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The cross-national structure of mental disorders: results from the World Mental Health Surveys

  • Peter de Jonge (a1) (a2), Klaas J. Wardenaar (a2), Carmen C.W. Lim (a3) (a4) (a5), Sergio Aguilar-Gaxiola (a6), Jordi Alonso (a7) (a8) (a9), Laura Helena Andrade (a10), Brendan Bunting (a11), Somnath Chatterji (a12), Marius Ciutan (a13), Oye Gureje (a14), Elie G. Karam (a15) (a16), Sing Lee (a17), Maria Elena Medina-Mora (a18), Jacek Moskalewicz (a19), Fernando Navarro-Mateu (a20), Beth-Ellen Pennell (a21), Marina Piazza (a22) (a23), José Posada-Villa (a24), Yolanda Torres (a25), Ronald C. Kessler (a26) and Kate Scott (a3)...



The patterns of comorbidity among mental disorders have led researchers to model the underlying structure of psychopathology. While studies have suggested a structure including internalizing and externalizing disorders, less is known with regard to the cross-national stability of this model. Moreover, little data are available on the placement of eating disorders, bipolar disorder and psychotic experiences (PEs) in this structure.


We evaluated the structure of mental disorders with data from the World Health Organization Composite International Diagnostic Interview, including 15 lifetime mental disorders and six PEs. Respondents (n = 5478–15 499) were included from 10 high-, middle- and lower middle-income countries across the world aged 18 years or older. Confirmatory factor analyses (CFAs) were used to evaluate and compare the fit of different factor structures to the lifetime disorder data. Measurement invariance was evaluated with multigroup CFA (MG-CFA).


A second-order model with internalizing and externalizing factors and fear and distress subfactors best described the structure of common mental disorders. MG-CFA showed that this model was stable across countries. Of the uncommon disorders, bipolar disorder and eating disorder were best grouped with the internalizing factor, and PEs with a separate factor.


These results indicate that cross-national patterns of lifetime common mental-disorder comorbidity can be explained with a second-order underlying structure that is stable across countries and can be extended to also cover less common mental disorders.


Corresponding author

Author for correspondence: Peter de Jonge, E-mail:


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The WHO World Mental Health Survey collaborators are Sergio Aguilar-Gaxiola, MD, PhD, Ali Al-Hamzawi, MD, Mohammed Salih Al-Kaisy, MD, Jordi Alonso, MD, PhD, Laura Helena Andrade, MD, PhD, Corina Benjet, PhD, Guilherme Borges,ScD, Evelyn J. Bromet, PhD, Ronny Bruffaerts, PhD, Brendan Bunting, PhD, Jose Miguel Caldas de Almeida, MD, PhD, Graça Cardoso, MD, PhD, Somnath Chatterji, MD, Alfredo H. Cia, MD, Louisa Degenhardt, PhD, Koen Demyttenaere, MD, PhD, John Fayyad, MD, Silvia Florescu, MD, PhD, Giovanni de Girolamo, MD, Oye Gureje, MD, DSc, FRCPsych, Josep Maria Haro, MD, PhD, Yanling He, MD, Hristo Hinkov, MD, PhD, Chi-yi Hu, MD, PhD, Yueqin Huang, MD, MPH, PhD, Peter de Jonge, PhD, Aimee Nasser Karam, PhD, Elie G. Karam, MD, Norito Kawakami, MD, DMSc, Ronald C. Kessler, PhD, Andrzej Kiejna, MD, PhD, Viviane Kovess-Masfety, MD, PhD, Sing Lee, MB, BS, Jean-Pierre Lepine, MD, Daphna Levinson, PhD, John McGrath, MD, PhD, Maria Elena Medina-Mora, PhD, Jacek Moskalewicz, PhD, Fernando Navarro-Mateu, MD, PhD, Beth-Ellen Pennell, MA, Marina Piazza, MPH, ScD, Jose Posada-Villa, MD, Kate M. Scott, PhD, Tim Slade, PhD, Juan Carlos Stagnaro, MD, PhD, Dan J. Stein, FRCPC, PhD, Margreet ten Have, PhD, Yolanda Torres, MPH, Dra.HC, Maria Carmen Viana, MD, PhD, Harvey Whiteford, MBBS, PhD, David R. Williams, MPH, PhD, Bogdan Wojtyniak, ScD.



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The cross-national structure of mental disorders: results from the World Mental Health Surveys

  • Peter de Jonge (a1) (a2), Klaas J. Wardenaar (a2), Carmen C.W. Lim (a3) (a4) (a5), Sergio Aguilar-Gaxiola (a6), Jordi Alonso (a7) (a8) (a9), Laura Helena Andrade (a10), Brendan Bunting (a11), Somnath Chatterji (a12), Marius Ciutan (a13), Oye Gureje (a14), Elie G. Karam (a15) (a16), Sing Lee (a17), Maria Elena Medina-Mora (a18), Jacek Moskalewicz (a19), Fernando Navarro-Mateu (a20), Beth-Ellen Pennell (a21), Marina Piazza (a22) (a23), José Posada-Villa (a24), Yolanda Torres (a25), Ronald C. Kessler (a26) and Kate Scott (a3)...


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