Prevalence, characteristics, and attribution of somatic symptoms in Spanish patients with major depressive disorder seeking primary health care

Impact of painful physical symptoms on first-episode major depressive disorder in adults with subthreshold depressive symptoms: A prospective cohort study

OBJECTIVE

To investigate the impact of baseline painful physical symptoms (PPS) on subsequent first-episode major depressive disorder (MDD) in adults with subthreshold depressive symptoms, including subgroup analyses to assess whether the associations differ in individuals with and without physical diseases.

METHODS

A total of 2343 adults with subthreshold depressive symptoms were recruited at 34 primary health care centers. PPS were measured at baseline. First-episode MDD during follow-up was diagnosed by professional psychiatrists using the Mini-International Neuropsychiatric Interview.

RESULTS

Baseline PPS showed independent impacts on first-episode MDD in adults with subthreshold depressive symptoms without physical diseases, but not in those with physical diseases. A non-linear association (P < 0.001) was observed between PPS burden and the risk of first-episode MDD. The HRs for first-episode MDD exhibited a rapidly increasing trend between PPS burden scores of 10-16, and maintained consistently high when scores exceeded 16. The analyses for specific PPS revealed that headache, neck pain, and heart or chest pain were independently associated with first-episode MDD in participants without physical diseases, the HRs were 1.57 (1.15-2.36), 1.53 (1.02-2.30), and 1.69 (1.14-2.50), respectively. Further network analysis demonstrated that heart or chest pain serves as a bridge symptom among the seven specific PPS and first-episode MDD in those without physical diseases.

CONCLUSION

PPS burden and heart or chest pain may be significant indicators for first-episode MDD in adults with subthreshold depressive symptoms without physical diseases. Future studies should investigate whether interventions targeting PPS can prevent episode MDD in this subthreshold population.

Predictive potential of somatic symptoms for the identification of subthreshold depression and major depressive disorder in primary care settings

BACKGROUND

The presence of heterogenous somatic symptoms frequently obscures the recognition of depression in primary care. We aimed to explore the association between somatic symptoms and subthreshold depression (SD) and Major Depressive Disorder (MDD), as well as to determine the predictive potential of somatic symptoms in identifying SD and MDD in primary care.

METHODS

Data were derived from the Depression Cohort in China study (ChiCTR registry number: 1900022145). The Patient Health Questionnaire-9 (PHQ-9) was used to assess SD by trained general practitioners (GPs), and the Mini International Neuropsychiatric Interview depression module was used to diagnose MDD by professional psychiatrists. Somatic symptoms were assessed using the 28-item Somatic Symptoms Inventory (SSI).

RESULTS

In total of 4,139 participants aged 18-64 years recruited from 34 primary health care settings were included. The prevalence of all 28 somatic symptoms increased in a dose-dependent manner from non-depressed controls to SD, and to MDD (P for trend <0.001). Hierarchical clustering analysis grouped the 28 heterogeneous somatic symptoms into three clusters (Cluster 1: energy-related symptoms, Cluster 2: vegetative symptoms, and Cluster 3: muscle, joint, and central nervous symptoms). Following adjustment for potential confounders and the other two clusters of symptoms, per 1 increase of energy-related symptoms exhibited significant association with SD (OR = 1.24, 95% CI, 1.18-1.31) and MDD (OR = 1.50, 95% CI, 1.41-1.60) The predictive performance of energy-related symptoms in identifying individuals with SD (AUC = 0.715, 95% CI, 0.697-0.732) and MDD (AUC = 0.941, 95% CI, 0.926-0.963) was superior to the performance of total SSI and the other two clusters (P < 0.05).

CONCLUSIONS

Somatic symptoms were associated with the presence of SD and MDD. In addition, somatic symptoms, notably those related to energy, showed good predictive potential in identifying SD and MDD in primary care. The clinical implication of the present study is that GPs should consider the closely related somatic symptoms for early recognition for depression in practice.

Screening PLHIV for depression using PHQs: A RCT comparing non-selective with selective screening strategy within a primary health care facility in Uganda

BACKGROUND

Depression is rarely screened for among People Living with Human Immunodeficiency Virus (PLHIV) although it is 2 to 3 times more prevalent among PLHIV than in the general population. In instances where depression is screened for using screening tools, it usually follows noticing depression risk factors. This practice of selectively screening for depression could be leaving some cases of depression unattended to. On the other hand, subjecting every client to screening tools (non-selective screening) offers every patient an opportunity to be managed for depression. However, this could require additional resources as compared to selective screening. We present and discuss results on whether non-selective and selective screening strategies differ in depression case detection, and in addition, we also present perceptions of the stake holders on the two screening strategies.

METHODS

The study was conducted in Princess Diana Memorial Health Centre IV HIV clinic using a randomized controlled trial with a qualitative component. To determine whether there was a difference in depression case detection, consecutively sampled participants were randomly allocated to either non-selective or selective screening strategy. Participants allocated to selective screening were screened for depression using the patient health questionnaire (s) (PHQs) if they were at "crisis points". While those allocated to non-selective screening were screened regardless of whether the "crisis points" were noticed or not. The PHQ-2 and PHQ-9 were used in sequence. 326 PLHIV participated in the study. Outcomes of the MINI evaluation were analyzed for those with PHQ-9 scores of 10 or more to confirm major depressive disorder (MDD). Data was analyzed using the two sample Z-test for proportions with Stata 2013 software. To explore the perceptions of the stake holders, key informant interviews were performed with six stakeholders that experienced the study.

RESULTS

Cases of depression (PHQ-9 score ≥ 5) were more likely to be detected by the non-selective screening strategy 30.2% (49/162) compared to the selective screening strategy 19.5% (32/164) (difference in proportions 0.107, 95% confidence interval 0.014-0.200, Cohen's h = 0.25, P = 0.03). The stake holders thought it was important to screen for depression among PLHIV with preference to non-selective screening strategy.

CONCLUSION

Evidence from this data suggests that more cases of depression (PHQ-9 score ≥ 5) are likely to be detected with non-selective screening as opposed to selective screening.

TRIAL REGISTRATION

PACTR201802003141213 (name: comparison of routine versus selective screening for depression strategies among PLHIV attending Princess Diana Memorial Health Centre iv Soroti).

Experiences and coping strategies of somatic symptoms in patients with depressive disorder: A qualitative study

BACKGROUND

Depressive disorder is the most prevalent mental illness and is characterised by the presence of mental and somatic symptoms, with the latter affecting 65.0% to 98.2% of patients with their general function and quality of life.

PURPOSE

The purpose of this study aimed to explore the experiences and coping strategies of somatic symptoms in Chinese patients with depressive disorder, and to gain new insight into the illness and the health care provided to patients.

METHODS

Semi-structured, in-depth interviews were conducted with 15 patients diagnosed with depressive disorder according to international classification of diseases 10th revision. The interviews were transcribed verbatim and the thematic analysis was adapted to the data. MAXQDA10 software was used to organise, encode, classify, induce, and extract themes.

RESULTS

Four major themes were extracted from the interviews: (1) descriptions of symptoms; (2) perceptions of the symptoms; (3) symptom disturbance; and (4) coping strategies of symptoms. Within the first theme, patients identified the following sub-themes: complex experiences of somatic symptoms, which were mainly in the neuromuscular system, circulatory respiratory system, gastrointestinal system and some symptoms without obvious systemic classification; difficulty in locating symptoms accurately; and being not consistent with examination results. The second theme included patient's inadequate understanding of somatic symptoms; and denial of the link between physical discomfort and depression. Disturbance of somatic symptoms embraced three sub-themes: (1) Uncertainty about somatic symptoms; (2) Struggling with daily life; (3) Impact on social activities; (4) feeling a decrease in family support. Lastly, coping strategies taken by patients in the face of various symptoms mainly included relying on drug treatment, avoiding stressors, diverting attention, and compromise or acceptance.

CONCLUSIONS

Patients with depressive disorder experience a variety of somatic symptoms that have a negative impact on social function and reduce their quality of life. Patients did not have an adequate understanding of their physical discomfort and lacked effective coping strategies for these somatic symptoms. Professional staff should pay more attention to patients' somatic symptoms and focus on targeted symptom management to facilitate patient recovery.

Characteristics of somatic symptoms among Chinese patients diagnosed with major depressive episode

PURPOSE

This study aimed to describe the clinical features of somatic symptoms among Chinese patients diagnosed with major depressive episode (MDE).

METHODS

A total of 213 inpatients with MDE from two mental health hospitals were recruited and investigated using the Somatic Symptom Inventory (SSI), Hamilton rating scale for depression, Hamilton rating scale for anxiety, and a demographic questionnaire.

RESULTS

The participants included 142 patients with unipolar depression and 71 patients with bipolar depression. The mean SSI score of all participants was 49.30 (SD = 14.80). "Feeling fatigued, weak, or tired all over" was found to be the most common somatic symptom (61.0% reported moderate levels or above), followed by "feeling of being not in as good physical health as most of your friends" (56.3%), and "feeling weak in parts of the body" (49.3%). "Headache" and "soreness in muscles" were common painful symptoms. Both patients with unipolar and bipolar depression had similar somatic symptoms, including painful and non-painful ones. The somatic symptoms of all participants were closely correlated with the severity of depression and anxiety (P < 0.01). Patients with anxiety, older age, low education, and negative life events in the last year had more somatic symptoms.

CONCLUSIONS

Inpatients with MDE of somatic symptoms are common, which were significantly correlated with the severity of depression and anxiety. Further efforts should focus on early recognition and integrated care model management of patients based on their characteristics to improve their quality of life and treatment outcomes.

Somatization Symptoms Regulate Emotional Memory Bias in Adolescents With Major Depressive Disorder

Objective: Somatization symptoms are commonly comorbid with depression. Furthermore, people with depression and somatization have a negative memory bias. We investigated the differences in emotional memory among adolescent patients with depressive disorders, with and without functional somatization symptoms (FSS). Methods: We recruited 30 adolescents with depression and FSS, 38 adolescents with depression but without FSS, and 38 healthy participants. Emotional memory tasks were conducted to evaluate the emotional memory of the participants in the three groups. The clinical symptoms were evaluated using the Hamilton Depression Rating Scale (HDRS) and the Children's Somatization Inventory (CSI). Results: The valence ratings and recognition accuracy rates for positive and neutral images of adolescent patients were significantly lower than those of the control group (F = 12.208, P < 0.001; F = 6.801, P < 0.05; F = 14.536, P < 0.001; F = 6.306, P < 0.05, respectively); however, the recognition accuracy rate for negative images of adolescent patients of depression without FSS was significantly lower than that of patients with FSS and control group participants (F = 10.316, P < 0.001). These differences persisted after controlling for HDRS scores. The within-group analysis revealed that patients of depression with FSS showed significantly higher recognition accuracy rates for negative images than the other types (F = 5.446, P < 0.05). The recognition accuracy rate for negative images was positively correlated with CSI scores (r = 0.352, P < 0.05). Conclusion: Therefore, emotional memory impairment exists in adolescent patients of depression and FSS are associated with negative emotional memory retention.

Self-care agency, lifestyle, and physical condition predict future frailty in community-dwelling older people

The purpose of this 2 year longitudinal study was to identify the relationship between self-care agency, lifestyle, physical condition, and frailty among community-dwelling older people in a rural area of Japan. The participants were 133 older individuals aged 65 years or above. Data collection was conducted via face-to-face interviews using self-administered questionnaires. Background information, such as age, sex, current employment status, family structure, medication use, comorbidities, and knee and lower back pain, were assessed. The definition of frailty was based on the Frailty Checklist. Self-care agency, lifestyle habits, and locomotive syndrome were assessed using specific assessment scores. Logistic regression analysis showed that locomotive syndrome, knee and lower back pain, and stroke are risk factors for frailty. Among the factors associated with frailty, current employment, regular exercise, and self-care agency were recognized as preventive factors of depression, decreased cognitive function, and being housebound. Our findings suggest that enhancing self-care agency, regular exercise, and self-management skills for chronic illness and disability may decrease the progression of frailty among older people.

Somatoform symptoms profiles in relation to psychological disorders - A population classification analysis in a large sample of general adults

In order to identifying somatoform symptoms profiles, classifying study population and evaluating of psychological disorders in extracted classes, we carried out a cross-sectional study on 4762 Iranian adults. Somatoform symptoms were assessed using a comprehensive 30-items questionnaire and psychological disorders were evaluated by 12-item General Health Questionnaire (GHQ-12) and Hospital Anxiety and Depression Scale (HADS) questionnaires. Factor analysis and factor mixture modeling (FMM) were used for data analysis. Four somatoform symptoms profiles were extracted, including 'psycho-fatigue', 'gastrointestinal', 'neuro- skeletal' and 'pharyngeal-respiratory'. According to FMM results, a two-class four-factor structure, based somatoform symptoms, was identified in our study population. Two identified classes were labeled as "low psycho-fatigue complaints" and "high psycho-fatigue complaints". The scores of psychological disorders profile was significantly associated with four somatoform symptoms profiles in both classes; however the stronger relationship was observed in high psycho-fatigue complaints class. The prevalence of all the somatoform symptoms among participants assigned to the "high psycho-fatigue complaints" class was significantly higher than other class. We concluded that somatoform symptoms have a dimensional-categorical structure within our study population. Our study also provided informative pathways on the association of psychological disorders with somatoform symptoms. These findings could be useful for dealing with treatment's approaches.

Evaluation of a multicomponent programme for the management of musculoskeletal pain and depression in primary care: a cluster-randomised clinical trial (the DROP study)

BACKGROUND

Chronic musculoskeletal pain and depression are very common in primary care patients. Furthermore, they often appear as comorbid conditions, resulting in additive effect on adverse health outcomes. On the basis of previous studies, we hypothesise that depression and chronic musculoskeletal pain may benefit from an integrated management programme at primary care level. We expect positive effects on both physical and psychological distress of patients.

OBJECTIVE

To determine whether a new programme for an integrated approach to chronic musculoskeletal pain and depression leads to better outcomes than usual care.

DESIGN

Cluster-randomised controlled trial involving two arms: a) control arm (usual care); and b) intervention arm, where patients participate in a programme for an integrated approach to the pain-depression dyad.

SETTINGS

Primary care centres in the province of Tarragona, Catalonia, Spain, Participants: We will recruit 330 patients aged 18-80 with moderate or severe musculoskeletal pain (Brief Pain Inventory, average pain subscale ≥5) for at least 3 months, and with criteria for major depression (DSM-IV).

INTERVENTION

A multicomponent programme according to the chronic care model. The main components are care management, optimised antidepressant treatment, and a psychoeducational group action. Blind measurements: The patients will be monitored through blind telephone interviews held at 0, 3, 6 and 12 months.

OUTCOMES

Severity of pain and depressive symptoms, pain and depression treatment response rates, and depression remission rates.

ANALYSIS

The outcomes will be analysed on an intent-to-treat basis and the analysis units will be the individual patients. This analysis will consider the effect of the study design on any potential lack of independence between observations made within the same cluster.

ETHICS

The protocol was approved by the Research Ethics Committee of the Jordi Gol Primary Care Research Institute (IDIAP), Barcelona, (P14/142).

DISCUSSION

This project strengthens and improves treatment approaches for a major comorbidity in primary care. The design of the intervention takes into account its applicability under typical primary care conditions, so that if the programme is found to be effective it will be feasible to apply it in a generalised manner.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02605278 ; Registered 28 September, 2015.

Relationship Between Palpitation and Mental Health

Background:

‘Palpitation’ is one of the most common complaints in patients referring to cardiologists. In modern medicine era, these patients suffer from much distress and some cases are known to be difficult to treat. Although the clinician’s first duty is obviously to search for an organic basis for this symptom, the diagnostic evaluation is frequently unrevealing. However, clinical experience suggests that psychiatric causes are relatively common.

Objectives:

This research aimed to screen for mental disorders in patients complaining of palpitation and healthy persons in order to perform a preliminary comparison between them.

Patients and Methods:

This is a case-control study to screen mental disorders. The target population consisted of adult volunteers with benign palpitation and their matched healthy persons. They were referred during a 10-month-period to the cardiology outpatient’s clinic of Mostafa Khomeini hospital in Tehran, Iran. Sampling was accidental and eventually 110 participants comprised the sample size. The measuring tool was GHQ-28 (28-item general health questionnaire) and the main variable was the questionnaire score obtained from the Likert scoring method.

Results:

Comparing two groups showed that the number of participants with the scores more than cut-off point in palpitation group was significantly more than healthy person group (85.4% vs. 43.6% with P < 0.001). Also the total score of GHQ-28 and scores of its subscale (somatization, anxiety, and social dysfunction) in patients complaining of palpitation were significantly more than those of the healthy participants (34.2 vs. 25.7, 8.9 vs. 6.4, 9.4 vs. 6.4, and 12.3 vs. 10.8, respectively with P < 0.001, P = 0.001, P < 0.001, and P < 0.007, respectively).

Conclusions:

Palpitation is the most common symptom in psychiatric disorders such as anxiety and somatization disorders. According to the results of this study, psychiatric causes have an important role in Iranian patients complaining of palpitations (benign form). Considering this fact may lead to a more effective treatment of benign palpitations.

Systematic depression screening in high-risk patients attending primary care: a pragmatic cluster-randomized trial

BACKGROUND

Systematic screening for depression in high-risk patients is recommended but remains controversial. The aim of this study was to assess the effectiveness of such screening in everyday clinical practice on depression recognition.

METHODS

A pragmatic, cluster randomized, controlled study that randomized primary care physicians (PCPs) in Spain either to an intervention or control group. The intervention group (35-PCPs) received training in depression screening and used depression screening routinely for at least 6 months. The control group (34-PCPs) managed depression in their usual manner. Adherence to (1-6; never-very frequently), feasibility (1-4; unfeasible-very feasible), and acceptance (1-5; very poor-very good) of the screening were evaluated. Underrecognition (primary outcome) and undertreatment rates of major depressive disorder (MDD) in the two groups were compared 6 months after randomization in a random sample of 3737 patients assigned to these PCPs using logistic regression adjusting for the clustering effect.

RESULTS

No significant differences were found for recognition rates (58.0% vs. 48.1% intervention vs. control; OR [95%CI] 1.40 [0.73-2.68], p = 0.309). The undertreatment rate did not differ significantly either (p = 0.390). The mean adherence to depression screening was 4.4 ± 1.0 ('occasionally'), the mean feasibility was 3.1 ± 0.5 ('moderately feasible'), and the mean acceptance was 4.2 ± 0.6 ('good').

CONCLUSIONS

This research was not able to show effectiveness of the systematic screening for MDD in high-risk patients on depression recognition in primary care. The poor adherence to screening implementation could partially explain the results. These reflect the difficulties of putting into practice the clinical guidelines usually based on interventional research.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01662817.

Somatic symptoms in consultation-liaison psychiatry

In medically ill patients the term 'somatic symptoms' is used to understand those symptoms which cannot be fully understood in the light of existing medical illness(es). These include a number of physical symptoms and also certain clinical syndromes such as irritable bowel syndrome, fibromyalgia, and chronic fatigue syndrome among others. However, it is increasingly recognized that such patients have larger degrees of psychological morbidities, especially depressive and anxiety disorders, and have disproportionately elevated rates of medical care utilization, including outpatient visits, hospitalizations and total healthcare costs. In view of this psychological morbidity, significant distress and functional impairment, the role of the consultation-liaison psychiatrist is prominent in the management of these patients. A consultation-liaison (CL) psychiatrist is expected to be part of the primary care team to manage patient with unexplained SS, and at the same time is expected to guide colleagues to practice a patient-centred approach to improve the outcome of patients with such symptoms. The clinical work of a CL psychiatrist involves evaluation of patients with medically unexplained symptoms for probable psychiatric disorders and treatment of psychiatric morbidity and also management of patients without psychiatric morbidity. Management strategies include reattribution, cognitive behaviour therapy and antidepressants, with each strategy showing varying degrees of success.

DoloTest in General Practice Study: Sensitivity and Specificity Screening for Depression

Background. Coexistence of pain and depression has significant impact on the patient's quality of life and treatment outcome. DoloTest is a pain and HRQoL assessment tool developed to provide shared understanding between the clinician and the patient of the condition by a visual profile. Aim. To find the sensitivity and specificity of DoloTest as a screening tool for depression for patients in primary care. Methods. All patients coming to a primary care clinic were asked to fill in a DoloTest and a Major Depression Inventory. Results. 715 (68.5%) of 1044 patients entered the study. 34.4% came due to pain. 16.1% met depression criteria, and 26.8% of patients coming due to pain met criteria for depression. 65.6% of the men and 54.2% of the women meeting the criteria for depression came due to pain. Depressed patients had statistically significant higher scores on all DoloTest domains. Selecting the cutoff value for the domain "low spirits" to be "65" (0-100) for depression gave a sensitivity of 78% (70-85%) and a specificity of 95% (93-96%) for meeting depression criteria. Conclusion. DoloTest can with a high sensitivity and specificity identify persons meeting criteria for depression and is an easy-to-use screening tool to identify patients with the coexistence of pain and depression.

[Integral Care Guide for Early Detection and Diagnosis of Depressive Episodes and Recurrent Depressive Disorder in Adults. Integral Attention of Adults with a Diagnosis of Depressive Episodes and Recurrent Depressive Disorder: Part I: Risk Factors, Screening, Suicide Risk Diagnosis and Assessment in Patients with a Depression Diagnosis]

INTRODUCTION

Depression is an important cause of morbidity and disability in the world; however, it is under-diagnosed at all care levels.

OBJECTIVE

The purpose here is to present recommendations based on the evidence gathered to answer a series of clinical questions concerning risk factors, screening, suicide risk diagnosis and evaluation in patients undergoing a depressive episode and recurrent depressive disorder. Emphasis has been made upon the approach used at the primary care level so as to grant adult diagnosed patients the health care guidelines based on the best and more updated evidence available thus achieving minimum quality standards.

METHODOLOGY

A practical clinical guide was elaborated according to standards of the Methodological Guide of the Ministry of Social Protection. Recommendation from guides NICE90 and CANMAT were adopted and updated so as to answer the questions posed while de novo questions were developed.

RESULTS

Recommendations 1-22 corresponding to screening, suicide risk and depression diagnosis were presented. The corresponding degree of recommendation is included.

Frequency and outcomes of painful physical symptoms in a naturalistic population with major depressive disorder: an analysis of pooled observational studies focusing on subjects aged 65 years and over

AIMS

To estimate the frequency of painful physical symptoms (PPS) in elderly subjects (≥ 65 years) with major depressive disorder (MDD) in real-world clinical conditions and to establish whether PPS are associated with poor depression outcomes, including more severe depression and worse health-related quality of life (HRQoL).

METHODS

Observational studies of MDD that included assessment of PPS and elderly subjects were screened. Measures of PPS were based on the Somatic Symptom Inventory (SSI) or Visual Analogue Scale (VAS). Data from a variety of depressive symptom severity and HRQoL scales were used. Analysis cohorts were based on age [aged ≥ 65 years (elderly) or < 65 years (younger)] and/or PPS status (presence or absence); five subsets were used to examine specific outcomes in matched elderly subjects.

RESULTS

Data from seven studies (representing 26 countries) were collated. Of the 11,477 subjects, 14% were aged ≥ 65 years and 71% were classified as having PPS (PPS+). PPS were more frequent in elderly subjects (74% vs. 70% of younger subjects) and were positively associated with being female and Hispanic, and negatively associated with being East Asian in the elderly. The presence of PPS was associated with more severe clinical symptomatology and comparatively poorer HRQoL in elderly subjects.

CONCLUSIONS

PPS, although frequent in younger MDD patients, were slightly more frequent in elderly MDD patients and associated with comparatively poorer clinical and functional outcomes. As elderly patients report somatic symptoms more readily than emotional symptoms, physicians should consider depression in addition to physical causes when PPS are present.

Prevalence of depressive and anxiety disorders in Chinese gastroenterological outpatients

AIM: To investigate the prevalence and physicians’ detection rate of depressive and anxiety disorders in gastrointestinal (GI) outpatients across China.

METHODS: A hospital-based cross-sectional survey was conducted in the GI outpatient departments of 13 general hospitals. A total of 1995 GI outpatients were recruited and screened with the Hospital Anxiety and Depression Scale (HADS). The physicians of the GI departments performed routine clinical diagnosis and management without knowing the HADS score results. Subjects with HADS scores ≥ 8 were subsequently interviewed by psychiatrists using the Mini International Neuropsychiatric Interview (MINI) to make further diagnoses.

RESULTS: There were 1059 patients with HADS score ≥ 8 and 674 (63.64%) of them undertook the MINI interview by psychiatrists. Based on the criteria of Diagnostic and Statistical Manual of Mental Disorders (4th edition), the adjusted current prevalence for depressive disorders, anxiety disorders, and comorbidity of both disorders in the GI outpatients was 14.39%, 9.42% and 4.66%, respectively. Prevalence of depressive disorders with suicidal problems [suicide attempt or suicide-related ideation prior or current; module C (suicide) of MINI score ≥ 1] was 5.84% in women and 1.64% in men. The GI physicians’ detection rate of depressive and anxiety disorders accounted for 4.14%.

CONCLUSION: While the prevalence of depressive and anxiety disorders is high in Chinese GI outpatients, the detection rate of depressive and anxiety disorders by physicians is low.

Functional impairment related to painful physical symptoms in patients with generalized anxiety disorder with or without comorbid major depressive disorder: post hoc analysis of a cross-sectional study

BACKGROUND

Generalized anxiety disorder (GAD) is the most frequent anxiety disorder in primary care patients. It is known that painful physical symptoms (PPS) are associated with GAD, regardless the presence of comorbid major depressive disorder (MDD). However the specific role of such symptoms in patients' functional impairment is not well understood. The objective of the present study is to assess functional impairment related to the presence of PPS in patients with GAD.

METHODS

This is a post hoc analysis of a cross-sectional study. Functioning, in the presence (overall pain score >30; Visual Analog Scale) or absence of PPS, was assessed using the Sheehan Disability Scale (SDS) in three groups of patients; 1) GAD and comorbid MDD (GAD+MDD+), 2) GAD without comorbid MDD (GAD+MDD-), 3) controls (GAD-MDD-). ANCOVA models were used.

RESULTS

Of those patients with GAD+MDD+ (n = 559), 436 (78.0%) had PPS, compared with GAD+MDD- (249 of 422, 59%) and controls (95 of 336, 28.3%). Functioning worsened in both GAD groups in presence of PPS (SDS least squares mean total score: 16.1 vs. 9.8, p < 0.0001, GAD+MDD+; 14.3 vs. 8.2, p < 0.0001, GAD+MDD-). The presence of PPS was significantly associated with less productivity.

CONCLUSIONS

Functional impairment related to the presence of PPS was relevant. Clinical implications should be considered.

Generalized anxiety disorder, with or without co-morbid major depressive disorder, in primary care: prevalence of painful somatic symptoms, functioning and health status

BACKGROUND

Painful physical symptoms (PPS) have received little attention in patients with generalized anxiety disorder (GAD). The objective of the present study was to assess the prevalence of PPS in patients with GAD vs patients with GAD and co-morbid major depressive disorder (MDD) and a control group (patients neither with GAD nor MDD).

METHODS

This is a cross-sectional, multi-center, epidemiological study, in primary care. Patients were screened for GAD (HADS-A), followed by a diagnosis confirmation (MINI). Patients were considered to have PPS when VAS overall pain score >30. Functioning and health status was assessed (SDS, EUROQoL-5D). Relationships between the presence of PPS and functioning and health status was analyzed (ANCOVA models). Results were adjusted for confounding factors.

RESULTS

Of 7152 patients, 1546 (22%) screened positive for GAD, 981 (14%) had confirmed GAD diagnosis, of whom 559 (8%) had GAD with co-morbid MDD and 422 (6%) had GAD alone. Of the 5292 (74%) patients screened negative for GAD, 336 (5%) were confirmed as controls. PPS in patients with GAD were twice as prevalent as in the control group: 59.0% vs. 28.3%; p<0.001. The presence of co-morbid MDD was associated with a significantly higher prevalence of PPS: 78.0% vs. 59.0%; p<0.001. PPS were significantly associated with functioning and health status impairment (p<0.001) both in GAD alone and in GAD and co-morbid MDD compared with controls.

LIMITATIONS

Results do not prove causal relationships.

CONCLUSIONS

Our results support the clinical relevance of PPS in patients suffering from GAD; therefore they need to be considered when evaluating the patient.

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

BACKGROUND

Few studies have simultaneously compared the ability of depression, anxiety, and somatic symptoms to predict the outcome of major depressive disorder (MDD). This study aimed to compare the MDD outcome predictive ability of depression, anxiety, and somatic severity at 6-month and 2-year follow-ups.

METHODS

One-hundred and thirty-five outpatients (men/women=34/101) with MDD were enrolled. Depression and anxiety were evaluated by the Hamilton Depression Rating Scale, Hospital Anxiety and Depression Scale, and depression subscale of the Depression and Somatic Symptoms Scale (DSSS). Somatic severity was evaluated by the somatic subscale of the DSSS. Subjects undergoing pharmacotherapy in the follow-up month were categorized into the treatment group; the others were categorized into the no-treatment group. Multiple linear regressions were used to identify the scales most powerful in predicting MDD outcome.

RESULTS

Among the 135 subjects, 119 and 106 completed the 6-month and 2-year follow-ups, respectively. Somatic severity at baseline was correlated with the outcomes of the three scales at the two follow-ups. After controlling for demographic variables, somatic severity independently predicted most outcomes of the three scales at the two follow-ups in the no-treatment group and the cost of pharmacotherapy and DSSS score at the 6-month follow-up in the treatment group.

LIMITATIONS

Division of the subjects into treatment and no-treatment groups was not based on randomization and bias might have been introduced.

CONCLUSIONS

Somatic severity was the most powerful index in predicting MDD outcome. Psychometric scales with appropriate somatic symptom items may be more accurate in predicting MDD outcome.

Functional somatic complaints in depression: An overview

Depression is a disorder of major public health importance which often manifests through functional somatic complaints. Concept of functional somatic complaints dates back to the time of Wernicke and is later substantiated by various authors. Although considered as an alternative 'idiom of distress' in certain culture, functional somatic complaints are universal. Various international, cross-cultural, inpatient and outpatient based studies have reported that about two-third of subjects of depression present to clinicians with functional somatic complaints which often leads to misrecognition of their illness and in turn leads to increased utilization of health services. These functional somatic complaints can be related to various organ systems but show remarkable homogeneity in their presentation across culture. Various instruments have attempted to tap the functional somatic complaints but are limited by their cross-cultural validity. Among important correlates of functional somatic complaints are female gender, severity of depression, subsyndromal anxiety, alexithymia, somatosensory amplification and hypochondriacal worry are to name a few. Neurobiological understanding implicates neurotransmitters serotonin and norepinephrine, resultantly Serotonin Norepinephrine Reuptake Inhibitors have been found to be effective in treating functional somatic complaints in depression. Future revisions in the nosological systems should consider giving proper importance to some of these symptoms for diagnosing depression.

The role of beta-endorphin in the pathophysiology of major depression

A role for beta-endorphin (beta-END) in the pathophysiology of major depressive disorder (MDD) is suggested by both animal research and studies examining clinical populations. The major etiological theories of depression include brain regions and neural systems that interact with opioid systems and beta-END. Recent preclinical data have demonstrated multiple roles for beta-END in the regulation of complex homeostatic and behavioural processes that are affected during a depressive episode. Additionally, beta-END inputs to regulatory pathways involving feeding behaviours, motivation, and specific types of motor activity have important implications in defining the biological foundations for specific depressive symptoms. Early research linking beta-END to MDD did so in the context of the hypothalamic-pituitary-adrenal (HPA) axis activity, where it was suggested that HPA axis dysregulation may account for depressive symptoms in some individuals. The primary aims of this paper are to use both preclinical and clinical research (a) to critically review data that explores potential roles for beta-END in the pathophysiology of MDD and (b) to highlight gaps in the literature that limit further development of etiological theories of depression and testable hypotheses. In addition to examining methodological and theoretical challenges of past clinical studies, we summarize studies that have investigated basal beta-END levels in MDD and that have used challenge tests to examine beta-END responses to a variety of experimental paradigms. A brief description of the synthesis, location in the CNS and behavioural pharmacology of this neuropeptide is also provided to frame this discussion. Given the lack of clinical improvement observed with currently available antidepressants in a significant proportion of depressed individuals, it is imperative that novel mechanisms be investigated for antidepressant potential. We conclude that the renewed interest in elucidating the role of beta-END in the pathophysiology of MDD must be paralleled by consensus building within the research community around the heterogeneity inherent in mood disorders, standardization of experimental protocols, improved discrimination of POMC products in analytical techniques and consistent attention paid to important confounds like age and gender.