Accepted Manuscript

Increased prevalence of anxiety disorders in third-generation migrants in comparison

to natives and to first-generation migrants

Baptiste Pignon, Ali Amad, Antoine Pelissolo, Thomas Fovet, Pierre Thomas,
Guillaume Vaiva, Jean-Luc Roelandt, Imane Benradia, Benjamin Rolland, Pierre A.
Geoffroy
PII: S0022-3956(17)31317-1
DOI: 10.1016/j.jpsychires.2018.03.007
Reference: PIAT 3334

To appear in: Journal of Psychiatric Research

Received Date: 3 December 2017

Revised Date: 26 February 2018
Accepted Date: 19 March 2018

Please cite this article as: Pignon B, Amad A, Pelissolo A, Fovet T, Thomas P, Vaiva G, Roelandt J-
L, Benradia I, Rolland B, Geoffroy PA, Increased prevalence of anxiety disorders in third-generation
migrants in comparison to natives and to first-generation migrants, Journal of Psychiatric Research
(2018), doi: 10.1016/j.jpsychires.2018.03.007.

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 ACCEPTED MANUSCRIPT

1 Increased prevalence of anxiety disorders in third-

2 generation migrants in comparison to natives and to
3 first-generation migrants
4
5 Baptiste Pignon1, Ali Amad2,3, Antoine Pelissolo1, Thomas Fovet2, Pierre Thomas2,

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6 Guillaume Vaiva2, Jean-Luc Roelandt4, Imane Benradia4, Benjamin Rolland5, Pierre A.
7 Geoffroy6

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9 1
AP-HP, DHU PePSY, Hôpitaux universitaires Henri-Mondor, Pôle de Psychiatrie, Créteil, 94000, France ; Inserm, U955,

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10 team 15, Créteil, 94000, France ; Fondation FondaMental, Créteil, 94000, France ; UPEC, Université Paris-Est, Faculté de
11 médecine, Créteil, 94000, France.
12 2
Univ. Lille, CNRS UMR 9193-PsyCHIC-SCALab, & CHU Lille, Pôle de Psychiatrie, Unité CURE, F-59000 Lille, France.
13 3
Fédération régionale de recherche en santé mentale (F2RSM) Nord-Pas-de-Calais ; F-59000 Lille, France.

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EPSM Lille Métropole ; Centre Collaborateur de l’Organisation Mondiale de la Santé pour la recherche et la formation en
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15 santé mentale ; Equipe Eceve Inserm UMR 1123, Lille, France
16 5
Service Universitaire d’Addictologie, Pôle UP-MOPHA, CH Le Vinatier, Univ. Lyon, 69500 Bron, France ; CRNL Inserm
17 U1028 / CNRS UMR5292 – CH Le Vinatier, 69678 Bron cedex, France
18 6
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Inserm, U1144, Paris, F-75006, France ; Université Paris Diderot, Sorbonne Paris Cité, UMR-S 1144, Paris, F-75013,
19 France ; AP-HP, GH Saint-Louis – Lariboisière – F. Widal, Pôle de Psychiatrie et de Médecine Addictologique, 75475 Paris
20 cedex 10, France ; Fondation FondaMental, Créteil, 94000, France
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21
22 Corresponding author:
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23 Dr. Baptiste Pignon

24 Hôpital Albert Chenevier, Groupe hospitaliers Henri-Mondor, CHU de Créteil, Assistance
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25 Publique-Hôpitaux de Paris (AP-HP), 40 rue de Mesly, 94 000, Créteil, France

26 baptistepignon@yahoo.fr
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27 : + 33 1 49 81 31 31 ; Fax: +33 1 49 81 30 59
28
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29 Key-words:
30 Migrants, Anxiety disorders, Panic disorder, Social Anxiety Disorder, Generalized Anxiety
31 Disorder, Post-Traumatic Stress Disorder

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33 ABSTRACT
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35 Introduction
36 We sought to examine the prevalence of anxiety disorders associated with migration in the
37 first-, second- and third-generation.

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39 Methods

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40 The French Mental Health in the General Population cross-sectional survey interviewed
41 38,694 individuals using the MINI. The prevalence of lifetime anxiety disorders, and

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42 comorbidities was compared between migrants and non-migrants and by generation. All
43 analyses were adjusted for age, sex, and income and education levels.
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45 Results
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46 In comparison to natives, pooled anxiety disorders were more common among migrants
47 (25.3% vs. 20.7%, OR=1.24) and among the three studied generations of migrants. Moreover,
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48 the prevalence rate of the pooled anxiety disorders was significantly higher in third-generation
49 migrants, in comparison to first-generation (26.7% vs. 22.6%, OR=1.14). Prevalence rates
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50 were higher in migrants for panic disorder (6.6% vs. 5.3%, OR=1.20), general anxiety
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51 disorder (15.0% vs. 12.0%, OR=1.24), posttraumatic stress disorder (1.0% vs. 0.6%,
52 OR=1.51), but not for social anxiety disorder. In comparison to natives, migrants with anxiety
53 disorders had higher prevalence rates of suicide attempts (14.0% vs. 12.8% for natives),
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54 psychotic disorders (8.3 % vs. 5.7%), unipolar depressive disorder (29.5% vs. 25.4%), bipolar
55 disorder (5.0% vs. 4.0%), and addictive disorders (9.6% vs. 6.2% for alcohol use disorder,
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56 8.2% vs. 4.1% for substance use disorders).

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58 Conclusion
59 Migration was associated with a higher prevalence of all anxiety disorders, in the first, second
60 and third generation, and associated with more psychiatric comorbidities. Moreover, the
61 prevalence increased across generations, and was significantly higher among third-generation
62 migrants, in comparison to first-generation.

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64 INTRODUCTION
65
66 Anxiety disorders are the most common psychiatric disorders, affecting lifetime
67 between 20 and 40% of the general population (Kessler et al., 2005; Leray et al., 2011). They
68 include panic disorder (PD), social anxiety disorder (SAD), generalized anxiety disorder
69 (GAD), and post-traumatic stress disorder (PTSD).

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71 Some environmental risk factors of anxiety disorders have already been highlighted, as

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72 stressful life events, or history of trauma (Blanco et al., 2014). As migration has been
73 identified as a risk factor for several psychiatric disorders, including psychotic (Bourque et al.,

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74 2011) and mood disorders (Mindlis and Boffetta, 2017), it has also been suggested in anxiety
75 disorders. Some studies found higher prevalence rates of anxiety disorders among first-

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76 generation migrants than among natives (Beutel et al., 2016), or higher incidence rates in
77 second-generation migrants (Cantor-Graae and Pedersen, 2013). Of note, several studies
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78 made the opposite observation, and even described an “healthy migrant effect”, i.e., lower
79 rates of anxiety disorders among first-generation migrant than among natives, e.g., in the
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80 USA (Liddell et al., 2016; Salas-Wright et al., 2014). In addition, several studies found also
81 discrepancies between first- and second-generation migrations, e.g., an increased risk only in
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82 the first-generation (Beutel et al., 2016), or only in second-generation (Cantor-Graae and

83 Pedersen, 2013). For the first time, we have recently studied the third-generation migrants in
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84 the Mental Health in General Population (MHGP) survey. The studies showed that the
85 prevalence rates of psychotic, mood and addictive disorders were higher among third-
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86 generation migrants than among natives (Amad et al., 2013; Pignon et al., 2017a; Rolland et
87 al., 2017); and it could also be the case for anxiety disorders. Finally, migrants studies are
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88 important to replicate in varied cultural countries (Bhugra, 2004), and anxiety disorders have
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89 never been studied in France.

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91 It is important to note that no previous study has ever explored whether anxiety
92 disorders in migrants were associated with specific clinical characteristics. Yet, this is a major
93 issue since the migrant status could be associated with a specific profile of a disease, e.g.,
94 with higher rates of psychiatric comorbidities. Moreover, in a precedent study in the same
95 MHGP survey, we observed that migrants with mood disorders had a more severe profile,

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96 with increased rates of comorbid psychotic and substance use disorders (SUDs) (Pignon et al.,
97 2017a).
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99 In this context, the present study aimed to examine the prevalence of anxiety disorders
100 (including PD, SAD, GAD, PTSD, pooled anxiety disorders, and comorbid anxiety disorders)
101 in migrant groups, both overall and according to first- (1GM), second- (2GM) and third-

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102 generation (3GM), in a large cross-sectional survey, following the same methodology as our
103 precedent work in mood disorders (Pignon et al., 2017a). These prevalences among migrants

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104 were compared to the prevalence among natives. We also compared the rate of psychiatric
105 comorbidities of anxiety disorders, including suicide attempts, psychotic disorders, mood

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106 disorders and addictive disorders, between migrants and natives. Regarding the higher rate of
107 depression among migrants in our precedent work, our hypothesis was that migrants display
108 more anxiety disorders and that migrants with anxiety disorders displayed more comorbidities

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109 than natives.
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111 METHODS
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113 Mental Health in General Population (MHGP) survey
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115 The cross-sectional MHGP survey, conducted by the World Health Organization
116 French Collaborating Centre, interviewed 38,694 subjects in France between 1999 and 2003.

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117 The subjects providing consent, speaking French and aged over 18 were selected in 47 sites
118 by a quota-sampling method. Methodological details can be found elsewhere (Leray et al.,

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119 2011). Legal authorization (number 98.126) was obtained by the ‘Commission Nationale
120 Informatique et Liberté’ (CNIL) and the ‘Comité consultatif sur le traitement de l’information

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121 en matière de recherche’ (CCTIRS).
122

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123 Assessment of psychiatric disorders
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125 The Mini International Neuropsychiatric Interview (MINI, French version 5.0.0) was
126 used to screen for psychiatric disorders, including PD, SAD, GAD, and PTSD, according to
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127 ICD-10 criteria. It has been validated in the general population and has good to very good
128 validity, reliability (inter-rater and test-retest), sensitivity and specificity (Sheehan et al.,
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129 1997).
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131 Lifetime comorbidities possibly associated with anxiety disorders were screened:
132 history of suicide attempts, bipolar I disorder (BD), unipolar depressive disorder (UDD),
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133 dysthymia, psychotic disorders, alcohol use disorders (AUDs), and SUDs.
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135 Details regarding psychiatric disorders assessment in the MHGP survey are available
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136 elsewhere (Amad et al., 2013; Pignon et al., 2017a; Rolland et al., 2017; Tebeka et al., 2018).
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138 Assessment of migrant status
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140 As in precedent studies (Amad et al., 2013; Pignon et al., 2017c, 2017b; Rolland et al.,
141 2017), the designation of migrant status was based on the country of birth of the subject
142 (1GM), the subject’s parents (2GM), and the subject’s grandparents (3GM).
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144 Statistical analyses
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146 To examine the associations between anxiety disorders (PD, SAD, GAD, PTSD,
147 pooled anxiety disorders, and comorbid anxiety disorders) and migration status and/or
148 different generations of migration (1GM, 2GM or 3GM), we performed logistic regression
149 analyses adjusting for potential confounding factors: sex, age, income and education levels

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150 (Green and Benzeval, 2013; Kessler et al., 2005). Finally, we also assessed several
151 comorbidities according to migrant status using chi-square tests. All statistical analyses were

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152 performed using R software (http://www.R-project.org/) version 3.3.1.

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154 RESULTS
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156 Population and sociodemographic characteristics
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158 Migrants were younger, with a higher educational level, and a lower income level than
159 natives. There was a significant correlation between age and educational level (average age

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160 (standard-deviation) in years by educational level: low: 60.4 (16.5); medium: 41.5 (16.0);
161 high: 36.5 (14.5); p=0.05). Sex ratio was statistically different (more males among migrants).

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162 Sociodemographic characteristics of individuals with anxiety disorders are available in
163 Supplementary Table 1.

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165 Risk of anxiety disorders according to migrant status

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166
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167 Anxiety disorders were diagnosed in 21.9% of the total population, including 5.6% for
168 PD, 4.4% for SAD, 12.8% for GAD, and 0.7% for PTSD. 1.6% of the population displayed
169 two comorbid anxiety disorders, and 0.1% three (none displayed the four). Results of logistic
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170 regressions comparing anxiety disorders between natives and migrants are available in Table
171 1. Pooled anxiety disorders were more common among migrants (25.3% vs. 20.7%,
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172 OR=1.24), as in each of the three generations. Specifically, the prevalence rate of PD was also
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173 higher in the whole sample of migrants (6.6% vs. 5.3%, OR=1.20), and in 2GM and 3GM.
174 The rates were not significantly different in 1GM. We did not observe any significant
175 differences in the prevalence of SAD according to migrant status (4.8% vs. 4.4%), neither in
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176 each of the three generation. Concerning GAD, the prevalence rate was significantly higher
177 among the whole sample of migrants (15.0% vs. 12.0%, OR=1.24), as in each of the three
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178 generations. Finally, PTSD was more common among migrants (1.0% vs. 0.6%, OR=1.51),
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179 and in 1GM and 2GM. The rates were not significantly different in 3GM. The prevalence
180 rates of comorbid anxiety disorders were not significantly different according to migrant
181 status (two comorbid anxiety disorders: 1.4% vs. 1.8%, three: 0.1 for both), as well as in the
182 three generation of migrants (except in the first-generation: more three comorbid anxiety
183 disorders than among natives, 0.2% vs. 0.1%, OR=3.73).
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185 The different generations of migrants were also compared with each other
186 (Supplementary Table 2). After statistical adjustment, the prevalence rate of pooled anxiety

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187 disorders was higher in 3GM than in 1GM (26.7% vs. 22.6%, OR=1.14); the prevalence rate
188 of PTSD was higher in 1GM than in 3GM (1.4% vs. 0.7%, OR=2.16); and the prevalence rate
189 of three comorbid anxiety disorders was higher in 1GM than in 3GM (0.2% vs. 0.1%,
190 OR=9.76).
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192 The proportion of migrants from different regions of origin did not differ between the

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193 overall sample of migrants and migrants with each anxiety disorder and each generation,
194 except for PTSD in 1GM (more migrants from Maghreb in the sample with PTSD) and in

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195 3GM (more migrants from Sub-Saharan Africa in the sample with PTSD) (Supplementary
196 Table 3).

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198 Comorbidities of anxiety disorders associated with migrant status

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200 The migrant status in anxiety disorders was associated with more frequent history of
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201 suicide attempts (14.0% for migrants vs. 12.8% for natives), more psychotic disorders (8.3 %
202 vs. 5.7%), more UDD (29.5% vs. 25.4%), more BD (5.0% vs. 4.0%), and more addictive
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203 disorders (9.6% vs. 6.2% for AUD, 8.2% vs. 4.1% for SUDs). There were no significant
204 differences concerning dysthymia. The increased prevalence of suicide attempts history was
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205 observed among migrants with PD (20.2% vs. 18.7%) and SAD (17.0% vs. 11.1%) but not in
206 other anxiety disorders. Concerning psychotic disorders, the prevalence was increased in
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207 migrants with PD (14.1 % vs. 8.2%), SAD (11.9 % vs. 6.7%), and GAD (6.1% vs. 4.7%).
208 UDD was more frequent in migrants with each one of the anxiety disorders (38.9% vs. 33.0%
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209 for PD, 32.3% vs. 25.6% for SAD, 26.6% vs. 24.0% for GAD, and 35.7% vs. 24.3% for
210 PTSD). Likewise for SUDs (12.3% vs. 5.7% for PD, 10.5% vs. 5.3% for SAD, 6.1% vs. 3.2%
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211 for GAD, and 18.4% vs. 6.2% for PTSD). AUDs were more frequent in migrants with PD
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212 (12.6% vs. 8.3%) and GAD (8.9% vs. 5.2%) (Table 2).
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215 DICUSSION
216
217 The present study found that migrant status was associated with a higher prevalence
218 rate of anxiety disorders. When examining the different generations, the risk effect appeared
219 significant in the three generations. Interestingly, this risk increased across the three migrant
220 generations for SAD and GAD, while remained stable for PD and decreased for PTSD.

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221 Considering the high risk of psychotic disorders among migrants (Bourque et al., 2012), we
222 repeated the analysis adjusting on psychotic disorders. The associations between migrants and

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223 the different anxiety disorders remained significant. The differences between generations of
224 migrants were significant for 3GM in comparison of 1GM for the pooled anxiety disorders.

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225 Finally, the migrant status in individuals presenting with anxiety disorders was also associated
226 with a higher rate of psychiatric comorbidities.

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227
228 The prevalence rate found in our study for all anxiety disorders (21.9%) was
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229 consistent with other figures from the literature (28.8% in the USA (Kessler et al., 2005), 21%
230 in Europe (Wittchen and Jacobi, 2005)). Prevalence rates of PD, GAD, and SAD were higher
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231 than in a meta-analysis of European studies (5.6% in our study vs. 2.3 % for PD, 12.8% vs.
232 1.5% for GAD, 4.4% vs. 2.0% for SAD) (Wittchen and Jacobi, 2005). Concerning GAD, the
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233 gap may be related to the use of MINI in the MHGP survey, and to the focus on somatic
234 symptoms rather than cognitive symptoms, as discussed by Leray et al. (2011). Finally, the
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235 prevalence rate of PTSD (0.7%) was lower than in previous literature (between 2.0% and
236 4.0%) (Vaiva et al., 2008). Of note, PTSD does not belong to anxiety disorders according to
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237 ICD-10. However, its classification as anxiety disorders is debated (Friedman et al., 2011),
238 and we chose to study the large spectrum of anxiety disorders.
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239
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240 Previous studies that investigated the prevalence of whole anxiety disorders in
241 migrants and ethnic minority groups found conflicting results. Contrary to the present study,
242 several prevalence and incidence studies of anxiety disorders did not find any significant
243 differences between 1GM and natives, e.g., in Austria or Netherlands (de Wit et al., 2008;
244 Kerkenaar et al., 2013). Several other studies found a healthy migrant effects for whole
245 anxiety disorders (Liddell et al., 2016; Salas-Wright et al., 2014; Szaflarski et al., 2017). In
246 the study in Danish population, as in the present study, the 2GM with one foreign-born parent
247 (i.e., the majority of 2GM) displayed higher incidence rate of anxiety and somatoform

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248 disorders (Cantor-Graae and Pedersen, 2013). In a 2011 meta-analysis on primary care
249 patients, Tarricone et al. (2012) did not find any difference between ethnic minorities, natives
250 and ethnic majorities for prevalence of anxiety disorders (RR=1.01, 95% CI [0.76-1.32]).
251 Interestingly, to our knowledge, the present study is the first to explore the 3GM.
252
253 Some of the previous findings specifically regarding PD in migrants and ethnic

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254 minority groups were conflicting with our observations of increased prevalence rates in 2GM
255 and 3GM and non-significant differences for the 1GM. Indeed, several studies found a

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256 healthy migrant effect for PD among 1GM and 2GM or ethnic minorities in the USA (Blanco
257 et al., 2014; Salas-Wright et al., 2014). On the other hand, in Spain, the rate of PD among

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258 Latin American-born patients consulting in a primary health care for PD was significantly
259 higher than Spanish-born patients (20.5% vs. 15.3%) (Salinero-Fort et al., 2015). Regarding
260 SAD, as in the present study, Beutel et al. (2016) did not find any significant difference in the

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261 prevalence rates within 1GM and 2GM in Germany. As for the other anxiety disorders
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262 analysed in Salas-Wright et al. (2014) study, there was a healthy migrant effect in SAD for
263 both 1GM and 2GM in the USA. Moreover, few studies have investigated the prevalence rate
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264 of GAD in migrant populations. Confirming our results, an Indian study found that Kashmiri
265 migrants in a refugees camp displayed higher rate of GAD than native controls (Banal et al.,
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266 2010). Several studies on ethnic minority groups in the USA did not find significant
267 differences in prevalence rates (Brenes et al., 2008; Hoppe et al., 1989). Concerning PTSD
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268 among migrants and ethnic minority groups, several studies reported high prevalence rates in
269 1GM, specifically in non-voluntary and refugee migrants (Rasmussen et al., 2012; Schweitzer
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270 et al., 2006). To our knowledge, the present study is the first to compare prevalence rates of
271 PTSD in 2GM and 3GM to natives.
272
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273 The increased prevalence rates of anxiety disorders among migrant populations could
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274 be explained by several factors; and these factors might be variable according to both the
275 considered host country and the migrant population, explaining some of the discrepancies
276 between the present study and previous studies. For example, trauma or stressful life events
277 might be involved in developing anxiety disorders (Hovens et al., 2010; Tebeka et al., 2016),
278 and may occur in pre-migration, per-migration and post-migration periods. Concerning 2GM
279 and 3GM, transmission of pre-migration trauma psychiatric disorders have been suggested,
280 with several studies on Shoah survivor families supporting this hypothesis (Baider et al.,
281 2000; Baranowsky et al., 1998). The gap between cultural backgrounds related to both

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282 country of origin and host country, that involve acculturation issues, may also be implicated
283 both in the increased prevalence rates in the present study, and in the discrepancies with
284 precedent studies (Lewis-Fernández et al., 2016). Other hypotheses address migrants’ socio-
285 economic conditions (post-migration factors), as anxiety disorders have been previously
286 found to be associated with psychosocial and economic adversities (Green and Benzeval,
287 2013). The fact that, in the MHGP sample, migrants with anxiety disorders had a higher

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288 educational level and a lower income level is consistent with this hypothesis. This fact could
289 be due to discrimination phenomena. Specifically, the increased prevalence in 3GM in

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290 comparison to 1GM could be related to the ethnic density effect related phenomena (Shaw et
291 al., 2012). Indeed, 1GM may live in neighbourhoods with higher ethnic density, which has

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292 been shown to be a protective factor against psychiatric disorders, including anxiety disorders.
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294 In comparison to psychotic disorders, which has been showed consistently as

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295 associated to the migrant status, the increased prevalence rates of anxiety disorders in the
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296 2GM and 3GM for PD and GAD (OR between 1.15 and 1.25) were lower (OR=2.3 for 1GM
297 and OR=2.1 for 2GM) (Bourque et al., 2011). However, as anxiety disorders are more
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298 prevalent than psychotic disorders (21.9% in the present study vs. 0.46% for psychotic
299 disorders in a recent French study (Szöke et al., 2015)), the burden of anxiety disorders in
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300 migrants may be higher.

301
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302 Regarding comorbidities, migrants with anxiety disorders suffered from more
303 psychiatric comorbidities than natives with anxiety disorders. They displayed higher rates of
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304 psychotic, mood and addictive disorders, which is consistent with previous findings from the
305 MHGP regarding the effect of migration on the prevalence of these outcomes (Amad et al.,
306 2013; Tebeka et al., 2018; Pignon et al., 2017a, 2017c). Thus, these associated psychiatric
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307 comorbidities appear to be non-specific to migrants with anxiety disorders, but rather
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308 common in all migrants suffering from psychiatric disorders. Concerning addictive disorders,
309 different explanatory models could explain this phenomenon. Indeed, the increased
310 prevalences of AUDs and SUDs among migrants could imply that anxiety disorders are more
311 severe clinically. However, as addictive disorders are associated with anxiety disorder
312 (Kessler et al., 2005), it could also reflect the involvement of addictive disorders as causal
313 factors of anxiety disorders on the migrant populations. Likewise, cannabis use disorder could
314 explain the higher rate of suicide attempts among migrants (Serafini et al., 2012).
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316 Furthermore, methodological issues may also affect the results of the different migrant
317 studies on anxiety disorders and explain the discrepancies with the present study. For instance,
318 studies based on medical registers and census figures, e.g. Cantor Graae et al. (2013), may
319 underestimate the number of migrants (i.e., in the denominator) in these data (e.g.,
320 undocumented or recently moved), and therefore overestimate the risk of psychiatric disorders
321 (Bourque et al., 2011). Moreover, migrant studies may be affected by cultural biases (and the

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322 MINI has not been assessed cross-culturally) (Zandi et al., 2008). Regarding the sampling
323 method, as it was done by quotas within regions, and thus non probabilistic, we can’t assume

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324 that our sample was representative of the general population. However, quota sampling
325 method warrant same socio-demographic characteristics of the general population. The other

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326 limitations of this study, as the French language in inclusion criterion, the absence of data
327 concerning the subjects that refused to participate, have already been discussed in other
328 papers on MHGP survey (Pignon et al., 2017c; Rolland et al., 2017).

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329
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330 In conclusion, the prevalence of whole anxiety disorders was increased in 1GM, 2GM
331 and 3GM. Migration led to a profile of anxiety disorders with higher rates of psychiatric
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332 comorbidities, i.e., of psychotic, mood and addictive disorders. Clinicians and public
333 authorities should take account of this fact to prevent, identify, and rapidly care of the
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334 affected subjects.

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Table 1. Prevalence and odds ratio (OR) of anxiety disorders comparing natives to different generations of migrants
adjusted for age, sex, income level and level of education

Panic disorder (N = 2,178)

Prevalence (%) OR [95%CI] p-values*
Natives (N = 1,520) 5.3 - -
All generation migrants (N = 658) 6.6 1.20 [1.08-1.32] < 0.001
First-generation (N = 127) 6.2 1.20 [0.98-1.45] 0.065
Second-generation (N = 274) 6.6 1.19 [1.04-1.36] 0.012
Third-generation (N = 257) 6.8 1.20 [1.04-1.38] 0.012

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Social anxiety disorder (N = 1,698)
Prevalence (%) OR [95%CI] p-values*
Natives (N = 1,221) 4.3 - -

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All generation migrants (N = 477) 4.8 1.03 [0.92-1.16] 0.550
First-generation (N = 77) 3.8 0.88 [0.69-1.12] 0.327
Second-generation (N = 194) 4.7 1.00 [0.85-1.17] 0.976

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Third-generation (N = 206) 5.5 1.15 [0.98-1.34] 0.080

Generalized anxiety disorder (N = 4,946)

Prevalence (%) OR [95%CI] p-values*

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Natives (N = 3,460) 12.0 - -
All generation migrants (N = 1,486) 15.0 1.24 [1.16-1.33] < 0.001
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First-generation (N = 274) 13.4 1.24 [1.01-1.31] 0.048
Second-generation (N = 628) 15.3 1.15 [1.13-1.37] < 0.001
Third-generation (N = 584) 15.6 1.30 [1.18-1.43] < 0.001
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Post-Traumatic Stress Disorder (N = 275)

Prevalence (%) OR [95%CI] p-values*
Natives (N = 177) 0.6 - -
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All generation migrants (N = 98) 1.0 1.51 [1.21-2.00] 0.001

First-generation (N = 28) 1.4 2.28 [1.49-3.36] < 0.001
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Second-generation (N = 44) 1.1 1.54 [1.07-2.15] 0.015

Third-generation (N = 26) 0.7 1.05 [0.67-1.58] 0.690

At least one anxiety disorder (N = 8,459)

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Prevalence (%) OR [95%CI] p-values*

Natives (N = 5,939) 20.7 - -
All generation migrants (N = 2,520) 25.3 1.24 [1.17-1.31] < 0.001
First-generation (N = 463) 22.6 1.14 [1.02-1.28] 0.019
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Second-generation (N = 1,056) 25.4 1.23 [1.14-1.33] < 0.001

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Third-generation (N = 1,001) 26.7 1.30 [1.20-1.41] < 0.001

Two comorbid anxiety disorders (N = 615)

Prevalence (%) OR [95%CI] p-values*
Natives (N = 409) 1.4 - -
All generation migrants (N = 183) 1.8 1.18 [0.99-1.41] 0.067
First-generation (N = 35) 1.7 1.30 [0.91-1.81] 0.129
Second-generation (N = 78) 1.9 1.17 [0.91-1.50] 0.202
Third-generation (N = 70) 1.9 1.13 [0.86 -1.46] 0.358

Three comorbid anxiety disorders (N = 23)

Prevalence (%) OR [95%CI] p-values*
Natives (N = 15) 0.1 - -
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All generation migrants (N = 8) 0.1 1.20 [0.48-2.78] 0.684
First generation (N = 4) 0.2 3.73 [1.06-10.42] 0.020
Second-generation (N = 3) 0.1 0.98 [0.22-2.99] 0.970
Third-generation (N = 1) 0.0 0.38 [0.02-1.90] 0.353

*Results from logistic regression

NB: No subject displayed the four considered anxiety disorders

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Table 2. Comorbidities of subjects with anxiety disorders in natives and three generations of migrants (N, %)
All-generation p-values* Third-
Natives First-generation Second-generation
of migrants generation
Pooled anxiety disorders (N = 8,459) N = 5,939 N = 2,520 N = 463 N = 1,056 N = 1,001
Suicide attempt 761 (12.8) 354 (14.0) 0.018 48 (10.3) 140 (13.3) 166 (16.6)
Psychotic disorder 340 (5.7) 210 (8.3) < 0.001 46 (9.9) 78 (7.4) 86 (8.6)
Unipolar depressive disorder 1508 (25.4) 744 (29.5) < 0.001 163 (35.2) 324 (30.7) 257 (25.7)
Bipolar disorder 238 (4.0) 126 (5.0) 0.040 23 (5.0) 52 (4.9) 51 (5.1)
Dysthymia 328 (5.5) 135 (5.4) 0.503 19 (4.1) 49 (4.6) 67 (6.7)

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Alcohol use disorders 367 (6.2) 243 (9.6) < 0.001 43 (9.6) 84 (8.0) 116 (11.6)
Substance use disorders 244 (4.1) 206 (8.2) < 0.001 18 (3.9) 94 (8.9) 94 (9.4)

Panic disorder (N = 2,178) N = 1,520 N = 658 N = 127 N = 274 N = 257

Suicide attempt 284 (18.7) 133 (20.2) 0.018 24 (18.9) 54 (19.7) 55 (21.4)

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Psychotic disorder 124 (8.2) 93 (14.1) < 0.001 21 (16.5) 38 (13.9) 34 (13.2)
Unipolar depressive disorder 501 (33.0) 256 (38.9) 0.007 62 (48.8) 109 (39.8) 85 (33.1)

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Bipolar disorder 128 (8.4) 62 (9.4) 0.447 12 (9.4) 25 (9.1) 25 (9.7)
Dysthymia 117 (7.7) 55 (8.4) 0.599 8 (6.3) 21 (7.7) 26 (10.1)
Alcohol use disorders 126 (8.3) 83 (12.6) 0.002 20 (15.7) 31 (11.3) 32 (12.4)
Substance use disorders 86 (5.7) 81 (12.3) < 0.001 9 (7.1) 32 (11.7) 40 (15.6)

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Social anxiety disorders (N = 1,698) N = 1,221 N = 477 N = 77 N = 194 N = 206
Suicide attempt 135 (11.1) 81 (17.0) < 0.001 17 (22.1) 28 (14.4) 36 (17.5)
AN
Psychotic disorder 82 (6.7) 57 (11.9) < 0.001 14 (18.2) 22 (11.3) 21 (10.2)
Unipolar depressive disorder 312 (25.6) 154 (32.3) 0.005 35 (45.5) 67 (34.5) 52 (25.2)
Bipolar disorder 66 (5.4) 36 (7.5) 0.095 6 (7.8) 18 (9.3) 12 (5.8)
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Dysthymia 80 (6.6) 31 (6.5) 0.968 7 (9.1) 12 (6.2) 12 (5.8)

Alcohol use disorders 84 (6.9) 46 (9.6) 0.054 9 (11.7) 15 (7.7) 22 (10.7)
Substance use disorders 65 (5.3) 50 (10.5) < 0.001 5 (6.5) 22 (11.3) 23 (11.2)
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Generalized anxiety disorder

N = 3,460 N = 1,486 N = 274 N = 628 N = 584
(N = 4,946)
TE

Suicide attempt 395 (11.4) 181 (12.2) 0.152 18 (6.6) 72 (11.5) 91 (15.6)
Psychotic disorder 163 (4.7) 91 (6.1) 0.039 18 (6.6) 31 (4.9) 42 (7.2)
Unipolar depressive disorder 829 (24.0) 395 (26.6) 0.050 81 (29.6) 172 (27.4) 142 (24.3)
Bipolar disorder
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84 (2.4) 47 (3.2) 0.140 8 (2.9) 18 (2.9) 21 (3.6)

Dysthymia 163 (4.7) 63 (4.2) 0.467 8 (2.9) 21 (3.3) 34 (5.8)
Alcohol use disorders 181 (5.2) 132 (8.9) < 0.001 18 (6.6) 41 (7.0) 70 (12.0)
Substance use disorders 111 (3.2) 90 (6.1) < 0.001 7 (2.6) 42 (6.7) 41 (7.0)
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Post-Traumatic Stress Disorder

N = 177 N = 98 N = 28 N = 44 N = 26
(N = 275)
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Suicide attempt 6 (21.4) 10 (22.7) 7 (26.9)

43 (24.3) 23 (23.5) 0.699
Psychotic disorder 15 (8.5) 13 (13.3) 0.208 3 (10.7) 5 (11.4) 5 (19.2)
Unipolar depressive disorder 43 (24.3) 35 (35.7) 0.044 13 (46.4) 14 (31.8) 8 (30.8)
Bipolar disorder 11 (6.2) 11 (11.2) 0.142 3 (10.7) 6 (13.6) 2 (7.7)
Dysthymia 10 (5.6) 8 (8.2) 0.420 3 (10.7) 3 (6.8) 2 (7.7)
Alcohol use disorders 20 (11.3) 18 (18.4) 0.103 5 (17.9) 6 (13.6) 7 (26.9)
Substance use disorders 11 (6.2) 18 (18.4) 0.002 4 (14.3) 9 (20.5) 5 (19.2)
*Comparisons between all generations of migrants and non-migrants using chi-squared test.
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HIGHLIGHTS

- Migrants in the three considered generations displayed higher prevalence rates of

anxiety disorders than natives.
- The prevalence of anxiety disorders increased from the first to the third-generation
migrants.

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- Migrants with anxiety disorders displayed more psychiatric comorbidities than
natives.

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