Skip to main content

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

  • R. C. Kessler (a1), N. A. Sampson (a1), P. Berglund (a2), M. J. Gruber (a1), A. Al-Hamzawi (a3), L. Andrade (a4), B. Bunting (a5), K. Demyttenaere (a6), S. Florescu (a7), G. de Girolamo (a8), O. Gureje (a9), Y. He (a10), C. Hu (a11), Y. Huang (a12), E. Karam (a13) (a14) (a15), V. Kovess-Masfety (a16), S Lee (a17), D. Levinson (a18), M. E. Medina Mora (a19), J. Moskalewicz (a20), Y. Nakamura (a21), F. Navarro-Mateu (a22), M. A. Oakley Browne (a23), M. Piazza (a24), J. Posada-Villa (a25), T. Slade (a26), M. ten Have (a27), Y. Torres (a28), G. Vilagut (a29), M. Xavier (a30), Z. Zarkov (a31), V. Shahly (a1) and M. A. Wilcox (a32)...

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.

Corresponding author
* Address for correspondence: R. C. Kessler, Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115, USA. (Email:
Hide All
Altemus M, Sarvaiya N, Neill Epperson C (2014). Sex differences in anxiety and depression clinical perspectives. Frontiers in Neuroendocrinology 35, 320330.
Andrade L, Caraveo-Anduaga JJ, Berglund P, Bijl RV, Dragomericka E, Kohn R, Keller MB, Kessler RC, Kawakami N, Kilic C, D, O, Ustun TB, Vicente B, Wittchen H (2003). The epidemiology of major depressive episodes: results from the International Consortium of Psychiatric Epidemiology (ICPE) Surveys. International Journal of Methods in Psychiatric Research 12, 321.
Asselmann E, Wittchen HU, Lieb R, Hofler M, Beesdo-Baum K (2015). Danger and loss events and the incidence of anxiety and depressive disorders: a prospective-longitudinal community study of adolescents and young adults. Psychological Medicine 45, 153163.
Beesdo K, Pine DS, Lieb R, Wittchen HU (2010). Incidence and risk patterns of anxiety and depressive disorders and categorization of generalized anxiety disorder. Archives of General Psychiatry 67, 4757.
Bernert S, Matschinger H, Alonso J, Haro JM, Brugha TS, Angermeyer MC (2009). Is it always the same? Variability of depressive symptoms across six European countries. Psychiatry Research 168, 137144.
Birnbaum HG, Kessler RC, Kelley D, Ben-Hamadi R, Joish VN, Greenberg PE (2010). Employer burden of mild, moderate, and severe major depressive disorder: mental health services utilization and costs, and work performance. Depression and Anxiety 27, 7889.
Bittner A, Goodwin RD, Wittchen HU, Beesdo K, Hofler M, Lieb R (2004). What characteristics of primary anxiety disorders predict subsequent major depressive disorder? Journal of Clinical Psychiatry 65, 618626, quiz 730.
Copeland WE, Shanahan L, Costello EJ, Angold A (2009). Childhood and adolescent psychiatric disorders as predictors of young adult disorders. Archives of General Psychiatry 66, 764772.
Cuijpers P, Sijbrandij M, Koole S, Huibers M, Berking M, Andersson G (2014). Psychological treatment of generalized anxiety disorder: a meta-analysis. Clinical Psychology Review 34, 130140.
Cummings CM, Caporino NE, Kendall PC (2014). Comorbidity of anxiety and depression in children and adolescents: 20 years after. Psychological Bulletin 140, 816845.
de Graaf R, ten Have M, Tuithof M, van Dorsselaer S (2013). First-incidence of DSM-IV mood, anxiety and substance use disorders and its determinants: results from the Netherlands Mental Health Survey and Incidence Study-2. Journal of Affective Disorders 149, 100107.
Fichter MM, Quadflieg N, Fischer UC, Kohlboeck G (2010). Twenty-five-year course and outcome in anxiety and depression in the Upper Bavarian Longitudinal Community Study. Acta Psychiatrica Scandinavica 122, 7585.
Finlay-Jones R, Brown GW (1981). Types of stressful life event and the onset of anxiety and depressive disorders. Psychological Medicine 11, 803815.
First M, Spitzer R, Gibbon M, Williams J (2002). Structured Clinical Interview for DSM-IV Axis I Disorders, Research Version, Non-patient Edition (SCID-I/NP). Biometrics Research, New York State Psychiatric Institute: New York.
Flannery-Schroeder EC (2006). Reducing anxiety to prevent depression. American Journal of Preventive Medicine 31, S136S142.
Garber J, Weersing VR (2010). Comorbidity of anxiety and depression in youth: implications for treatment and prevention. Clinical Psychology: a Publication of the Division of Clinical Psychology of the American Psychological Association 17, 293306.
Goodwin R, Olfson M (2001). Treatment of panic attack and risk of major depressive disorder in the community. American Journal of Psychiatry 158, 11461148.
Goodwin RD, Gorman JM (2002). Psychopharmacologic treatment of generalized anxiety disorder and the risk of major depression. American Journal of Psychiatry 159, 19351937.
Hamdi NR, Iacono WG (2014). Lifetime prevalence and co-morbidity of externalizing disorders and depression in prospective assessment. Psychological Medicine 44, 315324.
Harkness J, Pennell BE, Villar A, Gebler N, Aguilar-Gaxiola S, Bilgen I (2008). Translation procedures and translation assessment in the World Mental Health Survey Initiative. In The WHO World Mental Health Surveys: Global Perspectives on the Epidemiology of Mental Disorders (ed. Kessler RC and Üstün TB), pp. 91113. Cambridge University Press: New York, NY.
Haro JM, Arbabzadeh-Bouchez S, Brugha TS, de Girolamo G, Guyer ME, Jin R, Lepine JP, Mazzi F, Reneses B, Vilagut G, Sampson NA, Kessler RC (2006). Concordance of the Composite International Diagnostic Interview Version 3.0 (CIDI 3.0) with standardized clinical assessments in the WHO World Mental Health surveys. International Journal of Methods in Psychiatric Research 15, 167180.
Hayward C, Varady S, Albano AM, Thienemann M, Henderson L, Schatzberg AF (2000). Cognitive-behavioral group therapy for social phobia in female adolescents: results of a pilot study. Journal of the American Academy of Child and Adolescent Psychiatry 39, 721726.
Heeringa S, Wells J, Hubbard F, Mneimneh Z, Chiu W, Sampson N (2008). Sample designs and sampling procedures. In The WHO World Mental Health Surveys: Global Perspectives on the Epidemiology of Mental Disorders (ed. Kessler RC and Üstün T), pp. 1432. Cambridge University Press: New York.
Hofmann SG, Smits JA (2008). Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. Journal of Clinical Psychiatry 69, 621632.
Jacobi F, Wittchen HU, Holting C, Hofler M, Pfister H, Muller N, Lieb R (2004). Prevalence, co-morbidity and correlates of mental disorders in the general population: results from the German Health Interview and Examination Survey (GHS). Psychological Medicine 34, 597611.
Jakubovski E, Bloch MH (2014). Prognostic subgroups for citalopram response in the STAR*D trial. Journal of Clinical Psychiatry 75, 738747.
Kelly JM, Jakubovski E, Bloch MH (2014). Prognostic subgroups for remission and response in the Coordinated Anxiety Learning and Management (CALM) trial. Journal of Clinical Psychiatry.
Kendler KS, Hettema JM, Butera F, Gardner CO, Prescott CA (2003). Life event dimensions of loss, humiliation, entrapment, and danger in the prediction of onsets of major depression and generalized anxiety. Archives of General Psychiatry 60, 789796.
Kessler RC (1995). Epidemiology of psychiatric comorbidity. In Textbook in Psychiatric Epidemiology (ed. Tsuang MT and Zahner GEP), p. 18. John Wiley & Sons, Inc: New York.
Kessler RC, Üstün TB (2004). The World Mental Health (WMH) Survey Initiative Version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). International Journal of Methods in Psychiatric Research 13, 93121.
Kessler RC, Keller MB, Wittchen HU (2001). The epidemiology of generalized anxiety disorder. Psychiatric Clinics of North America 24, 1939.
Kessler RC, Ormel J, Petukhova M, McLaughlin KA, Green JG, Russo LJ, Stein DJ, Zaslavsky AM, Aguilar-Gaxiola S, Alonso J, Andrade L, Benjet C, de Girolamo G, de Graaf R, Demyttenaere K, Fayyad J, Haro JM, Hu C, Karam A, Lee S, Lepine JP, Matchsinger H, Mihaescu-Pintia C, Posada-Villa J, Sagar R, Ustun TB (2011 a). Development of lifetime comorbidity in the World Health Organization world mental health surveys. Archives of General Psychiatry 68, 90100.
Kessler RC, Petukhova M, Zaslavsky AM (2011 b). The role of latent internalizing and externalizing predispositions in accounting for the development of comorbidity among common mental disorders. Current Opinions in Psychiatry 24, 307312.
Klein DN, Glenn CR, Kosty DB, Seeley JR, Rohde P, Lewinsohn PM (2013). Predictors of first lifetime onset of major depressive disorder in young adulthood. Journal of Abnormal Psychology 122, 16.
Knäuper B, Cannell CF, Schwarz N, Bruce ML, Kessler RC (1999). Improving accuracy of major depression age-of-onset reports in the US National Comorbidity Survey. International Journal of Methods in Psychiatric Research 8, 3948.
Lamers F, van Oppen P, Comijs HC, Smit JH, Spinhoven P, van Balkom AJ, Nolen WA, Zitman FG, Beekman AT, Penninx BW (2011). Comorbidity patterns of anxiety and depressive disorders in a large cohort study: the Netherlands Study of Depression and Anxiety (NESDA). Journal of Clinical Psychiatry 72, 341348.
Leach LS, Butterworth P, Olesen SC, Mackinnon A (2013). Relationship quality and levels of depression and anxiety in a large population-based survey. Social Psychiatry and Psychiatric Epidemiology 48, 417425.
Leon AC, Olfson M, Portera L, Farber L, Sheehan DV (1997). Assessing psychiatric impairment in primary care with the Sheehan Disability Scale. International Journal of Psychiatry in Medicine 27, 93105.
Li Y, Aggen S, Shi S, Gao J, Tao M, Zhang K, Wang X, Gao C, Yang L, Liu Y, Li K, Shi J, Wang G, Liu L, Zhang J, Du B, Jiang G, Shen J, Zhang Z, Liang W, Sun J, Hu J, Liu T, Miao G, Meng H, Hu C, Huang G, Li G, Ha B, Deng H, Mei Q, Zhong H, Gao S, Sang H, Zhang Y, Fang X, Yu F, Yang D, Chen Y, Hong X, Wu W, Chen G, Cai M, Song Y, Pan J, Dong J, Pan R, Zhang W, Shen Z, Liu Z, Gu D, Liu X, Zhang Q, Flint J, Kendler KS (2014). Subtypes of major depression: latent class analysis in depressed Han Chinese women. Psychological Medicine 44, 32753288.
Lin CH, Wang FC, Lin SC, Chen CC, Huang CJ (2014). A comparison of inpatients with anxious depression to those with nonanxious depression. Psychiatry Research 220, 855860.
Mathew AR, Pettit JW, Lewinsohn PM, Seeley JR, Roberts RE (2011). Co-morbidity between major depressive disorder and anxiety disorders: shared etiology or direct causation? Psychological Medicine 41, 20232034.
McDowell RD, Ryan A, Bunting BP, O'Neill SM, Alonso J, Bruffaerts R, de Graaf R, Florescu S, Vilagut G, de Almeida JM, de Girolamo G, Haro JM, Hinkov H, Kovess-Masfety V, Matschinger H, Tomov T (2014). Mood and anxiety disorders across the adult lifespan: a European perspective. Psychological Medicine 44, 707722.
McLaughlin TP, Khandker RK, Kruzikas DT, Tummala R (2006). Overlap of anxiety and depression in a managed care population: prevalence and association with resource utilization. Journal of Clinical Psychiatry 67, 11871193.
McLean PD, Woody S, Taylor S, Koch WJ (1998). Comorbid panic disorder and major depression: implications for cognitive-behavioral therapy. Journal of Consulting and Clinical Psychology 66, 240247.
Merikangas KR, Jin R, He JP, Kessler RC, Lee S, Sampson NA, Viana MC, Andrade LH, Hu C, Karam EG, Ladea M, Medina-Mora ME, Ono Y, Posada-Villa J, Sagar R, Wells JE, Zarkov Z (2011). Prevalence and correlates of bipolar spectrum disorder in the world mental health survey initiative. Archives of General Psychiatry 68, 241251.
Mineka S, Vrshek-Schallhorn S (2008). Comorbidity of unipolar depressive and anxiety disorders. In Handbook of Depression (ed. Gotlib IH and Hammen CL), pp. 84102. Guilford Press: New York.
Moffitt TE, Caspi A, Harrington H, Milne BJ, Melchior M, Goldberg D, Poulton R (2007). Generalized anxiety disorder and depression: childhood risk factors in a birth cohort followed to age 32. Psychological Medicine 37, 441452.
Moffitt TE, Caspi A, Taylor A, Kokaua J, Milne BJ, Polanczyk G, Poulton R (2010). How common are common mental disorders? Evidence that lifetime prevalence rates are doubled by prospective versus retrospective ascertainment. Psychological Medicine 40, 899909.
Murphy JM, Olivier DC, Sobol AM, Monson RR, Leighton AH (1986). Diagnosis and outcome: depression and anxiety in a general population. Psychological Medicine 16, 117126.
Ormel J, VonKorff M, Ustun TB, Pini S, Korten A, Oldehinkel T (1994). Common mental disorders and disability across cultures. Results from the WHO Collaborative Study on Psychological Problems in General Health Care. Journal of the American Medical Association 272, 17411748.
Ormel J, Petukhova M, Chatterji S, Aguilar-Gaxiola S, Alonso J, Angermeyer MC, Bromet EJ, Burger H, Demyttenaere K, de Girolamo G, Haro JM, Hwang I, Karam E, Kawakami N, Lepine JP, Medina-Mora ME, Posada-Villa J, Sampson N, Scott K, Ustun TB, Von Korff M, Williams DR, Zhang M, Kessler RC (2008). Disability and treatment of specific mental and physical disorders across the world. British Journal of Psychiatry 192, 368375.
Parker G, Brotchie H (2010). Gender differences in depression. International Review of Psychiatry 22, 429436.
Pennell B, Mneimneh Z, Bowers A, Chardoul S, Wells J, Viana M, Dinkelmann K, Gebler N, Florescu S, He Y, Huang Y, Tomov T, Vilagut G (2008). Implementation of the World Mental Health Surveys. In The WHO World Mental Health Surveys: Global Perspectives on the Epidemiology of Mental Disorders (ed. Kessler R and Ustun T), pp. 3357. Cambridge University Press: Cambridge, UK.
Rapee RM, Lyneham HJ, Hudson JL, Kangas M, Wuthrich VM, Schniering CA (2013). Effect of comorbidity on treatment of anxious children and adolescents: results from a large, combined sample. Journal of the American Academy of Child and Adolescent Psychiatry 52, 4756.
Research Triangle Institute (2002). SUDAAN: Professional Software for Survey Data Analysis [computer program]. Research Triangle Institute: Research Triangle Park, NC.
Roy-Byrne PP, Stang P, Wittchen HU, Ustun B, Walters EE, Kessler RC (2000). Lifetime panic-depression comorbidity in the National Comorbidity Survey. Association with symptoms, impairment, course and help-seeking. British Journal of Psychiatry 176, 229235.
Saveanu R, Etkin A, Duchemin AM, Goldstein-Piekarski A, Gyurak A, Debattista C, Schatzberg AF, Sood S, Day CV, Palmer DM, Rekshan WR, Gordon E, Rush AJ, Williams LM (2014). The International Study to Predict Optimized Treatment in Depression (iSPOT-D): outcomes from the acute phase of antidepressant treatment. Journal of Psychiatric Research.
Schrier AC, de Wit MA, Rijmen F, Tuinebreijer WC, Verhoeff AP, Kupka RW, Dekker J, Beekman AT (2010). Similarity in depressive symptom profile in a population-based study of migrants in the Netherlands. Social Psychiatry and Psychiatric Epidemiology 45, 941951.
Scott KM, Wells JE, Angermeyer M, Brugha TS, Bromet E, Demyttenaere K, de Girolamo G, Gureje O, Haro JM, Jin R, Karam AN, Kovess V, Lara C, Levinson D, Ormel J, Posada-Villa J, Sampson N, Takeshima T, Zhang M, Kessler RC (2010). Gender and the relationship between marital status and first onset of mood, anxiety and substance use disorders. Psychological Medicine 40, 14951505.
Shippee ND, Rosen BH, Angstman KB, Fuentes ME, DeJesus RS, Bruce SM, Williams MD (2014). Baseline screening tools as indicators for symptom outcomes and health services utilization in a collaborative care model for depression in primary care: a practice-based observational study. General Hospital Psychiatry 36, 563569.
Simon GE, Goldberg DP, Von Korff M, Ustun TB (2002). Understanding cross-national differences in depression prevalence. Psychological Medicine 32, 585594.
Stiles-Shields C, Kwasny MJ, Cai X, Mohr DC (2014). Comorbid anxiety as a differential treatment predictor for telephone versus face-to-face administered cognitive behavioral therapy for depression. Depression and Anxiety 31, 934940.
Takayanagi Y, Spira AP, Roth KB, Gallo JJ, Eaton WW, Mojtabai R (2014). Accuracy of reports of lifetime mental and physical disorders: results from the Baltimore Epidemiological Catchment Area study. JAMA Psychiatry 71, 273280.
van Loo HM, de Jonge P, Romeijn JW, Kessler RC, Schoevers RA (2012). Data-driven subtypes of major depressive disorder: a systematic review. BMC Medicine 10, 156.
Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, Shibuya K, Salomon JA, Abdalla S, Aboyans V et al. (2012). Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380, 21632196.
Wang PS, Aguilar-Gaxiola S, Alonso J, Angermeyer MC, Borges G, Bromet EJ, Bruffaerts R, de Girolamo G, de Graaf R, Gureje O, Haro JM, Karam EG, Kessler RC, Kovess V, Lane MC, Lee S, Levinson D, Ono Y, Petukhova M, Posada-Villa J, Seedat S, Wells JE (2007). Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys. Lancet 370, 841850.
Wolter KM (1985). Introduction to Variance Estimation. Springer-Verlag: New York, NY.
Woody S, McLean PD, Taylor S, Koch WJ (1999). Treatment of major depression in the context of panic disorder. Journal of Affective Disorders 53, 163174.
World Bank (2009). Data & Statistics, Country Groups by Income. From
Wu Z, Fang Y (2014). Comorbidity of depressive and anxiety disorders: challenges in diagnosis and assessment. Shanghai Arch Psychiatry 26, 227231.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Epidemiology and Psychiatric Sciences
  • ISSN: 2045-7960
  • EISSN: 2045-7979
  • URL: /core/journals/epidemiology-and-psychiatric-sciences
Please enter your name
Please enter a valid email address
Who would you like to send this to? *


Type Description Title
Supplementary materials

Kessler supplementary material
Appendix Tables 1-28

 Word (263 KB)
263 KB


Altmetric attention score

Full text views

Total number of HTML views: 27
Total number of PDF views: 233 *
Loading metrics...

Abstract views

Total abstract views: 996 *
Loading metrics...

* Views captured on Cambridge Core between September 2016 - 17th January 2018. This data will be updated every 24 hours.