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Prevalence and Incidence Studies of Anxiety Disorders: A Systematic Review of The Literature
Prevalence and Incidence Studies of Anxiety Disorders: A Systematic Review of The Literature
Julian M Somers, MSc, PhD1, Elliot M Goldner, MHSc, MD 2, 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)
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.
n recent years, it has been increasingly acknowledged not published between 1980 and 2004. Reference lists of relevant
I only that anxiety disorders are highly prevalent, but also
that the burden of illness associated with these disorders is
primary and review articles identified were also searched.
Prevalence and incidence studies were eligible for inclusion if
often considerable. A broad understanding of the etiology of they were community surveys using probability sampling
anxiety includes a multiplicity of factors, such as biological, techniques. Eligible publications were restricted to studies
psychological, and social determinants, which are mediated having sample sizes of 450 people or more that examined age
by a range of risk and protective factors. Cross-cultural stud- ranges covering the adult population. Only studies using
ies in epidemiology are a critical source of information current diagnostic criteria and case identification based on
regarding the interplay between these factors. Effective forms either standardized instruments or clinician diagnosis were
of intervention are available and are the subject of ongoing included. Prevalence and incidence data, including overall,
research, but it is an immense public health challenge to coor- sex-specific and age-specific rates, were extracted from
dinate the delivery of these programs and services. Studies in eligible studies.
comparative epidemiology play a vital role in the develop-
ment of health policy concerning anxiety. Empirical knowl- Qualitative analyses of variables related to methodology were
edge of regional prevalence is fundamental to understanding conducted to summarize and elucidate any observed differ-
the relative demand for services. Such knowledge is also nec- ences between rates. Each set of rates was also pooled accord-
essary to identify the most appropriate avenues for ing to a Bayesian approach to metaanalysis; the Fastpro
intervention. software program was used. Readers interested in a more
detailed discussion of this approach should refer to Eddy and
The present review, which is the fifth in a series of papers that
others (2). Each of the pooled rates was analyzed for heteroge-
will present systematic reviews of the prevalence and inci-
neity with chi-square tests according to the Fleiss method (3).
dence of psychiatric disorders drawn from studies published
in the English literature in the years 1980 to 2004, sought to
Results
synthesize international research on this topic. Results and
observed patterns of heterogeneity are discussed in relation to Description of Studies
health services planning as well as implications for additional From the citations and abstracts generated by the initial elec-
research. tronic search, we identified 80 prevalence and 10 incidence
studies potentially meeting inclusion criteria, in addition to 28
Methods review papers (4–31). The full texts of these articles were
The methods employed in this review have been presented in retrieved. We searched all reference lists of identified studies
more detail elsewhere (1). The MEDLINE and HealthSTAR and reviews, generating an additional 38 prevalence and 6
databases were searched for relevant studies; the key index- incidence studies for which full-text articles were obtained.
ing terms epidemiology, prevalence, and incidence were used, Of the 118 prevalence studies for which full-text articles were
combined with the search terms mental disorders, anxiety dis- reviewed, 71 prevalence papers of anxiety disorders met eligi-
orders, panic disorder, phobia, obsessive–compulsive dis- bility criteria (32–95,96–102), resulting in a total of 41
order, posttraumatic stress disorder, and generalized anxiety unique primary investigations of anxiety disorders included in
disorder. The search was limited to English-language studies 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
Abbreviations used in this article not meet inclusion criteria, and 3 were based on duplicate
CI confidence interval study samples. This resulted in 5 incidence studies of anxiety
disorders that could be included (54,90,103–105). Most stud-
CIDI Composite International Diagnostic Interview
ies meeting inclusion criteria used nonhierarchical diagnostic
DIS Diagnostic Interview Schedule
approaches. Predictably, the few studies using hierarchical
GAD generalized anxiety disorder
diagnoses reported relatively lower rates of individual
NCS US National Comorbidity Study disorders.
OCD obsessive–compulsive disorder
PD panic disorder Prevalence Studies
PTSD posttraumatic stress disorder Findings, for the 34 papers reporting overall and (or)
sex-specific 1-year and (or) lifetime prevalence rates for panic
SADS-L Schedule of Affective Disorders and Schizophrenia-
Lifetime disorder, agoraphobia, social phobia, specific phobia, OCD,
TAD total anxiety disorder
PTSD, GAD, and TAD, are presented in Tables 1 to 3.
Age-specific lifetime prevalence rates for these disorders are
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), C; SADS/DSM-IV; — — — — — — — — — 1.8 — — — — — —
Iran (101) CLI; AD
Norris and others (2003), C; CIDI/DSM-IV; LI — — — — — — — — — — — 11.2 — — — —
Mexico - 4 sites, urban and rural
(102)
Hunt and others (2002), C; CIDI/DSM-IV; LI; — — — — — — — — — — — — 3.6 — — —
Australia (98) AD
McConnell and others (2002), C; SCAN/ICD-10; CLI; 2.4 — 0.7 — — — 0.2 — — — 0.12 — 0.15 — — —
The Canadian Journal of Psychiatry—Review Paper
1-year Life 1-year Life 1-year Life 1-year Life 1-year Life 1-year Life 1-year Life 1-year Life
c c c c c
Chen and others (1993), C; DIS-III-CM/DSM-III; — 0.28 — 0.73 — — — 2.1 — 1.0 — 0.6c* — 9.5 — —
Hong Kong (35) LI; AD
Bourdon and others (1992), C; DIS/DSM-III; LI; AD — — — — — — — — 1.6 2.5 — — — — 10.1 14.6
USA (ECA) - 5 sites, mainly
urban (46)
Wacker and others (1992), C; CIDI/DSM-III-R and — 3.4 — 10.8 — 16.0 — 4.5 — — — — — 1.9d — 28.7d
Switzerland, Basle (48) ICD-10; CLI
9.2e 23.0e
Bland and others (1988), C; DIS/DSM-III; LI; AD 0.7 1.2 — 2.9 — 1.7 — 7.2 1.8 3.0 — — — — — —
Canada - metropoitan
Edmonton (33,51,109)
Lee and others (1987), C; DIS/DSM-III; LI; AD — 1.8 — 2.1 — 0.53 — 5.4 — 2.3 — — — 3.6 — 9.2
Korea-Dong, Seoul (urban) and
Myeon (rural) (40)
103
Prevalence and Incidence Studies of Anxiety Disorders: A Systematic Review of the Literature
The Canadian Journal of Psychiatry—Review Paper
(12.7–
a l s o p r e s e n t e d in F i g u r e 1
21.1)
Life
13.6
16.6
—
—
(33,34,40,44,59,66,73,81,
TAD
84,94,101,106). The results of studies
1–year
14.3)
(7.5–
10.6
reporting only data for point preva-
—
lence or 6-month prevalence are not
(4.0–
Life
9.2)
presented (36,37,41,45,49,53,54,
6.2
—
—
GAD
56,6,63,67,69,70,74–76,78,86,87,
—Not reported; AD = algorithm diagnosis; C=census; CD = clinical diagnosis; CLI = clinical interviewers; LI = lay interviewers; Life = Lifetime; TS = telephone survey; Q = questionnaire
1–year
(1.4–
92,93,107). Analysis of data was car-
4.2)
2.6
—
—
ried out only when 3 or more rates
4.9)
2.1
—
—
PTSD
3.4)
1.2
—
—
All the studies presented are commu-
Life
0.86) 1.8)
3.2
1.3
—
—
nity surveys using samples ranging
OCD
Prevalence rate (%)
1–year
0.54
20 000 (106) people. For each of these
—
—
studies, the percentage CI width or
Specific phobia
Life
2.7
4.9
—
3.0
.8)
leagues (108, p 282). For the most
—
(1.4–
Life
45.6
1.9d
7.3e
4.0)
4.2c
3.1
2.5
—
(3.0–
44.2
derive diagnoses.
6.4)
2.3c
7.2
4.5
—
—
Agoraphobia
(2.1–
Life
4.4)
7.6c
6.9
3.1
—
Qualitative Analysis
1–year
(1.0–
2.3)
1.6
—
Overall rate calculated from raw data (only sex– and age–specific rates reported)
Life
1.9)
1.2
—
—
PD
C; CIDI/DSM-III-R; CI; —
Best–estimate
CD
AD
AD
France (83)
d
c
Rate (%)
reporting 1-year and lifetime
10
sex-specific rates for panic dis-
order showed consistently 8
M W M W M W M W M W M W M W
Carter and others (2001), — — — — — — — — — — 1.0 2.1 — —
Germany (96)
Wang and others (2000), US 4.3 8.8 — — — — — — — — 1.8 4.3 — —
(79)
Grabe and others (2000), — — — — — — — — 0.05 0.74 — — — —
Germany (77)
Henderson and others (2000), 0.6 2.0 0.7 1.5 2.4 3.0 — — 0.3 0.4 2.4 3.7 7.1 12.1
Australia (47)
Bijl and others (1998), 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
Netherlands (32)
Offord and others (1996), —b 1.5 0.7 2.5 5.4 7.9 4.1 8.9 — — 0.9 1.2 8.9 15.5
Ontario, Canada (42)
Lepine and Lellouch (1995), — — — — 1.2 2.9 — — — — — — — —
France (62,84)
Kessler and others (1994), 1.3 3.2 1.7 3.8 6.6 9.1 4.4 13.2 — — 2.0 4.3 11.8 22.6
US (NCS) (39)
Robins and Regier (1991), 0.58 1.2 — — — — — — 1.4ª 1.9ª 2.4ª 5.0ª — —
US (ECA) (106)
Bourdon and others (1988), — — 2.1 5.9 1.4 2.2 4.8 10.4 — — — — — —
US (ECA) (91)
Best estimate 95%CI 1.2 2.7 1.1 2.9 3.0 4.6 4.4 10.6 0.31 0.5 1.4 2.6 8.9 16.4
(0.54– (1.4– (0.72– (1.8– (1.7– (2.8–7 (4.1– (9.0– (0.08– (0.31– (0.96– (1.6– (7.2– (12.6–
2.1) 4.3) 1.7) 4.4) 4.7) .0) 4.8) 12.3) 0.65) 0.76) 2.0) 3.8) 10.9) 20.8)
— = Not reported; M = men W = women
ªRate not included in pooled best–estimate rate as sex–specific population sizes not provided
b
Numbers were too small to be reported
The best-estimate rates for 1-year and lifetime prevalence 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% were 1.6% (95%CI, 1.0% to 2.3%) and 3.8% (95%CI, 2.5% to
to 1.9%), respectively (Table 1). The variations in the 1-year 5.6%), respectively (Table 1). The variations in the CIs for
and lifetime prevalence rates, as shown by the CIs, are both these 1-year and lifetime prevalence rates are 2.3-fold and
2.7-fold. Across individual studies, the 1-year prevalence 2.2-fold, respectively. By contrast, 1-year prevalence rates for
rates ranged from 0.13% in rural villages in Taiwan (38) to agoraphobia ranged, among different studies, from 0.6% in
3.2% in Florence, Italy (95), which is a difference of almost Florence, Italy, to 2.9% (95) in Christchurch, New
25-fold. Lifetime prevalence rates for panic disorder ranged
Zealand (55), which is a 4.5-fold variation. The lifetime prev-
from 0.13% in rural villages in Taiwan (38) to 3.8% in the
alence rates for agoraphobia ranged from 0.73% in Hong
Netherlands (32), a variation of approximately 29-fold. Heter-
Kong (35) to 10.8% in Basle, Switzerland (48), a variation of
ogeneity analysis demonstrated significant differences across
1-year and lifetime prevalence rates of panic disorder. For almost 15-fold. Heterogeneity was demonstrated for 1-year
studies conducted in Asia, the pooled 1-year rates were found and lifetime prevalence rates of agoraphobia. For studies
to be approximately 9 times lower than that of studies con- employing lay interviewers, the pooled 1-year rate was over
ducted elsewhere (Table 4). All studies with lifetime preva- 2.5 times higher than that of studies using clinical interview-
lence rates under 3.0% used DSM-III criteria and, for the most ers (Table 4). Studies conducted in Asian countries produced
part, the DIS, whereas all studies with rates above 3.0% a pooled lifetime rate that was almost 4 times lower than
employed the CIDI and DSM-III-R criteria. studies carried out in non-Asian countries.
M W M W M W M W M W M W M W
Best-estimate (95%CI) 0.76 1.6 1.7 4.2 1.8 2.9 3.5 8.2 1.0 1.6 5.2 8.4 10.4 18.5
(0.47– (0.85– (1.0– (2.8– (0.79– (1.4– (2.2– (5.8– (0.67 (1.0– (2.6–8. (4.6– (5.7–1 (12.0–
1.2) 2.6) 2.5) 6.2) 3.2) 4.7) 5.2) 11.2) –1.6) 2.2) 6) 13.1) 6.0) 26.7
1-year Life 1-year Life 1-year Life 1-year Life 1-year Life 1-year Life 1-year Life
Country studied
Lay 1.9
(1.3-2.6)
Clinical 0.74
(0.31-1.3)
Year study published
Social Phobia
Lifetime
The best-estimate rates for 1-year and lifetime
TAD prevalence were 4.5% (95%CI, 3.0% to 6.4%)
and 3.6% (95%CI, 2.0% to 5.6%), respec-
(6.0-16.7)
(9.4-10.5)
tively (Table 1). Across individual studies,
10.9
1-year
9.9
1-year prevalence rates ranged from 2.3% in
France (62) to 44.2% in Udmurtia, Udmurt
Lifetime
(0.1-0.32)
0.2
(6.1-8.8)
1.3
7.4
5.5
1.4
Social phobia
3.6
Specific Phobia
1-year
Table 4 continued
£ 10 000
Variable
£ 7000
< 80%
£ 80%
individual studies ranged from 0.2% in Northern Ireland 2.3-fold, respectively. Across individual studies, 1-year prev-
(100) to 8.8% in the US (NCS) (39), a 44-fold variation. The alence ranged from 0.15% in Northern Ireland (100) to 12.7%
lifetime prevalence rates across individual studies ranged in Christchurch, New Zealand (55). Lifetime prevalence rates
from 0.63% in Florence, Italy (88), to 11.3% in the US (NCS) ranged from 1.9% in Basle, Switzerland (48) to 31.1% in
(39), which is a difference of almost 18-fold. Heterogeneity Christchurch, New Zealand (55). Heterogeneity was demon-
was demonstrated for 1-year and lifetime prevalence rates of strated for 1-year and lifetime prevalence rates of GAD. Stud-
specific phobia. For studies conducted in North America, the ies employing DIS–DSM-III or published before 1994
pooled 1-year rate was almost 4 times higher, compared with produced a pooled 1-year rate that was 4.5 times higher than
that of studies outside North American countries (Table 4). that of studies using other diagnostic instruments and criteria
For both 1-year and lifetime rates, the study conducted in and published on or after 1994 (Table 4). For studies con-
Italy, which reported the lowest rates, employed the SADS-L, ducted in European countries, the pooled lifetime rate was
whereas the remaining studies used the CIDI or DIS. approximately 3 times lower, compared with that of studies
conducted outside European countries. There were no appar-
Obsessive–Compulsive Disorder ent methodological differences to account for the variation in
The best-estimate rates for 1-year and lifetime prevalence lifetime prevalence rates.
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
Incidence Studies
CIs for these 1-year and lifetime prevalence rates are approxi-
Five studies provided data on 1-year incidence rates of anxi-
mately 3-fold and 2-fold respectively. Across individual stud-
ety disorders. The incidence studies conducted in Edmonton,
ies, variations of 13.8-fold and 10.7-fold respectively, were
Canada (104) and the US (90,103,105) were prospective
observed. Heterogeneity was demonstrated for 1-year and
follow-up studies of community-based samples with total
lifetime prevalence rates of OCD. For studies conducted in
populations ranging from 1964 to 12 823. The study con-
Asian countries or with response rates of 80% or lower, the
ducted in Norway (54) was also based on a community sample
pooled 1-year rates were approximately 4 times lower, com-
but involved a retrospective assessment of incidence. The pro-
pared with those of studies conducted outside Asian countries
spective studies used the DIS and an algorithm to extract diag-
or with response rates of more than 80% (Table 4). For pooled
noses, whereas the retrospective study employed the CIDI and
lifetime rates, studies conducted in Asian countries produced
a clinician diagnosis. An inadequate number of rates from
rates that were almost 2 times lower than studies conducted
unique primary investigations were available for the various
outside Asia. Examination of each of the studies does not
anxiety disorder categories; therefore, the rates are presented
reveal any relevant methodological differences that might
for the sake of interest, and no analyses of the rates were
help to explain the variation in rates of OCD.
performed.
Posttraumatic Stress Disorder
The best-estimate rates for 1-year and lifetime prevalence Discussion
were 1.2% (95%CI, 0.09% to 3.4%) and 2.1% (95%CI, 0.4% The results of this study further confirm the high international
to 4.9%), respectively (Table 1). The variation in the CIs for prevalence of anxiety disorders, and illustrate patterns of con-
the 1-year pooled rate was approximately 37-fold, which is siderable heterogeneity. Best-estimates for the 1-year and
higher than the 33-fold difference found across individual lifetime prevalence of TADs were 10.6% and 16.6%, respec-
rates. For lifetime prevalence, the variation in the CIs was tively. The ratio between 1-year and lifetime rates indicates
approximately 12-fold, which is considerably lower than the that a large number of people experience anxiety disorders on
62-fold variation observed across individual rates. Heteroge- a continuing or recurring basis.
neity was demonstrated for lifetime prevalence rates of PTSD. Across studies, anxiety disorders were approximately twice as
Further analysis to determine which variables may be contrib- prevalent among women, with overall age-specific rates
uting to heterogeneity was not carried out, owing to the small remaining relatively stable or increasing across the lifespan.
number of rates. The lowest rate reported was based on the Overall, the results suggest a burden of illness that eclipses the
SADS-L and clinical interviews and diagnoses, while all other capacity of specialized mental health service providers.
studies were based on the DIS or CIDI and lay interviewers.
Between studies, there was considerable variability on all
Generalized Anxiety Disorder observed prevalence rates. For most categories of anxiety dis-
The best-estimate rates for 1-year and lifetime prevalence order there was at least a 10-fold variation between the preva-
were 2.6% (95%CI, 1.4% to 4.2%) and 6.2% (95%CI, 4.0% to lence rates reported by different studies. In contrast, the
9.2%), respectively (Table 1). The variations in the CIs for degree of variability between rates of TADs was much smaller
these 1-year and lifetime prevalence rates are 3-fold and than the variation associated with individual disorders.
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Research Assistant, Mental Health Evaluation and Community
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www.biomedcentral.com/1471-244X/4/2. Accessed 15 June 2004. Address for correspondence: Dr Somers, Faculty of Health Sciences,
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posttraumatic stress disorder in Mexico. J Abnorm Psychol 2003;112:646–56. 5K3, jsomers@sfu.ca