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Guest Editorial
Mental Health Care and the Workplace

Dan Bilsker

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In Review
Common Mental Disorders in the Workforce: Recent Findings From Descriptive and Social Epidemiology

Kristy Sanderson, Gavin Andrews

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Managing Depression-Related Occupational Disability: A Pragmatic Approach
Dan Bilsker, Stephen Wiseman, Merv Gilbert

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Original Research Descriptive Epidemiology of Major Depression in Canada
Scott B Patten, MD, Jian Li Wang, Jeanne VA Williams, Shawn Currie, Cynthia A Beck, Colleen J Maxwell, Nady el-Guebaly

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La comorbidité dans le trouble d’anxiété généralisée : prévalence et évolution suite à une thérapie cognitivo-comportementale
Martin D Provencher, Robert Ladouceur, Michel J Dugas

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Review Paper
Prevalence and Incidence Studies of Anxiety Disorders: A Systematic Review of the Literature

Julian M Somers, Elliot M Goldner, Paul Waraich, Lorena Hsu

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Recent Advances in the Treatment of Delusional Disorder
Theo C Manschreck, Nealia L Khan

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Book Reviews
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Basic Child Psychiatry
Review by
Nasreen Roberts


The Neurobiology of Autism
Review by
Stuart Fine


Madness Explained: Psychosis and Human Nature
Review by
Paul Franceschi


Aggression, Antisocial Behavior and Violence among Girls
Review by
Vera Lantos


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Letters to the Editor
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Re: Late-Onset Neutropenia With Clozapine

Reply: Late-Onset Neutropenia With Clozapine

Re: Characteristics of Methylphenidate in a University Student Sample

Reply: Characteristics of Methylphenidate in a University Student Sample

Problem Gambling in the Canadian North Neglected

Reply: Problem Gambling in the Canadian North Neglected

Review Paper

Prevalence and Incidence Studies of Anxiety Disorders: A Systematic Review of the Literature

Julian M Somers, MSc, PhD1, Elliot M Goldner, MHSc, MD2, Paul Waraich, MHSc, MD1, Lorena Hsu, MSc3

 

Objective: To present the results of a systematic review of literature published between 1980 and 2004 reporting findings of the prevalence and incidence of anxiety disorders in the general population.

Method: A literature search of epidemiologic studies of anxiety disorders was conducted, using MEDLINE and HealthSTAR databases, canvassing English-language publications. Eligible publications were restricted to studies that examined age ranges covering the adult population. A set of predetermined inclusion and exclusion criteria were used to identify relevant studies. Prevalence and incidence data were extracted and analyzed for heterogeneity.

Results: A total of 41 prevalence and 5 incidence studies met eligibility criteria. We found heterogeneity across 1-year and lifetime prevalence rates of all anxiety disorder categories. Pooled 1-year and lifetime prevalence rates for total anxiety disorders were 10.6% and 16.6%. Pooled rates for individual disorders varied widely. Women had generally higher prevalence rates across all anxiety disorder categories, compared with men, but the magnitude of this difference varied.

Conclusion: The international prevalence of anxiety disorders varies greatly between published epidemiologic reports. The variability associated with all anxiety disorders is considerably smaller than the variability associated with individual disorders.Women report higher rates of anxiety disorders than men. Several factors were found to be associated with heterogeneity among rates, including diagnostic criteria, diagnostic instrument, sample size, country studied, and response rate.

(Can J Psychiatry 2006;51:100–113)

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Clinical Implications

  • Significant heterogeneity in the prevalence of anxiety disorders signals the need for population-specific health policies and planning.

  • The prevalence of anxiety disorders eclipses the capacity of specialized mental health services.

  • Anxiety disorders remain prevalent throughout ages 18 to 64 years.

Limitations

  • The observed heterogeneity may be related to environmental or cultural factors associated with the location of each contributing investigation.

  • Variance owing to methods of diagnosis and measurement account for a limited portion of the observed heterogeneity.

  • An insufficient number of incidence studies are available to clarify details concerning the onset of symptoms.

Key Words: anxiety disorders, panic disorder, phobia, obsessive–compulsive disorder, posttraumatic stress disorder, generalized anxiety disorder, prevalence, incidence, systematic review

Résumé : Études de la prévalence et de l’incidence des troubles anxieux : une étude systématique de la littérature


AbbrSomers.jpg - 0 Bytes

In recent years, it has been increasingly acknowledged not only that anxiety disorders are highly prevalent, but also that the burden of illness associated with these disorders is often considerable. A broad understanding of the etiology of anxiety includes a multiplicity of factors, such as biological, psychological, and social determinants, which are mediated by a range of risk and protective factors. Cross-cultural studies in epidemiology are a critical source of information regarding the interplay between these factors. Effective forms of intervention are available and are the subject of ongoing research, but it is an immense public health challenge to coordinate the delivery of these programs and services. Studies in comparative epidemiology play a vital role in the development of health policy concerning anxiety. Empirical knowledge of regional prevalence is fundamental to understanding the relative demand for services. Such knowledge is also necessary to identify the most appropriate avenues for intervention.

The present review, which is the fifth in a series of papers that will present systematic reviews of the prevalence and incidence of psychiatric disorders drawn from studies published in the English literature in the years 1980 to 2004, sought to synthesize international research on this topic. Results and observed patterns of heterogeneity are discussed in relation to health services planning as well as implications for additional research.

Methods

The methods employed in this review have been presented in more detail elsewhere (1). The MEDLINE and HealthSTAR databases were searched for relevant studies; the key indexing terms epidemiology, prevalence, and incidence were used, combined with the search terms mental disorders, anxiety disorders, panic disorder, phobia, obsessive–compulsive disorder, posttraumatic stress disorder, and generalized anxiety disorder. The search was limited to English-language studies published between 1980 and 2004. Reference lists of relevant primary and review articles identified were also searched.

Prevalence and incidence studies were eligible for inclusion if they were community surveys using probability sampling techniques. Eligible publications were restricted to studies having sample sizes of 450 people or more that examined age ranges covering the adult population. Only studies using current diagnostic criteria and case identification based on either standardized instruments or clinician diagnosis were included. Prevalence and incidence data, including overall, sex-specific and age-specific rates, were extracted from eligible studies.

Qualitative analyses of variables related to methodology were conducted to summarize and elucidate any observed differences between rates. Each set of rates was also pooled according to a Bayesian approach to metaanalysis; the Fastpro software program was used. Readers interested in a more detailed discussion of this approach should refer to Eddy and others (2). Each of the pooled rates was analyzed for heterogeneity with chi-square tests according to the Fleiss method (3).

Results

Description of Studies

From the citations and abstracts generated by the initial electronic search, we identified 80 prevalence and 10 incidence studies potentially meeting inclusion criteria, in addition to 28 review papers (4–31). The full texts of these articles were retrieved. We searched all reference lists of identified studies and reviews, generating an additional 38 prevalence and 6 incidence studies for which full-text articles were obtained.

Of the 118 prevalence studies for which full-text articles were reviewed, 71 prevalence papers of anxiety disorders met eligibility criteria (32–95,96–102), resulting in a total of 41 unique primary investigations of anxiety disorders included in this review. We excluded a total of 47 studies: 35 studies did not meet eligibility criteria, and 12 presented duplicate data. Of the 16 incidence studies identified, 11 were excluded, 8 did not meet inclusion criteria, and 3 were based on duplicate study samples. This resulted in 5 incidence studies of anxiety disorders that could be included (54,90,103–105). Most studies meeting inclusion criteria used nonhierarchical diagnostic approaches. Predictably, the few studies using hierarchical diagnoses reported relatively lower rates of individual disorders.

Prevalence Studies

Findings, for the 34 papers reporting overall and (or) sex-specific 1-year and (or) lifetime prevalence rates for panic disorder, agoraphobia, social phobia, specific phobia, OCD, PTSD, GAD, and TAD, are presented in Tables 1 to 3. Age-specific lifetime prevalence rates for these disorders are also presented in Figure 1 (33,34,40,44,59,66,73,81, 84,94,101,106). The results of studies reporting only data for point prevalence or 6-month prevalence are not presented (36,37,41,45,49,53,54, 56,6,63,67,69,70,74–76,78,86,87, 92,93,107). Analysis of data was carried out only when 3 or more rates were reported as this was the minimum number of values required to produce pooled rates.

Table 1  1-Year and lifetime prevalence rates of anxiety disorders 


Author(s), year of study, and study site 

Case-finding method 

Prevalence rate (%) 

 

 

PD 


Agoraphobia 


Social phobia 


Specific phobia 


OCD 


PTSD 


GAD 


TAD 


 

 

1-year 

Life 

1-year 

Life 

1-year 

Life 

1-year 

Life 

1-year 

Life 

1-year 

Life 

1-year 

Life 

1-year 

Life 


Mohammadi and others (2004), Iran (101) 

C; SADS/DSM-IV; CLI; AD 

— 

— 

— 

— 

— 

— 

— 

— 

— 

1.8 

— 

— 

— 

— 

— 

— 

Norris and others (2003),
Mexico - 4 sites, urban and rural (102) 

C; CIDI/DSM-IV; LI 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

11.2 

— 

— 

— 

— 

Hunt and others (2002),
Australia (98) 

C; CIDI/DSM-IV; LI; AD 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

3.6 

— 

— 

— 

McConnell and others (2002),
Northern Ireland (100) 

C; SCAN/ICD-10; CLI; AD 

2.4 

— 

0.7 

— 

— 

— 

0.2 

— 

— 

— 

0.12 

— 

0.15 

— 

— 

— 

Carter and others (2001), Germany (96) 

C; DIA-X/M-CIDI/DSM-IV; CLI; AD 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

1.5 

— 

— 

— 

Creamer and others (2001), Australia (97) 

C; CIDI/DSM-IV; LI; AD 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

1.3 

— 

— 

— 

— 

— 

Grabe and others (2000), Germany - northern region of Lubeck (77) 

C; CIDI/DSM-IV; LI; AD 

— 

— 

— 

— 

— 

— 

— 

— 

0.39 

0.5 

— 

— 

— 

— 

— 

— 

Henderson and others (2000), Australia (47) 

C; CIDI-A/ICD-10; LI 

1.3 

— 

1.1 

— 

2.7 

— 

— 

— 

0.4 

— 

3.3 

— 

3.1 

— 

9.7 

— 

Bijl and others (1998), Netherlands (32) 

C; CIDI/DSM-III-R; LI; AD 

2.2 

3.8 

1.6 

3.4 

4.8 

7.8 

7.1 

10.1 

0.5 

0.9 

— 

— 

1.2 

2.3 

12.4 

19.3 

Faravelli and others (1997),
Italy , Florence (95) 

C; SADS-L/DSM-III-R; CLI; CD 

3.2 

— 

0.6 

— 

— 

— 

0.3 

— 

— 

— 

— 

— 

0.4 

— 

4.2 

— 

Fournier and others (1997),
Canada, Montreal (52) 

TS; CIDIS/DSM-III-R; LI; AD 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

11.5 

— 

14.7 

Offord and others (1996),
Canada, Ontario (42) 

C; UM-CIDI/DSM-III-R; LI; AD 

1.1 

— 

1.6 

— 

6.7 

13.0a 

6.4 

— 

— 

— 

— 

— 

1.1 

— 

12.2 

— 

Kessler and others (1995),
USA (NCS) national (60) 

C; revised DIS/DSM-III-R; LI; AD 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

3.9a 

7.8 

— 

— 

— 

— 

Kessler and others (1994)
USA (NCS) national (39) 

C; UM-CIDI/DSM-III-R; LI; AD 

2.3 

3.5 

2.8 

5.3 

7.9 

13.3 

8.8 

11.3 

— 

— 

— 

— 

3.1 

5.1 

17.2 

24.9 

Chen and others (1993),
Hong Kong  (35) 

C; DIS-III-CM/DSM-III; LI; AD 

— 

0.28c 

— 

0.73c 

— 

— 

— 

2.1c 

— 

1.0c 

— 

0.6c* 

— 

9.5c 

— 

— 

Bourdon and others (1992),
USA (ECA) - 5 sites, mainly urban (46) 

C; DIS/DSM-III; LI; AD 

— 

— 

— 

— 

— 

— 

— 

— 

1.6 

2.5 

— 

— 

— 

— 

10.1 

14.6 

Wacker and others (1992), Switzerland, Basle (48) 

C; CIDI/DSM-III-R and ICD-10; CLI 

— 

3.4 

— 

10.8 

— 

16.0 

— 

4.5 

— 

— 

— 

— 

— 

1.9d 

9.2e 

— 

28.7d 

23.0e 

Wittchen and others (1992), Former West Germany (44) 

C; DIS/DSM-III; CI; CD 

— 

2.4 

— 

5.7 

— 

— 

— 

— 

— 

2.0 

— 

— 

— 

— 

— 

13.9 

Davidson and others (1991), USA (ECA) - North Carolina site (64) 

C; DIS/DSM-III; LI; AD 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

1.3 

— 

— 

— 

— 

Robins and Regier (1991),
USA (ECA) - 3 sites, mainly urban (106) 

C; DIS/DSM-III; LI; AD 

0.91 

1.6 

— 

5.6 

— 

2.7 

— 

11.2 

— 

— 

— 

— 

3.8 

4.1-6.6b 

— 

— 

Faravelli and others (1989),
Italy, Florence (88) 

C; SADS-L/DSM-III; CLI; CD 

— 

1.4 

— 

1.3 

— 

0.99 

— 

0.63 

— 

0.72 

— 

0.18 

— 

3.9 

— 

— 

Oakley-Browne and others (1989), New Zealand,  Christchurch (55) 

C; DIS/DSM-III; LI; AD 

1.4 

2.2 

2.9 

3.8 

2.8 

3.9 

4.8 

5.9 

1.1 

2.2 

— 

— 

12.7 

31.1 

— 

— 

Hwu and others (1989),
Taiwan (38) 

    Metropolitan Taipei 

    Small towns 

    Rural villages 

C; DIS-CM/DSM-III; LI; method of diagnosis unclear 


 

0.18 

0.17 

0.13 


 

0.2 

0.34 

0.13 


 

— 

— 

— 


 

1.1 

1.5 

1.3 

 


 

— 

— 


 

0.6 

0.54 

0.4 


 

— 


     

3.6 

4.9 

2.6


 

0.25 

0.13 

0.13

 
 

0.94 

0.54 

0.3 


 

— 


 

— 

 
 

3.4 

8.6 

6.4 

 
 

3.7 

10.5 

7.8 


 

— 


 

— 

Bland and others (1988),
Canada - metropoitan Edmonton (33,51,109) 

C; DIS/DSM-III; LI; AD 

0.7 

1.2 

— 

2.9 

— 

1.7 

— 

7.2 

1.8 

3.0 

— 

— 

— 

— 

— 

— 

Lee and others (1987), Korea-Dong, Seoul (urban) and Myeon (rural) (40) 

C; DIS/DSM-III; LI; AD 

— 

1.8 

— 

2.1 

— 

0.53 

— 

5.4 

— 

2.3 

— 

— 

— 

3.6 

— 

9.2 

Canino and others (1987), Puerto Rico (34) 

C; DIS/DSM-III; LI; AD 

— 

1.7 

— 

6.9 

— 

1.6 

— 

8.6 

— 

3.2 

— 

— 

— 

— 

— 

13.6 

Faravelli and others (2000), Italy, Florence (82) 

C; FPI/DSM-IV; CI; CD 

— 

— 

— 

— 

— 

3.1 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

Pelissolo and others (2000), France (83) 

C; CIDI/DSM-IV; Q; AD 

— 

— 

— 

— 

— 

1.9d 

7.3e 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

Stein and others (2000), Canada, Winnipeg and Alberta (80) 

TS; CIDI/DSM-IV; LI; AD 

— 

— 

— 

— 

7.2 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

Pakriev and others (1998), Udmurt Republic, Udmurtia regions (rural) (50) 

C; CIDI/ICD-10 & DSM-III-R; CD 

— 

— 

— 

— 

44.2 

45.6 

2.3 

2.7 

— 

— 

— 

— 

— 

— 

— 

— 

Lepine and Lellouch (1995), France, town near Paris (62,84) 

C; CIDI/DSM-III-R; CI; CD 

— 

— 

— 

7.6c 

2.3c 

4.2c 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 


 

Best–estimate 
(95%CI) 

0.99 

(0.55–1.5) 

1.2 

(0.7–
1.9) 

1.6 

(1.0–
2.3) 

3.1 

(2.1–
4.4) 

4.5 

(3.0–
6.4) 

2.5 

(1.4–
4.0) 

3.0 

(.98–5.8) 

4.9 

(3.4–
6.8) 

0.54 

(0.28–0.86) 

1.3 

(0.86–1.8) 

1.2 

(0.09–3.4) 

2.1 

(0.4–
4.9) 

2.6 

(1.4–
4.2) 

6.2 

(4.0–
9.2) 

10.6 

(7.5–
14.3) 

16.6 

(12.7–21.1) 


—Not reported; AD = algorithm diagnosis; C=census; CD = clinical diagnosis;  CLI  =  clinical interviewers; LI  =  lay interviewers; Life = Lifetime; TS  =  telephone survey; Q = questionnaire  
aFrom Kessler and others (1999); bRange of rates for 3 sites
cOverall rate calculated from raw data (only sex– and age–specific rates reported)
dRate based on DSM–III–R diagnosis; eRate based on ICD–10 diagnosis 



Table 2  Sex-specific 1-year prevalence rates of anxiety disorders 


Authors, year of study, and study site 

Prevalence rate  (%) 
 

PD 


Agoraphobia 


Social phobia 


Specific phobia 


OCD 


GAD 


TAD 


 


Carter and others (2001), Germany (96) 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

1.0 

2.1 

— 

— 

Wang and others (2000), US (79) 

4.3 

8.8 

— 

— 

— 

— 

— 

— 

— 

— 

1.8 

4.3 

— 

— 

Grabe and others (2000), Germany (77) 

— 

— 

— 

— 

— 

— 

— 

— 

0.05 

0.74 

— 

— 

— 

— 

Henderson and others (2000), Australia (47) 

0.6 

2.0 

0.7 

1.5 

2.4 

3.0 

— 

— 

0.3 

0.4 

2.4 

3.7 

7.1 

12.1 

Bijl and others (1998), Netherlands (32) 

1.1 

3.4 

0.9 

2.2 

3.5 

6.1 

4.1 

10.1 

0.5 

0.4 

0.8 

1.5 

8.3 

16.6 

Offord and others (1996), Ontario, Canada (42) 

b 

1.5 

0.7 

2.5 

5.4 

7.9 

4.1 

8.9 

— 

— 

0.9 

1.2 

8.9 

15.5 

Lepine and  Lellouch (1995), France (62,84) 

— 

— 

— 

— 

1.2 

2.9 

— 

— 

— 

— 

— 

— 

— 

— 

Kessler and others (1994), US (NCS) (39) 

1.3 

3.2 

1.7 

3.8 

6.6 

9.1 

4.4 

13.2 

— 

— 

2.0 

4.3 

11.8 

22.6 

Robins and  Regier (1991), US (ECA) (106) 

0.58 

1.2 

— 

— 

— 

— 

— 

— 

1.4ª 

1.9ª 

2.4ª 

5.0ª 

— 

— 

Bourdon and others (1988), US (ECA) (91) 

— 

— 

2.1 

5.9 

1.4 

2.2 

4.8 

10.4 

— 

— 

— 

— 

— 

— 


Best estimate 95%CI 

1.2 

(0.54–2.1) 

2.7 

(1.4–
4.3) 

1.1 

(0.72–1.7) 

2.9 

(1.8–
4.4) 

3.0 

(1.7–
4.7) 

4.6 

(2.8–7.0) 

4.4 

(4.1–
4.8) 

10.6 

(9.0–
12.3) 

0.31 

(0.08–
0.65) 

0.5 

(0.31–
0.76) 

1.4 

(0.96–
2.0) 

2.6 

(1.6–
3.8) 

8.9 

(7.2–
10.9) 

16.4 

(12.6–20.8) 


— = Not reported; M = men W = women 

ªRate not included in pooled best–estimate rate as sex–specific population sizes not provided 

bNumbers were too small to be reported 



Table 3  Sex-specific lifetime prevalence rates of anxiety disorders 


Authors, year of study, and study site 

Prevalence rate (%) 
 

PD 


Agoraphobia 


Social phobia


Specific phobia


OCD 


GAD 


TAD 


 


Mohammadi and others (2004), Iran (101) 

— 

— 

— 

— 

— 

— 

— 

— 

0.7 

2.8 

— 

— 

— 

— 

Stein and Kean (2000), Ontario, Canada (81) 

— 

— 

— 

— 

10.4 

15.6 

— 

— 

— 

— 

— 

— 

— 

— 

Faravelli and others (2000), Florence, Italy (82) 

— 

— 

— 

— 

1.9ª 

4.0ª 

— 

— 

— 

— 

— 

— 

— 

— 

Grabe and others (2000), Germany (77) 

— 

— 

— 

— 

— 

— 

— 

— 

0.15 

0.84 

— 

— 

— 

— 

Bijl and others (1998), Netherlands (32) 

1.9 

5.7 

1.9 

4.9 

5.9 

9.7 

6.6 

13.6 

0.9 

0.8 

1.6 

2.9 

13.8 

25.0 

Lepine and Lellouch (1995), France (62) 

— 

— 

3.7 

9.9 

2.1 

5.4 

— 

— 

— 

— 

— 

— 

— 

— 

Kessler and others (1994), US (NCS) (39) 

2.0 

5.0 

3.5 

7.0 

11.1 

15.5 

6.7 

15.7 

— 

— 

3.6 

6.6 

19.2 

30.5 

Chen and others (1993), Hong Kong (35) 

0.2 

0.34 

0.61 

0.84 

— 

— 

0.96 

3.2 

0.87 

1.2 

7.8 

11.1 

— 

— 

Wittchen and others (1992), Former West Germany (44) 

1.7 

2.9 

2.8 

8.3 

— 

— 

— 

— 

1.8 

2.3 

— 

— 

9.1 

18.1 

Robins and Regier (1991), US (ECA) (106) 

0.99 

2.1 

3.2 

7.9 

2.5 

2.9 

7.8 

14.4 

2.0 

3.0ª 

2.6–
5.7a,c 

5.5–
7.8a,c 

— 

— 

Wells and others (1989), New Zealand (43) 

0.9 

3.4 

— 

— 

4.3 

3.5 

— 

— 

1.0 

3.4 

27.1 

35.1 

— 

— 

Hwu and others (1989), Taiwan (38) 

Taipei 

Towns 

Villages 


 

0.1 

0.3 

0.06 


 

0.3 

0.4 

0.2 


 

0.8 

0.7 

0.4 


 

1.5 

2.3 

2.3 


 

0.2 

0.6 

0.4 


 

1.0 

0.5 

0.4 


 

2.2 

2.1 

1.7 


 

5.0 

7.9 

3.8 


 

0.8 

0.4 

0.4 


 

1.1 

0.7 

0.2 


 

2.4 

8.8 

6.2 


 

5.0 

12.4 

9.0 

— 

— 

Bland and others (1988), Edmonton, Canada (33,57,109) 

0.8 

1.7 

1.5 

4.3 

1.4 

2.0 

4.6 

9.8 

2.8 

3.1 

— 

— 

— 

— 

Lee and others (1987), Korea (40) 

Seoul 

Rural Korea 


 

0.37 

1.0 


 

3.0 

6.8 


 

0.7 

1.2 


 

3.3 

6.1 


 

0.0 

0.2 


 

1.0 

1.1 


 

2.6 

1.8 


 

7.9 

8.1 


 

2.2 

1.8 


 

2.4 

2.0 


 

2.4 

2.1 


 

4.3 

4.0 


 

5.3 

1.3 


 

12.8 

2.5 

Canino and others (1987), Puerto Rico (34) 

1.6 

1.9 

4.9 

8.7 

1.5 

1.6 

7.6 

9.6 

3.3 

3.1 

— 

— 

11.2 

15.7 


Best-estimate (95%CI) 

0.76 

(0.47–1.2) 

1.6 

(0.85–2.6) 

1.7 

(1.0–
2.5) 

4.2 

(2.8–
6.2) 

1.8 

(0.79–
3.2) 

2.9 

(1.4–
4.7) 

3.5 

(2.2–
5.2) 

8.2 

(5.8–
11.2) 

1.0 

(0.67–1.6) 

1.6 

(1.0–
2.2) 

5.2 

(2.6–8.6) 

8.4 

(4.6–13.1) 

10.4 

(5.7–16.0) 

18.5 

(12.0–26.7 


–– = Not reported; M = men; W = women 

ªRate not included in pooled best-estimate rate as sex-specific population sizes not provided 

 bNumbers were too small to be reported 

cRange of rates for 3 sites 



Figure 1 Age-specific lifetime prevalence rates of anxiety disorders

Frame4_52.JPG - 0 Bytes

All the studies presented are community surveys using samples ranging from approximately 500 (48) to 20 000 (106) people. For each of these studies, the percentage CI width or error rate for estimated prevalence at a 95%CI may be calculated with the formula provided by Kelsey and colleagues (108, p 282). For the most part, studies used either the DIS or the CIDI administered by trained lay interviewers and applied algorithms to derive diagnoses.

Qualitative Analysis

Total Anxiety Disorders

For TADs, 1-year prevalence rates ranged from 4.2% in Florence, Italy (95), to 17.2% in the NCS (39), which is a variation of 4.1-fold (Table 1). The study with the lowest rate, conducted in Florence, Italy, employed the SADS-L to identify cases, whereas most other studies used the CIDI. Lifetime prevalence rates ranged from 9.2% in Korea (40) to 28.7% in Basle, Switzerland (48), a variation of slightly over 3-fold. The study conducted in Basle, Switzerland, was the only one to use clinical interviewers, while all other studies employed lay interviewers and diagnostic algorithms. Further, studies with the lowest rates used the DIS and DSM-III criteria, whereas other studies used the CIDI and DSM-III-R criteria.

Sex-Specific Prevalence

Tables 2 and 3 present findings from studies reporting sex-specific 1-year and lifetime prevalence rates, respectively, for anxiety disorders. For TADs, 1-year and lifetime prevalence rates were generally found to be about twice as high for women, compared with men. Studies reporting 1-year and lifetime sex-specific rates for panic disorder showed consistently higher rates for women, compared with men, but varied in the magnitude of this difference with rates that were 1.2-fold (34) to 6.8-fold (40) higher for women than men. Most rates for panic disorder, however, were generally found to be between 2 and 3.5 times higher for women, compared with men. With regard to phobic disorders, 1-year and lifetime prevalence rates were generally found to be between 2 and 4 times higher for women, compared with men, for agoraphobia and specific phobia. While most 1-year and lifetime rates for social phobia were found to be between 1.2 and 2.6 times higher for women, compared with men, there were studies reporting lifetime rates for women that were 5 times (38) and 12.5 times (40) rates for men. Furthermore, there were studies demonstrating higher lifetime prevalence rates for social phobia in men, compared with women (38,43).

For OCD, there was little consistency observed for sex-specific rates. Most rates were found to be higher for women than for men but several studies demonstrated higher rates for men, compared with women (32,34,38). For studies reporting higher female rates, most rates were 1.1 to 1.8 times higher for women than for men, while one study found a female rate that was 14.8 times that of the male rate (77). With regard to GAD, the 1-year and lifetime rates were generally found to be 1.5 to 2 times higher for women, compared with men.

Age-Specific Lifetime Prevalence

Figure 1 presents results from each study reporting age-specific lifetime prevalence rates for anxiety disorders. As shown, lifetime prevalence rates for agoraphobia and OCD appear to remain fairly stable throughout ages 18 to 64 years. For social phobia, there seems to be a slight decrease in prevalence with increasing age. When all anxiety disorders are taken together, there appears to be an increase in lifetime prevalence throughout ages 18 to 64 years.

Qualitative observations associated with individual anxiety disorders appear alongside the results presented in the following section.

Estimation and Heterogeneity Analysis of Pooled Best-Estimate Rates

Total Anxiety Disorders

The best-estimate rates for 1-year and lifetime prevalence of TADs were 10.6% (95%CI, 7.5% to 14.3%) and 16.6% (95%CI, 12.7% to 21.1%), respectively (Table 1). The CI variations for the 1-year and lifetime prevalence estimates are 1.9-fold and 1.7-fold, respectively, which are lower than the respective 4.1-fold and 3.1-fold variations observed across individual rates. Heterogeneity analysis of 1-year and lifetime prevalence rates revealed significant differences across each set of proportions. Chi-square tests for heterogeneity were conducted for the following variables: country studied, year study published, type of sample (that is, national, regional, or municipal); sample size; sample inclusion (that is, community only or community and institutional), diagnostic instrument used, type of interviewer (that is, lay or clinician), mode of establishing diagnosis (that is, algorithm or clinical judgment), and diagnostic criteria used. Variables that may be contribute to heterogeneity are shown in Table 4. For lifetime prevalence, the diagnostic criteria and instruments used were variables that may have contributed to heterogeneity (Table 4). Studies that employed the DIS and DSM-III criteria had pooled lifetime rates that were almost 2 times lower than those of studies that used other diagnostic instruments and criteria.

Table 4  1-year and lifetime prevalence rates of anxiety disorders 


Variable 

Prevalence rate (%) 

 

PD 


Agoraphobia 


Social phobia 


Specific phobia 


OCD 


GAD 


TAD 


 

1-year 

Life 

1-year 

Life 

1-year 

Life 

1-year 

Life 

1-year 

Life 

1-year 

Life 

1-year 

Life 


Country studied 


                           

Asian 

0.18 
(0.091-0.29)

   

1.3 
(0.91-1.8) 

 

0.54 
(0.41-0.70) 

   

0.2 
(0.1-0.32) 

0.90 
(0.45-1.5) 

       

Non-Asian 

1.6 
(1.1-2.1) 

   

4.8 
(3.4-6.5) 

 

5.2 
(2.7-8.3) 

   

0.83 
(0.45-1.3) 

1.7 
(1.1-2.4) 

       

North American 

       

7.3 
(6.5-8.1) 

 

7.5 
(5.3-10.3) 

9.8 
(7.4-12.7) 

           

Non-North American 

       

5.9 
(1.4-12.5) 

 

1.9 
(0.39-4.3) 

4.0 
(2.7-5.7) 

           

European 

                     

2.7 
(1.8-3.9) 

7.8 
(1.9-16.6) 

 

Non-European 

                     

8.0 
(5.0-12.0) 

12.0 
(9.2-15.3) 

 

Diagnostic instrument 


                           

DIS 

                 

1.5 
(0.96-2.3) 

6.3 
(3.7-9.4) 

8.2 
(4.4-12.9) 

 

12.6 
(10.1-15.4) 

Other 

                 

0.74  (0.49-1.0) 

1.4 
(0.68-2.3) 

4.3 
(2.2-6.9) 

 

21.4 
(16.2-27.5) 

Diagnostic criteria 


DSM-III 

 

0.91 
(0.49-1.4) 

 

2.4 
(1.5-3.5) 

 

1.1 
(0.65-1.8) 

       

6.3 
(3.7-9.4) 

   

12.6 
(10.1-15.4) 

Other 

 

3.6 
(3.2-4.1) 

 

6.2 
(3.7-9.4) 

 

6.8 
(3.5-10.9) 

       

1.4 
(0.68-2.3) 

   

21.4 
(16.2-27.5) 

Type of interviewers 


                           

Lay 

   

1.9 
(1.3-2.6) 

                     

Clinical 

   

0.74 
(0.31-1.3) 

                     

Year study published 


< 1994 

                   

6.3 
(3.7-9.4) 

     

³ 1994 

                   

1.4 
0.68-2.3 

     

Response rate 


                           

< 80% 

       

3.6 
(2.4-5.2) 

5.5 
(2.8-8.9) 

   

0.83 
(0.45-1.3) 

         

£ 80% 

       

15.2 
(3.3-32.8) 

1.4 
(0.61-2.4) 

   

0.2 
(0.1-0.32) 

         

Sample size 


                           

< 10 000 

                       

10.9 
(6.0-16.7) 

 

£ 10 000 

                       

9.9 
(9.4-10.5) 

 

< 7000 

           

1.3 
(0.19-3.1) 

             

£ 7000 

           

7.4 
(6.1-8.8) 

             

Life = Lifetime 

Panic Disorder

The best-estimate rates for 1-year and lifetime prevalence were 0.99% (95%CI, 0.55% to 1.5%) and 1.2% (95%CI, 0.7% to 1.9%), respectively (Table 1). The variations in the 1-year and lifetime prevalence rates, as shown by the CIs, are both 2.7-fold. Across individual studies, the 1-year prevalence rates ranged from 0.13% in rural villages in Taiwan (38) to 3.2% in Florence, Italy (95), which is a difference of almost 25-fold. Lifetime prevalence rates for panic disorder ranged from 0.13% in rural villages in Taiwan (38) to 3.8% in the Netherlands (32), a variation of approximately 29-fold. Heterogeneity analysis demonstrated significant differences across 1-year and lifetime prevalence rates of panic disorder. For studies conducted in Asia, the pooled 1-year rates were found to be approximately 9 times lower than that of studies conducted elsewhere (Table 4). All studies with lifetime prevalence rates under 3.0% used DSM-III criteria and, for the most part, the DIS, whereas all studies with rates above 3.0% employed the CIDI and DSM-III-R criteria.

Agoraphobia

The best-estimate rates for 1-year and lifetime prevalence were 1.6% (95%CI, 1.0% to 2.3%) and 3.8% (95%CI, 2.5% to 5.6%), respectively (Table 1). The variations in the CIs for these 1-year and lifetime prevalence rates are 2.3-fold and 2.2-fold, respectively. By contrast, 1-year prevalence rates for agoraphobia ranged, among different studies, from 0.6% in Florence, Italy, to 2.9% (95) in Christchurch, New Zealand (55), which is a 4.5-fold variation. The lifetime prevalence rates for agoraphobia ranged from 0.73% in Hong Kong (35) to 10.8% in Basle, Switzerland (48), a variation of almost 15-fold. Heterogeneity was demonstrated for 1-year and lifetime prevalence rates of agoraphobia. For studies employing lay interviewers, the pooled 1-year rate was over 2.5 times higher than that of studies using clinical interviewers (Table 4). Studies conducted in Asian countries produced a pooled lifetime rate that was almost 4 times lower than studies carried out in non-Asian countries.

Social Phobia

The best-estimate rates for 1-year and lifetime prevalence were 4.5% (95%CI, 3.0% to 6.4%) and 3.6% (95%CI, 2.0% to 5.6%), respectively (Table 1). Across individual studies, 1-year prevalence rates ranged from 2.3% in France (62) to 44.2% in Udmurtia, Udmurt Republic (a sovereign republic within the Russian Federation) (50), an approximate 19-fold difference. Excluding the outlying value reported in Udmurtia, the rates vary up to 7.9%, which is a much smaller difference of 3.4-fold. Both studies reporting the highest and lowest 1-year rates used the CIDI and clinician diagnoses. With respect to lifetime prevalence of social phobia, the rates ranged from 0.53% in Korea (40) to 45.6% in Udmurtia (50). This is a difference of 86-fold. Excluding the outlying rate reported in Udmurtia, the rates vary up to 16.0%, which is a variation of approximately 30-fold. The CI variations for the 1-year and lifetime best-estimate rates are 2.1-fold and 2.8-fold, respectively, which are much lower than the respective 3.4-fold and 30-fold differences observed across individual rates. Inclusion of the outlying rate in the pooled estimate would produce a 1-year and lifetime prevalence of 6.3% (95%CI, 2.9% to 10.8%) and 4.5% (95%CI, 2.3% to 7.2%), respectively. Significant differences were found among 1-year and lifetime prevalence rates of social phobia. For studies using the DIS, the pooled lifetime prevalence was 4 times lower than that of studies using other diagnostic instruments (Table 4). Similarly, for studies using DSM-III criteria, the pooled lifetime prevalence was over 5 times lower than that of studies using other diagnostic criteria. In general, studies reporting lifetime rates under 4.0% employed the DIS and DSM-III criteria, while studies reporting rates above 4.0% used the CIDI and DSM-III-R criteria.

Specific Phobia

The best-estimate rates for 1-year and lifetime prevalence were 3.0% (95%CI, 0.98% to 5.8%) and 5.3% (95%CI, 3.4% to 7.9%), respectively (Table 1). The variations in the CI for these 1-year and lifetime prevalence rates are almost 6-fold and 2.3-fold respectively. By contrast, prevalence rates reported across individual studies ranged from 0.2% in Northern Ireland (100) to 8.8% in the US (NCS) (39), a 44-fold variation. The lifetime prevalence rates across individual studies ranged from 0.63% in Florence, Italy (88), to 11.3% in the US (NCS) (39), which is a difference of almost 18-fold. Heterogeneity was demonstrated for 1-year and lifetime prevalence rates of specific phobia. For studies conducted in North America, the pooled 1-year rate was almost 4 times higher, compared with that of studies outside North American countries (Table 4). For both 1-year and lifetime rates, the study conducted in Italy, which reported the lowest rates, employed the SADS-L, whereas the remaining studies used the CIDI or DIS.

Obsessive–Compulsive Disorder

The best-estimate rates for 1-year and lifetime prevalence were 0.54% (95%CI, 0.28% to 0.86%) and 1.3% (95%CI, 0.86% to 1.8%), respectively (Table 1). The variations in the CIs for these 1-year and lifetime prevalence rates are approximately 3-fold and 2-fold respectively. Across individual studies, variations of 13.8-fold and 10.7-fold respectively, were observed. Heterogeneity was demonstrated for 1-year and lifetime prevalence rates of OCD. For studies conducted in Asian countries or with response rates of 80% or lower, the pooled 1-year rates were approximately 4 times lower, compared with those of studies conducted outside Asian countries or with response rates of more than 80% (Table 4). For pooled lifetime rates, studies conducted in Asian countries produced rates that were almost 2 times lower than studies conducted outside Asia. Examination of each of the studies does not reveal any relevant methodological differences that might help to explain the variation in rates of OCD.

Posttraumatic Stress Disorder

The best-estimate rates for 1-year and lifetime prevalence were 1.2% (95%CI, 0.09% to 3.4%) and 2.1% (95%CI, 0.4% to 4.9%), respectively (Table 1). The variation in the CIs for the 1-year pooled rate was approximately 37-fold, which is higher than the 33-fold difference found across individual rates. For lifetime prevalence, the variation in the CIs was approximately 12-fold, which is considerably lower than the 62-fold variation observed across individual rates. Heterogeneity was demonstrated for lifetime prevalence rates of PTSD. Further analysis to determine which variables may be contributing to heterogeneity was not carried out, owing to the small number of rates. The lowest rate reported was based on the SADS-L and clinical interviews and diagnoses, while all other studies were based on the DIS or CIDI and lay interviewers.

Generalized Anxiety Disorder

The best-estimate rates for 1-year and lifetime prevalence were 2.6% (95%CI, 1.4% to 4.2%) and 6.2% (95%CI, 4.0% to 9.2%), respectively (Table 1). The variations in the CIs for these 1-year and lifetime prevalence rates are 3-fold and 2.3-fold, respectively. Across individual studies, 1-year prevalence ranged from 0.15% in Northern Ireland (100) to 12.7% in Christchurch, New Zealand (55). Lifetime prevalence rates ranged from 1.9% in Basle, Switzerland (48) to 31.1% in Christchurch, New Zealand (55). Heterogeneity was demonstrated for 1-year and lifetime prevalence rates of GAD. Studies employing DIS–DSM-III or published before 1994 produced a pooled 1-year rate that was 4.5 times higher than that of studies using other diagnostic instruments and criteria and published on or after 1994 (Table 4). For studies conducted in European countries, the pooled lifetime rate was approximately 3 times lower, compared with that of studies conducted outside European countries. There were no apparent methodological differences to account for the variation in lifetime prevalence rates.

Incidence Studies

Five studies provided data on 1-year incidence rates of anxiety disorders. The incidence studies conducted in Edmonton, Canada (104) and the US (90,103,105) were prospective follow-up studies of community-based samples with total populations ranging from 1964 to 12 823. The study conducted in Norway (54) was also based on a community sample but involved a retrospective assessment of incidence. The prospective studies used the DIS and an algorithm to extract diagnoses, whereas the retrospective study employed the CIDI and a clinician diagnosis. An inadequate number of rates from unique primary investigations were available for the various anxiety disorder categories; therefore, the rates are presented for the sake of interest, and no analyses of the rates were performed.

Discussion

The results of this study further confirm the high international prevalence of anxiety disorders, and illustrate patterns of considerable heterogeneity. Best-estimates for the 1-year and lifetime prevalence of TADs were 10.6% and 16.6%, respectively. The ratio between 1-year and lifetime rates indicates that a large number of people experience anxiety disorders on a continuing or recurring basis.

Across studies, anxiety disorders were approximately twice as prevalent among women, with overall age-specific rates remaining relatively stable or increasing across the lifespan. Overall, the results suggest a burden of illness that eclipses the capacity of specialized mental health service providers.

Between studies, there was considerable variability on all observed prevalence rates. For most categories of anxiety disorder there was at least a 10-fold variation between the prevalence rates reported by different studies. In contrast, the degree of variability between rates of TADs was much smaller than the variation associated with individual disorders. Perhaps a predisposition to one of several anxiety disorders could be differentially expressed in other contexts. Similarly, specific anxiety symptoms may vary over the course of time, crossing diagnostic boundaries but without relief from suffering. Alternatively, there may be cross-cultural differences in the genetic basis of one or more of the anxiety disorders. The pattern of results is consistent with the view that anxiety disorders are determined by a multiplicity of factors, including biological, psychological, and social variables.

A few methodological factors were associated with the observed heterogeneity between rates. Pooled rates for TADs were lower in studies that incorporated DIS and DSM-III criteria than in studies using the CIDI and DSM-III-R. This pattern was also observed for some studies that estimate the prevalence of individual disorders. Several other factors were associated with heterogeneity, including the country studied, the response rate, and the size of the study sample. However, each of these factors was available for evaluation in relation to a small number of individual disorders. In most cases, different studies were distinguished on the basis of several factors simultaneously (for example, location, type of disorders investigated, method of diagnosis, and sample size). Hence, it is not possible to attribute unique variance to any one of these potential sources of variability. Three studies used different diagnostic schemes with the same subjects. However, there was no consistent pattern to the results associated with different criteria across this small number of studies.

An insufficient number of incidence studies were available for inclusion, signalling an important omission in the epidemiologic literature. Further knowledge is required about the onset of anxiety disorders, including risk and protective factors, as well as social variables that may mediate the expression of these disorders and help explain the level of heterogeneity observed in the present study.

There is a dearth of information regarding the prevalence of anxiety disorders among special populations. Some research suggests that risk of anxiety may be greater within certain subgroups, such as medical patients (109) and residents of nursing homes (110). Further investigation of these and other subgroups is required to identify concentrations of need and hasten the deployment of requisite services.

As a class, anxiety disorders are seldom treated. Only a limited subset of treatment appears to be consistent with evidence-based recommendations (79). The challenge of reducing the burden of illness associated with anxiety disorders is immense. To meet this challenge, it is essential to further clarify the epidemiology of anxiety, which will allow for the targeted deployment of programs and services on the basis of a probabilistic understanding of need.

Funding and Support

This review received no funding or support.


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Author(s)

Manuscript received December 2004, revised, and accepted October 2005. This is the fifth in a series of papers that presents systematic reviews of the prevalence and incidence of psychiatric disorders drawn from studies published in the English literature in the years 1980 to 2004. The series discusses the implications of these epidemiologic findings to mental health policy and practice.

1. Associate Professor, Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia.

2. Professor, Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia.

3. Research Assistant, Mental Health Evaluation and Community Consultation Unit (Mheccu), University of British Columbia.

Address for correspondence: Dr Somers, Faculty of Health Sciences, Simon Fraser University, 7238-515 Hastings Street, Vancouver BC, V6B 5K3

e-mail: jsomers@sfu.ca

1 | 2



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