The case for eliminating excessive worry as a requirement for generalized anxiety disorder: a cross-national investigation

Ayelet Meron Ruscio; Madeleine Rassaby; Murray B. Stein; Dan J. Stein; Sergio Aguilar-Gaxiola; Ali Al-Hamzawi; Jordi Alonso; Lukoye Atwoli; Guilherme Borges; Evelyn J. Bromet; Ronny Bruffaerts; Brendan Bunting; Graça Cardoso; Stephanie Chardoul; Giovanni de Girolamo; Peter de Jonge; Oye Gureje; Josep Maria Haro; Elie G. Karam; Aimee Karam; Andrzej Kiejna; Viviane Kovess-Masfety; Sue Lee; Fernando Navarro-Mateu; Daisuke Nishi; Marina Piazza; José Posada-Villa; Nancy A. Sampson; Kate M. Scott; Tim Slade; Juan Carlos Stagnaro; Yolanda Torres; Maria Carmen Viana; Cristian Vladescu; Zahari Zarkov; Ronald C. Kessler

doi:10.1017/S003329172400182X

The case for eliminating excessive worry as a requirement for generalized anxiety disorder: a cross-national investigation

Ayelet Meron Ruscio, Madeleine Rassaby, Murray B. Stein, Dan J. Stein, Sergio Aguilar-Gaxiola, Ali Al-Hamzawi, Jordi Alonso, Lukoye Atwoli, Guilherme Borges, Evelyn J. Bromet, Ronny Bruffaerts, Brendan Bunting, Graça Cardoso, Stephanie Chardoul, Giovanni de Girolamo, Peter de Jonge, Oye Gureje, Josep Maria Haro, Elie G. Karam, Aimee KaramAndrzej Kiejna, Viviane Kovess-Masfety, Sue Lee, Fernando Navarro-Mateu, Daisuke Nishi, Marina Piazza, José Posada-Villa, Nancy A. Sampson, Kate M. Scott, Tim Slade, Juan Carlos Stagnaro, Yolanda Torres, Maria Carmen Viana, Cristian Vladescu, Zahari Zarkov, Ronald C. Kessler

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Abstract

Around the world, people living in objectively difficult circumstances who experience symptoms of generalized anxiety disorder (GAD) do not qualify for a diagnosis because their worry is not 'excessive' relative to the context. We carried out the first large-scale, cross-national study to explore the implications of removing this excessiveness requirement. Data come from the World Health Organization World Mental Health Survey Initiative. A total of 133 614 adults from 12 surveys in Low- or Middle-Income Countries (LMICs) and 16 surveys in High-Income Countries (HICs) were assessed with the Composite International Diagnostic Interview. Non-excessive worriers meeting all other criteria for GAD were compared to respondents meeting all criteria for GAD, and to respondents without GAD, on clinically-relevant correlates. Removing the excessiveness requirement increases the global lifetime prevalence of GAD from 2.6% to 4.0%, with larger increases in LMICs than HICs. Non-excessive and excessive GAD cases worry about many of the same things, although non-excessive cases worry more about health/welfare of loved ones, and less about personal or non-specific concerns, than excessive cases. Non-excessive cases closely resemble excessive cases in socio-demographic characteristics, family history of GAD, and risk of temporally secondary comorbidity and suicidality. Although non-excessive cases are less severe on average, they report impairment comparable to excessive cases and often seek treatment for GAD symptoms. Individuals with non-excessive worry who meet all other criteria for GAD are clinically significant cases. Eliminating the excessiveness requirement would lead to a more defensible GAD diagnosis.

Original language	English
Pages (from-to)	3447-3458
Number of pages	12
Journal	Psychological Medicine
Volume	54
Issue number	12
Early online date	4 Oct 2024
DOIs	https://doi.org/10.1017/S003329172400182X
Publication status	Published (in print/issue) - 4 Oct 2024

Bibliographical note

Publisher Copyright:
Copyright © The Author(s), 2024. Published by Cambridge University Press.

Funding

The World Health Organization World Mental Health (WMH) Survey Initiative is supported by the United States National Institute of Mental Health (NIMH; R01 MH070884), the John D. and Catherine T. MacArthur Foundation, the Pfizer Foundation, the United States Public Health Service (R13-MH066849, R01-MH069864, and R01 DA016558), the Fogarty International Center (FIRCA R03-TW006481), the Pan American Health Organization, Eli Lilly and Company, Ortho-McNeil Pharmaceutical Inc., GlaxoSmithKline, and Bristol-Myers Squibb. We thank the staff of the WMH Data Collection and Data Analysis Coordination Centers for assistance with instrumentation, fieldwork, and consultation on data analysis. None of the funders had any role in the design, analysis, interpretation of results, or preparation of this paper. The Argentina survey – Estudio Argentino de Epidemiología en Salud Mental (EASM) – was supported by a grant from the Argentinian Ministry of Health (Ministerio de Salud de la Nación) – (Grant Number 2002-17270/13-5). The 2007 Australian National Survey of Mental Health and Wellbeing was funded by the Australian Government Department of Health and Ageing. The São Paulo Megacity Mental Health Survey is supported by the State of São Paulo Research Foundation (FAPESP) Thematic Project Grant 03/00204-3. The Bulgarian Epidemiological Study of common mental disorders -EPIBUL – is supported by the Ministry of Health and the National Center for Public Health Protection. (For papers that include the Bulgaria 2 survey, add: EPIBUL 2, conducted in 2016–17, is supported by the Ministry of Health and European Economic Area Grants. The Colombian National Study of Mental Health (NSMH) is supported by the Ministry of Social Protection. The Mental Health Study Medellín – Colombia was carried out and supported jointly by the Center for Excellence on Research in Mental Health (CES University) and the Secretary of Health of Medellín. The ESEMeD surveys (Belgium; France; Germany; Italy; Netherlands; Spain) were funded by the European Commission (Contracts QLG5-1999-01042; SANCO 2004123, and EAHC 20081308), the Piedmont Region (Italy), Fondo de Investigación Sanitaria, Instituto de Salud Carlos III, Spain (FIS 00/0028), Ministerio de Ciencia y Tecnología, Spain (SAF 2000-158-CE), Generalitat de Catalunya (2017 SGR 452; 2014 SGR 748), Instituto de Salud Carlos III (CIBER CB06/02/0046, RETICS RD06/0011 REM-TAP), and other local agencies and by an unrestricted educational grant from GlaxoSmithKline. Implementation of the Iraq Mental Health Survey (IMHS) and data entry were carried out by the staff of the Iraqi Ministry of Health and Ministry of Planning with direct support from the Iraqi IMHS team with funding from both the Japanese and European Funds through United Nations Development Group Iraq Trust Fund (UNDG ITF). The Israel National Health Survey is funded by the Ministry of Health with support from the Israel National Institute for Health Policy and Health Services Research and the National Insurance Institute of Israel. The World Mental Health Japan (WMHJ) Survey is supported by the Grant for Research on Psychiatric and Neurological Diseases and Mental Health (H13-SHOGAI-023, H14-TOKUBETSU-026, H16-KOKORO-013, H25-SEISHIN-IPPAN-006) from the Japan Ministry of Health, Labour and Welfare. The Lebanese Evaluation of the Burden of Ailments and Needs of the Nation (L.E.B.A.N.O.N.) is supported by the Lebanese Ministry of Public Health, the WHO (Lebanon), National Institute of Health/Fogarty International Center (R03 TW006481-01), anonymous private donations to IDRAAC, Lebanon, and unrestricted grants from Algorithm, AstraZeneca, Benta, Bella Pharma, Eli Lilly, Glaxo Smith Kline, Lundbeck, Novartis, OmniPharma, Pfizer, Phenicia, Servier, and UPO. The Mexican National Comorbidity Survey (MNCS) is supported by the National Institute of Psychiatry Ramon de la Fuente (INPRFMDIES 4280) and by the National Council on Science and Technology (CONACyT-G30544-H), with supplemental support from the Pan American Health Organization (PAHO). Te Rau Hinengaro: The New Zealand Mental Health Survey (NZMHS) is supported by the New Zealand Ministry of Health, Alcohol Advisory Council, and the Health Research Council. The Northern Ireland Study of Mental Health was funded by the Health & Social Care Research & Development Division of the Public Health Agency. The Peruvian World Mental Health Study was funded by the National Institute of Health of the Ministry of Health of Peru. The Polish project Epidemiology of Mental Health and Access to Care –EZOP Project (PL 0256) was carried out by the Institute of Psychiatry and Neurology, Warsaw in consortium with the Department of Psychiatry, Medical University, Wroclaw, the National Institute of Public Health – National Institute of Hygiene, Warsaw and in partnership with Psykiatrist Institut, Vinderen, Universitet Oslo. The project was funded by the European Economic Area Financial Mechanism and the Norwegian Financial Mechanism. EZOP project was co-financed by the Polish Ministry of Health. The Portuguese Mental Health Study was carried out by the Department of Mental Health, Faculty of Medical Sciences, NOVA University of Lisbon, with collaboration of the Portuguese Catholic University, and was funded by Champalimaud Foundation, Gulbenkian Foundation, Foundation for Science and Technology (FCT), and the Portuguese Ministry of Health. The Romania WMH study projects ‘Policies in Mental Health Area’ and ‘National Study regarding Mental Health and Services Use’ were carried out by National School of Public Health & Health Services Management (present National School of Public Health Management & Professional Development, Bucharest), with technical support of Metro Media Transilvania, the National Institute of Statistics, SC Cheyenne Services SRL, and Statistics Netherlands. Funding was provided by the Ministry of Public Health with supplemental support of Eli Lilly Romania SRL. The South Africa Stress and Health Study (SASH) is supported by the US National Institute of Mental Health (R01-MH059575) and National Institute of Drug Abuse with supplemental funding from the South African Department of Health and the University of Michigan. The Psychiatric Enquiry to General Population in Southeast Spain – Murcia (PEGASUS-Murcia) Project has been financed by the Regional Health Authorities of Murcia (Servicio Murciano de Salud and Consejería de Sanidad y Política Social) and Fundación para la Formación e Investigación Sanitarias (FFIS) of Murcia. The Ukraine Comorbid Mental Disorders during Periods of Social Disruption (CMDPSD) study is funded by the US National Institute of Mental Health (NIMH; R01-MH61905). The US National Comorbidity Survey Replication (NCS-R) is supported by the National Institute of Mental Health (NIMH; U01-MH60220) with supplemental support from the National Institute of Drug Abuse (NIDA), the Substance Abuse and Mental Health Services Administration (SAMHSA), the Robert Wood Johnson Foundation (RWJF; Grant 044708), and the John W. Alden Trust. DJS is supported by the Medical Research Council of South Africa (MRC). MBS has received research support from NIH, Department of Veterans Affairs, and the Department of Defense. A complete list of all within-country and cross-national WMH publications can be found at http://www.hcp.med.harvard.edu/wmh/

Keywords

classification
diagnosis
epidemiology
generalized anxiety disorder
global mental health
worry

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

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10.1017/S003329172400182X

Ruscio et al., 2024 epub ahead of printFinal published version, 228 KBLicence: CC BY

Cite this

Ruscio, A. M., Rassaby, M., Stein, M. B., Stein, D. J., Aguilar-Gaxiola, S., Al-Hamzawi, A., Alonso, J., Atwoli, L., Borges, G., Bromet, E. J., Bruffaerts, R., Bunting, B., Cardoso, G., Chardoul, S., de Girolamo, G., de Jonge, P., Gureje, O., Haro, J. M., Karam, E. G., ... Kessler, R. C. (2024). The case for eliminating excessive worry as a requirement for generalized anxiety disorder: a cross-national investigation. Psychological Medicine, 54(12), 3447-3458. https://doi.org/10.1017/S003329172400182X

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title = "The case for eliminating excessive worry as a requirement for generalized anxiety disorder: a cross-national investigation",

abstract = "Around the world, people living in objectively difficult circumstances who experience symptoms of generalized anxiety disorder (GAD) do not qualify for a diagnosis because their worry is not 'excessive' relative to the context. We carried out the first large-scale, cross-national study to explore the implications of removing this excessiveness requirement. Data come from the World Health Organization World Mental Health Survey Initiative. A total of 133 614 adults from 12 surveys in Low- or Middle-Income Countries (LMICs) and 16 surveys in High-Income Countries (HICs) were assessed with the Composite International Diagnostic Interview. Non-excessive worriers meeting all other criteria for GAD were compared to respondents meeting all criteria for GAD, and to respondents without GAD, on clinically-relevant correlates. Removing the excessiveness requirement increases the global lifetime prevalence of GAD from 2.6\% to 4.0\%, with larger increases in LMICs than HICs. Non-excessive and excessive GAD cases worry about many of the same things, although non-excessive cases worry more about health/welfare of loved ones, and less about personal or non-specific concerns, than excessive cases. Non-excessive cases closely resemble excessive cases in socio-demographic characteristics, family history of GAD, and risk of temporally secondary comorbidity and suicidality. Although non-excessive cases are less severe on average, they report impairment comparable to excessive cases and often seek treatment for GAD symptoms. Individuals with non-excessive worry who meet all other criteria for GAD are clinically significant cases. Eliminating the excessiveness requirement would lead to a more defensible GAD diagnosis.",

keywords = "classification, diagnosis, epidemiology, generalized anxiety disorder, global mental health, worry",

author = "Ruscio, \{Ayelet Meron\} and Madeleine Rassaby and Stein, \{Murray B.\} and Stein, \{Dan J.\} and Sergio Aguilar-Gaxiola and Ali Al-Hamzawi and Jordi Alonso and Lukoye Atwoli and Guilherme Borges and Bromet, \{Evelyn J.\} and Ronny Bruffaerts and Brendan Bunting and Gra{\c c}a Cardoso and Stephanie Chardoul and \{de Girolamo\}, Giovanni and \{de Jonge\}, Peter and Oye Gureje and Haro, \{Josep Maria\} and Karam, \{Elie G.\} and Aimee Karam and Andrzej Kiejna and Viviane Kovess-Masfety and Sue Lee and Fernando Navarro-Mateu and Daisuke Nishi and Marina Piazza and Jos{\'e} Posada-Villa and Sampson, \{Nancy A.\} and Scott, \{Kate M.\} and Tim Slade and Stagnaro, \{Juan Carlos\} and Yolanda Torres and Viana, \{Maria Carmen\} and Cristian Vladescu and Zahari Zarkov and Kessler, \{Ronald C.\}",

note = "Publisher Copyright: Copyright {\textcopyright} The Author(s), 2024. Published by Cambridge University Press.",

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language = "English",

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Ruscio, AM, Rassaby, M, Stein, MB, Stein, DJ, Aguilar-Gaxiola, S, Al-Hamzawi, A, Alonso, J, Atwoli, L, Borges, G, Bromet, EJ, Bruffaerts, R, Bunting, B, Cardoso, G, Chardoul, S, de Girolamo, G, de Jonge, P, Gureje, O, Haro, JM, Karam, EG, Karam, A, Kiejna, A, Kovess-Masfety, V, Lee, S, Navarro-Mateu, F, Nishi, D, Piazza, M, Posada-Villa, J, Sampson, NA, Scott, KM, Slade, T, Stagnaro, JC, Torres, Y, Viana, MC, Vladescu, C, Zarkov, Z & Kessler, RC 2024, 'The case for eliminating excessive worry as a requirement for generalized anxiety disorder: a cross-national investigation', Psychological Medicine, vol. 54, no. 12, pp. 3447-3458. https://doi.org/10.1017/S003329172400182X

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T1 - The case for eliminating excessive worry as a requirement for generalized anxiety disorder: a cross-national investigation

AU - Ruscio, Ayelet Meron

AU - Rassaby, Madeleine

AU - Stein, Murray B.

AU - Stein, Dan J.

AU - Aguilar-Gaxiola, Sergio

AU - Al-Hamzawi, Ali

AU - Alonso, Jordi

AU - Atwoli, Lukoye

AU - Borges, Guilherme

AU - Bromet, Evelyn J.

AU - Bruffaerts, Ronny

AU - Bunting, Brendan

AU - Cardoso, Graça

AU - Chardoul, Stephanie

AU - de Girolamo, Giovanni

AU - de Jonge, Peter

AU - Gureje, Oye

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AU - Navarro-Mateu, Fernando

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AU - Piazza, Marina

AU - Posada-Villa, José

AU - Sampson, Nancy A.

AU - Scott, Kate M.

AU - Slade, Tim

AU - Stagnaro, Juan Carlos

AU - Torres, Yolanda

AU - Viana, Maria Carmen

AU - Vladescu, Cristian

AU - Zarkov, Zahari

AU - Kessler, Ronald C.

PY - 2024/10/4

Y1 - 2024/10/4

N2 - Around the world, people living in objectively difficult circumstances who experience symptoms of generalized anxiety disorder (GAD) do not qualify for a diagnosis because their worry is not 'excessive' relative to the context. We carried out the first large-scale, cross-national study to explore the implications of removing this excessiveness requirement. Data come from the World Health Organization World Mental Health Survey Initiative. A total of 133 614 adults from 12 surveys in Low- or Middle-Income Countries (LMICs) and 16 surveys in High-Income Countries (HICs) were assessed with the Composite International Diagnostic Interview. Non-excessive worriers meeting all other criteria for GAD were compared to respondents meeting all criteria for GAD, and to respondents without GAD, on clinically-relevant correlates. Removing the excessiveness requirement increases the global lifetime prevalence of GAD from 2.6% to 4.0%, with larger increases in LMICs than HICs. Non-excessive and excessive GAD cases worry about many of the same things, although non-excessive cases worry more about health/welfare of loved ones, and less about personal or non-specific concerns, than excessive cases. Non-excessive cases closely resemble excessive cases in socio-demographic characteristics, family history of GAD, and risk of temporally secondary comorbidity and suicidality. Although non-excessive cases are less severe on average, they report impairment comparable to excessive cases and often seek treatment for GAD symptoms. Individuals with non-excessive worry who meet all other criteria for GAD are clinically significant cases. Eliminating the excessiveness requirement would lead to a more defensible GAD diagnosis.

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KW - classification

KW - diagnosis

KW - epidemiology

KW - generalized anxiety disorder

KW - global mental health

KW - worry

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JO - Psychological Medicine

JF - Psychological Medicine

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ER -

The case for eliminating excessive worry as a requirement for generalized anxiety disorder: a cross-national investigation

Abstract

Bibliographical note

Funding

Keywords

UN SDGs

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