Discussion

This research presented current data on the incidence, prevalence, YLDs, and age-standardised rates of anxiety disorders for the 21 MENA nations from 1990 to 2021. In 2021, anxiety disorders accounted for 37.8 million prevalent cases, 5.7 million incident cases, and 4.5 million YLDs. Furthermore, the incidence rate increased by 21.3%, and the age-standardised prevalence and YLD rates have risen by 20.3% since 1990. The age-standardised prevalence, incidence, and YLD rates were highest in Lebanon, Iran, and Tunisia. Conversely, the lowest age-standardised YLD rates were found in Yemen, Kuwait, and Qatar, while the lowest age-standardised prevalence rates were observed in Saudi Arabia, Kuwait, and Qatar. The lowest age-standardised incidence rates were seen in Qatar, Yemen, and Kuwait. Furthermore, the burden related to anxiety disorders increased up to the 15–19 age group, after which it declined with age, with women bearing a consistently greater burden. Additionally, the MENA region exhibited higher YLD rates due to anxiety disorders across most age groups when compared to the global average. Lastly, the analysis revealed no clear association between SDI and the burden of anxiety disorders.

A number of researchers have rigorously investigated the global burden of anxiety disorders (Xiong et al., Reference Xiong, Liu, Liu and Hall2022, Baxter et al., Reference Baxter, Vos, Scott, Ferrari and Whiteford2014, Yang et al., Reference Yang, Fang, Chen, Zhang, Yin, Man, Yang and Lu2021). In addition, several national and international studies have offered estimates of the burden of mental disorders, including anxiety disorders (Baxter et al., Reference Baxter, Charlson, Cheng, Shidhaye, Ferrari and Whiteford2016, Chen et al., Reference Chen, Huang, Xu, Peng, Wang, Li, Zhao, Shi, Zhang, Shi, Peng and Tang2024, Charara et al., Reference Charara, Forouzanfar, Naghavi, Moradi-Lakeh, Afshin, Vos, Daoud, Wang, El Bcheraoui, Khalil, Hamadeh, Khosravi, Rahimi-Movaghar, Khader, Al-Hamad, Makhlouf Obermeyer, Rafay, Asghar, Rana, Shaheen, Abu-Rmeileh, Husseini, Abu-Raddad, Khoja, Al Rayess, AlBuhairan, Hsairi, Alomari, Ali, Roshandel, Terkawi, Hamidi, Refaat, Westerman, Kiadaliri, Akanda, Ali, Bacha, Badawi, Bazargan-Hejazi, Faghmous, Fereshtehnejad, Fischer, Jonas, Kuate Defo, Mehari, Omer, Pourmalek, Uthman, Mokdad, Maalouf, Abd-Allah, Akseer, Arya, Borschmann, Brazinova, Brugha, Catalá-López, Degenhardt, Ferrari, Haro, Horino, Hornberger, Huang, Kieling, Kim, Kim, Knudsen, Mitchell, Patton, Sagar, Satpathy, Savuon, Seedat, Shiue, Skogen, Stein, Tabb, Whiteford, Yip and Mokdad2017, Iovu & Breaz, Reference Iovu and Breaz2019, Ciobanu et al., Reference Ciobanu, Ferrari, Erskine, Santomauro, Charlson, Leung, Amare, Olagunju, Whiteford and Baune2018, Bonadiman et al., Reference Bonadiman, Passos, Mooney, Naghavi and Melo2017, Rehm & Shield, Reference Rehm and Shield2019, Charara et al., Reference Charara, Forouzanfar, Naghavi, Moradi-Lakeh, Afshin, Vos, Daoud, Wang, El Bcheraoui, Khalil, Hamadeh, Khosravi, Rahimi-Movaghar, Khader, Al-Hamad, Makhlouf Obermeyer, Rafay, Asghar, Rana, Shaheen, Abu-Rmeileh, Husseini, Abu-Raddad, Khoja, Al Rayess, AlBuhairan, Hsairi, Alomari, Ali, Roshandel, Terkawi, Hamidi, Refaat, Westerman, Kiadaliri, Akanda, Ali, Bacha, Badawi, Bazargan-Hejazi, Faghmous, Fereshtehnejad, Fischer, Jonas, Kuate Defo, Mehari, Omer, Pourmalek, Uthman, Mokdad, Maalouf, Abd-Allah, Akseer, Arya, Borschmann, Brazinova, Brugha, Catalá-López, Degenhardt, Ferrari, Haro, Horino, Hornberger, Huang, Kieling, Kim, Kim, Knudsen, Mitchell, Patton, Sagar, Satpathy, Savuon, Seedat, Shiue, Skogen, Stein, Tabb, Whiteford, Yip and Mokdad2017, Castelpietra et al., Reference Castelpietra, Knudsen, Agardh, Armocida, Beghi, Iburg, Logroscino, Ma, Starace, Steel, Addolorato, Andrei, Andrei, Ayuso-Mateos, Banach, Bärnighausen, Barone-Adesi, Bhagavathula, Carvalho, Carvalho, Chandan, Chattu, Couto, Cruz-Martins, Dargan, Deuba, Da Silva, Fagbamigbe, Fernandes, Ferrara, Fischer, Gaal, Gialluisi, Haagsma, Haro, Hasan, Hasan, Hostiuc, Iacoviello, Iavicoli, Jamshidi, Jonas, Joo, Jozwiak, Katikireddi, Kauppila, Khan, Kisa, Kisa, Kivimäki, Koly, Koyanagi, Kumar, Lallukka, Langguth, Ledda, Lee, Lega, Linehan, Loureiro, Madureira-Carvalho, Martinez-Raga, Mathur, McGrath, Mechili, Mentis, Mestrovic, Miazgowski, Mirica, Mirijello, Moazen, Mohammed, Mulita, Nagel, Negoi, Negoi, Nwatah, Padron-Monedero, Panda-Jonas, Pardhan, Pasovic, Patel, Petcu, Pinheiro, Pollok, Postma, Rawaf, Rawaf, Romero-Rodríguez, Ronfani and Sagoe2022, Ferrari et al., Reference Ferrari, Santomauro, Herrera, Shadid, Ashbaugh, Erskine, Charlson, Degenhardt, Scott, McGrath and Allebeck2022, Hong et al., Reference Hong, Liu, Gao, Jin, Shi, Liang, Maimaitiming, Ning and Luo2022, Whiteford et al., Reference Whiteford, Ferrari, Degenhardt, Feigin, Vos and Forloni2015). In contrast, only one previous study has documented the burden of mental disorders in the MENA region (Effatpanah et al., Reference Effatpanah, Nakhostin-Ansari, Gorgani, Khotbehsara, Seifi, Nasoori, Memari and Darijani2024). However, this study is now outdated, particularly due to the fact that the recent COVID-19 pandemic significantly affected mental health.

In 2019, global age-standardised rates of anxiety disorders were estimated to be 3779.5, 585, and 360 per 100,000, for prevalence, incidence, and DALYs, respectively (Yang et al., Reference Yang, Fang, Chen, Zhang, Yin, Man, Yang and Lu2021, 2022). In MENA, these rates were 5135.7, 783, and 492 per 100000, respectively (Yang et al., Reference Yang, Fang, Chen, Zhang, Yin, Man, Yang and Lu2021, Ferrari et al., Reference Ferrari, Santomauro, Herrera, Shadid, Ashbaugh, Erskine, Charlson, Degenhardt, Scott, McGrath and Allebeck2022). According to the current study’s results, the MENA region had a higher burden of anxiety disorders, although the estimated prevalence and incidence rates are quite similar to previous studies. This may have been influenced by the 2020 COVID-19 pandemic, which increased the burden of anxiety disorders. A previously released study reported that the COVID-19 pandemic caused an extra 1664.8 cases of anxiety disorders per 100,000 people in 2020, representing a 32.4% increase (2021). In the MENA region, the estimated prevalence of anxiety disorders was 5148.9 per 100,000 population prior to the pandemic. After adjusting for the pandemic, the prevalence in 2020 was 6813.6 per 100,000 (2021). During the pandemic, quarantine measures played a significant role in contributing to the burden of COVID-19–related anxiety disorders. It has been demonstrated that quarantine has a major psychological impact, especially on hospital employees and those who are impacted. A study revealed that quarantine was the most significant predictor of acute stress symptoms immediately following the event, with personnel experiencing weariness, alienation, worry, irritability, sleeplessness, decreased job performance, and even contemplating resignation (Bai et al., Reference Bai, Lin, Lin, Chen, Chue and Chou2004). Quarantine measures were associated with persistent mental health consequences, with hospital staff showing elevated rates of depression and PTSD symptoms that endured for up to three years later (Wu et al., Reference Wu, Fang, Guan, Fan, Kong, Yao, Liu, Fuller, Susser, Lu and Hoven2009). Comparative analyses revealed quarantined children had post-traumatic stress scores that were four times higher than those of non-quarantined peers. Among parents, 28% of those quarantined met the diagnostic criteria for trauma-related mental health disorders versus 6% of non-quarantined controls (Sprang & Silman, Reference Sprang and Silman2013).

During quarantine, insufficient access to essential resources such as food, water, clothes, and shelter was a major cause of dissatisfaction and correlated with heightened anxiety and anger, enduring for months after the quarantine period (Blendon et al., Reference Blendon, Benson, DesRoches, Raleigh and Taylor‐Clark2004, Wilken et al., Reference Wilken, Pordell, Goode, Jarteh, Miller, Saygar, Maximore, Borbor, Carmue, Walker and Yeiah2017, Jeong et al., Reference Jeong, Yim, Song, Ki, Min, Cho and Chae2016). Moreover, interruptions in standard medical care exacerbated these challenges (Blendon et al., Reference Blendon, Benson, DesRoches, Raleigh and Taylor‐Clark2004). A key obstacle was the financial cost of quarantine, since those who were unable to work experienced severe socioeconomic hardship (Pellecchia et al., Reference Pellecchia, Crestani, Decroo, Van den Bergh, Al-Kourdi and Braunstein2015). Long after the quarantine was over, this financial burden continued to be a risk factor for psychiatric problems, showing up as increased anxiety and anger (Mihashi et al., Reference Mihashi, Otsubo, Yinjuan, Nagatomi, Hoshiko and Ishitake2009, Jeong et al., Reference Jeong, Yim, Song, Ki, Min, Cho and Chae2016). Individuals with lower household incomes had elevated levels of post-traumatic stress and depressive symptoms, possibly attributable to their increased susceptibility to income loss (Hawryluck et al., Reference Hawryluck, Gold, Robinson, Pogorski, Galea and Styra2004). Targeted economic interventions are needed to mitigate the mental health burden of quarantine, particularly through financial reimbursements and structured assistance programmes for low-income households (Brooks et al., Reference Brooks, Webster, Smith, Woodland, Wessely, Greenberg and Rubin2020).

The stigma attached to quarantine was another persistent problem; those who were placed under quarantine frequently experienced rejection and social exclusion (Bai et al., Reference Bai, Lin, Lin, Chen, Chue and Chou2004, Brooks et al., Reference Brooks, Webster, Smith, Woodland, Wessely, Greenberg and Rubin2020). One of the most important steps in reducing stigma is to educate the public about the illness and the need for quarantine, as well as to give schools and workplaces relevant information (Brooks et al., Reference Brooks, Webster, Smith, Woodland, Wessely, Greenberg and Rubin2020). These findings underscore the extensive and enduring mental health effects of quarantine restrictions during the COVID-19 outbreak.

Additionally, consistent with our findings, extensive research has shown that women experience higher prevalence, incidence, and YLD rates of anxiety disorders compared to men (Yang et al., Reference Yang, Fang, Chen, Zhang, Yin, Man, Yang and Lu2021, Whiteford et al., Reference Whiteford, Ferrari, Degenhardt, Feigin, Vos and Forloni2015, Hong et al., Reference Hong, Liu, Gao, Jin, Shi, Liang, Maimaitiming, Ning and Luo2022, Baxter et al., Reference Baxter, Vos, Scott, Ferrari and Whiteford2014, Kumar et al., Reference Kumar, Njuguna, Amin, Kanana, Tele, Karanja, Omar, Yator, Wambugu, Bukusi and Weaver2024, McLean et al., Reference McLean, Asnaani, Litz and Hofmann2011). According to McLean et al., one in three women will meet the criteria for an anxiety disorder at some point in their lives, compared to 22% of men (McLean et al., Reference McLean, Asnaani, Litz and Hofmann2011). Their study found that women had lifetime and past-year rates of anxiety disorder that were 1.5 to 2 times higher than those of men (McLean et al., Reference McLean, Asnaani, Litz and Hofmann2011). Gender socialisation plays a role in shaping the psychosocial traits that serve as risk factors for women and protective factors for men in the initiation and progression of anxiety (Leach et al., Reference Leach, Christensen, Mackinnon, Windsor and Butterworth2008, Seedat et al., Reference Seedat, Scott, Angermeyer, Berglund, Bromet, Brugha, Demyttenaere, de Girolamo, Haro, Jin, Karam, Kovess-Masfety, Levinson, Medina Mora, Ono, Ormel, Pennell, Posada-Villa, Sampson, Williams and Kessler2009, Stoyanova & Hope, Reference Stoyanova and Hope2012, Zalta & Chambless, Reference Zalta and Chambless2012, McLean & Anderson, Reference McLean and Anderson2009). In addition, anxiety issues may be exacerbated by the inferior living conditions experienced by women. Studies have indicated that one of the main obstacles to improving women’s health is the social environment, which includes the market economy, beauty standards, sexual division of labour, and environmental degradation (Sánchez, Reference Sánchez2018). Socioeconomic crises, such as the one following the COVID-19 pandemic, have the potential to exacerbate these issues. As previously mentioned, the COVID-19 pandemic led to an increase in the prevalence and disease burden of anxiety disorders, with women experiencing this rise at a significantly higher rate than men (2021). One plausible explanation is that women are disproportionately affected by adverse social and economic effects (Hupkau & Petrongolo, Reference Hupkau and Petrongolo2020, Women, Reference Women2020, Wenham et al., Reference Wenham, Smith, Davies, Feng, Grépin, Harman, Herten-Crabb and Morgan2020, Burki, Reference Burki2020). They were more likely to assume additional caregiving and household responsibilities due to sick family members or school closures (Women, Reference Women2020). Women faced greater financial hardship during the pandemic, primarily due to lower wages, smaller financial reserves, and more unstable employment compared to men (Women, Reference Women2020, Wenham et al., Reference Wenham, Smith, Davies, Feng, Grépin, Harman, Herten-Crabb and Morgan2020, Burki, Reference Burki2020). Furthermore, women faced a higher risk of becoming targets of domestic violence, a problem that intensified during lockdowns and stay-at-home mandates (Piquero et al., Reference Piquero, Jennings, Jemison, Kaukinen and Knaul2021, Arenas-Arroyo et al., Reference Arenas-Arroyo, Fernandez-Kranz and Nollenberger2021). The financial crisis of 2009 and other socioeconomic strains have been shown to significantly influence the exacerbation of mental illnesses, including anxiety disorders (Frasquilho et al., Reference Frasquilho, Matos, Salonna, Guerreiro, Storti, Gaspar and Caldas-de-Almeida2016, Economou et al., Reference Economou, Madianos, Peppou, Patelakis and Stefanis2013). Hence, social safety nets and support programmes that help those facing financial hardships can be implemented by policymakers. The reduction of economic stressors that contribute to anxiety disorders could be achieved by implementing these measures, which could also promote mental well-being in the community.

Genetic and neurobiological factors, alongside psychosocial factors, have been explored as potential reasons for the increased incidence of anxiety disorders among women. Fluctuations in sex hormones that affect women’s anxiety (Li & Graham, Reference Li and Graham2017, Hodes & Epperson, Reference Hodes and Epperson2019, Donner & Lowry, Reference Donner and Lowry2013, Day & Stevenson, Reference Day and Stevenson2020, McLean et al., Reference McLean, Asnaani, Litz and Hofmann2011, Lungu et al., Reference Lungu, Potvin, Tikàsz and Mendrek2015), genetic factors (Merikangas & Almasy, Reference Merikangas and Almasy2020, Donner & Lowry, Reference Donner and Lowry2013, Brivio et al., Reference Brivio, Lopez and Chen2020, Palma-Gudiel et al., Reference Palma-Gudiel, Peralta, Deuschle, Navarro and Fañanás2019, Burton et al., Reference Burton, Williams, Richard Clark, Harris, Schofield and Gatt2015, Ask et al., Reference Ask, Torgersen, Seglem and Waaktaar2014), and differences in brain structures related to emotional regulation – which influence how negative information is processed (Cerasa et al., Reference Cerasa, Quattrone, Piras, Mangone, Magariello, Fagioli, Girardi, Muglia, Caltagirone and Spalletta2014, Gardener et al., Reference Gardener, Carr, MacGregor, Felmingham and Gray2013, Kaczkurkin et al., Reference Kaczkurkin, Raznahan and Satterthwaite2019) – are all considered potential contributors to this gender disparity.

Nevertheless, although men appear to exhibit lower levels of anxiety, some experts warn that this interpretation may be biased. According to a recent systematic review on anxiety in males, men generally prefer to rely on themselves rather than seek assistance when managing anxiety (Fisher et al., Reference Fisher, Seidler, King, Oliffe and Rice2021). This tendency aligns with masculine gender norms. Men’s anxiety has also been linked to other potential risk factors, such as mistrust of receiving assistance, a lack of awareness of anxiety, and limited means for seeking treatment (Clark et al., Reference Clark, Hudson, Dunstan and Clark2018).

The MENA region had higher age-standardised prevalence, incidence, and YLD rates of anxiety disorders than the global averages, as previously mentioned. This discrepancy can be attributed to several factors. Firstly, varying attitudes towards mental illness across countries can foster a reluctance to recognise symptoms of psychiatric disorders (Andrade et al., Reference Andrade, Alonso, Mneimneh, Wells, Al-Hamzawi, Borges, Bromet, Bruffaerts, de Girolamo, de Graaf, Florescu, Gureje, Hinkov, Hu, Huang, Hwang, Jin, Karam, Kovess-Masfety, Levinson, Matschinger, O’Neill, Posada-Villa, Sagar, Sampson, Sasu, Stein, Takeshima, Viana, Xavier and Kessler2014). This challenge is especially acute for anxiety disorders, as their symptoms can be profoundly embarrassing (Sorsdahl et al., Reference Sorsdahl, Kakuma, Wilson and Stein2012). Furthermore, mental illnesses may manifest and be experienced differently in various settings, and survey questions might not adequately account for this heterogeneity (Lewis-Fernández et al., Reference Lewis-Fernández, Hinton, Laria, Patterson, Hofmann, Craske, Stein, Asnaani and Liao2010). In specific contexts where emotional reactions like anxiety play an adaptive role, it can be particularly difficult to differentiate between a pathological disorder and normal distress (Nesse & Stein, Reference Nesse and Stein2012). Additionally, the use of diagnostic interviews in epidemiological surveys can be undermined by poorly formulated questions, potentially introducing substantial biases that vary across nations (Stein et al., Reference Stein, Scott, de Jonge and Kessler2017). Moreover, there may be significant variations in prevalence estimates due to country-specific differences in survey field settings, such as sampling, quality control and the level of interviewer training. Finally, as risk and resilience factors vary significantly between geographic regions, there may be true variations in the frequency of mental illnesses among nations (Stein et al., Reference Stein, Scott, de Jonge and Kessler2017). In order to address this issue, the establishment of a regional mental health research and surveillance network across MENA countries would represent a transformative approach to addressing this growing public health challenge. This network would deliver essential data, encourage evidence-based interventions, and enhance collaboration among nations, eventually improving mental health outcomes for individuals in the region.

Compelling global evidence establishes adverse childhood experiences – particularly sexual abuse, bullying victimisation, and exposure to violence – as significant risk factors for anxiety disorders across sexes (Bauer et al., Reference Bauer, Herrenkohl, Lozano, Rivara, Hill and Hawkins2006, Bell et al., Reference Bell, Méndez, Martínez, Palma and Bosch2012, Blanco et al., 2014). In the Middle East, the estimated prevalence of intimate partner abuse is approximately 26.3%, with the most common form being psychological abuse (Moshtagh et al., Reference Moshtagh, Amiri, Sharafi and Arab-Zozani2023). Furthermore, MENA is the region with the highest rates of violence and armed conflict in the world (Sørli et al., Reference Sørli, Gleditsch and Strand2005). It is also among the three regions with the highest burden of mental disorders, including anxiety disorder, linked to bullying victimisation (Hong et al., Reference Hong, Liu, Gao, Jin, Shi, Liang, Maimaitiming, Ning and Luo2022). These findings may partially explain the high burden of anxiety disorders in MENA.

Compared to other MENA nations, Lebanon, Tunisia, and Iran had significantly higher age-standardised incidence, prevalence, and YLD rates for anxiety disorders in 2021. This finding aligns with earlier research on the burden of mental disorders in the region, which identified Palestine, Iran, and Lebanon as having the highest rates (Effatpanah et al., Reference Effatpanah, Nakhostin-Ansari, Gorgani, Khotbehsara, Seifi, Nasoori, Memari and Darijani2024). Several explanations exist for these elevated rates. For instance, as previously mentioned, childhood sexual abuse is a factor that influences anxiety disorders. However, regional level research on the prevalence of child sexual abuse is lacking. Studies conducted in Lebanon have shown that the incidence of such abuse is between 17% and 24%, which is high (Usta & Farver, Reference Usta and Farver2010, El Khoury et al., Reference El Khoury, Mutchler, Abi Ghanem, Kegeles, Ballan, Mokhbat and Wagner2021). The socioeconomic crises in these countries are another reason for these high rates. For instance, since 2019, Lebanon has seen a devastating economic collapse characterised by hyperinflation, currency devaluation, and rampant unemployment, resulting in most people living in poverty (Guеchаti & Chаmi, Reference Guеchаti and Chаmi2022, Youssef, Reference Youssef2020, Daher, Reference Daher2022). The economic decline has resulted in people and families struggling to fulfil fundamental necessities, exacerbating emotions of fear and pessimism that lead to anxiety disorders. An atmosphere of constant tension is produced by the financial burden combined with sporadic fuel, power, and healthcare shortages (Guеchаti & Chаmi, Reference Guеchаti and Chаmi2022, Youssef, Reference Youssef2020, Daher, Reference Daher2022). In Tunisia, inflation, deteriorating government services, and ongoing unemployment – especially among youth – are key contributors to rising anxiety levels (Matta et al., Reference Matta, Appleton and Bleaney2019, Achy, Reference Achy2011, Ayadi & Mattoussi, Reference Ayadi and Mattoussi2014). The population’s anxiety has been exacerbated by these economic stressors, as well as public discontent over unfulfilled assurances of prosperity following the Arab Spring (Matta et al., Reference Matta, Appleton and Bleaney2019, Achy, Reference Achy2011, Ayadi & Mattoussi, Reference Ayadi and Mattoussi2014).

Furthermore, Iran is the world’s second most sanctioned nation, after Russia (Forbes.ge & Forbes.ge, 2024). The sanctions imposed on the country have significantly impacted both Iran’s economy and the mental health of its people (Aloosh et al., Reference Aloosh, Salavati and Aloosh2019). The limitations on access to essential goods, healthcare, and services have led to widespread anxiety, helplessness, and elevated stress levels among Iranians. Inflation and job losses caused by the economic burden exacerbate feelings of fear and hopelessness in families and communities (Aloosh et al., Reference Aloosh, Salavati and Aloosh2019). There is substantial evidence that unemployment, another consequence of sanctions (Aloosh et al., Reference Aloosh, Salavati and Aloosh2019), increases the likelihood of developing and progressing psychiatric problems, particularly anxiety and depression disorders (Zhang & Bhavsar, Reference Zhang and Bhavsar2013, Paul & Moser, Reference Paul and Moser2009). However, reverse causation is also possible, whereby existing psychiatric conditions may increase the risk of unemployment. For instance, Mojtabi et al., demonstrated that individuals with a mental illness were more likely to experience future unemployment (Mojtabai et al., Reference Mojtabai, Stuart, Hwang, Susukida, Eaton, Sampson and Kessler2015). Political unrest, unstable economies, and cultural elements are all closely linked to mental health issues in high-burden areas like the MENA region. Resolving these issues necessitates focused, interdisciplinary strategies that integrate health, education, and social support frameworks. For the purpose of creating strong and culturally aware care systems, research on the long-term psychological effects of displacement and conflict is especially important. Cooperative initiatives across governments, NGOs, and international organisations are crucial for establishing sustainable mental health infrastructure, providing both enduring remedies and avenues for resilience and hope for communities experiencing chronic stress.

Saudi Arabia, Kuwait, and Qatar recorded the lowest age-standardised prevalence rates. A study conducted between 2014 and 2016 in Saudi Arabia assessed the lifetime prevalence of mental disorders among youth and adolescents (Altwaijri et al., Reference Altwaijri, Kazdin, Al-Subaie, Al-Habeeb, Hyder, Bilal, Naseem and De Vol2023). Their study found that the lifetime prevalence of anxiety disorders was approximately 26.9%, which is significantly higher than our findings (Altwaijri et al., Reference Altwaijri, Kazdin, Al-Subaie, Al-Habeeb, Hyder, Bilal, Naseem and De Vol2023). This discrepancy may be attributed to the Saudi study’s focus on a limited participant population of young adults and adolescents (Altwaijri et al., Reference Altwaijri, Kazdin, Al-Subaie, Al-Habeeb, Hyder, Bilal, Naseem and De Vol2023). It is widely recognised that younger individuals exhibit a higher incidence of anxiety disorders. In a study by Kroenke et al., 19.5% of the 965 randomly sampled patients attending clinics in the US were found to have at least one anxiety disorder (29). Their study collected data using the PHQ-15 somatic symptom scale, 10-item anxiety subscale from the Hopkins Symptom Checklist, Medical Outcomes Study Short Form-20 (SF-20), 3-item version of the Social Phobia Inventory (Mini-SPIN), 5-item PHQ panic module, PHQ-8 depression scale, and GAD-7 (29). The higher prevalence reported in their study, compared to ours, may be due to their non-random sampling of patients from certain primary care clinics, which may have inflated the frequency of anxiety disorders due to the over-representation among frequent clinic attendees (29).

Research conducted in the United States has demonstrated that mental and functional health decline with poverty and low socioeconomic status (Charara et al., Reference Charara, El Bcheraoui, Kravitz, Dhingra and Mokdad2016, Strine et al., Reference Strine, Lesesne, Okoro, McGuire, Chapman, Balluz and Mokdad2006, Li et al., Reference Li, Barker, Ford, Zhang, Strine and Mokdad2008, Li et al., Reference Li, Ford, Zhao, Ahluwalia, Pearson and Mokdad2009, Strine et al., Reference Strine, Chapman, Kobau, Balluz and Mokdad2004). Higher-income nations tend to have more stable lifestyles than lower-income nations, which enables their citizens to better address their mental health needs during difficult or emergency situations (Charara et al., Reference Charara, Forouzanfar, Naghavi, Moradi-Lakeh, Afshin, Vos, Daoud, Wang, El Bcheraoui, Khalil, Hamadeh, Khosravi, Rahimi-Movaghar, Khader, Al-Hamad, Makhlouf Obermeyer, Rafay, Asghar, Rana, Shaheen, Abu-Rmeileh, Husseini, Abu-Raddad, Khoja, Al Rayess, AlBuhairan, Hsairi, Alomari, Ali, Roshandel, Terkawi, Hamidi, Refaat, Westerman, Kiadaliri, Akanda, Ali, Bacha, Badawi, Bazargan-Hejazi, Faghmous, Fereshtehnejad, Fischer, Jonas, Kuate Defo, Mehari, Omer, Pourmalek, Uthman, Mokdad, Maalouf, Abd-Allah, Akseer, Arya, Borschmann, Brazinova, Brugha, Catalá-López, Degenhardt, Ferrari, Haro, Horino, Hornberger, Huang, Kieling, Kim, Kim, Knudsen, Mitchell, Patton, Sagar, Satpathy, Savuon, Seedat, Shiue, Skogen, Stein, Tabb, Whiteford, Yip and Mokdad2017). This stability could explain the lower rates of anxiety observed in the region’s countries with a higher SDI. The higher-than-expected burdens of anxiety disorders in some countries, even with their high SDI scores, could be due to the stigma-induced under-reporting, which can conceal the true extent of these disorders. Moreover, mental health burdens may be excessively affected by factors that are not directly included in the SDI, like conflict, displacement, economic instability, or climate change. This is particularly evident in certain MENA countries, where these stressors are prevalent and may exacerbate the mental health challenges faced by the population.

Our findings indicate that the incidence of anxiety disorders increased between 1990 and 2021 in most age groups, which is consistent with previous research (Vasiliadis et al., Reference Vasiliadis, Dionne, Préville, Gentil, Berbiche and Latimer2013, Yang et al., Reference Yang, Fang, Chen, Zhang, Yin, Man, Yang and Lu2021). Additionally, the incidence rate peaked in the 10 to 14 age range. This could be linked to various factors such as low socioeconomic status, childhood abuse, corporal punishment, an overly protective or harsh parenting style, increased self-consciousness, and increased opposition to parents (Vachon et al., Reference Vachon, Krueger, Rogosch and Cicchetti2015, Clauss & Blackford, Reference Clauss and Blackford2012, Moreno-Peral et al., Reference Moreno-Peral, Conejo-Cerón, Motrico, Rodríguez-Morejón, Fernández, García-Campayo, Roca, Serrano-Blanco, Rubio-Valera and Ángel Bellón2014, Beesdo-Baum & Knappe, Reference Beesdo-Baum and Knappe2012). It is important to recognise that many anxiety disorders begin early, often serving as predictors of later psychopathology. These disorders typically onset in childhood and adolescence and tend to decline with age. Consequently, identifying at-risk individuals and implementing interventions during early life stages are crucial considerations for effective treatment, as with increasing age, rigid cognitive and behavioural patterns become ingrained and often the failure to respond to treatment stems from these entrenched behaviour patterns, which are challenging to reverse (Baxter et al., Reference Baxter, Vos, Scott, Ferrari and Whiteford2014, Craske & Stein, Reference Craske and Stein2016, Grenier et al., Reference Grenier, Payette, Gunther, Askari, Desjardins, Raymond and Berbiche2019, Solmi et al., Reference Solmi, Radua, Olivola, Croce, Soardo, Salazar de Pablo, Il Shin, Kirkbride, Jones, Kim, Kim, Carvalho, Seeman, Correll and Fusar-Poli2022, Donovan & Spence, Reference Donovan and Spence2000, Craske & Zucker, Reference Craske and Zucker2001). Moreover, mental health treatment services are frequently inaccessible or unavailable to many young people with mental health disorders. This demographic can be reached in a natural and accessible way by using the school system as the setting for prevention programmes (Gulliver et al., Reference Gulliver, Griffiths, Christensen and Brewer2012). Therefore, the implementation of mental health education targeted at certain demographics, such as school students, can be cost-effective. Additionally, there is a promising potential for advancing and refining multi-channel interventions and treatments, including mental health mobile applications, internet- and telephone-based helplines, and film-based education (Holmes et al., Reference Holmes, Ghaderi, Harmer, Ramchandani, Cuijpers, Morrison, Roiser, Bockting, O’Connor, Shafran, Moulds and Craske2018, Kang et al., Reference Kang, Wang, Li, Tao, Yang, Deng, Yu, Zhou, Li and Guo2021, White et al., Reference White, Linardon, Stone, Holmes-Truscott, Olive, Mikocka-Walus, Hendrieckx, Evans and Speight2022, Goodwin et al., Reference Goodwin, Saab, Dillon, Kilty, McCarthy, O’Brien and Philpott2021).

The aetiology of anxiety disorders remains a topic of debate. An overprotective parenting style, low socioeconomic status, and a parental history of mental illness are some characteristics that are thought to be linked to an elevated risk of anxiety disorders (Beesdo-Baum & Knappe, Reference Beesdo-Baum and Knappe2012, Moreno-Peral et al., Reference Moreno-Peral, Conejo-Cerón, Motrico, Rodríguez-Morejón, Fernández, García-Campayo, Roca, Serrano-Blanco, Rubio-Valera and Ángel Bellón2014). Research in genetic epidemiology indicates that anxiety disorders display a moderate level of familial aggregation, with heritability estimated at 30–50% (Beesdo-Baum & Knappe, Reference Beesdo-Baum and Knappe2012). Moreover, there is strong evidence linking bullying victimisation to anxiety (Jadambaa et al., Reference Jadambaa, Thomas, Scott, Graves, Brain and Pacella2019). Notably, the prevalence of school bullying has been increasing, becoming a widespread issue that affects the physical and mental well-being of children and adolescents (Juvonen & Graham, Reference Juvonen and Graham2014).

With population growth, there will likely be an increased demand for healthcare services. Furthermore, anxiety disorders can lead to significant waste of medical resources and impose a substantial burden on society and the economy, as they often develop into chronic conditions and recur in a fluctuating pattern throughout life if left untreated (Kessler et al., Reference Kessler, Ruscio, Shear and Wittchen2010). Early prevention is expected to mitigate the functional deficits associated with anxiety disorders, making it highly cost-effective (Baxter et al., Reference Baxter, Vos, Scott, Ferrari and Whiteford2014). This is particularly important in low- and middle-income nations, where providing appropriate care and treatment to the expanding population is critical (Hudson, Reference Hudson2005). Robust intervention methods exist for mental disorders, providing significant potential to substantially mitigate the burden these conditions impose (Reichenberg & Seligman, Reference Reichenberg and Seligman2016). These treatments may decrease the risk of death, improve recovery chances, and lower symptom intensity (Belvederi Murri et al., Reference Belvederi Murri, Ekkekakis, Magagnoli, Zampogna, Cattedra, Capobianco, Serafini, Calcagno, Zanetidou and Amore2018, Fusar-Poli et al., Reference Fusar‐Poli, McGorry and Kane2017). Unfortunately, significant barriers to accessing these services exist worldwide, and there is insufficient funding to support their expansion. Moreover, obstacles to care include the stigma attached to mental health conditions and the belief that one does not need treatment (Patel et al., Reference Patel, Chisholm, Parikh, Charlson, Degenhardt, Dua, Ferrari, Hyman, Laxminarayan, Levin, Lund, Medina Mora, Petersen, Scott, Shidhaye, Vijayakumar, Thornicroft and Whiteford2016, Coombs et al., Reference Coombs, Meriwether, Caringi and Newcomer2021).

Policymakers should urgently address the growing burden of mental disorders in the MENA region by ensuring the provision of sufficient facilities for the treatment and care of people with conditions like anxiety disorders. This is particularly crucial given the region’s inadequate infrastructure, limited services, and gaps in insurance coverage. Resolving these problems by increasing the number of mental health professionals, providing telehealth services, and subsidising mental health treatments could reduce the burden of anxiety disorders in the region (Nawaz et al., Reference Nawaz, Mahmood, Al Mughairbi and Khera2023, Pocock, Reference Pocock2017). Moreover, raising awareness of mental health issues in the region can help reduce stigma and encourage more people with mental health issues to seek healthcare services, considering that stigma plays a major role in creating barriers in the MENA region (Pocock, Reference Pocock2017, Sewilam et al., Reference Sewilam, Watson, Kassem, Clifton, McDonald, Lipski, Deshpande, Mansour and Nimgaonkar2015). Furthermore, given the rate of bullying in MENA is higher than in most other regions, it is critical to address factors that increase the risk of bullying victimisation (such as social inequality, gender norms, bullying culture, and cultural conflicts) and enhance those that protect against bullying victimisation (such as parental support, school-based supportive teams, children’s rights empowerment, and an anti-bullying culture) (Hong et al., Reference Hong, Liu, Gao, Jin, Shi, Liang, Maimaitiming, Ning and Luo2022). Successive interventions are required to prevent bullying victimisation and support victims’ mental health. Effective strategies include promoting supportive legislation and policy frameworks, minimising cultural tensions by establishing safe and welcoming environments at home and in schools (Hatzenbuehler et al., Reference Hatzenbuehler, Schwab-Reese, Ranapurwala, Hertz and Ramirez2015), and reaffirming strong commitments to children’s rights and empowerment (Zambuto et al., Reference Zambuto, Palladino, Nocentini and Menesini2020).

In light of the substantial and frequently neglected burden of anxiety disorders in the MENA region, it is essential to urgently strengthen national and regional mental health surveillance systems. Effective surveillance, especially the systematic gathering and analysis of data disaggregated by age, gender, and other sociodemographic factors, is crucial for monitoring epidemiological trends and evaluating the real-world impact of policy interventions. Simultaneously, emphasis should be placed on integrating evidence-based screening, prevention, and treatment approaches for anxiety disorders into the primary healthcare system. In order to improve early detection and intervention, reduce stigma, and ensure equitable access to mental health services – particularly in marginalised and conflict-affected communities – this integration must be paired with comprehensive, culturally sensitive training for primary care providers.

Additionally, it is imperative to create and execute psychoeducational and preventive initiatives that are specifically designed for adolescents and other high-risk groups, such as those impacted by conflict and forced displacement. Social determinants significantly influence mental health outcomes in the region. Therefore, collaborative multi-sectoral approaches that include education, social welfare, and the justice system are essential for addressing risk factors like violence, economic instability, and displacement. Public awareness campaigns that are culturally appropriate are also necessary to enhance mental health literacy, mitigate widespread stigma, and promote prompt assistance. Increasing investment in the training, retention, and ongoing professional development of mental health specialists, particularly in managing anxiety and trauma-related conditions, is essential for establishing a resilient and responsive mental health workforce in the MENA context.

Given all these facts, anxiety disorders represent a multidimensional burden, spanning medical, social, and economic elements. Thus, promoting interdisciplinary approaches that unite social workers, educators, legislators, and healthcare professionals is essential. This kind of cooperation can help develop comprehensive treatment plans that address the underlying causes of anxiety disorders as well as their symptoms.