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Lifetime experience of multiple common mental disorders and 19-year mortality: results from a Canadian population-based cohort

  • M. Kingsbury (a1), E. Sucha (a1), N. J. Horton (a2), H. Sampasa-Kanyinga (a1), J. M. Murphy (a3) (a4) (a5), S. E. Gilman (a6) (a7) and I. Colman (a1)...



To examine the impact of multiple psychiatric disorders over the lifetime on risk of mortality in the general population.


Data came from a random community-based sample of 1397 adults in Atlantic Canada, recruited in 1992. Major depression, dysthymia, panic disorder, generalised anxiety disorder and alcohol use disorders were assessed using the Diagnostic Interview Schedule (DIS). Vital status of participants through 2011 was determined using probabilistic linkages to the Canadian Mortality Database. Cox proportional hazard models with age at study entry as the time scale were used to investigate the relationship between DIS diagnoses and mortality, adjusted for participant education, smoking and obesity at baseline.


Results suggested that mood and anxiety disorders rarely presented in isolation – the majority of participants experienced multiple psychiatric disorders over the lifetime. Elevated risk of death was found among men with both major depression and dysthymia (HR 2.56; 95% CI 1.12–5.89), depression and alcohol use disorders (HR 2.45; 95% CI 1.18–5.10) and among men and women who experienced both panic disorder and alcohol use disorders (HR 3.80; 95% CI 1.19–12.16).


The experience of multiple mental disorders over the lifetime is extremely common, and associated with increased risk of mortality, most notably among men. Clinicians should be aware of the importance of considering contemporaneous symptoms of multiple psychiatric conditions.


Corresponding author

Author for correspondence: Ian Colman, E-mail:


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Adams, KF, Schatzkin, A, Harris, TB, Kipnis, V, Mouw, T, Ballard-Barbash, R, Hollenbeck, A and Leitzmann, MF (2006) Overweight, obesity, and mortality in a large prospective cohort of persons 50 to 71 years old. New England Journal of Medicine 355, 763778.
Bateson, M, Brilot, B and Nettle, D (2011) Anxiety: an evolutionary approach. Canadian Journal of Psychiatry 56, 707715.
Bolton, J, Cox, B, Clara, I and Sareen, J (2006) Use of alcohol and drugs to self-medicate anxiety disorders in a nationally representative sample. The Journal of Nervous and Mental Disease 194, 818825.
Bolton, JM, Robinson, J and Sareen, J (2009) Self-medication of mood disorders with alcohol and drugs in the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Affective Disorders 115, 367375.
Boyd, JH, Burke, JD, Gruenberg, E, Holzer, CE, Rae, DS, George, LK, Karno, M, Stoltzman, R, McEvoy, L and Nestadt, G (1984) Exclusion criteria of DSM-III: a study of co-occurrence of hierarchy-free syndromes. Archives of General Psychiatry 41, 983989.
Brown, C, Schulberg, HC, Madonia, MJ, Shear, MK and Houck, PR (1996) Treatment outcomes for primary care patients with major depression and lifetime anxiety disorders. The American Journal of Psychiatry 153, 12931300.
Brown, TA, Campbell, LA, Lehman, CL, Grisham, JR and Mancill, RB (2001) Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large clinical sample. Journal of Abnormal Psychology 110, 585599.
Colman, I, Kingsbury, M, Sucha, E, Horton, NJ, Murphy, JM and Gilman, SE (2018) Depressive and anxious symptoms and 20-year mortality: evidence from the Stirling County Study. Depression and Anxiety 35, 638647.
Coryell, W, Noyes, R and Clancy, J (1982) Excess mortality in panic disorder: a comparison with primary unipolar depression. Archives of General Psychiatry 39, 701703.
Cuijpers, P, Vogelzangs, N, Twisk, J, Kleiboer, A, Li, J and Penninx, BW (2014 a) Comprehensive meta-analysis of excess mortality in depression in the general community versus patients with specific illnesses. American Journal of Psychiatry 171, 453462.
Cuijpers, P, Vogelzangs, N, Twisk, J, Kleiboer, A, Li, J and Penninx, BW (2014 b) Is excess mortality higher in depressed men than in depressed women? A meta-analytic comparison. Journal of Affective Disorders 161, 4754.
Dierker, LC, Avenevoli, S, Stolar, M and Merikangas, KR (2002) Smoking and depression: an examination of mechanisms of comorbidity. American Journal of Psychiatry 159, 947953.
Dobson, KS (1985) The relationship between anxiety and depression. Clinical Psychology Review 5, 307324.
Ezzati, M and Lopez, AD (2003) Estimates of global mortality attributable to smoking in 2000. Elsevier The Lancet 362, 847852.
Gilman, SE and Abraham, HD (2001) A longitudinal study of the order of onset of alcohol dependence and major depression. Drug and Alcohol Dependence 63, 277286.
Gilman, SE, Sucha, E, Kingsbury, M, Horton, NJ, Murphy, JM and Colman, I (2017) Depression and mortality in a longitudinal study: 1952–2011. Canadian Medical Association Journal 189, E1304E1310.
Gräsbeck, A, Rorsman, B, Hagnell, O and Isberg, PE (1996) Mortality of anxiety syndromes in a normal population. The Lundby Study. Neuropsychobiology 33, 118126.
Harris, EC and Barraclough, B (1998) Excess mortality of mental disorder. British Journal of Psychiatry 173, 1153.
Henriksson, MM, Aro, HM, Marttunen, MJ, Heikkinen, ME, Isometsa, ET, Kuoppasalmi, KI and Lonnqvist, JK (1993) Mental disorders and comorbidity in suicide. American Journal of Psychiatry 150, 935940.
Hoge, EA, Brandstetter, K, Moshier, S, Pollack, MH, Wong, KK and Simon, NM (2009) Broad spectrum of cytokine abnormalities in panic disorder and posttraumatic stress disorder. Depression and Anxiety 26, 447455.
Holahan, CJ, Moos, RH, Holahan, CK, Cronkite, RC and Randall, PK (2003) Drinking to cope and alcohol use and abuse in unipolar depression: a 10-year model. Journal of Abnormal Psychology 112, 159165.
Howe, GR and Lindsay, J (1981) A generalized iterative record linkage computer system for use in medical follow-up studies. Computers and Biomedical Research 14, 327340.
Hummer, RA and Hernandez, EM (2013) The effect of educational attainment on adult mortality in the United States. Population bulletin 68, 116.
Keller, MB and Shapiro, RW (1982) ‘Double depression’: superimposition of acute depressive episodes on chronic depressive disorders. American Journal of Psychiatry 139, 438442.
Kessler, RC, Wai, TC, Demler, O and Walters, EE (2005) Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry 62, 617627.
Kikkenborg Berg, S, Caspar Thygesen, L, Hastrup Svendsen, J, Vinggaard Christensen, A and Zwisler, AD (2014) Anxiety predicts mortality in ICD patients: results from the cross-sectional national CopenHeart ICD survey with register follow-up. PACE – Pacing and Clinical Electrophysiology 37, 16411650.
Laan, W, Termorshuizen, F, Smeets, HM, Boks, MPM, De Wit, NJ and Geerlings, MI (2011) A comorbid anxiety disorder does not result in an excess risk of death among patients with a depressive disorder. Journal of Affective Disorders 135, 284291.
Lai, HMX, Cleary, M, Sitharthan, T and Hunt, GE (2015) Prevalence of comorbid substance use, anxiety and mood disorders in epidemiological surveys, 1990–2014: a systematic review and meta-analysis. Drug and Alcohol Dependence 154, 113.
Larson, SL, Owens, PL, Ford, D and Eaton, W (2001) Depressive disorder, dysthymia, and risk of stroke: thirteen-year follow-up from the Baltimore epidemiologic catchment area study. Stroke 32, 19791983.
Lasser, K, Boyd, JW, Woolhandler, S, Himmelstein, DU, McCormick, D and Bor, DH (2000) Smoking and mental illness: a population-based prevalence study. Journal of the American Medical Association 284, 26062610.
Lee, WE, Wadsworth, MEJ and Hotopf, M (2006) The protective role of trait anxiety: a longitudinal cohort study. Psychological medicine 36, 345351.
Lovibond, PF and Lovibond, SH (1995) The structure of negative emotional states: comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behaviour Research and Therapy 33, 335343.
Luppino, FS, De Wit, LM, Bouvy, PF, Stijnen, T, Cuijpers, P, Penninx, BWJH and Zitman, FG (2010) Overweight, obesity, and depression: a systematic review and meta-analysis of longitudinal studies. Archives of General Psychiatry 67, 220229.
Maser, JD, Cloninger, CR (eds) (1990) Comorbidity of Mood and Anxiety Disorders. Washington, DC: American Psychiatric Press Inc.
Merikangas, KR, Mehta, RL, Molnar, BE, Walters, EE, Swendsen, JD, Aguilar-Gaziola, S, Bijl, R, Borges, G, Caraveo-Anduaga, JJ, Dewit, DJ, Kolody, B, Vega, WA, Wittchen, H-U and Kessler, RC (1998) Comorbidity of substance use disorders with mood and anxiety disorders. Addictive Behaviors 23, 893907.
Miech, RA and Shanahan, MJ (2000) Socioeconomic status and depression over the life course. Journal of Health and Social Behavior 41, 162.
Murphy, JM (1994) The Stirling county study: then and now. International Review of Psychiatry 6, 329348.
Murphy, JM, Monson, RR, Olivier, DC, Sobol, AM and Leighton, AH (1987) Affective disorders and mortality. Archives of General Psychiatry 44, 473.
Murphy, JM, Burke, JD, Monson, RR, Horton, NJ, Laird, NM, Lesage, A, Sobol, AM and Leighton, AH (2008) Mortality associated with depression. Social Psychiatry and Psychiatric Epidemiology 43, 594601.
Naicker, K, Johnson, JA, Skogen, JC, Manuel, D, Øverland, S, Sivertsen, B and Colman, I (2017) Type 2 diabetes and comorbid symptoms of depression and anxiety: longitudinal associations with mortality risk. Diabetes Care 40, 352358.
Nock, MK, Hwang, I, Sampson, NA and Kessler, RC (2010) Mental disorders, comorbidity and suicidal behavior: results from the National Comorbidity Survey Replication. Molecular psychiatry 15, 868876.
Phillips, AC, Batty, GD, Gale, CR, Deary, IJ, Osborn, D, MacIntyre, K and Carroll, D (2009) Generalized anxiety disorder, major depressive disorder, and their comorbidity as predictors of all-cause and cardiovascular mortality: the Vietnam experience study. Psychosomatic Medicine 71, 395403.
Prince, M, Patel, V, Saxena, S, Maj, M, Maselko, J, Phillips, MR and Rahman, A (2007) No health without mental health. Lancet 370, 859877.
Rehm, J, Room, R, Graham, K, Monteiro, M, Gmel, G and Sempos, CT (2003) The relationship of average volume of alcohol consumption and patterns of drinking to burden of disease: an overview. Addiction 98, 12091228.
Rhebergen, D, Beekman, AT, de Graaf, R, Nolen, WA, Spijker, J, Hoogendijk, WJ and Penninx, BW (2009) The three-year naturalistic course of major depressive disorder, dysthymic disorder and double depression. Journal of Affective Disorders 115, 450459.
Robins, LN, Helzer, JE, Croughan, J and Ratcliff, KS (1981) National Institute of Mental Health diagnostic interview schedule. Archives of General Psychiatry 38, 381389.
Roca, M, Gili, M, Garcia-Garcia, M, Salva, J, Vives, M, Garcia Campayo, J and Comas, A (2009) Prevalence and comorbidity of common mental disorders in primary care. Journal of Affective Disorders 119, 5258.
Room, R, Babor, T and Rehm, J (2005) Alcohol and public health. The Lancet 365, 519530.
Roy-Byrne, PP, Stang, P, Wittchen, HU, Ustun, B, Walters, EE and Kessler, RC (2000) Lifetime panic-depression comorbidity in the National Comorbidity Survey: association with symptoms, impairment, course and help-seeking. British Journal of Psychiatry 176, 229235.
Russ, T, Stamatakis, E, Hamer, M, Starr, JM, Kivimaki, M and Batty, GD (2012) Association between psychological distress and mortality: individual participant pooled analysis of 10 prospective cohort studies. BMJ 345, e4933.
Simon, GE (1992) Psychiatric disorder and functional somatic symptoms as predictors of health care use. Psychiatric Medicine 10, 4959.
Smith, JP and Randall, CL (2012) Anxiety and alcohol use disorders: comorbidity and treatment considerations. Alcohol Research: Current Reviews 34, 414431.
Smith, ME and Newcombe, HB (1982) Use of the Canadian mortality data base for epidemiological follow-up. Canadian Journal of Public Health 73, 3946.
van Hout, HP, Beekman, AT, de Beurs, E, Comijs, H, van Marwijk, H, de Haan, M, van Tilburg, W and Deeg, DJ (2004) Anxiety and the risk of death in older men and women. British Journal of Psychiatry 185, 399404.
Walker, ER, McGee, RE and Druss, BG (2015) Mortality in mental disorders and global disease burden implications: a systematic review and meta-analysis. JAMA Psychiatry 72, 334341.
Whiteford, HA, Degenhardt, L, Rehm, J, Baxter, AJ, Ferrari, AJ, Erskine, HE, Charlson, FJ, Norman, RE, Flaxman, AD, Johns, N, Burstein, R, Murray, CJ and Vos, T (2013) Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. The Lancet 382, 15751586.
Whooley, MA, de Jonge, P, Vittinghoff, E, Otte, C, Moos, R, Carney, RM, Ali, S, Dowray, S, Na, B, Feldman, MD, Schiller, NB and Browner, WS (2008) Depressive symptoms, health behaviors, and risk of cardiovascular events in patients with coronary heart disease. JAMA 300, 23792388.



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