Is Depression the End Stage of Anxiety?

We often talk about anxiety and depression as separate conditions, but in real life, they so often coexist. Sometimes, I wonder whether what we call “depression” can actually look like late-stage, unresolved anxiety.

When life stops aligning with our values, expectations, or basic emotional needs, stress and anxiety naturally rise. Our nervous system shifts into fight/flight/freeze. If this state becomes chronic, it slowly drains us leading to fatigue, helplessness, hopelessness, and “burnout”. It then can affect multiple domains of our lives.

At a certain point, something else can happen.

When our care factor drops to near zero, the anxiety may ease, but in its place comes a depressed mood, with loss of motivation, meaning and purpose.

Many people we see are right at this junction, oscillating between anxious distress and emotional numbness/depressed mood.

This is why early stress and anxiety management matters so much.

If we can support people early, we don’t just reduce anxiety, we may prevent deeper depression.

Are You a Fish Out of Water

Feeling Anxious? You might just be a “Fish Out of Water”.  

When we talk about anxiety, it’s easy to focus only on the symptoms—feeling tense, racing thoughts, trouble sleeping, or even physical signs like a racing heart. But there’s a deeper question that can often provide clarity and help us move forward:

Is this anxiety primary, or is it secondary?

In other words—are you living, working, or studying in an environment that doesn’t suit your natural personality or way of thinking/cognition? 

Sometimes, anxiety isn’t the core issue—it’s a signal. A red flag telling you that something about your surroundings or daily routine just doesn’t “fit” with who you are.  Maybe your personality thrives on calm and connection, but you’re stuck in a high-pressure, competitive environment. Or perhaps you’re someone who values structure and detail, but your job requires constant flexibility and chaos. 

This kind of mismatch between who you are and the world around you can cause a chronic, unhealthy level of stress.

When we explore anxiety through this lens, it becomes less about “what’s wrong with me?” or about “what’s wrong around me?” but more about where is the mismatch.  This shift in perspective can be empowering. It can help you:

1. Understand your stress from a new angle. 
2. Make clearer decisions about your environment and lifestyle. 
3. Create or seek out spaces that better support your natural strengths and values. 

Over time, finding or creating a better-fitting context—whether it’s a change in the type of work, relationships, or daily rhythm—can dramatically reduce anxiety and improve overall well-being.

So if you’re feeling anxious, it might be worth asking: Am I just a fish out of water? 

And if the answer is yes, it’s not a flaw—it’s a sign. A sign that it’s time to explore new waters where you can thrive.

Exploring alternative perspectives to common mental health labels

It’s common for stigma and unhelpful judgements to be attached to those with “mental health” issues. 

If one has a body, one will have some kind of physical health issues. Likewise, if one has a mind, then one will also have some kind of mental health issues. None of us are immune to this are we?

I sometimes prefer to use different terms to describe some of our common mental health diagnoses to reduce stigma, judgements, or to offer an alternative description of the problem perhaps.  It can normalize it to some extent. 

Borderline Personality Disorder to “Emotional Personality”

Attention Deficit Disorder to “Curious and Distractible Personality”

Depression/anxiety to “Adjustment issues with stress response”

ODD to “Inner compass personality”

ASD to “Logical or a more emotionally defused personality style”. 

I also find these especially helpful when taking a transdiagnostic approach to treat mental health issues.

Leading with both thoughts and feelings

Being able to sense other people’s feelings or empathy is great isn’t it, but at times, it can work against us too if we are not careful or unaware.

Why?

Imagine if someone is angry with us. We then can sense their anger. We then hold their feelings with the anger we sense. They then sense our anger, and now we may have an escalation of two angry people.

Same goes with sadness and anxiety. We may end up with two very sad or anxious people too.

So how can we mitigate this?

Consider holding other people’s anger, anxiety, or sadness with care, hope, and compassion instead. If they can then sense our care, hope, and compassion, they may then be able to use those feelings to hold/shift their own feelings.

We sometimes lead with our thoughts, but don’t forget to lead with our feelings too.

Feelings are “contagious” and can be “transmitted” in both ways.

Can medications help me zoom in and zoom out from my thoughts and feelings

When thinking about pharmacological solutions for folks with mood disorders, I tend to think in terms of “zooming in” and “zooming out” problems rather the the usual “chemical imbalance” theory.

For folks with excessive zooming in to thoughts and feelings, I tend to think about SSRI’s, SNRIs, Antidepressants in general, Quetiapine, Anitipsychotics etc as “numbing agents” or “detaching agents”. Interestingly, a few years ago at Griffith Uni, they trialed oral Ketamine for severe depression, which is very “detaching” in action.

For folks with “primary” excessive zooming out from thoughts and feelings, some of the above may have more “dissociative/detaching” side effects, so I would use it with a degree of caution.

I do wonder if we can view ADHD as a lack of zooming in OR “loose anchoring” to various thoughts and feelings, and hence, fleeting from one thing to another perhaps. Hence a “zooming in” agent like Dexamphetamine seems to make sense.

The challenge is, most mood disorders are not simply a zooming in problem, or a zooming out problem. Often there is a mix.

Some people have both extreme zooming in, and extreme zooming out problems, and a single drug is not going to be the whole answer unfortunately.

There’s no such thing as a “zooming in and zooming out drug according to context” is there?

Hence, many will have to do the hard work of learning how to zoom out on the things that don’t matter, or matter but can’t control, and zoom into the things that truly matter, or things that they can control.

Alleviate the loneliness to alleviate the fear and anxiety

I often see folks who suffer chronic loneliness, or even if they are not “lonely”, there connection with their tribe is very labile. It’s an insecure connection. They sense that they can lose it at anytime. 

Most of their connection is often conditional. Conditional on them being a certain way. Being agreeable perhaps. Being of a certain standard.

Like they say, everyone needs at least one source of unconditional love from at least one creature. If you don’t, you might be in trouble.

This can give them a lot of fear and anxiety, and if not resolved, are in a constant “fight or flight” response.

This “flight or flight” response will then emulate through all aspects of their lives. It can be very destructive, as they may “fight or flight” with whatever is in front of them.

Alleviate the loneliness, and the “fight or flight” may lessen. Challenge the “fight or flight”, and it might just escalate, worsen, and create more loneliness.

So how do we “fix” loneliness?

At a societal level, more education in relationships perhaps.  We can provide more support and create more opportunities for people to connect.  We can provide more support and create more opportunities for people to connect.  

At a primary care level, more support for families and individuals around what we are doing already, and possibly more interpersonal skills, parenting support work, family therapy work, couple counseling, and more counseling/coaching work in general.

I understand that it’s not easy, and at the same time, that may be what is required, to shift society in a more “positive” direction perhaps.

Learning to “zoom in” or “zoom out” from our thoughts and feelings

We all know the importance of justice, fairness, and equality in society. It’s a common theme in our society.

Without it, society would not work. Like everything, there’s balance. Too much of anything, including the “good stuff”, can cause expected or unexpected issues.

So, if we can represent our thoughts and feelings around “equality” and “fairness” on a piece of paper, and apply the “zoom in”, “zoom out” function to that, what can we see?

If we are super “zoomed in” onto it at the “OCD” unhealthy level, “fairness” may become more of an obsession, where we demand that “all things MUST be fair and equal”. This is going to create unhealthy stress because how can it always be. We can certainly try to create equal opportunity, but to create equal outcome, it will require ironically, some “unfair” measures.

When we “zoom out” a bit more, it becomes “Life SHOULD be fair”. At this level, it can also be a bit stressful, and may be problematic. 

“Zoom out” a little bit further and it becomes, “It would be nice if life is fair and I will do my part to make it fair. I will help those in need and who are less fortunate”.

“Zoom out” a bit more and we may find, “It is what it is”.

“Zoom out” a bit more and we may see, “Life is not fair, and I don’t care”.

The real question is, are you stuck on any of these “zoom levels”, and is it at a healthy or unhealthy level for your particular context?

If we are not aware or can’t find our “zoom function” in life, we risk a life of unhealthy stress, ongoing conflict, and failures.

So, do we need to “zoom in” more or “zoom out” more? And at what level of zoom do we think is most healthy for our particular context?

A metaphor to help us observe our thoughts and feelings for better processing and clarity

If we represent our thoughts and feelings on a piece of paper or iPad, and really “zoom in” and focus on that with a level “obsession” or “passion”, then that can be a double edge sword. 

A good outcome or not, will depend on the quality of those thoughts and feelings.

So it’s really important to “zoom out” to observe those thoughts and feelings, and ask .....

Is this old news, fake news, or useful news, and let that guide us. If it’s old, fake, or unhelpful news, we may choose to ignore it. If it’s useful news, “zoom in” and take assertive actions.

Your “piece of paper” or “iPad” with your thoughts and feelings, is like the internet. It’s undeniable that it’s a wonderful tool, but one needs the space to differentiate the good quality information from the bad ones.

Focusing at the “root level” to get the most leverage for change in counseling

In counseling, when we try to change our “unhelpful” thoughts and behaviors, we are trying to change it at the “leaves” level to get to the roots. 

When we try to change our feelings, we are trying to change it at a “trunk” level to get to the roots.

When we try to change our values and beliefs, we are trying to change things at the “root” level itself.

Changing things that are above the surface is easier and more practical, but may have less “deeper impact”.

Changing things below the surface is much harder because often we can’t see it, but much stronger in impact if we can achieve that. It’s leveraging.

Imagine if we can change the belief in ourselves and the people we look after from, “I am not good enough” to “I am not perfect, I accept me for me, and I commit to growth and learning”, then what would the world look like.....

Why mindfulness of thoughts and feelings are like punctuations in our writings

Imagine trying to write a story without a comma, full stop, paragraphs, or chapters. 

It’s amazing how much a simple pause can make a difference to the meaning of a sentence and the outcome of a story.

Likewise, when one has thoughts or feelings showing up in our minds, and we don’t have the ability to apply mindfulness and defusion in the right places for the “pause, think, before we do”, we might not get the perspective and the outcome that we want. It can lead to impulsivity, obsessive compulsive tendencies, and unwanted behaviours and drama.

A comma or full stop can be insignificant by itself, but without it, our writing may turn out very differently.

Likewise, practicing mindfulness and defusion is pretty boring by itself, but without it, the narrative in our minds can get quite distorted.

How to preserve your energy tank

When we take action, we can take action with the following emotional states or mindsets. 

1. We can do it with joy and enthusiasm.

2. We can do it with emotional acceptance.

3. We can do it with intellectual acceptance but emotionally, we are really just “putting up with it”.

4. We do it with resistance, resentment, and dread.

The first type may give us more energy in emotional terms. The second is probably energy neutral. The last two will drain us physically and emotionally.

So I try this simple principle when taking action.

If I can’t do something with joy, enthusiasm, or at least emotional acceptance, I won’t do it. Maybe short term but definitely not long term. Emotional acceptance is acceptable in most cases.

Maybe you can try that too to preserve your energy tank.

Consider approaching life like playing Angry Birds

In counseling work, we often see folks with the triad features of unrelenting standards, together with self criticism and the fear of failure. This “triad” is a guarantee for excessive stress and suboptimal performance. 

So how can we improve it?

We can consider the “Angry Birds” metaphor. 

Life is sometimes like playing Angry Birds. We have a specific target or goal. We do the best we can. We fail. We self reflect rather than self criticize. We approach it at a different angle. We repeat the process until final success. We stay present and enjoy the process.

Getting it right every time is not the aim either, because that would simply be too boring isn’t it?

So aim high. Have a go and prepare to fail often, but review, reflect, learn, get a new plan, and reimplement often. The more we fail, the better we get. Most importantly, be present and enjoy the process ...

Learning to hold uncomfortable feelings with love, hope, care, kindness and compassion

If one holds a crying child with feelings of worry, fear, helplessness, anger, and frustration, it’s an awful experience. 

If one can hold a crying child with feelings of love, care, and compassion, it may lead us to a very different place.

So what’s my point?

The “feelings” with which we use to solve our problems matter. It matters deeply. It can make all the difference between a terrible or a wonderful outcome.

So next time we have an uncomfortable thought or feeling, consider holding it like a crying child, but with hope, care, love, kindness and compassion, and let that guide us, rather than the anger or helplessness.

How can we deal with the “storms” within our relationships

In counseling, I often like to talk about Tuchman’s 4 stages of group dynamics when it comes down to group conflict at work or homes, and for couples. 

1 The forming of the group. There’s no conflict and everything seems okay on the surface. We are polite to each other. We don’t want any conflict. Things are still new. It’s interesting, novel, and exciting. It’s the “honeymoon” period. 

2 The “storming” which is often inevitable. We are now able to express our differences in opinions, values and beliefs. We are now “more real” which is a great thing, if we can manage it well. If we cannot manage it well, we run the risk of being stuck in a “storm” of fight or flight responses, and if we are not careful, we can take this experience with us into other domains of our lives. This will inevitably create more storms. 

3 The “norming”. We come to the true “emotional acceptance” that we are all different. We have different values and beliefs. We have different ways of thinking. We now have the emotional literacy to appreciate and acknowledge each other and to ourselves that none of us are perfect. Every positive has a negative, and negative has a positive. Two or more opposing ideas and beliefs can coexist, and complement each other. When one is right, the other one doesn’t necessarily have to be wrong.

4 The “performing” which is the exciting bit. At this stage, we truly realize that life is a team sport, and we are able to bring the diverse personalities together and work towards a common meaning and purpose. 

So the real question is, how often do we find ourselves stuck in the middle of the “storm”. 

What do we do in the “storm”?

Do we “norm” to perform, or do we stay or run away?

Be the Author of your life story

One of the key features of Acceptance Commitment Therapy (ACT) is to help folks work on their “psychological flexibility”. Many of us may be strong “fighters”, but being psychologically flexible, we may not.

Psychological flexibility consists of 6 core skills.

1. Being present rather than excessive past and future focused.

2. Being defused rather than excessive fusion/attachment with our thoughts and feelings, AND the thoughts and feelings of others.

3. Acceptance especially with things we cannot change.

4. Self as context rather than self as content. Identify self as the Author of one’s story rather than the main character in the story/book.

5. Know one’s values and knowing who we are.

6. Take value driven actions and stay true to who we are.

Rate each core skills out of 10 perhaps. Many of us may score low in all domains. It’s part of the human experience. Once we have awareness, that’s the first step to change.

Out of the 6, “self as context” may be the most fundamental in my opinion.

If one can self identified as the Author of one’s story rather than the main character in the story, the rest will come much more easily.

Working on both our external locus of control and our internal locus of control to reduce stress

As Family Doctors, we often see folks whose lives are not in line with their values and expectations.

The bigger the gap, the bigger the stress it seems.

To close the gap, we only have 3 options.

1. We can try and create a life that is congruent with our values and expectations. It’s about making changes to the outside world i.e. the external locus of control OR

2. We can try to defuse/detach, and change our values and expectations to be in line with our life. This is more about changing our internal world and how we perceive things i.e. the internal locus of control OR

3 We can work on both of course. This will give us best chance of “closing the gap”. 

There’s actually a 4th option, and it’s not about closing the gap. It’s more about accepting the gap. 

Whichever way, the first step is have clarity around what those values and expectations actually are.

So the real question is, do we have clarity around those?

Have you ever bought into an unhelpful narrative in your mind?

Have you ever had an unhelpful narrative in your mind, and have “bought into”, “hooked into”, or fused with that story like being fully immersed into a drama show or book?

This is normal of course, but if the narrative is unhelpful and the fusion is intense and prolonged, then we will have a mood problem. 

In counseling, we are curious to understand the narrative, where it came from, and the intensity of the fusion with that story. 

If it’s more of a story problem, and not so much about fusion, then we try to reframe, challenge, and change that story. This is more in line with a CBT (Cognitive Behavioral Therapy) strategy. 

If it’s more of a fusion problem, then we may prefer to work on defusion, unhooking, or detachment of that story.  This is more of an ACT (Acceptance Commitment Therapy) strategy. 

Often it’s both, so we need to work on both, but probably defusion first perhaps before the story can effectively be changed or reframed. 

When we are stuck with a difficult problem, structured problem solving may help

Structured problem solving is a simple CBT (Cognitive Behavioral Therapy) tool.

The key problem for many us is that, when we are faced with a difficult problem, and there are no perfect or good solutions, we may get stuck in procrastination.  Being stuck in limbo can be worse than bad news.  Our job then is to get unstuck.  

So how can we get unstuck through structured problem solving?

Here are the following steps:

1 We start with defining the problem accurately.  It is a very important part of the process because, if we define the problem incorrectly, wrong problem definition equals wrong solution. 

2 Next step is to explore ALL possible options including the bad ones.  We can write them all down.  We acknowledge that our primary aim is to find the best option, and accept that the best option can be still be a bad one, but at least it is the BEST.

3 Next step is to narrow down the list. First, we cross out the options that are a definite “no”.  These are the more obvious ones. 

Hopefully at this stage, we have narrowed it down to 2-3 options. 

4 Next step is to write down a detailed list of pros and cons for each of these options.  Explore those to facilitate a decision towards what is our best option, i.e. one with the most pros and the least cons. 

5 Then we take committed action towards the best option.  We can break down the task to smaller and achievable chunks.  

6 Review, check progress, and fine tune towards our best option.

The relationship between primary, secondary, and tertiary emotions

I often share with my patients the ideas and concepts around primary emotions, secondary emotions, and tertiary emotions.

The primary emotion of disconnectedness and loneliness can lead to a secondary emotion of fear/anxiety which then can lead to a tertiary emotion of anger/frustration/avoidance/withdrawal or distraction through food, smoke, alcohol, drugs, gambling etc. 

People tend to fix the problem at the tertiary and secondary level because these are what people can see, but it’s much more effective if one can fix it at the primary level.  Fix the relational issues. Fix the disconnectedness. Fix the loneliness, and many other health issues will be much easier to manage. 

Can you relate to the above?

How can counseling help us to adapt better and thrive

The use of metaphors and analogies can be very useful in counseling because many ideas and concepts in mental health can be quite abstract. I often liken the mind to a computer, with our system of values, beliefs, internal rules, principles, and the way we think, being the operating system.

The problem is, the operating system needs regular updates as our environment and society is changing so rapidly.

To complicate things, it is also hooked into the network with other computers which use different operating systems. A mixture of Windows, iOS, Linux and a few others.

With that in mind, it’s not surprising to see so many internal and external conflicts in our lives, and the lives of our patients. Furthermore, if these internal and external conflicts are not resolved, it may manifest as stress, anxiety, depression, and adjustment disorders with anxious or depressed mood.

So counseling is to assist our patients to update their operating system on a regular basis, and to understand and find ways to reconcile with the other operating systems in the network. It can be a tough gig for sure.