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Cited by 1,028Child and Adolescent Psychosocial and Emotional DevelopmentAnxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesMental Health Treatment and Access

Comorbidity of anxiety and depression in children and adolescents: 20 years after

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Cummings, Colleen M., Caporino, Nicole E., Kendall, Philip C.·2014·Psychological Bulletin
DOI 10.1037/a0034733PMC PMC4006306
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Abstract

Brady and Kendall (1992) concluded that although anxiety and depression in youths are meaningfully linked, there are important distinctions, and additional research is needed. Since then, studies of anxiety-depression comorbidity in youths have increased exponentially. Following a discussion of comorbidity, we review existing conceptual models and propose a multiple pathways model to anxiety-depression comorbidity. Pathway 1 describes youths with a diathesis for anxiety, with subsequent comorbid depression resulting from anxiety-related impairment. Pathway 2 refers to youths with a shared diathesis for anxiety and depression, who may experience both disorders simultaneously. Pathway 3 describes youths with a diathesis for depression, with subsequent comorbid anxiety resulting from depression-related impairment. Additionally, shared and stratified risk factors contribute to the development of the comorbid disorder, either by interacting with disorder-related impairment or by predicting the simultaneous development of the disorders. Our review addresses descriptive and developmental factors, gender differences, suicidality, assessments, and treatment-outcome research as they relate to comorbid anxiety and depression and to our proposed pathways. Research since 1992 indicates that comorbidity varies depending on the specific anxiety disorder, with Pathway 1 describing youths with either social phobia or separation anxiety disorder and subsequent depression, Pathway 2 applying to youths with coprimary generalized anxiety disorder and depression, and Pathway 3 including depressed youths with subsequent social phobia. The need to test the proposed multiple pathways model and to examine (a) developmental change and (b) specific anxiety disorders is highlighted.

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Crossref · 10.1037/a0034733

Cites

401 of 402 references verified1 citation errors · 0 not checkable

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  • The relationship between anxiety and depressive disorders is based on the common presence of internalizing factors such as neuroticism and rumination.

    “Studies indicated that the relationship between the two disorders is based on the common presence of internalizing factors (i.e. neuroticism, rumination).47,62”

    From Factors associated with gender and sex differences in anxiety prevalence and comorbidity: A systematic review (2022) · cites this paper as [62]

    The Existing Theoretical Models section identifies neuroticism and rumination as possible transdiagnostic factors within shared negative affectivity; the Gender Differences section also reports that rumination accounted for a large portion of symptom overlap. The source presents these as a possible explanation for the relationship, rather than establishing that the relationship is based on them. (LLM, conf=0.83)

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  • When persistent, internalizing problems often result in emerging psychiatric disorders affecting young people's daily lives, their future, and society.

    “When persistent, internalizing problems often result in emerging psychiatric disorders affecting young people’s daily lives, their future, and society [1-3,6].”

    From A Smartphone Serious Game for Adolescents (Grow It! App): Development, Feasibility, and Acceptance Study (2022) · cites this paper as [2]

    The Multiple Pathways Model says untreated anxiety-related impairment can increase youths’ risk of depression, and the Comorbidity section describes effects on functioning and later life. The Conclusions and Future Directions section also notes an impact on society. The claim is broader and more certain than the review: it does not establish that persistent internalizing problems generally or often result in psychiatric disorders. (LLM, conf=0.82)

    Experimental — accuracy not yet measured

  • Internalizing problems such as anxiety and mood problems have a substantial impact on young people's lives and are associated with school dropout, reduced social functioning, loneliness, unemployment, and reduced quality of life.

    “Internalizing problems, such as anxiety and mood problems, have a substantial impact on young people’s lives. These internalizing problems are often associated with school dropout, reduced social functioning, loneliness, unemployment, and reduced quality of life [1-3].”

    From A Smartphone Serious Game for Adolescents (Grow It! App): Development, Feasibility, and Acceptance Study (2022) · cites this paper as [2]

    The Abstract (page unavailable) says anxiety and depression in youth are associated with substantial functional impairment. The Comorbidity section reports academic difficulties and impaired functioning, while the Longitudinal Research section links youth social anxiety with loneliness. The paper does not establish the more specific claims of school dropout or unemployment; its reference to life dissatisfaction concerns generally comorbid individuals, not specifically young people with anxiety or mood problems. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

  • Youth depression and anxiety symptoms highly correlate and can be treated by combined interventions.

    “Given that youth depression and anxiety symptoms highly correlate8 and can be treated by combined interventions, we examined the overall effects of all interventions on symptoms of anxiety and depression in a common analysis.34”

    From Comparative efficacy and acceptability of bibliotherapy for depression and anxiety disorders in children and adolescents: a meta-analysis of randomized clinical trials (2018) · cites this paper as [8]

    The Comorbidity section reports that depression and anxiety often co-occur in youth, supporting a relationship between the symptoms, though it does not establish how strongly they correlate. The Treating Comorbid Anxiety and Depression section describes interventions targeting both conditions, but says the available data are preliminary and trials are needed to establish their efficacy; it does not establish that combined interventions successfully treat both. (LLM, conf=0.84)

    Experimental — accuracy not yet measured

  • Of the 44 documents, 31 were empirical/quantitative studies and 13 were reviews.

    “Of the 44 documents, 31 were empirical/quantitative studies30–60 and 13 were reviews.61–73”

    From Factors associated with gender and sex differences in anxiety prevalence and comorbidity: A systematic review (2022) · cites this paper as [62]

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Cites

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Research works printed but not linked: 3

  1. Gray JA 1991 Neural systems of motivation, emotion, and affect Madden J Neurobiology of Learning, Emotion, and Affect 273 306 New York Raven Press
  2. Gray JA McNaughton N 2000 The neuropsychology of anxiety: An inquiry into the functions of the septo-hippocampal system Oxford Oxford University Press
  3. Kendall PC O’Neil K Villabø M Martinsen K Stark K Banneyer K in press Therapy with children and adolescents: Cognitive-behavioral therapy offers a transdiagnostic perspective Ehrenreich-May J Chu B Transdiagnostic mechanisms and treatment for youth psychopathology New York: NY Guilford

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Authors
Cummings, C. M., Caporino, N. E., & Kendall, P. C.
Affiliations
Temple University (US)
ORCID
Venue
Psychological Bulletin
Publisher
American Psychological Association (APA)
Published
2014-05
Volume
140
Issue
3
Pages
816-845
ISSN
  • 0033-2909 (ISSN-L)
  • 1939-1455
DOI
10.1037/a0034733
PMC
PMC4006306
OpenAlex
W2117486684
Cited by
1,028
References
391
Citations by year
2026: 92 · 2025: 112 · 2024: 116 · 2023: 99 · 2022: 103 · 2021: 105 · 2020: 92 · 2019: 81 · 2018: 76 · 2017: 55 · 2016: 49 · 2015: 33 · 2014: 15
FWCI
35.65
Type
journal article
Language
en
Open access
Locations
  • Psychological Bulletin (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
National Institute of Mental Health (MH063747 and MH086438)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Child and Adolescent Psychosocial and Emotional Development
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
  • Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
Keywords
comorbid depression and anxiety, children and adolescents, diathesis, social anxiety disorder, separation anxiety disorder, generalized anxiety disorder, gender differences, suicidality, developmental changes, risk factors, treatment outcomes
MeSH terms
Adolescent, Antidepressive Agents, Anxiety Disorders, Child, Depressive Disorder, Female, Humans, Male, Sex Factors, Comorbidity, Cognitive Behavioral Therapy, Suicidal Ideation

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