Age at onset of mental disorders worldwide: large-scale meta-analysis of 192 epidemiological studies

Abstract

Promotion of good mental health, prevention, and early intervention before/at the onset of mental disorders improve outcomes. However, the range and peak ages at onset for mental disorders are not fully established. To provide robust, global epidemiological estimates of age at onset for mental disorders, we conducted a PRISMA/MOOSE-compliant systematic review with meta-analysis of birth cohort/cross-sectional/cohort studies, representative of the general population, reporting age at onset for any ICD/DSM-mental disorders, identified in PubMed/Web of Science (up to 16/05/2020) (PROSPERO:CRD42019143015). Co-primary outcomes were the proportion of individuals with onset of mental disorders before age 14, 18, 25, and peak age at onset, for any mental disorder and across International Classification of Diseases 11 diagnostic blocks. Median age at onset of specific disorders was additionally investigated. Across 192 studies (n = 708,561) included, the proportion of individuals with onset of any mental disorders before the ages of 14, 18, 25 were 34.6%, 48.4%, 62.5%, and peak age was 14.5 years (k = 14, median = 18, interquartile range (IQR) = 11-34). For diagnostic blocks, the proportion of individuals with onset of disorder before the age of 14, 18, 25 and peak age were as follows: neurodevelopmental disorders: 61.5%, 83.2%, 95.8%, 5.5 years (k = 21, median=12, IQR = 7-16), anxiety/fear-related disorders: 38.1%, 51.8%, 73.3%, 5.5 years (k = 73, median = 17, IQR = 9-25), obsessive-compulsive/related disorders: 24.6%, 45.1%, 64.0%, 14.5 years (k = 20, median = 19, IQR = 14-29), feeding/eating disorders/problems: 15.8%, 48.1%, 82.4%, 15.5 years (k = 11, median = 18, IQR = 15-23), conditions specifically associated with stress disorders: 16.9%, 27.6%, 43.1%, 15.5 years (k = 16, median = 30, IQR = 17-48), substance use disorders/addictive behaviours: 2.9%, 15.2%, 48.8%, 19.5 years (k = 58, median = 25, IQR = 20-41), schizophrenia-spectrum disorders/primary psychotic states: 3%, 12.3%, 47.8%, 20.5 years (k = 36, median = 25, IQR = 20-34), personality disorders/related traits: 1.9%, 9.6%, 47.7%, 20.5 years (k = 6, median = 25, IQR = 20-33), and mood disorders: 2.5%, 11.5%, 34.5%, 20.5 years (k = 79, median = 31, IQR = 21-46). No significant difference emerged by sex, or definition of age of onset. Median age at onset for specific mental disorders mapped on a time continuum, from phobias/separation anxiety/autism spectrum disorder/attention deficit hyperactivity disorder/social anxiety (8-13 years) to anorexia nervosa/bulimia nervosa/obsessive-compulsive/binge eating/cannabis use disorders (17-22 years), followed by schizophrenia, personality, panic and alcohol use disorders (25-27 years), and finally post-traumatic/depressive/generalized anxiety/bipolar/acute and transient psychotic disorders (30-35 years), with overlap among groups and no significant clustering. These results inform the timing of good mental health promotion/preventive/early intervention, updating the current mental health system structured around a child/adult service schism at age 18.

Fig. 1. Meta-analytic median age at onset of mental disorders.

The line indicates the median age at onset of mental disorders (ICD-11 diagnostic blocks or spectra above, specific mental disorders below), the bar indicates the 25th and 75th percentiles. ICD-11 blocks of mental disorders. Addiction disorders: disorders due to substance use or addictive behaviour, Anxiety and fear: anxiety and fear-related disorders, OCD related: obsessive-compulsive or related disorders, Schizophrenia spectrum disorders: schizophrenia-spectrum and primary psychotic disorders. ICD-11 specific mental disorders. ADHD attention deficit hyperactivity disorder, ASD: autism spectrum disorder, ATPD, acute and transient psychotic disorder; Binge eating: binge eating disorder, Bipolar disorder: bipolar or related disorders, GAD generalised anxiety disorder, OCD obsessive-compulsive disorder, Phobia: specific phobia, PTSD post-traumatic stress disorder, Separation anxiety: separation anxiety disorder, Social anxiety: social anxiety disorder.

Fig. 2. Meta-analytic distribution of age of onset for any mental disorders.

Meta-analytic epidemiological proportion (y-axis) and peak age at onset (red line) for any mental disorders in the general population, with 95%CIs (pink shadows).

Fig. 3. Meta-analytic distribution of age of onset for specific mental disorders blocks.

Meta-analytic epidemiological proportion (y-axis) and peak age at onset (red line) for neurodevelopmental, anxiety and fear-related, obsessive-compulsive related, and feeding or eating disorders (ICD-11 blocks) in the general population, with 95%CIs (pink shadows).

Fig. 4. Meta-analytic distribution of age of onset for specific mental disorders blocks.

Meta-analytic epidemiological proportion (y-axis) and peak age at onset (red line) for disorders due to substance use or addictive behaviour, personality, mood, and schizophrenia-spectrum and primary psychotic disorders (ICD-11 blocks) in the general population, with 95%CIs (pink shadows).