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DEPRESSION AND ANXIETY 30:917–929 (2013)

Risk Factors
THE ASSOCIATION BETWEEN ANXIETY DISORDERS
AND SUICIDAL BEHAVIORS: A SYSTEMATIC REVIEW
AND META-ANALYSIS
Amrit Kanwar,1 Shaista Malik, M.D.,2 Larry J. Prokop, M.L.S.,2 Leslie A. Sim, Ph.D.,2 David Feldstein, M.D.,3
Zhen Wang, Ph.D.,2 ∗ and M. Hassan Murad, M.D., M.P.H.2

Background: Although anxiety has been proposed to be a potentially modifiable

risk factor for suicide, research examining the relationship between anxiety and
suicidal behaviors has demonstrated mixed results. Therefore, we aimed at test-
ing the hypothesis that anxiety disorders are associated with suicidal behaviors
and evaluate the magnitude and quality of supporting evidence. Methods: A
systematic literature search of multiple databases was conducted from database
inception through August 2011. Two investigators independently reviewed and
determined the eligibility and quality of the studies based upon a priori estab-
lished inclusion criteria. The outcomes of interest were suicidal ideations, suicide
attempts, completed suicides, and a composite outcome of any suicidal behaviors.
We pooled odds ratios from the included studies using random effects models.
Results: Forty-two observational studies were included. The studies had variable
methodological quality due to inconsistent adjustment of confounders. Compared
to those without anxiety, patients with anxiety were more likely to have suicidal
ideations (OR = 2.89, 95% CI: 2.09, 4.00), attempted suicides (OR = 2.47, 95%
CI: 1.96, 3.10), completed suicides (OR = 3.34, 95% CI: 2.13, 5.25), or have any
suicidal behaviors (OR = 2.85, 95% CI: 2.35, 3.46). The increase in the risk of
suicide was demonstrated for each subtype of anxiety except obsessive-compulsive
disorder (OCD). The quality of this evidence is considered low to moderate due
to heterogeneity and methodological limitations. Conclusions: This systematic
review and meta-analysis provides evidence that the rates of suicides are higher
in patients with any type of anxiety disorders excluding OCD. Depression and
Anxiety 30:917–929, 2013. 
C 2013 Wiley Periodicals, Inc.

Key words: anxiety disorder; suicidal behavior; posttraumatic stress disorder;

obsessive-compulsive disorder; panic disorder; systematic review; meta-analysis

1 Universityof Wisconsin-Madison, Madison, Wisconsin
2 Mayo Clinic, Rochester, Minnesota
3 School of Medicine and Public Health, University of
Wisconsin-Madison, Madison, Wisconsin
∗ Correspondence to: Zhen Wang, Ph.D., Mayo Clinic, 200 1st Street
SW, Rochester, MN 55905. E-mail: Wang.Zhen@mayo.edu
Received for publication 30 October 2012; Revised 20 December
2012; Accepted 21 January 2013
DOI 10.1002/da.22074
Published online 13 February 2013 in Wiley Online Library
(wileyonlinelibrary.com).

C 2013 Wiley Periodicals, Inc.
INTRODUCTION
Suicide is the 10th leading cause of death in the United
States and among the top three reasons for death for
those aged between 15 and 44, globally. Given that sui-
cide is considered a preventable cause of death, efforts
to decrease suicide represent a significant public health
agenda. Because suicidal behavior is included as a symp-
tom in the diagnostic criteria for depression,[1] depres-
sive illnesses have received a great deal of research and
clinical attention in predicting suicide. Yet, suicide does
occur in the context of a number of other psychiatric con-
ditions including anxiety disorders. In spite of the fact
that anxiety disorders commonly co-occur with depres-
sive illnesses, less research has been focused on anxiety

918 Kanwar et al.
in the prediction of suicidal behavior. This relative lack
of empirical attention directed toward the relationship
between anxiety and suicide may stem from a perception
that the fear of harm, characteristic of individuals with
anxiety disorders, may restrain those individuals from
acting on suicidal ideations and impulses.[2] However,
research examining harm avoidance as a temperamen-
tal trait finds, rather than protecting against suicidal be-
havior, this trait seems to increase the risk for suicide
among some individuals.[3, 4] Moreover, it is well estab-
lished that avoidance behavior, a characteristic feature
of anxiety disorders, commonly leads to significant func-
tional disability, reduced quality of life, and significant
social isolation,[5, 6] all factors that heighten vulnerability
to suicide.[7]
Several studies have been conducted to understand the
relationship between anxiety disorders and suicidal be-
havior; however, the findings have been inconsistent. In
the available literature, few studies have shown a posi-
tive relationship[8–13] whereas others have not demon-
strated any relationship between anxiety disorders and
suicidality.[14–30] These mixed findings may be due to
methodological limitations of the study, lack of power
(small sample size), or due to heterogeneity in how the
studies were conducted or how the outcomes (suicide)
or exposure (anxiety) were defined and measured. Over
the last 30 years, the category of anxiety disorders has
been broadened to include posttraumatic stress disorder
(PTSD) that has consistently been associated with suici-
dal behavior.[31–33] Moreover, a population-based study
concluded that the risk of suicide in inpatients with anx-
iety disorders may be as high as that in persons with de-
pression or other diagnoses requiring inpatient care.[9]
This study underscores the importance of understanding
the relationship between anxiety disorders and suicidal
behavior.
Therefore, we conducted this systematic review and
meta-analysis to quantitatively estimate the magnitude
of the association of the various anxiety disorders with
suicide and appraise the quality of the supporting ev-
idence. To our knowledge, this is the first systematic
review on this subject.
METHODS
This systematic review complies with the reporting standard set
by the Preferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) statement.[34]
INCLUSION AND EXCLUSION CRITERIA
Eligible studies were controlled studies that reported suicidal behav-
iors (ideation, attempt, or completion) in patients with anxiety disor-
ders. Studies that enrolled patients with concomitant depression were
excluded unless they adjusted for the presence of depression in anal-
ysis; therefore, depression would less likely affect the estimate of the
outcome of interest (suicidal behaviors). Studies were also excluded if
they did not provide sufficient data to estimate the association between
suicidal behaviors and anxiety disorder. We also excluded publications
without original data (clinical reviews, editorials, letters, or erratum).
Depression and Anxiety
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SEARCH STRATEGY
We conducted a comprehensive literature search of Ovid MED-
LINE, Ovid EMBASE, Ovid PsycInfo, Ovid Cochrane Database of
Systematic Reviews, Ovid Cochrane Central Register of Controlled
Trials, and Scopus databases for all studies published from earliest in-
clusive dates to August 2011. An experienced librarian and the principal
investigator designed and conducted the search strategy. Controlled
vocabulary supplemented with keywords was used to search for the
concept areas: suicide and anxiety disorders, and included case-control,
cohort, and randomized studies. Among several keywords related to
anxiety and suicide used for searching were suicide, anxiety disorders,
PTSDs, and obsessive-compulsive disorder (OCD). The search terms
were broad without language or country restrictions. Foreign language
studies were translated to English. The complete search strategy is
listed in Appendix.
STUDY SELECTION AND DATA ABSTRACTION
Using a predefined protocol, two investigators independently re-
viewed and determined studies eligibility based upon abstract and full
text screening of relevant articles. The two reviewers independently
abstracted data from eligible studies and evaluated study quality. A
third reviewer double-checked all of the included studies. Disagree-
ments between the three reviewers were resolved by discussion and
consensus.
STUDY QUALITY
To assess the quality of the included studies, we adapted the New
Castle-Ottawa Quality Assessment Scale by evaluating the following
items: ascertainment of outcomes (suicide), ascertainment of expo-
sures (anxiety), adjustment for confounders, loss to follow-up, and
sample-selection procedures.[35] Two independent reviewers assessed
the quality independently and in duplicates. Conflicts were resolved
through discussion and consensus.
STATISTICAL ANALYSIS
The outcomes of interest were suicidal ideations, suicide attempts,
completed suicides, and a composite outcome of any suicidal behav-
iors. From each study, we extracted or calculated relative association
measures comparing any suicidal activities between patients with and
without anxiety and its 95% confidence interval (CI). Since suicide is a
rare event in patients with anxiety (incidence <4%), relative risk (RR),
hazard ratio (HR), and standardized mortality ratio (SMR) asymp-
totically approach odds ratio (OR) and were treated as OR in the
analysis.[8] When the effect size was adjusted for confounders within
each study, we chose the most adjusted estimate. The overall effect
size was estimated by pooling ORs from the included studies using the
DerSimonian and Laird random effects methods with the heterogene-
ity from the Mantel–Haenszel method.[36] We conducted subgroup
analyses based on generalized anxiety disorder (GAD), OCD, panic
disorder (PD), and PTSD. To further explore the difference on sex
and age, we constructed multivariate nested random effects metare-
gression models.[37]
We assessed the consistency of the outcomes by testing the het-
erogeneity across the included studies using the I2 statistic, where I2
> 50% suggests high level of heterogeneity.[38] To assess potential
publication bias that might bias our results, we visually inspected the
funnel plots. We also conducted the Egger regression asymmetry test,
where P-value <.05 suggests publication bias is likely.[39, 40] All sta-
tistical analyses were conducted using STATA version 12 (StataCorp,
College Station, TX).

Risk Factors: Association Between Anxiety and Suicide
Figure 1. Selection strategy of included studies in this meta-analysis.
RESULTS
We identified 828 articles, of which 42 met our inclu-
sion criteria and were included in this systematic review.
The process of study selection is depicted in Fig. 1. The
included studies enrolled 309,974 patients with a me-
dian study size of 1,689. The proportion of females was
51%. Fifteen studies were cross-sectional but the major-
ity (24/42) was longitudinal with follow-up that ranged
from 3 to 25 years. Geographically, most of the stud-
ies were conducted in North America and Europe; with
few in Australia/New Zealand, South America and Asia;
and none in Africa. Table 1 shows characteristics of the
included studies. The quality of the studies was vari-
able and is described in Table 2. The ascertainment of
the exposure and outcome was adequate in most studies;
however, the loss of follow-up was not reported in most
studies and controlling for confounder was not done
in all studies, limiting the inferences provided in this
review.
META-ANALYSIS
Compared to those without anxiety, patients with anx-
iety were more likely to have suicidal ideations (OR =
2.89, 95% CI: 2.09, 4.00), attempted suicides (OR =
2.47, 95% CI: 1.96, 3.10), completed suicides (OR =
3.34, 95% CI: 2.13, 5.25), or have any suicidal activities
(OR = 2.85, 95% CI: 2.35, 3.46). The increase in risk
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919
of suicide was demonstrated for each subtype of anxiety
except OCD. Table 3 summarizes the pooled ORs for all
outcomes. Random effects metaregression model did not
demonstrate difference in the association between males
and females. Studies that exclusively enrolled children
also reported association of anxiety disorders with suici-
dal ideations (OR = 3.08, 95% CI: 1.94, 4.90) and any
suicidal activities (OR = 2.82, 95% CI: 1.92, 4.14).
Across the included studies, substantial heterogeneity
was observed in most of the pooled outcomes (I2 > 50%).
Egger regression asymmetry tests (P < .05) and funnel
plots of outcomes also suggested potential publication
bias in this meta-analysis.
DISCUSSION
The findings from this meta-analysis suggest that pa-
tients with anxiety disorders (other than OCD) are more
likely to have completed suicides, suicidal attempts, sui-
cidal ideations, and any type of suicidal behaviors.
Of the 42 studies included in this meta-analysis,
we found 31 studies that reported a significant associ-
ation. Of the 11 studies that did not report any associa-
tion, findings may have been obscured by small sample
size, [14, 20, 23, 24, 28–30] limited length of follow-up, and
uncertain ascertainment of diagnosis especially through
self-reports[21, 25] or interview[22, 24] (Table 1). The
lack of significant findings may also be related
Depression and Anxiety
 920

TABLE 1. Description of included studies

Author, No. of Females Age Ethnicity/ Anxiety Length of Outcome Source of

year patients (%) (years) country diagnosis follow-up, years measure population

Angst, 1992[30] 277 50.60 19–20 Swiss PD, GAD, PD + GAD, Ag, 10 SA Canton, Zurich

Depression and Anxiety

SP
Allgulander, 1994[41] 9,912 67 Median 39 Sweden Anxiety neurosis, phobic 8 CS Death certificates, psychiatric
R 15–89 neurosis, neurasthenic facilities
neurosis or combinations
Warshaw et al., 1995[28] 527 70 Mean 40 (SD = 12) n/r GAD, SP, PTSD 0.5–2.5 SB Hospital and clinic
R 18–87.
Fleet et al., 1996[42] 441 39 Mean 56.8 100% Caucasian PD n/a SI Patient discharge diagnoses
Warshaw et al., 2000[29] 498 n/r 18 plus n/r PTSD, GAD, SP 5 SB PD patients
Kaslow et al., 2000[43] 285 100 R 18–64 100% AA PTSD 1.5 SA Healthcare facilities
Mean 30.80
Beautrais et al., 2001[44] 477 22.3 SD SD: mean 36.8 New Zealand GAD n/a SA, SD Coroner’s reports: hospital
54.9 SA SA: mean 30 admissions
Dhossche et al., 2002[45] 2,076 n/r R 4–16 Dutch PTSD, SP 8 SI Birth registers
Waern et al., 2002[46] 85 45.90 Median 73 Scandinavian AD n/a CS Autopsy and medical records
R 65–97
Apter et al., 2003[16] 348 28.90 Mean 16.44 Israeli OCD n/a SA Hospital admissions
Drescher et al., 2003[47] 1,866 0 Mean 47.18 Caucasian 66.2% PTSD 5 SD Death certificates
AA 11.8%
Hispanic 13.4%
Native American
Kanwar et al.

3.7%
Goodwin and Hamilton, 5,877 n/r R 15–54 n/r SP, PTSD n/a SA, SI NCS
2003[48]
Price et al., 2004[25] 642 0 n/r Caucasian no PTSD 25 SI, SA Vietnam war veterans
suicidality, 86.3%
Caucasian
suicidality, 13.8%
AA no suicidality,
78.4%
AA suicidality,
21.7%
Fergusson et al., 2005[22] 1,265 n/r R 18–25 New Zealand AD 25 SA, SI Birth cohort in New Zealand
Sareen et al., 2005[49] 7,076 n/r R 18–64 Dutch AD, PD, Ag, simple and 3 SI, SA NMHS
social phobia, GAD,
OCD
Desai et al., 2005[8] 121,933 5.60 Mean 48.17 67.75% Caucasian, PTSD 1 SD VA hospitals
23.9% AA, 5.5%
Hispanic
Angst et al., 2005[14] 141 53 19–20 Swiss OCD 20 SA Canton, Zurich
Reinherz et al., 2006[26] 346 52 5 98% Caucasian AD 25 SI Community cohort

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 TABLE 1. Continued

Author, No. of Females Age Ethnicity/ Anxiety Length of Outcome Source of

year patients (%) (years) country diagnosis follow-up, years measure population

Balestrieri et al., 2006[50] 57 75.40 Mean 36.4 Italian PD n/a SA, SI Clinic based
Herba et al., 2007[51] 1,022 51.20 11 or younger Dutch AD 14 SI Birth registers
Boden et al., 2007[17] 1,265 n/r R 16–25 New Zealand GAD, phobia, PD, AD 25 SA, SI Birth cohort in New Zealand
Simon et al., 2007[23] 120 59.20 Mean 44.2 Predominantly AD, OCD PTSD, GAD, n/a SA, SI STEP-BD
(SE = 13.3) Caucasian Ag, social anxiety, PD
Simon et al., 2007[52] 32,360 65 Mean 38.4 n/r AD 2.7 SD Population-based sample of
(SD = 14.6) bipolar patients
Bolton et al., 2008[18] 1,920 62.50 65 plus 66% Caucasian Ag OCD, panic attacks 13 SA Institutionalized/community
Brezo et al., 2008[19] 2,000 49.95 R 6–12 Canadian AD 2 SA Public schools
Miranda et al., 2008[24] 1,729 63 Mean 15.5 51% Caucasian AD 6 SI High school screening
R 12–18 15% AA
20% Hispanic, 9%
Asian
Borges et al., 2008[53] 5,001 n/r R 15–55 Caucasian, AA, PD, Ag, simple and social 10 SI, SA NCS
Hispanic phobia, GAD, PTSD, any
AD
Ono et al., 2008[54] 2,436 n/r 20 plus Japanese AD n/a SI, SA WHO, MHS
Tidemalm et al., 2008[55] 39,685 53 Males, mean 38.4 Swedish AD 21–31 CS Hospital discharge
(SD = 16.5)
Females 37.0
(SD = 17.0)
Goldston et al., 2009[56] 180 50.56 R 12–19 80% Caucasian GAD, PD, phobia 13 SA Hospital admissions
Mean 14.8 16.7% AA
ten Have et al., 2009[57] 4,848 n/r R 18–64 Dutch AD, OCD GAD, Ag, 3 SA, SI NMHS
simple, and social phobia,
PD
Wilcox et al., 2009[58] 1,698 50.20 Mean 21 71% AA PTSD 15 SA Public school cohort
Dell’osso et al., 2009[20] 65 50.80 Mean 45.7 (SE = Italian PTSD n/a SI, SA Inpatients and outpatients from
Risk Factors: Association Between Anxiety and Suicide

14.8) Italian study

Diefenbach et al., 2009[21] 2,778 60.70 n/r n/r AD n/a SISB Psychiatric outpatients
Jakupcak et al., 2009[59] 407 9.6 Mean 32 65.1% Caucasian PTSD n/a SI, War veterans referred to VA
(SD = 9) 10.6% AA mental healthcare
7.7% Hispanic
4.4% Asian
Cougle et al., 2009[60] 3,085 100 R 18–34 83% Caucasian PTSD n/a SI, SA Telephone survey
10.1% AA;
4.5% Hispanic
1.5% native
American
0.9% racial groups

Depression and Anxiety

921

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 922

Depression and Anxiety

TABLE 1. Continued

Author, No. of Females Age Ethnicity/ Anxiety Length of Outcome Source of

year patients (%) (years) country diagnosis follow-up, years measure population

Alonso et al., 2010[15] 218 42.70 Mean 31.3 Spanish OCD 4.1 SA OCD clinic
R 18–65
Gradus et al., 2010[31] 9,612 29 R 15–90 Danish PTSD 2 CS Population-based sample
Nepon et al., 2010[61] 34,653 52.10 20–29 (16.3%) Caucasian, AA AD, PTSD, GAD, phobias, n/a SA NESARC II survey
30–44 (29.7%) American PD
45–64 (34.6%) Indian/Alaska
65 plus (19.3%) native
Asian/Hawaiian
Hispanic
Torres et al., 2011[27] 582 56.40 Mean 34.74 Brazilian, OCD n/a SI, SA OCD outpatients Brazilian
Kanwar et al.

SE 0.52 83.9% Caucasian Research Consortium

Kinley et al., 2011[62] 8,441 n/r R 16–54 Canadian PD n/a SI Canadian military
Lemaire and Graham., 1,740 11.30 Mean 29.4 43.4% Caucasian PTSD n/a SI War victims
2011[63] 36.3% AA
16.8% Hispanic

CS, completed suicide; SA, suicide attempts; SB, suicidal behavior; SI, suicidal ideation; SD, suicidal death; PTSD, posttraumatic stress disorder; GAD, generalized anxiety disorder; OCD,
obsessive-compulsive disorder; PD, panic disorder; Ag, agoraphobia; AD, anxiety disorder; R, range; NMHS, Netherlands Mental Health Survey; NCS, National Comorbidity Survey; AA,
African American; MHS, Mental Health Survey; WHO, World Health Organization; STEP-BD, Systematic Treatment Enhancement Program for Bipolar Disorder; NESARC II survey, The
National Epidemiologic Survey on Alcohol and Related Conditions II survey; VA, veterans affairs; n/r, not reported; n/a, not applicable.

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Risk Factors: Association Between Anxiety and Suicide 923

TABLE 2. Study Quality

Author, Study Ascertainment Ascertainment Loss to Sample

year design of outcome of exposure Adjustment follow-up selection

Angst, 1992 [30] Prospective SPIKE diagnostic SCL-90 No n/r Canton Zurich
longitudinal instrument
Allgulander, 1994[41] Retrospective Death certificate Inpatient stay No n/r Death certificates,
longitudinal psychiatric facilities
Warshaw et al., 1995[28] Prospective and SCALUP, LIFE surveys DSM-III No 8% Hospital and clinic based
retrospective
longitudinal
Fleet et al., 1996[42] Cross-sectional Beck Depression AXIS I, STAI No n/a Patient discharge
Inventory diagnoses, consecutive
ED patients
Warshaw et al., 2000[29] Prospective SCALUP YGNHHS, SCID-P, No n/r PD patients
longitudinal SADS-L
Kaslow et al., 2000[43] Case control n/r National Women’s Yes n/a Public healthcare
Study PTSD Module facilities
Beautrais et al., 2001[44] Case control Coroner’s report DSM-III Yes n/a Consecutive series
Dhossche et al., 2002[45] Prospective Self-report Youth Self-Report, Yes 14% Municipal birth registers
longitudinal DSM IV
Waern et al., 2002[46] Cross-sectional Death certificate, Questionnaire, DSMIV Yes n/a Autopsy and medical
forensic examiner, records
DCS
Apter et al., 2003[16] Cross-sectional CSPS STAI No n/a Hospital-based
admissions
Drescher et al., 2003[47] Longitudinal Social Security Death Clinically referred Yes n/r Consecutive male
Index admissions: VA
PTSD residential
rehabilitation
Goodwin and Hamilton, Cross-sectional NCS CIDI Yes n/a NCS
2003[48]
Price et al., 2004[25] Retrospective Death certificate Follow-up survey Yes n/r Vietnam War veterans:
longitudinal drug abuse prevention
database
Fergusson et al., Prospective Interview CIDI, DSM-IV Yes 19% Birth cohort in
2005[22] longitudinal Christchurch, New
Zealand
Sareen et al., 2005[49] Prospective CIDI CIDI Yes 21% Netherlands mental
longitudinal health survey
Desai et al., 2005[8] Retrospective National Death Index Patient records, VA Yes n/r Psychiatric inpatients
longitudinal and VA data database from VA hospitals
Angst et al., 2005[14] Prospective Interview DSM-III No n/r Random sample
longitudinal
Reinherz et al., 2006[26] Prospective Youth Self-Report DIS No 47% Community cohort
longitudinal
Balestrieri et al., Cross-sectional SCID, MOODS-SR SCID Yes n/a Clinic based
2006[50]
Herba et al., 2007[51] Prospective Self-reported, CBCL CIDI Yes n/r Birth registers
longitudinal
Boden et al., 2007[17] Prospective Interview CIDI Yes n/r Birth cohort
longitudinal
Simon et al., 2007[23] Cross-sectional Study questionnaire, MINI Yes n/a Hospital participants of
BS, SSI, SBQ-a STEP-BD
Simon et al., 2007[52] Retrospective Hospital records Outpatient visit records Yes n/r Population-based
longitudinal sample of bipolar
patients
Bolton et al., 2008[18] Prospective Interview DIS Yes 27% Institutionalized and
longitudinal community dwelling
Brezo et al., 2008[19] Prospective Interview, self- and SBQ-b, ISCA, DAPP Yes 43% Public francophone
longitudinal parental report schools
Miranda et al., 2008[24] Retrospective Interview, CSS DISC Yes 23% High school screening
longitudinal

Depression and Anxiety

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924 Kanwar et al.

TABLE 2. Continued

Author, Study Ascertainment Ascertainment Loss to Sample

year design of outcome of exposure Adjustment follow-up selection

Borges et al., 2008[53] Prospective NCS CIDI Yes 12.40% Nationally

longitudinal representative survey
Ono et al., 2008[54] Cross-sectional Interview CIDI Yes n/a WHO Mental Health
survey, voter
registration
Tidemalm et al., Retrospective Death register, hospital Hospital discharge Yes 20% Hospital discharge
2008[55] longitudinal records record register
Dell’osso et al., 2009[20] Cross-sectional MOODS-SR DSM-IV No n/a Inpatients and
outpatients
Diefenbach et al., Cross-sectional BSIS BSIS No n/a Psychiatric outpatients
2009[21]
Goldston et al., 2009[56] Prospective ISCA, medical records, ISCA, interview Yes 13.30% Consecutive discharges
longitudinal interview to an adolescent
psychiatric inpatient
hospital
ten Have et al., 2009[57] Prospective CIDI CIDI Yes n/r NMHSIS
longitudinal
Wilcox et al., 2009[58] Prospective National Death Index CIDI Yes 25% Public schools
longitudinal
Jakupcak et al., 2009[50] Cross-sectional Mississippi Scale for PCL-M, DSM-IV Yes n/a War veterans
PTSD and SSI
Cougle et al., 2009[60] Cross-sectional Interview DSM-III No n/a Telephone survey
Alonso et al., 2010[15] Prospective Suicide ideation: HDRS; Interview Yes 10% OCD clinic
longitudinal suicide attempts: BS
Gradus et al., 2010[31] Case control Cause of death register ICD-8, ICD-10, Yes n/a Danish registry
psychiatric register population-based
sample
Nepon et al., 2010[61] Cross-sectional Interview AUD Yes n/a NESARC II survey
Torres et al., 2011[27] Cross-sectional Questionnaire SCID, questionnaire, No n/a Consecutive OCD
YBOCS, DYBOCS, outpatients in
BAI Brazilian Research
Consortium
Kinley et al., 2011[62] Cross-sectional Interview CIDI Yes n/a Canadian military
Lemaire and Graham, Cross-sectional Clinical suicide Clinical diagnosis No n/a Iraq and Afghanistan
2011[63] evaluation war veterans

AUD, Alcohol Use Disorders and Associated Disabilities Interview; BAI, Beck Anxiety Inventory; BSIS, Behavior and Symptom Identification Scale;
BS, Beck Scale for Suicide Ideation; CBCL, Child Behavior Checklist; CIDI, Composite International Diagnostic Interview; CSPS, Childhood
Suicide Potential Scale; CSS, Columbia Suicidal Screen; DAPP, Diagnostic Assessment of Personality Pathology; DIS, National Institute of Mental
Health Diagnostic Interview Schedule; DCS, Rating Scale for Determining the Degree of Certainty of Suicide; DSM-III, Diagnostic and Statistical
Manual of Mental Disorders, Third Edition; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; DISC, Diagnostic
Interview Schedule for Children; DYBOCS, Dimensional Yale–Brown Obsessive Compulsive Scale; HDRS, Hamilton Depression Rating Scale;
ICD, International Classification of Diseases; ISCA, Diagnostic Interview Schedule for Children and Adolescents; MINI, Mini International
Neuropsychiatric Interview; MOODS-SR, Self-Report version of the Structured Clinical Interview for Mood Spectrum; SCL-90, The military
version of the PTSD Checklist-PCL-M, 90-item Hopkins Symptom Checklist; SADS-L, Schedule for Affective Disorders-Lifetime; SBQ-a, Suicide
Behaviors Questionnaire; SBQ-b, Social Behavior Questionnaire; SCALUP, SCID-P plus SADS-L; SCID-P, Structured Clinical Interview for the
DSM-III-R Non-Affective Disorders—Patient Version; SPIKE, The Structured Psychopathological Interview and Rating of Social Consequences
of Psychic Disturbances for Epidemiology; SSI, Scale for Suicidal Ideation; STAI, State Trait Anxiety Inventory; YBOCS, Yale–Brown Obsessive
Compulsive Scale; YGNHHS, Yale Greater New Haven Health Survey—Community Interview; NCS, National Comorbidity Survey; NMHSIS,
Netherlands Mental Health Survey and Incidence Study; n/a, not applicable; n/r, not reported.

to the variability in outcome that was studied (e.g., sui-
cidal thoughts, behaviors, or completion) and how the
outcome was ascertained. Confounding variables such
as psychotropic medications, alcoholism, and substance
abuse, which have been associated with suicide, may have
also obscured the findings.[25] Other limitations include
no differentiation between subgroups of anxiety disor-
ders, high proportion of OCD patients in the study
sample, and unrepresentative samples (such as those re-
cruited from specialized clinics or overrepresent certain
age groups).[21, 23–25]
Although the causal role of anxiety in suicidal behav-
ior is unclear, it is possible that avoidance strategies asso-
ciated with anxiety disorders exacerbates psychological

Depression and Anxiety

 15206394, 2013, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/da.22074 by <Shibboleth>-member@open.ac.uk, Wiley Online Library on [26/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Risk Factors: Association Between Anxiety and Suicide 925

TABLE 3. Pooled odds ratio of suicidal activities

No. of cohorts Odds ratio 95% confidence interval P value I2 (%)

Any suicidal behaviors

Any type of anxiety disorder 56 2.85 2.35, 3.46 .000 95.1
GAD 8 2.05 1.61, 2.61 .000 15.5
OCD 4 0.99 0.89, 1.10 .885 0.0
PD 7 4.08 2.63, 6.33 .000 68.0
PTSD 16 2.71 1.84, 3.98 .000 93.4
Suicidal ideations
Any type of anxiety disorder 26 2.89 2.09, 4.00 .000 95.9
GAD 4 1.78 1.41, 2.25 .000 0.0
OCD n/a n/a n/a n/a n/a
PD 4 4.39 2.38, 8.10 .000 78.6
PTSD 10 2.92 1.76, 4.87 .000 92.2
Suicide attempts
Any type of anxiety disorder 27 2.47 1.96, 3.10 .000 91.3
GAD 5 2.70 1.92, 3.79 .000 0.0
OCD 4 0.99 0.89, 1.10 .885 0.0
PD 4 3.96 2.13, 7.35 .000 38.3
PTSD 6 2.21 1.17, 4.18 .015 90.6
Completed suicides
Any type of anxiety disorder 14 3.34 2.13, 5.25 .000 95.5
GAD n/a n/a n/a n/a n/a
OCD n/a n/a n/a n/a n/a
PD n/a n/a n/a n/a n/a
PTSD 3 2.50 0.47, 13.41 .285 97.8

GAD, generalized anxiety disorder; OCD, obsessive-compulsive disorder; PD, panic disorder; PTSD, posttraumatic stress disorder; n/a, not
applicable; I2 , a statistic measuring the heterogeneity of the outcomes across the included studies, where I2 > 50% suggests high level of heterogeneity.

distress,[64, 65] rendering patients with anxiety more vul-
nerable to suicidal behavior as a way to reduce or escape
from such distress. In fact, suicidal behavior has been
thought of as an escape from aversive self-awareness and
negative emotion,[66] or as relief from negative affect.[67]
In addition, anxiety is associated with significant nega-
tive emotionality that has been associated with suicidal
behavior.[68] It is also possible that social isolation, dis-
ability, and reductions in quality of life associated with
anxiety disorders,[6, 69] may provide an individual with
fewer reasons for living. Social support is an important
protective factor for suicide[70] and this is frequently
reduced for patients with anxiety.[71–74] Avoidant cop-
ing strategies characteristic of anxiety disorders have
been shown to increase suicide risk.[64] Other mecha-
nisms of risk may include shared genetic risk and com-
mon biological vulnerability (e.g., corticrotrophin re-
leasing factor) between suicidal behavior and anxiety
disorders,[75] or mutual risk factors such as childhood
trauma, temperament, and stress vulnerability.[76] Fu-
ture research is necessary to examine the specific mech-
anism of risk. Research should also examine how anxiety
may interact with other risk factors to heighten vulner-
ability. For example, research suggests that the comor-
bidity of anxiety and depression seems to be a more sig-
nificant risk factor for suicide attempts than depression
alone[77] and this also seems to be the case for bipolar
disorder.[23]
CLINICAL IMPLICATIONS
Given the findings of this study suggesting an approx-
imate threefold increase in the risk of suicidal behav-
iors in patients with anxiety disorders, an assessment
of anxiety may assist in the identification of individuals
with heightened vulnerability toward suicide. In addi-
tion, because anxiety disorders are considered relatively
treatable,[78, 79] yet they are underidentified and treated
in the general population,[80] efforts to better screen and
treat anxiety in the community and primary care settings
may represent a reasonable opportunity to prevent sui-
cide. Measures such as the Beck Anxiety Inventory[81]
or the General Anxiety Disorder-7[82] are reliable and
valid screening measures to identify those in further need
of evaluation. In terms of intervention, there is consid-
erable evidence for the efficacy of cognitive behavioral
therapy (CBT), and exposure therapy in particular, with
large effect sizes found in meta-analytic studies.[78, 79]
Research suggests that this treatment is as effective as
medication for the treatment of anxiety[83] and does not
have the untoward, yet rare side effect of suicidal behav-
ior that has been found in several antidepressant medi-
cation trials.[84, 85] Nevertheless, pharmacological treat-
ments should also be given consideration as they have
shown substantial benefit for anxiety disorders.[83, 86–88]
Given that suicide is a preventable cause of death, im-
proved identification and treatment of anxiety disorders
may represent an important public health intervention.

Depression and Anxiety


926 Kanwar et al.
LIMITATIONS AND STRENGTHS
Our study had several methodological limitations. Di-
verse study designs, patient characteristics, and potential
confounding variables make the interpretation of aggre-
gated estimates challenging, and causality could not be
inferred. Additionally, it limits the relevance and reli-
ability of the results. For these analyses, we only had
summary estimates that may not have been adjusted for
important patient-level covariates. Moreover, hetero-
geneity was high in some of the analyses lowering con-
fidence in the estimated magnitude of association. The
understanding of the relationship between anxiety and
suicidal behavior may be limited by the inclusion of vari-
ous types of suicidal behavior given that suicidal ideation,
suicide attempts, and completed suicide, which are qual-
itatively different behaviors. We were not able to gather
information on antianxiety medications such as selec-
tive serotonin reuptake inhibitors that study patients may
have been taking, which may also be associated with sui-
cidal behavior,[84, 85] and therefore can confound the as-
sociation of anxiety disorders and suicide. Lastly, data
on specific types of phobia were insufficient for meta-
analysis; hence, conclusions regarding these conditions
are limited.
Our study method had several strengths. The num-
ber of patients included in the meta-analysis was large.
We used bias protection measures (reviewing studies in
duplicate with good interreviewer agreement). We per-
formed a comprehensive literature search of multiple
databases without language restriction.
CONCLUSION
This meta-analysis provides evidence that the rates of
suicides are higher in patients with any type of anxiety
disorder excluding OCD.
REFERENCES
1. American Psychiatric Association. Diagnostic Criteria from
DSM-IV-TR. Washington, DC: American Psychiatric Associa-
tion; 2000.
2. Placidi GP, Oquendo MA, Malone KM, et al. Anxiety in ma-
jor depression: relationship to suicide attempts. Am J Psychiatry
2000;157(10):1614–1618.
3. Gil S. The role of personality traits in the understanding of suicide
attempt behavior among psychiatric patients. Arch Suicide Res
2003;7(2):159–166.
4. Bulik CM, Sullivan PF, Joyce PR. Temperament, character and
suicide attempts in anorexia nervosa, bulimia nervosa and major
depression. Acta Psychiatr Scand 1999;100(1):27–32.
5. Massion AO, Warshaw MG, Keller MB. Quality of life and psychi-
atric morbidity in panic disorder and generalized anxiety disorder.
Am J Psychiatry 1993;150(4):600–607.
6. Mendlowicz MV, Stein MB. Quality of life in individu-
als with anxiety disorders. Am J Psychiatry 2000;157(5):
669–682.
7. Kaplan MS, McFarland BH, Huguet N, Newsom JT. Physical
illness, functional limitations, and suicide risk: a population-based
study. Am J Orthopsychiatry 2007;77(1):56–60.
Depression and Anxiety
15206394, 2013, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/da.22074 by <Shibboleth>-member@open.ac.uk, Wiley Online Library on [26/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
8. Desai RA, Dausey DJ, Rosenheck RA. Mental health service de-
livery and suicide risk: the role of individual patient and facility
factors. Ame J Psychiatry 2005;162(2):311–318.
9. Allgulander C. Excess mortality among 3302 patients with ’pure’
anxiety neurosis. Arch Gen Psychiatry 1991;48(7):599–602.
10. Cox BJ, Direnfeld DM, Swinson RP, Norton GR. Suicidal
ideation and suicide attempts in panic disorder and social pho-
bia. Am J Psychiatry 1994;151:882–887.
11. Coryell W, Noyes R, Clancy J. Excess mortality in panic disor-
der: a comparison with primary unipolar depression. Arch Gen
Psychiatry 1982;39(6):701–703.
12. Placidi GPA, Oquendo MA, Malone KM, et al. Anxiety in ma-
jor depression: relationship to suicide attempts. Am J Psychiatry
2000;157(10):1614–1618.
13. Sareen J, Cox BJ, Afifi TO, et al. Anxiety disorders and risk for
suicidal ideation and suicide attempts: a population-based longi-
tudinal study of adults. Arch Gen Psychiatry 2005;62(11):1249–
1257.
14. Angst J, Gamma A, Endrass J, et al. Obsessive-compulsive syn-
dromes and disorders: significance of comorbidity with bipo-
lar and anxiety syndromes. Eur Arch Psychiatry Clin Neurosci
2005;255(1):65–71.
15. Alonso P, Segalas C, Real E, et al. Suicide in patients treated for
obsessive-compulsive disorder: a prospective follow-up study. J
Affect Disord 2010;124(3):300–308.
16. Apter A, Horesh N, Gothelf D, et al. Depression and suicidal be-
havior in adolescent inpatients with obsessive compulsive disorder.
J Affect Disord 2003;75(2):181–189.
17. Boden JM, Fergusson DM, Horwood LJ. Anxiety disorders and
suicidal behaviours in adolescence and young adulthood: findings
from a longitudinal study. Psychol Med 2007;37(3):431–440.
18. Bolton JM, Cox BJ, Afifi TO, et al. Anxiety disorders and
risk for suicide attempts: findings from the Baltimore Epi-
demiologic Catchment area follow-up study. Depress Anxiety
2008;25(6):477–481.
19. Brezo J, Barker ED, Paris J, et al. Childhood trajectories of anx-
iousness and disruptiveness as predictors of suicide attempts. Arch
Pediatr Adolesc Med 2008;162(11):1015–1021.
20. Dell’osso L, Carmassi C, Rucci P, et al. Lifetime subthreshold ma-
nia is related to suicidality in posttraumatic stress disorder. CNS
Spectr 2009;14(5):262–266.
21. Diefenbach GJ, Woolley SB, Goethe JW. The association be-
tween self-reported anxiety symptoms and suicidality. J Nerv Ment
Dis 2009;197(2):92–97.
22. Fergusson DM, Horwood LJ, Ridder EM, Beautrais AL. Suicidal
behaviour in adolescence and subsequent mental health outcomes
in young adulthood. Psychol Med 2005;35(7):983–993.
23. Simon NM, Zalta AK, Otto MW, et al. The association of comor-
bid anxiety disorders with suicide attempts and suicidal ideation
in outpatients with bipolar disorder. J Psychiatr Res 2007;41(3–
4):255–264.
24. Miranda R, Scott M, Hicks R, et al. Suicide attempt characteristics,
diagnoses, and future attempts: comparing multiple attempters to
single attempters and ideators. J Am Acad Child Adolesc Psychi-
atry 2008;47(1):32–40.
25. Price RK, Risk NK, Haden AH, et al. Post-traumatic stress disor-
der, drug dependence, and suicidality among male Vietnam vet-
erans with a history of heavy drug use. Drug Alcohol Depend
2004;76(Suppl):S31–43.
26. Reinherz HZ, Tanner JL, Berger SR, et al. Adolescent suici-
dal ideation as predictive of psychopathology, suicidal behav-
ior, and compromised functioning at age 30. Am J Psychiatry
2006;163(7):1226–1232.
27. Torres AR, Ramos-Cerqueira ATA, Ferrao YA, et al. Suicidal-
ity in obsessive-compulsive disorder: prevalence and relation to

Risk Factors: Association Between Anxiety and Suicide
symptom dimensions and comorbid conditions. J Clin Psychiatry
2011;72(1):17–26; quiz 119–120.
28. Warshaw MG, Massion AO, Peterson LG, et al. Suicidal behavior
in patients with panic disorder: retrospective and prospective data.
J Affect Disord 1995;34(3):235–247.
29. Warshaw MG, Dolan RT, Keller MB. Suicidal behavior in pa-
tients with current or past panic disorder: five years of prospective
data from the Harvard/Brown Anxiety Research Program. Am J
Psychiatry 2000;157(11):1876–1878.
30. Angst J, Degonda M, Ernst C. The Zurich Study: XV. Suicide
attempts in a cohort from age 20 to 30. Eur Arch Psychiatry Clin
Neurosci 1992;242(2–3):135–141.
31. Gradus JL, Qin P, Lincoln AK, et al. Posttraumatic stress disorder
and completed suicide. Am J Epidemiol 2010;171(6):721–727.
32. Panagioti M, Gooding P, Tarrier N. Post-traumatic stress disor-
der and suicidal behavior: a narrative review. Clin Psychol Rev
2009;29(6):471–482.
33. Tarrier N, Gregg L. Suicide risk in civilian PTSD patients—
predictors of suicidal ideation, planning and attempts. Soc Psy-
chiatry Psychiatr Epidemiol 2004;39(8):655–661.
34. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred report-
ing items for systematic reviews and meta-analyses: the PRISMA
statement. Ann Intern Med 2009;151(4):264–269, W64.
35. Wells G, Shea B, O’Connell D, et al. The Newcastle-
Ottawa Scale (NOS) for assessing the quality of nonrandom-
ized studies in meta-analysis; 2010. Available at: http://www.ohri.
ca/programs/clinical_epidemiology/oxford_web.ppt2010.
36. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control
Clin Trials 1986;7(3):177–188.
37. Freemantle N, Cleland J, Young P, et al. beta Blockade after my-
ocardial infarction: systematic review and meta regression analysis.
BMJ 1999;318(7200):1730–1737.
38. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring
inconsistency in meta-analyses. BMJ 2003;327(7414):557–560.
39. Egger M, Davey Smith G, Schneider M, Minder C. Bias
in meta-analysis detected by a simple, graphical test. BMJ
1997;315(7109):629–634.
40. Sterne JA, Egger M, Smith GD. Systematic reviews in health
care: investigating and dealing with publication and other biases
in meta-analysis. BMJ 2001;323(7304):101–105.
41. Allgulander C. Suicide and mortality patterns in anxiety neuro-
sis and depressive neurosis. Arch Gen Psychiatry 1994;51(9):708–
712.
42. Fleet RP, Dupuis G, Marchand A, et al. Panic disorder in
emergency department chest pain patients: prevalence, comor-
bidity, suicidal ideation, and physician recognition. Am J Med
1996;101(4):371–380.
43. Kaslow N, Thompson M, Meadows L, et al. Risk factors for sui-
cide attempts among African American women. Depress Anxiety
2000;12(1):13–20.
44. Beautrais AL. Suicides and serious suicide attempts: two popula-
tions or one? Psychol Med 2001;31(5):837–845.
45. Dhossche D, Ferdinand R, van der Ende J, et al. Diagnostic out-
come of adolescent self-reported suicidal ideation at 8-year follow-
up. J Affect Disord 2002;72(3):273–279.
46. Waern M, Runeson BS, Allebeck P, et al. Mental disor-
der in elderly suicides: a case-control study. Am J Psychiatry
2002;159(3):450–455.
47. Drescher KD, Rosen CS, Burling TA, Foy DW. Causes of
death among male veterans who received residential treatment
for PTSD. J Trauma Stress 2003;16(6):535–543.
48. Goodwin RD, Hamilton SP. Lifetime comorbidity of antisocial
personality disorder and anxiety disorders among adults in the
community. Psychiatry Res 2003;117(2):159–166.
15206394, 2013, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/da.22074 by <Shibboleth>-member@open.ac.uk, Wiley Online Library on [26/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
927
49. Sareen J, Cox BJ, Afifi TO, et al. Anxiety disorders and risk for
suicidal ideation and suicide attempts: a population-based longi-
tudinal study of adults. Arch Gen Psychiatry 2005;62(11):1249–
1257.
50. Balestrieri M, Rucci P, Sbrana A, et al. Lifetime rhythmicity and
mania as correlates of suicidal ideation and attempts in mood dis-
orders. Comprehens Psychiatry 2006;47(5):334–341.
51. Herba CM, Ferdinand RF, van der Ende J, Verhulst FC. Long-
term associations of childhood suicide ideation. J Am Acad Child
Adolesc Psychiatry 2007;46(11):1473–1481.
52. Simon GE, Hunkeler E, Fireman B, et al. Risk of suicide attempt
and suicide death in patients treated for bipolar disorder. Bipolar
Disord 2007;9(5):526–530.
53. Borges G, Angst J, Nock MK, et al. Risk factors for the incidence
and persistence of suicide-related outcomes: a 10-year follow-up
study using the National Comorbidity Surveys. J Affect Disord
2008;105(1–3):25–33.
54. Ono Y, Kawakami N, Nakane Y, et al. Prevalence of and risk
factors for suicide-related outcomes in the World Health Organi-
zation World Mental Health Surveys Japan. Psychiatry Clin Neu-
rosci 2008;62(4):442–449.
55. Tidemalm D, Langstrom N, Lichtenstein P, Runeson B. Risk of
suicide after suicide attempt according to coexisting psychiatric
disorder: Swedish cohort study with long term follow-up. BMJ
2008;337:a2205.
56. Goldston DB, Daniel SS, Erkanli A, et al. Psychiatric diagnoses
as contemporaneous risk factors for suicide attempts among ado-
lescents and young adults: developmental changes. J Consult Clin
Psychol 2009;77(2):281–290.
57. ten Have M, de Graaf R, van Dorsselaer S, et al. Incidence and
course of suicidal ideation and suicide attempts in the general
population. Can J Psychiatry 2009;54(12):824–833.
58. Wilcox HC, Storr CL, Breslau N. Posttraumatic stress disorder
and suicide attempts in a community sample of urban american
young adults. Arch Gen Psychiatry 2009;66(3):305–311.
59. Jakupcak M, Cook J, Imel Z, et al. Posttraumatic stress disorder
as a risk factor for suicidal ideation in Iraq and Afghanistan War
veterans. J Trauma Stress 2009;22(4):303–306.
60. Cougle JR, Resnick H, Kilpatrick DG. PTSD, depression, and
their comorbidity in relation to suicidality: cross-sectional and
prospective analyses of a national probability sample of women.
Depress Anxiety 2009;26(12):1151–1157.
61. Nepon J, Belik S-L, Bolton J, Sareen J. The relationship between
anxiety disorders and suicide attempts: findings from the National
Epidemiologic Survey on Alcohol and Related Conditions. De-
press Anxiety 2010;27(9):791–798.
62. Kinley DJ, Walker JR, Mackenzie CS, Sareen J. Panic attacks and
panic disorder in a population-based sample of active Canadian
military personnel. J Clin Psychiatry 2011;72(1):66–74; quiz 119–
20.
63. Lemaire CM, Graham DP. Factors associated with suicidal
ideation in OEF/OIF veterans. J Affect Disord 2011;130(1–
2):231–238.
64. Amir M, Kaplan Z, Efroni R, Kotler M. Suicide risk and coping
styles in posttraumatic stress disorder patients. Psychother Psy-
chosom 1999;68(2):76–81.
65. Littleton H, Horsley S, John S, Nelson DV. Trauma coping strate-
gies and psychological distress: a meta-analysis. J Trauma Stress
2007;20(6):977–988.
66. Baumeister RF. Suicide as escape from self. Psychol Rev
1990;97(1):90–113.
67. Boergers J, Spirito A, Donaldson D. Reasons for adolescent suicide
attempts: associations with psychological functioning. J Am Acad
Child Adolesc Psychiatry 1998;37(12):1287–1293.
Depression and Anxiety

928 Kanwar et al.
68. Stein D, Apter A, Ratzoni G, et al. Association between multiple
suicide attempts and negative affects in adolescents. J Am Acad
Child Adolesc Psychiatry 1998;37(5):488–494.
69. Schonfeld WH, Verboncoeur CJ, Fifer SK, et al. The functioning
and well-being of patients with unrecognized anxiety disorders and
major depressive disorder. J Affect Disord 1997;43(2):105–119.
70. Gunnell D, Harbord R, Singleton N, et al. Factors influencing the
development and amelioration of suicidal thoughts in the general
population. Cohort study. Br J Psychiatry 2004;185:385–393.
71. Angst J, Vollrath M. The natural history of anxiety disorders. Acta
Psychiatr Scand 1991;84(5):446–452.
72. Cramer V, Torgersen S, Kringlen E. Quality of life and anxiety
disorders: a population study. J Nerv Ment Dis 2005;193(3):196–
202.
73. Davidson J, Hughes D, DG B, George L. Post-traumatic stress
disorder in the community: an epidemiological study. Psychol
Med 1991;21:713–721.
74. Davidson J, Hughes D, George L, Blazer D. The epidemiology of
social phobia: findings from the Duke Epidemiological Catchment
Area Study. Psychol Med 1993;23(3):709–718.
75. Risbrough VB, Stein MB. Role of corticotropin releasing factor
in anxiety disorders: a translational research perspective. Horm
Behav 2006;50(4):550–561.
76. Heim C, Nemeroff CB. The role of childhood trauma in the neu-
robiology of mood and anxiety disorders: preclinical and clinical
studies. Biol Psychiatry 2001;49(12):1023–1039.
77. Bronisch T, Wittchen HU. Suicidal ideation and suicide at-
tempts: comorbidity with depression, anxiety disorders, and
substance abuse disorder. Eur Arch Psychiatry Clin Neurosci
1994;244(2):93–98.
78. Hofmann SG, Smits JA. Cognitive-behavioral therapy for
adult anxiety disorders: a meta-analysis of randomized placebo-
controlled trials. J Clin Psychiatry 2008;69(4):621–632.
Depression and Anxiety
15206394, 2013, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/da.22074 by <Shibboleth>-member@open.ac.uk, Wiley Online Library on [26/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
79. James A, Soler A, Weatherall R. Cognitive behavioural therapy for
anxiety disorders in children and adolescents. Cochrane Database
Syst Rev 2005;(4):CD004690.pub2.
80. Stein MB, Sherbourne CD, Craske MG, et al. Quality of care
for primary care patients with anxiety disorders. Am J Psychiatry
2004;161(12):2230–2237.
81. Steer RA, Beck AT. Beck Anxiety Inventory. In: Wood C, editor.
Evaluating Stress: A Book of Resources. Lanham, MD: Scarecrow
Education; 1997:23–40.
82. Spitzer RL, Kroenke K, Williams JB, Lowe B. A
brief measure for assessing generalized anxiety disor-
der: the GAD-7. Arch Intern Med 2006;166(10):1092–
1097.
83. Gould RA, Otto MW, Pollack MH, Yap L. Cognitive behav-
ioral and pharmacological treatment of generalized anxiety dis-
order: a preliminary meta-analysis. Behav Therapy 1997;28(2):
285–305.
84. Khan A, Khan S, Kolts R, Brown WA. Suicide rates in
clinical trials of SSRIs, other antidepressants, and placebo:
analysis of FDA reports. Am J Psychiatry 2003;160(4):
790–792.
85. Whittington CJ, Kendall T, Fonagy P, et al. Selective serotonin
reuptake inhibitors in childhood depression: systematic review of
published versus unpublished data. Lancet 2004;363(9418):1341–
1345.
86. Bakker A, van Balkom AJ, Spinhoven P. SSRIs vs. TCAs in the
treatment of panic disorder: a meta-analysis. Acta Psychiatr Scand
2002;106(3):163–167.
87. Blanco C, Schneier FR, Schmidt A, et al. Pharmacological treat-
ment of social anxiety disorder: a meta-analysis. Depress Anxiety
2003;18(1):29–40.
88. Van Etten ML, Taylor S. Comparative efficacy of treatments for
post-traumatic stress disorder: a meta-analysis. 1998;5:126–144.

Risk Factors: Association Between Anxiety and Suicide
APPENDIX: SEARCH STRATEGY
OVID
Database(s): Embase 1988–2011, week 33; Ovid
MEDLINE(R) in-process and other non-indexed ci-
tations; and Ovid MEDLINE(R) 1948 to present,
PsycINFO 1987 to August week 4, 2011; EBM
Reviews—Cochrane Central Register of Controlled
Trials third quarter 2011; EBM Reviews—Cochrane
Database of Systematic Reviews 2005 to August 2011
search strategy:
Number Searches
1 exp suicide
2 suicid*.mp.
3 1 or 2
4 exp anxiety disorders
5 (“Anxiety disorder*” or “acute stress disorder*”
or “anxiety neurosis” or “cardiac anxiety” or
“catastrophizing” or “distress syndrome” or
koro or “obsessive-compulsive disorder*” or
panic or phobia* or “posttraumatic stress
disorder*” or “posttraumatic stress
disorder*” or psychathenia or “separation
anxiety” or “castration anxiety” or “death
anxiety” or agoraphobia* or
“neurocirculatory asthenia” or phobic or
“traumatic stress disorder*”). mp. [mp = ti,
ab, sh, hw, tn, ot, dm, mf, dv, kw, ps, rs, nm,
ui, tc, id, tm, tx, ct]
6 4 or 5
7 exp cohort analysis
8 exp case-control study
9 exp cohort studies
10 exp case-control studies
11 ([Cohort or concurrent or incidence or
“follow-up” or longitudinal or retrospective
or prospective] adj [study or studies or
analysis or analyses]). mp. [mp = ti, ab, sh,
hw, tn, ot, dm, mf, dv, kw, ps, rs, nm, ui, tc,
id, tm, tx, ct]
12 ([“case-control” or “case-referrent” or
“case-compeer” or “case-comparison” or
“case-base”] adj [study or studies or analysis
or analyses]). mp. [mp = ti, ab, sh, hw, tn, ot,
dm, mf, dv, kw, ps, rs, nm, ui, tc, id, tm, tx,
ct]
13 or/7–12
14 3 and 6 and 13
15 Remove duplicates from 14
16 Limit 15 to (book or book series or editorial or
erratum or letter or trade journal or
addresses or autobiography or bibliography
or biography or dictionary or directory or
duplicate publication or in vitro or
interactive tutorial or interview or lectures
or legal cases or legislation or news or
newspaper article or overall or patient
education handout or periodical index or
portraits or webcasts or “0200 book” or
“0240 authored book” or “0280 edited
Continued
15206394, 2013, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/da.22074 by <Shibboleth>-member@open.ac.uk, Wiley Online Library on [26/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
929
Number Searches Results
book” or “0300 encyclopedia”) [Limit not
valid in Embase, Ovid MEDLINE(R), Ovid
MEDLINE(R) In-Process, PsycINFO,
CCTR, CDSR; records were retained]
17 From 16 keep 1–24 24
18 15 not 17 810
SCOPUS
1. TITLE-ABS-KEY(suicid*).
2. TITLE-ABS-KEY(“anxiety disorder*” or “acute
Results stress disorder*” or “anxiety neurosis” or “cardiac
82,820
anxiety” or “catastrophizing” or “distress syndrome”
150,203 or koro or “obsessive compulsive disorder*” or panic
150,203 or phobia* or “posttraumatic stress disorder*” or
209,062 “posttraumatic stress disorder*” or psychathenia or
298,365 “separation anxiety” or “castration anxiety” or “death
anxiety” or agoraphobia* or “neurocirculatory asthe-
nia” or phobic or “traumatic stress disorder*”).
3. TITLE-ABS-KEY((cohort W/1 study) or (cohort
W/1 studies) or (cohort W/1 analysis) or (cohort
W/1 analyses) or (concurrent W/1 study) or (con-
current W/1 studies) or (concurrent W/1 analysis)
or (concurrent W/1 analyses) or (incidence W/1
study) or (incidence W/1 studies) or (incidence W/1
analysis) or (incidence W/1 analyses) or (“follow-
up” W/1 study) or (“follow-up” W/1 studies) or
(“follow-up” W/1 analysis) or (“follow-up” W/1
312,353 analyses) or (longitudinal W/1 study) or (longitudi-
1,309,516 nal W/1 studies) or (longitudinal W/1 analysis) or
582,627 (longitudinal W/1 analyses) or (retrospective W/1
1,308,676
study) or (retrospective W/1 studies) or (retrospec-
582,627
2,008,478
tive W/1 analysis) or (retrospective W/1 analyses)
or (prospective W/1 study) or (prospective W/1
studies) or (prospective W/1 analysis) or (prospec-
tive W/1 analyses) or (“case-control” W/1 study) or
(“case-control” W/1 studies) or (“case-control” W/1
analysis) or (“case-control” W/1 analyses) or (“case-
240,418 referrent” W/1 study) or (“case-referrent” W/1 stud-
ies) or (“case-referrent” W/1 analysis) or (“case-
referrent” W/1 analyses) or (“case-compeer” W/1
study) or (“case-compeer” W/1 studies) or (“case-
compeer” W/1 analysis) or (“case-compeer” W/1
2,196,071 analyses) or (“case-comparison” W/1 study) or (“case-
1204 comparison” W/1 studies) or (“case-comparison”
834 W/1 analysis) or (“case-comparison” W/1 analyses)
61 or (“case-base” W/1 study) or (“case-base” W/1 stud-
ies) or (“case-base” W/1 analysis) or (“case-base” W/1
analyses)).
4. 1 and 2 and 3.
5. PMID(0*) or PMID(1*) or PMID(2*) or PMID(3*)
or PMID(4*) or PMID(5*) or PMID(6*) or PMID(7*)
or PMID(8*) or PMID(9*).
6. 4 and not 5.
7. DOCTYPE(le) OR DOCTYPE(ed) OR DOC-
TYPE(bk) OR DOCTYPE(er) OR DOCTYPE(no)
OR DOCTYPE(sh).
8. 6 and not 7.
Depression and Anxiety