We read with interest the article by Mak et al.[1] The authors have provided some of the first stringent data linking psychological distress and functional dyspepsia (FD) defined by Rome III criteria. We suggest, however, that the authors' assertion that coincident onset between major depressive episodes and generalised anxiety disorder and FD is probably premature.

We reiterate the authors' point that making causal inferences from cross-sectional data is problematic. Participants in this study were asked for their respective ages when each disorder first came on in their lives, to estimate the chronological association of the disorders. This life-time self-report approach has the potential to be fraught with recall or ‘memory’ bias, with evidence that recall for gastrointestinal (GI) symptoms beyond 1 year is prone to respondent error.[2]

This study may also have been confounded by the phenomenon of ‘effort after meaning’, whereby ill people tend to seek a reason for their illness, such as from a stressful event, which in turn may have resulted in psychological distress.[3] Somatisation, health anxiety and abuse are known to be high in FD[4, 5] and are also important to consider as they may have promoted selective attention on GI symptoms at the time of onset.[6] Moreover, the exact dating of illness onset via self-report in FD is difficult, and there is emerging evidence that there may be changes on a biological level that happen before the symptoms are actually noticed and reported.[7]

The most recent prospective evidence supports a brain-gut hypothesis in FD.[8, 9] In a 12-year prospective population-based study, we found higher levels of depression, but not anxiety, at baseline were predictive of Rome II FD at follow-up.[9] Only further prospective population-based studies will disentangle the association between anxiety and depression and FD.


  1. Top of page
  2. Acknowledgement
  3. References

Declaration of personal and funding interests: None.


  1. Top of page
  2. Acknowledgement
  3. References
  • 1
    Mak AD, Wu JCY, Chan FKL, et al. Dyspepsia is strongly associated with major depression and generalized anxiety disorder – a community study. Aliment Pharmacol Ther 2012; 36: 80010.
  • 2
    Sobieraj DM, Coleman SM, Coleman CI. US prevalence of upper gastrointestinal symptoms: a systematic literature review. Am J Manag Care 2011; 17: e44958.
  • 3
    Creed FH. Psychosocial stress in pregnancy. Br Med J 1979; 2: 9345.
  • 4
    Quadri A, Vakil N. Health-related anxiety and the effect of open-access endoscopy in US patients with dyspepsia. Aliment Pharmacol Ther 2003; 17: 83540.
  • 5
    Van Oudenhove L, Vandenberghe J, Vos R, et al. Abuse history, depression, and somatization are associated with gastric sensitivity and gastric emptying in functional dyspepsia. Psychosom Med 2011; 73: 64855.
  • 6
    Haenen MA, Schmidt AJ, Kroeze S, Hout MA. Hypochondriasis and symptom reporting – the effect of attention versus distraction. Psychother Psychosom 1996; 65: 438.
  • 7
    Kwang JL, Tack J. Duodenal implications in the pathophysiology of functional dyspepsia. J Neurogastroenterol Motil 2010; 16: 2517.
  • 8
    Koloski NA, Talley NJ, Boyce PM. Does psychological distress modulate functional gastrointestinal symptoms and health care seeking? A prospective community cohort study. Am J Gastroenterol 2003; 98: 78997.
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  • 9
    Koloski NA, Jones M, Kalantar JS, Weltman M, Talley NJ. The brain-gut pathway in functional gastrointestinal disorders is bidirectional: a 12-year prospective population-based study. Gut 2012; 61: 128490.