Analysis of Somatic Symptoms of Major Depressive Patients

Introduction 

The patients with depression disorder commonly express psychological and somatic symptoms to psychiatrists.¹ Somatic symptoms (SS) are called as medically unexplained complaints. SS reflect painful perception and dysfunction of various organs in the body of depressive patients. As a consequence, depressive patients often report different SS to various extents with psychological symptoms. About 75% of depressive patients were found to commonly report SS such as headache, stomach ache, vague body pain, back pain, chest pain, palpitations and weakness in the world.²

Few clinical studies have reported that major depressive patients report more SS at clinical centers that offer walk-in care than the centers, which offer personal form of primary care. In addition, the extent of reporting of SS depends on somatization criteria used for study patients.³ Many clinical studies have reported that major depressive patients report SS widely when structured interviews are used.^4,5 These results indicate that the prevalence, nature and frequency of report of SS by depressive patients depends on the type of clinical care center, somatization criteria and the way depressive patients are interviewed.

A review of multi centric studies carried out in India mentioned that the depressive patients report many SS such as lack of energy, severe headache, feeling tired when not working, pain in legs, palpitations, head feeling heavy, aches and pain all over the body, mouth or throat getting dry, pain or tension in neck and shoulder, head feeling hot or burning and dark or mist in front of the eyes [Range: 49-76%] along with psychological symptoms.⁶ In view of these reports, the present study was designed to analyze the prevalence, nature and frequency SS reported by major depressive patients in absence and presence of structured interview in south western Indian patient population.

Methodology

Study design: It was an open label, cohort and prospective study.

Study site:

The study was conducted in a tertiary care multi-specialty teaching hospital located in the Mysore city, India. The patients who visit this hospital were from urban, peri-urban and village areas of Mysore. Those patients who visited out-patient wards of psychiatry department as new registrants were enrolled into the study over a period of two years.

Study criteria:

All out patients who were of either sex, newly diagnosed as suffering from Major depressive disorder as per Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text revision (DSM-IV-TR) and aged between 18 and 60 years were enrolled. The patients who were suffering from other psychiatric disorders or painful diseases like arthritis, or depression due to drug/chronic medical illness, uncooperative, history of substance abuse or alcoholic dependence, and pregnant/lactating/in puerperal stage were excluded from the study.

Study Instruments:

Hamilton Depression Rating Scale:

The 17-item Hamilton Depression Rating Scale (HAM-D 17 items) was used to assess the severity of depression. Items in this scale are rated from 0 to 4 or from 0 to 2 according to the intensity and frequency of symptoms over the past week. The total score range was from 0 to 52. Scores of 0-7 indicates no depression; 8-13 as mild depression; 14-18 as moderate depression; 19-22 as severe depression, and 23-52 very severe depression.⁷

Somatic Questionnaire Scale:

The somatic questionnaire scale is a self-rated instrument containing 92 items, which are grouped under 4-symptom subscale (anxiety, depression, anger/hostility and somatic symptoms) and 4 wellbeing subscales. Our study focused on the somatic symptoms subscale containing 18 SS to document various SS reported by depressive patients.⁸

Data collection form:

It was prepared to document demography and clinical data of the patients who were enrolled into the study. 

Ethical consideration:

Ethical approval to conduct the study was obtained from The Institution ethics committee. Written consent was obtained, after explaining the study protocol, from each patient or patient’s relatives before enrolling the study patients to participate in the study.

Procedure

The patients, who satisfied the study criteria after the diagnosis as suffering from major depressive disorder as per DSM-IV-TR criteria, were enrolled into the study. Demographic and clinical data was documented. Further, the patients were equally assigned to qualitative and quantitative measurements. To measure SS qualitatively, each patient was empathetically interviewed in person with open-ended questions. For quantitative measurement of SS, each patient was administered somatic questionnaire-18 somatic symptoms (SQ-SS-18) scale. Major depressive patient was considered as somatizing if he/she reports at least one or more somatic symptoms irrespective of measurement type. All the patients were subsequently administered HAM-D-17 scale to assess their depression severity.

Data Analysis

Descriptive statistics (prevalence, range, median) was used to analyze all the collected data. Welch’s t-test was used to find out the significant difference in the mean of extent of report of most common SS between qualitative and quantitative measurements at the significance level P<0.05. Excel with application “Analysis Toolpak” was used for all statistical analysis.

Results

The patients who were diagnosed as suffering from major depressive disorder were enrolled in to the study. Five hundred and ten patients were totally recruited. These patients were further equally allocated for qualitative and quantitative measurements. As a consequence, 255 patients were there for each measurement. Few patients were dropped out from the study during the measurements. Four patients were found dropped out (1.57% [4/255]) in qualitative measurement while five patients were dropped out (2.00% [5/255]) in quantitative measurement (Total patients dropout rate: 3.57%). The reason for such drop out was due to inability of the patients to express the somatic symptoms clearly.

Demography of the study patients indicate the mean age of 30.0±18.6years in qualitative and 34.65±1.6years in quantitative measurements. The number of patients with very severe form of depression disorder were more in both the measurements (Qualitative: 48.6% [122/251]); Quantitative: 45.2% [113/250]) when compared to the number of patients who were suffering from severe, moderate and mild form of depression (Table 1).

Prevalence of Somatizing Major Depressive Patients:

The prevalence of somatizing patients who were diagnosed as suffering from major depression disorder was found to be 98.81% (248/251) and 98.8% (247/250) in qualitative and quantitative measurements, respectively. These data indicate that the prevalence of somatizing major depressive patients is equally high in both qualitative and quantitative measurements.

Frequency and nature of Somatic Symptoms in Major Depressive Patients:

Qualitative Measurement:

Totally, nine different types of somatic symptoms were self-reported by major depressive patients. Somatic symptoms (SS) that were self-reported to various extent by major depressive patients are: paresthetic sensation, fatigue, body pain, headache, heaviness in the head, palpitation, chest pain, back pain and pain in the abdomen [Range: 14.92% to 60%]. Of these SS, paresthetic sensation was found to be reported frequently [60% (149/248)] while back pain and pain in the abdomen were equally reported to the lower extent [14.9% (37/248)]. Median of the frequency distribution of SS indicates that less than 47% of major depressive patients report four SS such as palpitation, chest pain, back pain and pain abdomen whereas more than 47% of the patients report five SS such as heaviness in the head, headache, body pain, fatigue and paresthetic sensations (Figure 1).

Quantitative Measurement

Totally, eighteen different types of somatic symptoms were reported by major depressive patients. Somatic symptoms that were reported to various extent by major depressive patients are: headache, weak arms or legs, feeling of pressure in the head or body, heart beating fast or pounding, parts of the body feel numb or tingling, muscle pain, appetite poor, heavy arms or legs, tight head or neck, crams, pressure on head, nausea, sick to stomach, breathing difficult, feeling of not enough air, upset bowels or stomach, head pain and choking feeling [Range: 20.2% to 72.7%]. Of these SS, headache was found to be reported frequently [72.5% (179/247)] while head pains and choking feeling were equally reported to the lower extent [20.2% (50/247)]. Median of the frequency distribution of SS indicates that less than 46% of major depressive patients report nine SS such as crams, pressure on the head, nausea, sick to stomach, breathing difficult, feeling of not enough air, upset bowels or stomach, head pains and chocking feeling whereas more than 46% of the patients report nine SS such as headache, weak arms or legs, feeling of pressure in the head or body, heart beating fast or pounding, parts of the body feels numb or tingling, muscle pain, appetite poor, heavy arms or legs and tight head or neck(Figure 2).

Comparison of Somatic Symptoms commonly reported by Major Depressive Patients in both Qualitative and Quantitative Measurements

We found that there are five SS that were commonly reported by most of the major depressive patients in both qualitative and quantitative measurements above the median frequency level. They are mentioned here with respect to qualitative [quantitative] measurement: paresthetic sensation (60.1%) [Parts of the body feel numb or tingling (59%)], fatigue (54%)[weak arms or legs (65%)], body pain (54% [muscle pain (53%)], headache (48%) [headache (72.5%)] and heaviness in the head (47%)[feeling of pressure in the head or body (62.8%)]. The frequency of report of common SS was found to be significantly more in quantitative measurement than qualitative measurement (P<0.05; 0.044). Three more SS such as appetite poor (53%), heavy arms or legs (50.3%) and tight head or neck (47.5%) were found reported frequently only during the quantitative measurement but not in the qualitative measurement.

These data suggests that five SS such as paresthetic sensation [parts of the body feel numb or tingling], fatigue [weak arms or legs], body pain [muscle pain], headache [headache] and heaviness in the head [feeling of pressure in the head or body] are the most commonly reported SS by major depressive patients irrespective of measurement tool in our study (Figure 3).

Discussion

The purpose of this study was to assess the prevalence, nature and frequency of reported somatic symptoms (SS) with or without structured interview among major depressive patients. Totally 510 patients who were suffering from major depressive disorder were enrolled in to the study. These patients were equally  allocated for qualitative and quantitative measurements to assess the somatic symptoms. Mean age of these patients was 30.0 ±18.6 and 34.65±1.6 years respectively. Gender distribution was equal in both the assessments. Nearly 50% of the enrolled patients were with very severe form of major depression disorder in both the measurements. These data shows that the number of adult depressive patients who were suffering from very severe form of major depression disorder was substantially more in this study. 

Prevalence of Somatizing Major Depressive Patients:

Our study results showed that the majority of major depressive out patients reported somatic symptoms when they were assessed with (98.8%) and without (98.81%) somatic symptoms structured questionnaire. It could be due to the presence of substantial number of major depressive patients who were suffering from very severe form of major depression in this study. A review on somatic symptoms and their treatment mentions that the presence of painful symptoms (back pain, musculoskeletal pain, and chest pain) indicates the more severity of depression disorder.² This fact perhaps influenced high prevalence of somatizing depressive patients. However, further studies are required to relate somatic symptoms with the severity of depression in major depressive patients.

Another factor that may be responsible for high prevalence of somatizing depressive patients in our study was the somatization criteria used. Accordingly, the study patients who have reported at least one somatic symptom were considered. In support to this fact, the prevalence of somatizing depressive patients was found to be less (87%) in an international study that assessed the relationship between somatic symptoms and depression in Indian depressive patient population. In this study, depressive patient was considered as somatizing only he/she reports at least three somatic symptoms. These results clearly indicate that the prevalence of somatizing depressive patients is dependent on the somatization criteria used.³

Frequency and nature of Somatic Symptoms reported by Major Depressive Patients:

The number and nature of the somatic symptoms reported by major depressive patients varied between qualitative and quantitative measurements in this study. Nine different types of SS such as paresthetic sensation, fatigue, body pain, headache, heaviness in the head, palpitation, chest pain, back pain and pain in abdomen were found reported at various frequencies [Range: 14.92% to 60%]. Of these SS, paresthetic sensation was reported by majority of the patients in qualitative group [60%] (Figure 1). In quantitative measurement, eighteen different types of SS such as headache, weak arms or legs, feeling pressure in the head or body, heart beating fast or pounding, parts of the body feel numb or tingling, muscle pain, appetite poor, heavy arms or legs, tight head or neck, crams, pressure on the head, nausea, sick to stomach, breathing difficult, feeling of not enough air, upset bowels or stomach, head pain and choking feeling were reported at various frequencies [Range: 20.2% to 72.7%]. Of these, headache was reported by most of the study patients [72.5%] (Figure 2).  These results reveals that the major depressive patients tend to report more (twice) number of SS with structured questionnaire than without the questionnaire. Previous clinical studies have also found that the SS are widely reported when structured somatic questionnaire used.^5,9 In spite of headache and paresthetic sensation are being the frequently reported somatic symptoms in quantitative and qualitative measurements, nature of all the somatic symptoms reported by the study patients was similar to that of other clinical studies involving the depressive patients.^10,11

Comparison of Somatic Symptoms commonly reported by Major Depressive patients in Qualitative and Quantitative measurements:

Five somatic symptoms were found reported by substantial number (over 50%) of the major depressive patients commonly during both qualitative and quantitative measurements among other SS. Five SS commonly reported are paresthetic sensation, fatigue, body pain, headache and heaviness in the head. The frequency of report of such SS was significantly more (P<0.05; 0.044) in quantitative measurement when compared to the frequency value in the qualitative measurement (Figure 3). The reason for such difference is mentioned elsewhere. These data suggest that the above somatic symptoms are the chief complaints of major depressive patients as reported similarly in previous clinical studies.^2,3,12

Conclusion

Majority of major depressive patients report different types of somatic symptoms. The number and nature of such symptoms was found to be more with structured interview. Commonly reported somatic symptoms are headache, paresthetic sensation, heaviness in the head, fatigue and body pain.