The Positive Impact of Somatic Symptoms in Understanding Depression
The field of psychology is ever growing with its numerous disorders, ways of classifying them, and treating them. A mental disorder that has been getting more and more attention throughout the years as an alarming amount of people have been diagnosed with it, is depression. In fact, is said that by the year 2030 major depressive disorder (MDD) will be the second leading cause of burden of diseases worldwide (3). Depressions is a vast and complex disorder that contains a wide range of symptoms, these symptoms can be placed into two categories. The main one in the psychology field being endogenous, these are symptoms that relate to a chemical/hormone imbalance inside of a person, as well as depression relating with genetics. Then there is somatic depression, which are physical symptoms that may feel unpleasant to the human body, such as stomach pain, back pain, pain in arm/ joints, nauseam trouble, sleeping, chest pain, headaches, and countless others somatic indicators (3). Overall, a majority of today’s focus when diagnosing and treating depression goes into seeing if a depressed patient meets the quota for at least five symptoms, where they are then giving a generalized treatment plan regardless of symptom types. However, what I want to bring to light and push forward is that looking further in to the type of symptoms the patient has in addition to the quantity can make a world of difference. Being that countless depression symptoms exist, my topic of interest is somatic symptoms and how putting more emphasis and evaluating them in a clinical setting can be very advantageous in ways like, predicting severe cases in MDD or knowing the effectivity of an antidepressant on a patient.
To further touch on how major depressed patients are diagnosed, psychologist often refer to The Diagnostic and Statistical Manual of Mental Disorder (DSM-5). Here an individual has to exhibit five or more symptoms with the requirement that one being either depressed mood or diminished pleasure/interest (1). Hence, the way diagnosing for MDD is standardized, prioritization goes more towards the amount of symptoms present, over what exactly were those indicators. In a STAR*D study with 3703 depressed outpatients it was found that only 2% of those individuals shared a similar symptom profile, where 14% had a profile unique to themselves alone (1). While counting up the symptoms may provide a sum score for an approximate depression severity, this system is too general and at times inaccurate. As people with fewer than five symptoms can have a severer case of MDD, this being because different symptoms vary their impact on the impairment of the psychosocial function. Analyzing individual symptoms like those that correspond with somatic depression could provide far better insight of an MDD patient than a proxy sum score could achieve.
Somatic symptoms being more physical based signs used to diagnose MDD patients are very common in depressed patients. As previously mentioned, a person may contain more symptoms than another patient, but whether they are endogenous or somatic makes a huge difference. Somatic more specifically those than are pain symptoms are heavily linked with a more drastic case of depression, and those with somatic depression are said to be harder to provide treatment than the people who have emotional symptoms (2). The main reason is that people who exhibit somatic signs show worse remission to treatment, and are more prone to relapse, therefore analyzing the patterns of somatic symptoms could serve as a predictor for major depressive disorder. In a study titled ““The impact of headache and somatic symptoms on MDD II,”, it was worth noting that in a test group examining somatic, endogenous, and anxiety symptoms, somatic symptoms were the best in predicting the severity outcome of MDD patients(2). This was for the group that received no treatment/medication, after 6 month and 2–year periods; those with somatic signs a grave instance of MDD participants. In addition, for groups that did receive anti-depressants the main one being venlafaxine, out the three, individuals with somatic signs once again proved to have the worst course of depression in the 6 month and 2–year period. There was a positive correlation between the higher cost of this medication therapy over time and somatic symptoms out of all groups, an explanation for this could be that somatic symptoms are harder to treat in MDD patients than those of emotional symptoms which anti-depressant are more geared towards. Either way, with or without medication individuals with somatic indicators in the end had a more extreme depression occurrence, if psychologist were to pay more attention to those that have somatic signs, then a different treatment plan could be provided that is more effetive than a person who has a symptom profile that is mainly endogenous, but receiving the same therapy.
In one study that focuses on people Major Depressed Disorder, but this time being in patients that are part of primary care, these are their regular doctors not specialized professionals in the MDD field. This was done to show the correlation between the natural course of a person with MDD over 39 months, with somatic and depressive symptoms. In terms of the attendees diagnosed for somatic symptoms, they were screened for 15 physical symptoms, that included the likes of low energy, stomach pain, dizziness, shortness of breath, headache, and on forth (3). In order to properly access the impact of these symptoms, a baseline was constructed for participants with and without MDD, along with a flow chart for the three types of MDD groups being observed. Patients who were showing remission from the baseline, those where fluttering in their MDD course, and those that had chronic MDD. Out of the 1,338 participants over the time frame of 39 months, 43% were remising from the baseline, 40% fluctuated in that baseline, and 17% were chronically depressed (3). What was interesting is that analyzing those with somatic symptoms a pattern was exhibited like in the study with MDD people over 6 months and two years. This time the correlation was that the participants remitting from baseline had less somatic symptoms, than those in the fluctuating and chronic MDD group. These two groups rising above the MDD baseline had more severe somatic symptoms and a rise in mental dysfunction (3). Over the 39 months in the chronic group, the participants with the somatic symptoms continued to have an incline in mental dysfunction with no sign of remission like the first group who had little somatic and or endogenous symptoms. This appears to follow a continuous trend that comes examining somatic signs in people and its’ connection with a more severe form of MDD.
Another research paper that also talks about primary care patients with somatic symptom is the one where they looked at the connection between the severity of MDD between Asian individuals and their somatic signs. According to a WHO study in 1999 you can see how common it was for people to have somatic signs along their MDD episodes, 2/3 of thier patients were shown to exhibit these symptoms (4). The somatic symptoms examined here deal with instances of pain such as headaches, stomach pain, and back pain, also known as painful physical symptoms (PPS). In a study done with 909 patients with MDD patients separated in three clusters, one with few to no somatic symptoms, one wth moderate symptoms signs, and those with severe somatic symptoms. Like the previous case study the results were quite similar in the way that remission was highest in the cluster with little to no somatic signs, 68.4% remission rate(4). However, as the number of somatic signs increased the remission rates declined significantly to 54.7% in the moderate cluster and 29.3% in the severe somatic cluster (4). While the association between somatic symptoms and a worse case of depression has been established in these past two studies, another important issue is the under diagnosing of patients that come into their primary care doctor with these somatic symptoms. As these pain signs are under evaluated and few individuals are informed of their correlation to depression, often than not many people walk in their general doctors claiming discomfort and weakness, which leads to an improper diagnosis for a physical disease(4). Henceforth, not only psychologist but patients as well being more informed of somatic signs can help in the proper diagnosis of MDD, accounting an individual with these signs can be used a caution for a more severe set of depression that will require further and more complex treatment that those with endogenous or feeling based symptoms.
Previously a connection was made between a worse remission state and individuals that has somatic symptoms, this remission rates can also apply to MDD individuals being treated with anti-depressant. Also as mentioned, under DSM-5 depressed individual are all treated in a similar manner, no wonder a remission gap exists between people with somatic and non-somatic indicators. In a STAR*D research, a comparison was made of the effectiveness of anti-depressants on pure vs somatic depressed individuals. This is one of the largest studies ever done testing anti-depressants with over 4041 people participating, test results focused on test trails with level 1-3, testing different varieties of anti-depressant per level and their effectiveness on those who met the criteria for somatic and pure depression(5). In the STAR*D study it showed those who exhibited somatic symptoms in levels 1 and 3 did not show remission to the anti-depressant administered as those individuals who were under the pure depression criteria, (5). The overarching conclusion was that identifying people with somatic symptoms proved to be quite positive, as you could pin-point anti-depressants that were more suited for endogenous symptoms and had relatively no useful effect on participants with somatic signs.
Overall, in today’s practice of depression the standard for diagnosing and treating MDD has become too generalized and to an extend very inaccurate. Psychologist relying on sum-scores to get a proxy on the severity of the depression is not as reliable as analyzing the specific symptoms a person has and proceeding treatment from there. While there exists a plethora of depression symptom, my concern was that of somatic signs, a better understanding of somatic signs has been shown to be quite beneficial in the diagnosis of worse cases of MDD. Knowing patients have those symptoms in a clinical setting, psychologist could detect early on that their patients are more prone to poorer remission rates after and before therapy. This includes knowing which anti-depressant are less effective because of the awareness of somatic signs. All in all, somatic symptoms have proven to change the way depression can be diagnosed for the better, and directly provide a favorable treatment plan.
Citations
1.Eiko I. Fried, Randolph M. Nesse,Depression is not a consistent syndrome: An investigation of unique symptom patterns in the STAR*D study,Journal of Affective Disorders Volume 172,2015, Pages 96-102,
2.Ching-I Hung, Chia-Yih Liu, Shuu-Jiun Wang, Yeong-Yuh Juang, Ching-Hui Yang,Somatic symptoms: An important index in predicting the outcome of depression at six-month and two-year follow-up points among outpatients with major depressive disorder,Journal of Affective Disorders,Volume 125, Issues 1–3,2010,Pages 134-140
3.Stegenga, B.T., Kamphuis, M.H., King, M. et al. The natural course and outcome of major depressive disorder in primary care: the PREDICT-NL study (2012) Volume 47, Issue 1, pp 87–95
4.Diego Novick, William Montgomery, Jaume Aguado, Zbigniew Kadziola, Xiaomei Peng, Roberto Brugnoli, Josep Maria Haro,Which somatic symptoms are associated with an unfavorable course in Asian patients with major depressive disorder? Journal of Affective Disorders,Volume 149, Issues 1–3,2013,Pages 182-188,
5.Brett Silverstein, Priya Patel,Poor response to antidepressant medication of patients with depression accompanied by somatic symptomatology in the STAR*D Study,Psychiatry Research,Volume 187, Issues 1–2,2011,Pages 121-124,
