      Wechsler LR, Tsao JW, Levine SR, et al. Teleneurology applications: Report of the telemedicine work group of the American Academy of Neurology. Neurology. 2013;80:670–676.

13.      Russell C, Patterson V, Hu PJ, et al. " User satisfaction with realtime teleneurology. 1999;1222:1–15.

14.      Wechsler LR. Advantages and limitations of teleneurology. JAMA Neurol. 2015;72:349–354.

15.      Oskui M, Pringsheim T, Holler-Managan Y, et al. Practice guideline update: Acute treatment of migraine in children and adolescents. Am Acad Neurol. Epub 2019.

16.      Update: Pharmacologic treatment for episodic prevention in adults. Am Acad Neurol. Epub 2012.

17.      Szperka CL, Ailani J, Barmherzig R, et al. Migraine Care in the Era of COVID‐19: Clinical Pearls and Plea to Insurers. Headache J Head Face Pain [online serial]. 2020;60:833–842. Accessed at:

18.      Dorosch T, Ganzer CA, Lin M, Seifan A. Efficacy of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers in the Preventative Treatment of Episodic Migraine in Adults. Curr Pain Headache Rep [online serial]. 2019;23:85. Accessed at:

19.      Boudreau, Grosberg B, McAllister P, Lipton R, Buse D. Prophylactic onabotulinumtoxinA in patients with chronic migraine and comorbid depression: An open-label, multicenter, pilot study of efficacy, safety and effect on headache-related disability, depression, and anxiety. Int J Gen Med [online serial]. Epub 2015 Feb.:79. Accessed at:….

20.      Zhang H, Zhang H, Wei Y, Lian Y, Chen Y, Zheng Y. Treatment of chronic daily headache with comorbid anxiety and depression using botulinum toxin A: a prospective pilot study. Int J Neurosci [online serial]. 2017;127:285–290. Accessed at:

21.      Maassenvandenbrink A, De Vries T, Danser AHJ. Headache medication and the COVID-19 pandemic. J Headache Pain. The Journal of Headache and Pain; 2020;21:1–4.

22.      Ferrario CM, Jessup J, Chappell MC, et al. Effect of Angiotensin-Converting Enzyme Inhibition and Angiotensin II Receptor Blockers on Cardiac Angiotensin-Converting Enzyme 2. Circulation [online serial]. 2005;111:2605–2610. Accessed at:

23.      Wang X, Ye Y, Gong H, et al. The effects of different angiotensin II type 1 receptor blockers on the regulation of the ACE-AngII-AT1 and ACE2-Ang(1–7)-Mas axes in pressure overload-induced cardiac remodeling in male mice. J Mol Cell Cardiol [online serial]. 2016;97:180–190. Accessed at:

24.      Soler MJ, Ye M, Wysocki J, William J, Lloveras J, Batlle D. Localization of ACE2 in the renal vasculature: amplification by angiotensin II type 1 receptor blockade using telmisartan. Am J Physiol Physiol [online serial]. 2009;296:F398–F405. Accessed at:

25.      Bobker SM, Robbins MS. COVID-19 and Headache: A Primer for Trainees. Headache. Epub 2020.:1806–1811.

26.      Diener H-C, Holle-Lee D, Nägel S, et al. Treatment of migraine attacks and prevention of migraine: Guidelines by the German Migraine and Headache Society and the German Society of Neurology. Clin Transl Neurosci [online serial]. 2019;3:2514183X1882337. Accessed at:

27.      Heckman BD, Holroyd KA, Himawan L, et al. Do psychiatric comorbidities influence headache treatment outcomes? Results of a naturalistic longitudinal treatment study. Pain [online serial]. 2009;146:56–64. Accessed at:

28.      Sorensen P, Larsen B, Rasmussen M, et al. Flunarizine versus metoprolol in migraine prophylaxis: a double-blind, randomized parallel group study of efficacy and tolerability. Headache [online serial]. 1991;31:650–657. Accessed at:

29.      Martin PR, Aiello R, Gilson K, Meadows G, Milgrom J, Reece J. Cognitive behavior therapy for comorbid migraine and/or tension-type headache and major depressive disorder: An exploratory randomized controlled trial. Behav Res Ther [online serial]. 2015;73:8–18. Accessed at:

30.      Luo C, Sanger N, Singhal N, et al. A comparison of electronically-delivered and face to face cognitive behavioural therapies in depressive disorders: A systematic review and meta-analysis. EClinicalMedicine [online serial]. 2020;24:100442. Accessed at: