Research reportGeneralized anxiety disorder, with or without co-morbid major depressive disorder, in primary care: Prevalence of painful somatic symptoms, functioning and health status
Introduction
Generalized anxiety disorder (GAD) is the most prevalent anxiety disorder in primary care (PC), with cross-sectional rates of about 8% among PC attendees (Lieb et al., 2005, Wittchen, 2002). Patients with GAD show a marked functioning and quality of life impairment (Lieb et al., 2005, Wittchen, 2002, Kroenke et al., 2007). They also experience a high degree of co-morbidity, with 80%–90% presenting at least one additional current psychiatric diagnosis (Roy-Byrne et al., 2008). It is common for patients to experience co-morbid GAD and depression, finding a prevalence of co-morbid GAD and depression of 40 to 62% (Wittchen et al., 1994, Wittchen, 2002).
Painful physical symptoms (PPS) in depression have been widely studied; they are present in two thirds of PC patients with major depressive disorder (MDD) (Tylee & Gandhi, 2005, Bair et al., 2004), are often present as multiple physical manifestations without a clear organic origin and commonly constitute the main reason for seeking medical help (Simon et al., 1999). In addition, PPS were shown to be associated with increased depression severity and decreased quality of life and health resources utilization in PC patients in Spain (García-Campayo et al., 2008, Caballero et al., 2008).
Contrary to depression, PPS have received little attention in patients with GAD, particularly in the PC setting. The prevalence of PPS and its specific role in functioning and quality of life in patients suffering from GAD are yet not well understood. Although there is an increasing awareness that PPS are associated with GAD (Sheehan et al., 2008, Hartford et al., 2008, Russell et al., 2008, Beesdo et al., 2009), there are limited published studies regarding their prevalence, characteristics and relation with functionality impairment, in PC patients with GAD with or without co-morbid MDD. Much of the research on this topic evaluated the prevalence of anxiety disorders in samples reporting chronic pain (Asmundson & Katz, 2009, Gureje et al., 2008, Von Korff et al., 2005, Demyttenaere et al., 2007). A small number of studies have assessed the prevalence of pain in patients with anxiety disorders, but most of them were limited to panic disorder and posttraumatic stress disorder (Asmundson and Katz, 2009), or were conducted in community samples (Beesdo et al., 2009). The study of PPS in primary care patients suffering from GAD is relevant since they have an implication in assessment and treatment strategies, as well as in the quality of life of the patient.
Our hypothesis was that patients with GAD would have a higher prevalence of PPS than patients with neither GAD nor MDD (control group), and that the co-morbidity of GAD with MDD would increase this prevalence. This is supported by preliminary clinical evidence suggesting the presence of multiple PPS in patients with GAD (Sheehan et al., 2008, Hartford et al., 2008, Russell et al., 2008). Therefore, this study was aimed to assess the prevalence of PPS in PC patients with GAD vs patients with GAD and co-morbid MDD, and vs a control group (patients without GAD and MDD). Secondary objectives were to assess the association between PPS and functioning, health status and heath resources utilization.
Section snippets
Study design
This is a cross-sectional, multi-center, epidemiological study carried out in the PC setting. The study consisted of a three-stage design: a screening to identify high-risk patients for GAD, a diagnosis confirmation of GAD [GAD (+)] as per the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) criteria and a clinical evaluation for the presence of PPS (Fig. 1). The study was performed between April and June 2007 at 87 participating sites in Spain. Patients were enrolled in this
Study population
The flow of the patients in this study is shown in Fig. 1. Briefly, a total of 7152 patients, following a consecutive procedure, were invited for screening. Screening was not performed in 314 patients. Those patients not performing screening were slightly older (mean age 57.3, 95% CI = 54.2, 60.3) than those screened (mean age 51.8, 95% CI = 51.4, 52.2; p value < 0.001). Also, there were slightly less number of female patients not performing screening than in those screened (54.1% vs. 61.1%
Discussion
This epidemiological study in a large sample of primary care attendees reports that the prevalence of PPS is significantly higher in patients with GAD (59%) compared to controls (28%) and is significantly much higher in the presence of co-morbid MDD (78%). The prevalence of PPS according to location and severity of pain was also higher in patients who suffer from GAD and co-morbid MDD, and differences between groups remained significant, therefore suggesting that prevalence estimates of PPS in
Role of the funding source
This study was supported by Eli Lilly and Company, Spain. All authors have been involved in the study design, interpretation of data, revision of the manuscript and in the decision to submit the paper for publication. Dr. Irene Romera, Helena Delgado-Cohen, Durisala Desaiah, and Pepa Polavieja have been involved in the writing of the manuscript. The analysis of the data has been carried out by AAIPHARMA.
Conflict of interest
Drs. Romera and Gilaberte and Mss Polavieja and Fernández-Pérez are full time employees of Lilly SA. Dr. Desaiah is a full time employee of Eli Lilly and Company, Indianapolis, IN, USA and holds company stocks. Ms. Delgado-Cohen was an employee of Lilly SA during the conduct of this study. Dr. Arbesú has received grant support from Lilly SA and Wyeth; has served as a consultant for and/or on advisory boards for Lilly SA; and has served as a speaker for Lilly SA, Lundbeck, Wyeth, Esteve,
Acknowledgments
This study was supported by Eli Lilly and Company, Spain. The authors thank all the primary care centers and all patients who participated in this study.
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