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Anxiety and depression in the primary health

care clinics and the use of complementary and
alternative medicine.

Article in International Medical Journal (1994) June 2005

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 Anxiety and depression in the primary health care clinics and the use of
complementary and alternative medicine

International Medical Journal, Vol 12 (2), pp. 93-97.

Taha AB, Lee PY, Lin K, Siti RG and Hassan S

Faculty of Medicine and Health Science, University Malaysia Sarawak,

Correspondent address:

Lee Ping Yein,

No 2, Jalan Awan Cempaka 4, Taman O.U.G., 58200 Kuala Lumpur. Malaysia

Tel. 603 79826867 Fax 603 87376784 e-mail: dr_ong@tm.net.my, pylee02@hotmail.com or

pylee@fmhs.unimas.my

ABSTRACT

Objective: To determine the prevalence of depression and anxiety disorder in the primary care

clinics in Kuching city and to examine the usage of complementary and alternative medicine

(CAM) among the primary care patients who have psychiatric problems. Design: A cross-

sectional survey design was used. Materials and Methods: This is a cross-sectional study of

patients attending the primary care clinics. They were given core screening questionnaire,
general questions on socio-demographic and questions pertaining to the usage of CAM. Patients

who were positively screened for psychiatric problems will be interviewed by one of the

researchers using the confirmatory questions. Results: The prevalence of all psychiatric

problems in the primary care clinics was 16.6%. The commonest problem was depression at

6.7% prevalence rate followed by anxiety at 5.6%. 46.4% of the patients with psychiatric

problems used CAM compared to only 20.8% of those without psychiatric problems.

Significantly more patients with psychiatric problems consulted the Chinese temple medium or

taking herbal medicine prescription. Conclusion: Depression and anxiety disorder are common

psychiatric problems among the primary care clinic attendee and they are more likely to use

CAM.

Key words: Primary care, core screening questionnaire, depression, anxiety disorder,

complementary and alternative medicine (CAM)

INTRODUCTION
 Anxiety and depression are common psychiatric disorders in the community and these

two conditions often coexist (1, 2). The results of the national health and morbidity survey in 1996
(3)
showed that there is considerable psychiatric morbidity in the Malaysian community . 18.8%

of the respondent in the survey complained of having sleep difficulties, 11.8% feeling unhappy

and depressed and 11.7% feeling under strained. These symptoms reflect the presence of

depression and anxiety in the community. This survey, though not specific, gave us some insight

into the magnitude of anxiety and depressive problems in our community. Chiu and Schmidt did

the earliest recorded mental health epidemiological study in Sarawak in 1967. Chiu cited the
(4)
results of this unpublished study in his book , which showed neuroses as the common

psychiatric disorders in the community, of which depression was the commonest, and followed

by anxiety. It is not clear where these individuals will go for the treatment of their anxiety or

depression.
(5, 6)
In developed countries, many are managed in the primary care facilities and only a

small number reached the specialist mental health facilities. There is also increasing trend in the

use of complementary and alternative medicine in western societies. Studies done in other

countries reported that patients with anxiety and depression are more likely to use

complementary and alternative medicine (7, 8). Malaysian patients are still very much influence by

traditional medicine. This is especially so among patients with mental health problems where
(9)
symptoms are associated with supernatural beings or dirt . Razali reported that 73% of Malay

psychiatric patients had consulted the traditional Malay medicine men or bomoh, before
(10)
attending the conventional western medicine facilities . Razali also noted that complementary

and alternative medicine such as homeopathy, herbal remedies, acupuncture and spiritualism are
popular in this country but it is not clear which group of patients make use of these different

medical systems (11).

We do not know the prevalence of anxiety and depression in the primary health care

setting in this country. The two studies that were published in the local journal indicated that

psychiatric morbidity was estimated to be in the region of 29.9% in a general practitioners clinic
(12, 13)
and more than 15% in a rural health clinic . These studies did not survey the prevalence of

anxiety or depression specifically. Most studies done in this country were based on

questionnaires with no actual clinical assessments being done to confirm the diagnosis.

The aim of this study is to screen patients attending the primary care clinic for anxiety

and depression using core-screening questions and to clinically assess those who may have

depression or anxiety by a confirmatory interview. This interview was done using the structured

questionnaire based on the confirmatory questions recommended by the international consensus

group on depression and anxiety (14). The other aim is to study the usage of complementary and

alternative medicine among the patients who were confirmed to have anxiety and depression.

MATERIALS AND METHOD

This was a cross sectional study of patients attending three primary care clinics in

Kuching. Patients, 15 years old and above, who attended any of these clinics were given the self

reporting core screening questionnaire as well as general questions on socio-demographic and

questions on complementary and alternative medicine before they were seen by their primary

care doctors. The researchers spent about two hours per week in each clinic over four months

from January to April 2004. 198 patients were recruited for the study. Patients who were too ill,

those below 15 years of age and those who came to the clinic to collect their medications were

excluded from the study. The interview was conducted only when the patient had consented to

participate in the study.

 181 patients or 91.4% agreed to answer the questionnaire and participate in the study

(participants) and 17 patients (8.6%) refused (non participants). Among the 17 non-participants,

15 agreed to provide only their socio-demographic details while 2 others totally refused to give

any data.

The questionnaire used in this study has 10 screening questions that would screen for the

common conditions in the community, that is, depression, anxiety disorders, panic disorders and

posttraumatic stress disorder. The screening questionnaire is translated into Malay language and

Chinese. The usual process of translation and back translation was done for these two versions.

The original English version and the two translated versions were used in this study. If the

patient indicates a yes to any of the core screening questions, they will be interviewed using

confirmatory questions by one of the researchers to determine whether they have any psychiatric

diagnosis or not. This questionnaire is essentially a structured clinical interview that helps a

clinician to generate a psychiatric diagnosis. There is no other gold standard besides the clinical

interview to validate a questionnaire. Since the confirmatory questionnaire is a clinical interview,

it is not really necessary to validate it against another questionnaire. It is sufficient to take the

diagnosis generated from the interview as the final diagnosis.

Analysis of data

All the variables collected were analysed using the standard descriptive statistics.

RESULTS
Demographic characteristics of all the patients

This analysis on demographic variables was based on the data obtained from 196 patients

as 2 patients totally refuse to participate in the study.

 96 (48.5%) were male and 100 (50.5%) were female. Majority of the patients are between

20 years old and 40 years old and their mean age was 36.51 (+14.3). 76 (38.4%) patients were

Chinese and 73 (36.9%) were Malays, followed by Iban (21 or 10.6%), Bidayuh (17 or 8.6%)

and other indigenous groups (4.5%). There were almost equal number of those who were married

98 (50%) and those who were single 96 (49%) while 2 (1%) were widower. Most of them

profess Islam (84 patients or 42.9%) followed by Christianity, 63 (32.1%), Buddhism 37

(18.9%), 10 (5.1%) other religions and 2 (1%) patients did not indicate their religion. More than

half of the patients are on full time employment 117 (59.7%) and 8 (4.1%) on part time

employment. The others are never employed 26 (13.3%) currently unemployed 22 (11.2%), self

employed 10 (5.1%), and 13 (6.6%) unknown employment status. 124 patients (63.3%) had

upper secondary education or above, that is, 56 patients had upper secondary education, 36

patients with diploma and 32 with degree. The other 28 or 14.3% had lower secondary education,

33 (16.8%) had primary education, 3 (1.5%) had no formal education and 8 (4.1%) did not

indicate their educational achievement.

The patients mean total family income was RM 2636.2 (+ 2256.8) where a majority of

them had the total family income of between RM 1000 to RM 3000. There was significantly

higher proportion of Chinese (80.0%) in the non-participating group than the participating group

(2 = 12.267, df = 4, p = 0.015). The non-participants were also found to be older (mean age

44.27 years) and had higher total family income comparing to the participants. There was no

significant difference in gender, marital status, religion, and education level as well as

employment status between the two groups.

Patients with depression and anxiety disorders

 180 participants answered both the screening questions and the complementary and

alternative medicine questionnaire. One of the participants answered only the complementary

and alternative medicine questionnaire. 106 participants (58.9%) were found to be positive for

one category or more from the screening questionnaire. Only 30 (28.3%) of the 106 participants

were confirmed to have psychiatric problem when further clinical evaluation was done. The

positive predictive value of the screening questionnaire was low; with only 28.3% of the

screened positives cases were true positives. Only 2 of these 30 participants had overt

psychological complains. Among the 52 Malay patients who were screened positive for

psychiatric problems, only 11 patients or 21.2% were true positives compared to 40.7% true

positives among the Chinese patients.

The prevalence of all psychiatric problems in the primary care clinics was 16.6%. The

commonest psychiatric problem detected in this study was depression followed by generalized

anxiety disorder. The prevalence of depression and generalized anxiety disorder in the primary

care clinics was 6.7% and 5.6% respectively. The other conditions were mixed depression and

anxiety, alcohol abuse and panic disorder. Further details are shown in chart 1.

Usage of complementary and alternative medicine among patients with psychiatric

problems

Patients with psychiatric problem were more likely to use complementary and alternative

medicine for their current problem. 46.4% of the participants with psychiatric problems use

complementary and alternative medicine comparing to only 20.9% of those without any

psychiatric problems (2 = 8.09, df = 1, p = 0.0045). 28.6% of those with psychiatric problems

and 9.7% with no psychiatric problems were using complementary and alternative medicine

before the current clinic visit (2 = 7.47, df = 1, p = 0.0063). The common complementary and
alternative medicine used by both groups was massage and herbal remedy. The group with and

without psychiatric problems were compared with regards to the use of various types of

complementary and alternative medicine. There was no significant difference between the groups

with and without psychiatric problems on the usage of homeopathy, acupuncture, massage,

herbal medicine, consulting bomoh (Malay traditional healer), and aromatherapy except

consultation with Chinese temple medium (2 = 7.579, df = 2, p = 0.023) where 20% and 6% of

those with and without psychiatric problems respectively had consulted the Chinese temple

medium and herbal medicine (2 = 6.127, df = 2, p = 0.047).

DISCUSSION

The prevalence of psychiatric problems at a rural primary health care clinic in Peninsula

Malaysia is more than 15% (13) and in an urban setting, the prevalence is much higher, estimated

to be in the region of 29.9% (12). It is not possible to compare these results with that of the current

study, where the prevalence is 16.6%, as the former studies were based on general health

questionnaire (GHQ), which is a screening questionnaire. Although the picture is different in

each of the above study, the results however, indicate that psychiatric problems are prevalent in

the primary health care clinics. In this study the prevalence of depression and anxiety disorder is
6.7% and 5.6% respectively. The results of the current study is a better estimate of the

prevalence of depression and anxiety in the primary care setting for this country compared with

the results mentioned above as the results of the current study is based on the confirmatory

interview rather than based on a screening questionnaire. It could have been better if the

population studied were more representative of the country and more primary care clinics were

involved in the study. Taking into consideration these limitations, the findings of this study,

however, are almost similar to the findings in studies done elsewhere. Wittchen et. al, reported

5.3% of patients attending primary care clinics met the criteria for generalise anxiety disorders

and 6% for major depressive episodes (15) while Katon and colleague reported the prevalence of

6% to 8% for major depression in a primary care setting (16). Another limitation that could affect

the results of this study was the relatively high percentage of Chinese not participating in the

study. The reason for this is not clear but it could be related to the obliging nature of the Malays

and other ethnic groups resulting in very few of them refusing to participate compared to the

Chinese.

Several studies indicate that significant number of people with anxiety or depression has

functional disabilities that may affect their well-being, their relationship with people around
(17, 18, 19)
them or their work performance . Therefore it is important to recognise these patients in

the primary health care clinics. Primary care doctors frequently fail to recognise patients with
(20)
depression . Some studies reported 30% to 50% of depressed patients are not recognised by

primary care doctors (21). Anxiety is also under recognised by the primary care doctors (22, 23). For

this reason, primary care doctors must have a high degree of suspicion to avoid under diagnosing

depression and anxiety. Very few patients attending the primary care clinics present with overt

psychological complains. In this study only 1.1% of the patients attending the primary care
clinics presented with psychological complaints and treated for their psychological problems. It

is possible that patients in this country do not have psychological mind and tend to somatise their

psychological problems. Stigmatisation of patients with psychological problems might be

another reason for the low presentation of overt psychological complaints at the primary care

clinics. In developed countries a higher percentage (17%) present with at least one psychosocial
(23)
problems but the rest also present with somatic symptoms . The absence of psychological

complaints makes it more difficult for the primary care doctors to recognise psychiatric problems

in their patients. The introduction of core screening questions will help to improve the degree of

suspicion among the primary care doctors. The positive predictive value of the core-screening

questionnaire was 28.3%. This is comparable to the positive predictive value of many other

screening questionnaires except Hospital Anxiety and Depression Scale (HADS), PRIME-MD

Patient Health Questionnaire (PHQ) and PRIME-MD Patient Health Questionnaire 9 (PHQ-9).

The positive predictive value for HADS, PHQ and PHQ-9 are 41.3%, 50.4% and 55%
(24)
respectively . The low positive predictive value for the core screening questionnaire was the

result of the low true positives among the Malays who were screened positive. The question is

whether the language used in the screening questionnaire or the length of the questionnaire can

affect the result of the screening. Further research is necessary to answer this question. As

mention earlier, the positive predictive value of the core questionnaire was low but when used in

conjunction with the confirmatory questions, the detection of psychiatric problems becomes

better. The screening and confirmatory questionnaires appear to be a practical approach to help

the primary care doctors to identify people with psychiatric problems especially anxiety and

depression. This approach using the core screening and the confirmatory questionnaire has the

advantage over the above instruments because the actual clinical assessments are being done to
arrive at a diagnosis. All new patients and patients who come to the clinic repeatedly within a

short period should be asked to fill up the screening questionnaires while at the waiting room.

The U.S. Preventive Services Task Force currently recommends screening adults for depression

but no definite recommendation for adolescents because of insufficient evidence (25).

In this study, patients with psychiatric problems are more likely to use complementary

and alternative medicine than those without any psychiatric problems. 46.4% of patients with

psychiatric problems use some form of complementary and alternative medicine and at the same

time making use of the conventional system. In the United States, people with anxiety or severe

depression are more likely to use complementary and alternative medicine than conventional
(26)
medicine therapy . The traditional community resources (temples or other religious

institutions) are frequently used in managing mental illnesses in India and people tend to use this

alternative system because of the lack of availability of the conventional medical system
(27)
especially in the rural areas . It is not the lack of availability of the conventional medical

system that motivates Malaysian to use alternative system but their beliefs. Malaysian believes

that any mental illness is caused by supernatural and physical factors and their vulnerability to
(9)
the illness increase when the semangat or the vital force within the person is lost . Naturally

the treatment modality is influenced by these beliefs and hence the complementary and

alternative medicine as well as the conventional medical practitioner. The patients will go for

either the Malay traditional healers or the temple medium depending on their ethnic background.

This is more obvious for people with more serious mental disorders and Razali had reported that

almost 75% of psychiatric patients will go for alternative medicine before consulting the

psychiatrist (10).
 Chart 1: Psychiatric problems in the primary health
care clinics

depression
7%
generalized anxiety
disorder
17% 40% panic disorder
3%
mix depression and
33% anxiety disorder

alcohol abuse

ACKNOWLEDGEMENT

This study is funded by University Malaysia Sarawak short-term grant

01(81)/418/2003(155). The authors acknowledge the support given by the university. The

authors also would like to thank Dr. KS Yii, Dr. Hazland Hipni, and Dr. Norhayati Hassan for

permission to conduct the study at their clinics. We would also like to thank Ms. Maimunah

Razali, and Ms. Katijah Yaman, our research assistants for their untiring help in this study. We

would extend our sincere gratitude to Mr. Rekaya Vincent, a psychiatric male nurse for his

contribution during the field work.

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