Journal of Psychiatric Research 47 (2013) 128e132

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Journal of Psychiatric Research

journal homepage: www.elsevier.com/locate/psychires

Gastritis and mental disorders

Renee D. Goodwin a, b, *, Robert A. Cowles c, Sandro Galea b, Frank Jacobi d
a
Department of Psychology, Queens College, City University of New York (CUNY), Flushing, NY, USA
b
Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
c
Division of Pediatric Surgery, Columbia University College of Physicians and Surgeons, Morgan Stanley Children’s Hospital of New York-Presbyterian, New York, NY, USA
d
Institute of Clinical Psychology and Psychotherapy, Center of Epidemiology and Longitudinal Studies (CELOS), Technische Universitat Dresden, and Psychologische Hochschule Berlin,
Berlin, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Although previous studies have suggested an association between various gastrointestinal disorders and
Received 8 May 2012 mood and anxiety disorders, no previous study has examined the relationship between a diagnosis of
Received in revised form gastritis and mood and anxiety disorders in the community. This work aimed to investigate the asso-
14 September 2012
ciation between physician-diagnosed gastritis and DSM-IV mood and anxiety disorders among adults in
Accepted 20 September 2012
the general population, and to examine sex differences in these relationships. Data were drawn from
a population-based, representative sample of 4181 adults aged 18e79 in the German National Health
Keywords:
Interview and Examination Survey. Anxiety disorders (27.0% vs. 15.3%) and affective disorders (20.1% vs.
Gastritis
Mood disorders
11.5%) were significantly more common among adults with compared to without a diagnosis of gastritis.
Anxiety Lifetime and current physician diagnosed gastritis were associated with an increased prevalence of panic
Gender attacks, social phobia, any mood disorder and major depression, compared to those without gastritis.
Gastroenterology There were no significant sex differences in these associations. A diagnosis of gastritis appears to be
Epidemiology associated with significantly increased odds of mood and anxiety disorders among adults in the general
population. Contrary to findings from animal studies, we found the relationship between gastritis and
mood/anxiety consistent among both sexes.
Ó 2012 Published by Elsevier Ltd.

1. Introduction in the general population. Second, murine models have demon-

There has been persistent interest in the relationship between
gastrointestinal disorders and mood and anxiety disorders. Several
clinical and epidemiologic studies have found significant relation-
ships between mood and anxiety disorders and various common
gastrointestinal disorders, including peptic ulcer, irritable bowel
syndrome and Crohn’s Disease (Dunlop et al., 2003; Goodwin et al.,
2006; Mawdsley and Rampton, 2005; Mayer, 2000; Mayer et al.,
2001; Schwarz et al., 1993; Walker et al., 2008; Whitehead et al.,
2002). A small number of clinical studies have documented
elevated levels of depressive symptoms among selected samples of
patients with gastritis (Magni et al., 1982; Solov’eva et al., 1997) and
high rates of mood and anxiety disorder diagnoses among general
gastroenterology outpatients (Jiang et al., 2009).
Yet, some key questions remain unanswered regarding the
relationship between gastritis and mental disorders. First, to our
knowledge, no previous epidemiologic studies have examined the
relationship between gastritis and mental disorders among adults
strated gender-related differences in the relationship between
gastritis and anxiety and depression. For instance, Painsipp et al.,
2007 found that induced gastritis is associated with increased
anxiety (and a reduction of circulating corticosteroid) in female but
not male murine models. Whether and to what degree this gender
difference in the relationship between gastritis and anxiety exists
among humans has not been examined. If the same gender differ-
ence is seen in humans, this would be strong evidence suggesting
a key gender-related difference in brainegut relations.
Against this background, the present study aimed to fill these
gaps. First, the study investigated the relationship between
physician-diagnosed gastritis and mood and anxiety disorders
among adults in a representative community sample. Second, the
study examined gender-based differences in the relationship
between a diagnosis of gastritis and mood and anxiety disorders.
2. Materials and methods

* Corresponding author. Department of Psychology, Queens College, City
University of New York (CUNY), Flushing, NY 11367, USA. Tel.: þ1 718 997 3247;
fax: þ1 718 997 3225.
E-mail address: rdg66@columbia.edu (R.D. Goodwin).
2.1. Sample
The sample of the German National Health Interview and
Examination Survey (GHS) survey was drawn from the population

0022-3956/$ e see front matter Ó 2012 Published by Elsevier Ltd.

http://dx.doi.org/10.1016/j.jpsychires.2012.09.016
 R.D. Goodwin et al. / Journal of Psychiatric Research 47 (2013) 128e132 129

registries of subjects aged 18e79 living in Germany in the year
1997. It represents a stratified random sample from 113 commu-
nities throughout Germany with 130 sampling units. The first
sampling step was the selection of communities; the second step
was the selection of sampling units. The third step was the selection
of inhabitants. Reasons for non-participation, analyses of non-
respondents, and further information on samples and weighting
are provided elsewhere (Jacobi et al., 2004, 2002). The current
analyses include only the subsample that also underwent
comprehensive mental health assessment (participants of the
Mental Health Supplement; GHS-MHS). The GHS-MHS included
only persons aged 18e65 years of age. The conditional response
rate of the GHS-MHS was 87.6%, resulting in a total of 4181
respondents who completed both core survey (physical assess-
ment) and mental health assessment. Socioeconomic status was
measured using a composite measure derived from educational
level, job status, and income (see Jacobi et al., 2002). The investi-
gation was carried out in accordance with the latest version of the
Declaration of Helsinki. The study design was reviewed by the
Robert Koch Institute and informed consent of the participants was
obtained after the nature of the procedures had been fully
explained.
2.2. Assessment of gastritis
The core survey assessment included a standardized computer
assisted medical interview (CAPI) conducted by study physicians.
Gastritis was diagnosed within the medical interview with the
following questions: Have you ever been diagnosed with gastritis
(doctors could ask additional questions or explain the condition if
a respondent was not sure)? If YES: 2. When was the first onset
(age), and when did you have that condition last time (within last
four weeks/within last 12 months/more than a year ago).
2.3. Assessment of mental disorders
differences among males and females, and analyses were adjusted
for SES. Odds ratios (OR) with 95% confidence intervals (CI) were
calculated with Stata software package, release 7.0 (StataCorp,
2000).
3. Results
3.1. Demographic characteristics associated with gastritis
The prevalence of gastritis was significantly higher among
females compared with males, and a marginal association between
lower socioeconomic status and increased levels of gastritis (see
Table 1). There was no statistically significant relationship between
gastritis and age.
3.2. Gastritis and mental disorders
Gastritis was associated with a significantly increased likelihood
of any anxiety disorder, panic attacks, social phobia, any mood
disorder and major depression in the past 12-months when
compared to those without gastritis (see Table 2). These associa-
tions remained significant after adjusting for differences in demo-
graphic characteristics and regardless of the timeframe of
measurement for gastritis.
3.3. Gastritis and mental disorders among females
Results indicated a statistically significant relationship between
current (prior to past 12 months) and remitted (past 12 months)
gastritis and any anxiety, any mood, major depression, panic
attacks and social phobia in the past 12 months when compared to
those without lifetime gastritis (see Table 3). The associations
remained statistically significant after adjusting for age and socio-
economic status.

Most interviews of the GHS-MHS took place within two to four
weeks of the core survey medical examination in order to ensure
that data gathered in both examinations was contemporaneous.
Psychopathological and diagnostic assessments were based on the
computer-assisted version of the Munich Composite International
Diagnostic Interview (DIA-X/M-CIDI) (Knauper and Wittchen,
1994; Wittchen and Pfister, 1997; Wittchen, 1994). The DIA-X/M-
CIDI is a modified version of the World Health Organization CIDI,
version 1.2, supplemented with questions to cover DSM-IV and
ICD-10 criteria. The DIA-X/M-CIDI is a fully structured interview
3.4. Gastritis and mental disorders among males
Current (past 12 month) and remitted (prior to past 12 month)
gastritis was associated with significantly increased likelihood of
any anxiety, social phobia, panic attacks and any mood disorders in
the past 12 months (see Table 4). The associations between gastritis
Table 1
Demographics associated with remitted and current gastritis.

that allows for the assessment of symptoms, syndromes, and None (3094) Prior to 12 12 Months p value
current and lifetime diagnoses of DSM-IV mental disorders months (691) (170)
(Wittchen et al., 1999). The following diagnoses were included: Age
mood disorders (unipolar major depression/dysthymia and bipolar 18e35 1140 130 49 p ¼ .4
36.1% 18.4% 28.2%
disorders), anxiety disorders (panic disorder with or without
36e55 1096 262 62
agoraphobia), social phobia, specific phobias, generalized anxiety 34.7% 37.2% 35.6%
disorder (GAD), and obsessive-compulsive disorder (OCD). 55þ 920 313 63
29.2% 44.4% 36.2%
2.4. Analytic strategy Sex
Male 1499 291 68 p < .0001
47.5% 41.3% 39.1%
First, bivariate analyses were used to investigate the relation- Female 1657 414 106
ships between gastritis and demographic characteristics, and 52.5% 58.7% 60.9%
between gastritis and mood and anxiety disorders. Multiple logistic SES
1 607 148 34 p ¼ .05
regression analyses were then used to examine the association
19.6% 21.4% 20.0%
between gastritis and the odds of each mood and anxiety disorder 2 1790 395 98
by comparing the likelihood of each mental disorder among those 57.9% 57.2% 57.7%
with, compared to those without, gastritis in each analysis. These 3 697 148 38
analyses were adjusted for differences in age, sex, SES, and alcohol 22.5% 21.4% 22.4%

use disorders. The same procedure was then used to examine these SES ¼ socioeconomic status.
130 R.D. Goodwin et al. / Journal of Psychiatric Research 47 (2013) 128e132

Table 2
Gastritis and mood and anxiety disorders among adults in the community.

None Prior to OR AOR1 12 Months OR AOR1 AOR2

12 months (n ¼ 705) (n ¼ 174)
Any anxiety disorder 484 153 1.5 1.5 47 2.0 1.9 1.9
15.3% 21.7% (1.2, 1.9) (1.2, 1.8) 27.0% (1.4, 2.9) (1.4, 2.8) (1.4, 2.8)
Panic attack 141 66 2.2 2.1 18 2.4 2.3 2.3
4.5% 9.2% (1.6, 2.9) (1.5, 2.9) 10.3% (1.5, 4.1) (1.4, 3.9) (1.3, 3.9)
Social phobia 254 75 1.4 1.3 30 2.4 2.2 2.2
8.1% 10.6% (1.0, 1.8) (1.0, 1.8) 17.2% (1.6, 3.6) (1.5, 3.4) (1.4, 3.4)
Any mood disorder 364 121 1.6 1.6 37 2.1 2.1 2.1
11.5% 17.2% (1.3, 2.0) (1.2, 2.0) 21.3% (1.4, 3.0) (1.4, 3.0) (1.4, 3.0)
MDD 332 106 1.5 1.4 35 2.1 2.1 2.1
10.5% 15.0% (1.2, 1.9) (1.1, 1.8) 20.1% (1.5, 3.2) (1.4, 3.1) (1.4, 3.1)
1
AOR ¼ adjusted for age, sex and socioeconomic level.
AOR2 ¼ adjusted for age, sex, socioeconomic level and alcohol.
MDD ¼ major depressive disorder.

and mood and anxiety disorders were stronger among males
compared with females.
4. Discussion
The study has two main findings. First, a diagnosis of gastritis
appears to be associated with significantly increased odds of mood
and anxiety disorders among adults in the general population. The
strength of this association is stronger when the two conditions
occur contemporaneously, but remains significant even when they
are not. Second, the association between a diagnosis of gastritis and
mood and anxiety disorders is evident among both females and
males. The strength of the association is somewhat stronger among
males.
Numerous previous studies have documented higher rates of
psychiatric disorders among individuals with gastrointestinal
disorders (Goodwin et al., 2006; Schwarz et al., 1993; Walker et al.,
2008). To our knowledge, this study is the first to specifically
investigate gastritis with respect to mental disorders. Based on
these data, a diagnosis of gastritis appears to be associated with
increased odds of mood and anxiety disorders. While it is not
possible to identify the detailed mechanisms of these relationships
based on this study, two dominant possibilities exist. First, there
could be a causal relationship between the two. It is conceivable
that the discomfort, pain and/or functional limitations associated
with gastritis e depending on severity e could lead to increased
feelings of anxiety or depression perhaps among those who are
vulnerable. It is also possible that anxiety at extremely high levels
which is characteristic of anxiety disorders could lead to gastritis
via a neural pathway leading to irritation/inflammation of stomach
lining (Konturek et al., 2011). Second, there could be a common
genetic or environmental risk factor for both gastritis and
depression/anxiety. For instance, there might be common genetic
variants that predispose an individual to both gastrointestinal and
affective disturbances. Regardless of the exact mechanism, a rela-
tionship between emotional or psychological stress and gastroin-
testinal disease has been recognized and raises important
questions regarding potential links between the brain and the
gastrointestinal (GI) tract. The finding that the brain controls
certain physiologic functions of the GI tract is not new and has been
accepted since Pavlov conducted his classic experiments on canine
salivation and gastric acid secretion in the late 19th century
(Konturek, 2003). Chemically, the neurotransmitters that are active
in the brain are also known to be active in the GI tract. Serotonin, for
example, a neurotransmitter that is implicated in many psychiatric
disorders, is also known to be an important factor in certain GI
disorders such as irritable bowel syndrome (Sikander et al., 2009).
Anatomically, the innervation of the GI tract can be traced back to
the brain with the most obvious example being the vagus nerve.
The vagus nerve extends from the brainstem to the GI tract where it
provides innervation to the esophagus, stomach, small intestine,
liver and pancreas (Ratcliffe et al., 2011). Based upon the findings of
Pavlov and others and since the brain and the GI tract are so clearly
connected chemically and anatomically, the presence of a func-
tional “BraineGut Axis” has been proposed. While much of the
impact of the BraineGut Axis on normal function is understood, the
impact of this relationship on pathologic processes is the subject of
current research (Konturek et al., 2011). Although the findings of
the current report unfortunately cannot shed additional light on
the mechanisms that underlie the BraineGut Axis, the presence of
such an Axis however provides a very plausible mechanism by
which our findings can occur. Alternatively, it could be that expo-
sure to a chronic stressor, such as financial insecurity/poverty,
community violence and/or standard housing conditions could

Table 3
Gastritis and mood and anxiety disorders among females.

None Prior to 12 months (n ¼ 414) OR AOR1 12 Months (n ¼ 106) OR AOR1

Any anxiety disorder 342 107 1.3 1.4 35 1.9 1.9
20.6% 25.9% (1.0, 1.7) (1.1, 1.8) 33.0% (1.2, 2.9) (1.2, 2.9)
Panic attack 90 45 2.1 2.2 14 2.6 1.6
5.4% 10.9% (1.5, 3.1) (1.5, 3.3) 13.2% (1.5, 4.8) (1.4, 4.8)
Social phobia 184 56 1.3 1.3 23 2.2 2.2
11.1% 13.5% (0.9, 1.7) (0.9, 1.8) 21.7% (1.4, 3.6) (1.3, 3.6)
Any mood disorder 243 86 1.5 1.5 23 1.6 1.7
14.7% 20.8% (1.2, 2.0) (1.2, 2.0) 21.7% (1.0, 2.6) (1.0, 2.7)
MDD 228 75 1.4 1,4 21 1.5 1.9
13.8% 18.1% (1.0, 1.8) (1.0, 1.8) 19.8% (1.0, 2.5) 6 (0.97, 2.6)

AOR1 ¼ adjusted for age and socioeconomic level.

 R.D. Goodwin et al. / Journal of Psychiatric Research 47 (2013) 128e132 131

Table 4
Gastritis and mood and anxiety disorders among males.

None Prior to 12 months (n ¼ 291) OR AOR1 12 Months (n ¼ 68) OR AOR1

Any anxiety disorder 142 46 1.8 1.7 12 2.0 2.1
9.5% 15.8% (1.3, 2.6) (1.2, 2.4) 17.7% (1.1, 3.9) (1.1, 4.0)
Panic attack 51 20 2.1 1.8 4 1.8 1.7
3.4% 6.9% (1.2, 3.6) (1.0, 3.1) 5.9% (0.6, 5.1) (0.6, 4.9)
Social phobia 70 19 1.4 1.5 7 2.3 2.4
4.7% 6.5% (0.8, 2.4) (0.8, 2.5) 10.3% (1.0, 5.3) (1.1, 5.5)
Any mood disorder 121 35 1.6 1.6 14 3.0 3.1
8.1% 12.0% (1.0, 2.3) (1.1, 2.4) 20.6% (1.6, 5.5) (1.7, 5.7)
MDD 104 31 1.6 1.5 14 3.5 3.6
6.9% 10.7% (1.0, 2.4) (0.98, 2.4) 20.6% (1.9, 6.5) (1.9, 6.6)

AOR1 ¼ adjusted for age and socioeconomic level.

potentially lead to the development of both gastritis and mood/
anxiety disorders.
We examined gender differences in an attempt to replicate
findings from an animal study (Painsipp et al., 2007). In contrast to
results using a murine model of gastritis and increased anxiety, we
found the association between gastritis and anxiety in both males
and females. We also found a slightly stronger relationship among
males. It is unclear what may account for these discrepancies.
Methodological differences in measurement are one possibility,
and another is that there are differences in murine and human
modeling of these pathways. Replication of either of these findings
is needed.
There were several shortcomings that limit the generalizability
of this study. First, while participants were interviewed and eval-
uated by physicians, there were no objective diagnostic tests for
gastritis. It is possible that mood and anxiety disorders could lead
to increased recall of gastritis versus those without mood/anxiety
problems thereby leading to inflated odd ratios. It is also conceiv-
able that adults with mood/anxiety disorders might have seen
more doctors e due to seeking mental health treatment e and
therefore those with gastritis may be more likely to receive
a diagnosis than those without mental health problems due to the
fact that they have seen more physicians and are more likely to be
referred to a gastroenterologist. However, since only a small
percentage of those with mood/anxiety disorders seek mental
health treatment, this idea seems less likely to be a threat than if
this were a clinical sample. Using endoscopy, for instance, to
confirm diagnoses would strengthen confidence in the diagnosis
and potentially could provide information on severity which would
also be of interest in this context. However, we are not aware of any
population-based representative studies that have obtained
endoscopy on large numbers of participantsdgiven that it is an
invasive procedure. In the absence of this, our data are an
improvement over self-report alone. Second, we have no infor-
mation on medications taken for either gastritis or mental disor-
ders, which are a plausible pathway that could link the two. It is
further possible that functional dyspeptic symptoms (which are
common in mood and anxiety disorders) could be misdiagnosed as
gastritis. Diagnosis by a physician who evaluated each participant
for mental health conditions as well should reduce the likelihood of
this error (as awareness of mood/anxiety problems by the physi-
cians should enable them to ask questions on the timing/frequency
of dyspeptic symptoms to tease this apart). Yet, this is a possible
source of error that cannot be ruled out without more objective
tests.
To our knowledge, this is the first epidemiologic study to
examine the relationship between a diagnosis of gastritis and
mental disorders in a representative sample of adults in the
community. Our results suggest a significant link between a diag-
nosis of gastritis and increased likelihood of mood and anxiety
disorders. We did not find significant gender differences in these
relationships. Future studies that can investigate possible physio-
logical pathways of these relationships are needed, and may help to
shed light on etiology of both gastritis and mood and anxiety
disorders. Given our results suggesting that almost one in three
adults with gastritis had an anxiety disorder and one in five had
a mood disorder in the past year, it may be pertinent to consider
screening for mental health problems in this clinical population, if
these findings are replicated. Our results also imply that treatment
for mood and anxiety disorders may contribute to causing relief of
gastrointestinal illness.
Funding source
The authors have received no funding for this paper.
Contributors
RDG conceived of the study, RDG and FJ analyzed the data, SG
and RC wrote sections of the manuscript and assisted in interpre-
tation of results.
Conflict of interest
The authors report no conflicts of interest.
Acknowledgments
The authors would like to thank Jamie Chiel for editing and
manuscript preparation assistance.
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