Canadian

Psychiatric Association

Association des psychiatres

du Canada

Descriptive Epidemiology of Generalized

Anxiety Disorder in Canada
Epidemiologie descriptive du trouble danxiete generalisee au
Canada

The Canadian Journal of Psychiatry /

La Revue Canadienne de Psychiatrie
1-6
The Author(s) 2016
Reprints and permission:
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DOI: 10.1177/0706743716645304
TheCJP.ca | LaRCP.ca

Rita A. Watterson, MD, MPH1, Jeanne V.A. Williams, MSc2,

Dina H. Lavorato, MSc1,2, and Scott B. Patten, MD, PhD1,2,3

Abstract
Objective: The first national survey to assess the prevalence of generalized anxiety disorder (GAD) in Canada was the 2012
Canadian Community Health Survey: Mental Health and Well-Being (CCHS-MH). The World Mental Health Composite
International Diagnostic Interview (WMH-CIDI), used within the representative sample of the CCHS-MH, provides the best
available description of the epidemiology of this condition in Canada. This study uses the CCHS-MH data to describe the
epidemiology of GAD.
Method: The analysis estimated proportions and odds ratios and used logistic regression modelling. All results entailed
appropriate sampling weights and bootstrap variance estimation procedures.
Results: The lifetime prevalence of GAD is 8.7% (95% CI, 8.2% to 9.3%), and the 12-month prevalence is 2.6% (95% CI, 2.3%
to 2.8%). GAD is significantly associated with being female (OR 1.6; 95% CI, 1.3 to 2.1); being middle-aged (age 35-54 years)
(OR 1.6; 95% CI, 1.0 to 2.7); being single, widowed, or divorced (OR 1.9; 95% CI, 1.4 to 2.6); being unemployed (OR 1.9; 95%
CI, 1.5 to 2.5); having a low household income (<$30 000) (OR 3.2; 95% CI, 2.3 to 4.5); and being born in Canada (OR 2.0; 95%
CI, 1.4 to 2.8).
Conclusions: The prevalence of GAD was slightly higher than international estimates, with similar associated demographic
variables. As expected, GAD was highly comorbid with other psychiatric conditions but also with indicators of pain, stress,
stigma, and health care utilization. Independent of comorbid conditions, GAD showed a significant degree of impact on both
the individual and society. Our results show that GAD is a common mental disorder within Canada, and it deserves significant
attention in health care planning and programs.
Abrege
Objectif : La premie`re enquete nationale qui a evalue la prevalence du trouble danxiete generalisee (TAG) au Canada a ete
lEnquete sur la sante dans les collectivites canadiennes Sante mentale (ESCC SM) de 2012. Lentrevue WMH-CIDI, utilisee
dans lechantillon representatif de lESCC SM, offre la meilleure description disponible de lepidemiologie de cette affection
au Canada. Cette etude decrit lepidemiologie du TAG a` laide des donnees de lESCC SM.
Methode : Lanalyse a estime les proportions, les rapports de cotes, et utilise les mode`les de regression logistique. Tous les
resultats produits utilisaient les procedures de poids dechantillonnage appropriees et destimation de variance bootstrap.

1
2
3

Department of Psychiatry, University of Calgary, Calgary, Alberta

Department of Community Health Sciences, University of Calgary, Calgary, Alberta
Mathison Centre for Mental Health Research & Education, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta

Corresponding Author:
Scott B. Patten, MD, PhD, Department of Community Health Sciences, University of Calgary, 3rd Floor TRW Building, 3280 Hospital Drive NW, Calgary, AB
T2N 4Z6, Canada.
Email: patten@ucalgary.ca

The Canadian Journal of Psychiatry

Resultats : La prevalence du TAG de duree de vie est de 8,7% (IC a` 95% 8,2 a` 9,3), et la prevalence de 12 mois est de 2,6% (IC
a` 95% 2,3 a` 2,8). Le TAG est significativement associe au fait detre femme (RC 1,6; IC a` 95% 1,3 a` 2,1), dage moyen (age 35-54;
RC 1,6; IC a` 95% 1,0 a` 2,7), celibataire, veuf ou divorce (RC 1,9; IC a` 95% 1,4 a` 2,6), sans emploi (RC 1,9; IC a` 95% 1,5 a` 2,5),
davoir un faible revenu du menage (< 30 000 $) (RC 3,2; IC a` 95% 2,3 a` 4,5) et detre ne au Canada (RC 2,0; IC a` 95% 1,4 a` 2,8).
Conclusions : La prevalence du TAG etait lege`rement plus elevee que les estimations internationales, avec des variables
demographiques associees semblables. Comme prevu, le TAG etait tre`s comorbide avec dautres affections psychiatriques,
mais aussi avec des indicateurs de douleur, de stress, de stigmates et dutilisation des soins de sante. Independamment des
affections comorbides, le TAG revelait un degre significatif dimpact sur la personne et la societe. Nos resultats indiquent que
le TAG est un trouble mental commun au Canada, et quil merite une attention significative dans la planification et les programmes de soins de sante.
Keywords
generalized anxiety disorder, epidemiology, anxiety, population studies, cross-sectional studies, major depressive disorder

Anxiety disorders are a pervasive problem and account for

approximately 2% of health-related disability in Canada.1
Generalized anxiety disorder (GAD) is recognized as the
most common anxiety disorder within primary care, carrying
a significant degree of comorbidity, impairment, and disability.2 GAD is characterized by a chronic, persistent pattern of
worrying, anxiety symptoms, and tension that has a waxing
and waning course often without full remission.3 Estimates
indicate that 2.4 million Canadians will report symptoms
consistent with a diagnosis of GAD in their lifetime.4
The descriptive epidemiology of GAD has lagged because
of the shifting Diagnostic and Statistical Manual of Mental
Disorders (DSM) nosology and concerns regarding the independence of GAD as its own unique disorder.5 In addition,
basic Canadian epidemiological data are limited in national
estimates, and inconsistencies are seen in research methods
applied in provincial and regional surveys.6 This has left a
major gap in our understanding of GAD across Canada.
The 2012 Canadian Community Health Survey, Mental
Health (CCHS-MH) used the World Mental Health (WMH)
version of the Composite International Diagnostic Interview
(CIDI) to provide the first ever description of the epidemiology of GAD in the national population. The large, representative sample of the CCHS-MH allows description of the
patterns of distribution of GAD within Canada. To date, only
2 studies have used the CCHS-MH 2012 data in relation to
GAD. Pearson et al.4 examined the basic epidemiology of 6
major disorders described in the CCHS-MH. Their study
showed that the lifetime prevalence of GAD was 8.7%, that
higher rates were seen in females, that GAD was frequently
seen with comorbid depressive disorders, and that GAD had
a somewhat stable prevalence across the age spectrum. Sunderland and Findlay7 investigated perceived need for mental
health services by using the CCHS-MH 2012 data. The
investigators found that individuals reporting a mood or
anxiety disorder had significantly higher odds of perceiving
a mental health need (information, counselling, medication)
compared with individuals without a mental disorder.
This study provides further investigation into the descriptive epidemiology of GAD, extending the results of the

earlier studies by Pearson et al.4 and Sunderland and Findlay.7 Sunderland and Findlay7 demonstrated that there is a
significant, unmet health care need for mental health conditions in Canada. This study reviews further the impact of
GAD alone compared with substance use and mood disorders. This greater understanding of the epidemiology of
GAD is necessary to inform future health care decisions and
generate hypotheses for prevention strategies in the Canadian population.

Methods
The 2012 CCHS-MH is designed to provide a comprehensive
analysis of mental health in Canadians. The initial sample
design included 43 000 dwellings, based on individuals over
the age of 15 in geographical clusters across Canada.8 From
the initial raw sample, 36 443 dwellings were found to be in
scope of the survey, and 79.8% of these households (29 088)
agreed to participate.8 A final individual sample of 25 113 was
obtained, resulting in an individual response rate of 86.3% and
an overall response rate of 68.9%.8 Interviews were performed across Canada between January 2012 and December
2012 using computer-assisted personal interviewing. 8
Approximately 87% of interviews were performed in person.8
Roughly 3% of the population was excluded from the surveys
sampling frame, including individuals living on reserves and
other Aboriginal settlements, full-time members of the Canadian Forces, and the institutionalized population.8
Sampling weights were produced by Statistics Canada to
ensure that the survey estimates are representative of the
Canadian household population.8 Each participant was given
a survey weight, so that his or her responses represent a
certain number of people in the entire population.8 This
weight is based on several factors but includes adjustments
for nonresponse at the household and personal level; it also
accounts for extreme values, unequal selection probabilities,
and exclusion of out-of-scope units.8 Five hundred replicate
bootstrap weights are applied to all output data to create
accurate confidence intervals and account for clustering in
the multistage sampling procedure.8

La Revue Canadienne de Psychiatrie

Various versions of the CIDI have been the mainstay of

community-based studies in psychiatric epidemiology during the past 2 decades. A version of the CIDI developed for
the WMH Survey program, the WMH-CIDI incorporated
many improvements over earlier versions,9 especially the
use of cognitive interviewing techniques. Reappraisal in
relation to Structured Clinical Interview for DSM-IV (SCID)
interviews could not specifically examine GAD but found
that 83.7% of past-year anxiety disorders were identified by
this version of the CIDI.10
The standardized interview consists of multiple different
modules that can be used for analysis. The WMH-CIDI
modules used DSM-IV criteria to estimate lifetime and 12month prevalence of psychiatric disorders. Diagnoses
included GAD, major depressive disorder (MDD), bipolar
disorder (BD), alcohol abuse, alcohol dependence, drug
abuse, and drug dependence.9 The module for each psychiatric disorder was determined through the standardized questions and identified using a diagnostic algorithm to
determine who met criteria for each disorder.7 Demographic
indicators assessed in the survey included gender, age, marital status, level of education, employment, immigrant status,
and urban living, all which were determined by standardized
interview questions.8 Household income was determined by
income decile brackets.
As GAD is a highly comorbid condition, the impact of
GAD was determined by separating GAD from 12-month
prevalence of mood and substance use disorders (MSUDs).
A substance use disorder was considered to be a diagnosis of
alcohol or drug dependence or alcohol or drug abuse, as
based on DSM-IV criteria. Mood disorders encompassed
both bipolar disorder and MDD. Adjusted odds ratios were
then reported based on the presence of GAD alone, MSUDs
alone, or both GAD and MSUDs. These 3 categories were
then analyzed in respect to areas of impact, including work
and income, self-perceived interference with life, health care
utilization, and suicide. These different areas were evaluated
through self-reported health scales, health care utilization
modules, and suicide modules. To assess pain, items used
to classify pain-specific health states for the Health Utility
Index10 were used. These items identify respondents with a
usual experience of pain sufficient to interfere with their
day-to-day activities. The remainder of CCHS measures
consisted of field-tested, but not formally validated, survey
items and modules. Interference with life was determined by
multiple scales and items to assess self-perceived health,
stress, and pain. Stigma was assessed using a module developed through collaboration between the Mental Health Commission of Canada and Statistics Canada and administered to
participants who had received treatment within the last
year.11 Health care utilization was assessed by a module
developed by Statistics Canada to determine professional
consultation and hospitalization.8 Suicide was assessed in a
module by Statistics Canada that addressed 12-month and
lifetime prevalence of thoughts, plans, and attempts.8 The
survey also assessed work absenteeism in the last week and

income strain, based on respondent-reported difficulty meeting basic household expenses.8

Data analysis used Stata version 12.8 at the Statistics
Canada Prairie Regional Data Centre. Descriptive techniques were used for the cross-sectional data, including estimation of frequencies and odds ratios. Logistic regression
modeling was used to produce adjusted estimates and to help
describe a smoothed pattern of age-specific prevalence by
incorporating age as a continuous variable. Past-year rather
than lifetime GAD prevalence was the primary focus of the
analysis, as there are concerns regarding the validity of lifetime prevalence.12

Results
Demographic characteristics of the CCHS-MH sample population in association with 12-month prevalence of GAD
are shown in the Appendix, Supplementary Table 1. Results
showed a 8.7% (95% CI, 8.2% to 9.3%) lifetime prevalence
of GAD, a 2.6% (95% CI, 2.3% to 2.8%) 12-month prevalence of GAD, and a 1.6% (95% CI, 1.3% to 1.8%) 30-day
prevalence of GAD. The 12-month prevalence of GAD
amongst women was 3.2% (95% CI, 2.7 to 3.6), whereas
the prevalence amongst men was 2.0% (95% CI, 1.6% to
2.3%). An unadjusted odds ratio (OR) of 1.6 (95% CI, 1.3 to
2.1) indicated a significantly higher annual prevalence of
GAD in women. Widowed, separated, and divorced individuals also had a higher prevalence, relative to married
respondents: 3.8% (95% CI, 2.9% to 4.7%), which was
associated with an unadjusted OR of 1.9 (95% CI, 1.4 to
2.6). Level of education (unadjusted OR for secondary
level graduation or less, 1.1; 95% CI, 0.9 to 1.5) and urban
living (unadjusted OR 1.0; 95% CI, 0.8 to 1.4) were not
significantly associated with GAD. Subjects who were not
working in the last week had 1.9 times higher odds (95%
CI, 1.5 to 2.5) of GAD in comparison to those with full-time
work. Last, subjects born in Canada were 2.0 times (95%
CI, 1.4 to 2.8) more likely to experience GAD when compared with immigrants. Figure 1 presents age-specific prevalence from a model including age and age squared,
providing a smoothed nonlinear description of annual prevalence as a function of age. Figure 2 shows the relation
between household income and GAD, demonstrating the
trend of higher rates of GAD amongst those with lower
incomes.
A logistic regression was performed to further analyze the
demographic indicators with 12-month prevalence of GAD.
The analysis included the same variables included in Supplementary Table 1. Variables found to be significant
included sex, age, age squared, marital status, Canadian
birth, part-time work and unemployment, and low household
income (<$29 999 and $30 000-$59 999). The results of this
multivariable analysis resembled the unadjusted estimates,
except that an effect of marital status was no longer evident,
the associations with alcohol use disorders weakened, and
those for cannabis and drug use disorders were no longer

The Canadian Journal of Psychiatry

Table 1. Workplace and economic impact, interference with life, health care utilization, and suicide indicator analysis with generalized
anxiety disorder, mood or substance use disorders, or botha.

Workplace and economic impact

Work absenteelast week
Current household incomedifficulty meeting basic expenses
Interference with life
Self-perceived health in general
Self-perceived life stress
Pain and discomfortHUI function code
Perceived prejudice or discrimination regarding mental health
Health care utilization
Consultation with professional servicespast 12 months
Hospitalized overnightb
Suicide
Suicide thoughtspast 12 months
Suicide plan or attemptpast 12 months

GAD yes, MSUDs no

GAD no, MSUDs yes

GAD yes, MSUDs yes

1.9 (1.1-3.4)
3.3 (2.2-4.8)

1.6 (1.1-2.4)
2.5 (2.0-3.1)

1.9 (1.0-3.5)
6.6 (4.7-9.2)

5.4 (3.7-8.0)
3.5 (2.4-5.1)
5.1 (3.5-7.4)
1.6 (0.9-2.9)

3.5 (2.8-4.2)
2.4 (2.0-2.8)
3.1 (2.5-3.7)
2.7 (1.8-4.1)

13.4 (9.9-18.0)
7.9 (5.8-10.6)
8.8 (6.3-12.2)
2.8 (1.8-4.5)

16.9 (11.9-24.0)
8.1 (2.7-24.7)

8.8 (7.3-10.6)
12.8 (7.3-22.3)

29.4 (20.5-42.1)
33.9 (17.6-65.1)

10.0 (6.1-16.6)
11.5 (4.3-30.5)

11.2 (8.6-14.7)
22.4 (13.2-38.0)

28.4 (20.0-40.4)
61.6 (34.4-110.3)

Values are expressed as odds ratios (adjusted for sex, age, and age squared) and 95% confidence intervals. N 24 861 for all data.
At least overnight in the preceding 12 months for reasons of mental health, alcohol, or drugs.
GAD generalized anxiety disorder; HUI health utility index; MSUDs mood and substance use disorders.
b

Figure 1. Past year generalized anxiety disorder (GAD) prevalence by age and gender.

Figure 2. Past year generalized anxiety disorder (GAD) prevalence

by household income.

significant. The adjusted estimates are available in the

Appendix (Supplementary Table 2) for further review.
Further analysis was performed to estimate the impact of
GAD alone, MSUD alone, or both GAD and an MSUD,
when compared with a baseline group with no disorders.
These analyses were undertaken in order to discern the
extent to which the impact of GAD was due to comorbidity
with other conditions. Table 1 shows the adjusted odd ratios
of each indicator controlled for age, age squared, and gender
that were found to be significant in our logistic regression
analysis (see Supplementary Table 2). The adjusted odds
ratio for the effect of GAD alone on perceived life stress
was 3.5 (95% CI, 2.4-5.1), whereas MSUD alone had an
adjusted odds ratio of 2.4 (95% CI, 2.0-2.8). When both
conditions were combined there was an adjusted odds ratio

La Revue Canadienne de Psychiatrie

of 7.9 (95% CI, 5.8-10.6), significantly higher than each

alone and roughly equal to the product of their 2 effects. For
many variables the joint effect was less than multiplicative
(Table 1). Analysis showed that 12-month suicide thoughts
and plans or attempts were more strongly associated with
MSUDs without GAD than with GAD without comorbidity.
When an individual had both, his or her odd ratios were
again significantly higher than when individually reported
(Table 1). The finding of substantially higher impact in those
with comorbid conditions was not seen for some other variables, such as household income and perceived stigma.
In respect to health care utilization, individuals who seek
professional support were more likely to have GAD in the
absence of MSUD rather than MSUD in the absence of GAD.
However, consistent with expectation, hospitalization was
more strongly associated with MSUD (in the absence of
GAD) than with GAD (in the absence of MSUD). However,
the greatest elevation in the risk/odds of hospitalization was
seen in respondents with comorbid GAD and MSUD, suggesting that this comorbidity may be an indicator of the severity of
respondents mental health difficulties (Table 1).

Discussion
Somers et al.13 produced a systematic review of prevalence
and incidence rates of anxiety disorders globally. It was
found that lifetime prevalence of GAD ranged from
1.9% in Basel, Switzerland, to 31.1% in Christchurch,
New Zealand.10 The 12-month prevalence of GAD ranged
from 0.15% in Northern Ireland to 12.7% in Christchurch,
New Zealand.13 Our results (lifetime prevalence of GAD at
8.7% and 12-month prevalence of GAD of 2.6%) are slightly
above estimates from the United States, New Zealand
(a different estimate than the one from Christchurch), and
Australia. The lifetime prevalence of GAD ranges from
5.7% in the United States to 6.1% in Australia. 14 The
12-month prevalence of GAD in these countries ranges from
1.9% (New Zealand) to 3.1% (United States), consistent with
our estimates.14 The very high prevalence in the Christchurch estimate contrasts with the lower prevalence estimates
reported in a more recent Australian review.14 This variability can potentially be accounted for by vulnerabilities in
measurement or other aspects of study design. The Canadian
estimates are based on an adaptation of the WMH-CIDI, as is
the estimate provided by the Australian researchers.14 The
wide range of estimates in the review by Somers et al.13
resulted from the use of both clinician and diagnostic tools
for GAD estimates. The Canadian prevalence estimates from
the CCHS-MH seem to be at the high end of the range of
international estimates.
The demographic indicators found in our study population are in keeping with international studies, including
being female, being out of the labour force, being divorced
or widowed, and being in the middle age ranges.2,14 Some
studies have found that young women have the highest risk
for GAD.15 European data, similar to our data, suggest that

GAD is a relatively rare condition before the age of 20, with

the majority of onsets being amongst older females.3 In
addition, a difference was noted between lifetime and
12-month prevalence rates of GAD. This suggests that GAD
potentially has a more episodic course or a higher rate of
remission than is usually assumed. These demographic factors suggest that in Canada, GAD is most common amongst
middle-aged women.
Immigrant status was protective for GAD in our Canadian
data, in keeping with similar results found in Australia.14
Because our data are cross-sectional in nature, it is difficult
to state whether this finding is related to a healthy immigrant
effect, reflects true differences related to immigrant status, or
results from cultural differences in mental health presentations or measurement. Low household incomes have been
found to be associated with anxiety disorders and GAD specifically.15 The etiological implications of this association
are difficult to decipher from cross-sectional data, as GAD
could lead to lower income from decreased work productivity, or poverty itself may be a predisposing factor.15
As expected, GAD was found to be highly comorbid with
multiple psychiatric conditions including MDD, alcohol
abuse or dependence, and bipolar disorder. The lifetime
comorbidity rates of psychiatric conditions within GAD are
estimated to be above 90%, and our findings are in keeping
with this.3 This rate of high comorbidity has historically
supported the view that GAD is a prodromal, residual, or
severity marker of other psychiatric conditions.5 Although
GAD does have a significant rate of comorbidity, data now
suggest that it is its own unique condition and needs to be
looked at independently.5 Wittchen et al.16 showed that high
comorbidity was a predictor of GAD in patients who sought
medical treatment. Wittchen et al. believed that this created a
bias in sample selection, artificially changing data on comorbidities. However, this would not affect our results since the
CCHS-MH method did not depend on health care use. Additionally, the definition of GAD has changed over several
iterations of the DSM, but it is recognized now that GAD
has its own distinct symptom cluster apart from MDD.5 Last,
it has been argued that the clinical course, sociodemographic
predictors, and impairments related to GAD are unique when
compared with comorbid conditions, suggesting that GAD
should be studied as its own condition.5
In our study, we found that GAD carried significant
impairment, independent of MSUDs. Our results suggest
that individuals with GAD in the absence of these comorbidities experience a significant amount of stress and pain and
have poorly perceived health. They are also significantly
more likely to have difficulty attending work and making
ends meet at home. Stigma and discrimination are also experienced by those with GAD. It is found that across multiple
studies, GAD alone leads to disability and decreased work
productivity equal to or greater than the burden caused by
depression.2
Last, GAD is a common presentation amongst primary
care and emergencies, leading to significant health care

utilization and costs. This was seen in our results, as individuals who consulted professional support were more likely
to have GAD alone when compared with MSUDs. When an
individual had both diagnoses, these rates were dramatically
increased. Unfortunately, GAD has relatively low rates of
recognition and treatment amongst primary care practices.3
This suggests that interventions should be aimed at improving the recognition and treatment of GAD. Early recognition
could halt the onset of significant impairments and comorbidities and possibly stop future relapses.3
Our study has several limitations. First, the CCHS-MH is
a cross-sectional survey, and so no causality can be implied
in our results. The assessment is performed by nonclinicians
and thus does not have the rigor seen in a detailed clinical
assessment. Although GAD was included in the 2012 CCHSMH World Health Organization CIDI module, limited coverage of other anxiety disorders is provided. As such, our
efforts to isolate the effects of GAD from those of MSUD
were limited by an inability to assess all possible comorbidities. Many of the diagnostic categories assessed in the
CCHS-MH were based on self-report and may be subject
to inaccuracy.

Conclusion
Historically, GAD has been conceptualized as a highly
comorbid condition, with little understanding regarding its
impact on the individual and society. Our results demonstrate that GAD is a highly prevalent condition that carries
a significant burden of disease. In Canada, individuals with
GAD experience significant pain, stress, stigma, and discrimination and use significant health care resources, particularly in the outpatient setting. Therefore, it is imperative
that future health care strategies and research take into consideration the burden of GAD in the Canadian population.
Acknowledgements
The estimates reported in this article are derived from data collected by Statistics Canada, but the analysis and results are the sole
responsibility of the authors and do not reflect the views of Statistics Canada. This work was approved by the University of Calgary
Conjoint Health Research Ethics Board.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.

Funding
The author(s) declared receipt of the following financial support for
the research, authorship, and/or publication of this article: This
study was funded by a grant from the Calgary Health Trust and the
University of Calgary Department of Psychiatry.

Supplemental Material
The online appendix and tables are available at http://cpa.sagepub.
com/supplemental.

The Canadian Journal of Psychiatry

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