Gastrointestinal symptoms in primary care: Prevalence and association with depression and anxiety

doi:10.1016/j.jpsychores.2008.02.019

Journal of Psychosomatic Research

Volume 64, Issue 6, June 2008, Pages 605-612

https://doi.org/10.1016/j.jpsychores.2008.02.019 Get rights and content

Abstract

Objective

Results from general population studies suggest a relationship between gastrointestinal (GI) symptoms, depression, and anxiety. However, no primary care study has investigated this issue. This study investigates the prevalence of GI symptoms in primary care and their association with depression and anxiety.

Method

Within a cross-sectional survey, 2091 consecutive patients from 15 primary care clinics in the United States completed self-report questionnaires regarding GI symptoms [15-item Patient Health Questionnaire (PHQ-15)], anxiety [seven-item Generalized Anxiety Disorder Scale (GAD-7)], and depression (PHQ-8). Of those, 965 randomly selected patients additionally underwent a criterion standard diagnostic telephone interview (Structured Clinical Interview for DSM-IV) for the most common anxiety disorders.

Results

A total of 380 [18% (95% CI, 16.3% to 19.3%)] patients reported to be substantially bothered by at least one GI symptom in the previous 4 weeks. The prevalence of severe levels of depression (PHQ-8 score ≥15) was nearly fivefold in patients with GI symptoms compared to patients without GI symptoms (19.1% vs. 3.9%; P<.001), and the prevalence of severe levels of anxiety (GAD-7 score ≥15) was nearly fourfold in patients with GI symptoms compared to patients without GI symptoms (19.4% vs. 5.6%; P<.001). Similarly, with each additional GI symptom, the odds for an interview-based diagnosis of specific anxiety disorders increased significantly: For example, compared to patients with no GI symptom, the odds ratio (OR) (95% CI) for generalized anxiety disorder in patients with one GI symptom was 3.7 (2.0 to 6.9); in patients with two GI symptoms, OR=6.5 (3.1 to 13.6); and in patients with three GI symptoms, OR=7.2 (2.7 to 18.8).

Conclusion

GI symptoms are associated significantly with depression and anxiety in primary care. It is suggested to screen as a routine for anxiety and depression in patients with GI symptoms and, if indicated, to initiate specific treatment.

Introduction

Gastrointestinal (GI) symptoms are common in primary health care, accounting for about 1 in 12 consultations [1]. For example, abdominal pain accounts for more than 10 million clinical visits annually in the United States [2]. At the same time, about 30% of primary care patients suffer from the two most frequent mental health problems in primary care, that is, depression and anxiety [3], [4], [5], [6], [7], [8], [9]. In patients with unexplained GI complaints undergoing upper endoscopy, psychiatric disorders were detected in 60% of patients [10]. Data from the general population suggest that there is a strong association between GI symptoms, depression, and specific anxiety disorders, such as agoraphobia and panic disorder [11], [12], [13]. In addition, a recent general population study found that GI diseases were significantly associated with anxiety disorders [14]. However, there is only limited knowledge on the association of GI symptoms, anxiety, and depression in medical settings, and primary care studies investigating this issue are completely lacking.

In unselected primary care patients, several studies identified the number of physical complaints as predictor of psychiatric comorbidity [15], [16], [17], [18], [19]. Based on this finding, we hypothesized that GI symptoms are associated with elevated rates of depression and anxiety in primary care. Given that the recognition of mental health problems in primary care is often difficult [20] and that depression and anxiety often go unrecognized [8], [21], [22], the knowledge of the co-occurrence with GI symptoms can help to enhance physicians' attention toward the presence of anxiety and depression in patients with GI symptoms and to initiate treatment as appropriate.

To investigate the relationship between GI symptoms, anxiety, and depression, we sought to answer the following questions: First, what is the prevalence of self-reported GI symptoms in the primary care setting? Second, do patients with GI symptoms differ from those without GI symptoms in terms of demographic characteristics, health-related quality of life (HRQoL), depression, and anxiety? Third, is there a higher risk of current depression and anxiety in patients with GI symptoms? Fourth, are specific GI symptoms related with specific types of anxiety disorders and is the number of GI symptoms associated with the presence of specific anxiety disorders?

Section snippets

Patient sample

This study was part of the first phase of the Patient Health Questionnaire (PHQ) Anxiety Study that was conducted to develop a short self-administered measure for generalized anxiety disorder [8], [23]. Patients were enrolled from a research network of 15 primary care sites (13 family practices, 2 internal medicine) located in 12 states in the United States and administered centrally by Clinvest, Inc., from November 2004 to June 2005. To minimize sampling bias, we approached consecutive

Patient characteristics and prevalence of GI symptoms

Of the 2149 patients, 31 (1.4%) did not complete the PHQ-15 items on GI complaints, and of these 31, 8 belong to the telephone interviewed subgroup. These patients were excluded from further data analysis. The mean age of the remaining 2118 patients was 47.1 years (S.D.=15.4, range=18–95 years). Sixty-six percent of the patients were women, 81% were non-Hispanic White, and 64% were married. Regarding education, 63% had some college education or were college graduates. Patients reported a mean

Discussion

This is the first study that investigates the relationship between GI symptoms, anxiety, and depression in primary health care. With 18% of patients being bothered substantially by at least one GI symptom, our results support conclusions from earlier studies in that GI symptoms are a major problem in primary health care [1], [2]. The clinical relevance of this finding is underlined by the fact that patients with GI symptoms were significantly more impaired with respect to disability days,

Acknowledgments

Collection of data in this study was supported by an unrestricted educational grant from Pfizer, Inc., for the development of the Generalized Anxiety Disorder Screener (GAD-7). The authors have no conflict of interest in connection with this article.

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Original articlesGastrointestinal symptoms in primary care: Prevalence and association with depression and anxiety

Abstract

Objective

Method

Results

Conclusion

Introduction

Section snippets

Patient sample

Patient characteristics and prevalence of GI symptoms

Discussion

Acknowledgments

J Affect Disord

J Psychosom Res

Am J Med

Psychosomatics

J Psychosom Res

J Affect Disord

J Psychiatr Res

J Psychiatr Res

J Affect Disord

J Psychosom Res

Lancet

Behav Ther

J Psychosom Res

Irritable bowel syndrome in general practice: prevalence, characteristics, and referral

Gut

National Ambulatory Medical Care Survey: 1989 summary

Vital Health Stat

Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study

JAMA

Prevalence of mental disorders in primary care. Implications for screening

Arch Fam Med

Common mental disorders and disability across cultures. Results from the WHO Collaborative Study on Psychological Problems in General Health Care

JAMA

Mental disorders and disability among patients in a primary care group practice

Am J Psychiatry

Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection

Ann Intern Med

Comorbidity of gastrointestinal complaints, depression, and anxiety in the Epidemiologic Catchment Area (ECA) Study

Am J Med

Gastrointestinal symptoms and psychiatric disorders in the general population. Findings from NIMH Epidemiologic Catchment Area Project

Dig Dis Sci

Panic disorder and gastrointestinal symptoms: findings from the NIMH Epidemiologic Catchment Area project

Am J Psychiatry

Disability and poor quality of life associated with comorbid anxiety disorders and physical conditions

Arch Intern Med

Predictors of psychiatric comorbidity in medical outpatients

Psychosom Med

Clinical predictors of mental disorders among medical outpatients

Arch Intern Med

Physical symptoms in primary care. Predictors of psychiatric disorders and functional impairment

Arch Fam Med

Original articles
Gastrointestinal symptoms in primary care: Prevalence and association with depression and anxiety