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Epidemiol Psychiatr Sci. 2015 Jun;24(3):210-26. doi: 10.1017/S2045796015000189. Epub 2015 Feb 27.

Anxious and non-anxious major depressive disorder in the World Health Organization World Mental Health Surveys.

Author information

Department of Health Care Policy,Harvard Medical School,Boston,MA,USA.
Institute for Social Research, University of Michigan,Ann Arbor,MI,USA.
College of Medicine, Al-Qadisiya University,Diwania governorate,Iraq.
Institute of Psychiatry, University of São Paulo Medical School,São Paulo,Brazil.
School of Psychology, Ulster University,Londonberry,Ireland.
Department of Psychiatry,University Hospital Gasthuisberg, Katholieke Universiteit Leuven,Leuven,Belgium.
National School of Public Health,Management and Professional Development,Bucharest,Romania.
Unit of Epidemiological and Evaluation Psychiatry,IRCCS St John of God Clinical Research Centre,Brescia,Italy.
Department of Psychiatry,Centre for Research and Training in Mental Health, Neurosciences, Drug and Alcohol Abuse, University of Ibadan,Ibadan,Nigeria.
Shanghai Mental Health Center, Shanghai Jiao Tong University, School of Medicine,Shanghai,People's Republic of China.
Shenzhen Institute of Mental Health & Shenzhen Kanging Hospital,Guangdon Province,PRC.
Institute of Mental Health, Peking University,Beijing,China.
Department of Psychiatry and Clinical Psychology,Faculty of Medicine,Balamand University,Beirut,Lebanon.
Ecole des Hautes Etudes en Santé Publique (EHESP), EA 4057 Paris Descartes University,Paris,France.
Department of Psychiatry,The Chinese University of Hong Kong,Shatin,Hong Kong SAR.
Ministry of Health Israel,Mental Health Services,Jerusalem,Israel.
Ramond e la Fuente Muñiz National Institute of Psychiatry,Mexico City,Mexico.
Institute of psychiatry and Neurology,Warsaw,Poland.
Department of Public Health,Jichi Medical University,Shimotsuke,Tochigi,Japan.
Unidad de Docencia, Investigación y Formación en Salud Mental (UDIF-SM),Servicio Murciano de Salud,IMIB-Arrixaca,CIBERESP-Nodo Murcia,Spain.
Department of Psychiatry,School of Medicine, University of Tasmania,Tasmania,Australia.
National Institute of Health,Lima,Peru.
Universidad Colegio Mayor de Cundinamarca,Bogota,Colombia.
National Drug and Alcohol Research Centre, University of New South Wales,Sydney,Australia.
Netherlands Institute of Mental Health and Addiction,Utrecht,The Netherlands.
Center for Excellence on Research in Mental Health, CES University,Medellin,Colombia.
Health Services Research Unit, IMIM (Institut Hospital del Mar d'Investigacions Mèdiques),Carrer del Doctor Aiguader,88,Edifici PRBB,08003,Barcelona,Spain.
Department of Mental Health - CEDOC and Faculdade Ciencias Medicas,Universidade Nova de Lisboa,Lisbon,Portugal.
Department Mental Health,NCPHA,Sofia,Bulgaria.
Janssen Pharmaceutical Research & Development,Titusville,NJ,USA.



To examine cross-national patterns and correlates of lifetime and 12-month comorbid DSM-IV anxiety disorders among people with lifetime and 12-month DSM-IV major depressive disorder (MDD).


Nationally or regionally representative epidemiological interviews were administered to 74 045 adults in 27 surveys across 24 countries in the WHO World Mental Health (WMH) Surveys. DSM-IV MDD, a wide range of comorbid DSM-IV anxiety disorders, and a number of correlates were assessed with the WHO Composite International Diagnostic Interview (CIDI).


45.7% of respondents with lifetime MDD (32.0-46.5% inter-quartile range (IQR) across surveys) had one of more lifetime anxiety disorders. A slightly higher proportion of respondents with 12-month MDD had lifetime anxiety disorders (51.7%, 37.8-54.0% IQR) and only slightly lower proportions of respondents with 12-month MDD had 12-month anxiety disorders (41.6%, 29.9-47.2% IQR). Two-thirds (68%) of respondents with lifetime comorbid anxiety disorders and MDD reported an earlier age-of-onset (AOO) of their first anxiety disorder than their MDD, while 13.5% reported an earlier AOO of MDD and the remaining 18.5% reported the same AOO of both disorders. Women and previously married people had consistently elevated rates of lifetime and 12-month MDD as well as comorbid anxiety disorders. Consistently higher proportions of respondents with 12-month anxious than non-anxious MDD reported severe role impairment (64.4 v. 46.0%; χ 2 1 = 187.0, p < 0.001) and suicide ideation (19.5 v. 8.9%; χ 2 1 = 71.6, p < 0.001). Significantly more respondents with 12-month anxious than non-anxious MDD received treatment for their depression in the 12 months before interview, but this difference was more pronounced in high-income countries (68.8 v. 45.4%; χ 2 1 = 108.8, p < 0.001) than low/middle-income countries (30.3 v. 20.6%; χ 2 1 = 11.7, p < 0.001).


Patterns and correlates of comorbid DSM-IV anxiety disorders among people with DSM-IV MDD are similar across WMH countries. The narrow IQR of the proportion of respondents with temporally prior AOO of anxiety disorders than comorbid MDD (69.6-74.7%) is especially noteworthy. However, the fact that these proportions are not higher among respondents with 12-month than lifetime comorbidity means that temporal priority between lifetime anxiety disorders and MDD is not related to MDD persistence among people with anxious MDD. This, in turn, raises complex questions about the relative importance of temporally primary anxiety disorders as risk markers v. causal risk factors for subsequent MDD onset and persistence, including the possibility that anxiety disorders might primarily be risk markers for MDD onset and causal risk factors for MDD persistence.


Anxious depression; comorbidity; epidemiology

Conflict of interest statement

In the past three years, Dr. Kessler has been a consultant for Hoffman-La Roche, Inc., Johnson & Johnson Wellness and Prevention, and Sonofi-Aventis Groupe. Dr. Kessler has served on advisory boards for Mensante Corporation, Plus One Health Management, Lake Nona Institute, and U.S. Preventive Medicine. Dr. Kessler owns 25% share in DataStat, Inc. Dr. Wilcox is an employee of Janssen Pharmaceuticals.

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