The association of anxiety and depression among health specialties students with GERD in Makkah city, kingdom of Saudi Arabia (KSA). Cross-sectional study

Introduction: The correlation between psychological factors and digestive abnormalities is significant, yet, the entire mechanism still undetermined. Objectives: Our study aimed to study the correlation between anxiety, depression, and GERD among health specialties students in Makkah city, Saudi Arabia (KSA). Methods : a survey-based study was demonstrated among health-related students in different medical colleges at Umm Al-Qura University in the period time between December 2020 and January 2021. GERD symptom frequency was evaluated using a previously validated gastroesophageal reflux symptom questionnaire GERD-Q; however, depressive and anxious symptoms were assessed using a Hospital Anxiety/Depression Scale (HADS). Result: A total of 353 students participated in the current study. The mean age of participants in the present study was 22.69 ± 2.27. Male participants represents the predominant of replying. The majority of respondents were 2nd-year students. There is a significant correlation between anxiety and depression among students with GERD (P-value, 0.001), (P-value, 0.017), respectively. Conclusions: Depression and anxiety represent a significant factor in correlation with students with GERD. association of anxiety depression

The association of anxiety and depression among health specialties students with GERD in Makkah city, kingdom of Saudi Arabia (KSA). Cross-sectional study.
Association with GERD among health specialties students in the Middle East and Saudi Arabia. Consequently, the current study aimed to study anxiety, depression, and their association with GERD among health specialties students in Makkah city, the kingdom of Saudi Arabia (KSA).

Methods
This cross-sectional survey was held between July 2021 to September 2021. The study was approved by the Medical Ethics Committee of Umm Al-Qura university, Saudi Arabia (ethical approval number: HAPO-02-K-012-2021-07-707) on July 18, 2021. All health-related departments were included in this survey, while students who refused to participate were excluded. The Epi Info™ 7.1.5 software (Center for Disease Control and Prevention; Atlanta, Georgia, USA) was used for sample size estimation. Thereby, the smallest sample size to accomplish enough power is 353. We surveyed students using a structured survey distributed using the google platform containing three parts; the first part focused on gathering students' demographics. Then, we gathered participants' symptoms of GERD using the validated questionnaire GERD-Q [29]. Lastly, we gathered participants' symptoms of anxiety and depression using a validated questionnaire [30]. Microsoft Excel sheets were used for data collection in the beginning. Then data were uploaded to a Statistical Package for the Social Scientists ver. 23 spreadsheets after being checked for completeness and minor typographical mistakes (IBM, Armonk, NY). For categorical variables, percentages were used, while mean and standard deviation were used for continuous data. A P-value of less than 5% is statistically significant. The categorical variables were compared using the Chi-square test.

Results
Overall, 353 students of health-related faculties were surveyed. More than half of the students were males (60.9%); ( Therefore, past medical history and description were given in (Table 2). Regarding Contributor's family history, 45.3% of participants had a positive family history of GERD, while 42.8% and 50.1% had a positive family history of anxiety and depression. Family history descriptions are given in (Table 2). According to the validated questionnaire, in diagnosing GERD [29], the majority of participants (33.7%) had a 50% likelihood rate of having GERD; Conversely, (18.4%) of participants had an 89% likelihood rate of having GERD ( Figure  1). On the other hand, concerning anxiety and depression diagnosis, based on the validated questionnaire in diagnosing both of them [30], 50.99 % of participants had anxiety while 37.68% had depression ( Figure 2), ( Figure 3). The most common mild symptoms of GERD duration among participants are burning feelings, difficulty getting sleep due to heartburn or regurgitation, and regurgitation. Moreover, the most common moderate symptoms of GERD among participants are nausea, pain in the center of the abdomen, and regurgitation. Furthermore, the most common severe symptoms of GERD among students are nausea, difficulty in getting sleep due to heartburn or regurgitation, and pain in the center of the abdomen. All GERD symptoms' are given in (Table 3). The association between students' collages and finals likelihood ratios and scores of GERD, anxiety, and depression are given in (Table 4); there is significant variation between students' collages and likelihood ratio of GERD (p-value, 0.013). Concerning the association relation of anxiety and depression among participants with GERD, Depression and anxiety were significantly higher in students with GERD (Table 5).

18.41%
Likelihood persentage of being diagnosed with GRED participants with a 0% probability of being diagnosed with GRED participants with a 50% probability of being diagnosed with GRED participants with a 79% probability of being diagnosed with GRED participants with a 89% probability of being diagnosed with GRED The association of anxiety and depression among health specialties students with GERD in Makkah city, kingdom of Saudi Arabia (KSA      The correlation between anxiety and depression among students with or without GERD. The association of anxiety and depression among health specialties students with GERD in Makkah city, kingdom of Saudi Arabia (KSA). Cross-sectional study. 15  The association of anxiety and depression among health specialties students with GERD in Makkah city, kingdom of Saudi Arabia (KSA). Cross-sectional study.

Discussion
Psychological factors complicate the treatment of functional GI disorder, resulting in poor outcomes [31][32]. Still, the correlation between the severity of symptoms of GERD and pathophysiological abnormalities is not significant. This supports the concept that psychological factors strongly affect GERD symptoms [31,33]. Limited studies globally have been investigating the relationship between depression and anxiety and GERD symptoms; however, no constant outcome from those studies [31,34]. To specify the appropriate treatment, a clear picture of the relationship between psychological factors and GERD should be established [31]. However, if left undetermined, it will lead to poor consequences as these psychological factors can increase GERD symptoms and worsen treatment and quality of life. [31]. Thus, the current study aims to recognize the frequency of GERD, depression, and anxiety and identify their relationship. Our study emphasizes a substantial level of anxiety and depression compared to GERD. A Pakistani crosssectional study [31] revealed that 41.4% of respondents had depression, and 34.4% of participants had anxiety. This closely corresponds with the present study in which 51% of participants had anxiety while 33.1% were still borderline abnormal. Additionally, the majority of participants, 46.2%, remain in borderline abnormal depression, while 37.7% had depression. The association between anxiety and depression among GERD students is not yet understood. However, the association between the brain and the GI tract has been recognized. The disturbance of GI function may be influenced and escalated by stress and emotions by inducing the pain perception through the gut-brain axis; the same induction was also applicable to patients with GERD [31,32]. A significant association between anxiety and depression among participants with GERD was emphasized in the current study, and this strongly agreed with the study of Mohammad S, 2019 [31]. Concerning the frequency of GERD symptoms among students, our study shows that nausea is the most common moderate and severe symptom. This disagrees with one of the Saudis studies in which regurgitation represents the most common symptom among participants [35]. The current study found that GERD had a significant association with students' collages. However, the univariate and multivariable analysis of factors associated with GERD among university students in one of the Saudi studies [1] shows that students in non-health colleges could be a factor in association with GERD, which disagrees with our study. Furthermore, another international study reveals that in individuals with major depressive disorder, the prevalence of GERD was substantially higher [36]. Moreover, Indian research founds that there are psychiatric illnesses among people with GERD [37]. Our study aimed to investigate the frequency of depression and anxiety among students with GERD at UQU in Makkah city, Saudi Arabia. However, a few possible limitations may be noticed; firstly, this is a single-center study; accordingly, the results are not illustrative. A second potential article limitation is that the particular direction of correlation between GERD and psychological symptoms cannot be determined, as this is a cross-sectional study. Henceforth, we recommend more investigation to determine the exact prevalence of depression and anxiety among people with GERD and find out the correlated risk factors.

Conclusion
The study findings suggests a significant frequency proportion of anxiety and depression among students with GERD. However, this topic needs supplementary investigation to determine the particular frequency of depression and anxiety among people with GERD and the correlated risk factors.