|Year : 2020 | Volume
| Issue : 3 | Page : 224-229
A cross-sectional study of co-morbid generalized anxiety disorder and major depressive disorder in patients with tension-type headache attending tertiary health care centre in central rural India
Ajinkya Sureshrao Ghogare, Pradeep Shriram Patil
Department of Psychiatry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Sawangi, Wardha, Maharashtra, India
|Date of Submission||06-Feb-2020|
|Date of Decision||24-Feb-2020|
|Date of Acceptance||25-Apr-2020|
|Date of Web Publication||17-Jul-2020|
Dr. Ajinkya Sureshrao Ghogare
Department of Psychiatry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Tension-type headache (TTH) is one of the most common reasons patients seek medical treatment. Psychiatric co-morbidities such as anxiety and depression have been commonly observed in patients with TTH. Objective: The objective was to study the prevalence and severity of co-morbid generalized anxiety disorder (GAD) and major depressive disorder (MDD) in patients with TTH. Materials and Methods: The present cross-sectional study was conducted in the Tertiary Health Care Centre in Central Rural India, with a sample size of 85. Data were recorded in the predesigned, semi-structured questionnaire. Hamilton Anxiety Rating Scale (HAM-A) and Hamilton Depression Rating Scale (HDRS) were used to categorise the co-morbid anxiety and depression. Results: About 48.2% of the study participants were in the age group of 31–40 years with a mean age of 36.8 ± 7.1 years. Higher proportions of female study participants (64.7%) were observed. Majority of the study participants were literate (76.5%), employed (57.7%), married (78.8%) and had rural residence (54.1%). The prevalence of co-morbid GAD was 70.6%, whereas the prevalence of co-morbid MDD was 54.1%. According to HAM-A, 31.8% had mild, 21.2% had moderate, while 17.6% had severe anxiety levels. According to HDRS, 34.1% had mild, 16.5% had moderate and 3.5% had severe co-morbid depression. Conclusion: TTH is frequently associated with co-morbid GAD and MDD.
Keywords: Anxiety, depression, Hamilton Anxiety Rating Scale, Hamilton Depression Rating Scale, tension-type headache
|How to cite this article:|
Ghogare AS, Patil PS. A cross-sectional study of co-morbid generalized anxiety disorder and major depressive disorder in patients with tension-type headache attending tertiary health care centre in central rural India. Niger Postgrad Med J 2020;27:224-9
|How to cite this URL:|
Ghogare AS, Patil PS. A cross-sectional study of co-morbid generalized anxiety disorder and major depressive disorder in patients with tension-type headache attending tertiary health care centre in central rural India. Niger Postgrad Med J [serial online] 2020 [cited 2020 Aug 11];27:224-9. Available from: http://www.npmj.org/text.asp?2020/27/3/224/289909
| Introduction|| |
Headache is one of the most common reasons patients seek medical attention on a global basis, being responsible for more disability than any other neurologic problem. Every year about 80% of the population suffer at least one episode of headache, and 10%–20% go to a physician with headache as their primary complaint. Headache is a common neurological disorder that ranks among the top 10 most disabling conditions for both men and women worldwide, causing decline in quality of life, Most work-ups for common headache complaints have negative findings, and such results may be frustrating for both patient and physician. Physicians not well versed in psychological medicine may attempt to reassure such patients by telling them that they have no disease. However, this reassurance may affect patients oppositely, and it may increase the patient's anxiety and even escalate into a disagreement about whether the pain is real or imagined. Tension-type headache (TTH) is one of the most common primary headaches, with a prevalence ranging from 30%–78% worldwide, and among them, the majority have an episodic type and 2%–3% of patients have a chronic type.,,,
The association of headache and psychiatric disorders is common, of which depression, bipolar disorders, anxiety and somatoform disorders being the most common co-morbidities. Psychiatric co-morbidities have been commonly observed in patients with TTH and that may be explained by affective distress, personality disorders and maladaptive coping. Anxiety disorders, especially generalized anxiety disorder (GAD) and depression commonly occur in Chronic TTH., The HADAS Study (2011), showed that 12.8% of patients with TTH had psychiatric co-morbidities, of whom, 67% had a depressive episode, 19.3% had anxiety disorders, 5.5% had panic disorder and 1.1% had an obsessive-compulsive disorder. The presence of psychiatric co-morbidity in headache further complicates and makes headache management more difficult and portends a poorer prognosis for headache treatment. After reviewing the literature, data on this topic from central rural India is scarce, hence the need for further comprehensive studies on TTH with psychiatric co-morbidities in central rural India. Therefore, this study was aimed to find the psychiatric co-morbidities in the form of GAD and major depressive disorder (MDD) in patients with TTH in Central Rural India.
| Materials and Methods|| |
This cross-sectional observational study was conducted in the Department of Psychiatry of Tertiary Health Care Center in Central Rural India. The study was approved by the Institutional Ethics Committee of Datta Meghe Institute of Medical Sciences University on 19th December 2019 with reference letter number DMIMS (DU)/IEC/DEC – 2019/8573. Informed written consent was taken from all study subjects. Patients attending the headache clinic of the outpatient department of Psychiatry were recruited as the study population. The study began on date 20th December 2019, and data collection was completed on 5th February 2020.
The final number of the study participants was 85. The sample size was calculated using the formula for cross-sectional study (n = 4pq/L2), where P is the prevalence of the TTH, q = 100 − p, L is the allowable error and it is 20% of the p. By considering the prevalence of TTH to be 54%,,,, 95% confidence and 20% allowable error of margin, the minimum sample size required was 85. Inclusion criteria adopted for the study were patients in the age group of 18–50 years and fulfilling diagnostic criteria for Episodic and Chronic TTH according to the International Classification of Headache Disorders–2 (ICHD– 2) Criteria. Exclusion criteria were patients not fulfilling the criteria for TTH as per ICHD–2 criteria, patients with severe neurological disorders such as head injuries, pregnant women, and co-morbid medical disorders and other psychiatric disorders, including substance use disorders other than nicotine. All the study participants fulfilling ICHD–2 diagnostic criteria for TTH were screened for GAD and MDD using the DSM–5 diagnostic criteria. The severity of TTH was divided into mild and moderate categories as per the ICHD–2 diagnostic criteria. Data from selected study participants who were included in the study consecutively after fulfilling inclusion criteria were recorded in a pre-designed, semi-structured questionnaire. It was used to record the sociodemographic data, general examination, systemic examination and mental status examination of the study participants.
Hamilton Anxiety Rating Scale (HAM-A) was used to measure the severity of GAD. It is 14-item scale. Scores of 0–7 indicate no anxiety, 8–14 indicate mild, 15–23 indicates moderate and 24 and above indicates severe anxiety. The HAM-A is widely used oldest clinician rating scale. Maier et al., in a reliability and validity study in two different samples, reported the reliability of the global score of the HAM-A > 0.70 for each rater.
Hamilton Depression Rating Scale (HDRS) was used to measure the severity of depression. It is 17-item scale. Scores of <7 indicate no depression, 8–16 indicates mild depression, 17–23 indicates moderate depression and >24 indicates severe depression. Hamilton found an excellent correlation (0.9) between raters in his original paper. Others have found that Pearson's r ranged from 0.82 to 0.98, and the intra-class r ranged from 0.46 to 0.99. This reliability has been found to hold good for raters using video-recorded interviews. Prasad et al., in their Indian study, found excellent inter-rater reliability of 0.9891. Another Indian study also found Cronbach's alpha of HDRS 17-item version to be 0.674.
Data from both HAM-A and HDRS clinician-rated scales were entered with the help of Microsoft Excel version 2007. The final data were analysed with the help of SPSS statistical software version 15 (IBM, Chicago, Illinois, United States of America). Continuous data were presented as mean and standard deviation (SD); categorical data were presented as frequency and percentage. The Chi-square test and Fisher's exact test were used to determine the level of significance.
| Results|| |
Sociodemographic parameters of study population
[Table 1] shows sociodemographic parameters among the study population. The mean age of study participants was 36.8 (SD 7.1 years) and range between 18 and 50 years. There was female preponderance (64.7%) compared to men. 76.5% of the study participants were literate, and 57.7% were employed. Majority of the study participants 67 (78.8%) were married. 54.1% of the study population were from the rural area and 58.8% belonged to nuclear families.
Tension-type headache characteristics
[Table 2] shows the distribution of TTH related parameters among the study population. Majority of the study participants had the chronic type of TTH (58.8%), moderately perceived severity of TTH (61.2%), and 6–10 years of the total duration of TTH illness. Majority were drug naïve (62.4%) and were without family history any headache disorder (55.3%).
|Table 2: Tension-type headache related parameters among study population (n=85)|
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Prevalence and severity of generalized anxiety disorder co-morbid with tension-type headache
[Table 3] depicts the prevalence and severity of co-morbid anxiety among study subjects according to the scores on HAM-A. Mild level of anxiety was found in 27 (31.8%) of study participants, followed by a moderate level of anxiety in 18 (21.2%), and severe level of anxiety among 15 (17.6%). 25 (29.4%) of the study population had no co-morbid anxiety.
Prevalence and severity of major depressive disorder co-morbid with tension-type headache
[Table 4] depicts the prevalence and severity of co-morbid depression among study subjects according to the scores on HDRS. Mild depression was found in 29 (34.1%) of study participants, followed by a moderate level of depression in 14 (16.5%), and severe level of depression among 3 (3.5%). 39 (45.9%) of the study population had no co-morbid depression.
Sociodemographic parameters and Comorbid generalized anxiety disorder in tension-type headache
[Table 5] shows the association between sociodemographic parameters and GAD. Gender and occupation were significantly associated with the score on HAM-A. Age, education status, marital status, area of residence and family type were not significantly associated with the score on HAM-A.
|Table 5: Association between sociodemographic parameters of the study population and generalized anxiety disorder|
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Tension-type headache parameters associated with comorbid generalized anxiety disorder
[Table 6] shows the association between TTH parameters and GAD. Type of TTH, perceived severity of TTH, treatment status and family history of headache disorder were significantly associated with the score on HAM-A. However, the total duration of TTH illness was not significantly associated with the score on HAM-A.
|Table 6: Association between tension type headache parameters of the study population and generalized anxiety disorder|
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Sociodemographic parameters and comorbid major depressive disorder in tension-type headache
[Table 7] shows the association between sociodemographic parameters and MDD. Age, occupation and marital status were significantly associated with the score on HDRS. Gender, education, area of residence and family type were not significantly associated with the score on HDRS.
|Table 7: Association between socio-demographic parameters of the study population and major depressive disorder|
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Tension-type headache parameters associated with comorbid major depressive disorder
[Table 8] shows the association between TTH parameters and MDD. The perceived severity of TTH was significantly associated with the score on HDRS. While other TTH parameters such as type of TTH, total duration of TTH illness, treatment status and family history of headache disorder were not significantly associated with the score on HDRS.
|Table 8: Association between tension type headache parameters of the study population and major depressive disorder|
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| Discussion|| |
The prevalence and severity of generalized anxiety disorder and major depressive disorder in tension-type headache
This study found that 70.6% had co-morbid GAD while 54.1% had MDD. Chandra Sekhar et al. found that 78% had depression and 72% had anxiety. In the present study, according to the scores on HAM-A 31.8% had mild, 21.2% had moderate and 17.6% had severe anxiety. According to HDRS, 34.1% had mild, 16.5% had moderate and 3.5% had severe depression. Puca F et al. found that GAD (83.3%) and dysthymia (45.6%) were the most frequent psychiatric co-morbidities in TTH. Juang et al. observed that 64% of patients with chronic TTH had psychiatric co-morbidities., among whom 51% had MDD, 8% had dysthymia, 22% had panic disorder and 1% had GAD. Several studies have reported a different prevalence of psychiatric co-morbidities among patients with TTH, which might be secondary to different methodologies used, as well as cultural and population characteristics of the studied patients.
Socio-demographic characteristics of patients with tension-type headache
In the present study, the mean age (SD) of the study population was 36.8 (7.1) years and nearly half of the study participants were in the age range of 31–40 years. Jain et al. observed a similar finding with a mean age of study population being 31 years, while the majority of the study participants with TTH were in the age range of 21–30 years (47.4%) followed by 17.9% in the age range of 31–40 years. Chandra Sekhar et al. also observed a similar finding that 80% of the study population belonged to the age group of 21–40 years, indicating that majority of the TTH occurring in the young population. In the present study, females (64.7%) outnumbered males (35.3%). Similar gender distribution was observed by Jain et al. and Ravi et al., which were consistent with the present study finding reflecting the fact that headaches are more common in women. Furthermore among women stress of social restrictions, social expectations and male dominance in the family can be associated with headaches. As regards the occupation domain, in the present study, 57.7% of patients were employed, 34.1% were housewives and 8.2% were unemployed. While Jain et al. observed that majority of patients with TTH (41.1%) were housewives. This might reflect that being employed and being housewife imparts more perceived stress and the perceived stress might lead to the increased impact of TTH among the employed population as well as housewives. Wittrock and Myers et al. found that persons with TTH experienced more stressful events, particularly more daily stressors than non-headache controls. Moreover, as the number of stressors increased, persons with TTH reported disproportionately greater levels of stress than might be reported by non-TTH persons. The majority of the patients in this study were married (78.8%). This is consistent with Chandra Sekhar et al. and Jain et al. who found 50% and 69.3% of married patients in their TTH studies, respectively. This might reflect that married people may have more number of psychological stressors due to their added responsibilities compared to unmarried people, probably predisposing them to primary headache disorders, including TTH. In the present study, the majority of study participants were from rural areas (54.1%). Finding similar to the present study finding was observed by Chandra Sekhar et al. who observed that 78% of the study population were from the rural areas. The majority of the study participants were from the nuclear family (58.8%). Jain et al. also observed the same. Probably with the decline of traditional joint families, in which there were shared responsibilities and readily available emotional support, people in nuclear families experience more stress.
Tension-type headache related characteristics
In this study, majority of the study participants had chronic TTH (58.8%). This finding is in contrast to Zebenholzer et al. study, which found that 59.2% had episodic TTH as the predominant type of TTH. That study also concluded that patients with chronic TTH suffer from depression and/or anxiety significantly more often than patients with episodic TTH. This might reflect that more the duration/chronicity of the TTH, more the probability of co-morbid anxiety and depression. As regards the perceived severity of TTH by study participants, majority had moderately severe TTH (61.2%). The majority of the patients had a total duration of TTH of 6 to 10 years. In the present study, 44.7% of patients with TTH had a family history of headache disorder. Russell et al. observed a similar finding with about 40% of the patients with TTH having a family history of headache disorder. It indicates that genetic loading might play a role in the TTH. It has been observed that children are likely to use their parents as role models, as shown by findings of Bener et al. as there was a family pattern of TTH, especially in girls. It might indicate that such role modelling of the illness can persist into adulthood, accounting for the female preponderance of primary headache disorders, including TTH. In the present study, as regards co-morbid GAD there was a significant association between sociodemographic parameters like gender and occupation status and scores on HAM-A. As regards comorbid MDD, we found significant association between sociodemographic parameters such as age, occupation status and marital status and scores on HDRS. We also found a significant association between TTH parameters such as type of TTH, perceived severity of TTH, treatment status and family history of headache and scores on HAM-A. While as regards co-morbid MDD, single TTH parameter, the perceived severity of TTH was significantly associated with the score on HDRS.
Limitations of the study
This is only an exploratory study. The well–matched control group would have added to scientific value of this work. Therefore, the generalisability of results must be concluded with caution. The cross-sectional study design precluded temporal assessment.
| Conclusion|| |
Co-morbid GAD and MDD were present in a significant proportion of study participants suffering from TTH. Socio-demographic parameters such as age, gender, occupation and marital status and TTH parameters such as type, perceived severity, treatment status and family history significantly influence the occurrence of co-morbid GAD and MDD among the patients suffering from TTH. The study suggests that the detailed evaluation, proper diagnosis and the treatment of psychiatric co-morbidities are needed for effective management of the patients suffering from TTH.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]