Asian Journal of Psychiatry 24 (2016) 110–117

Contents lists available at ScienceDirect

Asian Journal of Psychiatry

journal homepage: www.elsevier.com/locate/ajp

Regional update

A systematic review of anxiety prevalence in adults within primary

care and community settings in Malaysia
Chin Hoong Wonga,* , Zia U Bakt Sultan Shaha , Cheong Lieng Tenga , Tzi Quen Linc,
Zainab Abdul Majeedb , Chun Wai Chana
a
Department of Family Medicine, International Medical University, IMU Clinical School, Jalan Rasah, 70300 Seremban, Negeri Sembilan, Malaysia
b
Department of Psychiatry, International Medical University, IMU Clinical School, Jalan Rasah, 70300 Seremban, Negeri Sembilan, Malaysia
c
IMU Healthcare, International Medical University, No. 126 Jalan Jalil Perkasa 19, Bukit Jalil, 57000 Kuala Lumpur, Malaysia

A R T I C L E I N F O A B S T R A C T

Article history: Background: Anxiety disorders are common mental health disorders with significant impact on the
Received 8 December 2015 individual as well as burden on the country as a whole.
Accepted 27 August 2016 Methods: A systematic review of databases, reference lists, internet sources, and input from content
experts revealed 42 studies that documented the prevalence of anxiety symptoms or disorders. 12 of
Keywords: these studies specifically evaluated anxiety disorders.
Anxiety Results: 4 studies looked at the prevalence of anxiety disorders in the general population, whilst the
Prevalence
remainder focused on selected population groups: university students (4 studies); substance abuse
Malaysia
(3 studies); and victims of abuse (1 study). Studies in the general population showed that the prevalence
of generalised anxiety disorder was 0.4–5.6%, mixed anxiety and depression were 3–5%, panic without
agoraphobia 0.4%, phobia unspecified 0.5–1%, and anxiety not-otherwise-specified 0.3–6.5%. We found
significant variability in anxiety disorders in the studies in selected population groups. The variability
could also have been affected by methodological factors within each study.
Conclusion: This study provides a broad overview of the prevalence of anxiety disorders in Malaysia. More
research is required to develop diagnostic instruments that are validated for local use and comparable
with international standards. Reliable prevalence estimates are lacking within certain groups, e.g. those
in rural, indigenous, migrant population groups and those exposed to natural disasters.
ã 2016 Elsevier B.V. All rights reserved.

1. Introduction impact on both genders between the ages of 15 and 34 (Baxter

et al., 2014). Globally, anxiety disorders affect approximately 7.3%
Anxiety disorders are common mental health disorders of the population but vary depending on gender, culture, conflict,
associated with a high burden of disease (Somers et al., 2006). age and economic status (Baxter et al., 2013).
Diagnostic categories exist, such as the Diagnostic and Statistical In Malaysia, the estimated annual economic burden of anxiety
Manual of Mental Disorders (DSM) (American Psychiatric Associa- is more than 80 million USD (Manaf et al., 2009). However,
tion, 2013) and the International Classification of Diseases (ICD) by evidence suggests that primary care doctors in Malaysia struggle to
the World Health Organisation (WHO) (World Health Organiza- diagnose and manage anxiety disorders (Shahabudin et al., 1994).
tion, n.d.). Anxiety disorders are the sixth major cause of disability In addition, some studies show that mental health problems
worldwide, especially in high-income and middle-income coun- continue to be stigmatised in Malaysia (Hanafiah and Van Bortel,
tries. They are especially prevalent in females and have the highest 2015; Yeap and Low, 2009). Whilst there is a significant body of
data available regarding anxiety disorders in Malaysia, there has
yet to be a coherent aggregation of the studies to identify the
prevalence of anxiety disorders as a whole. The objective of this
* Corresponding author. review is to provide an overview of studies on the prevalence of
E-mail addresses: [email protected] (C.H. Wong),
anxiety disorders in Malaysia.
[email protected] (Z.U.B. Sultan Shah), [email protected]
(C.L. Teng), [email protected] (T.Q. Lin), [email protected]
(Z.A. Majeed), [email protected] (C.W. Chan).

http://dx.doi.org/10.1016/j.ajp.2016.08.020
1876-2018/ã 2016 Elsevier B.V. All rights reserved.
 C.H. Wong et al. / Asian Journal of PsychiatryAJP 24 (2016) 110–117 111

2. Methods Scholar with the same combination of terms for additional articles.
Articles were obtained with the assistance of the university
2.1. Search strategy librarian. A content expert reviewed the list of articles and
contributed further articles for screening. When the study had
A systematic search was conducted to obtain data on the been initiated, the definition of anxiety disorders in DSM 4
prevalence of different types of anxiety disorders in Malaysia. We included obsessive-compulsive disorder, posttraumatic stress
searched PubMed and Scopus using known text words and MeSH disorder and acute stress disorder, which have since then been
terms pertaining to anxiety and its related disorders with removed in DSM 5 (American Psychiatric Association, 2013).
“prevalence” and “Malaysia,” “Malaya,” and the names of every Hence, the study will be following the DSM 4 category of anxiety
state in Malaysia in turn. The text words and MeSH terms used disorders (Fig. 1).
were: “anxiety disorders,” “anxiety,” “panic disorders,” “panic,”
“obsessive compulsive disorder,” “OCD,” “generalized anxiety 2.2. Screening
disorder,” “GAD,” “agoraphobia,” “phobic disorders,” “stress
disorders,” “stress disorders, traumatic,” “post-traumatic stress Two researchers screened the articles in two phases. During the
disorder,” “PTSD,” “neurocirculatory asthenia.” No limitations were first screening phase, two researchers independently screened the
set on the language or year of publication. We also searched Google title and abstract of all articles. The researchers performed a

Fig. 1. Flow chart showing the process of article selection for review.
112 C.H. Wong et al. / Asian Journal of PsychiatryAJP 24 (2016) 110–117

preliminary screening of 20 articles to assess inter-observer From a survey instrument point of view, the preferred screening
variability – both researchers had a 90% agreement. A checklist tool was the Depression, Anxiety and Stress Scales (DASS), with 11
was used to maintain consistency, but any disagreement was of the 35 studies using the tool (9 using the shorter DASS-21 and 2
discussed between both researchers. Additionally, the researchers the full DASS). The preferred diagnostic tool was CIS-R (Clinical
searched articles that may have referred to other primary research Interview Schedule Revised), with 3 of the 35 studies using the
articles containing data on prevalence. During the second tool.
screening phase, the researchers independently screened the full A wide variation of anxiety symptoms exists in different
text of all articles. A second checklist was used by the researchers subgroups within the general population. Some population
for consistency and any uncertainty was resolved by a consensus subgroups exhibit higher levels, e.g. students and factory workers
decision. The researchers included all articles that involved adults (Table 4) (Table 5).
(aged 18 years and above). We only included studies that were Table 6 shows a summary of the prevalence of anxiety disorders
based on community or primary care samples. from the available studies. Students, victims of abuse, and those
involved with substance abuse demonstrate higher levels of
2.3. Data extraction and measures anxiety disorders.

The researchers extracted information from each article and 4. Discussion

entered the data in a database with mandatory entry of key
variables to maintain consistency. Researchers met regularly to This systematic review provides a comprehensive overview of
discuss issues. Additionally, the researchers contacted the studies that document the prevalence of anxiety symptoms and
primary authors of articles for further information when disorders in Malaysia. Table 4 shows the prevalence of anxiety
reporting was unclear. Tables 1 and 2 show the factors we symptoms among different groups. We found the prevalence of
considered for this study. anxiety symptoms to be 6–8% in the general population (Table 4).
In terms of anxiety disorders, our study shows that the commonest
3. Results types of anxiety disorder in our general population are mixed
anxiety-depressive disorder (MADD), followed by phobia unspeci-
We identified 1236 potential studies from the initial systematic fied and generalised anxiety disorder (GAD) (Table 6).
review; 35 of these studies met our preliminary inclusion criteria We can only make cautious comparisons with studies on
(9 studies performed in primary care and 26 studies performed in a prevalence from other countries due to methodological differences
variety of community settings) (Table 3). The majority of studies primarily related to the type of diagnostic instrument and the
were done within urban areas, with a preference for the more diagnostic criteria used. The World Mental Health Survey (WMHS),
developed states of Wilayah Persekutuan and Selangor. Few using the World Mental Health Composite International Diagnostic
studies were done to assess the prevalence of anxiety symptoms Interview (WMH-CIDI), demonstrated that the most common
or disorders in the general population and the majority focused on types of anxiety disorders within the general population in
selected subgroups. We found the majority of studies focused on Western countries are specific phobias followed by social phobia
screening for anxiety symptoms rather than the diagnosis of but the least common is obsessive compulsive disorder (OCD)
anxiety disorders. The data was too heterogeneous to appreciate (Michael et al., 2007). The prevalence of GAD (Table 6) in the
trends in anxiety symptoms or disorders or variations by gender, general population is comparable to a study in Singapore that used
age, urbanicity, or time of study. the WMH-CIDI (Chong et al., 2012). Comparisons with the WMHS
In terms of sampling strategy, 45% did not have a clear response show that the prevalence of GAD in Malaysia is similarly low when
rate and 67% did not have a good sampling strategy to reduce bias. compared with non-Western countries; the 12-month prevalence

Table 1
Methodological Factors.

Response Rate We considered response rates more than 80% to be “excellent.”

Coverage Categorised based on the geographical spread of the study: “local” indicating limited coverage to a town, city, or an institution. “Regional”
indicating a state, district, or studies involving regions beyond a single state. “National” indicates studies attempting to sample a nation-wide
representation.
Sampling strategy We classified studies based on whether they attempted to reduce sampling bias
Survey Instruments Survey instruments were categorised broadly into those used for screening and those for diagnostic purposes.
Primary Care vs. We defined “primary care” studies as studies done within a healthcare establishment providing primary care services. We defined “community”
Community studies as studies done within a non-healthcare establishment within the community.
Symptoms vs. Disorders We categorised studies into those that evaluated the presence of symptoms and those that evaluated the presence of disorders.

Table 2
Subject Factors.

Gender Categorised according to “male,” “female,” or “mixed.”

Age Age ranges as stated in the study, but we used “broad age” where an overall estimate was reported.
Time Categorised by: “2011–2015,” “2006–2010,” “2001–2005,” “1996–2000,” and “1991–1995.”
State Categorised by state
Type of Categorised according to: “disease specific,” “gender specific,” “natural disaster,” “students,” “substance abuse,” “victims of abuse,” “work specific,” and
population studies involving “general population/primary care” – according to the nature of the studies involved.
Conflict We indicated the presence of conflict if subjects had undergone current or past wars or persecution, either within Malaysia or abroad.
Urbanicity Categorised into “urban,” “rural,” or “mixed.”
 C.H. Wong et al. / Asian Journal of PsychiatryAJP 24 (2016) 110–117 113

Table 3
Summary of studies (35 studies).

Number of studies with anxiety Number of studies with anxiety disorders Number of studies with anxiety disorders
disorders/symptoms = 35 studies (diagnostic plus screening tools) = 12 (diagnostic instruments only) = 5 studies
studies

Total Community Primary Care Community Primary care Community Primary Care
Gender
Male 5 3 2 2 0 1 0
Female 4 3 1 1 0 1 0
Mixed 26 20 6 6 3 2 1

Age
18–30 years 6 6 0 0 0 0 0
Broad age 29 20 9 9 3 4 1

Time
2011–2015 5 4 1 2 0 0 0
2006–2010 8 6 2 2 0 2 0
2001–2005 6 5 1 2 1 1 0
1996–2000 2 1 1 1 1 1 1
1991–1995 1 0 1 0 0 0 0
Not stated 13 10 3 2 1 0 0

State
Selangor 11 9 2 3 1 1 1
Wilayah Persekutuan 17 12 5 4 2 2 1
Pahang 1 1 0 0 0 0 0
Penang 1 1 0 0 0 0 0
Kelantan 2 2 2 0 0 0 0
Negeri Sembilan 1 1 0 0 0 0 0
Sabah 1 1 0 1 0 1 0
Sarawak 1 0 1 0 1 0 0
2 states 8 6 2 1 1 1 1
3 or more states 3 3 0 1 0 1 0
Not stated 3 2 1 1 0 0 0

Type of population
Disease specific 7 3 4 0 0 0 0
Gender specific 1 0 1 0 0 0 0
Natural disasters 1 1 0 0 0 0 0
University students 14 14 0 4 0 0 0
Substance abuse 3 3 0 3 0 2 0
Victims of abuse 1 1 0 1 0 1 0
General population/primary care 7 3 4 1 3 1 1
Work specific 2 2 0 0 0 0 0

Conflict
Yes 2 2 0 1 0 0 0
No 33 24 9 8 3 4 1

Urbanicity
Urban 20 16 4 5 1 2 1
Rural 3 2 1 0 0 0 0
Mixed 12 8 4 4 2 2 0

Response Rate
More than 80% 13 8 5 1 1 1 0
Less than 80% 8 6 2 2 1 1 1
Not stated 14 12 2 6 1 2 0

Coverage
Local 28 20 8 8 3 3 1
Regional 6 5 1 0 0 0 0
National 1 1 0 1 0 1 0

Sampling strategy
Sampling strategy 12 10 2 4 1 2 0
No sampling strategy 23 16 7 5 2 2 1

Survey Instruments
Screening 30 23 7 5 2 – –
Diagnostic 5 4 1 4 1 – –
114 C.H. Wong et al. / Asian Journal of PsychiatryAJP 24 (2016) 110–117

Table 4
Prevalence of Anxiety Symptoms according to Type of Population.

Type of Population No. of Description of studies that examined the presence of anxiety symptoms No. of Prevalence of anxiety
Studies subjects symptoms
Disease specific 7 3 studies on patients with gastrointestinal problems; 5826 1.3–31%
1 on cancer patients; 1 on patients with hypertension;
1 on diabetic patients; 1 on men with erectile dysfunction
Gender specific 1 1 study on women in an urban primary care setting 845 7.8%
University students 10 7 studies on medical students; 3 on non-medical students 3445 38–85%
General population/ 3 2 studies done in the East Coast of Malaysia – 1 of which was a rural study. 1 study done in 8418 6–8%;
primary care Selangor of mixed urbanicity Rural study 17%
Work specific 2 1 study on electronic assembly workers; 1 study on automotive assembly workers 1224 24–47%

Table 5
Summary of studies studying the prevalence of anxiety disorders (12 studies).

Author and Type of Coverage Population Age Sampling Purpose of Study

Year Population size strategy?
1. Krishnaswamy General National 3666 Broad Yes To determine the prevalence and factors associated with the presence of common
et al. (2012b) Population mental disorders in the Malaysian population
2. Sidi (2000) Primary Care Local 418 Broad No To examine the differences between sexual functioning among patients with anxiety
(Malay only) disorder as compared to a normal control group.
3. ZamZam et al. Primary Care Local 263 Broad Yes To report the prevalence of psychiatric illness in a semi-urban primary care setting in
(2009) Malaysia.
4. Taha et al. Primary Care Local 180 Broad No To determine the prevalence of depression and anxiety disorder in the primary care
(2005) clinics in Kuching city and to examine the usage of complementary and alternative
medicine (CAM) among the primary care patients who have psychiatric problems.
5. Al-Naggar University Local 468 Broad Yes To determine most common phobias and associated factors in university students
(2012) Students
6. Al-Naggar et al. University Local 250 Broad Yes To determine relationship between perfectionism and social anxiety in university
(2013) Students students
7. Salina et al. University Local 101 Broad No To study the prevalence of social anxiety problem and potential risk factors that may
(2008) Students be associated with social anxiety among medical students.
8. Haque (2004) University Local 56 Mean No To determine prevalence of PTSD in Eastern European students in Malaysia.
Students age
26.9
9. Ardakani et al. Substance Local 50 Broad No To assess the prevalence of comorbid psychiatric disorders in patients on
(2013) Abuse age maintenance methadone therapy.
10. Sulaiman et al. Substance Local 292 Broad No To determine the types of non-psychotic psychiatric co-morbidities in Malaysian
(2013) Abuse age patients with methamphetamine dependence.
11. Gill et al. (2010)Substance Local 142 Broad No To determine the prevalence of anxiety disorders amongst drug users in a
Abuse age rehabilitation centre.
(male)
12. Din et al. (2010) Victims of Local 40 Broad Yes To determine the prevalence and factors influencing PTSD among a sample of help-
abuse age seeking women experiencing domestic violence.
(female)

ranged from 0 to 1.2%, whereas Western countries have a higher (Table 6). Subramaniam et al. (2006), in validating the CIS-R,
prevalence of 1–3.1% (Michael et al., 2007). Michael et al. (2007) acknowledged that the validated version was obtained through a
noted wide variability in less developed countries possibly related study on patients in clinical settings and their patient selection was
to the validity of diagnostic criteria within those settings. With unlikely to represent those within the community. To complicate
regards to MADD, the 12-month prevalence of MADD in matters, head-to-head comparison studies between diagnostic
Netherlands studied using the CIDI was 0.6% (Spijker et al., instruments also show variability in their validity (Jordanova et al.,
2010). Das-Munshi et al. (2008), using the CIS-R in a study in Great 2004).
Britain, found a 1-month prevalence of 8.8%. A systematic review of Additionally, the impact of cultural factors on diagnosis is a
anxiety disorders by Somers et al. (2006) demonstrated great further challenge that needs consideration. Current diagnostic
variability due to environmental and cultural factors, but instruments do not easily consider the impact of culture (Haque,
methodological factors (e.g. sampling methods, diagnostic criteria, 2008). Defining culture is difficult as is integrating its associated
diagnostic instrument) also contributed to this variability. elements within psychiatric diagnosis. This has broader implica-
In this review, the study by Krishnaswamy et al. (2012b) used tions not only on the training of healthcare professionals, but also
the CIS-R that is based on the ICD-10. This was the first time a for improving public awareness and healthcare policy. Although
validated version of the CIS-R has been used in Malaysia but the the DSM IV-TR and more latterly the DSM-5 incorporate a cultural
authors faced challenges with the literacy of the subjects in formulation tool, the tool has yet to be systematically tested.
response to the survey as well as the sensitive nature of some of the The three most prevalent natural disasters in Malaysia are
questions. To date, no other diagnostic instruments have been floods, storms, and landslides. These three disasters, especially
validated for use in Malaysia even though other diagnostic floods, account for the bulk of economic loss and mortality as a
instruments were used by other studies found during this review result of natural disasters occurring in Malaysia (PreventionWeb,
 C.H. Wong et al. / Asian Journal of PsychiatryAJP 24 (2016) 110–117 115

Table 6
Prevalence of anxiety disorders (12 studies).

Grouping No. of Total Diagnostic or Community GAD Mixed Social Panic Phobia Specific Anxiety OCD PTSD
studies subjects screening (C) or anxiety anxiety without unspecified phobia NOS
tools used primary care and agoraphobia
(PC) depression
General 1 3666 CIS-R C 0.4% 4% 0.5
population 1 418 GHQ-30 and PC 0.3%
DIS
1 180 Self-designed PC 5.6% 3% 0.4%
questionnaire
1 263 PHQ-9 PC 6.5%

Students 3 (local 819 LSAS, Social C 54– Up to

students) Phobia 88% 26.1%
Inventory,
SIAS
1 (foreign 56 TSI, Everstine C 27%
students in
Malaysia

Substance 2 434 SCID, MINI, C 1–18% 3–23% 4–5% 18% 63% 1–2% 1%
abuse
1 50 GHQ-28 and C 6% 34% 36%
SCL-90-R

Victims of 1 40 DAPS C 60%

abuse
(female
only)

Abbreviations: GAD = Generalised anxiety disorder; OCD = obsessive compulsive disorder; PTSD = post-traumatic stress disorder; NOS = not otherwise specified; CIS-
R = Clinical Interview Schedule-Revised; GHQ = General Health Questionnaire; DIS = Diagnostic Interview Schedule; LSAS = Liebowitz Social Anxiety Scale; SIAS = Social
Interaction Anxiety Scale; TSI = Trauma Symptom Inventory; Everstine = Everstine Trauma Response Index; SCID = Structured Clinical Interview for DSM Disorders;
MINI = Mini-International Neuropsychiatric Interview; PHQ-9 = Patient Health Questionnaire-9; SCL-90-R = Symptom Checklist-90-Revised; DAPS – Detailed Assessment of
Posttraumatic Stress.

2014). Despite the fact that natural disasters impact the country in prevalence of SAD among adults in East Asia is low, ranging from
a widespread fashion, little is known on the mental health impact 0.4% in Taiwan, 0.2–0.6% in Korea, 0.2% in China, and 0.8% in Japan.
following these disasters. Evidence from Katz et al. (2002) Both Hofmann et al. (2010) and Furmark (2002) noted that
demonstrated that acute stress disorder, PTSD and GAD have prevalence rates varied greatly and were influenced by cultural
been consistently present for years after natural disasters. The differences and methodological variables. For example, the
single study we found in this systematic review showed that the prevalence of SAD among Omani students ranged from 37% to
prevalence of GAD 4–6 weeks post intervention was comparable to 54%, depending on the instrument used. Conversely, the low rate in
the prevalence rate in the general population (Krishnaswamy et al., Japan could be attributed to Taijin-Kyofu-Sho, an acceptable
2012a). The relatively low prevalence rate of mental health culture bound syndrome that have features similar to SAD
sequaelae in this Malaysian study may be due to the protective (Hofmann et al., 2010; Lim, 2013). Similarly, Wilson (2005) found
effect of religion on mental health disorders (Sundram et al., 2008; that SAD in university students in Australia varied from 16% to 38%
van Griensven et al., 2006). This result has to be interpreted with depending on the course studied by the students, but the author
caution because it is based on one study. Additional research is expressed concerns regarding the validity of the screening tools
required to elucidate the impact of natural disasters on our used. The high prevalence of SAD in this review does warrant
population. further attention as SAD may negatively impact on the scope and
We found one study that showed the prevalence of PTSD in quality of learning as well as academic achievement (Brook and
foreign students studying in Malaysia to be 27% (Haque, 2004). In Willoughby, 2015; Topham and Russell, 2012).
recent years, Malaysia has been expanding its provision of higher Anxiety disorders are also a common co-comorbidity in
education for international students (UNESCO, 2013). Some of substance abuse and there is a significant association between
these students may have been victims of conflict or natural substance abuse and anxiety disorder. Among the anxiety
disasters. For example, Iran is a major source of international disorders, GAD and panic disorder with or without agoraphobia
students to Malaysia (UNESCO, 2013). As this is an isolated study, it had the highest associations with substance use (Compton et al.,
is difficult to draw any meaningful conclusions on the scale of PTSD 2007; Grant et al., 2004). Anxiety disorders were significantly
in foreign students in Malaysia. Nonetheless, the study does related to both alcohol and drug use disorders, with stronger
highlight a need for more research and preparedness for higher association in substance dependence than substance abuse (Smith
education and other related institutions that seek to cater for the and Book, 2008). The prevalence of GAD in this study is comparable
needs of increasing numbers of international students in Malaysia. to the findings from the National Epidemiologic Survey on Alcohol
Our study found the prevalence of social anxiety disorder (SAD), and Related Conditions (NESARC), which is about 2.04% (Alegria
or social phobia, to be unusually high in university students based et al., 2010). Among the substance abuse group in this study,
on the three studies we included for final analysis. Furmark (2002) anxiety disorder not-otherwise-specified (NOS) appears to have
found the lifetime prevalence of SAD to be between 7 and 13% in the highest prevalence rate. It is possible that the presentations
Western countries but the prevalence in Asian countries was were influenced by intoxication or withdrawal of substances and
noticeably lower at 0.5%. Hofmann et al. (2010), in reviewing the were therefore unable to meet the diagnostic criteria of other
relationship between culture and SAD, found the 12-month anxiety disorders. Other possibilities include the amount, the
116 C.H. Wong et al. / Asian Journal of PsychiatryAJP 24 (2016) 110–117

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00110-5.
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