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Summary

  1. Top of page
  2. Summary
  3. Introduction
  4. Subjects and methods
  5. Study patients
  6. Questionnaire
  7. General Health Questionnaire
  8. Diagnostic examinations
  9. Organic and functional dyspepsia
  10. Sample of the Finnish general population
  11. Data analysis and statistics
  12. Results
  13. Discussion
  14. Acknowledgements
  15. References

Background : It has been argued that patients with functional gastrointestinal disorders have mental disorders more often than healthy controls and patients with organic disease. Most studies surveying psychological factors at the population level have relied on symptom questionnaires to diagnose functional dyspepsia. However, the symptom patterns alone are unable to adequately discriminate organic from functional dyspepsia.

Aim : To evaluate the frequency of mental distress in primary care patients with organic or functional dyspepsia and compare the findings with a sample of the Finnish general population.

Methods : Four-hundred consecutive, unselected dyspeptic patients were referred for upper gastrointestinal endoscopy and other diagnostic examinations. All patients compiled a self-administered questionnaire including the 12-item General Health Questionnaire to detect cases of recent mental disorders.

Results : The prevalence of mental distress among patients with functional and organic dyspepsia was 38 and 36.4% respectively. The sex- and age-adjusted risk of having mental distress was nearly fourfold higher among patients with dyspepsia than in the general population.

Conclusion : Mental distress is common among patients with functional or organic dyspepsia. Nevertheless, there is no difference between patients with functional or organic dyspepsia in the prevalence or risk of mental distress.


Introduction

  1. Top of page
  2. Summary
  3. Introduction
  4. Subjects and methods
  5. Study patients
  6. Questionnaire
  7. General Health Questionnaire
  8. Diagnostic examinations
  9. Organic and functional dyspepsia
  10. Sample of the Finnish general population
  11. Data analysis and statistics
  12. Results
  13. Discussion
  14. Acknowledgements
  15. References

Functional gastrointestinal disorders (FGIDs), including functional dyspepsia (FD) and irritable bowel syndrome (IBS) represent chronic or recurrent symptoms referable to the gastrointestinal tract without biochemical or structural cause.1 They are the most frequent conditions seen in gastroenterology practice and constitute a significant portion of primary care visits.2, 3 National surveys in western countries have estimated that the prevalence of one or more FGIDs is 62–69%.4, 5 Although not life-threatening, the symptoms are long-lasting.6, 7 They interfere with daily activities and have a significant impact upon the quality of life and increased medical costs.8, 9

It has been argued that 42–61% of FGID patients in gastroenterology clinics compared with 25% of healthy controls meet the criteria for psychiatric diagnoses, usually anxiety or depression.10 A similarly higher prevalence of psychiatric morbidity has been found in studies conducted in tertiary centres comparing FD patients with those having organic gastrointestinal (GI) disease,11, 12 but not all studies agree.13, 14 Psychiatric disorders and personality traits, namely emotionality, somatization, neuroticism, anxiety and depression are more prevalent among FGID patients who seek health care and those with severe and refractory symptoms.15–18 On the contrary, volunteer studies comparing people with IBS who have not seen a physician with healthy community controls have shown no psychological difference between the two groups.19, 20 Whether there is a specific link between psychological factors and functional GI disorders or whether the latter simply alters illness behaviour is uncertain.

Only a few published studies have examined psychological factors in FD at the community or population level.16–18, 21–24 Most studies investigating mental disorders in FGID have examined patients with IBS. Furthermore, the diagnosis of FD in most of these studies has relied upon symptom-based questionnaires compiled via telephone interviews or by mail or clinical examination. However, the symptom patterns alone are unable to adequately discriminate organic dyspepsia from FD.25, 26 In this study, we aimed to evaluate the frequency of mental distress at the onset of dyspeptic symptoms in thoroughly investigated, unselected, consecutive, primary care patients with organic dyspepsia or FD and compare the findings with a sample of the Finnish general population.

Study patients

  1. Top of page
  2. Summary
  3. Introduction
  4. Subjects and methods
  5. Study patients
  6. Questionnaire
  7. General Health Questionnaire
  8. Diagnostic examinations
  9. Organic and functional dyspepsia
  10. Sample of the Finnish general population
  11. Data analysis and statistics
  12. Results
  13. Discussion
  14. Acknowledgements
  15. References

Four hundred and eleven consecutive, unselected dyspeptic patients were referred to the study from four health centres in eastern Finland. Dyspepsia was defined as upper abdominal or retrosternal pain, discomfort, heartburn, nausea, vomiting or other symptoms considered to arise from the upper GI tract.27 Patients with acute abdominal symptoms and patients with upper GI endoscopy performed within 3 months were not included in the study. Eleven patients refused to participate. The final sample, therefore, included 400 subjects with dyspepsia, of whom 151 were men and 249 women. The mean age of men was higher (58.6 years, s.d. 15.5; range 15–86) than that of women (53.8 years, s.d. 14.8, range 19–84; P = 0.002). All patients were enrolled between January 1993 and January 1994.

Questionnaire

  1. Top of page
  2. Summary
  3. Introduction
  4. Subjects and methods
  5. Study patients
  6. Questionnaire
  7. General Health Questionnaire
  8. Diagnostic examinations
  9. Organic and functional dyspepsia
  10. Sample of the Finnish general population
  11. Data analysis and statistics
  12. Results
  13. Discussion
  14. Acknowledgements
  15. References

All patients completed a self-administered questionnaire before diagnostic examination. A modified version of the previously validated Bowel Disease Questionnaire was used.28

General Health Questionnaire

  1. Top of page
  2. Summary
  3. Introduction
  4. Subjects and methods
  5. Study patients
  6. Questionnaire
  7. General Health Questionnaire
  8. Diagnostic examinations
  9. Organic and functional dyspepsia
  10. Sample of the Finnish general population
  11. Data analysis and statistics
  12. Results
  13. Discussion
  14. Acknowledgements
  15. References

The questionnaire also included the 12-item General Health Questionnaire (GHQ-12), which was developed in the early 1970s with the aim of devising an instrument to detect cases of recent mental disorders, mostly anxiety and depression. It is not a suitable instrument to detect long-term personality disorders, but it does identify psychotic disorders rather well.29 The GHQ-12 gives a total score between 0 and 12. A cut-off point of 3/4 has recently been suggested to be optimal for screening mental disorders in the Finnish population,30 and we used the same cut-off point in this study. Cronbach's alpha for the GHQ-12 was 0.80 in our study sample and 0.83 in the sample of the general population. The figures indicate good internal consistency of the scale. In this study, we use the term ‘mental distress’ to describe those who had a GHQ-12 score of 4 or more.

Diagnostic examinations

  1. Top of page
  2. Summary
  3. Introduction
  4. Subjects and methods
  5. Study patients
  6. Questionnaire
  7. General Health Questionnaire
  8. Diagnostic examinations
  9. Organic and functional dyspepsia
  10. Sample of the Finnish general population
  11. Data analysis and statistics
  12. Results
  13. Discussion
  14. Acknowledgements
  15. References

Upper GI endoscopy with biopsies, upper abdominal ultrasound and laboratory tests (B-count, S-alanine aminotransferase, S-alkaline phosphatase, S-amylase, C-reactive protein and a lactose absorption test) were performed on every patient within 1 week. No selection tests, for example, Helicobacter screening, were used for gastroscopy.

Organic and functional dyspepsia

  1. Top of page
  2. Summary
  3. Introduction
  4. Subjects and methods
  5. Study patients
  6. Questionnaire
  7. General Health Questionnaire
  8. Diagnostic examinations
  9. Organic and functional dyspepsia
  10. Sample of the Finnish general population
  11. Data analysis and statistics
  12. Results
  13. Discussion
  14. Acknowledgements
  15. References

A diagnosis of organic dyspepsia was made in 195 patients after the above investigations and after a follow-up of at least 1 year. The criteria for final organic diagnoses have been reported in detail elsewhere.2 Diagnoses are presented in Table 1. The diagnosis of FD was established after the negative diagnostic work up in 205 patients.

Table 1.  Final diagnoses (n = 400) among consecutive primary care patients with dyspepsia determined after investigations and at least 12 months of follow-up
Diagnosisn (%)
  1. * Oesophagitis or pathologic pH monitoring.

Gastro-oesophageal reflux disease*70 (17.5)
Peptic ulcer51 (13)
Lactose intolerance35 (9)
Gallstone disease9 (2)
Erosive duodenitis8 (2)
Malignancy7 (2)
Giardiasis5 (1)
Coeliac disease2 (0.5)
Other organic diseases8 (2)
Functional dyspepsia205 (51)
Total400 (100)

Sample of the Finnish general population

  1. Top of page
  2. Summary
  3. Introduction
  4. Subjects and methods
  5. Study patients
  6. Questionnaire
  7. General Health Questionnaire
  8. Diagnostic examinations
  9. Organic and functional dyspepsia
  10. Sample of the Finnish general population
  11. Data analysis and statistics
  12. Results
  13. Discussion
  14. Acknowledgements
  15. References

A stratified sample (n = 1906) was chosen from the Central Population Register to represent individuals aged 18–74 years living permanently in Finland. The study subjects were telephone-interviewed in May 1993 by Statistics Finland. Those subjects for whom a telephone number could not be found (7%) were interviewed personally, face-to-face. The overall response rate was 81.7% (n = 1557). All interviews included the GHQ-12. Five cases had to be excluded because of missing data. The final sample (n = 1552) included 783 women and 769 men. The exclusions were few and are not believed to have distorted the sample or results.

Data analysis and statistics

  1. Top of page
  2. Summary
  3. Introduction
  4. Subjects and methods
  5. Study patients
  6. Questionnaire
  7. General Health Questionnaire
  8. Diagnostic examinations
  9. Organic and functional dyspepsia
  10. Sample of the Finnish general population
  11. Data analysis and statistics
  12. Results
  13. Discussion
  14. Acknowledgements
  15. References

Data analyses were conducted using SPSS for Windows version 12.0.1. Differences between the groups with functional or organic dyspepsia were evaluated using the chi-squared test, Student's t-test and Mann–Whitney U-test. The risk of having mental distress was calculated with forced sex- and age-adjusted logistic regression models. Comparisons were made between patients with dyspepsia and the sample of general population and also between patients with FD and organic dyspepsia. P-values <0.05 were considered statistically significant.

Results

  1. Top of page
  2. Summary
  3. Introduction
  4. Subjects and methods
  5. Study patients
  6. Questionnaire
  7. General Health Questionnaire
  8. Diagnostic examinations
  9. Organic and functional dyspepsia
  10. Sample of the Finnish general population
  11. Data analysis and statistics
  12. Results
  13. Discussion
  14. Acknowledgements
  15. References

There were 195 patients with organic dyspepsia in the sample. The mean GHQ-12 score among them was 3.6 (s.d. 4.4) and the proportion of those with mental distress was 36.4%. Among those with FD (n = 205) the figures were similar [3.6 (s.d. 4.0) and 38.0% respectively].

There were more women among the patients with FD than among those with organic dyspepsia [141 (68.8%) vs. 108 (55.4%); P =  0.006]. No statistically significant differences were found in the mean GHQ-12 score between men and women among patients with either organic dyspepsia or FD. Neither was there any statistically significant difference in the frequency of mental distress between men and women in these groups. Contrary to patients with dyspepsia, the mean GHQ-12 score was significantly higher in women than in men among the general population subjects (Table 2).

Table 2.  Frequency of mental distress (GHQ-12 score ≥4) and mean GHQ-12 score in patients with dyspepsia and in a sample of the Finnish general population
 Mental distressGHQ-12 score
Men [n (%)]Women [n (%)]P-value*Men [mean (s.d.)]Women [mean (s.d.)]P-value†
  1. * Chi-squared test.

  2. † Mann–Whitney U-test.

Patients with dyspepsia
 Total49 (32.5)100 (40.2)0.123.2 (3.7)3.9 (4.4)0.20
 Organic28 (32.2)43 (39.8)0.273.1 (3.5)3.3 (4.0)0.36
 Functional21 (32.8)57 (40.4)0.303.3 (4.0)3.7 (3.9)0.36
Sample of general population93 (11.8)115 (14.9)0.081.1 (2.1)1.4 (2.3)<0.001

Mental distress was more common among patients with dyspepsia than in the sample of the general population (36.5% vs. 15.0%, P < 0.001). This difference was highly significant among both men (28.4% vs. 11.9%, P < 0.001) and women (36.6% vs. 14.8%, P < 0.001). The sex- and age-adjusted risk of having mental distress was nearly fourfold higher among patients with dyspepsia than the general population subjects. When analysed by gender, the age-adjusted risk of having mental distress was over threefold increased in both men and women with dyspepsia (Table 3). Those with FD did not have a higher risk of mental distress than those with organic dyspepsia (sex- and age-adjusted OR 1.04, 95% CI 0.69–1.58).

Table 3.  The risk of having mental distress in patients with dyspepsia as compared with a sample of the Finnish general population
 Odds ratio (95% confidence interval)
TotalMenWomen
Crude3.85 (3.00–4.94)3.58 (2.39–5.35)3.83 (2.78–5.28)
Age-adjusted3.91 (2.58–5.12)3.78 (2.47–5.79)3.81 (2.67–5.42)
Sex- and age-adjusted3.83 (2.91–5.01)

Discussion

  1. Top of page
  2. Summary
  3. Introduction
  4. Subjects and methods
  5. Study patients
  6. Questionnaire
  7. General Health Questionnaire
  8. Diagnostic examinations
  9. Organic and functional dyspepsia
  10. Sample of the Finnish general population
  11. Data analysis and statistics
  12. Results
  13. Discussion
  14. Acknowledgements
  15. References

Among consecutive, unselected primary care patients with FD or organic dyspepsia, mental distress was significantly more common than in a sample representing the general population. The sex- and age-adjusted risk of having mental distress was nearly fourfold increased. However, the risk of mental distress among patients with FD was not higher than among those with organic disease.

In contrast to most previous studies conducted at the community or primary care level, the diagnosis of either FD or organic dyspepsia in this study did not rely on clinical evaluation or a questionnaire. A large number of patients were thoroughly investigated. Endoscopy with biopsies, laboratory tests, upper abdominal ultrasound and questionnaires, including the GHQ, were performed within 1 week on every patient. The diagnosis of either organic dyspepsia or FD was established only after a follow-up of at least 1 year. The proximity of the evaluation of mental distress at the onset of symptoms allows us to weigh the association between psychological factors and dyspepsia, especially FD. We acknowledge the fact that the evaluation of mental distress as measured by the short GHQ is limited to screening purposes. It is not suitable for assessing personality factors. The screening properties, however, are similar to the longer GHQ-36 and SCL-90 and the optimal cut-off value for this purpose has recently been validated in Finland.30 As we studied all presenting consecutive patients with dyspepsia, the design of the study does not allow us to estimate the role of mental distress in health-care seeking.

Earlier published data have revealed high levels of psychiatric morbidity among patients with FD or IBS. Among gastroenterology clinic patients, the prevalence of psychiatric disorders varied between 65 and 87%. Life-time psychiatric diagnoses exceeding even these figures have been reported.11, 12, 15 These patients, however, are likely to have refractory and more difficult disease and are thus prone to selection bias. Psychological distress measured by the GHQ is present in 45–50% of symptomatic primary care or community FGID patients.21, 24 In these studies, the diagnosis of FD is based on symptoms or clinical examination, yet the symptom patterns do not reliably exclude organic disease.25, 26 Prior studies comparing psychiatric morbidity among patients with or without organic cause have produced conflicting results. In some studies, contrary to our findings, gastroenterology clinic patients with FD have been found to significantly more often fulfill the criteria for psychiatric diagnoses than their organic counterparts and also to receive higher scores in psychometric testing.11, 12 In other studies, similar to our findings, tertiary centre FD and IBS patients, while clearly distinct from healthy controls, have had similar personality, anxiety and depression scores compared with patients with duodenal ulcers.13, 14

We conclude that mental distress is common in patients with both FD and organic dyspepsia and should be taken into account when treating these patients. The finding that the frequency of mental distress is the same among patients with organic dyspepsia and FD indicates that mental distress may be a non-specific response to GI symptoms. Similarly, no difference in psychiatric morbidity was found in a study comparing chest pain patients with and without coronary disease.31 Finally, as we studied consecutive, unselected primary care patients, the results are directly applicable to clinical practices.

Acknowledgements

  1. Top of page
  2. Summary
  3. Introduction
  4. Subjects and methods
  5. Study patients
  6. Questionnaire
  7. General Health Questionnaire
  8. Diagnostic examinations
  9. Organic and functional dyspepsia
  10. Sample of the Finnish general population
  11. Data analysis and statistics
  12. Results
  13. Discussion
  14. Acknowledgements
  15. References

The authors thank Osmo Kontula, Heimo Viinamaki and Kaj Koskela (†) for permission to use the sample of Finnish general population which was collected under their supervision.

References

  1. Top of page
  2. Summary
  3. Introduction
  4. Subjects and methods
  5. Study patients
  6. Questionnaire
  7. General Health Questionnaire
  8. Diagnostic examinations
  9. Organic and functional dyspepsia
  10. Sample of the Finnish general population
  11. Data analysis and statistics
  12. Results
  13. Discussion
  14. Acknowledgements
  15. References
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