Dyspepsia and Depression, Anxiety, Stress Scales (DASS) Score

Background: Dyspepsia is a constellation of symptoms referable to the gastroduodenal region of the upper gastrointestinal tract. Emotional disturbances are often associated with dyspepsia and have been proposed as one of the possible causes of dyspepsia. This study was aimed to evaluate the difference between the severity depression, anxiety, stress scales (DASS). Method: Results: There were 90 subjects that enrolled in this study, consisted of 47 (52.2%) males and 43 (47.8%) with dyspepsia symptoms. There is a difference in DASS scores between subjects with different categories of Conclusion: There was a difference in the severity of emotional disturbances among subjects with dyspepsia symptoms and without dyspepsia symptoms. The severity of emotional disturbances parallel with the severity of dyspepsia. Evaluation of emotional disturbances in case of dyspepsia will be helpful in the management of dyspepsia.


INTRODUCTION
Dyspepsia is a constellation of symptoms referable to the gastroduodenal region of the upper gastrointestinal tract. 1 The dyspeptic symptoms are epigastric pain, epigastric burning, postprandial fullness, early satiation, and others, including bloating in the upper abdomen, nausea, vomiting, and belching. Dyspepsia is one of the most common disorders in medicine, with dyspeptic patients seen on a daily basis not only by gastroenterologists but also by physicians in a variety 2, 3 In Indonesia, it is estimated that there are 30% cases diagnosed in general practice and 60% are found in specialist practice. 4 Based on Indonesian 10 th in the category of the most common disease in hospitalized patients, with total hospitalized patients of 34,029 or about 1.59% in 2006. 5 Emotional disturbances are often associated with dyspepsia and have been proposed as one of the possible causes of dyspepsia. 2 Emotional disturbances in the form of anxiety, depression and stress were frequently seen in patients suffering from dyspepsia. 6 Stressful life events in the patient's social environment are also thought to be associated with the onset or exacerbation of dyspeptic symptoms. Various studies show that depression and anxiety play a role in the occurrence of functional dyspepsia and the severity of emotional disturbances is in line with the severity of dyspepsia. 2,3,7 This study aimed to evaluate the difference between the severity of dyspepsia using porto alegre dyspeptic symptoms questionnaire (PADYQ) and emotional disturbances using depression, anxiety, stress scales (DASS).

METHOD
This study was ananalytical cross-sectional study at University of North Sumatera, Medan, Indonesia from October-December 2015. A total of ninety consecutive medical students of the class of 2012 were enrolled in this study. Inclusion criteria are stated as followings: recruited in the study and signed the informed consent. stomach malignancy, the presence of stomach surgery, and subjects in NSAIDs therapy. The study was approved by the local ethics committee. Each patient was giving and asked to sign informed consent paper. The baseline information from patients' demographics was recorded. Subsequently, all the subjects were evaluated using PADYQ and DASS.
All data were analyzed with SPSS for Windows version 22. Categorical data were described as number and continuous data as mean ± SD. Statistical analysis was done by Independent t-test and Mann-Whitney two-tailed p < 0.05.

RESULTS
There were 90 subjects that enrolled in this study, consisted of 47 (52.2%) males and 43 (47.8%) females. The mean age of these subjects was 20.88 ± 0.7 with range 19 to 24 years old. Among 90 subjects, 33 (36.7%) subjects had PADYQ score < 6, while showed that 32 (56.1%) female subjects had dyspepsia symptoms, meanwhile only 25 (43.9%) male subjects had dyspepsia symptoms.  The DASS Scores were higher in female subjects (14.19 ± 11.01) than male subjects (11.45 ± 8.08). DASS scores in cases with positive dyspepsia symptoms were higher than those with negative dyspepsia symptoms. The more severe the dyspepsia symptoms, the higher the DASS scores (Table 3).  different (p < 0.05) in subjects without dyspepsia symptoms (PADYQ < 6) compared to subjects with dyspepsia symptoms had higher mean DASS scores than those without dyspepsia symptoms, so we can conclude that subjects with dyspepsia symptoms had higher DASS scores than those without dyspepsia symptoms.

Figure 1. Comparison of PADYQ category with DASS scores
Using independent t-test, the result showed that subjects with different categories of dyspepsia symptoms (mild, moderate and severe dyspepsia symptoms). From the mean value between those categories, it showed that the more severe dyspepsia symptoms, the higher DASS scores (Figure 1).

DISCUSSION
The prevalence of dyspepsia in this study (63.3%) was higher than those of previous studies. Shah et al reported the prevalence of dyspepsia was 30.4% in India. 10 In Taiwan, Lu et al reported that the prevalence of dyspepsia was 27.8%. 11 Mahadewa et al reported that the prevalence of dyspepsia was 14.6% in Malaysia. 12 This difference might be because this study was not population based study and using different criteria in diagnosis dyspepsia. The high prevalence of dyspepsia in medical students at University of North Sumatera The demographic pattern of this study showed the majority of the dyspepsia subjects were female. This result in line with Mahadewa et al study. Females seem to be had higher DASS score than males. This indicated that females more susceptible to develop emotional disturbances, this result was same with Haider et al and Oei et al study. 6,9 The mean DASS scores in subjects without dyspepsia symptoms was 7.64, whereas in subjects with dyspepsia symptoms the DASS scores were higher than those of without dyspepsia symptoms. The difference of DASS scores between subjects with and without < 0.05). It seems that emotional disturbances have correlation with dyspepsia. This results in accordance with Xiaoping et al and Mahadewa et al. 13,14 All of data shows that there was a difference of DASS score between different severity of dyspepsia symptoms. Moreover, the more severe the dyspepsia symptoms, the higher the DASS scores. This result was < 0.05). It was shown that the severity of dyspepsia parallel with the severity of emotional disturbances. This result in line with Li et al and Mujakovis et al study. 15,16

CONCLUSION
There is a difference in the severity of emotional disturbances among subjects with dyspepsia symptoms and without dyspepsia symptoms. The severity of emotional disturbances parallel with the severity of dyspepsia. Evaluation of emotional disturbances in case of dyspepsia will be helpful in the management of dyspepsia.