SOMATIC COMPLAINTS in

DEPRESSION
Blok XX
Psikosomatik
Universitas Tadulako
2012
 Physical Symptoms Common In
Psychiatric Patients
Psychiatric Healthy
Symptom Patients (%)Subjects (%)
Tiredness, lack of energy 85 40
Headache, head pains 64 48
Dizziness or faintness 60 14
Feeling of weakness in parts of body 57 23
Muscle pains, aches, rheumatism 53 27
Stomach pains 51 20
Chest pains 46 14

Data from Kellner R, Sheffield BF. The one-week prevalence of symptoms in neurotic
patients and normals.
Am J Psychiatry 1973;130:102–105
 Why Focus on Physical
Symptoms?
• A growing literature explores the mind-
body connection in mental illness
• Depression may have physical causes and
consequences (like appetite and sleep
disturbance, fatigue, and chronic pain)
• The presence of physical symptoms in
depression may affect response to
treatment
 Patients With Major Depressive
Disorder
• Report only physical symptoms in up to 69% of primary care
cases1
– E.g.,insomnia or hypersomnia, psychomotor agitation or
retardation, changes in appetite, fatigue
• Are at 4x greater risk than nondepressed patients for having a
chronic painful physical condition (CPPC)2
• Are more likely than nondepressed patients to have long-term
medical conditions3
1Simon GE, VonKorff M, Piccinelli M, et al. An international study of the relation between somatic symptoms
and depression. N Engl J Med 1999;341:1329–1335
2Ohayon MM, Schatzberg AF. Using chronic pain to predict depressive morbidity in the general population. Arch Gen Psychiatry

2003;60:39–47
3Patten SB. Long-term medical conditions and major depression in a Canadian population study at waves 1 and 2. J Affect Disord

2001;63:35–41
Depression. It’s not only a state of
mind.
The symptoms of depression
Emotional Symptoms Include: Physical Symptoms Include:
Sadness Vague aches and pains

Loss of interest or pleasure Headache

Overwhelmed Sleep disturbances

Anxiety Fatigue

Diminished ability to think or

Back pain
concentrate, indecisiveness
Significant change in appetite
Excessive or inappropriate guilt
resulting in weight loss or gain

Reference: Adapted from

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders.
Fourth Edition,Text Revision. Washington, DC; American Psychiatric Association. 2000:345-356,489.
 Depression – the physical
presentation

In a New England Journal of Medicine

study, 69% of diagnosed depressed
patients reported unexplained physical
symptoms as their chief compliant1

In patients
N = 1146 Primary care primary withcare, physical
major depression symptoms are often
the chief complaint in depressed patients
Reference:
1. Simon GE, et al. N Engl J Med. 1999;341(18):1329-1335.
 Aches/pain – a physical symptom
of significance
Aches/Pain as common as anxiety among depressed patients
70 National Comorbidity
Survey
60 58%
55%
% of Depressed Patients

NIMH Epidemiology
50 Study

40 38% 37%
35%

30 28%
25%

20 17%

10

0
Aches/Pain Aches/Pain Anxiety Disorder Anxiety Disorder
(Women) (Men) (Women) (Men)
Adapted from
1.Silverstein B. Am J Psychiatry. 1999;156(3):480-482.
2.Silverstein B. Am J Psychiatry. 2002;159(6):1051-1052.
The importance of emotional and
physical symptoms
• 76% of compliant depressed
patients with lingering symptoms
of depression relapsed within 10
months1*

94% of depressed patients

who experienced lingering
symptoms had mild to
moderate physical
symptoms1

*Psychiatric inpatients and outpatients.

Reference:
1. Adapted from: Paykel ES, et al. Psychol Med. 1995;25:1171-1180.
 Serotonin5HT and NorepinephrineNE
in the brain
Limbic System
Prefrontal
Cortex

Locus Ceruleus
Raphe Nuclei (NE Source)
(5-HT source)

Cooper JR, Bloom FE. The Biochemical Basis of Neuropharmacology. 1996.

 There are at least two sides to the neurotransmitter story
Functional domains of Serotonin and Norepinephrine1-4

Serotonin (5-HT) Depressed Mood

Norepinephrine (NE)

Anxiety
Sex Concentration

Appetite Vague Aches and Interest

pain
Irritability
Aggression Motivation
Thought
process

• Both serotonin and norepinephrine mediate a broad spectrum of

depressive symptoms
References:
1. Adapted from: Stahl SM. In: Essential Psychopharmacology: 2. Blier P, et al. J Psychiatry Neurosci. 2001;26(1):37-43.
Neuroscientific Basis and Practical Applications: 2nd ed. Cambridge 3. Doraiswamy PM. J Clin Psychiatry. 2001;62(suppl 12):30-35.
University Press 2000. 4. Verma S, et al. Int Rev Psychiatry. 2000;12:103-114.
 The neurotransmitter pathway story
It’s not all in your head
• Dysregulation of Serotonin (5HT) and
Norepinephrine (NE) in the brain are
strongly associated with depression

• Dysregulation of 5HT and NE in the

spinal cord may explain an increased Descending Pathway
pain perception among depressed Descending
patients1-3 Pathway Ascending
Pathway

• Imbalances of 5HT and NE may explain

the presence of both emotional and
physical symptoms of depression.
Ascending
Pathway

Adapted from References:

1. Stahl SM. J. Clin Psych. 2002;63:203-220.
2. Verma S, et al. Int Rev Psychiatry. 2000;12:103-114.
3. Blier P, et al. J Psychiatry Neurosci. 2001;26(1):37-43.
 Depression: Current treatment
outcomes1
• Up to 70% of depressed patients respond (
50% decrease in HAM-D score) to treatment
but fail to achieve remission from their
emotional and physical symptoms1*
• Approximately 30% of depressed patients
achieve remission ( 7 score on the HAM-D)
with treatment1*

* Antidepressant clinical drug trials.

References:
1. O’Reardon JR, et al. Psychiatr Ann. 1998;28:633-640.
 Response and Remission defined
Hamilton Depression Rating Scale (HAM-D): 17 Items, Total Score 0 - 52

HAM-D17
Scores Depression
(Major Depressive Disorder)
15
Response
  50% reduction from baseline HAM-D score

7
Remission: HAM-D Score  7

References:
1. Frank E. Conceptualization and rationale for consensus definition terms in MDD, Arch Gen Psych. 1991; 48:851-855.
Treatment outcome:Effect on work & social functioning

Remitted patients virtually equaled healthy controls on

Higher Score
indicates greater
functioning levels at endpoint of 12-week treatment trial
impairment (Responders & non-responders did not)
5
Social Adjustment Scale-SR

3
(Mean ± SD)

*
*
**
2

1
Normal Remission Response Nonresponse
(n=482) (n=202) (n=122) (n=299)
Study in chronic depressed patients
*p.05 vs nonresponse. **p.05 vs response.
Miller IW, et al. J Clin Psychiatry. 1998;59(11):608-619.
 Many depressed patients are still
depressed.
• Depressed patients present with emotional
and physical symptoms.
• Approximately 30% of depressed patients
achieve remission in clinical trials2*
• Up to 70% of patients who respond fail to
remit2*

*In antidepressant clinical drug trials.

• Incomplete relief from symptoms may
increase the risk of relapse2,3
• Lingering emotional and physical symptoms
may jeopardize achieving remission.

References:
1. Nierenberg AA, et al. J Clin Psychiatry. 1999:60(suppl 22):7-11.
2. O’Reardon JR, et al. Psychiatr Ann. 1998;28:633-640.
3. Lynch ME. J Psychiatry Neurosci. 2001;26(1):30-36.
 5-HT
cytokine dysregulation
neurotransmitter
dysregulation

Mechanisms
circadian rhythm
proposed as
vagal afferent disruption
underlying Fatigue
activation

alterations in muscle hypothalamic–pituitary–

and ATP metabolism adrenal axis dysfunction
 Summary
• Physical complaints are most common in
depression
• Subjective symptom of depression are
distinguished with somatic symptom in
anxiety
• Neurotransmitter and others cytokines may
contribute to physical symptom in depression