Table of Contents [Show]
- Anxiety Disorder & Depression Facts
- Types of anxiety & depression
- The most common anxiety disorders
- Depressive disorders
- The causes of anxiety and depression
- Treatment for anxiety and depression
The reason for this is that both groups of illnesses frequently co-occur, with half of those with a diagnosis of depression also having a diagnosis of an anxiety disorder.
Both anxiety disorders and depression are also two of the most prevalent mental disorders in the world.
The World Health Organization (WHO) reports that around 350 million people in the world are currently affected by depression which is slightly more than 4% of the world’s population.
The prevalence of anxiety disorders is even higher with studies estimating that 7.3% of the global population suffers from an anxiety disorder.
However, these numbers are likely to be much higher because the WHO also reports that the most (30-80%) of all people with mental illness don’t seek out treatment.
As evidence shows, mental illness is quite common but most people don’t see it that way.
Instead, mental illness is seen as something that affects only certain high-risk groups.
The truth is that mental illnesses like anxiety and depression can affect anyone, regardless of their age, gender, or social background.
Mental illness is also highly treatable so most people receiving treatment for anxiety and depression recover.
Experts believe that the most common reasons why people don’t seek out help for mental illness are a stigma, ignorance, distrust, and due to the nature of the illness itself.
The stigma of mental illness is particularly concerning given that we know more about mental illness than ever before.
Stigma can lead to discrimination and social isolation, both of which make it harder for a person to recover.
As far as treatment for anxiety disorders and depression are concerned, a combination of medication and psychotherapy are still the first in line treatments.
But these treatments may only help keep the disorders under control and minimize the chances of relapse.
Unfortunately, many people with these kinds of disorders experience more than one episode of severe anxiety and depression during their lifetime.
Getting to the root cause of these disorders may prove to be helpful to find long-lasting treatment and to slow down the mental illness epidemic happening across the globe.
Some researchers believe that mental disorders like anxiety disorders and depression begin in the brain, others think the origin of these disorders can be found in someone’s environment, genes, or personality.
But most believe that the combination of all these factors could explain mental illness.
Anxiety Disorder & Depression Facts
Anxiety disorders and depression were once classified under a group of mental disorders called neuroses.
Neurosis was a term for mental disorders characterized by distress but without changes in personality and major disturbances in perception.
This classification helped psychiatrists distinguish this group of disorders from psychoses which are characterized by a break from reality and hallucinations.
However, such a division is no longer in use because researchers noticed that mental disorders occurred in a spectrum as explained in an article published Schizophrenia Bulletin.
What this means is that disorders like anxiety and depression occur at the lower end of this spectrum while psychotic disorders occurred at the other end of the spectrum.
Furthermore, researchers noticed that people with psychotic disorders also experienced anxiety and depression before developing psychosis.
It is true that anxiety and depression are considered milder forms of mental illness when compared to schizophrenia, developmental disorders, and personality disorders.
Nevertheless, that does not make these disorders any less debilitating.
In fact, according to the WHO, depression is the leading cause of disability in the US and people with this illness are 4 times more likely to suffer a heart attack than those not affected.
The disorders are not considered mild in that the suffering the person experiences is milder than in other mental illness, but rather that these disorders are easier to treat than say, schizophrenia.
The major reasons why anxiety disorders and depression often occur within the same context is their high rate of co-occurrence and because both disorders also share some similarities.
Research shows that both disorders happen as a result of chronic and unrelenting stress, poor coping mechanisms, a strong genetic background, viral infections, immune system dysfunction, and even nutrition.
Both disorders also affect a person’s thoughts, emotions, and behavior albeit in a different way.
Anxiety disorders are characterized by persistent anxiety and fear.
The major feature of anxiety disorders is the anticipation of future events and fear related to current events.
A person with an anxiety disorder is hypervigilant and fearful of what is to come.
A person with depression, on the other hand, believes only in the worst future outcomes and is not anxious as much as they are pessimistic.
This gloomy outlook characteristic of depression can make a sufferer feel like life is not worth living.
Although feelings of anxiety and depression are normal reactions to stressful life events, when they become chronic, they are considered to be pathological.
Death of a loved one, financial difficulties, a breakup of a relationship normally evoke feelings of sadness and hopelessness.
But when these feelings persist for a very long time and impair a person’s ability to function in life, then they become problematic.
People suffering from these disorders have trouble focusing at work, avoid all social relationships, develop sleep problems, eating problems, and some even become suicidal.
The majority of people with these mental disorders do not commit suicide, but evidence shows that 90% of those who die by suicide have suffered from a mental disorder.
For all these reasons, people experiencing any of the symptoms of mental illness should seek help.
Treating mental illness early on reduces the severity of mental illness and improves overall health and functioning.
But when left untreated, mental illness tends to persist for a long time and even become worse.
If you suspect that what you or a loved one is experiencing is mental illness, do address this issue with your health care provider and they will provide you with the tools you need to address any issues you might be having.
The next lines cover the basic facts about anxiety disorders and depression, their classification and treatment options.
Types of Anxiety & Depression
Classifying mental disorders is a difficult task in psychiatry and other mental health professions.
This is mostly because mental illness, in general, is not well understood, and there is even no one consensus on what mental illness is and how to define it.
Nevertheless, for the sake of practicality, two widely-used systems for classifying mental disorders were developed:
- The WHO’s Chapter V of the International Classification of Diseases (ICD-10)
- The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) by the American Psychiatric Association (APA).
Based on these two classification systems, anxiety and depression are divided as follows:
The Most Common Anxiety Disorders
Generalized Anxiety Disorder (GAD)
GAD affects approximately 3.1% of the US population.
The disorder is characterized by persistent and excessive worry the cause of which may not be known.
People with GAD find it hard to control their worry and they may worry even if there is no objective reason for such feelings.
They may worry about money, their health, their family, or any other aspect of their life.
They may feel restless, on the edge, fatigued, irritable, and develop sleeping problems due to constant feelings of anxiety.
GAD can become debilitating if left untreated; lead to a decline in functioning and relating, and easily progress into a depressive episode.
People with panic disorder have frequent and unexpected panic attacks.
Panic attacks are defined as periods of sudden feelings of fear and dread usually accompanied by uncomfortable physical symptoms.
These symptoms include a racing heart, sweating, trembling, shortness of breath, smothering, choking, and feelings of impending doom.
People with panic disorders usually also develop a fear of places where their panic attacks occurred and anxiety about future panic attacks.
Social Anxiety Disorder
Unlike GAD which is characterized by anxiety by everything and anything, in social anxiety, disorders, the object of fear is much easier to pinpoint.
People with social anxiety experience anxiety in most social situations. They may fear being embarrassed, ridiculed, or judged by others.
Because of their anxiety, people with this disorder may avoid social situations altogether and this can interfere with their ability to function in life.
Other less common types of anxiety disorders include selective mutism, specific phobias, and substance-medication-induced anxiety disorder.
Selective mutism is an anxiety disorder in which a person’s anxiety prevents them from speaking even when the consequences of not speaking include shame and punishment.
The disorder is most commonly seen in children.
Phobias refer to fears of places, objects, and situations even when these things don’t pose any threat and the person is aware of the irrationality of their fears.
Substance-induced anxiety is triggered by the use of a substance and can occur when the substance is used or during withdrawal.
Substances that commonly cause this form of anxiety disorder are amphetamines, analgesics, epinephrine, and lithium among others.
Depressive disorders are characterized by intense feelings of sadness, loss of interest in activities once enjoyed, an inability to feel pleasure, feelings of guilt or low self-worth, poor concentration, disturbed sleep, and appetite changes.
Sufferers often report a range of physical ailments as well for which a physical cause is difficult to find.
The DSM-V classifies depressive disorders by their specific symptoms:
Major Depressive Disorder
Also known as major depression, major depressive disorder is an acute type of depressive disorder characterized by intense feelings of sadness, worthlessness, and hopelessness.
The sufferer may cry a lot or may not experience any emotion at all.
The sufferer may neglect personal hygiene, stop caring for their loved ones, have trouble concentrating, getting out of bed, and eating.
They may lose or gain a significant amount of weight.
The symptoms are severe enough to interfere with normal functioning and family and friends usually notice changes in the sufferer.
The disorder can happen after a major stressful life event or out of the blue and the symptoms need to last 2 weeks for an official diagnosis.
With proper treatment, most people with major depression recover within months.
Persistent Depressive Disorder
When depressive symptoms persist for more than 2 years without remission, the disorder is classified as persistent depressive disorder (PDD), which was formerly known as dysthymia.
The first symptoms of PDD usually appear during adolescence and last for many years, even decades.
The number of symptoms fluctuates during one’s lifetime, but they are generally less severe than in major depressive disorder.
Those affected come off as gloomy, pessimistic, passive, hypercritical of self and others, lethargic, apathetic, and complaining.
Experts suggest that those with PDD are more likely to have a comorbid condition such as an anxiety disorder, substance abuse disorder, or a personality disorder.
To establish this diagnosis, a person must have a depressed mood for most of the day, every day for more than 2 years.
Other symptoms of PDD include:
- Poor appetite or being overweight
- Sleeping too much or too little
- Low energy levels and chronic fatigue
- Low self-esteem
- Poor concentration
- Feeling hopeless
Premenstrual Dysphoric Disorder
Premenstrual dysphoric disorder is similar to premenstrual syndrome (PMS) but the symptoms tend to be more severe.
The prevalence of this disorder is believed to be in 2-6% of menstruating women.
The symptoms of the premenstrual dysphoric disorder occur a few days to a few weeks before menstruation and they disappear completely in the days following menstruation. The symptoms of this rare disorder include:
- Noticeable mood swings
- Marked irritability and anger
- Strong depressed mood
- Strong feelings of anxiety
- Decreased interest in activities
- Problems concentrating
- Sleeping too much or too little
- Poor appetite or overeating
- Physical symptoms (breast tenderness, bloating, joint and muscle pain)
Seasonal Affective Disorder (SAD)
Seasonal affective disorder is characterized by depressive symptoms that most commonly occur during the winter months and the symptoms typically go away during spring and summer.
Treatment for SAD includes light therapy and phototherapy because this form of depression is believed to be a result of low levels of light during the colder months.
Psychotherapy and medication may also help.
Postpartum depression is a severe type of depression that can affect both sexes following childbirth, but it is most commonly seen in women.
The symptoms of postpartum depression are the same as with major depression but they happen in the weeks and months following childbirth.
Hormonal changes during this period of life are believed to be a contributing factor to the development of postpartum depression or due to the stress and major life changes taking place during this time.
In the case of psychotic depression, people may have the symptoms of depression such as low mood, feeling worthless and hopeless and also experience psychotic symptoms.
Psychotic symptoms in psychotic depression include:
- Hallucinations – usually auditory, but can be visual as well. Hallucinations referrers to sensing things those aren’t there. The most common type of psychotic hallucination is hearing voices.
- Delusions – a delusion is a false belief that a person holds on to despite evidence that their beliefs may be false. The delusions commonly experienced in psychotic depression include the belief that one is suffering a terminal illness or that they should be punished for something they did not do.
- Paranoia – A wrong belief that others are trying to harm you. Paranoia also has no basis in reality and is marked by irrational and strong fear.
Psychotic depression occurs in people who’ve had several episodes of depression without psychosis.
Once treated with a combination of antipsychotic medications and antidepressants, most people diagnosed with psychotic depression recover.
The disorder is difficult to distinguish from other psychotic disorders, such as schizoaffective disorder, but the prognosis for psychotic depression is usually good.
Psychotic depression, however, does occur in episodes with most people with this disorder experiencing several episodes during their lifetime.
Bipolar disorder, also called manic depression, is usually not classified under the same category as depression (also called unipolar depression).
However, we will include this disorder here because everyone with a diagnosis of bipolar disorder also experiences severe depression.
The National Institute of Mental Health (NIMH) defines manic depression as a brain disorder that causes unusual shifts in mood, energy levels, and activity.
These shifts are severe enough for family and loved ones to noticed that what the person is experiencing is not normal.
Although there are 4 different types of bipolar disorder, all are characterized by shifts from a so-called manic episode into a depressive episode.
People with this disorder usually have a few manic episodes in their life where they feel elevated, ecstatic, energetic, and they may even become psychotic.
Once this episode is over, the person may start feeling very depressed. People with bipolar disorders are often prescribed a mood stabilizer such as lithium.
Mixed Anxiety-Depressive Disorder (MADD)
According to ICD-10 criteria, mixed anxiety and depressive disorder (MADD) is characterized by co-occurring symptoms of anxiety and depression that are severe enough for a psychiatric diagnosis, but which are not clear enough for a clear diagnosis of one or the other.
The disorder seems to be very common, but researchers have recently brought this diagnosis under question.
The reason for this being that in MADD, the symptoms are frequently less severe than in full-blown anxiety or depression.
This apparent low severity means that the symptoms are considered to be sub-threshold.
However, some researchers believe that MADD is a valid diagnosis that should be included in the diagnostic categories.
As explained in a study published just last year in the European Archives of Psychiatry and Clinical Neuroscience, including MADD into classification systems will enable patients to receive treatment early.
After all, most people with a diagnosis of MADD develop much more severe symptoms over time if not treated and their condition is sure to become progressively worst.
MADD is characterized by feelings of low mood that persist for at least 4 weeks.
Other symptoms of this disorder include:
- Troubles concentrating
- Memory problems
- Sleep disturbances
- Chronic fatigue
- Constant worrying
- Constant apprehension
- Feeling worthless and hopeless
These symptoms should not be a result of medication use or an underlying health condition; they symptoms should cause significant impairment in functioning, and they symptoms do not meet the criteria for other psychiatric illnesses for a diagnosis of MADD.
People with anxiety often experience great problems in work and social functioning which can lead to depressive symptoms in the long run.
The Causes of Anxiety And Depression
Mental illness is in itself a controversial subject that is difficult to research simply because we do not know the exact origins of mental illness.
However, most psychology experts today agree that mental disorders like anxiety and depression are a result of a combination of different factors.
Some people may have a genetic predisposition to mental illness and whether or not they will develop mental illness depends on their upbringing, their life circumstances, their overall health, and other factors.
The same is true for all mental disorders with the exception of developmental disorders, schizophrenia, and dementia which scientists now agree is strongly rooted in the brain.
But in general, the causes of mental illness are found either in the brain, in the body, or in the environment.
Causes of Anxiety Disorders
Anxiety disorders are said to result from a combination of environmental, medical, genetic, brain, chemistry, substance, abuse, and other factors. The most common trigger for anxiety disorders is stress.
Stressful life events can overwhelm our limbic system leading to hypervigilance.
Our coping mechanisms may weaken in the face of stressful events and fear and anxiety may start to predominate.
Medical illness can also cause anxiety. Some people may have a genetic predisposition to anxiety disorders as anxiety is known to run in families.
Childhood trauma and abuse can also set the stage for anxiety disorders in the future.
But to put it simply, anxiety is caused by a stressful life event in individuals with a genetic or psychological predisposition for these disorders.
Other causes of anxiety disorders are underlying conditions such as depression, substance abuse disorder, and panic disorder.
Causes of Depression
While experts tend to be more clear on defining the origin of anxiety disorder, depression seems to be more baffling to the medical community than any other medical disorder.
This is because depression can happen to anyone, regardless of their age, life experiences, genetics, social background, and stress levels.
While depression may result in chronic stress just as anxiety disorders are known to, depression may also be a result of chemical imbalances in the brain among other things.
In fact, current research is largely focusing its attention on the biological origins of depression rather than psychological.
Take for instance the viewpoint of Thomas R. Insel, MD who is the director of the National Institute of Mental Health.
According to Insel, mental illnesses are no different from other chronic diseases such as diabetes or heart diseases.
The only difference here is that the origin of the illness is the brain rather than the heart or pancreas. However, researchers like Jerome Wakefield, Ph.D., DSW, a professor of social work and psychiatry at New York University believe that too much emphasis is being put on the brain.
He notes that all efforts to find the cause of mental disorders like depression in the brain have only given a few cues, but have yielded very little in terms of finding effective treatments.
With that being said, mental disorders like depression are difficult to define, diagnose, and to determine their origin.
Low serotonin levels in the brain were once thought to cause depression, but this theory is no longer valid.
Current research is turning its focus from the “chemical imbalance” theory to inflammation and immune system dysfunction as possible causes of depression.
For instance, a study published recently in the World Journal of Psychiatry proposes that immunological imbalances lead to subclinical inflammation in the body and this somehow affects the central nervous system.
Simply put, depression is now seen as possibly being a disorder caused by low-grade inflammation and poor immune system functioning.
Another study published in Molecular Psychiatry has joined in on this discussion with another proposed theory.
The study found a link between poor gut microbiota and altered brain functioning.
The study found that modifying the gut’s natural microorganism balance can lead to depressive symptoms.
These theories may explain the rise in depression in the past 50 years when drastic changes across the globe took place.
From changes in agriculture, urbanization, and heavy antibiotic use, there are so many things in our living environment that could negatively be affecting our physical and mental health.
As already explained, the view of mental illnesses with an unknown origin has drastically changed in the past few decades.
While we know that disorders such as autism and schizophrenia have a strong biological basis, disorders like anxiety and depression only cause slight changes in brain structure that don’t really explain much about these illnesses.
And while biological factors such as brain chemistry could explain these disorders to a certain extent, we shouldn’t overlook other important factors in the origin of anxiety and depressive disorders says, Wakefield.
Environmental, social, and behavioral factors play a great role in the origin of these disorders and when we know that this is the case, we also recognize that mental illness cannot be solely treated with medication.
Saying that people with depression and anxiety can get better simply by taking medicine to correct their faulty brain chemistry is very misleading and rather concerning.
Wakefield further proves his case with a study that raises reasons for concerned that was published in the American Journal of Psychiatry which found that the number of patients receiving psychotherapy for depression declined by 10% between 1997 and 2007 while the rates of antidepressant use remained the same.
But besides the question of whether the origins of anxiety and depression could be found exclusively in the brain, many other questions regarding these illnesses remain unanswered.
For instance, some researchers find that the link between these disorders could be stronger than we think.
Before the 1970s, anxiety, and depression were actually seen as different manifestations of the same affective disorder.
Today, research shows that both disorders have similar characteristics such as low mood and pessimism and this evidence could well suggest that the disorders represent two sides of the same coin.
Both disorders are also known to affect serotonin receptors in the brain and now, clinical guidelines recommend antidepressants not only as a treatment for depression but for anxiety disorders as well.
All this means that these mental disorders could very well have the same origin, but whether that origin is in the brain, in the genes, in the environment, or all these factors is hard to tell.
Treatment for Anxiety and Depression
Both anxiety and depression can be successfully treated with a combination of medication and psychotherapy.
A primary care physician can treat your depression but it is best to seek help from a psychotherapist to improve your outcomes.
A primary care physician can prescribe antidepressants and anxiolytics and suggest group therapy.
A psychotherapist can help you change your thinking patterns and help you understand your condition better.
However, what treatment will work for you depends on your specific situation, general health status, and severity of symptoms.
The Guidelines for the Management of Depression and Anxiety in Primary Care suggest that moderate and severe depression be treated with a combination of psychotherapy and antidepressant medicine.
Mild depression may only require psychological canceling.
Antidepressant medicine currently prescribed in the treatment of mild and severe depression includes:
- Tricyclic antidepressants (TCAs) – The first generation of antidepressants that are now rarely prescribed, mostly for depression that does not respond well to newer generation antidepressants.
- Selective serotonin reuptake inhibitors (SSRIs) – A class of drugs that limit the reabsorption of the neurotransmitter serotonin in the brain, increasing its availability.
- Selective serotonin noradrenaline reuptake inhibitors (SSNRIs) – In addition to limiting the reuptake of serotonin, these drugs also inhibit the reuptake of another neurotransmitter known to improve mood called norepinephrine.
- Norepinephrine reuptake inhibitors (NRIs) – Types of drugs that acts as a reuptake inhibitor for norepinephrine (noradrenaline) and epinephrine (adrenaline). They are most often used in treating ADHD and narcolepsy but also for depression, anxiety, and panic disorders.
There are different forms of psychotherapy that can help a person with depression cope and recover.
In addition to psychotherapy, patients are often given guidelines to manage their depressive symptoms at home.
Common recommendations are relaxation practices like yoga and meditation and other self-help techniques.
- Interpersonal Therapy: This form of talk therapy focuses on resolving issues around a person’s relationships and life circumstances. The basic concept behind this form of therapy is that relationships are the root cause of psychological distress.
- Cognitive-Behavioral Therapy (CBT): CBT helps a person change the maladaptive thinking and behaving patterns that may be exacerbating a person’s depression. In CBT, a patient works with their therapist to change negative thinking patterns into positive ones and this has proven to lead to successful outcomes in most cases.
- Psychodynamic Therapies: The focus in this type of therapy is helping patient resolve internal conflicts rooted in childhood. This form of therapy is recommended to patients with life-long depression and who are prone to self-injury.
Treating Anxiety Disorders
Mild anxiety can be treated with relaxation techniques and cognitive behavioral therapy.
Anxiety disorders can benefit from the same treatment for depressive disorders.
Antidepressants were found to help people with a generalized anxiety disorder and panic disorders.
Traditionally, however, anxiety disorders were treated with a class of drugs called benzodiazepines.
The most common drugs for anxiety are:
- Alprazolam (Xanax)
- Diazepam (Valium)
- Clonazepam (Klonopin)
- Lorazepam (Ativan)
Benzodiazepines work by enhancing the effects of the neurotransmitter gamma-aminobutyric acid (GABA) at the GABA receptors in the brain.
The GABA receptors main function is to inhibit neurotransmitter activity.
The result of this reduction in neurotransmitter signaling is slight sedation, anxiety-reduction, muscle relaxation, and sleepiness.
These drugs are considered generally safe with short-term use, but long-term use can lead to cognitive impairment and dependence.
They are usually prescribed to people with severe anxiety such as those experiencing frequent panic attacks and phobias.
Psychotherapy for Anxiety Disorders
There are several types of therapies commonly recommended for the treatment of anxiety disorders, but cognitive behavioral therapy (CBT) is currently the most popular treatment option.
Cognitive-behavioral therapy cannot only help people with anxiety address their maladaptive thinking patterns, but it may also help them develop behavioral strategies that will make it easier for them to cope in situations of severe anxiety.
Epidemiological studies show that physical activity can prevent the onset of mental illness.
Furthermore, what you eat could also have an impact on how you feel.
Current research emphasizes the importance of nutrition in brain health.
Although nutritional deficiencies cannot account for all mental illnesses, they could be a contributing factor.
If you suffer from a disorder such as anxiety and depression, boosting your nutrient intake can help improve the symptoms and prevent relapse.
Dietary recommendations for good mental health include eating plenty of fruits and vegetables, avoiding saturated fat and processed food.
Also, make sure to boost your intake of omega-3 fatty acids, B vitamins, vitamin E, niacin, folate, and vitamin C into your diet as these nutrients are crucial for normal brain functioning and neurotransmitter synthesis.
Although anxiety and depression are often referred to as the “common cold” of mental illness, these disorders can actually become severe enough to become life-threatening.
The majority of people who commit suicide have suffered from a mental illness such as depression and comorbid anxiety.
Anxiety and depression can make it hard for a person to function in everyday life if left untreated.
On the other hand, treating these disorders with a combination of different therapies have proven to be effective in the majority of cases.
Unfortunately, research has not provided an explanation for these disorders yet.
Nobody knows why some people become overtly anxious and depressed during stressful life events while others seem to cope better.
The explanation for this may lie in their genetic makeup, their upbringing, their psychology, environment, or overall health. With the depression epidemic on the rise, the problem may well be of collective nature and lie somewhere in our environment.
Current research is focusing more and more on things like inflammation and immunity as the possible cause of faulty brain chemistry.
But some researchers believe that biology is not the only place to look for the causes of depression.
This is why the most effective treatment for depression involves medication, talk therapy, and self-help techniques.
With this approach, most people with severe anxiety and depression can recover. But relapse does happen and their symptoms may vary in severity across their lifetime.
A great problem with mental disorders like anxiety and depression is a stigma.
Stigma makes a person feel ostracized, discouraged, and distrustful.
Due to the stigma of mental illness, most of those who should seek help for mental health problems don’t do so.
Not seeking treatment can lead to worsening of symptoms and even suicidal thinking.
Although most people tend to think that depression cannot happen to them or that their condition cannot advance to the point of thinking about suicide, this is simply not true.
The nature of the mental illness is that it skews a person’s perception and thinking.
In the midst of a depressive episode, people often truly think that life is not worth living without realizing that this type of thinking is the product of depression and not the objective reality they are living.
If you happen to experience any symptoms associated with depression or an anxiety disorder, do seek treatment.
If your symptoms are mild, gaining insight through self-help techniques can also help.
Whatever the case may be, know that anxiety and depression do not go away on their own.
Both require quite a bit of effort and support to resolve.
 https://www.ncbi.nlm.nih.gov/pubmed/22781489  https://www.dbsalliance.org/