Depression and anxiety disorders, also called mixed depressive and anxiety disorder (MADD), is characterized by symptoms of both anxiety and depression more days than not for a period of 2 weeks or more. Neither set of symptoms, considered separately, is sufficiently severe, numerous, or persistent to justify a diagnosis of a depressive episode (Pic. 1), dysthymia (chronic depression), or an anxiety and fear-related disorder. 

Depressed mood or diminished interest in activities must be present accompanied by additional depressive symptoms as well as multiple symptoms of anxiety. The symptoms result in significant distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. There have never been any prior manic, hypomanic, or mixed episodes, which would indicate the presence of a bipolar disorder, where mania is a state of abnormally elevated arousal, affect, and energy level, or "a state of heightened overall activation with enhanced affective expression together with lability of affect. Hypomania is a milder form of mania characterized with higher-than-normal energy level that’s not as extreme as mania.

In the topic of psychological factors, dissociation demonstrated to be the important element influencing treatment results in patients with depressive and anxiety disorders. The basis of dissociation lies in the splitting off thoughts, feelings, or behavior from normal integrated awareness.

Throughout studies of anxiety disorders and depressive disorders, scientists have come to multiple conclusions about the cause. This disorder is caused by a combination of biological, psychological, and environmental factors. These factors include imbalances to neurotransmitters in the brain, traumas, stresses, and an unstable home environment. Since the possible causes of anxiety disorders and depressive disorders are so similar, it is not surprising that these disorders occur so frequently together: approximately 58% of patients with major depression also have an anxiety disorder, and approximately 17.2% of patients with generalized anxiety disorder also have depression.

Both anxiety and depression should be treated together. The priority is to treat the most disabling of either the anxiety or depression first and then consider treatments such as SSRI antidepressants and/or CBT which are effective for both anxiety and depression. Further treatment may point to symptoms that require a diagnosis of either an anxiety disorder and a depressive disorder.


The symptoms of anxiety and depression disorders can be very similar:

  • constant, irrational fear and worry
  • physical symptoms like rapid heartbeat, fatigue, headaches, hot flashes, sweating, abdominal pain, and difficulty breathing
  • insomnia
  • changes in eating, either too much or too little
  • difficulty with memory, decision making, and concentration
  • constant feelings of sadness or worthlessness
  • loss of interest in hobbies and activities
  • feeling tired and cranky
  • inability to relax
  • panic attacks

Associated diseases

  • anxiety disorders
  • post-traumatic stress disorder
  • infertility
  • hyperprolactinemia (high blood prolactin level)
  • anorexia nervosa
  • adenomyosis (abnormal presence of endometrial tissue within the uterine muscle layer)
  • polycystic ovary syndrome (PCOS)



Anxiety and/or depression increases with duration of infertility. Infertility, mental disorders and infertility treatment are related in a very complex way. It cannot be denied that infertility is a deeply distressing experience for many couples. Assisted reproductive technologies like in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) are complex and stressful, and are therefore the subject of many studies investigating emotional distress and outcome of fertility treatment.

Negative emotionality

Possibly, personality traits may serve as vulnerability factors or may be the underlying cause of a disorder. For instance, neuroticism/negative emotionality (stress reactivity and a tendency to experience negative emotions) has shown to be elevated in both depressive and anxiety disorders and consequently could contribute to comorbidity among them.

Risk factors

These risk factors often overlap and may include:

  • history of mental health disorders in the family, including substance addictions
  • living in poverty
  • lack of social or familial support
  • having a serious or chronic illness
  • low self-esteem
  • childhood trauma
  • stress


Although some studies indicate that exercise does not differ from traditional treatment (antidepressant medication or psychotherapy) in reducing depression symptoms, exercise combined with psychotherapy appears to produce even better results than either by itself. Moreover, exercise training is inexpensive and there is no stigma attached to exercise. In other words, exercise is safe and has no side effects, thus it is more reliable than medications particularly for some patients such as pregnant women and children.

Male fertility

The mood disorders in man may also lead to decreased fertility through the induction of some sexual disorders (e.g. erectile dysfunction or ejaculatory disorders) and through the negative impact on semen quality caused by hormonal imbalance. Additionally, stress can actually lead to a lower sperm count.

Anxiety may appear as a result of worries about sexual performance, sexual technique, sexual frequency and so on. Anxiety with it centre in amygdala (center for emotions, emotional behavior, and motivation) may be the cause of serotonin disturbances (chemical substance inducing reaction between neurones). These changes in serotonin production and function may lead through a hormonal cascade to induction of mentioned sexual disorders. There has been also observed a relation between serotonin receptors and sexual disorders (premature ejaculation, delayed ejaculation, erectile dysfunction) which may be genetically predisposed. Hyposensitivity of serotonin receptors may be related to premature ejaculation, on the other hand hypersensitivity may be related to delayed ejaculation or even absent ejaculation despite full erection.

Female fertility

In case of stressful condition, such as low support received from partner, social discrimination or low self-esteem, anxiety may develop inducing unhealthy stress reaction of the body which may break gonadotropin-releasing hormone pulsation (GnRH; utmost importance in controlling the menstruation cycle) and lead to anovulation when the ovaries do not release the egg during a menstrual cycle. The egg cannot meet the sperm, and hence not fertilized.

Polycystic ovary syndrome (PCOS) is quite often connected with hyperandrogenimia (excessive levels of androgens in the body), increased body weight and menstrual irregularities. All these factors are associated with mood dysfunction which may lead to anxiety feelings. In some cases of PCOS also appear closely related disorders, such as hirsutism (an excessive hairiness) and obesity. Those have negative impact on the appearance of a woman and may induce or worsen the anxiety and social avoidance. Quite similarly, anxiety can be a symptom of anovulation or it can be even the cause of it.

Since MADD is associated with significant disability and impaired health-related quality of life, but in most cases is not a life-threatening condition, treatment should focus on the restoration of daily living skills and social functioning as well as on the prevention of an exacerbation to a potentially more serious psychiatric disorder, and should include only very limited risk. 

Of note, the use of drugs whose bothersome and partly disabling adverse effects, such as anticholinergic reactions, headache, sedation, gastrointestinal complaints, somnolence, weight gain, sexual dysfunction, or even anxiety and co-morbid insomnia, could aggravate the symptoms they were prescribed to treat, should be avoided. 

Co-morbid anxiety and depression have been shown to respond favorably to cognitive behavioral therapy. However, psychotherapy is often no viable option, due to lack of places on treatment programs. Therefore drugs that provide symptom alleviation at minimal risk are particularly important.

Basically, any changes related to increased activity of the body’s stress system make it harder to become pregnant. Therapy, antidepressant medications, and a social support structure all together will exponentially increase a person’s chances of dealing with depression successfully and to decrease the adverse effect of depression and anxiety on fertility.

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Mixed anxiety-depressive disorder ―sourced from Wikipedia licensed under CC BY-SA 3.0
Mania ―sourced from Wikipedia licensed under CC BY-SA 3.0
Anxiety ―sourced from Fertilitypedia licensed under CC BY-SA 4.0
Depression ―sourced from Fertilitypedia licensed under CC BY-SA 4.0
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