This study utilized data from the CMHS, a nationally representative household epidemiological survey conducted from July 2013 to March 2015. The survey aimed to investigate the prevalence of mental disorders and dementia, gather data on service use among individuals with mental disorders in China, and analyze the social and psychological risk factors associated with mental disorders and mental health services (15). The design and procedures of the CMHS, which include sampling methods and diagnostic assessments, have been described (15–17). In brief, the CMHS was a cross-sectional study employing proportional stratified random sampling to select 40,964 participants from 31 provinces in China. A total of 28,140 eligible participants completed the Composite International Diagnostic Interview-3.0 (CIDI), including 7,454 individuals aged 60 and above. Among the individuals aged 60 years and above 5,428 were reported to have chronic physical diseases.

The CMHS was conducted in two stages. Stage I focused on trained non-professional interviewers conducting face-to-face computer-assisted personal interviews (CAPI) with all respondents using CIDI to diagnose mental disorders including mood disorders, anxiety disorders, substance use disorders, impulsive control disorders, and eating disorders. It also included screening for psychosis and dementia, as well as the collection of demographic information, data on service use, and risk factors. Stage II focused the on the diagnoses of psychosis and dementia by trained psychiatrists using the Chinese version of SCID and the 10/66 Dementia Diagnosis Package. The data analyzed in this study were obtained from Stage I, using the CIDI. Data quality control procedures were implemented throughout the CMHS process, which consisted of computer-based logical checks, ordinal record checks, telephone checks by quality controllers and psychiatrists follow-up checks. Field procedures and data quality control are monitored and implemented in accordance with international standards (15–17).

The data was weighted using a comprehensive procedure. Each participant’s final analysis weight was calculated as the product of the sampling weight, non-response adjustment weight, post-stratification weight, and the trimmed weight adjustment. These weighting procedures follow well-documented methodologies, with detailed procedures and statistical analyses described in prior publications (15, 17). In this study, unweighted sociodemographic and weighted prevalence of anxiety disorders and depression are described. 95% Confidence Interval (CI) for prevalence estimates were calculated by the Taylor series linearization method, which adjusted for sampling weights and sample clustering. Univariate and multivariate logistic regression based on complex sampling was used to identify factors associated with 12-month ADs and DDs. For missing data, rigorous quality control minimized omissions, followed by thorough dataset cleaning. Median imputation was applied to questionnaire items with low missing rates. All analyses were conducted using SAS 9.4 and statistical significance level was set at P<0.05 (two-tailed).

Among 5,428 older adults with NCDs, 52.1% were female, and 39.5% were aged 60 to 64 years. Approximately 78% of participants were married or living together with a partner. About 48.3% lived in urban areas, while 49.3% had no formal education or had education below primary school. Approximately 45% of participants had an average annual household income below ¥10,500, and 48.4% had a BMI ranging from 18.5 to 23.9. Approximately 38% of individuals suffered from three or more chronic physical diseases. Detailed sample characteristics are presented in Table 1 .

Among 5,428 older individuals with NCDs, 490 experienced ADs or DDs, resulting in weighted lifetime and 12-month prevalence of 15.0% and 9.5%, respectively. Table 2 shows the weighted 12-month and lifetime prevalence of ADs and DDs among older adults with NCDs.

The lifetime prevalence of ADs was 8.3% and the 12-month prevalence of ADs was 5.8%. The two most prevalent ADs were specific phobia (SP; lifetime prevalence of 4.2% and 12-month prevalence of 3.1%) and obsessive-compulsive disorder (OCD; lifetime prevalence of 2.8% and 12-month prevalence of 2.1%). The lifetime prevalence of DDs was 10.1%, while the 12-month prevalence was 5.4%. The two most common DDs were major depressive disorder (MDD; lifetime prevalence of 7.2% and 12-month prevalence of 4.4%) and dysthymia (lifetime prevalence of 2.8% and 12-month prevalence of 2.2%).

ADs were most common in individuals with heart attacks (12%), chronic lung disease (11.2%), and other chronic pain (11%). The prevalence of ADs was 10% and 11% of individuals with headache and cardiopathy, respectively, and was below 10% in participants with gastric/intestinal ulcers, asthma, back and neck pain, seasonal allergies, stroke, phthisis, hypertension, diabetes, cancer, and epilepsy.

DDs are most commonly linked to heart attacks (13.8%), other chronic pain (13.2%), and cancer (13.1%). The prevalence of DDs among those with gastric/intestinal ulcers, epilepsy, chronic lung disease was between 10-11%, while it was less than 10% among individuals with cardiopathy, headache, asthma, back and neck discomfort, arthritis/rheumatism, diabetes, seasonal allergies, hypertension, stroke, and phthisis.

Older individuals with a history of heart attack (21%) or other chronic pain conditions (20%) had a higher prevalence of any ADs or DDs than those in other NCDs groups. Table 3 shows weighted 12-month prevalence of ADs and DDs across different types of NCDs among adults aged 60 years and above.

Associations between factors and the 12-month ADs and DDs are shown in Table 4 . The prevalence of ADs and DDs was associated with gender, age, education, marital status, alcohol use disorders, and the number of chronic physical diseases. No significant associations were observed with occupation, type of insurance, or other variables.

Older adults who were male (adjusted OR=0.67, 95% CI: 0.47-0.97) and those aged 70 years and above (adjusted OR=0.60, 95% CI: 0.44-0.82) were less likely to have 12-month ADs. In contrast, individuals with AUDs (adjusted OR=3.02, 95% CI: 1.91-4.78) and with two (adjusted OR=1.72, 95% CI: 1.16-2.55) or three or more (adjusted OR=3.72, 95% CI: 2.65-5.22) chronic diseases were more likely to suffer from 12-month ADs.

Similarly, being male (adjusted OR=0.64, 95% CI: 0.45-0.89) and aged 70 years and above (OR= 0.54, 95% CI: 0.40-0.74) were less likely to suffer from 12-month DDs. Those with primary education (adjusted OR= 1.37, 95% CI: 1.02-1.83), being not married or cohabitating (adjusted OR= 1.81, 95% CI: 1.37-2.40), with AUDs (adjusted OR= 1.89, 95% CI: 1.07-3.34) and with three or more NCDs (adjusted OR= 4.16, 95% CI: 2.96-5.85) were likely to suffer from 12-month DDs.

The lifetime and 12-month prevalence rates of ADs and DDs among community-dwelling older adults with NCDs are higher than those in the general population (16), suggesting that ADs and DDs are prevalent among older adults with NCDs in China. Researchers and clinical professionals should pay much attention to assess ADs and DDs when dealing with older adults with chronic diseases.

Consistent with findings in general population (16), our study demonstrates that ADs and DDs are the most common disorders among people with NCDs. For the ADs, SP and OCD were the two most common disorders. This may be explained by the fact that multiple physical diseases and the stress associated with physical illnesses are related to exacerbation of fearful responses to previous specific fearful scenarios and obsessive-compulsive symptoms in older adults (18, 19). For DDs, older people with NCDs are likely to have MDD and dysthymia. This is also consistent with previous findings (20, 21). Limitations on daily activities due to physical illness, discomfort from medications, disease recurrence and fear of death are associated with the onset of feelings of despair and helplessness in older patients, which in turn develop into major depression (22). Moreover, psychological distress and social isolation due to physical diseases are associated with the onset of dysthymia (23). However, a study of older patients in primary care in Wuhan found that mild depression is more common than dysthymia (13), which differs from our findings. This discrepancy may be due to differences in the study population, study methodology, and the subtypes of depression assessed.

Our study revealed that among 16 common NCDs, older adults with heart attack, other chronic pain, chronic lung disease and cancer are most likely to suffer from ADs and DDs. Therefore, it is imperative for clinicians and primary care physicians to priorities the mental health status of older adults afflicted by such conditions when managing their healthcare in the community.

In our study, heart attack patients had the highest 12-month prevalence of ADs and DDs. This may be related to the high mortality rate of heart attack and the stress survivors experience when confronted with the disease, which may generate fear, apprehension, and negative attitudes and beliefs, thereby increasing the risk of anxiety and depression (24, 25). In addition, heart attack may lead to enhanced toxicity of central monoamine neurons and impaired monoamine transmitter function, which may be associated with an increased risk of developing depression (24, 26).

Patients with chronic pain are more likely to experience anxiety and depression, which is related to their bidirectional correlation and a shared pathogenesis (27, 28). Moreover, chronic pain is one of the somatization symptoms of anxiety and depression, but older adults with psychiatric disorders whose main complaint was somatic pain were often misdiagnosed with other somatic disorders, leading to delayed treatment and excessive waste of healthcare resources.

Numerous studies have shown that anxiety and depression are prevalent in people with chronic lung disease, which aligns with our findings (29, 30). A systematic review showed that the prevalence of clinical anxiety in hospitalized patients with chronic obstructive pulmonary disease (COPD) ranged from 10% to 55%, and from 13% to 46% in outpatients (31). A study in South Korea on chronic airway lung disease patients aged 45 and above showed that 51% of the patients had clinically significant depressive symptoms (32). The emergence of anxiety and depression in older adults may be strongly correlated with the discomfort, sleep disorders and limitation of physical activity resulting from chronic lung disease (33).

A number of studies have demonstrated that older adults with cancer often suffer from DDs (34, 35), which is consistent with our research results. Cancer is a highly heterogeneous disease, and its disease characteristics, treatment methods, patients’ lifestyles and social support, demographic factors, comorbid chronic diseases, impaired physical function, and dependence in daily life are all strongly associated with the onset and progression of depression (34, 36).

In this survey, the prevalence of ADs and DDs was significantly associated with gender. Among older adults with NCDs, females exhibited a higher likelihood of experiencing these conditions, which aligns with previous researches (37, 38). The distinctiveness of women in genetics and neuroendocrine aspects (38), along with the pressures from traditional Chinese social and family roles (39), might render older women more susceptible to anxiety and depression than men.

Our study found that the risk of ADs and DDs was lower in the group of aged 70 years and above compared with the younger age group among older adults with NCDs. Although chronic diseases are generally believed to exacerbate anxiety and depressive symptoms in older adults, this trend does not appear to apply to individuals aged 70 years and above. A controlled study of long-term cancer survivors revealed a higher prevalence of anxiety and depression in patients under the age of 70 compared to gender- and age-matched general population samples, while no significant difference was observed among those aged 70 years and above (40). The possible cause for this phenomenon might be that the majority of people aged 70 years and above have a higher level of psychological acceptance of physical diseases than those under the age of 70, and psychological acceptance of illness is a key protective factor in the depression and anxiety network (41).

In the current study, participants with AUD have a higher risk of suffering from ADs and DDs than non-users, which is similar to the results of previous studies (42, 43). The inadequate management of alcohol abuse among older adults and long-term chronic drinking increase the risk of chronic NCDs, which are the reasons for the high prevalence. The impact of AUD on neurological function have been associated with increased susceptibility to depression (44), and recurrent alcohol abuse and withdrawal symptoms increase the risk of anxiety, depression, and psychotic symptoms (43).

Similar to previous research findings (44), our research has revealed a positive correlation between the number of chronic NCDs and an increased risk of ADs and DDs among older individuals. In the current study, the presence of two or more physical diseases elevates the risk of suffering from ADs, while the existence of three or more physical diseases enhances the risk of developing DDs. This suggests that with the increase in the number of NCDs, the psychological pressure of patients gradually intensifies, and patients are experiencing more and more negative emotions, ranging from initial worries and fears to depression, helplessness, and despair.