Aliment Pharmacol Ther 2002; 16: 20812088.

doi:10.1046/j.0269-2813.2002.01377.x

Anxiety but not depression determines health care-seeking behaviour in Chinese patients with dyspepsia and irritable bowel syndrome: a population-based study
W. H. C. HU *, W.-M. WONG *, C. L. K. LAM, K. F. LA M, W. M. HU I, K . C. LAI, H. X. H. XIA, S. K. LAM & B. C. Y . WONG Departments of Medicine and Statistics and Actuarial Science, University of Hong Kong, Hong Kong, China
Accepted for publication 7 August 2002

SUMMARY

Aims: To study the prevalence of dyspepsia and irritable bowel syndrome and the effects of co-existing anxiety and depression on health care utilization by a population survey in Chinese. Methods: Ethnic Chinese households were invited to participate in a telephone survey using a validated bowel symptom questionnaire and the hospital anxiety and depression scale. Gastrointestinal symptoms were classied as dyspepsia and irritable bowel syndrome according to the Rome I criteria and gastro-oesophageal reux disease by the presence of weekly heartburn or acid regurgitation. The anxiety and depression scores were compared between patients who sought medical attention and those who did not, using multiple logistic regression analysis.

Results: One thousand, six hundred and forty-nine subjects completed the interview (response rate, 62%). The population prevalences of dyspepsia, irritable bowel syndrome and gastro-oesophageal reux disease were 18.4%, 4.1% and 4.8%, respectively. Dyspepsia and irritable bowel syndrome were associated with anxiety, depression, medical consultation, sick leave and adverse effects on social life. The degree of anxiety was an independent factor associated with health care-seeking behaviour in both dyspeptics (P 0.003) and irritable bowel syndrome patients (P 0.036). Conclusions: Irritable bowel syndrome and dyspepsia are associated with anxiety, depression, signicant social morbidity, health care utilization and days off work. Anxiety is an independent factor in determining health care utilization in patients with dyspepsia and irritable bowel syndrome.

INTRODUCTION

Dyspepsia and irritable bowel syndrome are common diseases. Dyspepsia affects 25% of the US population each year and account for up to 5% of all visits to 1 primary care physicians.1, 2 The prevalence of dyspepsia in the community has been found to be 21% in the UK,3 2% of the population consult their primary care

*Contributed equally to this work. Correspondence to: Dr W.-M. Wong, Department of Medicine, University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong, China. E-mail: wmwongg@hku.hk 2002 Blackwell Science Ltd

physician with a new or rst episode of dyspepsia each year, and dyspepsia accounts for 40% of all gastroenterology consultations.3 Community surveys have suggested that only 35% of sufferers consult, although the proportion increases with increasing age.3 Similarly, the prevalence of irritable bowel syndrome in the USA is 620%, as established by numerous epidemiological studies.48 However, despite this high prevalence, the precise pathophysiology of dyspepsia and irritable bowel syndrome remains unclear and treatment remains suboptimal.9 Visceral sensory and motor abnormalities have been implicated in the pathogenesis, as well as psychological factors. However, the
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interaction between the various factors and their importance in the pathogenesis of intestinal symptoms are controversial. Various studies have shown increased psychological morbidity in patients attending specialist clinics.1014 This may be due to a causative effect of psychological factors on gastrointestinal symptoms, or the psychological morbidity may be a result of the functional bowel disease. Alternatively, psychological factors may inuence health care-seeking behaviour, and patients with co-morbid anxiety or depression may be more likely to seek medical consultation. Population-based data in Asian patients are scarce. Because of cultural and socio-economic differences, health care-seeking behaviour in Chinese patients may differ from that in Western populations. In this study, we attempted to investigate the population prevalence of dyspepsia, irritable bowel syndrome and reux-like symptoms in Hong Kong, and to determine the effects of co-existing anxiety and depression on medical care utilization. We hypothesized that anxiety and depression may have an effect on health care utilization, social morbidity and days off work.

Questionnaires Gastrointestinal symptoms were assessed by a translated Chinese version of a previously validated bowel symptom questionnaire.15 In the development of the Chinese version of the questionnaire, the original instrument was translated, back-translated and tested for reproducibility in a sample of 25 patients attending the gastrointestinal clinic. The intra-class correlation coefcient of the translated questionnaire was 0.9. Dyspepsia This was identied using the Rome criteria: recurrent or chronic pain or discomfort centred in the upper abdomen (above the umbilicus) for 3 months or more.16 Those with only lower abdominal pain or discomfort were excluded from this grouping. Further classication into ulcer-like or dysmotility-like dyspepsia was performed according to the Rome criteria as follows: (i) ulcer-like dyspepsia plus three or more of the following: (a) well-localized pain in the epigastrium; (b) pain relieved by food often; (c) pain relieved by antacids often; (d) pain occurring before meals or when hungry often; (e) night pain; and (f) periodic pain; (ii) dysmotility-like dyspepsia plus three or more of the following: (a) early satiety; (b) post-prandial fullness; (c) nausea; (d) retching and or vomiting; (e) bloating; and (f) pain or discomfort aggravated by food. Irritable bowel syndrome Irritable bowel syndrome was diagnosed according to the Rome I criteria,16 which have been extensively validated. The presence of irritable bowel syndrome was dened as 3 months or more of abdominal pain in the previous year, in combination with: (i) one of the following symptoms: (a) abdominal pain relieved by bowel movement (more than 25% of the time); (b) more frequent and or less frequent bowel movements with pain often; or (c) looser and or harder stools with pain often; and (ii) two or more of the following: (a) more than three bowel movements a day often, and or less than three bowel movements a week often; (b) stools very lumpy or hard often, and or stools very loose or watery often; (c) incomplete evacuation often, and or urgency often, and or straining often; (d) abdominal bloating or distension often; or (e) mucus in stool.

PATIENTS AND METHODS

Data collection The telephone interview was conducted over a period of 2 weeks by a team of 15 trained telephone interviewers from the Social Sciences Research Centre, University of Hong Kong, in 1996. Random telephone numbers were generated by computer and dialled automatically. Only numbers corresponding to ethnic Chinese households were used in the study. Ofce numbers, facsimile machines and non-Chinese households were excluded. On identication of target households, the interviewer asked to speak to the household member with the most recent birthday. This aimed to provide randomization amongst different members of the household. Baseline demographic data, education and occupation were assessed, followed by the bowel symptom questionnaire, the hospital anxiety and depression scale and an assessment of medical care utilization and impact of the disease on social activity as described below. This study was approved by the Ethics Committee of the University of Hong Kong.

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Gastro-oesophageal reux disease Patients were classied as having gastro-oesophageal reux disease if they had heartburn and or acid regurgitation once a week or more. Anxiety and depression Anxiety and depression in patients were assessed by the hospital anxiety and depression scale.17 The Chinese version of this questionnaire has previously been validated,18, 19 and consists of seven questions on anxiety and seven questions on depression. The cut-off scores for anxiety and depression were determined to be three and six, respectively, and the sensitivity and specicity were 80% and 90% in a local sample.19 Medical care utilization Medical care utilization for the abdominal complaint was classied into several categories including the use of over-the-counter medication, hospital visits, community-based medicine or alternative medicine. The impact of disease on the patients life was assessed by the number of days off work in the last 3 months due to gastrointestinal complaints, and whether the patients reported an adverse effect on their normal social life, i.e. symptoms sufcient to cause an interference with normal daily and social activity. Statistical analysis The statistics used included the chi-squared test, Fishers exact test and Students t-test, and the MannWhitney U-test for data with a skewed distribution. A P value of 0.05 or less was considered to be statistically signicant and all reported P values were two-sided. A multiple logistic regression model was designed to determine the factors [severity of symptoms by grading (1, mild; 2, moderate; 3, severe) and frequency (1, less than once per month; 2, 24 times per month; 3, more than once per week) gender, age, educational level (primary school or below, secondary or matriculation and tertiary), occupation (three levels), anxiety and depression scores] associated with health care-seeking behaviour in patients with dyspepsia and irritable bowel syndrome. To nd the best model, a backward elimination stepwise procedure was carried out in such a way that the factor was eliminated from the analysis if the corresponding P
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value was greater than 0.3, in order not to eliminate too much information in view of the small sample size.

RESULTS

Population sampled Two thousand, six hundred and forty ethnic Chinese households were contacted by telephone. The interview was completed in 1649 subjects (mean age, 37.9 15 years; 47% male, 53% female; comparable with the census data of Hong Kong in 199620). The demographic data of the study patients are shown in Table 1. There was no signicant difference between the sexes in the mean age, proportion of patients in each age group and housing environment. However, male subjects had a higher education level and a different occupation predominance, with a higher number of male subjects in professional and managerial work, technical work and the services and sales industry. In contrast, female subjects were predominantly housewives and clerical workers. Gastrointestinal symptoms 2 The prevalence of dyspepsia in the sample was 18.4% (n 304; 58% female; mean age, 35 years). The prevalences of irritable bowel syndrome and gastrooesophageal reux disease were 4.1% (n 68; 63% female; mean age, 34 years) and 4.8% (n 79; 59% female; mean age, 38 years), respectively. There was considerable overlap between the various diagnostic groups (Figure 1). Of the patients with dyspepsia, 14.6% had ulcer-like dyspepsia, 35.2% dysmotility-like dyspepsia and 50.2% non-specic dyspepsia according to previous criteria.21 Symptoms of heartburn or acid regurgitation occurred monthly or more in 9.3% (n 154) of patients. Health care utilization, days off work and effects on social life Fifty-six per cent (171 304) of patients with dyspepsia and 72% (49 68) of patients with irritable bowel syndrome had used one or more forms of treatment for their problems. Of the 304 patients with dyspepsia, 43 (14%) had bought over-the-counter medication, 110 (36%) had visited an out-patient clinic and 18 (6%) had visited the accident and emergency department for

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Table 1. Demographic data of patients in this study Male* (n 775) Mean age (years) Age range (%) 1829 years 3039 years 4049 years 5059 years > 60 years Total Education (%) Primary or below Secondary or matriculation Tertiary Total Housing (%) Public housing Private housing Total Occupation (%) Professional and managerial Technical worker and craftsmen Clerical work Service and sales Non-technical worker Student Housewife Others (retired and unemployed) Total 38 16 221 203 120 59 113 716 140 446 137 723 (31) (28) (17) (8) (16) (100) (19) (62) (19) (100) Female* (n 874) 38 14 240 232 137 61 133 803 228 485 104 817 (30) (29) (17) (8) (16) (100) (28) (59) (13) (100) P value 0.48

0.97

< 0.001

395 (55) 329 (45) 724 (100) 123 129 66 138 51 73 139 719 (17) (18) (9) (19) (7) (10) (19) (100)

453 (56) 356 (44) 809 (100) 78 50 157 73 31 65 278 76 808 (10) (6) (19) (9) (4) (8) (34) (9) (100)

0.57

< 0.001

* The total in each individual cell may be smaller because of subject refusal to answer question.

Figure 1. Overlap between patients with dyspepsia, irritable bowel syndrome (IBS) and gastro-oesophageal reux disease (GERD) in the Chinese population.

dyspepsia, 11 (4%) of whom were admitted to a regional hospital for further management. Of the 68 patients with irritable bowel syndrome, 10 (15%) had

bought over-the-counter medication, 30 (44%) had visited an out-patient clinic and nine (13%) had visited the accident and emergency department for abdominal complaints, six (9%) of whom were admitted to a regional hospital for further management. The diagnoses of dyspepsia (P < 0.001) and irritable bowel syndrome (P < 0.001) were signicantly correlated with increased health care utilization. A signicantly higher proportion of health care seekers with dyspepsia (43%) had moderate to severe symptoms when compared with non-health care seekers (24%) (Table 2). This difference in symptom severity was not observed in patients with irritable bowel syndrome. Furthermore, the proportion of patients with weekly epigastric or abdominal pain was similar between health care seekers and non-health care seekers in both dyspeptics and patients with irritable bowel syndrome. A signicantly higher proportion of subjects with dyspepsia (15% vs. 5%, P < 0.001) and irritable bowel
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Table 2. Comparison between subjects with dyspepsia and irritable bowel syndrome (by the Rome criteria) who did or did not seek health care Dyspepsia HCS (n 171) Mean age s.d. (years) Female (%) Pain severity moderate or worse (%) Pain once a week or more (%) Mean anxiety score Mean depression score 35 12 60 43 16 5.3 4.7 Dyspepsia NHCS (n 133) 35 13 56 24 14 3.9 4.4 IBS HCS (n 49) 34 13 71* 35 14 6.6 5.0* IBS NHCS (n 19) 34 14 39 26 16 5.9 3.7

HCS, health care seeker; IBS, irritable bowel syndrome; NHCS, non-health care seeker. *P < 0.05 when compared with non-health care seekers. P < 0.01 when compared with non-health care seekers.

syndrome (22% vs. 6%, P < 0.001) required days off work when compared with subjects without these conditions. Furthermore, a signicantly higher proportion of subjects with dyspepsia (18% vs. 3%, P < 0.001) and irritable bowel syndrome (25% vs. 5%, P < 0.001) reported an adverse effect on their social life (symptoms sufcient to cause an interference with normal daily and social activity) when compared with subjects without these conditions. Anxiety and depression score Patients with dyspepsia had higher average anxiety (4.5 vs. 2.9, P < 0.001) and depression (4.5 vs. 3.7, P < 0.001) scores when compared with patients with no dyspepsia, irritable bowel syndrome or gastrooesophageal reux disease. Similarly, patients with irritable bowel syndrome had higher anxiety (6.3 vs. 2.9, P < 0.001) and depression (4.5 vs. 3.7, P 0.018) scores when compared with patients with no irritable bowel syndrome. For dyspeptic patients, the mean anxiety score of patients who sought any medical consultation was higher (5.3 vs. 3.9, P 0.002) than that of those who did not (Table 2). Such a difference was not observed in patients with irritable bowel syndrome. For patients with irritable bowel syndrome, the mean depression score of patients who sought any medical consultation was higher (5.0 vs. 3.7, P 0.037) than that of those who did not. Similarly, the mean anxiety (5.7 vs. 2.9, P < 0.001) and mean depression (4.9 vs. 3.7, P 0.007) scores were signicantly higher in patients with gastro-oesophageal reux disease than in those without. However, the mean anxiety and depression scores were similar
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between gastro-oesophageal reux disease patients who sought any medical consultation and those who did not. Determinants of health care utilization By multiple logistic regression analysis, it was found that the degree of anxiety was an independent factor associated with health care-seeking behaviour in both dyspeptics (P 0.003) and irritable bowel syndrome patients (P 0.036), whereas age, gender, occupation, educational level, frequency and severity of symptoms and the degree of depression (depression score) had no effect on health care utilization (use of over-the-counter medication, hospital visits, community-based medicine or alternative medicine).
DISCUSSION

We have reported a population-based telephone survey of the prevalence of functional gastrointestinal disorders and the effects of co-existing anxiety and depression on health care utilization in a Chinese population. We found that the prevalences of dyspepsia, irritable bowel syndrome and gastro-oesophageal reux disease were 18.4%, 4.1% and 4.8%, respectively. Dyspepsia and irritable bowel syndrome were associated with anxiety, depression, medical consultation, sick leave and adverse effects on social life. The degree of anxiety was an independent factor associated with health care utilization in both dyspeptics and irritable bowel syndrome patients. The prevalence of dyspepsia found in this study correlated well with that of Western studies, as well

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as that reported by the Asia-Pacic consensus.22 However, the prevalence of irritable bowel syndrome was considerably lower than that in Western populations and was similar to that reported in an earlier study performed in a multi-racial Asian population.23 The reason for this nding is unknown and further studies are warranted. Similarly, the prevalence of gastro-oesophageal reux disease was lower than that in Western populations, which showed a prevalence of around 20% for weekly reux symptoms.1, 24 The marked difference in the prevalence of gastro-oesophageal reux disease between Chinese and Caucasians is unclear. Differences in dietary fat, body build, genetic factors and the prevalence of Helicobacter pylori infection have been postulated as contributing factors.25 Interestingly, the overlap of functional gastrointestinal disorders reported in Western studies1, 6 was preserved in the Chinese population (Figure 1). Functional gastrointestinal illnesses are costly to society. Although functional dyspepsia and irritable bowel syndrome do not result in mortality, such disorders cause much morbidity and loss of productivity, with profound economic and public health implications. It has been calculated that dyspepsia may account for 2070% of all gastrointestinal consultations with general practitioners; up to one-third of these patients may eventually be referred to a gastroenterologist.26 Estimates in Sweden have yielded annual health care expenses for dyspepsia of US$55 000 per 1000 citizens.27 An American study by Sonnenberg identied even higher costs.28 Patients with functional dyspepsia have been reported to have a 2.6-fold increased amount of sick leave.29 The socio-economic burden of functional gastrointestinal disorders is well illustrated in our study, as 15% of patients with dyspepsia and 22% of patients with irritable bowel syndrome required days off work, compared to 56% of subjects with no dyspepsia or irritable bowel syndrome. Furthermore, a signicantly higher proportion of patients with functional gastrointestinal disorders reported an adverse effect of their illness on their social life when compared with subjects without these conditions. Few data exist on the factors determining health care utilization in patients with functional bowel disease. Several studies have shown a higher level of anxiety and depression in patients with functional dyspepsia when compared with healthy controls.10, 11 However, their level of anxiety may not be different from patients with non-life-threatening organic bowel diseases.10, 12

Co-existing depression and anxiety may act as a catalyst for a patient to seek medical care, rather than being the cause of symptoms. An Australian study using postal questionnaires investigated the effects of psychological factors on health care-seeking behaviour, and found that there was no difference in anxiety and depression between patients who did or did not consult doctors.30, 31 In contrast, we found that patients with dyspepsia and irritable bowel syndrome were signicantly more anxious and depressed when compared with subjects without these conditions. Furthermore, the degree of anxiety was an independent factor associated with health care-seeking behaviour. The differences observed may reect cultural differences and health care economics. In the Australian study, 73% of irritable bowel syndrome patients sought medical care for abdominal pain. This compares with 44% of irritable bowel syndrome patients and 36% of dyspeptics visiting medical clinics in our population. Decreased accessibility to health care may restrict medical consultations to the most anxious and determined patients in our local setting. A study from the UK has demonstrated that Afro-Caribbeans and white Europeans have different health care-seeking behaviour.32 Furthermore, it has been demonstrated that the relief of anxiety during a medical specialist consultation can reduce the use of primary care in patients with irritable bowel syndrome.33 Although symptom severity was signicantly associated with health care-seeking behaviour in subjects with dyspepsia by univariate analysis, this factor disappeared during multivariate analysis. One may argue that this may be a chance nding. However, in view of the highly signicant anxiety and depression scores in patients with dyspepsia and irritable bowel syndrome, when compared with patients without functional gastrointestinal disorders, we believe that psychological morbidity may play an important role in health care-seeking behaviour. This is in contrast with previous studies, which reported increasing pain severity and duration of pain to be independently associated with health care-seeking behaviour.30, 31, 34 However, the intensity of symptoms accounted for one-third of health care-seeking behaviour in the study by Holtmann et al., suggesting that other factors, such as psychological morbidity, may be more important.34 Interestingly, another study conducted in Bangladesh, where medical consultations are not readily available, also showed no inuence of the number of symptoms
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on health care-seeking behaviour.35 Also, in addition to the symptom prole and severity, the patients perception of symptoms is important. A British study suggested that the fear of cancer is important.36 The fear of cancer is probably culturally dependent and may explain some of the differences observed between studies conducted in diverse populations. As this is a once-off survey, it is difcult to address the issue of the cycle of symptom intensity in patients with functional bowel disorders. Recall bias in a population survey may lower the symptom severity of patients. However, such effects should be equally distributed between health care seekers and non-health care seekers. In conclusion, the prevalence of dyspepsia in our Chinese population was similar to that in Western populations, but the prevalence of irritable bowel syndrome and gastro-oesophageal reux disease was lower. Irritable bowel syndrome and dyspepsia are associated with anxiety, depression, signicant social morbidity, health care utilization and days off work. Anxiety is an independent factor in determining health care utilization in patients with dyspepsia and irritable bowel syndrome.
ACKNOWLEDGEMENTS

This study was supported by the Peptic Ulcer Research Fund and the Simon K. Y. Lee Gastroenterology Research Fund, University of Hong Kong, Hong Kong, China.
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