Bahrain Medical Bulletin, Vol. 32, No. 1, March 2010
Treatment and Prevalence of Generalized Anxiety Disorder and Depression among
Primary Care Attendees
Ahmed Al Ansari, MBCHB, FRCPc* Basema Al Alaiwat, BSc, MA Counseling**
Randah Hamadeh, BSc, MSc, DPhil (Oxon)*** Mazen Ali, MBBS, AB Psy****
Basheer Mukarim, MD, MPH***** Raoof Othman, MBBCH, MSc, MHPE*****
Objective: The aim of the study was to evaluate the prevalence of generalized anxiety
disorder and depression and their treatment in a cross national sample of primary care
Setting: Four primary health care facilities in four Governorates, in the Kingdom of
Design: Clinical Survey.
Method: Four primary health care facilities in four Governorates participated in one
stage screening process to identify prevalence of generalized anxiety disorder and
depression. Structured diagnostic interviews among 300 consecutive attendees in one
day was used. The Mini International Neuro psychiatric Investigation (MINI) was used
as screening tool. The association of depression and anxiety with factors such as age, sex,
education and employment were evaluated.
Result: Generalized anxiety disorders prevalence rate was 52 (17.3), life time depression
was 58 (19.3%) and current depression was 17 (5.6%). Only 22 (7.3%) of the sample had
either anxiety or depression in the past, of whom 41% received treatment. None of the
examined factors was significantly linked to anxiety or depression.
Conclusion: This study shows that generalized anxiety disorder and major depressive
episode are very common among primary care attendees. Thus, primary care physicians
should be alerted of this fact.
A multifaceted program should be adopted for the detection and management of GAD
Bahrain Med Bull 2010; 32(1):
* Al Ansari A
Associate professor, Department of Psychiatry
College of Medicine and Medical Science
Arabian Gulf University
** Counselor, Psychiatric Hospital, Ministry of Health
*** Professor, Chairperson, Community Medicine and General Practice
Arabian Gulf University
**** Chief Resident, Psychiatric Hospital, Ministry of Health
*****Consultant Family Physician, Ministry of Health
Published data reveals under-recognition and inadequate treatment of Generalized Anxiety
Disorder (GAD) and depression in primary care1,2. In spite of the fact that these disorders are
largely found among primary health care (PHC) attendees; anxious and depressed patients do
not receive adequate attention and management3,6.
Data of the prevalence and treatment of GAD and depression in PHC in the developing
countries are scarce. The WHO-15 sites collaborative study of the prevalence of
psychological problems had revealed that nearly one third of those diagnosed as depressed
received antidepressant medication7. This finding was similar to the published by Simon
(2004) where only a quarter of PHC patients with depression received adequate acute- phase
treatment8. The Longitudinal Investigation of Expression Outcomes study (LIDO) had
reported a prevalence of 4-23% for current depression in six diverse primary care centers9.
In Bahrain, few attempts were performed to address this subject. Depression among the
elderly primary care population was examined and found to be high. A higher prevalence of
depressive symptoms (41%) among the elderly PHC attendees was reported by Habeeb
compared to Al Haddad (23%)10,11. However, GAD was never investigated as a separate
disorder in the primary care setting.
This is the first study that addresses the prevalence of depression and GAD in the adult
population of Bahrain and their treatment needs. We are not aware of any published national
figures of depression and GAD among PHC attendees from the region.
Bahrain is divided into five governorates Muharraq, Capital, Central, Northern and Southern.
The southern governorate was excluded from the study as the Primary Health Care Centers
(PHCCs) are different from those in other areas. One PHCC was randomly selected from the
first four governorates. These PHCCs were: National Bank of Bahrain (NBB) (Muharraq),
Sheikh Sabah (Capital), Aali (Central) and Hamad Town (Northern).Three family physicians
were randomly selected by the chief of medical services from each participating PHCC to
interview 25 consecutive attendees in one working day during between 24-28th June, 2006.
The sample was 300 patients, 75 from each PHCCs. All Bahraini subjects who attended the
PHCCs on that day and whose age ranged between 18-65 years were included in the study.
Attendees whose physical or mental status did not permit interviewing were excluded.
The Mini International Neuropsychiatry Interview (MINI) was used in this study to identify
patients who had or have GAD or Major Depressive Episode (MDE). The choice of MINI as
an instrument was based on its high levels of reliability and validity, which have been
reported in several studies12. The MINI is a structured interview tool, designed to evaluate the
presence of psychiatric disorders according to Axis I, of the DSM IV and ICD-10. MINI is
divided into modules which represent diagnostic categories. Each module begins with
screening questions corresponding to the main criteria of the disorders and ending with
diagnostic boxes to indicate whether the diagnostic criteria are met or not. The administration
time for MINI is usually around 16 minutes.
The MINI was translated into Arabic and translated back to English, the authors for clarity
and accuracy performed a pilot study. Twelve interviewers, all family physicians, attended
two workshops prior to data collection. The aims of the workshops were to orient the
interviewers regarding the objectives and procedures of the study, familiarize them with
diagnostic criteria of GAD and MDE, DSM-IV and ICD-10 and to practice the use of MINI in
simulated interview situation. Interrator reliability was not required as MINI is a diagnostic
tool based on DSM-IV and ICD-10. Each physician interviewed 25 consecutive PHCC
attendees in a day using MINI. A verbal informed consent was obtained from all participants.
The process was supervised by two team members, psychiatrist and psychologist, who were
available to answer any questions. Filled forms were manually checked for completeness. The
data were entered and analyzed using SPSS version 15. Chi-square test was used to evaluate
the significance of differences as applicable.
Table 1 shows the characteristics of the total sample, attendees with GAD and MDE. The
mean age for the total sample was 38.5 and 34.5 years for both GAD and MDE, respectively.
The number of females found to have GAD and MDE slightly exceeded males. Half of the
sample population received high school education and a quarter had college education. Two-
third of the MDE received high school education and only one fifth college education. In
GAD population, more than half 28 (54%) completed high school education and about one
third 16 (31%) college education. However, the differences were not statistical significant.
GAD 33 (63.5%), MDE 34 (58.6%) were employed, GAD 4 (7.7%), MDE 4 (6.9%), were
unemployed and home makers (19.2-25.9%) were almost similar among GAD and MDE
population. Employment/unemployment status was not statistically significant.
Table 2 shows the percentage of GAD and MDE according to health centre and type of
disorder. One hundred and ten (36.6%) achieved enough score to be diagnosed as either GAD
52 (17.3%) or MDE 58 (19.3%). Twenty-two (7.3%) of the 110 were previously diagnosed
cases with equal representation among GAD and MDE. The prevalence of MDE current type
was (5.6%). Nine (41%) of the known cases of GAD and MDE did not receive any treatment
in the past. Seven cases of MDE and five cases of GAD were due to physical illness and only
one MDE case was related to drug use.
Table 1: Personal Characteristic of the Sample
Total 52 58 300 100
Read & Write
≥ 13 grade
* p- Value > = NS
Table 2: Prevalence of GAD and MDE according to Health Centre and Type of Disorder
Health Centre Diagnostic Type
Sheikh. Sabah All
Due to physical illness
Due to physical illness
Due to physical illness
Hamad Town All
Due to physical illness
52 100 Total
Depression and anxiety disorders are frequently encountered among primary care attendees in
Bahrain, but the majority of cases are unrecognized. Hence, physicians working in primary
care should be aware of these disorders in their daily clinical practice. Similar high prevalence
figures of GAD and MDE were reported in several studies using similar screening methods13-
16. As expected, the number of females exceeded males in both groups, which is a well
established finding in several studies17. The prevalence of MDE – current type was within the
range of the established rate of 6% of the population who meet the criteria for major
depressive disorders at any time18.
Associated factors such as age, gender, education and employment were not significant
statically. However, a bigger sample might confirm that the attendees with higher education
and employment rates were at higher risk of developing GAD. Illiterate people were more
among the sample compared to GAD and MDE but such difference could not be evaluated
further due to the small numbers. Only one fifth of the GAD and MDE were recognized prior
to screening and less than half had received treatment. Screening instruments such as MINI
increased the total number of GAD and MDE four folds.
This will reinforce the notion whether PHCCs are equipped to manage such a large number
and whether recognition of cases of GAD and MDE translate into improved clinical
The study suffers from several limitations that should be considered while interpreting the
findings. The diagnoses of GAD and MDE were based on instrument guided interview
conducted by non-experienced staff in diagnosing mental illness. Hence, it is likely that false
positive cases were included which might have been reflected by increasing the prevalence
rates. The study sample was small, which could interfere with establishing significance of less
frequent social factors. In addition, choosing only one centre from each governorate restricts
comparing the characteristics of attendees among the governorates. However, restrictions of
the number of the participating PHCCs was inevitable due to limited financial and human
resources. Although the results of this study can be generalized to the PHCC attendees,
national generalization should be done with caution.
Efforts to improve recognition must be addressed within the context of management of
anxiety and depression. Screening of clinical disorders appears to work best if feedback to
PHCCs physicians was immediate and was part of multifaceted system of depression care19.
In overview of screening and feedback on recognition and outcome of depression found that
only feedback of high risk cases increased the rate of recognition20. Depression should be
managed like a chronic disease with a systematic sequence of acute, continuation and
maintenance phase intervention21. A multifaceted intervention that combines mutual health
skill training, adapted clinical guidelines to raise awareness is necessary22,23.
This study shows that in Bahrain generalized anxiety disorder and major depressive
episode are very common along primary care attendees. Thus, primary care physicians
should be alerted of this fact.
Future studies should be planned to include a bigger sample from all health centers with
an additional stage that examine all positive cases by experienced staff.
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