From August 2020 to February 2021, the percentage of adults with recent symptoms of an anxiety or a depressive disorder increased to 41.5% from 36.4%. This is not an issue unique to the United States. Anxiety and depression increased by 25% globally during the first year of the pandemic, according to the World Health Organization. Additionally, these statistics are not unique to adults. A meta-analysis of 29 studies of over 80,000 global youth found that pre-pandemic rates of depression (12.9%) and anxiety (11.6%) doubled to 25.2% and 20.5% respectively.
New Recommendations
In April of 2022, the worsening state of mental health among children prompted the U.S. Preventive Services Task Force (USPSTF) to recommend for the first time screening all children ages 8 to 18 for anxiety, one of the most common mental health disorders of childhood. And in late September 2022, the same task force recommended that doctors screen all adult patients under age 65 for anxiety, guidance that highlights the extraordinary stress levels people have been facing throughout the challenges of the pandemic, which have continued to exacerbate problems children and adults have been experiencing.
The USPSTF recommends utilizing screening tools such as the GAD-7, which are effective in picking up anxiety in patients before they may present with overt signs and symptoms. This screening guidance is intended to prevent mental health disorders from going undetected or untreated for years or decades.
Clinical Implementation Challenges
In response to these recommendations, health care providers emphasized that screening programs are useful only if they lead patients to effective solutions. Currently, the United States is struggling with insufficient numbers of mental health resources on all levels - psychiatrists, psychologists, and therapists. Functional medicine providers may be able to help bridge this gap as they are expertly skilled at assessing for and addressing some of the most common contributing factors affecting mental health – hormone and neurotransmitter levels, excess stress, and sleep disruptions.
Contributing Factors
Neurotransmitters
Neuroendocrine imbalance can contribute to the likelihood of mood concerns. Serotonin and dopamine are not the only factors at play in mood; other neurotransmitter imbalances could be involved – histamine, phenethylamine, glutamate, and so on -- as well as hormone changes.
Sex Hormones
Women have nearly double the risk of mood disorders compared to men. These sex differences are observed not only in the U.S. but are also documented worldwide. This sex disparity indicates a potential role for gonadal hormones in the etiology of anxiety and depressive disorders. In fact, studies have revealed that women are more likely to experience mood disturbances, anxiety, and depression during times of hormonal flux, such as puberty, menopause, perimenstrual and post-partum periods. But men are not immune. Hypogonadal men exhibit a significantly higher prevalence of anxiety disorders and major depressive disorder, compared to those with normal physiological levels of androgens. Collectively, several reports suggest that testosterone-replacement therapy in hypogonadal men greatly improves mood, alleviates anxiety, and mitigates symptoms of depression.
HPA Axis
The association of the stress response to depression and anxiety is well established. The stress response involves the coordination of epinephrine and norepinephrine as well as cortisol. Norepinephrine and epinephrine are released from the brain as well as storage vesicles in the adrenal medulla in response to stress. They increase degradation of glycogen and triacylglycerol, as well as increase blood pressure and cardiac output. Cortisol is then released to maintain the stress response and continues to be released until the threat is over.
However, when the fight or flight response persists due to chronic stressors, cortisol, epinephrine and norepinephrine levels adapt, and either persistently elevated stress hormones or eventually the depletion of stress hormones will disrupt the body’s processes. Patients then are at risk for a variety of disorders, including depression and anxiety. Chronic stress depletes the brain reserves of epinephrine and norepinephrine, and their precursor dopamine. Depletion of catecholamines are closely related to stress-induced issues with focus, energy, motivation, and mood.
Sleep
There is a bidirectional relationship between sleep and mental health. Depression, stress, or anxiety all increase a patient’s likelihood of developing insomnia. At the same time, up to 50% of patients experiencing insomnia also have a mental health disorder. A meta-analysis that collectively included 172,077 individuals found that those with insomnia had a twofold increased risk of developing depression compared with individuals without insomnia.
Unraveling the causes of insomnia is complicated. A foundation of proper sleep hygiene involving healthy bedtime routines and environments should be established first. Additionally, testing melatonin, cortisol, and neurotransmitter levels can help identify imbalances that make it harder for patients to fall asleep and stay asleep.
Assessment Considerations
In a world where depression and anxiety are increasingly common, and the number of health care providers is inadequate to meet the collective need, functional testing may allow more providers to bridge the gap. Identifying imbalances in hormones and neurotransmitters that can contribute to mood concerns is a consideration for functional medicine providers. It enables them to target particular areas of vulnerability in a patient, and work to modify these in order to help patients better manage symptoms.
