Get 20M+ Full-Text Papers For Less Than $1.50/day. Subscribe now for You or Your Team.

Learn More →

Epidemiology of anxiety disorders in the 21st century

Epidemiology of anxiety disorders in the 21st century Clinical research Epidemiology of anxiety disorders in the 21st century Borwin Bandelow, MD, PhD; Sophie Michaelis, MD Introduction I n 1621, Robert Burton described the symptoms of anxiety attacks in socially anxious people in his book The Anatomy of Melancholy : “Many lamentable effects this fear causeth in man, as to be red, pale, tremble, sweat; Anxiety disorders, including panic disorder with or with- it makes sudden cold and heat come over all the body, out agoraphobia, generalized anxiety disorder, social palpitation of the heart, syncope, etc. It amazeth many anxiety disorder, specific phobias, and separation anxi - men that are to speak or show themselves in public.” In ety disorder, are the most prevalent mental disorders the same book, Burton cited Hippocrates’ writing on one and are associated with immense health care costs and a of his patients, who apparently suffered from what we high burden of disease. According to large population- would call “social anxiety disorder” today: “He dare not based surveys, up to 33.7% of the population are af- come into company for fear he should be misused, dis- fected by an anxiety disorder during their lifetime. Sub- graced, overshoot himself in gestures or speeches, or be stantial underrecognition and undertreatment of these sick; he thinks every man observeth him.” disorders have been demonstrated. There is no evidence Pathological anxiety, such as social phobia, has al- that the prevalence rates of anxiety disorders have ways existed in humans. Is there a reason to believe st changed in the past years. In cross-cultural comparisons, that anything has changed in the 21 century? There prevalence rates are highly variable. It is more likely that is a widespread opinion that anxiety is a characteristic this heterogeneity is due to differences in methodology feature of our modern times, and that the prevalence of than to cultural influences. Anxiety disorders follow a anxiety disorders has increased due to certain political, chronic course; however, there is a natural decrease in societal, economical, or environmental changes. prevalence rates with older age. Anxiety disorders are Among all mental diseases, the anxiety disorders, highly comorbid with other anxiety disorders and other including panic disorder with or without agoraphobia, mental disorders. Author affiliations: Department of Psychiatry and Psychotherapy, Univer- © 2015, AICH – Servier Research Group Dialogues Clin Neurosci. 2015;17:327-335. sity Medical Centre, Göttingen, Germany Keywords: anxiety disorder; panic disorder; agoraphobia; generalized anxiety Address for correspondence: Prof Dr Borwin Bandelow, von-Siebold-Str. disorder; social anxiety disorder; specific phobia; separation anxiety disorder; 5, Department of Psychiatry and Psychotherapy, University Medical Cen- epidemiology; comorbidity tre, D-37075 Göttingen, Germany (e-mail: bbandel@gwdg.de) Copyright © 2015 AICH – Servier Research Group. All rights reserved 327 www.dialogues-cns.org Clinical research generalized anxiety disorder (GAD), social anxiety dis- institution. Moreover, the representativeness of such order (SAD), specific phobias, and separation anxiety rates would be limited because patients with certain disorder, are the most frequent. Because patients with psychiatric disorders, such as patients with somatiza- anxiety disorders are mostly treated as outpatients, they tion disorder, tend to have high medical care utilization, probably receive less attention from clinical psychia- while others, such as patients with specific phobias, may trists than patients with other disorders that require in- only rarely seek psychiatric help. Due to the stigma as- patient treatment but are less frequent, such as schizo- sociated with mental disorders, many affected individu- phrenia or bipolar affective disorders. als are reluctant to contact mental health professionals. Finally, many patients in some countries can simply not Methodology of epidemiologic studies afford to see a physician, which would lead to an under- estimation of the prevalence of certain disorders in this Epidemiologic studies in psychiatry may help in as- population. sessing the importance of a certain disorder in order The only way to obtain reliable prevalence rates is to develop treatment strategies and in planning special a so-called “doorknock” survey, in which representative health prevention programs. They may provide use- samples are collected by using methods known from ful information on the use of health services and the population polls. From a listing of all residential ad- economic impact of psychiatric disorders on the health dresses, systematic samples are selected from different care system. Epidemiologic research may also help us regions, including urban and rural sites. Then, interview- to better understand the etiology of mental disorders. ers contact these households and interview the selected member using a structured questionnaire. To obtain a Prevalence rates complete overview, representative surveys should also include patients currently hospitalized or in long-term In epidemiologic studies, different kinds of prevalence facilities. However, not all published studies have in- rates are assessed. The lifetime prevalence is the propor- corporated the inpatient population, perhaps due to the tion of individuals who have suffered from a certain high administrative burden associated with such surveys. disorder once in their life. The annual prevalence is the The sample sizes of epidemiological surveys should percentage of probands who experienced the disorder be very large, in order to obtain reliable and general- in the 12 months before the survey. Disorders of long- izable results not only for frequent disorders but also er duration are likely to be overrepresented in annual for rare illnesses. In particular, subgroup analyses that prevalence rates compared with those of short dura- compare prevalence rates with regard to gender, age, tion. The more chronic a disease, the more similarities ethnicity, and other factors require large sample sizes. between lifetime and 12-month prevalence rates should Community surveys are associated with certain be found. The point prevalence is the prevalence of a strengths and weaknesses. They are representative, not disorder on a certain effective day. confounded by the factor of treatment-seeking, and provide large sample sizes, which allow statistical analy- Representativeness of epidemiological studies ses with sufficient power. However, it is a disadvantage that in community surveys diagnoses are not made by Community surveys experienced psychiatrists or psychologists. When large samples are investigated in population surveys, it would One relatively simple way to find out how many people not be feasible to employ psychiatrists or psychologists suffer from certain psychiatric disorders would be to re- as interviewers, due to the higher expenditures and the view the charts of all patients who attend a large mental difficulty of recruiting a sufficient number of trained spe - health service. However, by simply counting the indi- cialists for the assessment. Therefore, these studies are viduals suffering from major depression or panic dis- usually conducted by professional interviewers without order who consult a psychiatrist in private practice or a medical backgrounds, who go through a specific train - mental hospital, one would obtain prevalence rates that ing program for psychiatric interviews. The fact that the are significantly biased, as they may be influenced by prevalence rates for some mental disorders obtained various factors such as specialty of the physician or the in community services seem to be grossly exaggerated 328 . . Epidemiology of anxiety disorders - Bandelow and Michaelis Dialogues in Clinical Neuroscience - Vol 17 No. 3 2015 has often been criticized. For example, according to the and sophisticated statistical methods. In Table I, the NCS study, every third woman suffers from an anxiety largest studies are shown: the Epidemiologic Catch- disorder once in her life. Even for well-trained lay inter- ment Area Program (ECA), the National Comorbidity viewers, it may be difficult to reliably differentiate be - Survey–Replication (NCS), and the European Study of tween subthreshold cases and clinically significant cases the Epidemiology of Mental Disorders (ESEMeD) on the basis of the Diagnostic and Statistical Manual for Mental Disorders (DSM) and International Classifica - Surveys in clinical settings tion of Diseases (ICD) classification systems. Some of the DSM and ICD criteria were decided by committees However, studies conducted in psychiatric outpatient rather than being empirically derived from field stud - services or in primary care settings may also yield valu- ies, and do not provide clear cutoff scores to identify able information. If interviews are conducted by psychi- clinical cases. For anxiety disorders, in particular, it is atrists (eg, Wittchen et al ) or the study uses a general difficult to draw a clear line between pathological and psychiatric outpatient sample (eg, Lépine et al ), the well-founded fear. Anxiety belongs to our daily life, clinical cases will probably be identified more reliably. and individuals without fear would not survive for long. A worldwide survey conducted by the World Health For example, even for qualified psychiatrists it may be Organization (WHO) explored the frequency of men- a challenge to differentiate between mild forms of so- tal problems in primary care or general health settings. cial anxiety disorder and “normal” shyness or modesty. In this study, persons who were consulting health care Likewise, many mothers would say “yes” to the ques- services were screened for psychological problems and tion as to whether they worry constantly that some ac- psychiatric disorders, regardless of their reason for at- cident could happen to their children, but an interview tending that service, ie, persons consulting the doctor could feasibly lead to a diagnosis of GAD in a healthy for a nonpsychiatric disorder, such as diabetes or hyper- mother. A psychiatrist who is seeing patients with GAD tension, were also included. These studies are not ap- every day would probably take other signs and symp- propriate for obtaining representative prevalence rates toms into account when differentiating between normal for the reasons given above. However, they may yield worries and pathological fear. valuable information on the use of health services and Some representative surveys have been conducted the social and financial burden of psychiatric disorders. in recent years, using complex sampling methods, well- In statistical investigations conducted in hospital- defined diagnostic criteria, elaborate questionnaires, ized psychiatric patients, mental disorders like depres- Abbreviation Study Description ECA Epidemiologic Catchment In this project conducted in the early 1980s, a probability sample of households Area Program was selected and one adult member was interviewed in 5 US states (Connecticut, Maryland, Missouri, North Carolina, and California). The DSM-III and the Diagnostic Interview Schedule were used. It included 24 371 respondents. NCS National Comorbidity A survey based on a stratified probability sample of persons aged 15 to 54 years in Survey 48 US states not receiving inpatient psychiatric treatment that was conducted in 1990–1992. DSM-III-R diagnoses were made with the Composite International Diag- nostic Interview. A total of 8098 persons were interviewed. The interviewers were not clinicians, had an average of 5 years of prior interviewing experience and went through a 7-day training program for this survey. NCS-R National Comorbidity Sur- Approximately one decade later, the NCS-Replication Study was conducted. Per- vey–Replication sonal interviews of 9282 respondents were carried out by professional interviewers between 2001 and 2003. 25 25 ESEMeD European Study of the The ESEMeD collected data on the prevalence, risk factors, disability, and health Epidemiology of Mental care utilization associated with mood, anxiety, and alcohol-related disorders Disorders throughout Europe. It was based on 21 425 non-institutionalized adults who under- went computer-assisted personal interviews. It was completed in 2003. Table I. Large epidemiological community surveys. 329 Clinical research sion, schizophrenia, or personality disorders are usually and ICD, which was designed to be a short but ac- overrepresented, because certain features of these dis- curate psychiatric interview for epidemiologic studies. orders require inpatient treatment, including suicidality, hostility, or reduced social integration. In these surveys, Prevalence rates patients with anxiety disorders are generally underrep- resented, as anxiety disorders rarely require inpatient In Table II, the prevalence rates for the three large com- treatment. munity surveys are presented. Additionally, Wittchen and Jacobi have summarized the results of 27 Europe- Diagnosis and interview technique an studies (including the ESEMeD study). Twenty-four of these were national studies and three were cross-na- In order to obtain reliable diagnoses, interviews are tional studies. According to these surveys, specific pho - usually based on the current version of the standard bias and SAD are the most common disorders. 7 8 diagnostic tools DSM or ICD. In order to structure Even the representative population surveys show the diagnostic process and to obtain objective results, substantial discrepancies in prevalence rates. This may special interview manuals have been developed. These be attributed to various factors, including methodologi- include: cal differences that could distort the actual prevalence 9,10 • The Structured Interview for DSM (SCID), a semi- rates, for example: structured interview for major DSM Axis I diagnoses, which is administered by clinicians • Variation in the use of the diagnostic criteria (eg, dif- • The Diagnostic Interview Schedule (DIS), which ferent versions of the DSM) made it possible for the first time for trained lay in - • Variation in the use of the diagnostic interview tools terviewers to carry out assessments of clinically sig- • Methods of data collection nificant mental disorders. Before its development, • Type of interviewer the comparability of cross-national comparisons was • Interviewer instructions hampered by the the absence of common standards • Language differences or translating problems and operational procedures for diagnostic interviews • Cultural styles in conveying psychiatric symptoms • The Composite International Diagnostic Interview • Target population of the sample investigated (eg, dif- (CIDI) 3.0 for DSM, which combines questions from ferences in age range, inclusion of hospitalized pa- the DIS with Present State Examination questions tients etc) and is administered by lay interviewers • Standardization of prevalence rates to the census • The Mini-International Neuropsychiatric Interview population of each site instead of to an identical pop- 13 16 (M.I.N.I. 6.0), a structured diagnostic tool for DSM ulation. 39 3 25 14 Anxiety disorders ECA NCS-R ESEMeD Wittchen et al Ages 18–64 Prevalence rate 12 months Lifetime 12 months Lifetime 12 months Lifetime 12 months Panic disorder 0.9 1.6 3.1 5.2 0.7 1.6 0.7–3.1 GAD – – 2.9 6.2 0.9 2.8 0.2–4.3 Agoraphobia – – 1.7 2.6 0.3 0.8 0.1–10.5 SAD – – 8.0 13.0 1.6 2.8 0.6–7.9 Specific phobia 8.8 12.6 10.1 13.8 5.4 8.3 0.8–11.1 All anxiety disorders* 10.1 14.6 21.3 33.7 8.4 14.5 11.1-13.0 * Note that before the introduction of DSM-5, obsessive-compulsive disorder and post-traumatic stress disorder were included in the anxiety disorders Table II. Prevalence rates of anxiety disorders in epidemiological surveys. ECA, Epidemiologic Catchment Area Program; NCS-R, National Comorbidity Survey–Replication; ESEMeD, European Study of the Epidemiology of Mental Disorders 330 . . Epidemiology of anxiety disorders - Bandelow and Michaelis Dialogues in Clinical Neuroscience - Vol 17 No. 3 2015 However, actual differences between the investigated Age of onset and course populations may also exist, which may be due to: Prospective studies suggest that anxiety disorders are • Biological differences across races and ethnic groups chronic, ie, patients may suffer from their disorder for • Culturally determined psychosocial differences (eg, years or decades. However, this does not mean that an different roles of women in society) anxiety disorder lasts permanently for the rest of the • Traumatic stressors that influence whole nations or patient’s life. Anxiety disorders start in childhood, ado- ethnic groups (eg, war, poverty, natural disasters, or lescence, or early adulthood until they reach a peak in suppression of minorities). middle age, then tending to decrease again with older age. Separation anxiety disorder In the NCS-R, mental disorders were studied in a large sample of 10 148 adolescents aged 13 to 17 years. Before the development of DSM-5, separation anxiety As in adults, anxiety disorders are the most common disorder could only be diagnosed in children or ado- class of mental disorders, with a 12-month prevalence lescents. Therefore, adult separation anxiety disorder rate of 24.9%. Specific phobias and social anxiety disor - did not appear in the older epidemiological studies. Ac- der were the most common disorders. Compared with cording to a newer survey, the lifetime prevalence rate adults aged 18 to 64, the lifetime prevalence was less for adolescents aged 13 to 17 was 7.7%, while it was for panic disorder, GAD, and SAD, whereas specific 6.6% in adults aged 18 to 64. phobias, separation anxiety disorder, and agoraphobia without a history of panic attacks were more common Sex differences in adolescents aged 13 to 17 years. The median age of onset for anxiety disorders is 11 In Table III, the female:male ratios for the prevalence years. Specific phobias and separation anxiety disor - rates of anxiety disorders are shown. Although these der start earliest, with a median age of onset of 7 years, rates are heterogenous, it is a consistent finding that the followed by SAD (13), agoraphobia without panic at- prevalence of anxiety disorders in women is approxi- tacks (20), and panic disorder (24). GAD has the latest mately twice as high as in men. Psychosocial contribu- median age at onset (31 years). According to a German tors (eg, childhood sexual abuse and chronic stressors), epidemiological study, the 12-month prevalence rates but also genetic and neurobiological factors, have been for SAD, GAD, and specific phobia were highest in the discussed as possible causes for the higher prevalence 18- to 34-year age group, while they were highest for in women. panic disorder in the 35- to 49-year group. In the 50- 40 3 41 14 Study ECA NCS-R ESEMeD Wittchen et al Prevalence rate 1 month Lifetime 12 months Lifetime 12 months Panic disorder 2.3 2.1 1.7 1.6 1.8 GAD 1.7 2.6 1.8 2.1 Agoraphobia 1.6 3.0 1.8 3.1 SAD 1.2 1.6 1.5 2.1 Specific phobia 2.2 1.8 2.6 2.1 2.4 All anxiety disorders* 2.1 1.5 2.3 1.8 2.1 * Note that before the introduction of DSM-5, obsessive-compulsive disorder and post-traumatic stress disorder were included in the anxiety disorders Table III. Female-to-male ratio of prevalence rates for anxiety disorders (calculated from the prevalence rates reported in major epidemiological sur- veys). ECA, Epidemiologic Catchment Area Program; NCS-R, National Comorbidity Survey–Replication; ESEMeD, European Study of the Epidemiology of Mental Disorders 331 Clinical research to 64-year age group, prevalence rates decreased. They or insects, without major restrictions in quality of life. were and were lowest in the elderly (65 to 79 years). Thus, these persons very rarely seek professional help. That means that even without treatment, anxiety disor- These considerations may explain why psychiatrists or ders do not last until old age in most cases. special anxiety disorders units mostly see patients with panic disorder. For example, in our special anxiety dis- Health care utilization orders unit at the University of Göttingen, Germany, the number of patients seeking help differed substan- Anxiety disorders can be treated successfully with tially from the actual prevalence rates in the population medication and psychological therapies, eg cognitive (Figure 1). Panic disorder with or without agoraphobia 21,22 behavioral therapy (CBT). According to newer was by far the most frequent reason to consult the unit. meta-analytical data, improvement effect sizes ob- SAD and GAD patients were underrepresented in this tained with psychopharmacological drugs are higher clinical setting, and no patient sought help for a specific 23 28 than those achieved with CBT. However, a substantial phobia. underrecognition and undertreatment of anxiety disor- ders and depression has been reported. According to Panic disorder/ a WHO study, only approximately half of the cases of Agoraphobia anxiety disorders have been recognized, and only one PTSD/Acute third of the affected patients were offered drug treat- stress disorder ment. In the ESEMeD study, only one fifth (20.6%) of participants with an anxiety disorder sought help from Obsessive-compulsive disorder health care services. Of those who contacted health ser- vices, 23.2 % received no treatment of all. Of the others, Social phobia 48 30.8% received only drug treatment, 19.6% received only psychological treatment, and 26.5 were treated Generalized anxiety with both medication and psychotherapy. 35 disorder For many patients it may last years until they are referred to a specialist. According to a survey among Mixed anxiety and depression psychiatrists who were experienced in the treatment of anxiety disorders, 45% of patients suffered from symp- Figure 1. Numbers of patients attending an anxiety disor ders unit at toms of GAD for 2 years or more before they were cor- the University of Goettingen, Germany over 6 months (May- rectly diagnosed with the disorder. Oct 1999, n=466). Primary diagnoses according to ICD-10. The different anxiety disorders show varying pat- PTSD, post-traumatic stress disorder terns in health care utilization, explaining why preva- lence rates found in representative epidemiologic sur- Burden of illness veys differ from statistical studies in clinical settings. For example, 54.4% of patients with panic disorder, but It was estimated that in 2004, anxiety disorders cost only 27.3% of patients with phobias, contacted health in excess of 41 billion Euros in the European Union. care services. Patients with panic disorder often as- Results from a German survey showed that the excess sume that they have a medical rather than a psychiatric costs associated with anxiety disorders ranged from condition, and tend to have themselves re-examined € 500 to € 1600 per case in 2004. The work loss days repeatedly in internal medical or emergency wards. In for some anxiety disorders are higher than for common contrast, patients with social phobia tend to hide their somatic disorders such as diabetes. In the European problem. As shyness and shame are typical features of Union, anxiety disorders are responsible for a large pro- social anxiety, it is not surprising that these patients portion of overall burden of disease. Disability-adjusted are hesitant to see a physician and to talk about their life years lost (DALY) is a global measure of disease problem. Patients with specific phobias can mostly cope burden, expressed as the number of years lost due to with their problem. They can avoid having contact with illness, disability, or early death. The DALY which can the objects or situations they fear, such as dogs, heights, be attributed to panic disorder were estimated at 383 332 . . Epidemiology of anxiety disorders - Bandelow and Michaelis Dialogues in Clinical Neuroscience - Vol 17 No. 3 2015 783. This is less than the DALY caused by the most im- ments, it seems less probable that these disorders can portant contributors to burden of disease—depression, be attributed mainly to cultural or psychosocial causes. dementia, and alcohol abuse, but more than the DALY If this is the case, genetic and neurobiological determi- for Parkinson’s disease, epilepsy, or multiple sclerosis. nants that are distributed statistically among all people, regardless of their sociocultural surroundings, must also Is the prevalence of anxiety disorders increasing? be seen as a relevant etiological factor. When, however, the distribution of anxiety disorders is different across It is a widespread opinion in the media that “each year various cultures and time periods, this would support more and more people are suffering from anxiety dis- environmental influences in the etiology of these dis - orders,” suggesting there has been a relative increase orders. in anxiety disorders over the past 10, 50, or 100 years. In a review of 27 epidemiological studies, Wittchen However, it is difficult to find reliable evidence for a and Jacobi compared the prevalence rates in 16 Euro- change in prevalence rates for anxiety disorders. Epide- pean countries. The findings were highly heterogenous. miologic data obtained before the introduction of psy- For example, 12-month prevalence rates were found chiatric classification systems such as the DSM-III are to be between 0.6 and 7.9% for SAD and between 0.2 too imprecise to be comparable with modern studies. In and 4.3 for GAD in the different countries. Likewise, 1980, the anxiety disorders were reclassified, and panic other articles comparing the prevalence of panic dis- disorder was incorporated as a new diagnostic entity. order across different countries and cultures (included To verify the hypothesis that there is an increase Canada, Germany, Italy, Korea, Lebanon, New Zealand, or decrease in certain psychiatric disorders, one would Puerto Rico, the USA, and Taiwan) found high variabil- 36,37 have to repeat large epidemiologic surveys after a cer- ity in prevalence rates. It would be premature to at- tain time span in the same population using the same tribute these differences to actual cultural influences— methodological setting. There is one epidemiological as the same high heterogeneity in prevalence rates was program that can provide comparable data for two found when different samples from the same countries timepoints: the National Comorbidity Survey (NCS) were compared with each other. It is more likely that was performed in the years 1990 to 1992 and replicated differences in methodology account for these differ- 11 years later (NCS-R) in the years 2001 to 2003. For ences. this relatively short time span, no significant increase of prevalence rates could be demonstrated for mental Comorbidity 2,33 disorders in general. However, the rate of treatment- seeking individuals increased, which may the reason Most studies show a high overlap among the anxiety for the general impression that these disorders are disorders and between the anxiety disorders and other more frequent. Likewise, a comparison of data from mental disorders, respectively. In the NCS-R, the high- the European Union did not show a significant change est tetrachoric correlations among the anxiety disorders in prevalence rates for anxiety disorders between 2005 were found between SAD and agoraphobia (r=0.68), and 2011. between panic disorder and agoraphobia (0.64), and be- There is a reason that it is unlikely that the preva- tween specific phobia and agoraphobia (0.57). Regard - lence rates have changed substantially over the years. ing the overlap with other mental disorders, the correla- For all anxiety disorders, a heritability of approximately tion between GAD with major depression (r=0.62) was 30% to 50% has been reported —and heritable disor- particularly high. Also, high correlations of 0.55 each ders would not change their clinical picture substantial- were found between dysthymia and GAD or SAD, re- ly over decades or centuries. spectively. In clinical settings, the relative proportion of comorbid Cross-cultural differences cases is usually higher than that found in representative population surveys, because individuals with two con- When it is found that the prevalence rates of the anxiety comitant disorders, suffering from a high overall bur- disorders are more or less the same in many different den, are more likely to seek treatment than individuals countries, despite different cultural and social environ- with only one disorder (Berkson’s paradox). 333 Clinical research Conclusions and not contact health services for treatment, and of those future perspectives who utilize these services, a high percentage is not di- agnosed correctly or not offered state-of-the-art treat- Anxiety disorders are the most prevalent psychiatric ment. There is no evidence that the prevalence rates disorders. According to epidemiological surveys, one have changed in the past years. Differences in preva- third of the population is affected by an anxiety dis- lence rates found in different countries and cultures order during their lifetime. They are more common may be due to differences in methodology rather than in women. During midlife, their prevalence is highest. to culture-specific factors. High comorbidity is found These disorders are associated with a considerable de- among the anxiety disorders and between the anxiety gree of impairment, high health-care utilization and an disorders and other mental disorders, respectively. Epi- enormous economic burden for society. Although effec- demiologic studies may help in planning treatment and tive psychological and pharmacological treatments ex- prevention programs, and they may also help us to bet- ist for anxiety disorders, many affected individuals do ter understand the etiology of these disorders. o 15. Robins LN, Helzer JE, Weissman MM, et al. Lifetime prevalence of spe- REFERENCES cific psychiatric disorders in three sites. Arch Gen Psychiatry. 1984;41(10):949- 1. Burton R. The Anatomy of Melancholy. London, UK: 1621. 16. Bland RC, Orn H, Newman SC. Lifetime prevalence of psychiatric di- 2. Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month sorders in Edmonton. Acta Psychiatr Scand Suppl. 1988;338:24-32. prevalence of DSM-III-R psychiatric disorders in the United States. Results 17. Bandelow B, Domschke K. Panic Disorder. In: Stein D, Vythilingum B, from the National Comorbidity Survey. Arch Gen Psychiatry. 1994;51(1):8- eds. Anxiety Disorders and Gender. Cham, Switzerland: Springer; 2015. 18. Kessler RC, Avenevoli S, Costello EJ, et al. Prevalence, persistence, and 3. Kessler RC, Petukhova M, Sampson NA, Zaslavsky AM, Wittchen HU. sociodemographic correlates of DSM-IV disorders in the National Comor- Twelve-month and lifetime prevalence and lifetime morbid risk of an- bidity Survey Replication Adolescent Supplement. Arch Gen Psychiatry. xiety and mood disorders in the United States. Int J Methods Psychiatr Res. 2012;69(4):372-380. 2012;21(3):169-184. 19. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters 4. Wittchen HU, Essau CA, von Zerssen D, Krieg JC, Zaudig M. Lifetime EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disor- and six-month prevalence of mental disorders in the Munich Follow-Up ders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. Study. Eur Arch Psychiatry Clin Neurosci. 1992;241(4):247-258. 2005;62(6):593-602. 5. Lepine JP, Pariente P, Boulenger JP, et al. Anxiety disorders in a French 20. Jacobi F, Hofler M, Strehle J, et al. [Mental disorders in the general general psychiatric outpatient sample. Comparison between DSM-III and population : Study on the health of adults in Germany and the additional DSM-IIIR criteria. Soc Psychiatry Psychiatr Epidemiol. 1989;24(6):301-308. module mental health (DEGS1-MH)]. Nervenarzt. 2014;85(1):77-87. 6. Sartorius N, Ustun TB, Costa e Silva JA, et al. An international study 21. Bandelow B, Zohar J, Hollander E, et al. World Federation of Societies of psychological problems in primary care. Preliminary report from the of Biological Psychiatry (WFSBP) guidelines for the pharmacological treat- World Health Organization Collaborative Project on ‘Psychological Pro- ment of anxiety, obsessive-compulsive and post-traumatic stress disorders blems in General Health Care’. Arch Gen Psychiatry. 1993;50(10):819-824. - first revision. World J Biol Psychiatry. 2008;9(4):248-312. 7. American Psychiatric Association. Diagnostic and Statistical Manual of 22. Baldwin DS, Anderson IM, Nutt DJ, et al. Evidence-based pharma- Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; cological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: a revision of the 2005 guidelines 8. World Health Organization. The ICD-10 Classification of Mental and Beha - from the British Association for Psychopharmacology. J Psychopharmacol. vioral Disorders. Clinical descriptions and diagnostic guidelines. Geneva, Switzer- 2014;28(5):403-439. land: World Health Organization; 1992. 23. Bandelow B, Reitt M, Rover C, Michaelis S, Gorlich Y, Wedekind D. 9. Spitzer RL, Williams JB, Gibbon M, First MB. The Structured Clinical Efficacy of treatments for anxiety disorders: a meta-analysis. Int Clin Psy- Interview for DSM-III-R (SCID). I: History, rationale, and description. Arch chopharmacol. 2015;30(4):183-192. Gen Psychiatry. 1992;49(8):624-629. 24. Sartorius N, Ustun TB, Lecrubier Y, Wittchen HU. Depression comorbid 10. Williams JB, Gibbon M, First MB, et al. The Structured Clinical Inter- with anxiety: results from the WHO study on psychological disorders in view for DSM-III-R (SCID). II. Multisite test-retest reliability. Arch Gen Psy- primary health care. Br J Psychiatry. 1996;30(30):38-43. chiatry. 1992;49(8):630-636. 25. Alonso J, Lepine JP, Committee ESMS. Overview of key data from the 11. Robins LN, Helzer JE, Croughan J, Ratcliff KS. National Institute of European Study of the Epidemiology of Mental Disorders (ESEMeD). J Clin Mental Health Diagnostic Interview Schedule. Its history, characteristics, Psychiatry. 2007;68(suppl 2):3-9. and validity. Arch Gen Psychiatry. 1981;38(4):381-389. 26. Baldwin DS, Allgulander C, Bandelow B, Ferre F, Pallanti S. An interna- 12. Kessler RC, Ustun TB. The World Mental Health (WMH) Survey Initia- tional survey of reported prescribing practice in the treatment of patients tive Version of the World Health Organization (WHO) Composite Interna- with generalised anxiety disorder. World J Biol Psychiatry. 2012;13(7):510-516. tional Diagnostic Interview (CIDI). Int J Methods Psychiatr Res. 2004;13(2):93- 27. Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Good- win FK. The de facto US mental and addictive disorders service system. 13. Sheehan DV, Lecrubier Y, Sheehan KH, et al. The Mini-International Epidemiologic catchment area prospective 1-year prevalence rates of Neuropsychiatric Interview (M.I.N.I.): the development and validation of disorders and services. Arch Gen Psychiatry. 1993;50(2):85-94. a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin 28. Bandelow B. Epidemiology of depression and anxiety. In: Kasper S, Psychiatry. 1998;59(suppl 20):22-33;quiz 34-57. den Boer JA, Sitsen AJM, eds. Handbook on Depression and Anxiety. New 14. Wittchen HU, Jacobi F. Size and burden of mental disorders in Eu- York, NY: M. Dekker; 2003:49-68. rope--a critical review and appraisal of 27 studies. Eur Neuropsychopharma- 29. Andlin-Sobocki P, Wittchen HU. Cost of anxiety disorders in Europe. col. 2005;15(4):357-376. Eur J Neurol. 2005;12(suppl 1):39-44. 334 . . Epidemiology of anxiety disorders - Bandelow and Michaelis Dialogues in Clinical Neuroscience - Vol 17 No. 3 2015 Epidemiología de los trastornos de ansiedad en el Epidémiologie des troubles anxieux au XXIe siècle siglo XXI Los trastornos de ansiedad, que incluyen el trastorno de Les troubles anxieux, dont le trouble panique avec ou pánico con o sin agorafobia, el trastorno de ansiedad sans agoraphobie, le trouble anxieux généralisé, l’an- generalizada, el trastorno de ansiedad social, las fobias xiété sociale, les phobies spécifiques et l’anxiété de sé - específicas y el trastorno de ansiedad por separación son paration, sont les troubles mentaux les plus prévalents los trastornos mentales más prevalentes y están asocia- avec des coûts immenses en termes de santé et une dos con inmensos costos de atención de salud y una alta charge élevée. D’après de grandes études basées sur carga de enfermedad. De acuerdo con investigaciones la population, jusqu’à 33,7 % de la population souffre basadas en grandes poblaciones, hasta un 33,7% de la d’un trouble anxieux au cours de la vie. Ces pathologies población presenta un trastorno de ansiedad durante sont manifestement sous-diagnostiquées et sous-trai- su vida. Se ha demostrado que el subdiagnóstico y el tées. Leur prévalence n’a pas montré de modification subtratamiento de estos trastornos es significativo. No ces dernières années et est très variable dans les compa- existe evidencia acerca del cambio en las frecuencias de raisons interculturelles. Cette hétérogénéité est proba- prevalencia de los trastornos de ansiedad en los últimos blement plus due à des biais méthodologiques qu’à des años. En comparaciones interculturales las frecuencias influences culturelles. L’évolution des troubles anxieux de prevalencia son altamente variables. Es más proba- est chronique mais leur prévalence diminue cependant ble que esta heterogeneidad se deba a diferencias en la naturellement avec l’âge. Leur comorbidité avec les metodología más que a influencias culturales. Los tras - autres troubles anxieux et les autres maladies mentales tornos de ansiedad siguen un curso crónico; sin embar- est très élevée. go, hay una disminución natural en las frecuencias de prevalencia a mayor edad. Los trastornos de ansiedad son altamente comórbidos con otros trastornos ansiosos y otros trastornos mentales. 30. Alonso J, Angermeyer MC, Bernert S, et al. Use of mental health 36. Amering M, Katschnig H. Panic attacks and panic disorder in cross- services in Europe: results from the European Study of the Epidemio- cultural-perspective. Psychiatr Annals. 1990;20(9):511-516. logy of Mental Disorders (ESEMeD) project. Acta Psychiatr Scand Suppl. 37. Weissman MM, Bland RC, Canino GJ, et al. The cross-national epide- 2004(420):47-54. miology of panic disorder. Arch Gen Psychiatry. 1997;54(4):305-309. 31. American Psychiatric Association. American Psychiatric Association. Dia- 38. Fichter MM, Narrow WE, Roper MT, et al. Prevalence of mental illness gnostic and Statistical Manual of Mental Disorders. 3rd ed. Washington DC: in Germany and the United States. Comparison of the Upper Bavarian American Psychiatric Association; 1980. Study and the Epidemiologic Catchment Area Program. J Nerv Ment Dis. 32. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, 1996;184(10):598-606. severity, and comorbidity of 12-month DSM-IV disorders in the National 39. Bourdon KH, Rae DS, Locke BZ, Narrow WE, Regier DA. Estimating Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617-627. the prevalence of mental disorders in U.S. adults from the Epidemiologic 33. Kessler RC, Demler O, Frank RG, et al. Prevalence and treatment of Catchment Area Survey. Public Health Rep. 1992;107(6):663-668. mental disorders, 1990 to 2003. N Engl J Med. 2005;352(24):2515-2523. 40. Regier DA, Narrow WE, Rae DS. The epidemiology of anxiety disor- 34. Wittchen HU, Jacobi F, Rehm J, et al. The size and burden of mental ders: the Epidemiologic Catchment Area (ECA) experience. J Psychiatr Res. disorders and other disorders of the brain in Europe 2010. Eur Neuropsy- 1990;24(suppl 2):3-14. chopharmacol. 2011;21(9):655-679. 41. Alonso J, Angermeyer MC, Bernert S, et al. Prevalence of mental 35. Shimada-Sugimoto M, Otowa T, Hettema JM. Genetics of anxiety disorders in Europe: results from the European Study of the Epidemio- disorders: Genetic epidemiological and molecular studies in humans. Psy- logy of Mental Disorders (ESEMeD) project. Acta Psychiatr Scand Suppl. chiatry Clin Neurosci. 2015;69(7):388-401. 2004(420):21-27. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Dialogues in Clinical Neuroscience Taylor & Francis

Epidemiology of anxiety disorders in the 21st century

Loading next page...
 
/lp/taylor-francis/epidemiology-of-anxiety-disorders-in-the-21st-century-SreGum2J9G

References (42)

Publisher
Taylor & Francis
Copyright
Copyright: © 2015 Institut la Conférence Hippocrate - Servier Research Group
ISSN
1958-5969
DOI
10.31887/DCNS.2015.17.3/bbandelow
Publisher site
See Article on Publisher Site

Abstract

Clinical research Epidemiology of anxiety disorders in the 21st century Borwin Bandelow, MD, PhD; Sophie Michaelis, MD Introduction I n 1621, Robert Burton described the symptoms of anxiety attacks in socially anxious people in his book The Anatomy of Melancholy : “Many lamentable effects this fear causeth in man, as to be red, pale, tremble, sweat; Anxiety disorders, including panic disorder with or with- it makes sudden cold and heat come over all the body, out agoraphobia, generalized anxiety disorder, social palpitation of the heart, syncope, etc. It amazeth many anxiety disorder, specific phobias, and separation anxi - men that are to speak or show themselves in public.” In ety disorder, are the most prevalent mental disorders the same book, Burton cited Hippocrates’ writing on one and are associated with immense health care costs and a of his patients, who apparently suffered from what we high burden of disease. According to large population- would call “social anxiety disorder” today: “He dare not based surveys, up to 33.7% of the population are af- come into company for fear he should be misused, dis- fected by an anxiety disorder during their lifetime. Sub- graced, overshoot himself in gestures or speeches, or be stantial underrecognition and undertreatment of these sick; he thinks every man observeth him.” disorders have been demonstrated. There is no evidence Pathological anxiety, such as social phobia, has al- that the prevalence rates of anxiety disorders have ways existed in humans. Is there a reason to believe st changed in the past years. In cross-cultural comparisons, that anything has changed in the 21 century? There prevalence rates are highly variable. It is more likely that is a widespread opinion that anxiety is a characteristic this heterogeneity is due to differences in methodology feature of our modern times, and that the prevalence of than to cultural influences. Anxiety disorders follow a anxiety disorders has increased due to certain political, chronic course; however, there is a natural decrease in societal, economical, or environmental changes. prevalence rates with older age. Anxiety disorders are Among all mental diseases, the anxiety disorders, highly comorbid with other anxiety disorders and other including panic disorder with or without agoraphobia, mental disorders. Author affiliations: Department of Psychiatry and Psychotherapy, Univer- © 2015, AICH – Servier Research Group Dialogues Clin Neurosci. 2015;17:327-335. sity Medical Centre, Göttingen, Germany Keywords: anxiety disorder; panic disorder; agoraphobia; generalized anxiety Address for correspondence: Prof Dr Borwin Bandelow, von-Siebold-Str. disorder; social anxiety disorder; specific phobia; separation anxiety disorder; 5, Department of Psychiatry and Psychotherapy, University Medical Cen- epidemiology; comorbidity tre, D-37075 Göttingen, Germany (e-mail: bbandel@gwdg.de) Copyright © 2015 AICH – Servier Research Group. All rights reserved 327 www.dialogues-cns.org Clinical research generalized anxiety disorder (GAD), social anxiety dis- institution. Moreover, the representativeness of such order (SAD), specific phobias, and separation anxiety rates would be limited because patients with certain disorder, are the most frequent. Because patients with psychiatric disorders, such as patients with somatiza- anxiety disorders are mostly treated as outpatients, they tion disorder, tend to have high medical care utilization, probably receive less attention from clinical psychia- while others, such as patients with specific phobias, may trists than patients with other disorders that require in- only rarely seek psychiatric help. Due to the stigma as- patient treatment but are less frequent, such as schizo- sociated with mental disorders, many affected individu- phrenia or bipolar affective disorders. als are reluctant to contact mental health professionals. Finally, many patients in some countries can simply not Methodology of epidemiologic studies afford to see a physician, which would lead to an under- estimation of the prevalence of certain disorders in this Epidemiologic studies in psychiatry may help in as- population. sessing the importance of a certain disorder in order The only way to obtain reliable prevalence rates is to develop treatment strategies and in planning special a so-called “doorknock” survey, in which representative health prevention programs. They may provide use- samples are collected by using methods known from ful information on the use of health services and the population polls. From a listing of all residential ad- economic impact of psychiatric disorders on the health dresses, systematic samples are selected from different care system. Epidemiologic research may also help us regions, including urban and rural sites. Then, interview- to better understand the etiology of mental disorders. ers contact these households and interview the selected member using a structured questionnaire. To obtain a Prevalence rates complete overview, representative surveys should also include patients currently hospitalized or in long-term In epidemiologic studies, different kinds of prevalence facilities. However, not all published studies have in- rates are assessed. The lifetime prevalence is the propor- corporated the inpatient population, perhaps due to the tion of individuals who have suffered from a certain high administrative burden associated with such surveys. disorder once in their life. The annual prevalence is the The sample sizes of epidemiological surveys should percentage of probands who experienced the disorder be very large, in order to obtain reliable and general- in the 12 months before the survey. Disorders of long- izable results not only for frequent disorders but also er duration are likely to be overrepresented in annual for rare illnesses. In particular, subgroup analyses that prevalence rates compared with those of short dura- compare prevalence rates with regard to gender, age, tion. The more chronic a disease, the more similarities ethnicity, and other factors require large sample sizes. between lifetime and 12-month prevalence rates should Community surveys are associated with certain be found. The point prevalence is the prevalence of a strengths and weaknesses. They are representative, not disorder on a certain effective day. confounded by the factor of treatment-seeking, and provide large sample sizes, which allow statistical analy- Representativeness of epidemiological studies ses with sufficient power. However, it is a disadvantage that in community surveys diagnoses are not made by Community surveys experienced psychiatrists or psychologists. When large samples are investigated in population surveys, it would One relatively simple way to find out how many people not be feasible to employ psychiatrists or psychologists suffer from certain psychiatric disorders would be to re- as interviewers, due to the higher expenditures and the view the charts of all patients who attend a large mental difficulty of recruiting a sufficient number of trained spe - health service. However, by simply counting the indi- cialists for the assessment. Therefore, these studies are viduals suffering from major depression or panic dis- usually conducted by professional interviewers without order who consult a psychiatrist in private practice or a medical backgrounds, who go through a specific train - mental hospital, one would obtain prevalence rates that ing program for psychiatric interviews. The fact that the are significantly biased, as they may be influenced by prevalence rates for some mental disorders obtained various factors such as specialty of the physician or the in community services seem to be grossly exaggerated 328 . . Epidemiology of anxiety disorders - Bandelow and Michaelis Dialogues in Clinical Neuroscience - Vol 17 No. 3 2015 has often been criticized. For example, according to the and sophisticated statistical methods. In Table I, the NCS study, every third woman suffers from an anxiety largest studies are shown: the Epidemiologic Catch- disorder once in her life. Even for well-trained lay inter- ment Area Program (ECA), the National Comorbidity viewers, it may be difficult to reliably differentiate be - Survey–Replication (NCS), and the European Study of tween subthreshold cases and clinically significant cases the Epidemiology of Mental Disorders (ESEMeD) on the basis of the Diagnostic and Statistical Manual for Mental Disorders (DSM) and International Classifica - Surveys in clinical settings tion of Diseases (ICD) classification systems. Some of the DSM and ICD criteria were decided by committees However, studies conducted in psychiatric outpatient rather than being empirically derived from field stud - services or in primary care settings may also yield valu- ies, and do not provide clear cutoff scores to identify able information. If interviews are conducted by psychi- clinical cases. For anxiety disorders, in particular, it is atrists (eg, Wittchen et al ) or the study uses a general difficult to draw a clear line between pathological and psychiatric outpatient sample (eg, Lépine et al ), the well-founded fear. Anxiety belongs to our daily life, clinical cases will probably be identified more reliably. and individuals without fear would not survive for long. A worldwide survey conducted by the World Health For example, even for qualified psychiatrists it may be Organization (WHO) explored the frequency of men- a challenge to differentiate between mild forms of so- tal problems in primary care or general health settings. cial anxiety disorder and “normal” shyness or modesty. In this study, persons who were consulting health care Likewise, many mothers would say “yes” to the ques- services were screened for psychological problems and tion as to whether they worry constantly that some ac- psychiatric disorders, regardless of their reason for at- cident could happen to their children, but an interview tending that service, ie, persons consulting the doctor could feasibly lead to a diagnosis of GAD in a healthy for a nonpsychiatric disorder, such as diabetes or hyper- mother. A psychiatrist who is seeing patients with GAD tension, were also included. These studies are not ap- every day would probably take other signs and symp- propriate for obtaining representative prevalence rates toms into account when differentiating between normal for the reasons given above. However, they may yield worries and pathological fear. valuable information on the use of health services and Some representative surveys have been conducted the social and financial burden of psychiatric disorders. in recent years, using complex sampling methods, well- In statistical investigations conducted in hospital- defined diagnostic criteria, elaborate questionnaires, ized psychiatric patients, mental disorders like depres- Abbreviation Study Description ECA Epidemiologic Catchment In this project conducted in the early 1980s, a probability sample of households Area Program was selected and one adult member was interviewed in 5 US states (Connecticut, Maryland, Missouri, North Carolina, and California). The DSM-III and the Diagnostic Interview Schedule were used. It included 24 371 respondents. NCS National Comorbidity A survey based on a stratified probability sample of persons aged 15 to 54 years in Survey 48 US states not receiving inpatient psychiatric treatment that was conducted in 1990–1992. DSM-III-R diagnoses were made with the Composite International Diag- nostic Interview. A total of 8098 persons were interviewed. The interviewers were not clinicians, had an average of 5 years of prior interviewing experience and went through a 7-day training program for this survey. NCS-R National Comorbidity Sur- Approximately one decade later, the NCS-Replication Study was conducted. Per- vey–Replication sonal interviews of 9282 respondents were carried out by professional interviewers between 2001 and 2003. 25 25 ESEMeD European Study of the The ESEMeD collected data on the prevalence, risk factors, disability, and health Epidemiology of Mental care utilization associated with mood, anxiety, and alcohol-related disorders Disorders throughout Europe. It was based on 21 425 non-institutionalized adults who under- went computer-assisted personal interviews. It was completed in 2003. Table I. Large epidemiological community surveys. 329 Clinical research sion, schizophrenia, or personality disorders are usually and ICD, which was designed to be a short but ac- overrepresented, because certain features of these dis- curate psychiatric interview for epidemiologic studies. orders require inpatient treatment, including suicidality, hostility, or reduced social integration. In these surveys, Prevalence rates patients with anxiety disorders are generally underrep- resented, as anxiety disorders rarely require inpatient In Table II, the prevalence rates for the three large com- treatment. munity surveys are presented. Additionally, Wittchen and Jacobi have summarized the results of 27 Europe- Diagnosis and interview technique an studies (including the ESEMeD study). Twenty-four of these were national studies and three were cross-na- In order to obtain reliable diagnoses, interviews are tional studies. According to these surveys, specific pho - usually based on the current version of the standard bias and SAD are the most common disorders. 7 8 diagnostic tools DSM or ICD. In order to structure Even the representative population surveys show the diagnostic process and to obtain objective results, substantial discrepancies in prevalence rates. This may special interview manuals have been developed. These be attributed to various factors, including methodologi- include: cal differences that could distort the actual prevalence 9,10 • The Structured Interview for DSM (SCID), a semi- rates, for example: structured interview for major DSM Axis I diagnoses, which is administered by clinicians • Variation in the use of the diagnostic criteria (eg, dif- • The Diagnostic Interview Schedule (DIS), which ferent versions of the DSM) made it possible for the first time for trained lay in - • Variation in the use of the diagnostic interview tools terviewers to carry out assessments of clinically sig- • Methods of data collection nificant mental disorders. Before its development, • Type of interviewer the comparability of cross-national comparisons was • Interviewer instructions hampered by the the absence of common standards • Language differences or translating problems and operational procedures for diagnostic interviews • Cultural styles in conveying psychiatric symptoms • The Composite International Diagnostic Interview • Target population of the sample investigated (eg, dif- (CIDI) 3.0 for DSM, which combines questions from ferences in age range, inclusion of hospitalized pa- the DIS with Present State Examination questions tients etc) and is administered by lay interviewers • Standardization of prevalence rates to the census • The Mini-International Neuropsychiatric Interview population of each site instead of to an identical pop- 13 16 (M.I.N.I. 6.0), a structured diagnostic tool for DSM ulation. 39 3 25 14 Anxiety disorders ECA NCS-R ESEMeD Wittchen et al Ages 18–64 Prevalence rate 12 months Lifetime 12 months Lifetime 12 months Lifetime 12 months Panic disorder 0.9 1.6 3.1 5.2 0.7 1.6 0.7–3.1 GAD – – 2.9 6.2 0.9 2.8 0.2–4.3 Agoraphobia – – 1.7 2.6 0.3 0.8 0.1–10.5 SAD – – 8.0 13.0 1.6 2.8 0.6–7.9 Specific phobia 8.8 12.6 10.1 13.8 5.4 8.3 0.8–11.1 All anxiety disorders* 10.1 14.6 21.3 33.7 8.4 14.5 11.1-13.0 * Note that before the introduction of DSM-5, obsessive-compulsive disorder and post-traumatic stress disorder were included in the anxiety disorders Table II. Prevalence rates of anxiety disorders in epidemiological surveys. ECA, Epidemiologic Catchment Area Program; NCS-R, National Comorbidity Survey–Replication; ESEMeD, European Study of the Epidemiology of Mental Disorders 330 . . Epidemiology of anxiety disorders - Bandelow and Michaelis Dialogues in Clinical Neuroscience - Vol 17 No. 3 2015 However, actual differences between the investigated Age of onset and course populations may also exist, which may be due to: Prospective studies suggest that anxiety disorders are • Biological differences across races and ethnic groups chronic, ie, patients may suffer from their disorder for • Culturally determined psychosocial differences (eg, years or decades. However, this does not mean that an different roles of women in society) anxiety disorder lasts permanently for the rest of the • Traumatic stressors that influence whole nations or patient’s life. Anxiety disorders start in childhood, ado- ethnic groups (eg, war, poverty, natural disasters, or lescence, or early adulthood until they reach a peak in suppression of minorities). middle age, then tending to decrease again with older age. Separation anxiety disorder In the NCS-R, mental disorders were studied in a large sample of 10 148 adolescents aged 13 to 17 years. Before the development of DSM-5, separation anxiety As in adults, anxiety disorders are the most common disorder could only be diagnosed in children or ado- class of mental disorders, with a 12-month prevalence lescents. Therefore, adult separation anxiety disorder rate of 24.9%. Specific phobias and social anxiety disor - did not appear in the older epidemiological studies. Ac- der were the most common disorders. Compared with cording to a newer survey, the lifetime prevalence rate adults aged 18 to 64, the lifetime prevalence was less for adolescents aged 13 to 17 was 7.7%, while it was for panic disorder, GAD, and SAD, whereas specific 6.6% in adults aged 18 to 64. phobias, separation anxiety disorder, and agoraphobia without a history of panic attacks were more common Sex differences in adolescents aged 13 to 17 years. The median age of onset for anxiety disorders is 11 In Table III, the female:male ratios for the prevalence years. Specific phobias and separation anxiety disor - rates of anxiety disorders are shown. Although these der start earliest, with a median age of onset of 7 years, rates are heterogenous, it is a consistent finding that the followed by SAD (13), agoraphobia without panic at- prevalence of anxiety disorders in women is approxi- tacks (20), and panic disorder (24). GAD has the latest mately twice as high as in men. Psychosocial contribu- median age at onset (31 years). According to a German tors (eg, childhood sexual abuse and chronic stressors), epidemiological study, the 12-month prevalence rates but also genetic and neurobiological factors, have been for SAD, GAD, and specific phobia were highest in the discussed as possible causes for the higher prevalence 18- to 34-year age group, while they were highest for in women. panic disorder in the 35- to 49-year group. In the 50- 40 3 41 14 Study ECA NCS-R ESEMeD Wittchen et al Prevalence rate 1 month Lifetime 12 months Lifetime 12 months Panic disorder 2.3 2.1 1.7 1.6 1.8 GAD 1.7 2.6 1.8 2.1 Agoraphobia 1.6 3.0 1.8 3.1 SAD 1.2 1.6 1.5 2.1 Specific phobia 2.2 1.8 2.6 2.1 2.4 All anxiety disorders* 2.1 1.5 2.3 1.8 2.1 * Note that before the introduction of DSM-5, obsessive-compulsive disorder and post-traumatic stress disorder were included in the anxiety disorders Table III. Female-to-male ratio of prevalence rates for anxiety disorders (calculated from the prevalence rates reported in major epidemiological sur- veys). ECA, Epidemiologic Catchment Area Program; NCS-R, National Comorbidity Survey–Replication; ESEMeD, European Study of the Epidemiology of Mental Disorders 331 Clinical research to 64-year age group, prevalence rates decreased. They or insects, without major restrictions in quality of life. were and were lowest in the elderly (65 to 79 years). Thus, these persons very rarely seek professional help. That means that even without treatment, anxiety disor- These considerations may explain why psychiatrists or ders do not last until old age in most cases. special anxiety disorders units mostly see patients with panic disorder. For example, in our special anxiety dis- Health care utilization orders unit at the University of Göttingen, Germany, the number of patients seeking help differed substan- Anxiety disorders can be treated successfully with tially from the actual prevalence rates in the population medication and psychological therapies, eg cognitive (Figure 1). Panic disorder with or without agoraphobia 21,22 behavioral therapy (CBT). According to newer was by far the most frequent reason to consult the unit. meta-analytical data, improvement effect sizes ob- SAD and GAD patients were underrepresented in this tained with psychopharmacological drugs are higher clinical setting, and no patient sought help for a specific 23 28 than those achieved with CBT. However, a substantial phobia. underrecognition and undertreatment of anxiety disor- ders and depression has been reported. According to Panic disorder/ a WHO study, only approximately half of the cases of Agoraphobia anxiety disorders have been recognized, and only one PTSD/Acute third of the affected patients were offered drug treat- stress disorder ment. In the ESEMeD study, only one fifth (20.6%) of participants with an anxiety disorder sought help from Obsessive-compulsive disorder health care services. Of those who contacted health ser- vices, 23.2 % received no treatment of all. Of the others, Social phobia 48 30.8% received only drug treatment, 19.6% received only psychological treatment, and 26.5 were treated Generalized anxiety with both medication and psychotherapy. 35 disorder For many patients it may last years until they are referred to a specialist. According to a survey among Mixed anxiety and depression psychiatrists who were experienced in the treatment of anxiety disorders, 45% of patients suffered from symp- Figure 1. Numbers of patients attending an anxiety disor ders unit at toms of GAD for 2 years or more before they were cor- the University of Goettingen, Germany over 6 months (May- rectly diagnosed with the disorder. Oct 1999, n=466). Primary diagnoses according to ICD-10. The different anxiety disorders show varying pat- PTSD, post-traumatic stress disorder terns in health care utilization, explaining why preva- lence rates found in representative epidemiologic sur- Burden of illness veys differ from statistical studies in clinical settings. For example, 54.4% of patients with panic disorder, but It was estimated that in 2004, anxiety disorders cost only 27.3% of patients with phobias, contacted health in excess of 41 billion Euros in the European Union. care services. Patients with panic disorder often as- Results from a German survey showed that the excess sume that they have a medical rather than a psychiatric costs associated with anxiety disorders ranged from condition, and tend to have themselves re-examined € 500 to € 1600 per case in 2004. The work loss days repeatedly in internal medical or emergency wards. In for some anxiety disorders are higher than for common contrast, patients with social phobia tend to hide their somatic disorders such as diabetes. In the European problem. As shyness and shame are typical features of Union, anxiety disorders are responsible for a large pro- social anxiety, it is not surprising that these patients portion of overall burden of disease. Disability-adjusted are hesitant to see a physician and to talk about their life years lost (DALY) is a global measure of disease problem. Patients with specific phobias can mostly cope burden, expressed as the number of years lost due to with their problem. They can avoid having contact with illness, disability, or early death. The DALY which can the objects or situations they fear, such as dogs, heights, be attributed to panic disorder were estimated at 383 332 . . Epidemiology of anxiety disorders - Bandelow and Michaelis Dialogues in Clinical Neuroscience - Vol 17 No. 3 2015 783. This is less than the DALY caused by the most im- ments, it seems less probable that these disorders can portant contributors to burden of disease—depression, be attributed mainly to cultural or psychosocial causes. dementia, and alcohol abuse, but more than the DALY If this is the case, genetic and neurobiological determi- for Parkinson’s disease, epilepsy, or multiple sclerosis. nants that are distributed statistically among all people, regardless of their sociocultural surroundings, must also Is the prevalence of anxiety disorders increasing? be seen as a relevant etiological factor. When, however, the distribution of anxiety disorders is different across It is a widespread opinion in the media that “each year various cultures and time periods, this would support more and more people are suffering from anxiety dis- environmental influences in the etiology of these dis - orders,” suggesting there has been a relative increase orders. in anxiety disorders over the past 10, 50, or 100 years. In a review of 27 epidemiological studies, Wittchen However, it is difficult to find reliable evidence for a and Jacobi compared the prevalence rates in 16 Euro- change in prevalence rates for anxiety disorders. Epide- pean countries. The findings were highly heterogenous. miologic data obtained before the introduction of psy- For example, 12-month prevalence rates were found chiatric classification systems such as the DSM-III are to be between 0.6 and 7.9% for SAD and between 0.2 too imprecise to be comparable with modern studies. In and 4.3 for GAD in the different countries. Likewise, 1980, the anxiety disorders were reclassified, and panic other articles comparing the prevalence of panic dis- disorder was incorporated as a new diagnostic entity. order across different countries and cultures (included To verify the hypothesis that there is an increase Canada, Germany, Italy, Korea, Lebanon, New Zealand, or decrease in certain psychiatric disorders, one would Puerto Rico, the USA, and Taiwan) found high variabil- 36,37 have to repeat large epidemiologic surveys after a cer- ity in prevalence rates. It would be premature to at- tain time span in the same population using the same tribute these differences to actual cultural influences— methodological setting. There is one epidemiological as the same high heterogeneity in prevalence rates was program that can provide comparable data for two found when different samples from the same countries timepoints: the National Comorbidity Survey (NCS) were compared with each other. It is more likely that was performed in the years 1990 to 1992 and replicated differences in methodology account for these differ- 11 years later (NCS-R) in the years 2001 to 2003. For ences. this relatively short time span, no significant increase of prevalence rates could be demonstrated for mental Comorbidity 2,33 disorders in general. However, the rate of treatment- seeking individuals increased, which may the reason Most studies show a high overlap among the anxiety for the general impression that these disorders are disorders and between the anxiety disorders and other more frequent. Likewise, a comparison of data from mental disorders, respectively. In the NCS-R, the high- the European Union did not show a significant change est tetrachoric correlations among the anxiety disorders in prevalence rates for anxiety disorders between 2005 were found between SAD and agoraphobia (r=0.68), and 2011. between panic disorder and agoraphobia (0.64), and be- There is a reason that it is unlikely that the preva- tween specific phobia and agoraphobia (0.57). Regard - lence rates have changed substantially over the years. ing the overlap with other mental disorders, the correla- For all anxiety disorders, a heritability of approximately tion between GAD with major depression (r=0.62) was 30% to 50% has been reported —and heritable disor- particularly high. Also, high correlations of 0.55 each ders would not change their clinical picture substantial- were found between dysthymia and GAD or SAD, re- ly over decades or centuries. spectively. In clinical settings, the relative proportion of comorbid Cross-cultural differences cases is usually higher than that found in representative population surveys, because individuals with two con- When it is found that the prevalence rates of the anxiety comitant disorders, suffering from a high overall bur- disorders are more or less the same in many different den, are more likely to seek treatment than individuals countries, despite different cultural and social environ- with only one disorder (Berkson’s paradox). 333 Clinical research Conclusions and not contact health services for treatment, and of those future perspectives who utilize these services, a high percentage is not di- agnosed correctly or not offered state-of-the-art treat- Anxiety disorders are the most prevalent psychiatric ment. There is no evidence that the prevalence rates disorders. According to epidemiological surveys, one have changed in the past years. Differences in preva- third of the population is affected by an anxiety dis- lence rates found in different countries and cultures order during their lifetime. They are more common may be due to differences in methodology rather than in women. During midlife, their prevalence is highest. to culture-specific factors. High comorbidity is found These disorders are associated with a considerable de- among the anxiety disorders and between the anxiety gree of impairment, high health-care utilization and an disorders and other mental disorders, respectively. Epi- enormous economic burden for society. Although effec- demiologic studies may help in planning treatment and tive psychological and pharmacological treatments ex- prevention programs, and they may also help us to bet- ist for anxiety disorders, many affected individuals do ter understand the etiology of these disorders. o 15. Robins LN, Helzer JE, Weissman MM, et al. Lifetime prevalence of spe- REFERENCES cific psychiatric disorders in three sites. Arch Gen Psychiatry. 1984;41(10):949- 1. Burton R. The Anatomy of Melancholy. London, UK: 1621. 16. Bland RC, Orn H, Newman SC. Lifetime prevalence of psychiatric di- 2. Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month sorders in Edmonton. Acta Psychiatr Scand Suppl. 1988;338:24-32. prevalence of DSM-III-R psychiatric disorders in the United States. Results 17. Bandelow B, Domschke K. Panic Disorder. In: Stein D, Vythilingum B, from the National Comorbidity Survey. Arch Gen Psychiatry. 1994;51(1):8- eds. Anxiety Disorders and Gender. Cham, Switzerland: Springer; 2015. 18. Kessler RC, Avenevoli S, Costello EJ, et al. Prevalence, persistence, and 3. Kessler RC, Petukhova M, Sampson NA, Zaslavsky AM, Wittchen HU. sociodemographic correlates of DSM-IV disorders in the National Comor- Twelve-month and lifetime prevalence and lifetime morbid risk of an- bidity Survey Replication Adolescent Supplement. Arch Gen Psychiatry. xiety and mood disorders in the United States. Int J Methods Psychiatr Res. 2012;69(4):372-380. 2012;21(3):169-184. 19. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters 4. Wittchen HU, Essau CA, von Zerssen D, Krieg JC, Zaudig M. Lifetime EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disor- and six-month prevalence of mental disorders in the Munich Follow-Up ders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. Study. Eur Arch Psychiatry Clin Neurosci. 1992;241(4):247-258. 2005;62(6):593-602. 5. Lepine JP, Pariente P, Boulenger JP, et al. Anxiety disorders in a French 20. Jacobi F, Hofler M, Strehle J, et al. [Mental disorders in the general general psychiatric outpatient sample. Comparison between DSM-III and population : Study on the health of adults in Germany and the additional DSM-IIIR criteria. Soc Psychiatry Psychiatr Epidemiol. 1989;24(6):301-308. module mental health (DEGS1-MH)]. Nervenarzt. 2014;85(1):77-87. 6. Sartorius N, Ustun TB, Costa e Silva JA, et al. An international study 21. Bandelow B, Zohar J, Hollander E, et al. World Federation of Societies of psychological problems in primary care. Preliminary report from the of Biological Psychiatry (WFSBP) guidelines for the pharmacological treat- World Health Organization Collaborative Project on ‘Psychological Pro- ment of anxiety, obsessive-compulsive and post-traumatic stress disorders blems in General Health Care’. Arch Gen Psychiatry. 1993;50(10):819-824. - first revision. World J Biol Psychiatry. 2008;9(4):248-312. 7. American Psychiatric Association. Diagnostic and Statistical Manual of 22. Baldwin DS, Anderson IM, Nutt DJ, et al. Evidence-based pharma- Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; cological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: a revision of the 2005 guidelines 8. World Health Organization. The ICD-10 Classification of Mental and Beha - from the British Association for Psychopharmacology. J Psychopharmacol. vioral Disorders. Clinical descriptions and diagnostic guidelines. Geneva, Switzer- 2014;28(5):403-439. land: World Health Organization; 1992. 23. Bandelow B, Reitt M, Rover C, Michaelis S, Gorlich Y, Wedekind D. 9. Spitzer RL, Williams JB, Gibbon M, First MB. The Structured Clinical Efficacy of treatments for anxiety disorders: a meta-analysis. Int Clin Psy- Interview for DSM-III-R (SCID). I: History, rationale, and description. Arch chopharmacol. 2015;30(4):183-192. Gen Psychiatry. 1992;49(8):624-629. 24. Sartorius N, Ustun TB, Lecrubier Y, Wittchen HU. Depression comorbid 10. Williams JB, Gibbon M, First MB, et al. The Structured Clinical Inter- with anxiety: results from the WHO study on psychological disorders in view for DSM-III-R (SCID). II. Multisite test-retest reliability. Arch Gen Psy- primary health care. Br J Psychiatry. 1996;30(30):38-43. chiatry. 1992;49(8):630-636. 25. Alonso J, Lepine JP, Committee ESMS. Overview of key data from the 11. Robins LN, Helzer JE, Croughan J, Ratcliff KS. National Institute of European Study of the Epidemiology of Mental Disorders (ESEMeD). J Clin Mental Health Diagnostic Interview Schedule. Its history, characteristics, Psychiatry. 2007;68(suppl 2):3-9. and validity. Arch Gen Psychiatry. 1981;38(4):381-389. 26. Baldwin DS, Allgulander C, Bandelow B, Ferre F, Pallanti S. An interna- 12. Kessler RC, Ustun TB. The World Mental Health (WMH) Survey Initia- tional survey of reported prescribing practice in the treatment of patients tive Version of the World Health Organization (WHO) Composite Interna- with generalised anxiety disorder. World J Biol Psychiatry. 2012;13(7):510-516. tional Diagnostic Interview (CIDI). Int J Methods Psychiatr Res. 2004;13(2):93- 27. Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Good- win FK. The de facto US mental and addictive disorders service system. 13. Sheehan DV, Lecrubier Y, Sheehan KH, et al. The Mini-International Epidemiologic catchment area prospective 1-year prevalence rates of Neuropsychiatric Interview (M.I.N.I.): the development and validation of disorders and services. Arch Gen Psychiatry. 1993;50(2):85-94. a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin 28. Bandelow B. Epidemiology of depression and anxiety. In: Kasper S, Psychiatry. 1998;59(suppl 20):22-33;quiz 34-57. den Boer JA, Sitsen AJM, eds. Handbook on Depression and Anxiety. New 14. Wittchen HU, Jacobi F. Size and burden of mental disorders in Eu- York, NY: M. Dekker; 2003:49-68. rope--a critical review and appraisal of 27 studies. Eur Neuropsychopharma- 29. Andlin-Sobocki P, Wittchen HU. Cost of anxiety disorders in Europe. col. 2005;15(4):357-376. Eur J Neurol. 2005;12(suppl 1):39-44. 334 . . Epidemiology of anxiety disorders - Bandelow and Michaelis Dialogues in Clinical Neuroscience - Vol 17 No. 3 2015 Epidemiología de los trastornos de ansiedad en el Epidémiologie des troubles anxieux au XXIe siècle siglo XXI Los trastornos de ansiedad, que incluyen el trastorno de Les troubles anxieux, dont le trouble panique avec ou pánico con o sin agorafobia, el trastorno de ansiedad sans agoraphobie, le trouble anxieux généralisé, l’an- generalizada, el trastorno de ansiedad social, las fobias xiété sociale, les phobies spécifiques et l’anxiété de sé - específicas y el trastorno de ansiedad por separación son paration, sont les troubles mentaux les plus prévalents los trastornos mentales más prevalentes y están asocia- avec des coûts immenses en termes de santé et une dos con inmensos costos de atención de salud y una alta charge élevée. D’après de grandes études basées sur carga de enfermedad. De acuerdo con investigaciones la population, jusqu’à 33,7 % de la population souffre basadas en grandes poblaciones, hasta un 33,7% de la d’un trouble anxieux au cours de la vie. Ces pathologies población presenta un trastorno de ansiedad durante sont manifestement sous-diagnostiquées et sous-trai- su vida. Se ha demostrado que el subdiagnóstico y el tées. Leur prévalence n’a pas montré de modification subtratamiento de estos trastornos es significativo. No ces dernières années et est très variable dans les compa- existe evidencia acerca del cambio en las frecuencias de raisons interculturelles. Cette hétérogénéité est proba- prevalencia de los trastornos de ansiedad en los últimos blement plus due à des biais méthodologiques qu’à des años. En comparaciones interculturales las frecuencias influences culturelles. L’évolution des troubles anxieux de prevalencia son altamente variables. Es más proba- est chronique mais leur prévalence diminue cependant ble que esta heterogeneidad se deba a diferencias en la naturellement avec l’âge. Leur comorbidité avec les metodología más que a influencias culturales. Los tras - autres troubles anxieux et les autres maladies mentales tornos de ansiedad siguen un curso crónico; sin embar- est très élevée. go, hay una disminución natural en las frecuencias de prevalencia a mayor edad. Los trastornos de ansiedad son altamente comórbidos con otros trastornos ansiosos y otros trastornos mentales. 30. Alonso J, Angermeyer MC, Bernert S, et al. Use of mental health 36. Amering M, Katschnig H. Panic attacks and panic disorder in cross- services in Europe: results from the European Study of the Epidemio- cultural-perspective. Psychiatr Annals. 1990;20(9):511-516. logy of Mental Disorders (ESEMeD) project. Acta Psychiatr Scand Suppl. 37. Weissman MM, Bland RC, Canino GJ, et al. The cross-national epide- 2004(420):47-54. miology of panic disorder. Arch Gen Psychiatry. 1997;54(4):305-309. 31. American Psychiatric Association. American Psychiatric Association. Dia- 38. Fichter MM, Narrow WE, Roper MT, et al. Prevalence of mental illness gnostic and Statistical Manual of Mental Disorders. 3rd ed. Washington DC: in Germany and the United States. Comparison of the Upper Bavarian American Psychiatric Association; 1980. Study and the Epidemiologic Catchment Area Program. J Nerv Ment Dis. 32. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, 1996;184(10):598-606. severity, and comorbidity of 12-month DSM-IV disorders in the National 39. Bourdon KH, Rae DS, Locke BZ, Narrow WE, Regier DA. Estimating Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617-627. the prevalence of mental disorders in U.S. adults from the Epidemiologic 33. Kessler RC, Demler O, Frank RG, et al. Prevalence and treatment of Catchment Area Survey. Public Health Rep. 1992;107(6):663-668. mental disorders, 1990 to 2003. N Engl J Med. 2005;352(24):2515-2523. 40. Regier DA, Narrow WE, Rae DS. The epidemiology of anxiety disor- 34. Wittchen HU, Jacobi F, Rehm J, et al. The size and burden of mental ders: the Epidemiologic Catchment Area (ECA) experience. J Psychiatr Res. disorders and other disorders of the brain in Europe 2010. Eur Neuropsy- 1990;24(suppl 2):3-14. chopharmacol. 2011;21(9):655-679. 41. Alonso J, Angermeyer MC, Bernert S, et al. Prevalence of mental 35. Shimada-Sugimoto M, Otowa T, Hettema JM. Genetics of anxiety disorders in Europe: results from the European Study of the Epidemio- disorders: Genetic epidemiological and molecular studies in humans. Psy- logy of Mental Disorders (ESEMeD) project. Acta Psychiatr Scand Suppl. chiatry Clin Neurosci. 2015;69(7):388-401. 2004(420):21-27.

Journal

Dialogues in Clinical NeuroscienceTaylor & Francis

Published: Sep 30, 2015

Keywords: anxiety disorder; panic disorder; agoraphobia; generalized anxiety disorder; social anxiety disorder; specific phobia; separation anxiety disorder; epidemiology; comorbidity

There are no references for this article.