Abstract
Background:
Generalized anxiety disorder is commonly underdiagnosed and undertreated in medical settings.
Aim:
The objectives of this study were to determine the prevalence and correlates of generalized anxiety disorder among patients presenting to medicine outpatient department in a tertiary care centre.
Materials and Methods:
A cross-sectional observational study was conducted among the patients visiting the outpatient department of General Medicine in a tertiary care teaching hospital. Sociodemographic and clinical parameters were collected using a structured pro forma. All patients were administered Generalized Anxiety Disorder-7 (GAD-7) to screen for the presence of generalized anxiety disorder. Patients who score 10 or more underwent a semi-structured evaluation using a generalized anxiety disorder module of Structured Clinical Interview for DSM-IV Axis I disorders.
Results:
Two hundred and fifty patients were recruited for the study. The mean age of the participants was 40.66 ± 12.8 years. More than one-fourth of them had diabetes mellitus and about one-fifth of the participants had systemic hypertension and hypothyroidism. Thirty five (14%) participants screened positive on GAD-7 scale. On detailed evaluation using SCID-I, 19 (7.6%) participants were confirmed to have a generalized anxiety disorder. Female gender was associated with the presence of GAD.
Conclusion:
One in thirteen patients presenting to the medicine outpatient department were found to have generalized anxiety disorder. Female patients had a greater prevalence of generalized anxiety disorder compared to male patients.
Keywords: Common mental disorder, general medicine, generalized anxiety disorder, medical outpatients
Depressive and anxiety disorders together constitute ‘common mental disorders’ and are associated with substantial disability.[1] As per World Health Organization, an estimated 3.6% of the global population suffer from anxiety disorders.[1] A recent systematic review of reviews reported that the prevalence of anxiety disorders in adult population varied from 3.8%-25%.[2] As per National Mental Health Survey 2016 conducted in India, the prevalence of anxiety disorders was 2.57% and was similar to depressive disorders. Also, a substantial disability was noted in these patients with anxiety disorders.[3]
Among the anxiety disorders, generalized anxiety disorder was found to be most common anxiety disorder globally.[2] Generalized anxiety disorder characterized by excessive uncontrollable worry is common in the population.[4] A wide variation in the rate of anxiety disorders particularly generalized anxiety disorder and panic disorder have been reported.[5] Notably, National Mental Health Survey 2016 reported the prevalence of 0.57% for generalized anxiety disorder which is lower than the global prevalence.
Anxiety disorders in general and generalized anxiety disorder in particular are more common among patients with physical disorders.[6,7,8,9] Considering that health-related worries are common among patients with generalized anxiety disorder, many of them are likely to consult the medicine department as outpatients. However, these patients are underdiagnosed and undertreated due to various factors including lack of physician training in diagnosing and treating common mental disorders, stigma, and lack of time. These underdiagnosed patients continue to suffer poorer quality of life and their recovery is hindered by the anxiety disorders.
In this context, this study was conducted with the objectives of determining the prevalence and correlates of generalized anxiety disorder among patients presenting to medicine outpatient departments in a tertiary care center.
MATERIALS AND METHODS
This was a cross-sectional observational study conducted among the outpatients visiting the general medicine department of a tertiary care teaching hospital in South India. The hospital is 740 bedded and has various specialty and super-specialty departments. The outpatient department of General Medicine is seen every day by the postgraduate trainees under the supervision of faculty. This study was conducted after obtaining Institute Ethics Committee approval (IEC: RC/2020/112). Written informed consent was obtained from all the study participants.
The sample for this study was derived from the outpatient departments of General Medicine department; convenience sampling was used due to logistic reasons. To be included in the study, the patient (both genders) must have been in the age group of 18-65 years and must have attended the medicine outpatient department for treatment. Patients with pre-existing psychiatric disorders, intellectual disability, critical illnesses, and sensory impairment were excluded from the study.
All patients presenting to the medicine outpatient department were approached and screened for eligibility for the study. Those who were found eligible were requested to participate in the study. After getting informed written consent, a semi-structured interview was used to collect the sociodemographic and clinical details of the study participants. Generalized Anxiety Disorder-7 (GAD-7)[10] was used to screen patients for anxiety disorders. Those who had a score of 10 and more on GAD-7 were considered to be screened positive for generalized anxiety disorder. These patients underwent detailed evaluations using the generalized anxiety disorder module of Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders–IV Axis I disorders (SCID-I).[11] Based on the evaluation on SCID-I, a diagnosis of generalized anxiety disorder was confirmed. The data collection was done by a postgraduate trainee from the Psychiatry department under the supervision of Psychiatry faculty between January 2021 and July 2022.
Study tools
GAD-7
This is a seven-item self-report scale with responses for each item - ‘Not at all’, ‘Several days’, ‘More than half the days’, and ‘Nearly every day’. The GAD-7 total score ranges from 0 to 21. When used as a screening tool for generalized anxiety disorder, a cut-off score of 10 or more has been recommended for further evaluation.[10] GAD-7 is a reliable and valid tool for screening for GAD and assessing its severity in clinical practice and research.
SCID-I
The Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders–IV Axis I disorders (SCID-I) is a widely used semi-structured interview intended to determine whether an individual meets the criteria for any DSM-IV disorder. The SCID is completed by an interviewer with sufficient clinical knowledge to complete a thorough diagnostic evaluation. The SCID assesses both current and lifetime diagnoses and prompts the interviewer to document the age of illness onset and to rate current illness severity. The SCID uses a decision tree approach that prompts the interviewer to skip subsequent questions or whole diagnostic sections when sufficient criteria are not met to warrant further questioning. For the purpose of this study, generalized anxiety disorder module of SCID-I was used.
Statistical analysis
The collected data were encoded and entered into a spread sheet on MS excel 2019 and were analysed using IBM SPSS Statistics for Windows, version 21 (IBM Corp., Armonk, NY, USA). The categorical variables were summarized as frequencies and percentages. Continuous variables were summarized as means and standard deviations. The prevalence of generalized anxiety disorder as per GAD-7 and SCID-I were reported as frequencies and percentages. Association between various sociodemographic and clinical factors and the presence of generalized anxiety disorder were evaluated using the Chi-square test and t-test as appropriate. P value <.05 was considered statistically significant.
Sample size calculation was done using OpenEpi software. Assuming that the prevalence of generalized anxiety disorder of 6% based on previous studies,[12] the study would require a sample size of 241 for estimating the expected proportion with 3% absolute precision and 95% confidence.
RESULTS
Two hundred and fifty patients were recruited for the study. The mean age of the participants was 40.66 ± 12.8 years. More than three-fourth of the participants were Hindus. The majority of the participants had completed high school and more. About half of the participants were unemployed. The common comorbid physical disorders among the participants were diabetes mellitus, systemic hypertension, and hypothyroidism. More than one-fourth of them had diabetes mellitus and about one-fifth of the participants had systemic hypertension and hypothyroidism [Table 1]. About one-fifth of the participants had a history of alcohol abuse/dependence.
Table 1.
Sociodemographic and clinical details of the study participants
| Sociodemographic/Clinical variable | Frequency | Percentage |
|---|---|---|
| Gender | ||
| Male | 104 | 41.6% |
| Female | 146 | 58.4% |
| Religion | ||
| Hindu | 218 | 87.2% |
| Christian | 15 | 6% |
| Muslim | 17 | 6.8% |
| Education | ||
| Illiterate | 30 | 12% |
| Primary school education | 25 | 10% |
| Middle school education | 34 | 13.6% |
| High school certificate | 50 | 20% |
| Intermediate/post high school | 27 | 10.8% |
| Graduate/Postgraduate | 73 | 29.2% |
| Professional or honours | 11 | 4.4% |
| Occupation | ||
| Unemployed | 107 | 42.8% |
| Unskilled worker | 10 | 4% |
| Semiskilled worker | 27 | 10.8% |
| Skilled worker | 46 | 18.4% |
| Clerical/shopkeeper/farmer | 24 | 9.6% |
| Semi-professional | 14 | 5.6% |
| Professional | 22 | 8.8% |
| Medical comorbidities | ||
| Diabetes mellitus | 69 | 27.6% |
| Systemic hypertension | 47 | 18.8% |
| Hypothyroidism | 43 | 17.2% |
| Hyperthyroidism | 3 | 1.2% |
| Dyslipidemia | 9 | 3.6% |
| Coronary artery disease | 7 | 2.8% |
| Cerebrovascular accident | 7 | 2.8% |
Among the study participants, 35 (14%) had a score of 10 and more on the GAD-7 scale. These patients were considered to have screened positive for generalized anxiety disorder. On further detailed evaluation using SCID-I, 19 of 35 (54.28%) participants were confirmed to have a generalized anxiety disorder. In our study of 250 participants, we found 19 participants had generalized anxiety disorder with a prevalence of 7.6% [Table 2]. Female patients had a greater prevalence of generalized anxiety disorder compared to male patients. This association approached statistical significance (P value of .059). Other variables like age, systemic hypertension, diabetes mellitus, hypothyroidism, and alcohol use disorder were not found to be associated with the presence of generalized anxiety disorder among the study participants [Table 3].
Table 2.
Prevalence of Generalized Anxiety Disorder based on GAD-7 and SCID-I
| Tool used | Present | Absent |
|---|---|---|
| GAD-7 n=250 |
35 (14%) | 215 (86%) |
| SCID-I n=35 n=250 |
19 (54.28%) 19 (7.6%) |
16 (45.71%) - |
Table 3.
Association between various sociodemographic and clinical parameters and the presence of generalized anxiety disorder
| Variable | Category | Generalised anxiety disorder as per SCID-I |
Chi-square value/t-value | P | |
|---|---|---|---|---|---|
| Present | Absent | ||||
| Age in years | 39.58 (13.95) | 40.69 (12.72) | 0.36 | 0.72 | |
| Gender | Male | 4 | 100 | 3.57 | 0.059 |
| Female | 15 | 131 | |||
| Systemic hypertension | Present | 17 | 186 | 0.92 | 0.337 |
| Absent | 2 | 45 | |||
| Diabetes mellitus | Present | 15 | 166 | 0.44 | 0.507 |
| Absent | 4 | 65 | |||
| Hypothyroidism | Present | 16 | 191 | 0.03 | 0.865 |
| Absent | 3 | 40 | |||
| Alcohol | Absent | 16 | 182 | 0.9 | 0.638 |
| Abuse | 3 | 39 | |||
| Dependence | 0 | 10 | |||
DISCUSSION
In our study, of 250 participants, we found 19 participants had generalized anxiety disorder with a prevalence of 7.6%. Female patients had a greater prevalence of generalized anxiety disorder compared to male patients. This association approached statistical significance (P value of .059).
Widely varying prevalence rates of anxiety disorders in medical outpatients were reported in Indian studies. A study conducted in cardiology outpatients reported a 49% prevalence of anxiety disorders using Hamilton Anxiety Scale and most of these patients had moderate anxiety.[13] On the other hand, a study conducted among patients attending general outpatient department reported a low prevalence of generalized anxiety disorder (0.96%) using DSM-5 criteria.[14] A well-conducted study on antenatal patients reported a 23% prevalence of generalized anxiety disorder and 13% prevalence of both depression and generalized anxiety disorder in this population.[15] This study used GAD-7 as a screening instrument similar to our study. Later, the diagnosis was confirmed using Mini-International Neuropsychiatric Interview.[16] In our study, female gender was associated with the prevalence of GAD. Other anxiety disorders including illness anxiety disorder are common in medical outpatients. This was not evaluated in the present study. This finding is similar to various other studies—females are twice more likely to have GAD.[2,4] The wide variation in the prevalence rates has been attributed to different study populations, varying study tools and assessment methods (self-report vs. clinician-administered).
Despite the high prevalence and consequences of GAD in medical outpatients, they are not routinely screened for in such settings. Use of GAD-7 self-report instrument (available free of cost in different languages) as part of routine screening is likely to increase the detection rate of generalized anxiety disorder in this accessible population. There is also a need to educate and train general practitioners and specialty doctors to diagnose and initiate first-line treatments for these patients. Incorporation of these skills as part of undergraduate curriculum will go a long way in training budding doctors to diagnose and treat common mental disorders including generalized anxiety disorder.
On a broader note, several modifiable risk and protective factors have been identified for anxiety disorders in general and generalized anxiety disorder in particular. Among the risk factors studied, cigarette smoking, alcohol use, cannabis use, negative appraisal of life events, avoidance, and occupational factors can be targeted as a preventive measure for generalized anxiety disorder.[17]
Strengths and limitations
The use of standardized instruments namely GAD-7 and SCID-I to make the diagnosis of generalized anxiety disorder is the most important strength of this study. Inclusion of an adequate sample of patients of both genders strengthens the validity of the findings.
This study has its share of limitations. The present study was conducted in a single center in a tertiary care teaching hospital. Hence, the study findings may not be generalizable to primary and secondary care settings. Common psychiatric comorbidities namely other anxiety disorders and depression were not evaluated in the present study.
Future directions
Future researchers can evaluate the role of comorbid generalized anxiety disorder in the treatment adherence and outcome of medical disorders. Intervention studies to evaluate treatment options in patients with generalized anxiety disorder in medical settings should be conducted.
CONCLUSION
One in 13 patients presenting to the medicine outpatient department were found to have generalized anxiety disorder. Female patients had a greater prevalence of generalized anxiety disorder compared to male patients. Other variables like age, systemic hypertension, diabetes mellitus, hypothyroidism, and alcohol use disorder were not found to be associated with the presence of generalized anxiety disorder. Routine screening using simple user-friendly tools can be considered in these patients in tertiary care settings for identification of generalized anxiety disorder and initiation of treatment.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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