Professional Documents
Culture Documents
Health, Primary Care Mental Health Group, University College London, UK, 5Institute for Research
and Development, Battaramulla, Sri Lanka, 6Institute of Psychiatry, Kings College, London, UK,
and 7London School of Hygiene and Tropical Medicine, UK
Abstract
Background: Across cultures, women are more likely than men to report somatoform disorders (SD), depression and
anxiety. The aim of this article is to describe the co-morbidity of SD with depression/anxiety and to investigate the possible
mechanisms of this relationship in women in low and middle income countries (LMIC). Methods: We reviewed two data-
bases: MEDLINE and PsycINFO from 1994 to 2012 for studies which assessed the association between any SD and
depression/ anxiety in women from LMIC. Our focus was on community and primary healthcare based studies. Both
For personal use only.
quantitative and qualitative studies were included. Results: A total of 21 studies covering eight LMICs were included in our
analysis. Our findings suggest a strong association between SD and depression/anxiety (with odds ratios ranging from
2.53.5), though we also observed that the majority of women with SD did not have depression/anxiety. The likely mecha-
nisms for this association are multidimensional, and may include shared aetiologies, that both conditions are in fact variants
of the same primary mental disorder, and that one disorder is a risk factor for the other. Anthropological research offers a
number of frameworks through which we can view these mechanisms. Conclusion: The current evidence indicates that
service providers at the primary care level should be sensitized to consider SD in women as variants of CMD (Common
Mental Disorders) and address both groups of disorders concurrently. Further research should explicitly seek to unpack
the mechanisms of the relationship between SD and CMD.
Background
for example, irritable bowel syndrome, premenstrual
Across cultures, women are more likely than men to syndrome, chronic pelvic pain, fibromyalgia, non-
report somatoform disorders and depression, and cardiac chest pain, hyperventilation syndrome,
anxiety (Kessler et al., 2003; Mirza & Jenkins, 2004). chronic (post-viral) fatigue syndrome and atypical
Somatic presentations are the rule in routine clinical facial pain (Wessely et al., 1999). In this paper, we
practice, and when physicians cannot find a refer to these syndromes collectively as somatoform
pathological basis for them they are referred to as disorders (SD).
somatization, somatoform disorders, medically unex- Although SD appears to be a heterogeneous group
plained symptoms, and functional somatic symp- of conditions (Creed, 2009; Creed & Barsky, 2004;
toms (Barsky & Borus, 1999; Mayou, 1993). Wessely Henningsen et al., 2003), they often-exist with
et al. defined a functional somatic symptom as one depression and anxiety and other somatoform
that, after appropriate medical assessment, cannot disorders (Lieb et al., 2007). While depression and
be explained in terms of a conventionally defined anxiety are widely accepted as distinct sub-categories
medical disease (Wessely et al., 1999). At least one of CMD in contemporary classifications, there is
third of all physical symptoms in the general popula- debate around the classification of SD. Contempo-
tion (Kroenke & Price, 1993) and in general medical rary classifications prefer to categorize SD as a
care settings (Kroenke et al., 1994) are medically separate diagnosis with variants of SD as further
unexplained. Different medical specialities tend to sub- or separate categories. The Diagnostic and Sta-
define their own variants of such somatic syndromes, tistical Manual of Mental Disorders (DSM-IV-TR)
Correspondence: Professor Vikram Patel, MRCPsych, PhD, FMedSci, Sangath Centre, Alto Porvorim, Goa, 403521, India. E mail: vikram.patel@lshtm.ac.uk
et al., 1997). Some authors argue that even the along with the list of LMIC countries were then
various somatic syndromes are largely an artefact of combined using the Boolean operator AND. The
medical specialization and the differentiation of search was limited to studies that included women.
specific functional syndromes reflects the tendency The search was repeated for the PsycINFO database
of specialists to focus on only those symptoms per- by making appropriate modifications to the subject
tinent to their speciality, rather than any real differ- headings and search strategy. Search results were
ences between patients (Sharpe & Carson, 2001; exported to EndNote and duplicates were automati-
Wessely et al., 1999). Furthermore, there is a lack cally discarded. The detailed search strategy is
of clear operational criteria for the category of SD reported in the Appendix.
and it has been argued that the number and sever-
ity of symptoms are better arranged as dimensions
For personal use only.
Table 1. List of quantitative studies assessing the association of SD with depression and anxiety in women in low and middle income
countries.
Int Rev Psychiatry Downloaded from informahealthcare.com by Kings College London on 02/08/13
Ball et al. (2010) Sri Lanka Cross-sectional survey Random sample from Total 3820
population-based twin registry Female 2056
Deveci et al. (2007) Turkey Cross-sectional survey Randomly selected households in Total 1086
urban area Female 594
Gulec et al. (2007) Turkey Case-control study Fibromyalgia cases from tertiary Fibromyalgia patients 37
care centre, women with Fibromyalgia non-patients 38
fibromyalgia (but not accessing Healthy controls 41
health services) from
community and healthy
controls from community
Guven et al. (2005) Turkey Case-control study Fibromyalgia cases from the Fibromyalgia patients 53
For personal use only.
68
Table 2. Methods of assessment of SD with depression and anxiety in quantitative studies with women in low and middle income countries.
Ball et al. Fatigue Chalder Fatigue Abnormal fatigue 28.6% Depression CIDI Not reported Bivariate correlation of fatigue with
(2010) Questionnaire (26.7%30.5%) lifetime depressive disorder:
Prolonged fatigue 1.0% abnormal fatigue 0.39 (0.320.47)
R. Shidhaye et al.
McMillan Orofacial pain and Patient questionnaire Not reported Depression Chinese version of Not reported OR for association of orofacial pain
et al. widespread pain the depression and with depression 3.5 (1.96.3)
(2010) somatization OR for association of widespread
sub-scales of the pain with depression 3.5
Symptom Checklist (1.67.6)
(SCL-90)
Mumford Somatic symptoms Bradford Somatic Women with BSI scores Depression and Psychiatric Not reported Prevalence of depression and
et al. Inventory (BSI-21) in middle, high or anxiety Assessment anxiety in women with high
(1996) very high range (BSI Schedule based on (2127) or very high (2842)
scores 1442) 82% present state BSI scores 60%
examination and
lCD-10 diagnostic
criteria for research
Mumford Somatic symptoms Bradford Somatic Women with BSI scores Depression and Psychiatric Not reported Prevalence of depression and
et al. Inventory (BSI-44) in middle or high anxiety Assessment anxiety in women with middle or
(1997) and Self Reporting range (BSI scores Schedule based on high range scores on BSI or SRQ
Questionnaire 2688) 82% present state scores 66%
(SRQ-20) Women with SRQ examination and
scores in middle and lCD-10 diagnostic
high range (SRQ criteria for research
scores 620) 76%
Mumford Somatic symptoms Bradford Somatic Women with BSI scores Depression and Psychiatric Not reported Prevalence of depression and
et al. Inventory (BSI-44) in middle or high anxiety Assessment anxiety in women with middle or
(2000) range (BSI scores Schedule based on high range scores on BSI 25%
above 20) 28% present state
examination and
lCD-10 diagnostic
criteria for research
Patel et al. Vaginal discharge Patient report Prevalence of vaginal Depression and CISR Prevalence of OR for association of vaginal
(2005) discharge 14.5% anxiety depression discharge with depression and
(13.1%15.9%) and anxiety anxiety 2.2 (1.43.2)
9.9%
(CISR
cut-off 8)
Patel et al. Vaginal discharge Patient report Incidence of vaginal Depression and CISR Prevalence of OR for association of vaginal
(2006) discharge 4.0% anxiety depression discharge with depression and
(3.2%5.0%) and anxiety: anxiety 2.2 (1.43.4)
9.9%
(CISR
cut-off 5)
(Continued)
Somatoform disorders, anxiety and depression in women in LMIC
69
70 R. Shidhaye et al.
In our analysis we included any SD or any somatic
1.12 (1.081.16)
method of assessment of SD and depression and
anxiety. Studies reported odds ratios, relative risk
(1.021.09)
symptoms:
and correlation coefficients as measures of associa-
tion between SD and depression and anxiety. As a
result of this heterogeneity it was not possible to pool
the data to generate summary estimates.
and anxiety in
Prevalence of
period 4.6%
period 12%
Prevalence of
depression
antenatal
postnatal
CMD
pregnant
women:
Results
Int Rev Psychiatry Downloaded from informahealthcare.com by Kings College London on 02/08/13
Selection of studies
*The data presented is not disaggregated by gender, but we included it as 86.9% of the individuals with conversion disorder were women.
Overall 770 references were initially identified from
the initial searches (Figure 1), the majority from
assessment
studies.
somatic symptoms
one or more PHQ
Somatic symptoms
Full papers included in the Papers excluded after reading the full
systematic review (n = 18) texts (n = 24) because:
No measure of association between any
SD/somatic symptom and any depression or
anxiety (n = 13)
No gender disaggregated data (n = 7)
Immigrant/refugee sample (n = 3)
Full text in Portuguese (n = 1)
mixed methods (n = 1)
Figure 1. Study selection process for systematic review of studies of the association between SD and depression and anxiety in women in
low and middle income countries.
There was variation in the way SD and depres- (CISR) and the Self-Report Questionnaire
sion and anxiety were measured. Some studies used (SRQ-20) were used for measuring CMD, and
standardized questionnaires such as the Patient depression and anxiety were assessed using CIDI,
Health Questionnaire (PHQ), the New Mexico DSM-IV SCID-I Clinical Version, the Beck Depres-
Refugee Symptom Checklist-41 (NMSCL-41) and sion Inventory (BDI) and the Beck Anxiety Inven-
the Bradford Somatic Inventory (BSI) for measure- tory (BAI), the Hamilton Depression and Anxiety
ment of somatic symptoms, the Chalder Fatigue Scale and the Chinese version of the depression and
Questionnaire for fatigue, the Composite Interna- somatization sub-scales of the Symptom Checklist
tional Diagnostic Interview (CIDI) (somatization (SCL-90).
subscale) for conversion disorder, and the Fibro- Cross-sectional studies reported a wide variation in
myalgia Impact Questionnaire (FIQ) for assess- overlap of depression and anxiety in women presenting
ment of fibromyalgia. In two studies diagnosis of with SD or somatic symptoms (from 23% to 66%).
fibromyalgia was based on the American College of Three community-based epidemiological surveys from
Rheumatology criteria, while patient report was Pakistan estimated that 25% to 66% of women suffered
used for detection of vaginal discharge and pain from anxiety and depressive disorders whereby the com-
symptoms in the rest of the studies. plaints predominantly were somatic in nature (Mum-
In terms of measurement of depression and ford et al., 1996, 1997. 2000). A community-based study
anxiety, the Clinical Interview Schedule Revised in Turkey determined that 23% of patients diagnosed
72 R. Shidhaye et al.
with conversion disorder had some form of depressive social distress (Patel et al. 2008).Vaginal discharge
disorder (Deveci et al., 2007). is experienced as a symptom, not of an underlying
Two case-control studies have reported a higher biological condition, but as part of a larger nexus
prevalence of depression and anxiety in cases diag- of womens psychosocial, economic and somatic
nosed with SD compared to healthy controls. problems (Kostick et al., 2010). In another study
Depression and anxiety were diagnosed in 80% from India, the complaint of abnormal vaginal dis-
(Martinez et al., 1995) and 90% (Guven et al., charge is an idiom linked to weakness, psychological
2005) of women who were diagnosed with fibromy- morbidity, and social adversities, and represents a
algia as compared to 12% and 51.8% in control culturally valid model of explaining such experi-
groups respectively. ences (Patel et al., 2008). Experiencing abnormal
Odds ratio as a measure of association between vaginal discharge is one way a woman can commu-
SD/symptoms and depression and/or anxiety were nicate to her husband and household her concerns
reported by four studies; three cross-sectional (Illanes for increased understanding and/or relief from cer-
et al., 2002; Kostick et al., 2010; Patel et al., 2005) tain aspects of life she sees as arduous or dissatisfy-
Int Rev Psychiatry Downloaded from informahealthcare.com by Kings College London on 02/08/13
and one case-control (McMillan et al., 2010). All ing (Kostick et al., 2010). It is one of the few
these studies show a statistically significant associa- ambulatory conditions that can legitimate womens
tion with odds ratios in the range of 2.53.5. limitation in performing certain roles and obliga-
Only two prospective studies have assessed the tions and allow her to move out of the house to seek
association of CMD with SD. Presence of CMD was treatment for the condition from public and private
significantly associated with incidence of abnormal allopathic and non-allopathic practitioners (Kostick
vaginal discharge in women (odds ratio (OR) 2.2, et al., 2010).
95% CI 1.43.4) in a population-based cohort study In patients with SD, the significant worry about
in Goa, India (Patel et al., 2006). An Ethiopian study the illness is a major determinant of distress and
assessing the impact of perinatal somatic and CMD medical consultations. Only one participant in a Sri
symptoms on functioning in Ethiopian women found Lankan primary care study gave a psychological
For personal use only.
that antenatal CMD was associated with postnatal explanation for the symptoms while the majority
somatic symptoms, though this association was not gave a physical explanation and some did not offer
very strong (risk ratio (RR) 1.05, 95% CI: 1.021.09) any diagnosis (Sumathipala et al., 2008).Similarly,
(Senturk et al., 2012). a study from South India which assessed the explan-
atory models and CMD in patients with unexplained
Studies with qualitative methods somatic symptoms attending a primary care facility
reported that half of the patients attributed their
Study characteristics. Our search yielded five qualita- problems to physical illness and believed that specific
tive studies which described the association between organs were affected (Nambi et al., 2002).The com-
SD and depression and anxiety. Four studies were mon thing in both the studies was that the patients
from India and one was from Sri Lanka. felt that their problems were serious and feared dis-
These studies involve both general SD (Nambi ability or death.
et al., 2002; Sumathipala et al., 2008) and more
specific somatic symptoms such as vaginal discharge
(Kostick et al., 2010; Patel et al., 2008; Pereira et al., Reviews
2007). Both the reviews obtained from the search were nar-
rative reviews; one conducted by authors from Pak-
Findings. Patients with somatic complaints do not istan (Minhas & Nizami, 2006) and the other from
usually attribute this to psychological distress. China (Parker et al., 2001). The review from Paki-
Women locate their distress in the social disadvan- stan looked at the epidemiology of somatic symp-
tages in their daily lives and offer a range of causes toms with a specific focus on the Bradford Somatic
for their somatic complaints (Patel et al., 2008). In Inventory (BSI) scale, discussing the diagnostic
a community study in Goa, women attributed dilemma around somatic and psychological symp-
abnormal vaginal discharge to economic difficulties, toms and suggested management strategy for SD
worries about children, family and health, repro- (Minhas & Nizami, 2006). The key finding of this
ductive and gynecological problems, excessive work paper was that 66% of women suffered from anxiety
load, trouble with in-laws, marital conflict, housing and depressive disorders whereby the complaints
problems and trouble with neighbours (Pereira predominantly were somatic in nature. The Chinese
et al., 2007). Although women give a very different paper focused on Chinese subjects and reviewed
weighting to the constellation of causal factors, so original studies and literature reviews considering
that tension is not included in their explanations, emotional distress, depression, neurasthenia, and
their narratives clearly contain references to psycho- somatization (Parker et al., 2001). This literature
Somatoform disorders, anxiety and depression in women in LMIC 73
review supports the concept that Chinese tend to to present only somatic symptoms or somatic
deny depression or express it somatically. The components of psychological symptoms when
authors conclude that this may be due to the stigma seeking help (Parker et al., 2001; Patel et al., 1995,
associated with the label of depression as well as the 1997, 1998).
tendency of this population to link emotional prob- The second plausible mechanism is that the asso-
lems with physical symbols and metaphors. ciation is explained due to shared risk factors. This
would imply that the two disorders are distinct, but
frequently co-exist because of their shared etiolo-
gies. There is certainly strong evidence to support
Discussion
this hypothesis with both CMD and SD being asso-
The findings of this review demonstrate an asso- ciated with similar risk factors, for example, female
ciation between SD and depression and anxiety in gender, low socioeconomic status and adverse life
women in community and primary healthcare set- events, and difficulties. Women who experience
tings. Most studies showed an association of SD stress due to social difficulties, such as economic
Int Rev Psychiatry Downloaded from informahealthcare.com by Kings College London on 02/08/13
with depression and anxiety alone or together; difficulties and conflict with family members, are
some studies demonstrated this relationship with much more likely to experience somatic symptoms
somatic symptoms, while others specified a cate- characteristic of both SD and depression (Patel
gory of SD, such as fibromyalgia, conversion disor- et al., 2008).
der, or chronic fatigue syndrome. About a quarter Finally, there is the possibility that one disorder
to a third of women who present with SD/somatic is a risk factor for the other. We found one study
symptoms were diagnosed with depression and/or which clearly showed that CMD was associated
anxiety. However, these studies also show that a with incident SD (Patel et al., 2006) while a second
significant proportion of women with SD do not prospective study found an association between
have a CMD. The qualitative studies demonstrate antenatal CMD with postnatal SD, although this
how women attribute social and economic prob- study did not measure the incident SD (Senturk
For personal use only.
lems as the causes of their somatic symptoms, et al., 2012). We did not find any study that assessed
although they do not attribute SD to depression or the relationship between SD leading to incident
anxiety. Our findings are consistent with the results depression and/or anxiety. However, a prospective
of studies from high income countries (Wessely longitudinal study from Europe demonstrated that
et al., 1999), suggesting that the association of SD depression predicted the first onset of secondary
with depression and anxiety among women is cross- SD (Lieb et al., 2002). The analysis of the retro-
cultural. For example, the Epidemiological Catch- spective cohort study, however, has shown a differ-
ment Area (ECA) study reported 11 times higher ent causal direction for this association. More than
probability of major depression in respondents with three quarters (78%) of the respondents with a con-
a lifetime diagnosis of DSM-III somatization dis- comitant lifetime depression and SD reported that
order (Swartz et al., 1990). A community-based the SD had an earlier onset than the depression and
study involving 3,021 adolescents and young adults SD was reported as the primary condition in 75%
found significant association between the sub-syn- of those cases with co-morbid depression (Frohlich
dromal diagnostic category of somatization disor- et al., 2006).
der and anxiety and depressive disorders (Lieb Not with standing the mechanism of the relation-
et al., 2000). However, apart from a few studies ship, which is likely to be multidimensional, our
such as these, there is a relative lack of epidemio- findings speak to more than 30 years of anthropo-
logical data about patterns of co-morbidity of SD logical research that has attended to the relation-
with depression and anxiety in the general popula- ship between somatic symptoms and psychological
tion (Lieb et al., 2007). distress, with a focus on women living in LMIC.
Much of the evidence in our review is based on This research demonstrates that women use physi-
cross-sectional studies, hence it is difficult to ascer- cal idioms to communicate psychological distress,
tain a causal inference. We can hypothesize a num- thereby demonstrating a strong association between
ber of possible mechanisms. The first possibility is somatic symptoms and depression and anxiety.
that SD and depression and anxiety are essentially Medical anthropologists have used various theo-
variants of the same underlying mental disorder. retical frameworks to demonstrate how social and
In support of this hypothesis is the fact that the psychological suffering become embodied and
relationship between SD and depression and anxi- identified in somatic symptoms, such as cultural
ety is both strong and universal, demonstrated in a syndromes (Good, 1977), idioms of distress
range of settings and countries. There is robust lit- (Nichter, 1981, 2010), and somatic modes of
erature, from LMIC and HIC, that patients possess attention (Csordas, 1993). Anthropological studies
awareness of psychological symptoms but choose underscore the common ways in which women use
74 R. Shidhaye et al.
somatic symptoms to communicate social and psy- their concepts of dysphoria in ways different from
chological problems. For example, in his landmark Western ones.
study, Nichter describes the use of idioms of dis- A main limitation of this review is that only
tress such as menstrual pain, headaches and back indexed English-language journals were reviewed.
pain by Havik Brahmin women in India to com- It is difficult to make conclusive remarks about the
municate social and psychological suffering. Klein- association between SD and depression and/or
mans research demonstrates the interconnection anxiety because of the heterogeneity of measures
of physical pain and neurasthenia with depression used across the studies; as standard terminology
among women in China (Kleinman, 1986). Oths are rarely used to describe somatic problems or
describes how illness results from a complex bio- even mental health problems; and because most
cultural interaction of stressful life experiences with studies were cross-sectional. All studies in this
gender, age, and the life cycle in the Andes (Oths, review reported a positive association between SD
1999). Kohrt and colleagues demonstrate a strong and CMD, suggesting the possible presence of pub-
association between depression and jhum-jhum, a lication bias. However, strong association between
Int Rev Psychiatry Downloaded from informahealthcare.com by Kings College London on 02/08/13
form of paraesthesia (subjective numbness or tin- SD and depression and anxiety has also been found
gling), in rural Nepal (Kohrt, 2005). Similarly, in studies based on high income countries; there is
Weller and Baer show a strong association between a large body of ethnographic evidence that sup-
the idioms of distress susto (fright) and nervios ports and explains the mechanism of such an asso-
(nerves), both having physical symptoms, with ciation. We therefore believe that our analysis of the
depression in urban Mexico (Weller et al., 2008). current data communicates the true association
A cross-cultural study of susto, nervios and ataque between SD and depression and anxiety in women
de nervios involving Spanish and Hispanic Ameri- in LMIC.
can populations demonstrated that people hold The question of whether SD and CMD are the
multiple models of distress and disorder which same primary disorder remains unanswered.
influences clinical presentations and help-seeking Prospective population-based research with sys-
For personal use only.
behaviour (Dura-Vila & Hodes, 2012). Nicaraguan tematic characterization of SD and CMD in diverse
women situate the dolor de cerebro (brainache) in settings is needed to address this question. In the
relation to their persistent worries about the impact meantime, what our review clearly demonstrates is
of death, abandonment, and outmigration on per- that, in community and primary healthcare studies
sonal and family well-being. Their pain is meaning- with women in LMIC, SD are closely linked with
ful primarily as an embodied expression of the depression and anxiety. Twinned with the findings
distress they experience as they confront the often- that somatic symptoms are the most common pre-
overwhelming circumstances of hardship in their sentations of CMD in LMIC, we suggest that it may
local social worlds (Yarris, 2011). A similar study not be useful to distinguish SD from CMD at the
from Peru found that womens attribution of their primary care level. Thus, service providers at the
headache was aligned with individual and shared primary care level should be sensitized to recognize
notions of suffering within larger contexts of social the medically unexplained somatic manifestations
dislocation (Darghouth et al., 2006). These anthro- as expression of underlying CMD. Indeed, there is
pological projects underscore the common ways in substantive evidence that the treatments of SD and
which women use somatic symptoms to communi- CMD share similar modalities (Mayou, 2007;
cate social and psychological problems. Ultimately, Sumathipala, 2007). Such an integrated, transdiag-
SD may be explained in terms of the way bodily nostic approach may not only greatly simplify
perceptions are processed; symptom perception is, the integration of mental healthcare in primary
in part, determined by environmental, emotional, care, but also contribute towards the reduction of
and cognitive characteristics, such as specific cog- the treatment gap a key goal of global mental
nitive illness schemes (Patel et al., 2008; Pereira health.
et al. 2007). Kirmayer and Young have proposed
that somatization is a concept that reflects the dual-
ism inherent in Western biomedical practice, Declaration of interest: Vikram Patel is supported
whereas in other traditions of medicine such as by a Wellcome Trust Senior Clinical Fellowship. R.S.
Chinese and Ayurvedic medicine there is no sharp was responsible for the conception, design,
distinction between mental and physical aspects database search and initial draft. R.S. and E.M. inde-
of health (Kirmayer & Young, 1998). People from pendently reviewed the titles, abstracts and full texts
traditional cultures may not distinguish between of retrieved articles. All authors participated in the
the emotions of anxiety, irritability and depression conceptualization of paper, drafting and commenting
because they tend to express distress in somatic on all draft versions.The authors alone are responsible
terms (Parker et al., 2001) or they may organize for the content and writing of the paper.
Somatoform disorders, anxiety and depression in women in LMIC 75
Kirmayer, L.J. & Young, A. (1998). Culture and somatization:
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