Original quantitative research – Distinct and shared risk factors for mood, anxiety and comorbid disorders among Canadians: evidence from the 2019–2020 Canadian Community Health Survey

Abstract

Introduction: Mood and anxiety disorders frequently co-occur, but few studies have differentiated their unique and shared risk factors. This study examines factors associated with mood disorders alone, anxiety disorders alone and comorbid mood and anxiety disorders among Canadians using 2019–2020 Canadian Community Health Survey data.

Methods: The analytic sample included 107 859 respondents, weighted to represent the Canadian population. Multinomial logistic regression with survey and bootstrap weights estimated adjusted relative risk ratios (aRRRs) for sociodemographic, socioeconomic, health-related and psychosocial factors.

Results: Prevalence was 4.17% for mood disorders alone, 4.99% for anxiety disorders alone and 4.85% for comorbid mood and anxiety disorders. Females had significantly higher risks across all categories (comorbidity aRRR = 2.284; 95% confidence interval [CI]: 1.951–2.673). Younger adults (18–34 years) had greater risks for anxiety disorders alone (aRRR = 3.036; 95% CI: 2.441–3.776) and comorbid disorders (9.311; 7.134–12.153) compared with those aged 65 years and older. Lower household income and poor perceived health were consistently associated with increased risks, with comorbid disorders showing the strongest associations (poor perceived health aRRR = 14.688; 95% CI: 9.908–21.775). Psychosocial factors, including low life satisfaction and a weak sense of community belonging, were also linked to higher risks, particularly for comorbid disorders.

Conclusion: Distinct and overlapping factors contribute to mood and/or anxiety disorders. Targeted prevention and intervention efforts addressing health status, socioeconomic disadvantage and psychosocial stressors—especially among younger people and females—are critical to reducing the burden of these mental health conditions in Canada.

Keywords: mental health, anxiety disorder, mood disorder, comorbid conditions, comorbidity

Introduction

Mood (e.g. depression, bipolar disorder) and anxiety disorders (e.g. generalized anxiety, panic disorder, phobias) are among the most common types of mental health conditions in Canada.^{Footnote 1Footnote 2Footnote 3} Their effects on daily functioning and quality of life are substantial.^{Footnote 3Footnote 4Footnote 5} The prevalence of diagnosed mood or anxiety disorders among people in Canada aged 12 years and older rose from 12% in 2015 to approximately 14% (equivalent to 4.4 million people) in 2019.^{Footnote 6}

A key complexity in mental health is the frequent co-occurrence of mood and anxiety disorders, known as psychiatric comorbidity.^{Footnote 7} This phenomenon suggests shared underlying psychological and neurobiological mechanisms^{Footnote 7Footnote 8Footnote 9Footnote 10} and heightened emotional reactivity.^{Footnote 11} Additional evidence also points to distinct etiological pathways, symptom profiles and social determinants of these disorders.^{Footnote 6Footnote 8Footnote 9Footnote 10} Mood disorders typically involve prolonged disturbances in mood, energy and motivation, whereas anxiety disorders are marked by excessive fear, worry and physiological arousal.^{Footnote 4Footnote 12Footnote 13Footnote 14Footnote 15} Individuals with comorbid mood and anxiety disorders often experience more severe symptoms, longer illness duration and greater treatment resistance than those with either disorder alone.^{Footnote 16} Aggregating mood and anxiety disorders into a single diagnostic category may therefore obscure important distinctions in risk factors and presentation.^{Footnote 17} Understanding both the shared and unique correlates of mood and anxiety disorders is essential for improving diagnosis, tailoring treatment and guiding public health strategies.^{Footnote 18}

Mental health outcomes reflect a broad set of determinants: sociodemographic (e.g. sex, age, immigration status),^{Footnote 16Footnote 17Footnote 19} socioeconomic (e.g. income and employment),^{Footnote 16Footnote 19Footnote 20} health-related (e.g. multimorbidity, unmet health care needs)^{Footnote 17Footnote 19} and psychosocial (e.g. stress, life satisfaction) factors.^{Footnote 17Footnote 19} Many factors relate to both disorders,^{Footnote 11} but some appear more specific: anxiety disorders have been associated with urban residence and childhood adversity, whereas mood disorders are more strongly linked to younger age, lower education level, being widowed or divorced and living in socioeconomically disadvantaged communities.^{Footnote 17Footnote 19} Mood disorders are generally more prevalent among females.^{Footnote 3Footnote 21} Multimorbidity, which is common among middle-aged and older adults, and unmet health care needs are especially relevant for mood disorders.^{Footnote 11Footnote 19Footnote 22Footnote 23Footnote 24Footnote 25Footnote 26Footnote 27} Chronic pain frequently co-occurs with mood and anxiety disorders, as cause or consequence (e.g. arthritis, chronic back pain and chronic headaches). The differences reported across the provinces and territories in Canada likely reflect variations in health system organization, service access and social environments across regions.^{Footnote 3} Finally, psychosocial factors like stress, poor perceived health and dissatisfaction with life are often modifiable, but cluster together and compound vulnerability.^{Footnote 28Footnote 29}

Despite growing research on mood and anxiety disorders in Canada, to the best of our knowledge, few studies have examined mood disorders alone, anxiety disorders alone and comorbid mood and anxiety disorders (henceforth referred to as “comorbid disorders”) in a single, nationally representative sample. Using the most recent pre-COVID-19 Canadian Community Health Survey (CCHS) data (2019–2020), we investigated a range of sociodemographic, socioeconomic, health-related and psychosocial factors associated with these three mental health outcomes. Our findings provide an up-to-date baseline for understanding mental health risk profiles and can inform targeted prevention and intervention strategies.

Methods

Data source and study population

This study used pooled data from the 2019–2020 CCHS Annual Components, which were harmonized by Statistics Canada and analyzed as a single cross-sectional dataset.^{Footnote 30} The CCHS uses a multistage, complex sampling design to collect comprehensive socioeconomic and health-related data, including information on health status, access to and utilization of health services, and various determinants of health.^{Footnote 30Footnote 31Footnote 32} The survey sample included 108252 people aged 12 years and older living in all the provinces and territories in Canada. The survey does not include people living on reserves and other Indigenous (referred to as “Aboriginal” in the CCHS) settlements, in specific remote areas or institutional settings and full-time members of the Canadian Armed Forces. Detailed descriptions of the CCHS methodology, design, instruments and sampling frame are available elsewhere.^{Footnote 31}

Study variables and measures

Outcome variable

The primary outcome was a four-category multinomial variable representing no reported disorder, mood disorders alone, anxiety disorders alone and comorbid mood and anxiety disorders, based on self-reported chronic (lasting, or expected to last, at least 6 months) diagnoses of mood and/or anxiety disorders by a health professional. Respondents were categorized as having a mood disorder if they answered “yes” to the question “Do you have a mood disorder such as depression, bipolar disorder, mania or dysthymia?” and as having an anxiety disorder if they answered “yes” to the question “Do you have an anxiety disorder such as a phobia, obsessive-compulsive disorder or panic disorder?” Respondents who answered “yes” to the question about having a mood disorder and “no” to the question about having an anxiety disorder were categorized as having a mood disorder alone, whereas those who answered “yes” to the question about having an anxiety disorder and “no” to the question about having a mood disorder were categorized as having an anxiety disorder alone. Respondents who answered “yes” to both questions were categorized as having comorbid disorders, and those who answered “no” were categorized as having no reported disorder.

Covariates

The covariates included the following sociodemographic factors: sex (male or female); age group (12–17, 18–24, 25–34, 35–50, 51–64 or ≥ 65 years); Indigenous identity (yes or no); immigration status (immigrant [either a permanent resident, referred to as “landed immigrant” in the 2020 CCHS, or a nonpermanent resident] or Canadian born); racialized identity (referred to as “visible minority,” with yes or no indicators, in the CCHS public-use file, which collapses multiple self-identified ethnic and/or cultural categories into a binary indicator); marital status (married or living common law vs. single, i.e. never married, divorced, separated or widowed); educational attainment (less than high school graduation, high school diploma or equivalent, or postsecondary certificate, diploma or university degree); and region of residence (the 10 provinces and a combined territories category).

Socioeconomic factors included household income (< Canadian dollars [CAD] 20000, 20000–39999, 40000–59999, 60000–79999 or ≥ 80000), based on Canadian national income groupings; and household food security status (food secure, marginally insecure, moderately insecure or severely insecure).

Health-related factors included perceived health (excellent, very good, good, fair, poor); pain status (no usual pain or discomfort vs. usual pain or discomfort); number of chronic physical conditions (0, 1, 2 or ≥ 3 based on indicators for seven diagnosed conditions, i.e. asthma, arthritis, high blood pressure, diabetes, chronic respiratory diseases, musculoskeletal disorders and cardiovascular disease). Unmet health care need in the past 12 months (no/yes) was coded “yes” if the respondent reported needing but not receiving health care and experiencing one or more barriers to receiving health care (e.g. waiting time, cost, lack of availability).

Psychosocial factors included sense of community belonging (very strong, somewhat strong, somewhat weak or very weak); life satisfaction (very satisfied, satisfied, neither satisfied nor dissatisfied, dissatisfied or very dissatisfied); and perceived life stress (not at all stressful, not very stressful, a bit stressful, quite a bit stressful or extremely stressful).

Unless otherwise noted, covariates use Statistics Canada–derived variables in the 2019–2020 CCHS public-use file; nonresponse (“don’t know,” “refused”) was coded as missing. Some variables (e.g. chronic conditions count, unmet health care need) were constructed from multiple CCHS items.

Conceptual framing

Psychosocial measures (life satisfaction, perceived stress, sense of community belonging) are treated as downstream social determinants shaped by broader social and economic conditions (e.g. poverty, discrimination or exclusion). We therefore interpreted associations involving these variables as conditional associations that may reflect accumulated structural disadvantage rather than purely individual attributes.

Statistical analysis

Descriptive analyses summarize respondent characteristics across the levels of the outcome variable. We report frequencies and percentages using survey- and bootstrap-weighted estimates to account for the complex survey design. Crude associations were examined with bivariate multinomial logistic regression; adjusted associations were estimated with survey-weighted multinomial logistic regression to obtain adjusted relative risk ratios (aRRRs) and 95% confidence intervals (CIs). Associations were considered statistically significant if the 95% CI for each aRRR did not include 1. All analyses incorporated the CCHS-provided sampling weights to account for the complex survey design and to ensure population-level representativeness.^{Footnote 30} Multicollinearity among explanatory variables was assessed using the variance inflation factor,^{Footnote 33} with values exceeding 2.5 indicating potential multicollinearity concerns.

Analyses were performed using STATA version 17 (StataCorp LLC, College Station, TX, US).

Ethics approval

This study used publicly available, deidentified secondary data from the CCHS, and is therefore exempt from institutional ethics review.

Results

In the analytic sample of 107 859 respondents, 4503 (4.17%) reported being clinically diagnosed with a mood disorder alone, 5381 (4.99%) with an anxiety disorder alone and 5226 (4.85%) with comorbid mood and anxiety disorders (Table 1). Females were more prevalent in all the groups, and younger adults (18–34 years) were particularly represented in the anxiety alone and comorbid disorders groups.

Table 1. Characteristics of respondents with mood and/or anxiety disorders or no reported mood or anxiety disorder,^{Footnote a} CCHS, 2019–2020

Variables	No reported disorder		Mood disordersFootnote b		Anxiety disordersFootnote c		Comorbid mood and anxiety disordersFootnote bFootnote c		Total
	n	%	n	%	n	%	n	%	n	%
Total	92 749	85.99	4503	4.17	5381	4.99	5226	4.85	107 859	100
Sociodemographic factors
Sex (n = 107 859)
Male	47 594	51.32	1834	40.73	1963	36.48	1878	35.93	53 269	49.39
Female	45 155	48.68	2669	59.27	3418	63.52	3348	64.07	54 590	50.61
Age, years (n = 107 859)
12–17	6880	7.42	109	2.43	579	10.76	253	4.84	7822	7.25
18–34	23 415	25.25	1034	22.97	1713	31.83	2164	41.42	28 327	26.26
35–49	20 999	22.64	1044	23.19	1257	23.36	1253	23.97	24 553	22.76
50–64	21 920	23.63	1354	30.07	1106	20.56	1114	21.31	25 494	23.64
≥ 65	19 534	21.06	961	21.34	726	13.50	442	8.46	21 663	20.08
Indigenous identity (n = 104 880)
No	87 814	97.36	4181	94.96	4996	95.49	4674	92.50	101 665	96.93
Yes	2378	2.64	222	5.04	236	4.51	379	7.50	3215	3.07
Immigration status (n = 105 728)
ImmigrantFootnote d	26 020	28.65	685	15.39	723	13.61	595	11.61	28 023	26.50
Canadian born	64 815	71.35	3769	84.61	4590	86.39	4532	88.39	77 705	73.50
Racialized identityFootnote e (n = 104 902)
Yes	21 659	24.04	487	11.02	597	11.30	575	11.29	23 317	22.23
No	68 453	75.96	3932	88.98	4684	88.70	4517	88.71	81 585	77.77
Marital status (n = 99 800)
Married/living common law	55 775	65.11	2373	54.18	2616	54.56	2115	42.64	62 879	63.00
SingleFootnote f	29 890	34.89	2007	45.82	2179	45.44	2845	57.36	36 921	37.00
Educational attainment (n = 102 176)
Less than high school	3769	4.28	199	4.67	231	4.57	197	4.06	4396	4.30
High school graduate	10 634	12.08	608	14.26	582	11.52	817	16.85	12 642	12.37
Postsecondary graduate	73 605	83.63	3457	81.06	4239	83.90	3836	79.09	85 138	83.32
Region of residence (n = 107 859)
Newfoundland and Labrador	1293	1.39	69	1.54	97	1.80	84	1.62	1543	1.43
Prince Edward Island	377	0.41	22	0.49	25	0.47	31	0.60	456	0.42
Nova Scotia	2236	2.41	159	3.52	171	3.18	253	4.84	2818	2.61
New Brunswick	1817	1.96	114	2.52	157	2.91	138	2.64	2225	2.06
Quebec	21 625	23.32	802	17.80	1437	26.71	637	12.20	24 501	22.72
Ontario	36 326	39.17	1747	38.80	2026	37.64	2273	43.50	42 372	39.28
Manitoba	3132	3.38	167	3.71	168	3.12	183	3.50	3649	3.38
Saskatchewan	2614	2.82	203	4.50	154	2.87	153	2.93	3124	2.90
Alberta	10 539	11.36	588	13.06	515	9.57	699	13.38	12 342	11.44
British Columbia	12 556	13.54	622	13.82	622	11.56	764	14.62	14 565	13.50
TerritoriesFootnote g	234	0.25	11	0.23	10	0.18	10	0.19	264	0.24
Socioeconomic factors
Household income, CAD (n = 106 620)
< 20 000	3280	3.58	320	7.21	305	5.74	479	9.32	4384	4.11
20 000–39 999	9622	10.49	601	13.55	673	12.66	743	14.47	11 639	10.92
40 000–59 999	11 281	12.30	637	14.35	703	13.22	811	15.80	13 431	12.60
60 000–79 999	11 271	12.29	636	14.34	670	12.61	601	11.71	13 179	12.36
≥ 80 000	56 281	61.35	2243	50.55	2964	55.76	2500	48.69	63 987	60.01
Household food security status (n = 91 125)
Food secure	71 675	91.54	3035	79.66	3914	83.85	3088	71.05	81 712	89.67
Marginally insecure	2591	3.31	213	5.60	226	4.84	230	5.29	3260	3.58
Moderately insecure	3062	3.91	325	8.52	337	7.23	538	12.37	4262	4.68
Severely insecure	973	1.24	237	6.22	191	4.09	491	11.29	1891	2.08
Health-related factors
Perceived health (n = 107 725)
Excellent	24 336	26.27	315	7.00	716	13.31	189	3.63	25 555	23.72
Very good	37 161	40.11	1190	26.47	1825	33.95	962	18.49	41 139	38.19
Good	23 871	25.76	1691	37.61	1931	35.91	1986	38.17	29 479	27.37
Fair	5655	6.10	948	21.09	683	12.70	1351	25.97	8638	8.02
Poor	1626	1.75	352	7.83	221	4.12	715	13.74	2914	2.71
Pain status (n = 107 570)
No usual pain or discomfort	73 409	79.35	2513	56.16	3585	66.69	2802	53.87	82 310	76.52
Usual pain or discomfort	19 108	20.65	1962	43.84	1791	33.31	2400	46.13	25 260	23.48
Number of chronic physical conditions (n = 107 859)Footnote h
0	56 801	61.24	1976	43.88	3058	56.82	2553	48.86	64 388	59.70
1	19 872	21.43	1194	26.51	1261	23.43	1429	27.34	23 755	22.02
2	9356	10.09	675	15.00	565	10.49	686	13.12	11 282	10.46
≥ 3	6719	7.24	658	14.62	498	9.25	559	10.69	8434	7.82
Unmet health care need in the past 12 months (n = 107 859)
No	89 634	96.64	4145	92.06	5054	93.92	4451	85.17	103 285	95.76
Yes	3114	3.36	357	7.94	327	6.08	775	14.83	4574	4.24
Psychosocial factors
Sense of community belonging (n = 103 408)
Very strong	17 355	19.38	534	12.77	820	16.52	405	8.56	19 114	18.48
Somewhat strong	47 042	52.54	1902	45.48	2439	49.14	1913	40.43	53 296	51.54
Somewhat weak	20 005	22.34	1277	30.54	1234	24.86	1496	31.62	24 012	23.22
Very weak	5129	5.73	469	11.21	471	9.48	917	19.39	6986	6.76
Life satisfaction (n = 104 005)
Very satisfied	39 076	43.38	788	18.75	1390	27.99	538	11.31	41 793	40.18
Satisfied	46 858	52.02	2620	62.31	3041	61.22	2762	58.06	55 281	53.15
Neither satisfied nor dissatisfied	2862	3.18	402	9.55	345	6.94	690	14.52	4299	4.13
Dissatisfied	1039	1.15	339	8.07	163	3.28	621	13.06	2162	2.08
Very dissatisfied	241	0.27	56	1.33	28	0.56	145	3.06	470	0.45
Perceived life stress (n = 107 478)
Not at all stressful	14 010	15.16	273	6.08	256	4.77	158	3.06	14 697	13.67
Not very stressful	23 916	25.87	678	15.11	905	16.85	441	8.51	25 940	24.13
A bit stressful	38 262	41.39	1939	43.23	2367	44.05	1995	38.48	44 562	41.46
Quite a bit stressful	14 443	15.62	1287	28.69	1565	29.12	1962	37.83	19 256	17.92
Extremely stressful	1806	1.95	309	6.89	280	5.21	628	12.12	3023	2.81

The comorbid disorders groups generally exhibited greater social and health disadvantages, including higher proportions of respondents identifying as Indigenous, single or with poorer perceived health, usual pain or discomfort, unmet health care needs, weaker sense of community belonging, lower life satisfaction and higher perceived stress. Household food insecurity had substantial missing data (about 16700 respondents; 15.5%) and was excluded from the regression analyses to avoid reducing the analytic sample.

Table 2 shows unadjusted associations.

Table 2. Unadjusted univariate multinomial logistic regression associations between sociodemographic, socioeconomic, health-related and psychosocial factors and mental health outcomes^{Footnote aFootnote b} among Canadians, CCHS, 2019–2020

Variables	Mood disordersFootnote a			Anxiety disordersFootnote b			Comorbid mood and anxiety disordersFootnote aFootnote b
	RRR	95% CI	p value	RRR	95% CI	p value	RRR	95% CI	p value
Sociodemographic factors
Sex (reference category: male)
Female	1.534	1.378–1.708	< 0.001	1.835	1.641–2.053	< 0.001	1.879	1.670–2.114	< 0.001
Age, years (reference category: ≥ 65 years)
12–17	0.324	0.232–0.451	< 0.001	2.264	1.883–2.722	< 0.001	1.626	1.267–2.085	< 0.001
18–34	0.898	0.766–1.053	0.187	1.967	1.705–2.270	< 0.001	4.085	3.539–4.715	< 0.001
35–49	1.011	0.878–1.165	0.879	1.610	1.405–1.845	< 0.001	2.637	2.271–3.061	< 0.001
50–64	1.256	1.108–1.423	< 0.001	1.357	1.179–1.562	< 0.001	2.246	1.928–2.616	< 0.001
Indigenous identity (reference category: no)
Yes	1.961	1.586–2.425	< 0.001	1.743	1.408–2.157	< 0.001	2.994	2.428–3.692	< 0.001
Immigration status (reference category: immigrantFootnote c)
Canadian born	2.208	1.885–2.586	< 0.001	2.548	2.140–3.034	< 0.001	3.057	2.565–3.644	< 0.001
Racialized identityFootnote d (reference category: no)
Yes	0.391	0.319–0.479	< 0.001	0.403	0.325–0.499	< 0.001	0.402	0.322–0.502	< 0.001
Marital status (reference category: married/living common law)
SingleFootnote e	1.578	1.418–1.756	< 0.001	1.554	1.385–1.744	< 0.001	2.510	2.251–2.799	< 0.001
Educational attainment (reference category: less than high school)
High school graduate	1.082	0.874–1.339	0.469	0.893	0.720–1.107	0.302	1.471	1.127–1.919	0.004
Postsecondary graduate	0.888	0.743–1.062	0.194	0.939	0.794–1.111	0.465	0.998	0.779–1.277	0.986
Region of residence (reference category: Ontario)
Newfoundland and Labrador	1.113	0.838–1.479	0.458	1.343	1.006–1.792	0.045	1.044	0.762–1.430	0.790
Prince Edward Island	1.212	0.861–1.707	0.270	1.203	0.852–1.697	0.294	1.329	0.983–1.798	0.065
Nova Scotia	1.474	1.161–1.872	0.001	1.371	1.105–1.700	0.004	1.807	1.457–2.241	< 0.001
New Brunswick	1.300	0.999–1.692	0.051	1.546	1.235–1.936	< 0.001	1.211	0.906–1.620	0.196
Quebec	0.771	0.651–0.913	0.003	1.192	1.041–1.365	0.011	0.471	0.397–0.559	< 0.001
Manitoba	1.110	0.872–1.412	0.397	0.960	0.758–1.217	0.739	0.932	0.741–1.172	0.547
Saskatchewan	1.612	1.310–1.981	< 0.001	1.058	0.785–1.427	0.709	0.936	0.715–1.226	0.631
Alberta	1.160	0.996–1.352	0.056	0.877	0.730–1.054	0.160	1.060	0.898–1.251	0.489
British Columbia	1.030	0.879–1.207	0.711	0.889	0.742–1.065	0.200	0.972	0.827–1.143	0.734
TerritoriesFootnote f	0.937	0.725–1.210	0.616	0.731	0.562–0.953	0.020	0.675	0.515–0.886	0.005
Socioeconomic factors
Household income, CAD (reference category: ≥ 80 000)
< 20 000	2.449	2.034–2.949	< 0.001	1.766	1.440–2.166	< 0.001	3.285	2.795–3.862	< 0.001
20 000–39 999	1.568	1.353–1.817	< 0.001	1.328	1.133–1.557	< 0.001	1.738	1.487–2.031	< 0.001
40 000–59 999	1.416	1.217–1.649	< 0.001	1.183	0.999–1.400	0.052	1.619	1.370–1.914	< 0.001
60 000–79 999	1.416	1.203–1.667	< 0.001	1.130	0.959–1.331	0.145	1.201	1.011–1.427	0.037
Health-related factors
Perceived health (reference category: excellent)
Very good	2.478	1.997–3.074	< 0.001	1.670	1.415–1.971	< 0.001	3.340	2.522–4.424	< 0.001
Good	5.481	4.445–6.759	< 0.001	2.750	2.328–3.248	< 0.001	10.734	8.220–14.016	< 0.001
Fair	12.974	10.426–16.144	< 0.001	4.106	3.356–5.024	< 0.001	30.829	23.360–40.687	< 0.001
Poor	16.756	12.946–21.686	< 0.001	4.628	3.611–5.931	< 0.001	56.716	42.423–75.825	< 0.001
Pain status (reference category: no usual pain or discomfort)
Usual pain or discomfort	2.999	2.698–3.333	< 0.001	1.919	1.722–2.138	< 0.001	3.290	2.954–3.665	< 0.001
Number of diagnosed chronic physical conditionsFootnote g (reference category: 0)
1	1.727	1.506–1.980	< 0.001	1.179	1.035–1.343	0.014	1.599	1.399–1.828	< 0.001
2	2.075	1.790–2.406	< 0.001	1.121	0.968–1.298	0.128	1.630	1.391–1.911	< 0.001
≥ 3	2.817	2.429–3.265	< 0.001	1.376	1.173–1.615	< 0.001	1.850	1.571–2.177	< 0.001
Unmet health care needs (reference category: no)
Yes	2.481	2.005–3.071	< 0.001	1.862	1.528–2.269	< 0.001	5.013	4.174–6.021	< 0.001
Psychosocial factors
Sense of community belonging (reference category: very strong)
Somewhat strong	1.314	1.120–1.542	0.001	1.097	0.942–1.277	0.233	1.742	1.451–2.092	< 0.001
Somewhat weak	2.075	1.745–2.468	< 0.001	1.305	1.101–1.547	0.002	3.205	2.651–3.875	< 0.001
Very weak	2.971	2.403–3.672	< 0.001	1.941	1.549–2.432	< 0.001	7.664	6.211–9.457	< 0.001
Life satisfaction (reference category: very satisfied)
Satisfied	2.772	2.379–3.230	< 0.001	1.824	1.618–2.057	< 0.001	4.282	3.545–5.174	< 0.001
Neither satisfied nor dissatisfied	6.959	5.623–8.612	< 0.001	3.387	2.639–4.347	< 0.001	17.530	13.942–22.041	< 0.001
Dissatisfied	16.190	12.567–20.858	< 0.001	4.411	3.286–5.920	< 0.001	43.438	33.636–56.095	< 0.001
Very dissatisfied	11.449	7.304–17.947	< 0.001	3.250	2.035–5.190	< 0.001	43.785	29.385–65.240	< 0.001
Perceived life stress (reference category: not at all stressful)
Not very stressful	1.456	1.156–1.833	0.001	2.069	1.673–2.559	< 0.001	1.632	1.140–2.338	0.007
A bit stressful	2.603	2.105–3.220	< 0.001	3.381	2.783–4.107	< 0.001	4.611	3.380–6.290	< 0.001
Quite a bit stressful	4.578	3.682–5.692	< 0.001	5.922	4.823–7.273	< 0.001	12.011	8.753–16.481	< 0.001
Extremely stressful	8.799	6.534–11.848	< 0.001	8.477	6.383–11.257	< 0.001	30.773	21.651–43.737	< 0.001

After adjustment, females had higher aRRRs for all three outcomes: mood disorders (aRRR = 1.688; 95% CI: 1.487–1.916); anxiety disorders (1.956; 1.712–2.234); and comorbid disorders (2.284; 1.951–2.673) in particular (Table 3 and Figure 1).

Table 3. Adjusted multinomial logistic regression^{Footnote a} associations between sociodemographic, socioeconomic, health-related and psychosocial factors and mental health outcomes^{Footnote bFootnote c} among Canadians, CCHS, 2019–2020

Variables	Mood disordersFootnote b			Anxiety disordersFootnote c			Comorbid mood and anxiety disordersFootnote bFootnote c
	aRRR	95% CI	p value	aRRR	95% CI	p value	aRRR	95% CI	p value
Sociodemographic factors
Sex (reference category: male)
Female	1.688	1.487–1.916	< 0.001	1.956	1.712–2.234	< 0.001	2.284	1.951–2.673	< 0.001
Age, years (reference category: ≥ 65 years)
12–17	Footnote d	Footnote d	Footnote d	Footnote d	Footnote d	Footnote d	Footnote d	Footnote d	Footnote d
18–34	1.586	1.269–1.982	< 0.001	3.036	2.441–3.776	< 0.001	9.311	7.134–12.153	< 0.001
35–49	1.653	1.349–2.027	< 0.001	2.350	1.923–2.872	< 0.001	5.319	4.157–6.804	< 0.001
50–64	1.612	1.371–1.895	< 0.001	1.457	1.228–1.730	< 0.001	3.013	2.454–3.700	< 0.001
Indigenous identity (reference category: no)
Yes	1.154	0.856–1.538	0.331	1.181	0.880–1.585	0.267	1.410	1.048–1.896	0.023
Immigration status (reference category: immigrantFootnote e)
Canadian born	1.723	1.414–2.099	< 0.001	1.701	1.355–2.136	< 0.001	1.984	1.544–2.551	< 0.001
Racialized identityFootnote f (reference category: no)
Yes	0.525	0.410–0.671	< 0.001	0.478	0.354–0.645	< 0.001	0.423	0.308–0.581	< 0.001
Marital status (reference category: married/living common law)
SingleFootnote g	1.313	1.139–1.513	< 0.001	1.156	1.004–1.331	0.044	1.415	1.230–1.628	< 0.001
Educational attainment (reference category: less than high school)
High school graduate	1.207	0.944–1.542	0.133	0.874	0.681–1.121	0.288	1.394	1.049–1.853	0.022
Postsecondary graduate	1.473	1.179–1.841	0.001	1.062	0.858–1.315	0.581	1.456	1.108–1.913	0.007
Region of residence (reference category: Ontario)
Newfoundland and Labrador	1.039	0.737–1.463	0.829	1.325	0.913–1.923	0.139	1.040	0.673–1.608	0.859
Prince Edward Island	1.140	0.778–1.672	0.502	1.019	0.638–1.626	0.938	1.225	0.818–1.834	0.325
Nova Scotia	1.451	1.102–1.909	0.008	1.305	1.001–1.700	0.049	1.547	1.139–2.102	0.005
New Brunswick	0.998	0.712–1.399	0.989	1.263	0.947–1.686	0.112	1.015	0.654–1.575	0.948
Quebec	0.799	0.660–0.968	0.022	1.133	0.957–1.340	0.146	0.462	0.368–0.581	< 0.001
Manitoba	1.130	0.864–1.476	0.372	0.914	0.681–1.227	0.551	0.736	0.554–0.978	0.034
Saskatchewan	1.591	1.228–2.062	< 0.001	1.064	0.751–1.508	0.727	1.016	0.716–1.443	0.928
Alberta	1.241	1.036–1.486	0.019	0.875	0.707–1.082	0.217	1.016	0.815–1.267	0.885
British Columbia	1.046	0.863–1.269	0.646	0.993	0.799–1.234	0.950	0.912	0.734–1.133	0.404
Territories	Footnote h	Footnote h	Footnote h	Footnote h	Footnote h	Footnote h	Footnote h	Footnote h	Footnote h
Socioeconomic factors
Household income, CAD (reference category: ≥ 80 000)
< 20 000	1.659	1.306–2.106	< 0.001	1.571	1.176–2.098	0.002	1.872	1.479–2.369	< 0.001
20 000–39 999	1.197	0.974–1.471	0.087	1.176	0.953–1.452	0.131	1.262	1.005–1.583	0.045
40 000–59 999	1.250	1.036–1.509	0.020	1.114	0.917–1.352	0.276	1.359	1.086–1.700	0.007
60 000–79 999	1.283	1.062–1.550	0.010	1.245	1.022–1.517	0.029	1.173	0.943–1.459	0.152
Health-related factors
Perceived health (reference category: excellent)
Very good	1.783	1.398–2.274	< 0.001	1.550	1.270–1.892	< 0.001	2.681	1.944–3.696	< 0.001
Good	3.177	2.481–4.069	< 0.001	2.358	1.912–2.910	< 0.001	7.038	5.142–9.632	< 0.001
Fair	4.832	3.605–6.477	< 0.001	3.182	2.410–4.203	< 0.001	12.874	9.058–18.297	< 0.001
Poor	4.422	3.082–6.345	< 0.001	2.632	1.883–3.679	< 0.001	14.688	9.908–21.775	< 0.001
Pain status (reference category: no usual pain or discomfort)
Usual pain or discomfort	1.392	1.219–1.590	< 0.001	1.382	1.204–1.586	< 0.001	1.364	1.168–1.592	< 0.001
Number of diagnosed chronic physical conditionsFootnote i (reference category: 0)
1	1.290	1.086–1.532	0.004	1.320	1.117–1.560	0.001	1.417	1.159–1.731	0.001
2	1.336	1.094–1.632	0.005	1.412	1.143–1.745	0.001	1.707	1.295–2.251	< 0.001
≥ 3	1.542	1.227–1.939	< 0.001	1.643	1.310–2.062	< 0.001	1.937	1.425–2.633	< 0.001
Unmet health care need (reference category: no)
Yes	1.268	0.991–1.622	0.059	1.264	1.001–1.595	0.049	2.296	1.710–3.083	< 0.001
Psychosocial factors
Sense of community belonging (reference category: very strong)
Somewhat strong	0.984	0.823–1.178	0.861	0.852	0.714–1.017	0.076	1.182	0.940–1.487	0.153
Somewhat weak	1.241	1.013–1.520	0.037	0.877	0.715–1.075	0.206	1.563	1.229–1.988	< 0.001
Very weak	1.313	1.024–1.683	0.032	1.178	0.902–1.539	0.229	2.221	1.703–2.895	< 0.001
Life satisfaction (reference category: very satisfied)
Satisfied	1.655	1.386–1.977	< 0.001	1.248	1.074–1.450	0.004	1.879	1.502–2.350	< 0.001
Neither satisfied nor dissatisfied	2.280	1.752–2.968	< 0.001	1.658	1.207–2.279	0.002	3.874	2.844–5.275	< 0.001
Dissatisfied	3.926	2.889–5.337	< 0.001	1.644	1.112–2.430	0.013	5.157	3.648–7.289	< 0.001
Very dissatisfied	2.906	1.638–5.156	< 0.001	0.797	0.452–1.404	0.432	4.819	2.821–8.232	< 0.001
Perceived life stress (reference category: not at all stressful)
Not very stressful	1.184	0.904–1.551	0.221	1.803	1.385–2.348	< 0.001	1.144	0.724–1.807	0.564
A bit stressful	1.770	1.376–2.276	< 0.001	2.446	1.902–3.145	< 0.001	2.205	1.467–3.313	< 0.001
Quite a bit stressful	2.340	1.789–3.061	< 0.001	3.620	2.769–4.733	< 0.001	3.447	2.272–5.229	< 0.001
Extremely stressful	2.856	1.981–4.116	< 0.001	4.228	2.896–6.172	< 0.001	3.927	2.390–6.453	< 0.001

Figure 1: Descriptive text

Adjusted relative risk ratios for mood, anxiety and comorbid disorders among Canadians, CCHS, 2019–2020

Variable	Outcome	aRRR	Lower CI	Upper CI
Sex: Female (ref: Male)	Mood Only	1.688	1.487	1.916
Sex: Female (ref: Male)	Anxiety Only	1.956	1.712	2.234
Sex: Female (ref: Male)	Comorbid	2.284	1.951	2.673
Age: 18–34 (ref: 65+)	Mood Only	1.586	1.269	1.982
Age: 18–34 (ref: 65+)	Anxiety Only	3.036	2.441	3.776
Age: 18–34 (ref: 65+)	Comorbid	9.311	7.134	12.153
Age: 35–49 (ref: 65+)	Mood Only	1.653	1.349	2.027
Age: 35–49 (ref: 65+)	Anxiety Only	2.350	1.923	2.872
Age: 35–49 (ref: 65+)	Comorbid	5.319	4.157	6.804
Age: 50–64 (ref: 65+)	Mood Only	1.612	1.371	1.895
Age: 50–64 (ref: 65+)	Anxiety Only	1.457	1.228	1.730
Age: 50–64 (ref: 65+)	Comorbid	3.013	2.454	3.700
Indigenous peoples: Yes (ref: No)	Mood Only	1.154	0.856	1.538
Indigenous peoples: Yes (ref: No)	Anxiety Only	1.181	0.880	1.585
Indigenous peoples: Yes (ref: No)	Comorbid	1.410	1.048	1.896
Immigration: Canadian born (ref: Immigrant)	Mood Only	1.723	1.414	2.099
Immigration: Canadian born (ref: Immigrant)	Anxiety Only	1.701	1.355	2.136
Immigration: Canadian born (ref: Immigrant)	Comorbid	1.984	1.544	2.551
Racialized identity: Yes (ref: No)	Mood Only	0.525	0.410	0.671
Racialized identity: Yes (ref: No)	Anxiety Only	0.478	0.354	0.645
Racialized identity: Yes (ref: No)	Comorbid	0.423	0.308	0.581
Marital status: Single (ref: Married/common-law)	Mood Only	1.313	1.139	1.513
Marital status: Single (ref: Married/common-law)	Anxiety Only	1.156	1.004	1.331
Marital status: Single (ref: Married/common-law)	Comorbid	1.415	1.230	1.628
Education: High school graduate (ref: < High school)	Mood Only	1.207	0.944	1.542
Education: High school graduate (ref: < High school)	Anxiety Only	0.874	0.681	1.121
Education: High school graduate (ref: < High school)	Comorbid	1.394	1.049	1.853
Education: Post-secondary graduate (ref: < High school)	Mood Only	1.473	1.179	1.841
Education: Post-secondary graduate (ref: < High school)	Anxiety Only	1.062	0.858	1.315
Education: Post-secondary graduate (ref: < High school)	Comorbid	1.456	1.108	1.913
Region: Prince Edward Island (ref: Ontario)	Mood Only	1.140	0.778	1.672
Region: Prince Edward Island (ref: Ontario)	Anxiety Only	1.019	0.638	1.626
Region: Prince Edward Island (ref: Ontario)	Comorbid	1.225	0.818	1.834
Region: Nova Scotia (ref: Ontario)	Mood Only	1.451	1.102	1.909
Region: Nova Scotia (ref: Ontario)	Anxiety Only	1.305	1.001	1.700
Region: Nova Scotia (ref: Ontario)	Comorbid	1.547	1.139	2.102
Region: New Brunswick (ref: Ontario)	Mood Only	0.998	0.712	1.399
Region: New Brunswick (ref: Ontario)	Anxiety Only	1.263	0.947	1.686
Region: New Brunswick (ref: Ontario)	Comorbid	1.015	0.654	1.575
Region: Quebec (ref: Ontario)	Mood Only	0.799	0.660	0.968
Region: Quebec (ref: Ontario)	Anxiety Only	1.133	0.957	1.340
Region: Quebec (ref: Ontario)	Comorbid	0.462	0.368	0.581
Region: Newfoundland and Labrador (ref: Ontario)	Mood Only	1.039	0.737	1.463
Region: Newfoundland and Labrador (ref: Ontario)	Anxiety Only	1.325	0.913	1.923
Region: Newfoundland and Labrador (ref: Ontario)	Comorbid	1.040	0.673	1.608
Region: Manitoba (ref: Ontario)	Mood Only	1.130	0.864	1.476
Region: Manitoba (ref: Ontario)	Anxiety Only	0.914	0.681	1.227
Region: Manitoba (ref: Ontario)	Comorbid	0.736	0.554	0.978
Region: Saskatchewan (ref: Ontario)	Mood Only	1.591	1.228	2.062
Region: Saskatchewan (ref: Ontario)	Anxiety Only	1.064	0.751	1.508
Region: Saskatchewan (ref: Ontario)	Comorbid	1.016	0.716	1.443
Region: Alberta (ref: Ontario)	Mood Only	1.241	1.036	1.486
Region: Alberta (ref: Ontario)	Anxiety Only	0.875	0.707	1.082
Region: Alberta (ref: Ontario)	Comorbid	1.016	0.815	1.267
Region: British Columbia (ref: Ontario)	Mood Only	1.046	0.863	1.269
Region: British Columbia (ref: Ontario)	Anxiety Only	0.993	0.799	1.234
Region: British Columbia (ref: Ontario)	Comorbid	0.912	0.734	1.133
Household income: < 20000 (ref: = $80 000)	Mood Only	1.659	1.306	2.106
Household income: < 20000 (ref: = $80 000)	Anxiety Only	1.571	1.176	2.098
Household income: < 20000 (ref: = $80 000)	Comorbid	1.872	1.479	2.369
Household income: 20000–39999 (ref: = $80 000)	Mood Only	1.197	0.974	1.471
Household income: 20000–39999 (ref: = $80 000)	Anxiety Only	1.176	0.953	1.452
Household income: 20000–39999 (ref: = $80 000)	Comorbid	1.262	1.005	1.583
Household income: 40000–59999 (ref: = $80 000)	Mood Only	1.250	1.036	1.509
Household income: 40000–59999 (ref: = $80 000)	Anxiety Only	1.114	0.917	1.352
Household income: 40000–59999 (ref: = $80 000)	Comorbid	1.359	1.086	1.700
Household income: 60000–79999 (ref: = $80 000)	Mood Only	1.283	1.062	1.550
Household income: 60000–79999 (ref: = $80 000)	Anxiety Only	1.245	1.022	1.517
Household income: 60000–79999 (ref: = $80 000)	Comorbid	1.173	0.943	1.459
Perceived health: Very good (ref: Excellent)	Mood Only	1.783	1.398	2.274
Perceived health: Very good (ref: Excellent)	Anxiety Only	1.550	1.270	1.892
Perceived health: Very good (ref: Excellent)	Comorbid	2.681	1.944	3.696
Perceived health: Good (ref: Excellent)	Mood Only	3.177	2.481	4.069
Perceived health: Good (ref: Excellent)	Anxiety Only	2.358	1.912	2.910
Perceived health: Good (ref: Excellent)	Comorbid	7.038	5.142	9.632
Perceived health: Fair (ref: Excellent)	Mood Only	4.832	3.605	6.477
Perceived health: Fair (ref: Excellent)	Anxiety Only	3.182	2.410	4.203
Perceived health: Fair (ref: Excellent)	Comorbid	12.874	9.058	18.297
Perceived health: Poor (ref: Excellent)	Mood Only	4.422	3.082	6.345
Perceived health: Poor (ref: Excellent)	Anxiety Only	2.632	1.883	3.679
Perceived health: Poor (ref: Excellent)	Comorbid	14.688	9.908	21.775
Pain status: Has usual pain or discomfort (ref: No pain)	Mood Only	1.392	1.219	1.590
Pain status: Has usual pain or discomfort (ref: No pain)	Anxiety Only	1.382	1.204	1.586
Pain status: Has usual pain or discomfort (ref: No pain)	Comorbid	1.364	1.168	1.592
Number of chronic physical conditions: 1 (ref: 0)	Mood Only	1.290	1.086	1.532
Number of chronic physical conditions: 1 (ref: 0)	Anxiety Only	1.320	1.117	1.560
Number of chronic physical conditions: 1 (ref: 0)	Comorbid	1.417	1.159	1.731
Number of chronic physical conditions: 2 (ref: 0)	Mood Only	1.336	1.094	1.632
Number of chronic physical conditions: 2 (ref: 0)	Anxiety Only	1.412	1.143	1.745
Number of chronic physical conditions: 2 (ref: 0)	Comorbid	1.707	1.295	2.251
Number of chronic physical conditions: 3+ (ref: 0)	Mood Only	1.542	1.227	1.939
Number of chronic physical conditions: 3+ (ref: 0)	Anxiety Only	1.643	1.310	2.062
Number of chronic physical conditions: 3+ (ref: 0)	Comorbid	1.937	1.425	2.633
Unmet health care need: Yes (ref: No)	Mood Only	1.268	0.991	1.622
Unmet health care need: Yes (ref: No)	Anxiety Only	1.264	1.001	1.595
Unmet health care need: Yes (ref: No)	Comorbid	2.296	1.710	3.083
Sense of belonging: Somewhat strong (ref: Very strong)	Mood Only	0.984	0.823	1.178
Sense of belonging: Somewhat strong (ref: Very strong)	Anxiety Only	0.852	0.714	1.017
Sense of belonging: Somewhat strong (ref: Very strong)	Comorbid	1.182	0.940	1.487
Sense of belonging: Somewhat weak (ref: Very strong)	Mood Only	1.241	1.013	1.520
Sense of belonging: Somewhat weak (ref: Very strong)	Anxiety Only	0.877	0.715	1.075
Sense of belonging: Somewhat weak (ref: Very strong)	Comorbid	1.563	1.229	1.988
Sense of belonging: Very weak (ref: Very strong)	Mood Only	1.313	1.024	1.683
Sense of belonging: Very weak (ref: Very strong)	Anxiety Only	1.178	0.902	1.539
Sense of belonging: Very weak (ref: Very strong)	Comorbid	2.221	1.703	2.895
Satisfaction with life: Satisfied (ref: Very satisfied)	Mood Only	1.655	1.386	1.977
Satisfaction with life: Satisfied (ref: Very satisfied)	Anxiety Only	1.248	1.074	1.450
Satisfaction with life: Satisfied (ref: Very satisfied)	Comorbid	1.879	1.502	2.350
Satisfaction with life: Neither satisfied nor dissatisfied (ref: Very satisfied)	Mood Only	2.280	1.752	2.968
Satisfaction with life: Neither satisfied nor dissatisfied (ref: Very satisfied)	Anxiety Only	1.658	1.207	2.279
Satisfaction with life: Neither satisfied nor dissatisfied (ref: Very satisfied)	Comorbid	3.874	2.844	5.275
Satisfaction with life: Dissatisfied (ref: Very satisfied)	Mood Only	3.926	2.889	5.337
Satisfaction with life: Dissatisfied (ref: Very satisfied)	Anxiety Only	1.644	1.112	2.430
Satisfaction with life: Dissatisfied (ref: Very satisfied)	Comorbid	5.157	3.648	7.289
Satisfaction with life: Very dissatisfied (ref: Very satisfied)	Mood Only	2.906	1.638	5.156
Satisfaction with life: Very dissatisfied (ref: Very satisfied)	Anxiety Only	0.797	0.452	1.404
Satisfaction with life: Very dissatisfied (ref: Very satisfied)	Comorbid	4.819	2.821	8.232
Perceived life stress: Not very stressful (ref: Not at all stressful)	Mood Only	1.184	0.904	1.551
Perceived life stress: Not very stressful (ref: Not at all stressful)	Anxiety Only	1.803	1.385	2.348
Perceived life stress: Not very stressful (ref: Not at all stressful)	Comorbid	1.144	0.724	1.807
Perceived life stress: A bit stressful (ref: Not at all stressful)	Mood Only	1.770	1.376	2.276
Perceived life stress: A bit stressful (ref: Not at all stressful)	Anxiety Only	2.446	1.902	3.145
Perceived life stress: A bit stressful (ref: Not at all stressful)	Comorbid	2.205	1.467	3.313
Perceived life stress: Quite a bit stressful (ref: Not at all stressful)	Mood Only	2.340	1.789	3.061
Perceived life stress: Quite a bit stressful (ref: Not at all stressful)	Anxiety Only	3.620	2.769	4.733
Perceived life stress: Quite a bit stressful (ref: Not at all stressful)	Comorbid	3.447	2.272	5.229
Perceived life stress: Extremely stressful (ref: Not at all stressful)	Mood Only	2.856	1.981	4.116
Perceived life stress: Extremely stressful (ref: Not at all stressful)	Anxiety Only	4.228	2.896	6.172
Perceived life stress: Extremely stressful (ref: Not at all stressful)	Comorbid	3.927	2.390	6.453

Age was strongly associated with mental health outcomes: young adults (18–34 years) had more than three times the risk for anxiety disorders (aRRR = 3.036; 95% CI: 2.441–3.776) and more than nine times the risk for comorbid disorders (9.311; 7.134–12.153) than older adults (≥ 65 years). Adults aged 35 to 64 years also had higher risks across all outcomes, though to a lesser extent than younger adults.

We tested an exploratory age-by-sex interaction term in the multinomial model; the global Wald test was not statistically significant (χ²(12) = 7.82; p = 0.80), indicating that the associations between sex and mental health outcomes did not differ significantly across age groups, contrary to previous Canadian surveillance findings that indicated higher mental health burden among younger females.^{Footnote 3}

Indigenous identity was associated with higher comorbid disorders (aRRR = 1.410; 95% CI: 1.048–1.896), but not with mood and anxiety disorders individually. Canadian-born respondents had higher risks than immigrants, particularly for comorbid disorders (1.984; 1.544–2.551). Racialized respondents were significantly less likely than nonracialized respondents to report mood disorders alone (0.525; 0.410–0.671), anxiety disorders (0.478; 0.354–0.645) and comorbid disorders (0.423; 0.308–0.581). Single respondents had higher risks across all outcomes compared with those who were married or in common-law relationships.

Compared with respondents with less than high school education, postsecondary graduates had higher risks for mood disorders alone (aRRR = 1.473; 95% CI: 1.179–1.841) and comorbid disorders (1.456; 1.108–1.913). High school graduates had a significantly increased risk for comorbid disorders (1.394; 1.049–1.853).

Regional differences in risks for mood and/or anxiety disorders were significant across five provinces. Relative to those in Ontario, respondents in Saskatchewan (aRRR = 1.591; 95% CI: 1.228–2.062) and Alberta (1.241; 1.036–1.486) showed a higher risk for mood disorders alone. Those in Nova Scotia had greater risks for comorbid disorders (1.547; 1.139–2.102) and anxiety disorders alone (1.305; 1.001–1.700). Conversely, respondents in Quebec had lower risks for mood disorders alone (0.799; 0.660–0.968) and comorbid disorders (0.462; 0.368–0.581) and those in Manitoba had lower risk for comorbid disorders (0.736; 0.554–0.978). Estimates for the territories combined are not reported due to very small cell sizes.

Lower income was linked to higher risks, especially for those with an income less than CAD 20000 (highest risk across the disorder categories). Mid-income effects were mixed and often nonsignificant for these diagnosed with anxiety disorders alone.

Poorer perceived health showed a strong gradient that was largest for comorbid disorders (aRRR of 2.681 [95% CI: 1.944–3.696] for very good perceived health to 14.688 [9.908–21.775] for poor perceived health). Experiencing usual pain or discomfort was associated with higher risk for mood (1.392; 1.219–1.590), anxiety (1.382; 1.204–1.586) and comorbid disorders (1.364; 1.168–1.592). Risk rose with the number of coexisting chronic conditions, with three or more associated with higher risks for mood (1.542; 1.227–1.939), anxiety (1.643; 1.310–2.062) and comorbid disorders (1.937; 1.425–2.633). Having unmet health care needs was associated with comorbid disorders (2.296; 1.710–3.083) and anxiety disorders alone (1.264; 1.001–1.595), but not with mood disorders alone.

Psychosocial factors were strongly associated with the outcomes. Compared with having a very strong sense of community belonging, a very weak sense of community belonging was linked to higher risks for mood disorders alone (aRRR = 1.313; 95% CI: 1.024–1.683) and comorbid disorders (2.221; 1.703–2.895). Life satisfaction was strongly associated with mental health outcomes. Compared with respondents who were very satisfied with life, progressively lower levels of life satisfaction were associated with higher risks of mood disorders and comorbid disorders with a clear dose–response pattern. Associations with anxiety disorders were present but generally weaker and less consistent.

Perceiving life stress demonstrated a clear dose–response relationship with mental health outcomes. Increasing levels of stress were associated with progressively higher risks of anxiety disorders and comorbid disorders, with the strongest associations observed among respondents reporting extreme stress. Associations with mood disorders were weaker at lower stress levels but became more pronounced at moderate to high levels of perceived stress.

Discussion

This study provides a prepandemic profile of factors associated with mood disorders, anxiety disorders and comorbid mood and anxiety disorders among adolescents (≥ 12 years) and adults in Canada, using nationally representative data from the 2019 to 2020 CCHS. We found that 4.17% of respondents reported receiving a clinical diagnosis of a mood disorder, 4.99% of an anxiety disorder and 4.85% of comorbid disorders. While the prevalence of mood and anxiety disorders individually is broadly consistent with earlier research,^{Footnote 16} the similar prevalence of comorbid disorders underscores the clinical and public health importance of co-occurring mental health conditions.

Our results confirm well-established sociodemographic patterns. Females had significantly higher relative risks, compared with males, across all mental health outcomes, with the strongest association for comorbid disorders (aRRR of 2.28 vs. 1.69 for mood disorders alone and 1.96 for anxiety disorders alone). This aligns with Canadian and global evidence showing greater prevalence of mood and anxiety disorders among females.^{Footnote 3Footnote 21} Likely contributors include biological differences in stress regulation, greater exposure to interpersonal stressors and gendered norms around emotional expression and help-seeking. Disproportionate caregiving roles and gendered socioeconomic disadvantage may further heighten chronic stress and risk for comorbidity risk.^{Footnote 22} In contrast, lower reported prevalence among males may partly reflect underdiagnosis and reluctance to disclose distress due to norms around stoicism and self-reliance.^{Footnote 16} Together, these patterns suggest that gendered social and structural determinants intersect with biology to shape disparities in mental health.

Compared with older adults (≥ 65 years), younger adults and particularly those aged 18 to 34 years had markedly higher risks for anxiety disorders alone and comorbid disorders, with a striking nearly nine-fold increase in risk for comorbidity. These findings align with prior Canadian and international studies, and likely reflect age-related differences in stress exposure, socioeconomic pressures, coping resources and help-seeking.^{Footnote 18Footnote 19} The findings also highlight the need for age-specific, low-barrier mental health supports for youth and young adults (e.g. campus-based services, youth-appropriate virtual care, brief counselling).

Individuals who identified as Indigenous had higher risk for comorbid mental health disorders (aRRR = 1.41). This is consistent with previous research findings^{Footnote 34} and likely reflects the enduring impacts of colonialism, intergenerational trauma, systemic inequities and underlying social determinants of health such as poverty, housing insecurity and limited access to culturally safe care.^{Footnote 35} However, the CCHS excludes people living on reserves, in Indigenous settlements and in many remote communities as well as in institutions,^{Footnote 31} which likely means our results underestimate the true burden of mental health disorders among Indigenous people. Because population surveys cannot fully capture the historical and structural determinants of Indigenous mental health, national surveillance and service planning should be conducted, in partnership with Indigenous organizations, in ways that respect Indigenous data sovereignty and support culturally grounded, community-led care.

Canadian-born respondents had higher risks across all mental health outcomes than immigrants. While this pattern is often described as consistent with the “healthy immigrant effect,”^{Footnote 36Footnote 37Footnote 38} its applicability to mental health outcomes warrants careful interpretation. The lower prevalence observed among immigrants may reflect underutilization of mental health services, stigma related to help-seeking and barriers to accessing care rather than true differences in underlying mental health burden.^{Footnote 39Footnote 40Footnote 41} Moreover, mental health risks vary substantially across immigrant groups, with refugees and individuals with forced migration experiences potentially experiencing greater risk than suggested by aggregated immigrant categories.^{Footnote 42Footnote 43}

Racialized respondents had lower relative risks for mood disorders, anxiety disorders and comorbid conditions (aRRRs = 0.423–0.525). While this may reflect protective cultural or familial support networks that buffer psychological distress, it too should be interpreted with caution. Lower reported prevalence among racialized populations may also arise from underdiagnosis and underreporting linked to stigma, limited access to culturally safe services and barriers to mental health assessment.^{Footnote 44Footnote 45} The CCHS public-use file collapses different racialized identities into a binary “visible minority” indicator, which obscures heterogeneity and likely masks disparities between specific racialized groups.^{Footnote 46} These findings reinforce the need for disaggregated analyses by race, ethnicity and immigration status and for culturally responsive measurement.

Education showed a more complex relationship. A completed postsecondary education was associated with increased risks for mood disorders and comorbid conditions, but not with anxiety disorders. This is not entirely consistent with earlier work that suggested a straightforward protective effect of education on mental health,^{Footnote 11} but it does align with Finnish and Canadian studies that have found no consistent protection of higher education against anxiety disorders.^{Footnote 19Footnote 47} One plausible explanation is that individuals with higher educational attainment may have greater mental health literacy, better access to primary care and more opportunities to receive and report a formal diagnosis of depression or a mood disorder. Conversely, work–family strain, job insecurity within professionalized labour markets and chronic work stress may contribute to mood symptoms despite higher educational attainment.

We observed differences between the provinces: compared with Ontario, Saskatchewan had the highest adjusted risk for mood disorders and Nova Scotia for comorbid conditions, while Quebec showed lower risks across most outcomes, consistent with previous research.^{Footnote 3Footnote 17} These patterns likely reflect unmeasured contextual factors—primary-care attachment and service organization (e.g. availability of stepped care, waiting times, rural access), social policy environments (income, housing, employment supports) and help-seeking or diagnostic practices (literacy, stigma, screening, billing/coding). Such factors may be especially relevant for comorbidity, which often requires more coordinated care pathways.

Lower household income was positively associated with all mental health outcomes even after adjustment, consistent with evidence linking socioeconomic disadvantage to depression and anxiety.^{Footnote 48Footnote 49Footnote 50Footnote 51} Our results underscore the continued importance of socioeconomic factors in mental health disparities and suggest that income remains a relevant consideration for targeted prevention and intervention strategies.

Finally, several health-related and psychosocial factors—poor perceived health and experiencing chronic pain, multimorbidity, unmet health care needs, dissatisfaction with life and higher stress—were strongly associated with all outcomes. Poor perceived health had the strongest association with comorbid disorders, suggesting heavier overall symptom burden and lower perceived capacity for self-management. Unmet health care needs may reflect structural and stigma-related barriers to timely mental health care.^{Footnote 24Footnote 52Footnote 53}

Having a weaker sense of community belonging was associated with higher risks for mood disorder and comorbidity, consistent with prior work linking low sense of community belonging to poorer mental health and higher risk for depression.^{Footnote 54Footnote 55} Rather than an individual trait, having a weaker sense of community belonging can indicate structural disconnection driven by poverty, exclusion and discrimination that undermines social cohesion and resilience. Large-scale CCHS analyses have also shown an inverse relationship between life satisfaction and mental illness, independent of income, health or gender.^{Footnote 28Footnote 29}

Taken together, these patterns are consistent with the social determinants of health and the socioecological frameworks^{Footnote 56Footnote 57} in which community belonging, stress and life satisfaction reflect upstream social and environmental contexts that shape exposure to—and coping with—psychological distress. We therefore interpret these psychosocial measures as markers and potential mediators of accumulated disadvantage, not merely individual attributes. While avoiding causal claims in this cross-sectional design, this framing helps explain why associations are strongest for comorbidity and suggests that linking social supports (e.g. income assistance, housing, community-connection programs such as social-prescribing initiatives) with clinical care may be especially relevant for people with multiple co-occurring needs.

Strengths and limitations

This study uses the large, nationally representative CCHS to examine population-level associations between sociodemographic, socioeconomic, psychosocial and health-related factors and mood and anxiety disorders among people living in Canada. Although the data were collected before the COVID-19 pandemic and may not reflect current mental health trends, it provides a useful snapshot of prepandemic mental health that can serve as a point of comparison for future studies. By distinguishing mood and anxiety disorders and comorbid outcomes and applying survey and bootstrap weights, this analysis offers a nuanced understanding of shared and distinct correlates.

Several limitations should be noted. The CCHS likely underestimates the true burden of mood and anxiety disorders because it relies on self-reported professionally diagnosed conditions and excludes undiagnosed or undisclosed cases. Its cross-sectional design precludes causal inference. The survey also excludes people living on reserves, in remote regions and in institutional settings, potentially resulting in underrepresentation of population groups facing structural inequities. In addition, the public-use file collapses diverse racialized identities into a binary “visible minority” variable, masking heterogeneity across groups. Important factors such as family history were unavailable.

Finally, several covariates (e.g. perceived health, multimorbidity, stress, life satisfaction) may act as mediators rather than independent predictors; adjusted estimates should therefore be interpreted as conditional associations. Future longitudinal and linkage studies could validate self-reports, assess temporality and better capture the mental health needs of excluded and marginalized populations.

Conclusion

This study identifies shared and distinct associations with mood disorders, anxiety disorders and their comorbidity in Canada. Higher relative risk was observed among younger adults, females and those with lower income, poorer perceived health, multimorbidity, unmet health care needs and adverse psychosocial profiles (dissatisfaction with life, weak sense of community belonging, higher stress). Individuals with comorbid mood and anxiety conditions exhibited the greatest overall burden across clinical and social indicators. While not causal, these patterns can inform service planning: age-tailored, low-barrier supports for youth and young adults; culturally grounded, community-led approaches for Indigenous people; and care models that link social supports (e.g. income, housing, community-connection programs) with clinical services for people reporting unmet needs or social isolation. Coordinated, team-based and culturally safe care (e.g. collaborative or stepped care) in primary and community settings may be particularly relevant for those with co-occurring conditions. Ensuring timely, equitable and culturally safe access to care remains a central priority.

Acknowledgements

We sincerely thank the Editor, Associate Editor and the two anonymous reviewers for their constructive and insightful comments, which substantially improved the clarity and rigour of this manuscript. We are additionally grateful to the English Editor, Joanna Odrowaz, as well as the French Editor, Anna Olivier, for their thorough, thoughtful and highly valuable editorial reviews.

Funding

This work was supported by Research Nova Scotia through the New Health Investigator Grant.

Conflicts of interest

The authors declare no conflicts of interest.

Authors’ contributions and statement

• FH: Conceptualization, methodology, data curation, formal analysis, writing—original draft; writing—review and editing.
• CF: Conceptualization, methodology, data curation, formal analysis, visualization, funding acquisition, project administration, supervision, validation, writing—review and editing.

The authors have read and approved the final manuscript and agree to be accountable for all aspects of the work.

The content and views expressed in this article are those of the authors and do not necessarily reflect those of the Government of Canada.

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