Review Paper

Prevalence and Incidence Studies of Anxiety Disorders:

A Systematic Review of the Literature
Julian M Somers, MSc, PhD
1
, Elliot M Goldner, MHSc, MD
2
, Paul Waraich, MHSc, MD
1
,
Lorena Hsu, MSc
3
Key Words: anxiety disorders, panic disorder, phobia, obsessivecompulsive disorder,
posttraumatic stress disorder, generalized anxiety disorder, prevalence, incidence,
systematic review
WCan J Psychiatry, Vol 51, No 2, February 2006 100
Objective: To present the results of a systematic review of literature published between 1980 and
2004 reporting findings of the prevalence and incidence of anxiety disorders in the general
population.
Method: A literature search of epidemiologic studies of anxiety disorders was conducted, using
MEDLINE and HealthSTAR databases, canvassing English-language publications. Eligible
publications were restricted to studies that examined age ranges covering the adult population. A
set of predetermined inclusion and exclusion criteria were used to identify relevant studies.
Prevalence and incidence data were extracted and analyzed for heterogeneity.
Results: A total of 41 prevalence and 5 incidence studies met eligibility criteria. We found
heterogeneity across 1-year and lifetime prevalence rates of all anxiety disorder categories.
Pooled 1-year and lifetime prevalence rates for total anxiety disorders were 10.6% and 16.6%.
Pooled rates for individual disorders varied widely. Women had generally higher prevalence rates
across all anxiety disorder categories, compared with men, but the magnitude of this difference
varied.
Conclusion: The international prevalence of anxiety disorders varies greatly between published
epidemiologic reports. The variability associated with all anxiety disorders is considerably
smaller than the variability associated with individual disorders.Women report higher rates of
anxiety disorders than men. Several factors were found to be associated with heterogeneity among
rates, including diagnostic criteria, diagnostic instrument, sample size, country studied, and
response rate.
(Can J Psychiatry 2006;51:100113)
Clinical Implications
Significant heterogeneity in the prevalence of anxiety disorders signals the need for
population-specific health policies and planning.
The prevalence of anxiety disorders eclipses the capacity of specialized mental health services.
Anxiety disorders remain prevalent throughout ages 18 to 64 years.
Limitations
The observed heterogeneity may be related to environmental or cultural factors associated with the
location of each contributing investigation.
Variance owing to methods of diagnosis and measurement account for a limited portion of the
observed heterogeneity.
An insufficient number of incidence studies are available to clarify details concerning the onset of
symptoms.
I
n recent years, it has been increasingly acknowledged not
only that anxiety disorders are highly prevalent, but also
that the burden of illness associated with these disorders is
often considerable. A broad understanding of the etiology of
anxiety includes a multiplicity of factors, such as biological,
psychological, and social determinants, which are mediated
by a range of risk and protective factors. Cross-cultural stud-
ies in epidemiology are a critical source of information
regarding the interplay between these factors. Effective forms
of intervention are available and are the subject of ongoing
research, but it is an immense public health challenge to coor-
dinate the delivery of these programs and services. Studies in
comparative epidemiology play a vital role in the develop-
ment of health policy concerning anxiety. Empirical knowl-
edge of regional prevalence is fundamental to understanding
the relative demand for services. Such knowledge is also nec-
essary to identify the most appropriate avenues for
intervention.
The present review, which is the fifth in a series of papers that
will present systematic reviews of the prevalence and inci-
dence of psychiatric disorders drawn from studies published
in the English literature in the years 1980 to 2004, sought to
synthesize international research on this topic. Results and
observed patterns of heterogeneity are discussed in relation to
health services planning as well as implications for additional
research.
Methods
The methods employed in this review have been presented in
more detail elsewhere (1). The MEDLINE and HealthSTAR
databases were searched for relevant studies; the key index-
ing terms epidemiology, prevalence, and incidence were used,
combined with the search terms mental disorders, anxiety dis-
orders, panic disorder, phobia, obsessivecompulsive dis-
order, posttraumatic stress disorder, and generalized anxiety
disorder. The search was limited to English-language studies
published between 1980 and 2004. Reference lists of relevant
primary and review articles identified were also searched.
Prevalence and incidence studies were eligible for inclusion if
they were community surveys using probability sampling
techniques. Eligible publications were restricted to studies
having sample sizes of 450 people or more that examined age
ranges covering the adult population. Only studies using
current diagnostic criteria and case identification based on
either standardized instruments or clinician diagnosis were
included. Prevalence and incidence data, including overall,
sex-specific and age-specific rates, were extracted from
eligible studies.
Qualitative analyses of variables related to methodology were
conducted to summarize and elucidate any observed differ-
ences between rates. Each set of rates was also pooled accord-
ing to a Bayesian approach to metaanalysis; the Fastpro
software program was used. Readers interested in a more
detailed discussion of this approach should refer to Eddy and
others (2). Each of the pooled rates was analyzed for heteroge-
neitywith chi-square tests according to the Fleiss method(3).
Results
Description of Studies
From the citations and abstracts generated by the initial elec-
tronic search, we identified 80 prevalence and 10 incidence
studies potentially meeting inclusion criteria, in addition to 28
review papers (431). The full texts of these articles were
retrieved. We searched all reference lists of identified studies
and reviews, generating an additional 38 prevalence and 6
incidence studies for which full-text articles were obtained.
Of the 118 prevalence studies for which full-text articles were
reviewed, 71 prevalence papers of anxiety disorders met eligi-
bility criteria (3295,96102), resulting in a total of 41
unique primaryinvestigations of anxietydisorders included in
this review. We excluded a total of 47 studies: 35 studies did
not meet eligibility criteria, and 12 presented duplicate data.
Of the 16 incidence studies identified, 11 were excluded, 8 did
not meet inclusion criteria, and 3 were based on duplicate
study samples. This resulted in 5 incidence studies of anxiety
disorders that could be included (54,90,103105). Most stud-
ies meeting inclusion criteria used nonhierarchical diagnostic
approaches. Predictably, the few studies using hierarchical
diagnoses reported relatively lower rates of individual
disorders.
Prevalence Studies
Findings, for the 34 papers reporting overall and (or)
sex-specific 1-year and (or) lifetime prevalence rates for panic
disorder, agoraphobia, social phobia, specific phobia, OCD,
PTSD, GAD, and TAD, are presented in Tables 1 to 3.
Age-specific lifetime prevalence rates for these disorders are
Prevalence and Incidence Studies of Anxiety Disorders: A Systematic Review of the Literature
Can J Psychiatry, Vol 51, No 2, February 2006 W 101
Abbreviations used in this article
CI confidence interval
CIDI Composite International Diagnostic Interview
DIS Diagnostic Interview Schedule
GAD generalized anxiety disorder
NCS US National Comorbidity Study
OCD obsessivecompulsive disorder
PD panic disorder
PTSD posttraumatic stress disorder
SADS-L Schedule of Affective Disorders and Schizophrenia-
Lifetime
TAD total anxiety disorder
WCan J Psychiatry, Vol 51, No 2, February 2006 102
The Canadian Journal of PsychiatryReview Paper
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Prevalence and Incidence Studies of Anxiety Disorders: A Systematic Review of the Literature
Can J Psychiatry, Vol 51, No 2, February 2006 W 103
T
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9
)
,
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t
a
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(
8
8
)
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;
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1
.
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1
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0
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9

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a
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9
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Z
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(
5
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1
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9
8
9
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3
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8
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3
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5
7
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8

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l
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s
(
1
9
8
8
)
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n
a
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p
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t
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(
3
3
,
5
1
,
1
0
9
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;
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M
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1
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7

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0

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e
e
a
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d
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r
s
(
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9
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r
e
a
-
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n
g
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e
o
u
l
(
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r
b
a
n
)
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n
d
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y
e
o
n
(
r
u
r
a
l
)
(
4
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S
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2
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9
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2
al so pr esent ed i n Fi gur e 1
( 3 3 , 3 4 , 4 0 , 4 4 , 5 9 , 6 6 , 7 3 , 8 1 ,
84,94,101,106). The results of studies
reporting only data for point preva-
lence or 6-month prevalence are not
presented (36,37,41,45,49,53,54,
56,6,63,67,69,70,7476,78,86,87,
92,93,107). Analysis of data was car-
ried out only when 3 or more rates
were reported as this was the mini-
mum number of values required to
produce pooled rates.
All the studies presented are commu-
nity surveys using samples ranging
from approximately 500 (48) to
20 000 (106) people. For each of these
studies, the percentage CI width or
error rate for estimated prevalence at a
95%CI maybe calculated with the for-
mula provided by Kelsey and col-
leagues (108, p 282). For the most
part, studies used either the DIS or the
CIDI administered by trained lay
interviewers and applied algorithms to
derive diagnoses.
Qualitative Analysis
Total Anxiety Disorders
For TADs, 1-year prevalence rates
ranged from 4.2% in Florence, Italy
(95), to 17.2% in the NCS (39), which
is a variation of 4.1-fold (Table 1).
The study with the lowest rate, con-
ducted in Florence, Italy, employed
the SADS-Lto identifycases, whereas
most other studies used the CIDI.
Lifetime prevalence rates ranged from
9.2% in Korea (40) to 28.7% in Basle,
Switzerland (48), a variation of
slightly over 3-fold. The study con-
ducted in Basle, Switzerland, was the
only one to use clinical interviewers,
while all other studies employed lay
interviewers and diagnostic algo-
rithms. Further, studies with the low-
est rates used the DIS and DSM-III
criteria, whereas other studies used the
CIDI and DSM-III-R criteria.
WCan J Psychiatry, Vol 51, No 2, February 2006 104
The Canadian Journal of PsychiatryReview Paper
T
a
b
l
e
1
c
o
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8
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3
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1
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=
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1
0
d
i
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o
s
i
s
Sex-Specific Prevalence
Tables 2 and 3 present findings
from studies reporting sex-spe-
cific 1-year and lifetime preva-
lence rates, respectively, for
anxiety disorders. For TADs,
1-year and lifetime prevalence
rates were generally found to be
about twice as high for women,
compared with men. Studies
reporting 1-year and lifetime
sex-specific rates for panic dis-
order showed consistently
higher rates for women, com-
pared with men, but varied in
the magnitude of this difference
with rates that were 1.2-fold
(34) to 6.8-fold (40) higher for
women than men. Most rates for
panic disorder, however, were
generally found to be between 2
and 3.5 times higher for women,
compared with men. With regard to phobic disorders, 1-year
and lifetime prevalence rates were generally found to be
between 2 and 4 times higher for women, compared with men,
for agoraphobia and specific phobia. While most 1-year and
lifetime rates for social phobia were found to be between 1.2
and 2.6 times higher for women, compared with men, there
were studies reporting lifetime rates for women that were 5
times (38) and 12.5 times (40) rates for men. Furthermore,
there were studies demonstrating higher lifetime prevalence
rates for social phobia in men, comparedwith women(38,43).
For OCD, there was little consistency observed for
sex-specific rates. Most rates were found to be higher for
women than for men but several studies demonstrated higher
rates for men, compared with women (32,34,38). For studies
reporting higher female rates, most rates were 1.1 to 1.8 times
higher for women than for men, while one study found a
female rate that was 14.8 times that of the male rate (77). With
regard to GAD, the 1-year and lifetime rates were generally
found to be 1.5 to 2 times higher for women, compared with
men.
Age-Specific Lifetime Prevalence
Figure 1 presents results from each study reporting
age-specific lifetime prevalence rates for anxiety disorders.
As shown, lifetime prevalence rates for agoraphobia and
OCD appear to remain fairly stable throughout ages 18 to 64
years. For social phobia, there seems to be a slight decrease in
prevalence with increasing age. When all anxiety disorders
are taken together, there appears to be an increase in lifetime
prevalence throughout ages 18 to 64 years.
Qualitative observations associated with individual anxiety
disorders appear alongside the results presented in the follow-
ing section.
Estimation and Heterogeneity Analysis of
Pooled Best-Estimate Rates
Total Anxiety Disorders
The best-estimate rates for 1-year and lifetime prevalence of
TADs were 10.6% (95%CI, 7.5% to 14.3%) and 16.6%
(95%CI, 12.7% to 21.1%), respectively (Table 1). The CI
variations for the 1-year and lifetime prevalence estimates are
1.9-fold and 1.7-fold, respectively, which are lower than the
respective 4.1-fold and 3.1-fold variations observed across
individual rates. Heterogeneity analysis of 1-year and lifetime
prevalence rates revealed significant differences across each
set of proportions. Chi-square tests for heterogeneity were
conducted for the following variables: country studied, year
study published, type of sample (that is, national, regional, or
municipal); sample size; sample inclusion (that is, community
only or community and institutional), diagnostic instrument
used, type of interviewer (that is, lay or clinician), mode of
establishing diagnosis (that is, algorithm or clinical judg-
ment), and diagnostic criteria used. Variables that maybe con-
tribute to heterogeneity are shown in Table 4. For lifetime
prevalence, the diagnostic criteria and instruments used were
variables that may have contributed to heterogeneity (Table
4). Studies that employed the DIS and DSM-III criteria had
pooled lifetime rates that were almost 2 times lower than those
of studies that used other diagnostic instruments and criteria.
Prevalence and Incidence Studies of Anxiety Disorders: A Systematic Review of the Literature
Can J Psychiatry, Vol 51, No 2, February 2006 W 105
0
2
4
6
8
10
12
14
16
18
20
Anxiety Disorder
R
a
t
e
(
%
)
18-24 years 25-44 years 45-64 years
Agoraphobia Social phobia OCD
TAD
Figure 1 Age-specific lifetime prevalence rates of anxiety disorders
Panic Disorder
The best-estimate rates for 1-year and lifetime prevalence
were 0.99%(95%CI, 0.55%to 1.5%) and 1.2%(95%CI, 0.7%
to 1.9%), respectively (Table 1). The variations in the 1-year
and lifetime prevalence rates, as shown by the CIs, are both
2.7-fold. Across individual studies, the 1-year prevalence
rates ranged from 0.13% in rural villages in Taiwan (38) to
3.2% in Florence, Italy (95), which is a difference of almost
25-fold. Lifetime prevalence rates for panic disorder ranged
from 0.13% in rural villages in Taiwan (38) to 3.8% in the
Netherlands (32), a variation of approximately29-fold. Heter-
ogeneity analysis demonstrated significant differences across
1-year and lifetime prevalence rates of panic disorder. For
studies conducted in Asia, the pooled 1-year rates were found
to be approximately 9 times lower than that of studies con-
ducted elsewhere (Table 4). All studies with lifetime preva-
lence rates under 3.0%used DSM-III criteria and, for the most
part, the DIS, whereas all studies with rates above 3.0%
employed the CIDI and DSM-III-R criteria.
Agoraphobia
The best-estimate rates for 1-year and lifetime prevalence
were 1.6%(95%CI, 1.0%to 2.3%) and 3.8%(95%CI, 2.5%to
5.6%), respectively (Table 1). The variations in the CIs for
these 1-year and lifetime prevalence rates are 2.3-fold and
2.2-fold, respectively. By contrast, 1-year prevalence rates for
agoraphobia ranged, among different studies, from 0.6% in
Florence, Italy, to 2.9% (95) in Christchurch, New
Zealand (55), which is a 4.5-fold variation. The lifetime prev-
alence rates for agoraphobia ranged from 0.73% in Hong
Kong (35) to 10.8% in Basle, Switzerland (48), a variation of
almost 15-fold. Heterogeneity was demonstrated for 1-year
and lifetime prevalence rates of agoraphobia. For studies
employing lay interviewers, the pooled 1-year rate was over
2.5 times higher than that of studies using clinical interview-
ers (Table 4). Studies conducted in Asian countries produced
a pooled lifetime rate that was almost 4 times lower than
studies carried out in non-Asian countries.
WCan J Psychiatry, Vol 51, No 2, February 2006 106
The Canadian Journal of PsychiatryReview Paper
Table 2 Sex-specific 1-year prevalence rates of anxiety disorders
Authors, year of study, and
study site
Prevalence rate (%)
PD Agoraphobia Social phobia Specific phobia OCD GAD TAD
M W M W M W M W M W M W M W
Carter and others (2001),
Germany (96)
1.0 2.1
Wang and others (2000), US
(79)
4.3 8.8 1.8 4.3
Grabe and others (2000),
Germany (77)
0.05 0.74
Henderson and others (2000),
Australia (47)
0.6 2.0 0.7 1.5 2.4 3.0 0.3 0.4 2.4 3.7 7.1 12.1
Bijl and others (1998),
Netherlands (32)
1.1 3.4 0.9 2.2 3.5 6.1 4.1 10.1 0.5 0.4 0.8 1.5 8.3 16.6
Offord and others (1996),
Ontario, Canada (42)

b
1.5 0.7 2.5 5.4 7.9 4.1 8.9 0.9 1.2 8.9 15.5
Lepine and Lellouch (1995),
France (62,84)
1.2 2.9
Kessler and others (1994),
US (NCS) (39)
1.3 3.2 1.7 3.8 6.6 9.1 4.4 13.2 2.0 4.3 11.8 22.6
Robins and Regier (1991),
US (ECA) (106)
0.58 1.2 1.4 1.9 2.4 5.0
Bourdon and others (1988),
US (ECA) (91)
2.1 5.9 1.4 2.2 4.8 10.4
Best estimate 95%CI 1.2
(0.54
2.1)
2.7
(1.4
4.3)
1.1
(0.72
1.7)
2.9
(1.8
4.4)
3.0
(1.7
4.7)
4.6
(2.87
.0)
4.4
(4.1
4.8)
10.6
(9.0
12.3)
0.31
(0.08
0.65)
0.5
(0.31
0.76)
1.4
(0.96
2.0)
2.6
(1.6
3.8)
8.9
(7.2
10.9)
16.4
(12.6
20.8)
= Not reported; M = men W = women
Rate not included in pooled bestestimate rate as sexspecific population sizes not provided
b
Numbers were too small to be reported
Prevalence and Incidence Studies of Anxiety Disorders: A Systematic Review of the Literature
Can J Psychiatry, Vol 51, No 2, February 2006 W 107
Table 3 Sex-specific lifetime prevalence rates of anxiety disorders
Authors, year of study,
and study site
Prevalence rate (%)
PD Agoraphobia Social phobia Specific phobia OCD GAD TAD
M W M W M W M W M W M W M W
Mohammadi and others
(2004), Iran (101)
0.7 2.8
Stein and Kean (2000),
Ontario, Canada (81)
10.4 15.6
Faravelli and others
(2000), Florence, Italy
(82)
1.9 4.0
Grabe and others (2000),
Germany (77)
0.15 0.84
Bijl and others (1998),
Netherlands (32)
1.9 5.7 1.9 4.9 5.9 9.7 6.6 13.6 0.9 0.8 1.6 2.9 13.8 25.0
Lepine and Lellouch
(1995), France (62)
3.7 9.9 2.1 5.4
Kessler and others
(1994), US (NCS) (39)
2.0 5.0 3.5 7.0 11.1 15.5 6.7 15.7 3.6 6.6 19.2 30.5
Chen and others (1993),
Hong Kong (35)
0.2 0.34 0.61 0.84 0.96 3.2 0.87 1.2 7.8 11.1
Wittchen and others
(1992), Former West
Germany (44)
1.7 2.9 2.8 8.3 1.8 2.3 9.1 18.1
Robins and Regier
(1991), US (ECA) (106)
0.99 2.1 3.2 7.9 2.5 2.9 7.8 14.4 2.0 3.0 2.6
5.7
a,c
5.5
7.8
a,c

Wells and others (1989),
New Zealand (43)
0.9 3.4 4.3 3.5 1.0 3.4 27.1 35.1
Hwu and others (1989),
Taiwan (38)
Taipei
Towns
Villages
0.1
0.3
0.06
0.3
0.4
0.2
0.8
0.7
0.4
1.5
2.3
2.3
0.2
0.6
0.4
1.0
0.5
0.4
2.2
2.1
1.7
5.0
7.9
3.8
0.8
0.4
0.4
1.1
0.7
0.2
2.4
8.8
6.2
5.0
12.4
9.0

Bland and others (1988),
Edmonton, Canada
(33,57,109)
0.8 1.7 1.5 4.3 1.4 2.0 4.6 9.8 2.8 3.1
Lee and others (1987),
Korea (40)
Seoul
Rural Korea
0.37
1.0
3.0
6.8
0.7
1.2
3.3
6.1
0.0
0.2
1.0
1.1
2.6
1.8
7.9
8.1
2.2
1.8
2.4
2.0
2.4
2.1
4.3
4.0
5.3
1.3
12.8
2.5
Canino and others
(1987), Puerto Rico (34)
1.6 1.9 4.9 8.7 1.5 1.6 7.6 9.6 3.3 3.1 11.2 15.7
Best-estimate (95%CI) 0.76
(0.47
1.2)
1.6
(0.85
2.6)
1.7
(1.0
2.5)
4.2
(2.8
6.2)
1.8
(0.79
3.2)
2.9
(1.4
4.7)
3.5
(2.2
5.2)
8.2
(5.8
11.2)
1.0
(0.67
1.6)
1.6
(1.0
2.2)
5.2
(2.68.
6)
8.4
(4.6
13.1)
10.4
(5.71
6.0)
18.5
(12.0
26.7
= Not reported; M = men; W = women
Rate not included in pooled best-estimate rate as sex-specific population sizes not provided
b
Numbers were too small to be reported
c
Range of rates for 3 sites
WCan J Psychiatry, Vol 51, No 2, February 2006 108
The Canadian Journal of PsychiatryReview Paper
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Social Phobia
The best-estimate rates for 1-year and lifetime
prevalence were 4.5%(95%CI, 3.0%to 6.4%)
and 3.6% (95%CI, 2.0% to 5.6%), respec-
tively (Table 1). Across individual studies,
1-year prevalence rates ranged from 2.3% in
France (62) to 44.2% in Udmurtia, Udmurt
Republic (a sovereign republic within the
Russian Federation) (50), an approximate
19-fold difference. Excluding the outlying
value reported in Udmurtia, the rates vary up
to 7.9%, which is a much smaller difference of
3.4-fold. Both studies reporting the highest
and lowest 1-year rates used the CIDI and cli-
nician diagnoses. With respect to lifetime
prevalence of social phobia, the rates ranged
from 0.53% in Korea (40) to 45.6% in
Udmurtia (50). This is a difference of 86-fold.
Excluding the outlying rate reported in
Udmurtia, the rates vary up to 16.0%, which is
a variation of approximately 30-fold. The CI
variations for the 1-year and lifetime
best-estimate rates are 2.1-fold and 2.8-fold,
respectively, which are much lower than the
respective 3.4-fold and 30-fold differences
observed across individual rates. Inclusion of
the outlying rate in the pooled estimate would
produce a 1-year and lifetime prevalence of
6.3% (95%CI, 2.9% to 10.8%) and 4.5%
(95%CI, 2.3% to 7.2%), respectively. Signifi-
cant differences were found among 1-year and
lifetime prevalence rates of social phobia. For
studies using the DIS, the pooled lifetime
prevalence was 4 times lower than that of stud-
ies using other diagnostic instruments (Table
4). Similarly, for studies using DSM-III crite-
ria, the pooled lifetime prevalence was over 5
times lower than that of studies using other
diagnostic criteria. In general, studies report-
ing lifetime rates under 4.0% employed the
DIS and DSM-III criteria, while studies
reporting rates above 4.0% used the CIDI and
DSM-III-R criteria.
Specific Phobia
The best-estimate rates for 1-year and lifetime
prevalence were 3.0% (95%CI, 0.98% to
5.8%) and 5.3% (95%CI, 3.4% to 7.9%),
respectively (Table 1). The variations in the CI
for these 1-year and lifetime prevalence rates
are almost 6-fold and 2.3-fold respectively. By
contrast, prevalence rates reported across
Prevalence and Incidence Studies of Anxiety Disorders: A Systematic Review of the Literature
Can J Psychiatry, Vol 51, No 2, February 2006 W 109
T
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individual studies ranged from 0.2% in Northern Ireland
(100) to 8.8% in the US (NCS) (39), a 44-fold variation. The
lifetime prevalence rates across individual studies ranged
from0.63% in Florence, Italy (88), to 11.3% in the US (NCS)
(39), which is a difference of almost 18-fold. Heterogeneity
was demonstrated for 1-year and lifetime prevalence rates of
specific phobia. For studies conducted in North America, the
pooled 1-year rate was almost 4 times higher, compared with
that of studies outside North American countries (Table 4).
For both 1-year and lifetime rates, the study conducted in
Italy, which reported the lowest rates, employed the SADS-L,
whereas the remaining studies used the CIDI or DIS.
ObsessiveCompulsive Disorder
The best-estimate rates for 1-year and lifetime prevalence
were 0.54% (95%CI, 0.28% to 0.86%) and 1.3% (95%CI,
0.86% to 1.8%), respectively (Table 1). The variations in the
CIs for these 1-year and lifetime prevalence rates are approxi-
mately 3-fold and 2-fold respectively. Across individual stud-
ies, variations of 13.8-fold and 10.7-fold respectively, were
observed. Heterogeneity was demonstrated for 1-year and
lifetime prevalence rates of OCD. For studies conducted in
Asian countries or with response rates of 80% or lower, the
pooled 1-year rates were approximately 4 times lower, com-
pared with those of studies conducted outside Asian countries
or with response rates of more than 80%(Table 4). For pooled
lifetime rates, studies conducted in Asian countries produced
rates that were almost 2 times lower than studies conducted
outside Asia. Examination of each of the studies does not
reveal any relevant methodological differences that might
help to explain the variation in rates of OCD.
Posttraumatic Stress Disorder
The best-estimate rates for 1-year and lifetime prevalence
were 1.2% (95%CI, 0.09% to 3.4%) and 2.1% (95%CI, 0.4%
to 4.9%), respectively (Table 1). The variation in the CIs for
the 1-year pooled rate was approximately 37-fold, which is
higher than the 33-fold difference found across individual
rates. For lifetime prevalence, the variation in the CIs was
approximately 12-fold, which is considerably lower than the
62-fold variation observed across individual rates. Heteroge-
neitywas demonstrated for lifetime prevalence rates of PTSD.
Further analysis to determine which variables may be contrib-
uting to heterogeneity was not carried out, owing to the small
number of rates. The lowest rate reported was based on the
SADS-Land clinical interviews and diagnoses, while all other
studies were based on the DIS or CIDI and lay interviewers.
Generalized Anxiety Disorder
The best-estimate rates for 1-year and lifetime prevalence
were 2.6%(95%CI, 1.4%to 4.2%) and 6.2%(95%CI, 4.0%to
9.2%), respectively (Table 1). The variations in the CIs for
these 1-year and lifetime prevalence rates are 3-fold and
2.3-fold, respectively. Across individual studies, 1-year prev-
alence ranged from0.15%in Northern Ireland (100) to 12.7%
in Christchurch, NewZealand (55). Lifetime prevalence rates
ranged from 1.9% in Basle, Switzerland (48) to 31.1% in
Christchurch, New Zealand (55). Heterogeneity was demon-
strated for 1-year and lifetime prevalence rates of GAD. Stud-
ies employing DISDSM-III or published before 1994
produced a pooled 1-year rate that was 4.5 times higher than
that of studies using other diagnostic instruments and criteria
and published on or after 1994 (Table 4). For studies con-
ducted in European countries, the pooled lifetime rate was
approximately 3 times lower, compared with that of studies
conducted outside European countries. There were no appar-
ent methodological differences to account for the variation in
lifetime prevalence rates.
Incidence Studies
Five studies provided data on 1-year incidence rates of anxi-
ety disorders. The incidence studies conducted in Edmonton,
Canada (104) and the US (90,103,105) were prospective
follow-up studies of community-based samples with total
populations ranging from 1964 to 12 823. The study con-
ducted in Norway (54) was also based on a communitysample
but involved a retrospective assessment of incidence. The pro-
spective studies used the DIS and an algorithmto extract diag-
noses, whereas the retrospective study employedthe CIDI and
a clinician diagnosis. An inadequate number of rates from
unique primary investigations were available for the various
anxiety disorder categories; therefore, the rates are presented
for the sake of interest, and no analyses of the rates were
performed.
Discussion
The results of this study further confirmthe high international
prevalence of anxiety disorders, and illustrate patterns of con-
siderable heterogeneity. Best-estimates for the 1-year and
lifetime prevalence of TADs were 10.6% and 16.6%, respec-
tively. The ratio between 1-year and lifetime rates indicates
that a large number of people experience anxiety disorders on
a continuing or recurring basis.
Across studies, anxietydisorders were approximatelytwice as
prevalent among women, with overall age-specific rates
remaining relatively stable or increasing across the lifespan.
Overall, the results suggest a burden of illness that eclipses the
capacity of specialized mental health service providers.
Between studies, there was considerable variability on all
observed prevalence rates. For most categories of anxiety dis-
order there was at least a 10-fold variation between the preva-
lence rates reported by different studies. In contrast, the
degree of variabilitybetween rates of TADs was muchsmaller
than the variation associated with individual disorders.
WCan J Psychiatry, Vol 51, No 2, February 2006 110
The Canadian Journal of PsychiatryReview Paper
Perhaps a predisposition to one of several anxiety disorders
could be differentially expressed in other contexts. Similarly,
specific anxiety symptoms may vary over the course of time,
crossing diagnostic boundaries but without relief fromsuffer-
ing. Alternatively, there may be cross-cultural differences in
the genetic basis of one or more of the anxiety disorders. The
pattern of results is consistent with the view that anxiety dis-
orders are determined by a multiplicity of factors, including
biological, psychological, and social variables.
A few methodological factors were associated with the
observed heterogeneity between rates. Pooled rates for TADs
were lower in studies that incorporated DIS and DSM-III cri-
teria than in studies using the CIDI and DSM-III-R. This pat-
tern was also observed for some studies that estimate the
prevalence of individual disorders. Several other factors were
associated with heterogeneity, including the country studied,
the response rate, and the size of the study sample. However,
each of these factors was available for evaluation in relation to
a small number of individual disorders. In most cases, differ-
ent studies were distinguished on the basis of several factors
simultaneously (for example, location, type of disorders
investigated, method of diagnosis, and sample size). Hence, it
is not possible to attribute unique variance to any one of these
potential sources of variability. Three studies used different
diagnostic schemes with the same subjects. However, there
was no consistent pattern to the results associated with
different criteria across this small number of studies.
An insufficient number of incidence studies were available
for inclusion, signalling an important omission in the
epidemiologic literature. Further knowledge is required about
the onset of anxiety disorders, including risk and protective
factors, as well as social variables that may mediate the
expression of these disorders and help explain the level of het-
erogeneity observed in the present study.
There is a dearth of information regarding the prevalence of
anxiety disorders among special populations. Some research
suggests that risk of anxiety maybe greater within certain sub-
groups, such as medical patients (109) and residents of nurs-
ing homes (110). Further investigation of these and other
subgroups is required to identify concentrations of need and
hasten the deployment of requisite services.
As a class, anxiety disorders are seldom treated. Only a lim-
ited subset of treatment appears to be consistent with
evidence-based recommendations (79). The challenge of
reducing the burden of illness associated with anxiety
disorders is immense. To meet this challenge, it is essential to
further clarify the epidemiology of anxiety, which will allow
for the targeted deployment of programs and services on the
basis of a probabilistic understanding of need.
Funding and Support
This review received no funding or support.
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Manuscript received December 2004, revised, and accepted October 2005.
This is the fifth in a series of papers that presents systematic reviews of the
prevalence and incidence of psychiatric disorders drawn from studies
published in the English literature in the years 1980 to 2004. The series
discusses the implications of these epidemiologic findings to mental health
policy and practice.
1
Associate Professor, Faculty of Health Sciences, Simon Fraser University,
Vancouver, British Columbia.
2
Professor, Faculty of Health Sciences, Simon Fraser University,
Vancouver, British Columbia.
3
Research Assistant, Mental Health Evaluation and Community
Consultation Unit (Mheccu), University of British Columbia.
Address for correspondence: Dr Somers, Faculty of Health Sciences,
Simon Fraser University, 7238-515 Hastings Street, Vancouver BC, V6B
5K3, jsomers@sfu.ca
Prevalence and Incidence Studies of Anxiety Disorders: A Systematic Review of the Literature
Can J Psychiatry, Vol 51, No 2, February 2006 W 113
Rsum : tudes de la prvalence et de lincidence des troubles anxieux :
une tude systmatique de la littrature
Objectif : Prsenter les rsultats dune tude systmatique de la littrature publie entre 1980 et 2004
rapportant les rsultats de la prvalence et de lincidence des troubles anxieux dans la population gnrale.
Mthode : Une recherche a t mene dans la littrature sur les tudes pidmiologiques des troubles
anxieux, laide des bases de donnes Medline et HealthStar, dans les publications de langue anglaise.
Les publications admissibles se limitaient aux tudes qui examinaient les groupes dge couvrant la
population adulte. Un ensemble prdtermin de critres dinclusion et dexclusion a t utilis pour
reprer les tudes pertinentes. Les donnes de prvalence et dincidence ont t extraites et analyses
quant leur htrognit.
Rsultats : En tout, 41 tudes de prvalence et 5 tudes dincidence satisfaisaient aux critres
dadmissibilit. Lhtrognit a t constate aux taux de prvalence dun an et de dure de vie, pour
toutes les catgories de troubles anxieux. Les taux de prvalence regroups dun an et de dure de vie
pour le total des troubles anxieux taient de 10,6 % et de 16,6 %. Les taux regroups des troubles
individuels variaient normment. Les femmes avaient gnralement des taux de prvalence plus levs
que les hommes dans toutes les catgories de troubles anxieux, mais lampleur de cette diffrence variait.
Conclusion : La prvalence internationale des troubles anxieux varie grandement entre les rapports
pidmiologiques publis. La variabilit associe tous les troubles anxieux est considrablement plus
modeste que la variabilit associe aux troubles individuels. Les femmes dclarent des taux plus levs de
troubles anxieux que les hommes. Plusieurs facteurs se sont rvls associs lhtrognit parmi les
taux, dont les critres diagnostiques, linstrument diagnostique, la taille de lchantillon, le pays tudi et
le taux de rponse.