1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  9. Supporting Information


The relationship between dyspepsia and psychiatric comorbidity such as anxiety and depression is poorly defined. Previous studies have been limited by lack of standardised diagnostic criteria.


To examine the prevalence and comorbidity of dyspepsia as defined by Rome III (6-month duration) with DSM-IV-TR generalised anxiety disorder (GAD) and major depressive episodes (MDE) in the general population.


A random population-based telephone survey was done using a questionnaire on symptoms of Rome III Dyspepsia, DSM-IV-TR GAD and MDE and their chronological relationship.


Of the 2011 respondents 8.0% currently had Rome III Dyspepsia, 3.8% reported GAD and 12.4% reported MDE respectively. Dyspeptic subjects had a twofold increased risk of GAD (OR = 2.03, 95% CI: 1.06–3.89, < 0.001) and a threefold increased risk of MDE (OR = 3.56, 95% CI: 2.33–5.43, < 0.001). MDE and GAD most often coincided with dyspepsia in onset. Dyspepsia (OR = 2.48, 95% CI: 1.65–3.72 < 0.001), MDE (OR = 2.39, 95% CI: 1.64–3.46, < 0.001) and female sex (OR = 1.65, 95% CI: 1.21–2.23, < 0.001) independently predicted frequent medical consultations. GAD independently predicted high investigation expenditure (OR = 4.65, 95% CI: 1.15–18.70, P = 0.03).


With stringently adopted Rome III and DSM-IV-TR criteria, dyspepsia was strongly associated and often coincident in onset with generalised anxiety disorder and major depressive episodes in the community. Excessive healthcare utilisation should alert clinicians to risk of psychiatric comorbidity.


  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  9. Supporting Information

Dyspepsia is a common gastrointestinal condition that is characterised by chronic recurrent epigastric symptoms such as pain, burning and postprandial symptoms. Dyspepsia is associated with significant functional impairment and burden on healthcare resources.[1] Estimates of community prevalence of dyspepsia have varied widely from 5% to 40%[2] depending on criteria used. Yet, community prevalence measured using strictly applied Rome III criteria,[3] which are more precise and restrictive than their predecessors, remains sparse.[4]

It has been reported that comorbid psychiatric disorders are common in patients with dyspepsia. Generalised anxiety disorder (GAD) and Major depressive episodes (MDE), in particular, have been most extensively related to dyspepsia. These three disorders share several commonalities. Similar to functional dyspepsia, both GAD and MDE are typically chronic and relapsing, more common in female, with onset and exacerbation often associated with psychosocial stress.[5, 6] Moreover, visceral hypersensitivity and somatisation have been associated with all three conditions.[4, 7-10]

Studies have found increased anxiety and depressive symptoms on rating scales,[11] and poorer psychological wellbeing[12] in organic and functional dyspepsia. However, their relevance to how specific comorbid mental disorders may contribute to the clinical and societal burden of dyspeptic symptoms[12] remains unclear. As effective interventions exist for mental disorders, their treatment may benefit the clinical outcome of dyspepsia.[13]

To date, most studies on psychiatric correlates in dyspeptic patients came from referral centres and clinics.[4] Selection bias may distort any association of psychiatric morbidity and dyspepsia found in these samples, because only 25–42%[14] of dyspepsia sufferers in the community seek medical care. It is unclear whether psychological distress may motivate or hinder patients in seeking care for dyspeptic symptoms. The recent community-based Kalixanda study[15] evaluated the relationship between anxiety, depression and functional dyspepsia. It found anxiety, but not depression, to be associated with functional and organic dyspepsia. However, the Rome III criteria used in this study were post hoc rated from a Rome II questionnaire with the Rome III 6-month onset criterion discarded. Meanwhile, HADS, as with most psychiatric symptom scales, captured symptoms as a dimensional score, and did not meet the duration and impairment requirements for diagnosis of GAD and MDE as mental disorders defined by the American Psychiatric Associations' Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition- Text Revision (DSM-IV-TR)[16] (Tables 2 and 3). Using the Structured Clinical Interview for DSM-IV Axis-I Disorder (SCID-I),[17] we found 38.2% and 16.4% of Chinese patients in a tertiary gastroenterology clinic with functional dyspepsia to have an anxiety disorder and depressive disorder respectively.[18]

We therefore set out to conduct a community survey to examine the current community prevalence of stringently defined Rome III Dyspepsia (Table 1), as well as the 12-month prevalence of GAD and MDE using DSM-IV-TR. We also evaluated the association between dyspepsia, GAD and MDE and the chronological relationship of their onsets. Although rarely examined in previous studies, the latter may shed light on whether these illnesses may be causally related to each other.[19]

Table 1. Rome III symptomatic criteria for functional dyspepsia[3]
  1. Criteria fulfilled for the last 3 months with symptom onset at least 6 months before diagnosis.

Must include
One or more of
 a Bothersome postprandial fullness
 b Early satiation
 c Epigastric pain
 d Epigastric burning


  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  9. Supporting Information

A random community-based telephone survey of the general population in the age range of 15–65 years was conducted from 22nd April to 13th May, 2009. The study was approved by the research ethics committee of The Chinese University of Hong Kong. The Hong Kong Institute of Asia-Pacific Studies of the Chinese University of Hong Kong, an independent survey research organisation, was commissioned to conduct the survey. Interviewers were university students with 1–3 years of part-time experience in telephone interviews. A briefing session was held by the investigators (AM, JW, YC) for training of administration of the questionnaire and explaining skills involved in eliciting symptoms of dyspepsia, GAD and MDE. Respondents were invited to take part in a telephone survey of ‘digestive problems and emotional health’. Interviews proceeded only after verbal consent was sought. The interviews were conducted in Cantonese dialect, the predominant spoken dialect in Hong Kong. On average, an interview took approximately 20 min to finish.

Hong Kong has a population of 7.0 million. More than 99% of households have a telephone line.[20] Sampling telephone lines should therefore generate a representative sample of households. Phone calls were made in the evening (18:00–22:00 hours) to cover the working population. Of the 6378 valid home telephone numbers randomly selected from the Hong Kong Telephone Directory, 2585 hung up immediately, and 720 had no interviewee in the suitable age range. Of the 3057 successful contacts, 1062 were rejected. Of the 1062 rejected participants, 931 were turned down by relatives of the suitable respondent, 82 were turned down by the suitable respondent and for the remaining 49, contact could not be made to the suitable respondent after initial successful contact (Figure 1). This resulted in a final sample of 2011 respondents (937 men, 1074 women; age distribution in years: 15–24 (16.9%), 25–34 (20.4%), 35–44 (22.6%), 45–54 (26%), 55–65 (20.7%). The distribution is highly comparable to that reported by the Census and Statistics Department[20] (Table 4). The participation rate was therefore 65.4%.


Figure 1. Flow diagram depicting various reasons for and number of subjects who did not participate in the study.

Download figure to PowerPoint


A 40-item questionnaire was used covering demographic information, dyspepsia using the Chinese version of the Rome III Dyspepsia Module,[21] symptoms of GAD and MDE (Tables 2 and 3) based on DSM-IV-TR Criteria and healthcare utilisation.

Table 2. Survey questions pertaining to the DSM IV-TR symptoms of generalised anxiety disorder
DSM-IV criteriaQuestions in the telephone surveyRequired response for diagnosis
A. Excessive anxiety and worry, occurring more days than not for at least 6 months, about a number of events or activities (e.g. work or school performance)A1. Do you think that you are prone to anxiety or worries?At least one response to A1–A3 has to be ‘Yes’
A2. Was there a period in the past twelve months that you were habitually worried?‘Yes’
A3. In the past twelve months, had you frequently worried about a number of events or activities (e.g. work or school performance)?‘Yes’
A4. Did your worries or anxiety last more than 6 months?‘Yes’
A5. During the period when you were worried or anxious, did you experience worries or anxiety for most of the time?‘Yes’
B. The person finds it hard to control the worryB1. During the period when you were worried or anxious, how often were you able to control your worry?‘Occasionally’ or ‘Very difficult’ or ‘Unable to control’

C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months)

 1. Restlessness or feeling keyed up or on edge

 2. Being easily fatigued

 3. Irritability

 4. Muscle tension

 5. Difficulty falling/staying asleep, or restless unsatisfying sleep

 6. Difficulty concentrating or the mind going blank

 C1. Did you frequently experience the following symptoms when you were worried or anxious:

 1. Restlessness

 2. Being easily fatigued

 3. Irritability

 4. Muscle tension

 5. Difficulty falling or staying asleep, or restless unsatisfying sleep

 6. Difficulty concentrating or the mind going blank

At least three of the six symptoms have to be met
D. Clinically significant distress or impairment in social, occupational/other important areas of functioningD1. Did the above experiences cause you significant distress? AND/OR‘Very distressed’ or ‘Quite distressed’ AND/OR
D2. Did the above experiences significantly impair your daily life (e.g. study/work, social & family life?‘Very impaired’ or ‘Quite impaired’
Table 3. Survey questions pertaining to the DSM IV-TR symptoms of major depressive episode
DSM –IV criteriaQuestions in the telephone surveyRequired response for diagnosis

FIVE or more of the following in the same 2 week period, representing a change from previous functioning. At least ONE should be either (1) or (2)

 1. Depressed mood most of the day, nearly every day (reported or observed)

 2. Markedly diminished interest or pleasure in (almost) all activities most of the day, nearly every day (reported or observed)

 3. Significant weight loss

 4. Insomnia or hypersomnia nearly every day

 5. Psychomotor agitation or retardation nearly every day (observed + subjective)

 6. Fatigue or loss of energy nearly every day

 7. Feelings of worthlessness or excessive or inappropriate guilt nearly every day (not merely self-reproach or guilt about being sick)

 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (subjective or objective)

 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

A1. In the past year, have you had 2 weeks or longer when you had depressed mood most of the day, nearly every day?

A2. In the past year, have you had 2 weeks or longer when you had markedly reduced interest or pleasure in almost all activities most of the time, nearly every day?

‘Yes’ in A1 or A2

B. During the period when you had (depressed mood) (reduced interest or pleasure), did you often have

 a Poor appetite or lost weight

 b Slept less than usual

 c Observable slowing of speech or actions

 d Fatigue or loss of energy

 e Difficulty to concentrate or make decisions

 f Observable restlessness and agitation

 g Increased appetite or body weight

 h Slept more than usual

 i Felt worthless

 j Thoughts of death or suicide

a and g counted as 1 item

b and h counted as 1 item

c and f counted as 1 item

‘Yes’ in at least FIVE items in sections A and B, including at least one item in A.

D. Clinically significant distress or impairment in social, occupational/other important areas of functioningD1. Did the above experiences cause you significant distress? AND/OR‘Very distressed’ or ‘Quite distressed’ AND/OR
D. Clinically significant distress or impairment in social, occupational/other important areas of functioningD2. Did the above experiences significantly impair your daily life (e.g. study/work, social & family life?‘Very impaired’ or ‘Quite impaired’

The same questionnaire for GAD and MDE diagnoses had been used in previous series of telephone surveys that found 12-month prevalence of GAD to be 4.1%[22] and 8.4% for major depressive episode (MDE).[23] Clinical re-appraisal for diagnoses of MDE and GAD using the gold standard of psychiatric diagnosis in research, the Structured Clinical Interview for DSM-IV Axis-I Disorders (SCID-I) yielded good agreement.[24, 25] The same series of telephone survey had assessed prevalence of Rome III Irritable Bowel Syndrome in Hong Kong to be 5.4%, comparable while conservative, with overseas estimates.[26]

We also asked ‘how much did you spend over the past 5 years on investigations for your gastrointestinal problems?’ to assess investigation expenditure and ‘how frequently did you see a doctor for your health problems’ to assess frequency of consultations. Subjects were also asked for each disorder their respective ages when the disorder first came on in their lives so as to estimate chronological association of the disorders.

Study power

Power calculation was performed post hoc based on the sample collected to estimate the size of odds ratio that can be detected in the whole sample and the dyspepsia subgroup. With an overall sample (n = 2011), a logistic regression of binary response variable of dyspepsia (n = 142, 7% dyspepsia without MDE) on the binary independent variable of GAD (n = 77, 3.8%), to achieve 80% power at a significance level of 0.05, will have a minimum detectable odds ratio of 2.60. For the dyspepsia-only subgroup (n = 161), for logistic regression of binary response variable of GAD (n = 4, 4% GAD without MDE) on the binary independent variable of MDE (n = 53, 33%), the minimum detectable odds ratio would be 5.24, to achieve 80% power at a significance level of 0.05.[27]


The current prevalence of dyspepsia and 12-month prevalence of generalised anxiety disorder and major depressive episode were presented as percentages. The study sample was weighted (Appendix S1) according to age and sex distribution of the Hong Kong general population based on the 2008 Census data (Table 4). To identify factors independently associated with dyspepsia, Chi-squared tests were used in the whole sample to explore the association of the psychiatric diagnoses and sociodemographic variables with dyspepsia. All diagnostic and sociodemographic variables were then entered into logistic regression (enter mode, without any elimination) with dyspepsia. Multivariate analysis did not proceed in the dyspepsia sub-group due to insufficient sample size. Logistic regression and ordinal regression were used to examine factors independently associated with high investigation expenditure [arbitrarily defined as spending HKD50000 (equivalent to USD6427) or more on investigations over the previous 5 years], frequent medical consultations (arbitrarily defined as monthly or more frequent medical consultations) and their respective association with all diagnostic and sociodemographic variables. Statistical analyses were performed using the Statistical Package for Social Studies, Version 16.0 (SPSS Inc., Chicago, IL, USA). All P values were two-tailed with the level of statistical significance specified at 0.05.

Table 4. Sociodemographic characteristics of the respondents and comparison with Hong Kong Census data
 Total sample (n = 2011), % (n)% Census 2008a
  1. a

    Data from Hong Kong Census and Statistics Department, 2008.

Male46.6 (937)47.2
Female53.4 (1074)52.8
15–2416.9 (341)17.0
25–3420.4 (411)20.4
35–4422.5 (454)22.6
45–5424.3 (488)24.2
55–6515.8 (317)15.8
Primary or below11.3 (317)
Secondary45.2 (905)
Pre college10.3 (206)
College or above33.3 (667)
Work status
Employed60.6 (1212)
Unemployed6.4 (129)
Retired7.0 (141)
Student12.1 (241)
Homemaker13.8 (278)
Marital status
Single38.4 (769)
Married/living together59.4 (1190)
Previously married2.1 (43)
Income level
HKD ≤ 10 00020.8 (389)
HKD 10 000–30 00046.6 (869)
HKD 30 000–60 00022.3 (416)
≥HKD 60 00010.3 (192)


  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  9. Supporting Information

Prevalence and sociodemographic profile

Of the 2011 respondents, 8.0% (n = 161) currently fulfilled Rome III criteria for dyspepsia. Among these respondents, 81.3% (n = 131) had postprandial distress syndrome (PDS), 7.5% (n = 12) had epigastric pain syndrome (EPS), 4.3% (n = 7) had both PDS and EPS, while 14.9% (n = 24) was unclassified (Table 5). All these subjects reported dyspeptic symptoms that were occurring more than once a week with onset at least 6 months ago. Amongst all sociodemographic variables, only lower levels of education were significantly associated with dyspepsia. There was also a nonsignificant trend of high prevalence of dyspepsia in female. (Table 4).

Table 5. Prevalence of dyspepsia and its subgroups, GAD and MDE
 Prevalence, % (n)
Dyspepsia (Rome III)8.0 (161)
Postprandial distress syndrome81.3 (131)
Epigastric pain syndrome7.5 (12)
Psychiatric diagnoses
Generalised anxiety disorder3.8 (77)
Major depressive episode12.4 (249)
Number of psychiatric diagnoses
No psychiatric diagnosis86.5 (1739)
One psychiatric diagnosis (GAD OR MDE)10.9 (219)
Two psychiatric diagnoses (GAD and MDE)2.6 (53)

The 12-month prevalence of GAD was 3.8% (n = 77). The 12-month prevalence of MDE, at 12.4% (n = 249), has been reported before.[28]

Comorbidities of dyspepsia

Dyspepsia was significantly associated with both GAD and MDE; 21.3% of respondents with MDE met Rome III criteria for dyspepsia vs. 6.1% of non-MDE respondents (P < 0.001). 32.9% of dyspeptic respondents vs. 10.6% of nondyspeptic respondents met criteria for MDE (P < 0.001) (Table 6).

Table 6. Sociodemographic characteristics and psychiatric comorbidity in dyspeptic respondents
 Dyspepsia (n = 161), % (n)Crude OR P Adjusted OR P
  1. a

    P < 0.05.

Male6.9 (75)1 1 
Female8.9 (86)1.32 (0.95–1.83)0.101.16 (0.78–1.80)0.47
Age    0.62
15–247.9 (27)0.90 (0.51–1.56)0.701.04 (0.36–3.02)0.95
25–347.1 (29)0.79 (0.46–1.37)0.400.90 (0.43–1.88)0.77
35–446.8 (31)0.78 (0.46–1.34)0.370.78 (0.40–1.53)0.47
45–549.6 (47)1.12 (0.68–1.84)0.651.18 (0.64–2.18)0.60
55–658.5 (27)11
Education    0.27
Primary or below10.2 (23)1.87 (1.09–3.19)0.02a1.51 (0.72–3.12)0.27
Secondary9.1 (82)1.61 (1.09–2.40)0.02a1.58 (0.99–2.53)0.06
Pre college7.2 (15)1.24 (0.67–2.31)0.501.08 (0.54–2.15)0.83
College or above5.8 (39)11
Work status    0.89
Employed7.6 (92)0.74 (0.47–1.15)0.180.88 (0.51–1.53)0.27
Unemployed8.5 (11)0.85 (0.41–1.76)0.660.87 (0.39–1.95)0.74
Retired5.7 (8)0.55 (0.25–1.24)0.150.60 (0.23–1.60)0.31
Student7.9 (19)0.77 (0.42–1.41)0.390.82 (0.28–2.39)0.72
Homemaker10.1 (28)11
Marital status    0.94
Single7.5 (58)11
Married/living together8 (95)1.08 (0.77–1.52)0.660.95 (0.57–1.60)0.85
Previously married14 (6)1.93 (0.77–4.83)0.161.11 (0.39–3.15)0.85
Income level    0.88
HKD ≤ 10 0009.5 (30.4)1.44 (0.75–2.76)0.280.89 (0.41–1.87)0.73
HKD 10 000–30 0007.9 (69)1.17 (0.83–2.15)0.620.84 (0.43–1.65)0.62
HKD 30 000–60 0006.5 (27)0.95 (0.48–1.88)0.880.75 (0.37–1.54)0.44
≥HKD 60 0006.8 (13)11
Psychiatric diagnoses



24.3 (19)

7.3 (142)

4.10 (2.37–7.08)<0.001a2.03 (1.06–3.89)0.03a

21.3 (53)

6.1 (108)

4.11 (2.86–5.89)<0.001a3.56 (2.33–5.43)<0.001a
Number of psychiatric diagnoses    <0.001a
No psychiatric diagnosis6.0 (104)11
One psychiatric diagnosis (GAD OR MDE)26.1 (42)3.72 (2.52–5.49)<0.001a3.62 (2.37–5.51)<0.001a
Two psychiatric diagnoses (GAD and MDE)9.3 (15)6.03 (3.21–11.33)<0.001a6.65 (3.35–13.21)<0.001a

In all 24.3% of GAD respondents had dyspepsia vs. 7.3% of non-GAD respondents (P < 0.001); 11.8% of dyspepsia respondents also had GAD, vs. 3.1% of nondyspepsia respondents (P < 0.001) (Table 6).

In the multivariate analysis that included all sociodemographic correlates, the adjusted odds ratio of GAD being associated with dyspepsia was 2.03 (95% CI: 1.06–3.89, P = 0.03), while the adjusted OR of MDE being associated with dyspepsia was 3.56 (95% CI: 2.33–5.43, P < 0.001).

Comorbidities of PDS and EPS

Generalised anxiety disorder was found in 10.6% (n = 14) of PDS [vs. 3.4% (n = 63) non-PDS, P < 0.001] respondents and 16.7% (n = 2) of EPS [vs. 3.8% (n = 75) non-EPS] respondents. MDE was found in 34.4% (n = 45) of PDS respondents [vs. 10.9% (n = 204) non-EPS] and 25% (n = 3) of EPS [vs. 12.3% (n = 246) non-EPS] respondents.

Concomitant MDE and GAD

Having concomitant MDE and GAD was associated with higher prevalence of comorbid dyspepsia than having only one or none psychiatric diagnosis; 28.3% (n = 15) of respondents with both GAD and MDE had dyspepsia (P < 0.001), vs. 19.2% (n = 42) with a single psychiatric diagnosis (P < 0.001), and 6.0% (n = 104) in those without psychiatric comorbidity. On multivariate analysis, having both GAD and MDE was significantly associated with higher prevalence of dyspepsia (Adjusted OR = 6.65, 95% CI: 3.35–13.21, P < 0.001) than having one psychiatric diagnosis (Adjusted OR = 3.62, 95% CI: 2.37–5.51, P < 0.001) and no psychiatric comorbidity.

Chronological relationship in the onset time of dyspepsia, GAD and MDE

In all, 28.6% of respondents with dyspepsia reported first onset of dyspeptic symptoms before age of 20. Current comorbidity with GAD was not significantly associated with early onset of dyspeptic symptoms (33.3% dyspeptic respondents with comorbid GAD vs. 31.3% without comorbid GAD, P = 1.0), nor was MDE comorbidity (31.4% MDE-comorbid vs. 31.9% non-MDE-comorbid dyspeptic respondents, P = 1.0).

For respondents with dyspepsia and MDE, 44.5% reported concomitant onset of the two disorders, 31.5% reported earlier onset of depression than dyspepsia, while 24% reported onset of dyspepsia before depression. For GAD-dyspepsia comorbid respondents, up to half (54%) of the respondents reported concomitant onset of the disorders, while 26.7% reported having dyspepsia first, 19.3% having GAD first. The vast majority (89.4%) of those with both GAD and MDE reported concomitant onset of GAD and MDE, while 7.8% and 2.8% of those had GAD and MDE first respectively.

To further examine the effect of order of onset of dyspepsia and mental disorders on occurrence of dyspepsia, prevalence of dyspepsia was compared between subjects with onset of mental disorders (GAD or MDE) preceding dyspepsia (To allow comparison, this group also comprised those with only mental disorders now, based on the assumption of future onset of dyspepsia) and those where onset of mental disorders did not precede dyspepsia. Dyspepsia was not more common in those with mental disorders preceding dyspepsia (7.7%) compared with those where mental disorders did not precede dyspepsia (8.0%, P = 0.87). On multivariate analysis that included all other sociodemographic factors, the association of precedent-onset mental disorders with dyspepsia remained insignificant (Adjusted OR = 0.83 95% CI: 0.47–1.45, P = 0.51).

Frequent medical consultations

Frequent medical consultations were, on univariate analysis, less common amongst male (M 10.9% vs. F 17.3%, P < 0.001) and students. It was more common amongst homemakers (Employed 14.9%, unemployed 14.1%, retired 17.1%, students 5%, homemakers 18.8%; P = 0.04).

Respondents with dyspepsia made significantly more frequent medical consultations than those with no dyspepsia (31.7% vs. 12.8%, P < 0.001). GAD and MDE were also associated with more frequent medical consultations (36.8% GAD vs. 13.5% non-GAD, P < 0.001; 30.4% MDE vs. 12.1% non-MDE, P < 0.001). Using multivariate analysis, dyspepsia (Adjusted OR = 2.48, 95% CI: 1.65–3.72 P < 0.001), MDE (Adjusted OR = 2.39, 95% CI: 1.64–3.46, P < 0.001), female gender (Adjusted OR = 1.65, 95% CI: 1.21–2.23, P < 0.001) were all found to be independent predictors of frequent medical consultations.

High investigation expenditure

In all, 14% of dyspeptic respondents vs. 9.4% of nondyspeptic respondents spent moderately [defined as more than HKD10000 (equivalent to USD 1289) on medical investigations over the past 5 years]. 3.2% dyspeptic vs. 1.3% nondyspeptic respondents had high investigation expenditure [defined as spending more than hkd 50 000 (equivalent to USD 6449) on medical investigations over the past 5 years]. There was a statistically nonsignificant trend of dyspepsia being associated with high investigation expenditure (P = 0.06). GAD (5.6% vs. 1.3%, P = 0.003), but not MDE (2.5% vs. 1.3%, P = 0.16), was associated with high investigation expenditure on univariate analysis. GAD was the only significant predictor of high investigation expenditure on multivariate analysis (Adjusted OR = 4.65, 95% CI: 1.15–18.70, P = 0.03).


  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  9. Supporting Information

We set out to determine the current prevalence of dyspepsia with stringent Rome III symptom criteria in a random, representative Chinese community sample. Participation rate was comparable to previous telephone health surveys.[26] We observed that dyspepsia was strongly associated and often had coincident onset with GAD and MDE in the community.

Direct comparisons for community prevalence of Rome III dyspepsia are sparse. Our conservative figure was, possible cross-national variation aside, consistent with the Rome III restrictiveness.[3] Omission of the 6-month onset requirement from Rome III criteria may explain the high prevalence of 20% in the Kalixanda study.[15] We found dyspepsia slightly more common in females, as in local and overseas data.[14, 15] Our GAD prevalence and sociodemographic correlates were consistent with extant community data, which were also similar to Western findings and a previous identically designed survey in Hong Kong.[26] The 12.4% MDE prevalence, reported previously, was higher than the 2007 figure of 8.5%, probably related to the 2008 global financial crisis.[28]

We found significant and independent association of dyspepsia with GAD and MDE as mental disorders. This is consistent with the reported association of anxiety symptoms with dyspepsia.[4, 15] The link with depression is more controversial. While we found a strong association between MDE and dyspepsia, even higher than that for GAD, the Kalixanda study found anxiety but not depression to be associated with dyspepsia.[15] This may be due to the inclusion of dyspepsia of shorter duration in the Kalixanda study, which may have a weaker association with depression than anxiety. In addition, the HADS depression subscale comprises only symptom scores over 1 week's duration and had no requirement for functional impairment, and therefore it was substantially less accurate than DSM-IV-TR MDE, which required 2 weeks of depressive symptoms causing significant functional impairment or marked distress (Table 3). Nonetheless, significant association between dyspepsia and depressive symptoms was noted in a previous local community survey using HADS and Rome II,[14] as well as a meta-analysis.[4] Future surveys on psychiatric comorbidity using standard diagnostic assessment will help clarify the relationship between dyspepsia and depression.

GAD and MDE were both more common in PDS, while only GAD was significantly more common in EPS. In view of the small sample size, between-group comparison would not be meaningful and as such should be examined in larger community samples.

Particularly salient was the finding that GAD and MDE, as mental disorders each having distinct biological and environmental aetiologies, were associated with dyspepsia. While cross-sectional studies map chronology poorly, our preliminary findings were that most of the comorbid subjects had coincident onset of mental disorders and dyspepsia, and that preceding mental disorders were not a significant risk factor for dyspepsia. Coincident-onset thus appears to be the predominant mode of comorbidity. This disputes the assertion of distress from dyspepsia itself totally explaining its association with depressive and anxiety features. It is also against the view of mental disorders ‘causing’ dyspepsia. Rather, the finding is consistent with neurophysiological findings that autonomic nervous system and hypothalamo-pituitary-adrenal axis derangements typical of anxiety disorders and depressive disorders[29] may alter gastrointestinal function.[30] It also concurs with evidence that onset of dyspeptic symptoms ‘behaves’ similarly as anxiety and depressive disorders as systemic reactions to major stressful life events.[31] This strong association between dyspepsia, GAD and MDE implies that mental disorders should be routinely screened during the assessment of patients with dyspepsia.

The stepwise increase in risk of dyspepsia with increased number of psychiatric diagnoses mirrors evidence from the psychosomatic literature that supports a dose-response link between somatic symptom load and psychopathology.[32] Studies with larger samples and detailed severity measures should confirm whether dyspeptic symptoms could predict level of psychiatric morbidity in a proportionate manner. Methodologically, this stresses the value of including both anxiety and depressive disorders when studying psychiatric comorbidity of medical disorders.

Psychiatric comorbidity seemed to have a complex impact on healthcare use. In this study, dyspepsia and MDE independently predicted frequent medical consultations while GAD predicted high investigation expenditure. The extent of somatic symptoms is unlikely to explain the difference, as patients with both GAD and MDE are associated with frequent physical complaints that would drive healthcare use.[32] Variances in doctor-patient interaction and cognitive factors may be other explanations. In particular, more than 70% of GAD sufferers have excessive health anxiety,[33] which may drive medical decisions into ordering more investigations. For MDE, medical consultations may be driven by the distinct distress and impairment in depression, and increased mental health literacy of patients regarding depression as an illness.

Our study has several limitations. First, endoscopy was not done. It is uncertain how strictly applied Rome III dyspepsia symptom criteria would predict lack of organicity. However, the subgroup of subjects with peptic ulcer disease and gastric ulcer is likely to be a small minority. Our previous endoscopy study in referred patients with dyspepsia found organicity in less than 10% of patients.[34] The Kalixanda study found no organicity in 77% of uninvestigated dyspepsia cases,[15] while a meta-analysis found positive endoscopy in 20% of dyspeptics, only 6% in Rome-defined dyspeptics.[35] Second, we did a brief telephone survey instead of a detailed face-to-face one. However, by avoiding face-to-face contact, telephone surveys may avoid psychiatric stigma, and facilitate disclosure of sensitive information.[36] This is critical for the Chinese for whom disclosing psychological distress may be culturally inhibited.[37] Third, other potentially important factors associated with dyspepsia were omitted owing to the need for brevity in a telephone survey, such as medication use. Fourth, recall bias and cross-sectional design limited the study of chronology. In particular, our analysis on order of onset and prevalence of dyspepsia had a clear limitation in assuming future onset of dyspepsia for those with only mental disorders currently, but such ‘comorbidity’ was not inevitable. The order of onset thus designated was limited by this assumption and any implications on causality need to be studied more rigorously in future prospective community studies. Fifth, the study was underpowered for multivariate analysis for variables associated with psychiatric comorbidity and healthcare utilisation in the dyspepsia subgroup. Future population-based studies using larger samples may endeavour to explore this area. Lastly, we assessed current prevalence of dyspepsia and 12-month prevalence of GAD and MDE so as to render the findings comparable to other community surveys. It should be noted that this approach may somewhat inflate the prevalence figures for the mental disorders relative to that of dyspepsia.

In conclusion, we found Rome III dyspepsia to be common and strongly associated with MDE and GAD as mental disorders, with substantial impact on healthcare use in the community. The implications are that one, mental disorders should be routinely screened in assessing dyspepsia, especially those exhibiting high levels of healthcare use. Two, clinicians treating dyspepsia with comorbid GAD or MDE should regard help-seeking behaviour as a salient part of illness experience. Instead of routinely discouraging unnecessary consultations or investigations, holistic and effective approaches in treating these complexly ill individuals may do their health better while reducing unnecessary expenses. Collaborative psychosomatic care involving gastroenterologists and mental health professionals may address this. Lastly, prospective research is needed on courses of dyspepsia and comorbid mental disorders, as well as translational research in such light.


  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  9. Supporting Information

Declaration of personal interests: Dr Arthur Mak is supported by an educational grant of Pfizer Pharmaceutical. Dr Justin Wu is supported by research funds of Department of Medicine & Therapeutics and educational grant of Pfizer Pharmaceutical. Dr Sing Lee received educational grants on mental health education from Pfizer Pharmaceuticals, GlaxoSmithkline, Wyeth Pharmaceuticals and Johnson & Johnson Pharmaceuticals. Declaration of funding interests: None.


  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  9. Supporting Information
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Supporting Information

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  9. Supporting Information
apt12036-sup-0001-AppendixS1.docxWord document12KAppendix S1. Comparison of study sample composition and 2008 Hong Kong Census population data, and weighting factor applied.

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