Depression and anxiety are prevalent mental health disorders that significantly impact individuals and societies worldwide.^1,2,3 According to the 2019 Global Burden of Disease Study, they are the leading causes of disability among mental health disorders, highlighting their substantial global health burden.^1,2 Despite available treatments, the prevalence of these conditions has not decreased since 1990, indicating an ongoing mental health crisis that necessitates urgent attention.⁴ Depression is characterised by persistent sadness and a lack of interest in previously enjoyable activities, while anxiety manifests as excessive worry and physiological arousal.⁵ There is a strong correlation between anxiety and depression, particularly generalised anxiety disorder (GAD) and major depression, with many individuals experiencing both conditions simultaneously.⁶ The co-occurrence of these disorders is associated with greater symptom severity and functional impairment. The consequences of these disorders extend beyond individual suffering, leading to disabilities and, in severe cases, suicide.⁷ These far-reaching consequences compromise quality of life and impose substantial economic burdens on society.

Many individuals seek help in primary care settings, where a significant comorbidity exists – up to 56% of those with depression also have anxiety.⁸ In Saudi Arabia, a notable proportion of individuals visiting primary healthcare facilities exhibit signs of mental health disorders, with depression being particularly prevalent at 20%.^1,9 Access to mental healthcare remains a global challenge; in the United States, around 25% of those with mental illness struggle to obtain necessary services, while less than 35% of affected individuals in developing countries receive adequate care.^10,11 Alarmingly, up to 50% of individuals with common mental disorders remain undiagnosed in primary care.¹² Enhanced screening and diagnostic methods are crucial to address this issue. Family medicine clinics are often the first point of contact for individuals seeking healthcare, making them vital in addressing depression and anxiety.⁵

The coexistence of anxiety and depression symptoms can significantly impact patients’ quality of life, treatment adherence, and overall health outcomes. While research has extensively explored these conditions in general populations and specific disease groups, there is a notable gap in understanding their co-occurrence among adult patients attending family medicine clinics in Saudi Arabia, particularly in the Najran region.¹³ Najran’s unique socio-cultural context, characterised by strong family ties, tribal identity, and cultural stigma surrounding mental illness, may influence mental health vulnerability and symptom expression. Local cultural perceptions may also affect help-seeking behaviours, symptom reporting, and treatment management.¹³ Given that the primary care setting is often the first point of contact, understanding the prevalence and co-occurrence of anxiety and depression is crucial for early identification, culturally sensitive screening, and effective intervention.

Existing research in Saudi Arabia has primarily focused on single conditions, specialised populations, or urban centres.^13,14 While a recent study in Najran reported depression and anxiety prevalence rates among cancer patients, there is limited research on the co-occurrence of these conditions in family medicine clinics. This study aims to fill this gap by exploring co-occurring anxiety and depression in a primary care setting, considering the local cultural context and socio-cultural characteristics that may influence mental health vulnerability and presentation in Najran. Therefore, this study aims to assess adult patients’ vulnerability to these conditions at family medicine clinics in Najran University Hospital, quantifying the risk of co-occurring anxiety and depression and identifying influencing factors.

The study found that most participants were aged 21–30 years (33.0%), predominantly female (64.0%), and married (52.1%). The majority were Saudi (68.7%) with university education, and 71.3% were unemployed, as shown in Table 1.

Regarding the medical characteristics of participants, chronic diseases were reported by 26.4% of participants, and 31.6% had a documented past medical history. Psychiatric illnesses affected 7.4% of patients. Regular medication usage was seen in 47.4%. Allergies were found in 13.8% of cases, and 35.4% reported sleep problems. Most were non-smokers (90.5%), while 73.3% consumed a mixed diet (Includes both plant-based foods and animal products, such as meats, dairy, and eggs, alongside a variety of fruits, vegetables, and grains). Physical activity levels ranged from none to mild (46.4%). Body weight distribution showed 39.7% normal weight, 33.6% overweight or obese, and 5.1% underweight.

Figure 1 shows that 21.7% of participants had depression symptoms, whereas 14% had anxiety. A significant proportion (10.7%) of patients experienced both conditions simultaneously. This highlights the prevalence of anxiety and depression in the population, with a substantial portion of patients exhibiting comorbid symptoms.

Table 2 illustrates the relationship between co-occurring anxiety and depression and the socio-demographic characteristics of participants. Individuals aged 30 years and younger exhibited higher prevalence rates compared to those over 30. Marital status, employment status, workload, and social relationships showed significant associations. Stress significantly correlated with a higher prevalence of co-occurring anxiety and depression among those reporting stress.

Table 3 examines the associations between co-occurring anxiety and depression and medical characteristics. Current illness progression, psychiatric co-morbidities, herbal treatments, and sleep problems were linked to increased co-occurring. Other factors showed no significant associations.

Table 4 presents multivariate regression analysis identifying stress as a significant predictor of co-occurring anxiety and depression, with stressed participants nearly nine times more likely to experience co-occurring. Having a psychiatric disorder was also significantly associated, with affected individuals being over 15 times more likely to exhibit co-occurring. In addition, those using herbal treatments and experiencing sleep problems were four times more likely to show these symptoms. However, age, marital status, and social relationships showed no significant associations.

This study examined the susceptibility of adult patients at family medicine clinics in Najran University Hospital to co-occurring anxiety and depression. The findings revealed a co-occurrence rate of 10.7%, with depression prevalence (21.7%) higher than that of anxiety (14%). These results provide valuable insights into the existing literature, especially in Saudi Arabia, where research on the co-occurrence of these mental health conditions has been limited. Given the high comorbidity and often indistinguishable symptoms of these disorders,¹⁸ there is a pressing need for enhanced screening and intervention strategies in primary care settings to effectively address these prevalent issues.

When comparing the study’s findings with those of previous studies, it is noteworthy that the rates of co-occurring varied across different regions and populations. For instance, a study conducted in Brazil reported a higher incidence of co-occurring, with anxiety prevalent among 74% of depressed patients and depression common among 61% of anxiety patients.¹⁹ Similarly, 27% of elderly individuals in the Netherlands had depression and coexisting general anxiety disorders.²⁰ These variations highlight the complex interplay between anxiety and depression and underscore the need for tailored interventions that consider cultural, demographic, and contextual factors. Interestingly, this study identified several risk factors associated with coexisting anxiety and depression, including stress, psychiatric diagnoses, use of traditional medicine, and sleep disorders. These findings align with existing literature regarding the multifactorial nature of these conditions. However, the study did not find significant differences in co-occurring symptoms based on chronic conditions, medical history, or physical activity, which contrasts with De La Rosa et al. (2024) and underscores the need for further research across diverse populations and settings.²¹

Patients with mental health conditions are often at increased risk for comorbidities and frequently utilise healthcare services. Up to 80% of people worldwide use herbal medicine, with around 22% of patients in Australia seeking treatment for mental illness opting for herbal remedies.²² This highlights the importance of healthcare providers engaging in discussions about these practices with their patients. This study found that younger age, unmarried status, and toxic relationships predict co-occurring anxiety and depression, supporting previous research on the role of socio-demographic factors. However, other variables did not significantly impact these conditions, which is consistent with Beekman et al..²³ Unlike other study found no significant link between age and depression, highlighting the need for further research on these complex relationships.²⁴ Prina et al. found that comorbid conditions were primarily linked to higher disability scores, independent of sex and socioeconomic status.²⁵

Furthermore, this study aligns with Hsu et al., identifying stress, psychiatric diagnoses, and sleep disorders as key risk factors for co-occurring anxiety and depression.²⁶ This reinforces the understanding that these factors play a critical role in the development of both conditions, emphasising the need for targeted interventions that address these underlying issues. Notably, factors such as illness progression, medication intake, and dietary habits were not significant predictors, contrasting with existing literature and highlighting the need for a re-evaluation of these relationships in future research.

This study highlights the significant prevalence of co-occurring anxiety and depression among adult patients at Najran University Hospital, with 10.7% affected. Key risk factors include stress, psychiatric co-morbidities, herbal medicine use, and sleep problems, emphasising the need for integrated treatment approaches to address these interconnected issues. Further prospective studies are necessary to clarify the causal relationships among these variables. Comparisons with existing literature reveal variability in prevalence rates, underscoring the complexity of these disorders. Overall, the findings advocate for comprehensive mental health strategies that prioritise early detection while considering socio-demographic, medical, and cultural factors in assessment and management, which are crucial for effectively addressing these complexities and improving patient outcomes.