BACKGROUND: Reported prevalence of restless legs syndrome (RLS), also known as 
Willis-Ekbom disease (WED), varies from country to country, and methodologic 
inconsistencies limit comparison of data. Impact of RLS on quality of life and 
health has been studied primarily in industrialized countries, particularly 
Europe and the United States. Many studies have relied exclusively on 
self-report of symptoms or have assessed only medical populations. Recently, 
interest has emerged on the impact of WED in rural, underserved populations 
globally.
METHODS: In a population-based survey conducted in rural Ecuador, we assessed 
the relationship of psychological distress to WED, evaluated with the Depression 
Anxiety Stress Scales-21. WED was diagnosed through a 2-phase method in which 
all residents were screened with the International Restless Legs Syndrome Study 
Group (IRLSSG) questionnaire and all suspected cases were subsequently confirmed 
through expert medical examination. WED severity was assessed with the IRLSSG 
rating scale.
RESULTS: Of 665 persons (mean [SD] age, 59.5 [12.6] years; women, 386 [58%]), 76 
had depression, 93 had anxiety, and 60 reported stress. Forty persons (6%) had 
WED, with 15 (38%) having severe disease. In a regression model adjusted for age 
and sex, the prevalence of depression, anxiety, and stress was about 3 times 
greater among persons with WED than the general population.
CONCLUSIONS: Although cross-sectional data cannot establish causation, this 
study shows the large behavioral health burden associated with WED in an 
untreated, rural population.