This is a short presentation on the significance of somatic symptoms in the diagnosis of depression. These slides question the hypothesis that somatic symptoms should always be removed when looking for depression in medical settings.

1. Significance of Somatic Symptoms in Depression
Significance of Somatic Symptoms in Depression
Include or Exclude when diagnosing depression in medical Settings?
Include or Exclude when diagnosing depression in medical Settings?
Alex J Mitchell ajm80@le.ac.uk
Department of Cancer & Molecular Medicine
Leicester Royal Infirmary
Department of Liaison Psychiatry, Leicester General Hospital
Liaison Team & Online Aug 2009
Liaison Team & Online Aug 2009

2. Context
Many authors have highlighted that somatic symptoms occur in both
depression and physical illness. Often it has been suggested that
these should be omitted when looking for comorbid depression,
assuming they contaminate the clinical presentation. This
assumption has not previously been examined in an evidence
based way.
Further, many groups have developed scales without somatic
symptoms. These include the GDS, HADS and BDI. Whilst their
performance has been tested, they have not been examined
relative to their performance with somatic symptoms un-excluded.
In short the diagnostic (low) significance of somatic symptoms is
plausible but untested.

3. 1. What Are Somatic Symptoms?

4. What Are Somatic Symptoms?
Somatic symptoms are physical (bodily) complaints that
occur in physical and mental disorders, as well as in the
healthy population
By Convention these might include
decreased (or change in) appetite
decreased (or change in) weight
diminished concentration (or indecisiveness)
loss of energy (or fatigue)
psychomotor agitation
psychomotor retardation
sleep disturbance (any type)
Painful physical symptoms

5. Importance of Somatic Symptoms in Depression1
1
Most depressed patients presenting in primary care have
at least one comorbid psychiatric condition and at least
one physical condition.[i] [ii]
[i] Niles BL, Mori DL, Lambert JF, et al. Depression in primary care: Comorbid
disorders and related problems Journal of Clinical Psychology in Medical Settings
2005; 12(1): 71-77.
[ii] Dwight-Johnson M, Sherbourne CD, Liao D,Wells KB. Treatment Preferences
Among Depressed Primary Care Patients. J Gen Intern Med. 2000; 15(8): 527–534.

6. Importance of Somatic Symptoms in Depression2
2
At least 75% of older depressed primary care patients
also have a known physical illness. [i] [ii] [iii] [iv] [v]
[i] Berardi D, Menchetti M, De Ronchi D, et al. Late-life depression in primary care: A
nationwide Italian epidemiological survey. Journal of the American Geriatrics
Society 2002; 50(1): 77-83.
[ii] Wells KB, Rogers W, Burnam A, Greenfield S, Ware Jr JE. How the medical
comorbidity of depressed patients differs across health care settings: results from
the Medical Outcomes Study. Am J Psychiatry 1991;148:1688–96.
[iii] Yates WR, Mitchell J, Rush AJ, et al. Clinical features of depressed outpatients with
and without co-occurring general medical conditions in STAR*D. General Hospital
Psychiatry 2004; 26(6): 421-429.
[iv] Aragones E, Pinol JL, Labad A. Depression and physical comorbidity in primary
care. Journal of Psychosomatic Research 2007; 63(2): 107-111.
[v] Vuorilehto M, Melartin T, Isometsa E. Depressive disorders in primary care:
recurrent, chronic, and co-morbid Psychological Medicine 2005; 35(5): 673-682.

7. Importance of Somatic Symptoms in Depression3
3
Patients with physical comorbidity are less likely to have
depression treatment initiated[i] and these patients
may be less likely to recover from depression.[ii] [iii]
[iv]
[i] Nuyen J, Spreeuwenberg PM, Van Dijk L, et al. The influence of specific chronic
somatic conditions on the care for co-morbid depression in general practice.
Psychological Medicine 2008; 38(2): 2: 265-277.
[ii] Cole MG, Bellavance F. Depression in elderly medical inpatients: a meta-analysis of
outcomes. Canadian Medical Association Journal 1997; 157:1055–60.
[iii] Oslin DW, Datton CJ, Kallan MJ, Katz IR, Edell WS, TenHave T. Association between
medical comorbidity and treatment outcomes in late-life depression. J Am Geriatr
Society 2002; 50: 823-828.
[iv] Bogner, HR; Cary, MS; Bruce, ML, et al. The role of medical comorbidity in outcome
of major depression in primary care - The PROSPECT study. American Journal of
Geriatric Psychiatry 2005; 13(10): 861-868.

8. 2. Somatic Symptoms in Depression Scales

9. HADS Scale (Zigmond & Snaith)
Adapted to show depression and
anxiety subscales separately.
Notice the items “slowed down” and
“butterflies” which are probably
somatic symptoms
The following slide compared the
symptom profile from 11 common
approaches to depression=>

11. Somatic Bias in Mood Scales Slide shows somatic vs non-somatic
symptoms in 11 scales/tools.

12. 3. Phenomenology of Somatic Symptoms
i - Primary Depression

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The following slide shows these sorted by ROC curve significance=>
cho
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when making a diagnosis of depression (Psychological Medicine 2008)
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15. 4. Phenomenology of Somatic Symptoms
ii - Comorbid Depression

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Loss of interest
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Data from Koenig (1993)
insomnia (middle)
GI symptoms
Genital symptoms
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Insomnia (late)
Hypochondriasis
Retardation
Loss of energy
Weight Loss
Agitation
Somatic Anxiety
Downhearted
Bored
Life is Empty
Life is Exciting
Feel like Crying
Satisfied
Worry about past
Feel helpless
Happy
Differential
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Feel worthless
Bothered by Thoughts
Rate in Medical Alone
Situation hopeless
In good spirits
Rate in Depressed+Medical
Avoid social
Wonderful to be alive
Hopeful about future
Dropped interests
Most people better off
Prefer to stay home
Enjoy getting up
Upset over little things
Example – Depression in General Medicine
Afraid of something bad
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Mind clear
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21. 5. Diagnostic Weight of Somatic Symptoms

22. Approaches to Somatic Symptoms of Depression
Inclusive
Uses all of the symptoms of depression, regardless of whether they may or may not be
secondary to a physical illness. This approach is used in the Schedule for Affective
Disorders and Schizophrenia (SADS) and the Research Diagnostic Criteria.
Exclusive
Eliminates somatic symptoms but without substitution. There is concern that this might
lower sensitivity. with an increased likelihood of missed cases (false negatives)
Etiologic
Assesses the origin of each symptom and only counts a symptom of depression if it is
clearly not the result of the physical illness. This is proposed by the Structured
Clinical Interview for DSM and Diagnostic Interview Schedule (DIS), as well as the
DSM-III-R/IV).
Substitutive
Assumes somatic symptoms are a contaminant and replaces these additional cognitive
symptoms. However it is not clear what specific symptoms should be substituted

23. Evidence Based Approach
Mitchell, Thombs, Coyne recently conducted a meta-
analysis of the diagnostic significance of somatic
symptoms in the following groups:
1. Depression with comorbid physical disease
2. Depression alone
3. Physical disease alone
4. Healthy individuals

24. Co-morbid Depression vs Medical Illness Alone

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26. Co-morbid Depression vs Primary Depressions