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

Published online by Cambridge University Press:  19 December 2017

Peter de Jonge*
Developmental Psychology, Department of Psychology, Rijksuniversiteit Groningen, Groningen, Netherlands Department of Psychiatry, Interdisciplinary Center Psychopathology and Emotion Regulation, University Medical Center Groningen, Groningen, Netherlands
Klaas J. Wardenaar
Department of Psychiatry, Interdisciplinary Center Psychopathology and Emotion Regulation, University Medical Center Groningen, Groningen, Netherlands
Carmen C.W. Lim
Department of Psychological Medicine, University of Otago, Dunedin, Otago, New Zealand Queensland Brain Institute, University of Queensland, St Lucia, Australia Queensland Centre for Mental Health Research, Wacol, Queensland, Australia
Sergio Aguilar-Gaxiola
Center for Reducing Health Disparities, UC Davis Health System, Sacramento, California, USA
Jordi Alonso
Health Services Research Unit, IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain Pompeu Fabra University (UPF), Barcelona, Spain CIBER en Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
Laura Helena Andrade
Núcleo de Epidemiologia Psiquiátrica - LIM 23, Instituto de Psiquiatria Hospital das Clinicas da Faculdade de Medicina da Universidade, de São Paulo, Brazil
Brendan Bunting
School of Psychology, Ulster University, Londonderry, UK
Somnath Chatterji
Department of Information, Evidence and Research, World Health Organization, Geneva, Switzerland
Marius Ciutan
National School of Public Health, Management and Development, Bucharest, Romania
Oye Gureje
Department of Psychiatry, University College Hospital, Ibadan, Nigeria
Elie G. Karam
Department of Psychiatry and Clinical Psychology, St George Hospital University Medical Center, Balamand University, Faculty of Medicine, Beirut, Lebanon Institute for Development, Research, Advocacy and Applied Care (IDRAAC), Beirut, Lebanon
Sing Lee
Department of Psychiatry, Chinese University of Hong Kong, Tai Po, Hong Kong
Maria Elena Medina-Mora
National Institute of Psychiatry Ramon de la Fuente Muñiz, Mexico City, Mexico
Jacek Moskalewicz
Institute of Psychiatry and Neurology, Warsaw, Poland
Fernando Navarro-Mateu
UDIF-SM, Subdirección General de Planificación, Innovación y Cronicidad, Servicio Murciano de Salud; IMIB-Arrixaca; CIBERESP-Murcia, Murcia, Spain
Beth-Ellen Pennell
Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor, Michigan, USA
Marina Piazza
Universidad Cayetano Heredia, Lima, Peru National Institute of Health, Lima, Peru
José Posada-Villa
Colegio Mayor de Cundinamarca University, Faculty of Social Sciences, Bogota, Colombia
Yolanda Torres
Center for Excellence on Research in Mental Health, CES University, Medellin, Colombia
Ronald C. Kessler
Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
Kate Scott
Department of Psychological Medicine, University of Otago, Dunedin, Otago, New Zealand
Author for correspondence: Peter de Jonge, E-mail:



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.

Original Articles
Copyright © Cambridge University Press 2017 

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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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