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www.elsevier.es/medicinaclinica

Review

Fibromyalgia: Prevalence, epidemiologic profiles and economic costs夽

Asensi Cabo-Meseguer a,∗ , Germán Cerdá-Olmedo b , José Luis Trillo-Mata c
a
Escuela de Doctorado, Universidad Católica de Valencia San Vicente Mártir, Valencia, Spain
b
Facultad de Medicina, Universidad Católica de Valencia San Vicente Mártir, Valencia, Spain
c
Departamento Clínico Malvarrosa, Conselleria de Sanidad, Generalitat Valenciana, Valencia, Spain

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

Article history: Fibromyalgia is an idiopathic chronic condition that causes widespread musculoskeletal pain, hyperal-
Received 18 April 2017 gesia and allodynia. This review aims to approach the general epidemiology of fibromyalgia according to
Accepted 8 June 2017 the most recent published studies, identifying the general worldwide prevalence of the disease, its basic
Available online xxx
epidemiological profiles and its economic costs, with specific interest in the Spanish and Comunidad
Valenciana cases.
Keywords: Fibromyalgia affects, on average, 2.10% of the world’s population; 2.31% of the European population;
Fibromyalgia
2.40% of the Spanish population; and 3.69% of the population in the Comunidad Valenciana. It supposes
Epidemiology
Prevalence
a painful loss of the quality of life of the people who suffer it and the economic costs are enormous: in
Economic impact Spain is has been estimated at more than 12,993 million euros annually.
© 2017 Elsevier España, S.L.U. All rights reserved.

Fibromialgia: prevalencia, perfiles epidemiológicos y costes económicos

r e s u m e n

Palabras clave: La fibromialgia es una enfermedad crónica idiopática que ocasiona dolor musculoesquelético
Fibromialgia generalizado, hiperalgesia y alodinia. La presente revisión pretende aproximarse a la epidemiología gen-
Epidemiología eral de la fibromialgia de acuerdo con los más recientes estudios publicados, identificar la prevalencia
Prevalencia
general de la enfermedad a nivel mundial, sus perfiles epidemiológicos básicos y los costes económicos
Impacto económico
que ocasiona, con interés específico en el caso de España y de la Comunidad Valenciana.
La fibromialgia afecta como promedio a un 2,10% de la población mundial; al 2,31% de la europea; al
2,40% en la población española y al 3,69% de la población en la Comunidad Autónoma Valenciana. Supone
una dolorosa pérdida de la calidad de vida de las personas que la presentan y los costes económicos son
enormes: en el caso español se han estimado en más de 12.993 millones de euros anuales.
© 2017 Elsevier España, S.L.U. Todos los derechos reservados.

Introduction loskeletal pain, with low tolerance to pain, hyperalgesia and

Fibromyalgia (FM) is a chronic condition of unknown aetiology,
characterized by the presence of chronic generalized muscu-
夽 Please cite this article as: Cabo-Meseguer A, Cerdá-Olmedo G, Trillo-Mata JL.
Fibromialgia: prevalencia, perfiles epidemiológicos y costes económicos. Med Clin
(Barc). 2017. https://doi.org/10.1016/j.medcli.2017.06.008
∗ Corresponding author.
E-mail address: asensicabo@hotmail.com (A. Cabo-Meseguer).
allodynia. In affected individuals, the presence of chronic pain
usually coexists with other symptoms, mainly fatigue, sleep prob-
lems, anxiety and depression, but patients may also experience
paresthesias, joint stiffness, headache, swelling in the hands, con-
centration difficulties and memory impairment. The natural course
of FM is chronic, with fluctuations in the intensity of symptoms
over time. Its etiopathogenesis is not clearly defined. It is consid-
ered multifactorial and combines genetic and epigenetic factors
that determine a persistent dysfunction in pain regulation systems
and central nociceptive hyperexcitability along with a decreased

2387-0206/© 2017 Elsevier España, S.L.U. All rights reserved.

MEDCLE-4151; No. of Pages 8

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inhibitory response activity related to pain modulation and
control.
The risk of suffering FM seems to be controlled by several
essential factors: being female (the sex ratio is approximately
9 women per every male); familial aggregation; the concomi-
tant existence of chronic regional pain (myofascial, pelvic, lumbar,
headache,. . .) and the presence of emotional stress (anxiety,
depression and, to a lesser extent, post-traumatic stress and
obsessive–compulsive disorder).1 In addition, it is more frequent
in the adult age, especially between 40 and 49 years of age;
more frequent in rural than in urban areas and is also more
common among people with lower educational and economic
levels.2,3
Objective
The objective of the present review is to analyze the general
prevalence of FM in different geographic areas of the world, its basic
epidemiological profiles and economic costs, with specific interest
in Spain and the Valencian Community.
Method
The present review derives from a systematic search in Pubmed,
Cochrane and Google Scholar databases, in addition to the man-
ual search related to articles of special relevance. Descriptors
were used with the following keywords: fibromyalgia epidemiol-
ogy; fibromyalgia impact; epidemiology of fibromyalgia; fibromyalgia
and epidemiology; epidemiological study and fibromyalgia; fibromyal-
gia prevalence; fibromyalgia costs; fibromyalgia and health care costs.
The search was aimed at both clinical studies and reviews and was
limited to publications in the last 10 years, although previous lit-
erature was considered due to its importance in understanding the
disease’s epidemiology (e.g., epidemiological and diagnostic stud-
ies conducted by Wolfe et al. which are mentioned later). A total
of 32 studies were selected. For this purpose, the studies had to
fulfil one of the following criteria -always for specific geographic
areas: (1) the study makes a specific estimate of the prevalence of
FM; (2) the study determines the impact or weight of FM among
other diseases; (3) the study estimates the economic costs of
FM.
Results
Prevalence in Spain
Numerous studies document the importance of rheumatolog-
ical and musculoskeletal diseases accompanied by chronic pain
among the Spanish population and their impact on quality of
life, restriction of activities and the use of health resources.2–8
According to the EPISER study,2 published in 2001, probably
the most cited as an epidemiological source of rheumatic dis-
orders in Spain, FM is a highly prevalent disease affecting 2.4%
of the population. In relation to other musculoskeletal disor-
ders, FM is more prevalent in Spain than rheumatoid arthritis
(0.5%), but less than osteoarthritis of the hand (6.2%), osteoarthri-
tis of the knee (10.2%) and low back pain (14.8%). However,
as we will see later, FM has the highest levels of quality of
life deterioration in terms of social, familial, intellectual, emo-
tional and health impact. In fact, comparing FM with other
rheumatic conditions,3 functional capacity impairment in FM
is only exceeded by rheumatoid arthritis. Regarding psycho-
logical factors of health-related quality of life, as measured
by the Soft form health survey (SF-12), FM is the rheumatic
disease with the highest level of involvement, besides being the
rheumatologic syndrome with the highest concomitant presence of
depression.3
Focusing again on FM, by gender, prevalence is much higher
in women (4.2%) than in men (0.2%), which would imply a 21:1
female/male ratio.3 The highest prevalence peak is found among
women within the 40–49 age group. In non-specialized health
services, consultations due to FM account for between 2.1% and
5.7% and among specialized rheumatology consultations, it rises to
10–20%.2
For its part, the EPIDOR study7,9 (Pain in Spanish rheumatol-
ogy outpatient offices: epidemiological study), published in 2003,
which focused on an extensive multicentric sample of rheuma-
tology patients, found that the prevalence of FM consultations
was 12.2%. A key finding in this study is the fact that the inten-
sity of pain experienced by people with FM is greater than that
experienced by the rest of the population affected by chronic
rheumatic pain. The female-to-male ratio is 7:1, with a preva-
lence of 2.2% for males and 15.8% for females. With respect to
the average age, the authors have estimated it to be 49 years,
with higher prevalence in the 46–65 years age group. As in
the case of EPISER,2 the prevalence of FM is higher in the case
of patients with low sociocultural levels, but, unlike EPISER,
EPIDOR7 shows that FM is more prevalent in urban than in rural
areas (only 10.4% of the sample of fibromyalgia patients comes
from rural areas). Other recent national studies10 find similar
results regarding the prevalence of FM in the general population
(2.3%).
The EPIFFAC study11 is also widely cited in the field of FM epi-
demiology, it is a nationwide, multicenter study which included
325 diagnosed patients. Its main objective was to study the famil-
ial and occupational impact of FM. It determined a fibromyalgia
patient profile as female in 96.6% of the cases, with an average
age of 52 years, with symptoms that began at a mean age of 37
and that, at the time of the study, had suffered the disease for
15 years, on average. From the start of symptomatology to diag-
nosis there is a latency of 6.6 years. The study collects a gloomy
set of familial and occupational impacts caused by the disease, in
addition to perceptions of deterioration caused by the disease in
terms of health, work, leisure, psychological health, career, fam-
ily economy, partner relationships, citizen rights, family and social
relations.
Other European countries
In relation to other European countries, in 2010, and using
the London Fibromyalgia epidemiological study screening question-
naire, Branco et al.12 estimated the prevalence of FM in Spain as
4%, higher than France (2.2%) and Portugal (3.7%), but lower than
Germany (5.8%) and Italy (6.6%). However, when comparing the
relative prevalence of these countries regarding FM comorbidity
with chronic fatigue, Spain reduces its prevalence to 2.3%. France
would have the most favourable prevalence (1.4%), while Germany,
Portugal and Italy would have the most unfavourable prevalence
(3.2, 3.6 and 3.7, respectively). By gender, according to the results
of this study for Spain, and if we consider FM alone, the preva-
lence of women stands at 5.2% and that of men at 2.7%. Considering
the joint diagnosis, the prevalence is 3.3% in women and 1.3% in
men.
The same author,13 in a nationwide comparative study of
rheumatic disorders in Portugal, reduces the prevalence of FM to
1.7% and confirms the significant deterioration of the quality of life,
high health costs and the psychological deterioration caused by
these diseases.
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The American case
There are numerous epidemiological studies that analyze the
characterization of FM in the USA. One of the first was con-
ducted by Wolfe et al.,14 in Wichita, Kansas. They estimate
the prevalence of generalized pain in 10.6% of the popula-
tion. Specifically, the estimated prevalence of FM diagnosed
with the ACR 1990 criteria is found in 2% of the population:
3.4% for women and 0.5% for men. The prevalence is higher
in women of all age groups, with a peak of 7.4% in the case
of women in the 70–79 years age range (values between 60
and 69 [7.1%] and 50–59 [5.6%] are also high). With this infor-
mation, Lawrence et al.,15 in a general study on rheumatic
conditions, estimate that, in the USA, FM affects a total of
approximately 5 million people aged 18 and over. In addition,
Wolfe et al.14 found that FM is associated with low educa-
tional levels and low incomes. Likewise, FM is related to a
higher number of doctor visits and the receipt of disability
benefits.
In 2014, the same team16 studied an extensive sample of
patients with FM, with the following characterization: mean
age 52 years; 96% women; married in 69% of cases; 40%
were working; 18% were smokers; overweight (mean muscle
mass of 31) and with an average income of $45,000 per year
(D 41,165).
Vincent et al.17 conducted an interesting study in Minnesota,
comparing the prevalence calculated by 2 methods: the prevalence
of FM was at 1.1% when the estimate was calculated by confirm-
ing the clinical diagnosis using the Rochester epidemiology project
(healthcare database). However, the prevalence of FM reached 6.4%
of the population when the estimate was calculated by means of a
randomized survey using the ACR Preliminary diagnostic criteria for
fibromyalgia 2010 established by Wolfe et al. for epidemiological
research.18
On the other hand, Walitt et al.,19 in a very recent epidemiologi-
cal study in the USA (2015) estimated a population’s FM prevalence
of 1.75% (approximately 3.94 million people), higher in women
(2.38%) than in men (1.06%). By age groups, the highest prevalence
was found in the group between 50 and 59 years of age (2.41%).
This group was also the most prevalent among males (2.29%);
however, among women, the 70–79 group was the most affected
(2.61%). They did not find significant differences among ethnicities
between Hispanic and non-Hispanic citizens, nor between Hispanic
and black or white non-Hispanic, but what was clearly identified
was the fact that Asian people had a significantly lower prevalence
(0.20%).
In Canada, a widely-cited study by White20 estimates the preva-
lence of FM in London (Ontario), at 3.3% (4.9 in women and 1.6 in
men). As in the previously mentioned US case, prevalence increases
with age and a peak of 7.9% is found in the case of women aged
55–64 years. Also in Canada, using the state’s national healthcare
database, McNally et al.21 found a prevalence of 1.1% for people
with FM over the total population. The ratio between women and
men is 6:1 (female prevalence is 1.8% and male prevalence is 0.3%).
The highest prevalence peak occurs in women between the ages of
55 and 64 years.
In Brazil, Rodrigues et al.22 performed a comparative study of
4 rheumatic disorders. For this study, FM had a prevalence of
2.5%, below the prevalence of osteoarthritis (4.14%), but above
rheumatoid arthritis (0.46%) and lupus erythematosus (0.098%).
The mean age found in this study for women with FM was
53.4 years. In Germany, Wolfe et al.23 conducted a survey based
on the new 2010 criteria and found a prevalence of 2.1% (2.4
in women and 1.8 in men). On the other hand, Perrot et al.,24
in a national study in France, found a prevalence of FM of
1.6%.
3
Global reviews
Neumann and Buskila,25 in an interesting review of epidemio-
logical studies, found an FM prevalence of between 0.66% and 3.3%
in the general population, corresponding to Denmark and Canada,
respectively. Intermediate values are found in Pakistan (1.5%), Swe-
den (1.3) and the USA (2%).
In this same line of literature systematization, Queiroz26 (2013)
analyzed the prevalence in different countries of Europe, Asia and
America, as well as in Tunisia, Africa. The results are mixed and vary
between 0.3% in Greece and 9.3 in Tunisia. The average prevalence
found in the 20 countries studied was 2.7%, with a mean percentage
for women of 4.2% and 1.4% for men (mean ratio 3:1). Queiroz26
cites an interesting study carried out in 2006 by Weir et al.27 which
determined that the incidence of FM for men is 6.88 new cases
per 1000 people/year and for women of 11.28 new cases per 1000
people/year.
Very recently (2017), Marques et al.,28 from the University of
Sao Paulo in Brazil published an interesting updated review of the
prevalence of FM in special populations and in different countries
in Europe, Asia and America.
Overall prevalence
Table 1 shows data on the prevalence of FM in different countries
around the world, according to a summary of the previously men-
tioned literature and global reviews by Neumann and Buskila,25
Queiroz26 and Marques et al.28 As can be observed, the results found
in the different studies show an average world prevalence of FM of
2.1%, with a higher average prevalence in women (4.3%) than in
men (0.95%), and a global ratio of 4:1.
If we look at the averaged results of the different countries of
the European, American and Asian continents, the prevalence by
country would remain as shown in Fig. 1.
The highest prevalence is observed in the European continent,
above America and Asia; with the lowest prevalence belonging
to the latter. It is clear that the study’s methodologies influ-
ence the results, even the determination of the FM concept itself
and the diagnostic criteria used, although it is true that in most
cases, the American College of Rheumatology30 criteria have been
followed.
In addition to Tunisia, which has the highest prevalence of the
countries considered (9.3%), Turkey, Italy, Portugal, Germany and
Spain are the countries with the highest prevalence, all on the
European continent. Brazil and Iran have the highest rates in the
Americas and Asia, respectively.
Considering that the shortage of studies in Africa and Ocea-
nia does not allow the same level of data segregation as the
rest of the continents, and averaging the values studied, the
basic prevalence of FM in the world would be as described in
Fig. 2.
Comparing the basic epidemiological data, there is a higher
prevalence in the European continent (2.31%), higher than North
America (1.90%), Asia (1.64%) and South America (1.12%). How-
ever, although in all cases the prevalence of women is higher
than that of men, the proportion of women over men varies
between continents: it is higher in South America (12:1), above
Asia (5:1), North America (4:1) and Europe (3:1). Fig. 1 pro-
vides information on the statistical behaviour of the female/male
ratio.
The Spanish case deserves a special caution: the female:male,
21:1 ratio comes from the EPISER study,2 performed by the Span-
ish Society of Rheumatology, without doubt the most accepted
epidemiological reference of FM in the literature in Spain (Fig. 3).
However, if we consider the study by Branco et al.12 conducted in 5
European countries in 2010, although Spain has a global prevalence
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Table 1
Prevalence of FM in the world.

Country n Age range Prevalence Reference

Total In women In men

Europe Germany 2.445 ≥14 2.1 2.4 1.8 Wolfe et al., 201323
Germany 1.002 ≥15 3.2 3.9 2.5 Branco et al., 201012
Denmark 1.219 18–79 0.7 1.3 0.1 Neuman and Buskila, 200325
Scotland 1.604 ≥25 1.7 Marques et al., 201728
Spain 2.192 ≥20 2.4 4.2 0.2 Mas et al., 20013
Spain 1.001 ≥15 2.3 3.3 1.3 Branco et al., 201012
Finland 7.217 ≥30 0.8 1.0 0.5 Queiroz, 201326
France 1.014 ≥15 1.4 2.0 0.7 Branco et al., 201012
France 3.081 ≥18 1.6 Perrot et al., 201124
Greece 8.740 ≥19 0.4 Queiroz, 201326
Holland 2.447 ≥18 1.3 Marques et al., 201728
Italy 1.000 ≥15 3.7 5.5 1.6 Branco et al., 201012
Italy 2.155 ≥18 2.2 Queiroz, 201326
Portugal 500 ≥15 3.6 5.2 1.8 Branco et al., 201012
Portugal 3.877 ≥18 1.7 3.1 0.1 Branco et al., 201613
Sweden 2.425 20–74 1.3 2.4 0.0 Neuman and Buskila, 200325
Turkey 600 8.8 12.5 5.1 Queiroz, 201326
North America Glen 3.395 ≥18 3.3 4.9 1.6 White et al., 199820
Glen 131.535 ≥12 1.1 1.8 0.3 McNally et al., 200621
USA 3.006 ≥18 2.2 3.4 0.5 Wolfe et al., 199514
USA 3.410 ≥21 1.1 2.0 0.2 Vincent et al., 201317
USA 8.446 ≥18 1.8 2.4 1.1 Walitt et al., 201519
South America Brazil 12.000 ≥18 2.0 Marques et al., 201728
Brazil 3.038 ≥16 2.5 3.9 0.1 Queiroz, 201326
Cuba 3.155 0.2 Marques et al., 201728
Mexico 19.213 ≥18 0.7 1.0 0.3 Marques et al., 201728
Venezuela 3.973 ≥18 0.2 Marques et al., 201728
Asia Bangladesh 5.211 ≥15 3.6 6.2 0.9 Queiroz, 201326
China 1.467 0.8 Queiroz, 201326
Iran 2.700 ≥15 2.3 3.7 0.9 Marques et al., 201728
Israel 1.019 ≥18 2.0 2.8 1.1 Queiroz, 201326
Japan 20.407 ≥20 2.1 Marques et al., 201728
Lebanon 3.530 15–90 1.0 2.0 0.0 Marques et al., 201728
Malaysia 2.594 ≥15 0.9 1.5 0.2 Queiroz, 201326
Pakistan 1.997 ≥15 1.5 Neuman and Buskila, 200325
Thailand 1.000 0.6 Queiroz, 201326
Oceania New Zealand 1.498 ≥12 1.3 Klemp et al., 200229
Africa Tunisia 1.000 ≥15 9.3 Queiroz, 201326
Averages 7.266 2.0968 3.4333 0.9542
Median 2.521

Source: Author’s own.

0.0 2.0 4.0 6.0 8.0 10.0 similar to that of the EPISER study, the specific prevalence of women
Germany 2.7 and men shows a more modest 2.5:1 ratio. In any case, judging by
Denmark 0.7
the clinical experience in the different Spanish FM guides, the real
Scotland 1.7
Spain 2.4 figure seems to be found somewhere between the two. For exam-
Finland 0.8 ple, the ministerial guide1 for Spain, published in 2011, establishes
France 1.5
Greece 0.4
a ratio of 9:1.
Holland 1.3
Italy 3.0
Portugal 2.7
Sweden 1.3
Prevalence in the Valencian Community
Turkey 8.8
Glen 2.2 The prevalence derived from the Spanish estimates is quite
USA 1.7
Brazill 2.3 significant, and this prevalence becomes worrying when we
Cuba 0.2 specifically look to the Valencian Community. Fig. 4 shows the
Mexico 0.7
Venezuela 0.2
epidemiological importance of FM in Spain and in the Valencian
Bangladesh 3.6 Community, with prevalences higher by 0.30 and 1.59 percent-
China 0.8 age points, respectively, in relation to the global average of the
Iran 2.3
Israel 2.0 countries studied.
Japan 2.1 In fact, the prevalence found in the Valencian Community,31
Lebanon 1.0
Malaysia
after verification of the official healthcare information sources,
0.9
Pakistan 1.5 determined in December 2016, establishes a FM prevalence of
Thailand 0.6 3.69% for that geographical area, which affects a total of 183,357
New Zealand 1.3
Tunisia 9.3 people who have an active nosological diagnosis on a total popu-
lation of 4,969,359 people. This result is noteworthy, since it is not
Fig. 1. Prevalence of FM according to countries and continents. Source: Author’s derived from a sample estimate, but from the actual calculation of
own. active diagnoses in the Valencian Community.
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EUROPE
Total Prev. 2.31 ASIA
NORTH AMERICA Female Prev. 3.90 Total Prev. 1.64
Total Prev. 1.90 Male Prev. 1.31 Female Prev. 3.24
Female Prev. 2.90 Ratio 3:1 Male Prev. 0.62
Male Prev. 0.74 Ratio 5:1
Ratio 4:1

AFRICA
Tunisia 9.30
SOUTH AMERICA
Total Prev. 1.12
Female Prev. 2.45
Male Prev. 0.20 OCEANIA
Ratio 12:1 New Zealand 1.30

GLOBAL PREV.
Total Prev. 2.10
Female Prev. 3.43
Male Prev. 0.95
Ratio 4:1

Fig. 2. Fibromyalgia in the world.

0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0 the city. Consequently, for the time being, it is difficult to establish
Germany 1.5 comparative assessments on the prevalence of FM in terms of an
Denmark 13.0 autonomous region.
Spain 21.0
Finland 2.0
France 2.9 Economic costs of fibromyalgia
Italy 3.4
Portugal 16.9
Turkey 2.5 Regarding the economic costs of FM, several studies of interest
Glen 4.5 have been carried out. Berger et al.,34 in the USA, demonstrated an
USA 6.3
Brazil 39.0 average annual cost per patient of $9575 (approximately D 8684),
Mexico 3.3 3 times more than the control group without FM ($3291, D 2985).
Bangladesh 6.9
Iran 4.1
The median costs were 5 times greater for patients with FM ($4247,
Israel 2.5 approximately D 3852) versus the control group ($822, about
Malaysia 7.5 D 745).
World 3.6
After some reviews, Spaeth,35 in an editorial article published
Fig. 3. Female/male ratio. Source: Author’s own.
in Arthritis Research & Therapy magazine, concludes that a minimal
increase from 78.9 points to 81.5 in the Fibromyalgia impact ques-
tionnaire score, represents a D 865-increase in annual costs. For its
part, an increase of one point in Brief pain inventory represents a
Unfortunately, we have not found any studies that include esti- D 1453-increase in annual costs.
mates of FM prevalence for any autonomous region in Spain, in In the Spanish case, the 2006 SER consensus document,36 sup-
order to compare the relative importance of the result found for ported by a study by Boonen et al.,37 estimates the patient/year
the Valencian Community. In fact, we have reviewed global studies cost of FM at D 7813. Sicras-Mainar et al.33 also accepts this esti-
on FM in Spain,2–7,9,11,32 multicentric in most cases, with sampling mate in his work regarding the total number of patients over 18
belonging to different autonomous regions; however, the results years of age treated during 2006 in 5 primary care centres in
are not published per region. The studies carried out in specific Badalona. They found that FM represented 1.4% of the patients
autonomous regions are scarce and do not provide estimates for FM visited (904 people, 96.5% women). The average number of health
prevalence, such as the case of Ballina’s study in the Principality of problems/year and visits/year was much higher in the case of FM
Asturias,5 or that of Pueyo in Catalonia.8 The only study analyzed than in the general population: 8.3 versus 4.6 and 12.9 versus
that could allow us a comparative assessment in similar geographic 7.4, respectively. The direct costs derived from caring for people
terms, without being the same dimension, is that of Sicras-Mainar with FM were compared to the rest of the population treated,
et al.,33 which establishes an FM prevalence in the municipality finding that, in all the partial parameters evaluated (laboratory,
of Badalona (Catalonia) of 1.4% over a sample of 63,349 patients, diagnostic imaging, complementary tests, referrals to specialists,
who, in 2006, were treated in one of the 5 healthcare centres in pharmaceutical prescription,. . .), the cost of FM was higher. In total,
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They found a total cost of D 9982 patient/year, of which D 3245.8

(32.5%) corresponded to direct health costs and the remaining
67.5% (D 6736.2) corresponded to indirect costs, attributable to
job productivity losses. More specifically, direct costs refer to the
costs of medical visits (847.1), complementary tests (473.5), non-
GLOBAL PREV. pharmacological therapies (1368.1), pharmacological therapies
2.10 (439.2) and others (117.9). The total indirect costs (occupational)
were derived from the reduction of working hours (913.1), sick
leave (3556.2) and permanent disability (2266.9). It was also
observed that health costs were directly proportional to functional
capacity, depression, physical comorbidity and age. On the other
hand, patients with permanent disability were the largest con-
sumers of resources.
As can be observed, the patient/year costs found in the different
studies are quite homogeneous if we consider the increase in the
PREV. EUROPE cost of living: D 7813 for Boonen et al.37 in 2005, D 8684 for Berger
2.31
et al.34 in 2007 and D 9982 for Rivera et al.32 in 2009.
If we estimate the results of the Rivera study with Spanish
population and consider the prevalence standards found in the
EPISER study,2 in which the prevalence of FM is estimated in
2.4% of the population, out of a total of 46,557,008 inhabitants
in Spain, according to official population figures as of January 1,
2016 (National Institute of Statistics), FM in Spain would affect
an estimated total of 1,117,368 people and its cost would amount
to more than 11,153 million euros per year. If we also consider
that between 2006 (year of data collection in the Rivera et al.32
study) and 2016 there has been an increase in the consumer price
index of 16.50%, this would mean a patient/year cost of 11,629.03,
with a global annual figure of more than 12,993 million euros in
Spain.
The data of the Valencian Community obtained in December
201631 allow us to establish a more accurate assessment for this
geographical area, since the calculated prevalence derived from
PREV. SPAIN active diagnoses found in the official databases, which represent
2.40 a real, rather than an estimated number. Therefore, as there were
183,357 people diagnosed with FM in the Valencian Community
at the cut-off date, according to the data obtained by Rivera et al.,
adjusted for the consumer price index (D 11,629.03 patient/year),
it can be established that FM in the Valencian Community entails
a cost of more than 2,132 million euros per year, of which 693 are
direct health costs of the disease. In other words, the economic
impact of FM in the Valencian Community represents a cost of
D 429 euros per year for each of its inhabitants. The following table
summarizes the costs of the disease in Spain and in the Valencian
Community (Table 2).

PREV. VALENCIAN
COMMUNITY
3.69
Fig. 4. Interterritorial comparison.
the estimated direct cost of Primary Care for the general popula-
tion per year is D 555.58 compared to D 908.67 in the case of FM
patients.
In 2009, in Spain, Rivera et al.32 conducted an interesting mul-
ticentric study in 301 already diagnosed patients, where the direct
and indirect costs of FM in Spain during 2006 were evaluated.
Discussion
The results should be considered with due caution, since we
have sought a global view of the impact of FM in the world, nev-
ertheless, we believe there is a need for a greater consensus in
the epidemiological consideration of the disease. The studies ana-
lyzed use diverse measuring methodologies and their comparison
must be considered with reasonableness and caution. For exam-
ple, the most contrasting methodology is observed in the case of
the study inclusion criteria, because different FM diagnostic cri-
teria still coexist: those of the American College of Rheumatology
(ACR) enjoy the greatest prestige, especially the 1990 ACR, but also
the 2010 ACR and the modified 2010 ACR. In addition, it is com-
mon to find the London fibromyalgia epidemiology study screening
questionnaire and the Community oriented programme for control of
rheumatic diseases criteria, as well as various forms of specialist
diagnosis or self-report.
As we have tried to explain, it is also necessary to be prudent
regarding the specific severity of FM in the Valencian Community
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Table 2
FM costs in Spain and the Valencian Community.
Total pop. Preval. FM affected population
Spain 46,557,008 2.40 1,117,368
Valencian Community 4,969,359 3.69 183,357
(Spain). Judging by the results, the weight of the disease in this geo-
graphic area and its socio-economic and socio-healthcare impact
is evident, but the lack of information regarding other Spanish
communities does not allow us to have an adequate comparative
perspective.
The need for further studies on FM, its pathophysiology, its
etiopathogenesis, its diagnosis and its therapeutic approach is evi-
dent, especially in a Spanish and autonomous region scope. In fact,
FM contains all the elements to merit and encourage its study: its
high prevalence, the profound impact it has on the quality of life,
on social and family life, its personal (patient), occupational and
healthcare costs. In addition, of course, its idiopathic identity, its
symptomatologic complexity, its biopsychosocial status, besides
that permanent need to justify itself as a disease and not as a psy-
chiatric somatoform disorder, which entails several processes of
social stigmatization.
We have seen that the personal costs are high, and the economic
ones are enormous, so much so that a deep reflection is necessary
in order to determine the need to develop research processes for
this disease: more than 12,993 million euros a year in costs for a
single disease in Spain is an unacceptable figure; and the more than
1,100,000 people who suffer it in Spain implies too much suffering:
so many, that their number makes us forget that behind each figure
there is a person with a certainly complex predicament.
Conflict of interest
The authors declare no conflict of interest.
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