At certain points in history, or due to personal circumstances, the mere act of staying alive can bring about a slew of mental health issues. Individuals with or without an official mental health diagnosis often find themselves contending with the symptoms of one or both of the two pillars of mental health—anxiety, and depression. Due to increased interest and visibility, the current point in history can be referred to as “the age of depression.” Yet anxiety can be just debilitating and had previously held the top spot in mental health research and professional concentration. What happened to bring about this shift in focus, and how does it relate to current treatment for both types of disorders?
Read on to find out.
Before delving into the present-day circumstances defining the world of mental health, it would be beneficial to examine the history leading up to the two categories of depression and anxiety.
Dating back to the time of Ancient Greece, early scholars viewed depression as the result of excessive black bile, translating into a personal inclination toward sadness. Later on, depression was defined by the trigger that had caused it, before Freud described depression as a sense of lacking, and the feeling that something precious but unknown has been lost. The modern-day diagnosis of depression still owes a great deal to Freud’s perception of the condition, as it is still viewed in terms of a profound sense of absence.
Nowadays, widely cited diagnostic manuals, such as the American Psychiatric Association’s (APA’s) Diagnostic and Statistical Manual (DSM-V), and the World Health Organization’s (WHO’s) International Classification of Diseases (ICD-11), refer to depression as major depressive disorder (or MDD), and place it within the depressive disorders family.
Major depression is primarily defined through a consistently low mood, an inability to feel joy, or both. Additional symptoms add to the disorder’s dearth of positive, enjoyable emotions: deep sadness, hopelessness, irritability, emptiness, low self-confidence, lack of energy and lack of concentration.
According to the DSM-V, major depression affects about one in 15 (or 6.7%) of the adult population. 17.3 million US adults (pr 7.1%) have reported experiencing one or more depressive episodes across their lifetime. This marks major depression as one of the most common mental health disorders, though the top spot belongs to another group of disorders—anxiety.
Unlike depression, anxiety was first acknowledged through bits and pieces of anxious symptoms, and was only considered a full-fledged mental health disorder with the publication of the DSM-III, in the 1980s.
Anxiety is derived from the Greek word “ango,” which means “to constrict.” It refers to the feeling of being trapped and reflects the intense sense of danger that feeling anxious brings about.
At its core, anxiety is a survival mechanism gone into overdrive. It mimics the unpleasant hyperarousal that characterizes fear, which helps the individual identify and respond to a present threat. But whereas fear subsides when the source of threat is removed, anxiety will keep going, causing an adverse alertness that prevents the individual from regaining a sense of calm.
While depression, or rather major depression, is a distinct disorder of its own, current-day diagnostic manuals do not refer to a specific anxiety disorder, but rather view it as a family of disorders (similar to the depressive disorders family). Anxiety disorders are defined by the source that brought them on; anxiety disorders such as separation anxiety or phobia are marked what caused them (separation from an attachment figure, or a specific object or setting, respectively).
Taken as a whole, though, anxiety is still considered the most common of disorders: one in 13 individuals contend with some type of anxiety disorder, with 40 US million adults, or 18.1% of the adult US population, battling this family of conditions.
In the period immediately following the two world wars, the global population as a whole began to contend with the stress and strain that marked everyday life. Thus, the age of anxiety was born: the very concrete concerns of the period, which included financial worries, health issues, interpersonal difficulties and occupational instability commonly manifested through “nerves,” an umbrella term for human responses to the issues that caused them the greatest concern.
The vast majority of individuals living through this era were focused on surviving and making it out of the terrifying traumas of war, the Holocaust, displacement and destabilizing upheaval, out of which the world had only began to climb out. Anxiety, therefore, became the central mental health affliction, as the fears of the day continued to churn within individuals’ psyches, even during moments of relative safety.
Depression, on the other hand, was seen as the very antithesis of anxiety, and relegated to the rare cases where patients no longer had any spark of life. Prior to the 1970s, depression had been associated with feelings of worthlessness, and even vegetative and psychotic states that broke away even further from reality. For those facing a daily struggle to survive, understanding depression as a condition that causes one to give up on trying to feel better, must have seemed like a petrifying possibility, and a very tall order. As a result, depression was pushed aside, garnered a relatively small number of studies, and only referred to the most extreme and dejected cases.
The power dynamics between anxiety and depression, however, began to change, due to three major developments: the development of antidepressants, repositioning mental health as a science, and the power of feminism.
During the 1950s, the first anti-anxiety medication (officially called an anxiolytic) was made publicly available. Used to relieve stress, anxiety and tension, the medication was in fact a tranquilizer that helped lower one’s level of adverse response and facilitate a state of calm (or sleepiness). By 1965, hundreds of millions of tranquilizer prescriptions had been written in the US, primarily aimed at assuaging patients’ disturbing emotions.
Around the beginning of the 1960s, though, mental health practitioners began noticing the relatively high prevalence of depressive cases among patients in primary care settings. As more cases of depression were being recognized, more individuals facing depression began receiving care for this condition. The increased public and practitioner interest in depression led to a greater number of empirical studies, and eventually, to a new type of medication—the antidepressant.
Since antidepressants also work to reduce symptoms of anxiety, all antidepressants are also considered anxiolytics. First-generation antidepressants were able to stabilize one’s mood whether they suffered from intense anxiety or demoralizing depression, though they often caused severely unpleasant side effects, such as increased heart rate and shaking.
Despite the intense focus on anxiety, since the 1980s, depression diagnoses have far surpassed anxiety diagnoses. Moreover, antidepressants are now much more commonly prescribed than older types of anxiolytics. The likely reason for this depressive takeover is the breakthrough offered by a second-generation group of antidepressants, called selective serotonin reuptake inhibitors (or SSRIs), which were first released during the late 1980s.
Unlike previously issued anxiolytics or first-generation antidepressants, SSRIs were unique in their high levels of tolerability. Previously released mood stabilizers had come with a cost, be it significant drowsiness (like the original anxiolytics), or heart palpitations (like first-generation antidepressants).
SSRIs, on the other hand, were able to accomplish a similar level of efficacy without causing severe side effects. This allowed more patients to stick with their treatment and experience the benefits of depression symptom relief.
In the time since SSRIs have been made public, medical advances have been able to offer other treatments empirically proven to be both safe and effective. Among them is Deep Transcranial Magnetic Stimulation, or Deep TMS: a medical device treatment FDA-cleared to treat depression, obsessive-compulsive disorder (or OCD) and smoking cessation, Deep TMS utilizes magnetic fields to safely regulate the neural activity of brain structures found to be associated with the targeted condition. Unlike conventional antidepressant medications, Deep TMS does not cause any long-lasting or significant side effects, allowing patients to adhere to the treatment. As a noninvasive treatment, Deep TMS does not necessitate the use of anesthesia, with patients being able to drive themselves to and from each session. Finally, Deep TMS has been shown to be effective both as a standalone treatment and in combination with medication, enhancing the treatment regimen’s overall efficacy.
Prior to the 20th Century, psychiatry (and in many ways, medicine as a whole) relied on rather vague diagnoses to describe what ailed patients. Broad categories such as melancholia, mania or hysteria were considered sufficient in psychiatry’s attempt to identify and treat a general malaise.
During the 20th Century, however, scientific demands of accuracy and symptomatology had reached the field of psychiatry, as the mental health profession at large began aspiring toward a more serious consideration, through its inclusion among the sciences.
As a result, the diagnostic manuals of psychiatry began to change. No longer primarily drawing their definitions from psychoanalytic theory, the diagnoses included in later editions of the DSM and ICD basing their conclusions on empirical, biological, and neurological studies. With anxiety being closely associated with psychoanalysis, biological researchers distanced themselves from this blanket term, and focused instead on the more specific condition of major depression.
Much more than anxiety, depression could be easily traced to chemical imbalances in the brain, making it a far superior candidate for positing psychiatry as a legitimate branch of medicine. Its relation to extreme symptoms, such as suicidality, further highlighted the importance of researching this condition.
As a result, when it came time for the DSM-III to be published, in 1980, the mental health community discovered that previous editions’ common referrals to anxiety as a catch-all were replaced with much more specific diagnoses that were based on research, instead of theory. For the first time, depression was taken out from under the anxiety umbrella, and given its own chapter in the DSM.
Within the pages of the DSM-III, depression had gained one more advantage over the category of anxiety: whereas previous editions had simply noted anxiety to be a common theme in mental health, the DSM-III split it up into many of the disorders still used today, such as panic disorder, post-traumatic stress disorder (or PTSD), and obsessive-compulsive disorder (or OCD, which was later removed from the anxiety chapter completely). Each of these disorders chipped away at the only non-specific anxiety condition that remained—generalized anxiety. As a result, the anxiety diagnosis no longer enjoyed the high prevalence it had in the past.
While the anxiety disorders family had been left in shambles, the newly anointed depressive disorders family had been built around a single condition—major depressive disorder—which aggregated most of the significant cases of diagnosed depression. This allowed major depressive disorder to gain a great deal of prominence, far outnumbering any of the anxiety disorders, and taking the lead in terms of prevalence. Depression had been set up to dominate the diagnostic manuals, which was reflected not only in an increase in diagnosed cases, but in an outpouring of depression research, pharmacological developments, and financial backing.
Despite their proven ability to lower rates of anxiety, tranquilizer types of anxiolytics became a lightning rod of dispute during the 1970s, due to their severe side effects. Among the most vocal of their critics were women, and the feminist movement at large.
Many feminists of this era vehemently opposed the ease with which tranquilizers were prescribed as a way to placate mental health difficulties. Side effects such as lethargy, fatigue, and suicidal ideation, as well as their addictiveness, were all presented as means to keep existing patriarchal conventions in place, thereby stifling women’s freedoms and their personal agency.
Anti-anxiety medications, it was positioned, were tools used for the continued oppression of all members of society, but particularly women. Such criticism was eventually echoed by Congress, which set its sights on the companies that manufactured tranquilizer anxiolytics. As a result, pharmaceutical companies found it difficult to market these medications, and in the 1980s began focusing their attention on the much more tolerable (and still anxiety-reducing) SSRI antidepressants.
Partly due to the significant criticism lobbed at them by 1970s feminists, traditional anti-anxiety tranquilizers were phased out. Instead, pharmaceutical companies’ promotional material began highlighting fewer debilitating antidepressants, such as SSRIs. The public outcry concerning tranquilizers became one of the central causes for the shift to “an age of depression,” and one that shows the power of public discourse in shaping our mental healthcare.
With all the advantages of an effective psychiatric medication class, and much more tolerable side effects, patients facing depression were able to achieve greater symptom relief with SSRIs. This new kind of antidepressant managed to bridge the gap between empirical scientific research, the diagnostic prevalence of this condition, and the public need for safe and effective treatment that decreases mental health symptoms without bringing about severe or debilitating side effects.
These days, anxiety may be taking a back seat to depression, but it is far from gone. This is particularly true in times of crisis, be it political, health-based, or in correlation with aspects of one’s national identity. As the age of depression continues to unfold, it remains to be seen in what direction the mental health field will branch out next.
