Prevalence of anxiety disorders among visitors at a military primary health center in UAE

ABSTRACT

Background:

Anxiety disorders are common. However, individuals suffering from anxiety disorders often do not seek treatment. These disorders impose a high individual and societal burden, especially on military personnel and their families, and place a significant burden on healthcare systems as care is often sought from primary care physicians rather than specialized professionals. This study was undertaken to determine the prevalence and correlates of anxiety among visitors at a Military Primary Health Center.

Results:

Anxiety disorders were high in our study population. Generalized Anxiety Disorder (GAD) was the most common, while social phobia was less prevalent. 72.5% were 18-40 years old and 63.5% were males. 68% were military personnel, 23% were military personnel family, and the rest were retired. The most common symptoms were sleep disturbances (60.4%), irritability (55%), and restlessness (51.4%). GAD, specific phobia, and panic disorder were more likely in divorced people, and chronic diseases were more likely in people suffering from GAD.

Conclusions:

The prevalence of anxiety disorders was considerably higher among visitors at a Military Primary Health Center due to the high stress levels and occupational difficulties associated with an unstable social and family life. Counseling services and follow-up of diagnosed cases should be available at the primary health care level for improved healthcare delivery by the primary care or family health physicians.

Background

Anxiety disorders are the most common psychiatric disorders. However, only a small proportion of patients with anxiety disorders (less than 30%) receive treatment.[1] Anxiety disorders impose high individual and social burdens, are often chronic, and can be as disabling as somatic disorders.[2] Compared to those with other psychiatric disorders, people with anxiety disorders are high utilizers of healthcare services and present to their primary care providers more frequently than psychiatric professionals, placing a strain on the healthcare system. The economic costs of anxiety disorders are substantial and include psychiatric, non-psychiatric, emergency care, hospitalization, prescription drugs, reduced productivity, absenteeism from work, and suicide.[3] The total cost of anxiety disorders in some countries has been estimated to be in the billions of dollars.[4,5]

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), anxiety disorders include disorders that share features of excessive fear and anxiety and related behavioral disturbances. The diagnoses of the disorders with four anxiety subtypes including GAD, panic disorder, and social and specific phobia were based on the DSM-V criteria.[5,6] Anxiety disorders appear to be caused by an interaction of biopsychosocial factors, including genetic vulnerability, which interacts with situations, stress, or trauma to produce clinically significant syndromes.[7]

In the UAE, a study performed in 2001 at the community level for mental health highlighted that the prevalence of GAD, social phobia, specific phobia, and panic disorder was less than 1%.[8] However, the underlying factors and the dynamics of anxiety in the military personnel and their families are expected to be vastly different due to different lifestyles and a deviation from the typical family norms and functioning.[9] The present study focused on anxiety-related disorders and determined their prevalence and correlates among visitors at a military Health Care Center in Abu Dhabi, UAE.

Materials and Methods

Study design and sample size

This cross-sectional study, focusing on outpatients, was conducted at Zayed Military Primary Health Care Center. The target population consisted of adults above the age of 18 years. Exclusion criteria were applied to those individuals who lacked proficiency in either Arabic or English. Written informed consent was obtained from all participants before their enrollment. With a 95% confidence interval and a 5% margin of error, the sample size was determined to be 353 participants.

Study questionnaire

To assess anxiety disorders, our research employed a self-administered anxiety disorder diagnostic questionnaire (ADDQ) that was designed based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). The questionnaire was professionally translated into Arabic. It comprised three sections: sociodemographic profile (consisting of eight questions), biopsychosocial history (containing 12 questions), and anxiety diagnostic questionnaire (including eight questions). Sociodemographic variables inquired about age, gender, nationality, education level, occupation, marital status, number of children, and monthly income. The biopsychosocial history section addressed chronic medical conditions, personal and familial anxiety histories, stress history, and social/behavioral history (such as exercise, smoking, alcohol, drugs, and social activities). The anxiety diagnostic questionnaire probed symptoms related to specific phobias, social phobias, panic disorders, and GADs. Additionally, it assessed the severity and impact of these disorders on individuals’ social and occupational functioning. Participants were recruited through a convenience sampling procedure, and the questionnaires were disseminated by research assistants at the Military Primary Health Care Center, who were available to address any questions or concerns. Confidentiality was ensured through anonymity, as the questionnaire obtained no identifying data. Completed questionnaires were collected in designated boxes. Versions of the questionnaire were available in both Arabic and English. A pilot study assessed the questionnaire’s reliability, confirming its adequacy for the main study.

Statistical analysis

Descriptive statistics, including means and standard deviations for continuous variables and frequencies and percentages for categorical variables, were utilized for data analysis. Proportions of anxiety disorders among different groups were compared using Chi-square tests. Statistical significance was set at a P- value of ≤0.05 for all analyses. The analytical procedures were performed using SPSS version 25 (IBM Corp, New York, USA).

Ethical considerations

Approval for this research was granted by the Ethics and Research Committee at Zayed Military Hospital, Abu Dhabi. The research team strictly adhered to principles of confidentiality and privacy. Coding was utilized to ensure the anonymity of the participant’s data in all research documentation. Access to data was strictly limited to the research team, and all data of this study was de-identified.

Results

Sociodemographic characteristics

The study sample was composed of 72.5% of respondents between the ages of 18 and 40, with a majority of males (63.5%). The majority of respondents were UAE nationals (82.4%) with a middle income (55.8%). Most of the respondents had a university degree (42.9%), were married (70.7%), and had 3 to 5 children (43.7%). Approximately 32.5% of respondents had two or fewer children, and an almost equal number had more than five children Table 1.

Table 1.

Sociodemographic characteristics of the study sample

Characteristic	No	(%)
Age (n=349)
18 – 40 years	253	-72.5
41 – 60 years	90	-25.8
>60 years	6	-1.7
Gender (n=353)
Male	224	-63.5
Female	129	-36.5
Nationality (n=352)
UAE	290	-82.4
Non-UAE	62	-17.6
Education (n=350)
Primary school	12	-3.4
Middle school	43	-12.3
Secondary school	145	-41.4
University and above	150	-42.9
Marital status (n=348)
Married	246	70.7)
Single	88	-25.3
Divorced	9	-2.6
Widowed	5	-1.4
No of children (n=252)
2 or less	82	-32.5
3 – 5	110	-43.7
More than 5	60	-23.8
Income (n=344)
Insufficient (≤ 15000AED)	98	-28.5
Sufficient (15000-30000)	192	-55.8
Sufficient and saving ≥30000	54	-15.7

Of the 303 respondents, 68% were active-duty military personnel, 23% were civilians (including family members of military personnel), 7% were retired military personnel, and 2% were students Figure 1.

Figure 1.

Occupation of the study participants (n = 303)

Of the 47 family members of military personnel, 49% were either employed or unemployed, while 11% were self-employed [Figure 2]. Of these self-employed individuals, 20% were health care providers.

Figure 2.

Occupation of family member participants (n = 47)

Seventy-five percent of the respondents suffered from one or the other chronic disease. 15% of the respondents had hypertension and 12.5% had diabetes mellitus Figure 3.

Figure 3.

Comorbidities among the study sample (n = 351)

11.1% reported a personal history of anxiety disorders or a family history of anxiety. Additionally, more than half of the respondents (54.2%) reported experiencing various stressors at home or work, with the majority (74.4%) lasting for more than 6 months Figure 4.

Figure 4.

Personal (n = 352) and family history (n = 349) of anxiety among the study sample

Of the study sample, 21.9% were regular smokers, 4.5% were occasional smokers, 1.1% were regular drinkers, 1.4% were occasional drinkers, 2.0% consumed drugs regularly, and 1.1% were occasional drug abusers Figure 5.

Figure 5.

Substance use among study sample (n = 351)

Of the 351 participants, 47.6% reported engaging in regular exercise, and 50.7% reported engaging in social activities such as pursuing hobbies and meeting with friends on a regular basis Figure 6.

Figure 6.

Exercise and social activities among study sample (n = 351)

The most prevalent clinically diagnosed anxiety disorders among the study sample were GAD (11.9%), panic disorder (8.0%), specific phobia (6.5%), and social phobia (5.4%) Figure 7.

Figure 7.

Different types of anxiety disorders among study sample (n = 352)

The most common symptom of anxiety disorder was sleep disturbance (60.4%) followed by irritability (55%) and restlessness (51.4%). Hot flashes (18%) and numbness (20.7%) were the least common symptoms Figure 8.

Figure 8.

Physical symptoms associated with anxiety disorder

Of those with a clinically diagnosed anxiety disorder, 38.1% reported that their social life was affected moderately, 13.6% reported that it was severely affected, and 20.3% reported that it was severely very affected [Figure 9].

Figure 9.

Effect of anxiety disorders on social life among study sample (n = 118)

Of the participants, 45.3% reported moderate anxiety disorders, 26.5% reported mild anxiety disorders, and 16.2% reported severe anxiety disorders [see Figure 10].

Figure 10.

Severity rate of anxiety disorders among study sample (n = 117)

Table 2 shows that none of the anxiety disorders were statistically significantly associated with age.

Table 2.

Distribution of different types of anxiety disorder among different age groups

	Specific phobia			Social phobia			Panic disorder			GAD
	No.	(%)	P	No.	(%)	P	No.	(%)	P	No.	(%)	P
Age
18 – 40 years	17	6.7	0.806	18	7.1	0.085	22	8.7	0.867	31	12.3	0.657
41 – 60 years	6	6.7		1	1.1		6	6.7		11	12.4
> 60 years	0	0		0	0		0	0		0	0

Table 3 presents the prevalence of anxiety disorders among males and females. There was no significant difference between males and females for any anxiety disorder, except for panic disorder and generalized anxiety disorder (GAD), for which the prevalence was significantly higher in females (12.5% and 16.4%, respectively) than in males (5.4% and 9.4%, respectively). The prevalence of specific and social phobias was also higher in females (9.4% and 5.5%, respectively) than in males (4.9% and 5.4%, respectively), but these differences did not reach statistical significance.

Table 3.

Distribution of different types of anxiety disorder as per gender

	Specific phobia			Social phobia			Panic disorder			GAD
	No.	(%)	P	No.	(%)	P	No.	(%)	P	No.	(%)	P
Gender
Male	11	4.9	0.103	12	5.4	0.964	12	5.4	0.045	21	9.4	0.05
Female	12	9.4		7	5.5		16	12.5		21	16.4

Table 4 shows that divorced individuals had a higher prevalence of GAD (33.3%), specific phobia (11.1%), and panic disorder (11.1%) than individuals in other marital status groups. Social phobia was found to be equal (5.7%) in married and single individuals. However, these results were not statistically significant.

Table 4.

Distribution of different types of anxiety disorder as per marital status

	Specific phobia			Social phobia			Panic disorder			GAD
	No.	(%)	P	No.	(%)	P	No.	(%)	P	No.	(%)	P
Marital status
Married	14	5.7	0.606	14	5.7	0.839	19	7.8	0.72	28	11.4	0.202
Single	8	9.1		5	5.7		8	9.1		11	12.5
Divorced	1	11.1		0	0		1	11.1		3	33.3
Widow	0	0		0	0		0	0		0	0

Table 5 shows that the prevalence of GAD and panic disorder was higher among those with insufficient income (18.6% and 12.4%, respectively). However, the prevalence of specific phobia and social phobia was equally higher among those with sufficient and saving income. However, the results were not statistically significant.

Table 5.

Distribution of different types of anxiety disorder as per income

	Specific phobia			Social phobia			Panic disorder			GAD
	No.	(%)	P	No.	(%)	P	No.	(%)	P	No.	(%)	P
Income
Insufficient income	7	7.1		3	3.1		12	12.4		18	18.6
Sufficient	10	5.2	0.507	11	5.7	0.259	13	6.8	0.072	19	9.9	0.081
Sufficient income with savings	5	9.4		5	9.4		3	5.6		5	9.3

Table 6 shows that the prevalence of anxiety disorders is higher among those with chronic diseases. Specifically, respondents with GAD were more likely to have a chronic disease (21.6%). While those with specific phobia (10.2%), social phobia (9.1%), and panic disorder (8.0%) did not show a significant relationship with underlying chronic diseases.

Table 6.

Distribution of different types of anxiety disorder among those with chronic diseases

	Specific phobia			Social phobia			Panic disorder			GAD
	No.	(%)	P	No.	(%)	P	No.	(%)	P	No.	(%)	P
Chronic Diseases
Yes	9	10.2		8	9.1	0.077	7	8		19	21.6
No	14	5.3	0.105	11	4.2		21	8	0.222	23	8.7	0.001

Table 7 indicates that a history of anxiety disorders is associated with a higher prevalence of GAD (33.3%), followed by panic disorder (20.5%) and social phobia (12.8%). In contrast, the relationship between specific phobia (7.7%) and a family history or personal history of anxiety disorders is not significant.

Table 7.

Distribution of different types of anxiety disorders among patients with previous history of anxiety

	Specific phobia			Social phobia			Panic disorder			GAD
	No.	(%)	P	No.	(%)	P	No.	(%)	P	No.	(%)	P
Previous H/o anxiety
Yes	3	7.7	0.76	5	12.8	0.021	8	20.5	0.009	13	33.3	0
No	20	6.4		13	4.2		20	6.4		28	9

Table 8 shows that a higher prevalence of all anxiety disorders, including GAD (37.5%), panic disorder (20%), and social phobia (12.5%), is observed among individuals with a family history of anxiety.

Table 8.

Distribution of different types of anxiety disorders among patients with family history of anxiety

	Specific phobia			Social phobia			Panic disorder			GAD
	No.	(%)	P	No.	(%)	P	No.	(%)	P	No.	(%)	P
Family history of anxiety
Yes	5	12.5	0.068	5	12.5	0.018	8	20	0	15	37.5	0
No	16	5.2		12	3.9		19	6.2		26	8.4

Table 9 shows that individuals with stress had the highest prevalence of GAD (33.7%), followed by panic disorder (23.3%), social phobia (12.9%), and specific phobia (10.6%). These results were statistically significant, except for specific phobia.

Table 9.

Distribution of different types of anxiety disorders among patients with stress

	Specific phobia			Social phobia			Panic disorder			GAD
	No.	(%)	P	No.	(%)	P	No.	(%)	P	No.	(%)	P
Stress
Yes	9	10.6	0.084	11	12.9	0	20	23.3	0	29	33.7	0
No	14	5.3		8	3		8	3		13	4.9

As shown in Table 10, home was the most stressful place, followed by work. The prevalence of GAD at home was 43.2%, while the prevalence of panic disorder was 37.8%. Social phobia and specific phobia were equally prevalent at home (16.7%). At work, the prevalence of GAD was 16.2%, while the prevalence of panic disorder was 13.5%. The prevalence of social phobia and specific phobia at work was 8.1%. The results of the prevalence of panic disorder depending on the stressor environment were statistically significant; however, for the other types of anxiety disorders, they were not.

Table 10.

Distribution of different types of anxiety disorder in different stressors like home, work environment

	Specific phobia			Social phobia			Panic disorder			GAD
	No.	(%)	P	No.	(%)	P	No.	(%)	P	No.	(%)	P
Stress place
At home	6	16.7	0.138	6	16.7	0.847	14	37.8	0.014	16	43.2	0.078
Work	3	8.1		5	13.5		6	16.2		7	18.9
Social life	0	0		2	11.1		1	5.6		6	33.3

Table 11 shows that the prevalence of GAD was significantly higher among regular (19.5%) and occasional (18.8%) smokers than non-smokers (9.3%). No significant differences were observed for any of the other anxiety disorders.

Table 11.

Correlation of different types of anxiety disorder among smokers

	Specific phobia			Social phobia			Panic disorder			GAD
	No.	(%)	P	No.	(%)	P	No.	(%)	P	No.	(%)	P
Smoker
Yes	2	2.6	0.276	4	5.2	0.605	5	6.5	0.177	15	19.5	0.038
No	20	7.8		15	5.8		20	7.8		24	9.3
Occasionally	1	6.2		0	0		3	18.8		3	18.8

Discussion

The study findings indicated that anxiety disorders were prevalent in the study population. Notably, GAD was the most common anxiety disorder, while social phobia was less prevalent. The overall prevalence was considerably higher than in a previous study on community mental health in the UAE.[10] The prevalence of other phobias was also higher in our study. The higher prevalence of anxiety disorders among primary health care center visitors, who are mainly military personnel and their families, is likely attributable to the high-stress levels associated with multiple obligatory tasks and difficult missions, as well as the unstable social life and the stress their families experience as a result. Furthermore, there have been significant changes in lifestyle, with busier schedules and more social and occupational stressors. In a study conducted in the United States, the prevalence of GAD and panic disorder was lower than in our study, while social phobia and specific phobia were higher.[11] These differences were most likely due to the higher number of female personnel in the military in the United States, and more diversity of work and missions. The leadership skills taught in military training and repeated exposure to social situations and difficult tasks may serve as a desensitization method against phobias in specific circumstances.[12] Furthermore, each society has substantially different sets of values, beliefs, and traditions. What may be questioned or stigmatized as a psychiatric disorder in Arabs may be completely acceptable in Western society. As a result, the diagnostic criteria established in the West may not be appropriate for describing the same symptom clusters in other cultures.[13] In addition, our study showed that females had a higher prevalence of all types of anxiety disorders than males, which is consistent with previous findings. The differences between the sexes are particularly pronounced in GAD and panic disorder. The higher prevalence of anxiety disorders is possibly attributable to females’ lower stress threshold. Females have multiple obligations compared to males, including family and children and are constantly juggling with other responsibilities.[14] Concerning marital status, married respondents had a lower prevalence of all anxiety subtypes than widowed, divorced, or unmarried respondents, similar to other studies. This finding may be partially explained by the social stigma and lack of social acceptability associated with being unmarried or divorced, as well as the long-term psychological trauma associated with being widowed. As expected, low income is associated with a higher prevalence of GAD and panic disorders[15] as the social strain placed on low-income groups is higher. A higher income is associated with a higher prevalence of specific and social phobia, which contradicts the findings of other studies. This might be attributable to cultural and social differences in the target population. Those with high incomes frequently face more social stressors as presenters and demonstrators. The study revealed that chronic comorbidity is critical in understanding the distribution of anxiety disorders. Individuals with a lifetime anxiety disorder also had at least one other lifetime medical condition with a history of chronic diseases, comorbidities, previous anxiety disorders, and smoking. These findings are reasonable, given that chronic medical conditions are major stressors. The high prevalence of anxiety disorders, higher stress levels, and occupational difficulties in military personnel impair their ability to perform their daily duties effectively. Targeted interventions tailored to the unique challenges faced by military personnel families are required to reduce the incidence of anxiety disorders in this population. An in-depth analysis of these issues could pave the way for more actionable and relevant policy formulation at national and international levels for this vulnerable population. There is a need for a well-planned awareness program for stress recognition and management in military personnel and their families. Counseling services and follow-up of diagnosed cases should be available at the primary health care level for improved healthcare delivery by primary care or family health physicians. The main limitation of this study was that previous studies on this topic, particularly on military personnel and their families, are not available in this region to compare and contrast.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.