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.

The cut-off points of the Depression and Somatic Symptoms Scale and the Hospital Anxiety and Depression Scale in detecting non-full remission and a current major depressive episode

OBJECTIVE

This study aimed to ascertain the cut-off scores of the Depression and Somatic Symptoms Scale (DSSS) for non-full remission (FR) and a current major depressive episode (MDE) and compare the discriminative abilities of the DSSS and the Hospital Anxiety and Depression Scale (HADS).

METHODS

One-hundred and nineteen depressive outpatients who completed a 6-month follow-up were used to ascertain the cut-off scores for non-FR, defined as a Hamilton Depression Rating Scale score ≥ 8; another 214 consecutive outpatients were assessed to identify the cut-off scores for a MDE, as defined by the Structured Clinical Interview for DSM-IV-TR. Receiver operating characteristic (ROC) analysis was used to ascertain the cut-off scores.

RESULTS

The area under the ROC curve was greatest for the DSSS depression subscale (DS), followed by the HADS depression subscale (HADS-D). The cut-off scores for non-FR were a DS score ≥ 9 (sensitivity and specificity: 88.7 and 71.9%, respectively) and a HADS-D score ≥ 8 (77.4 and 84.2%), and the cut-off scores for a MDE were a DS score ≥ 19 (86.3 and 75.6%) and a HADS-D score ≥ 11 (77.9 and 76.5%).

CONCLUSIONS

The DSSS and HADS can be used to distinguish different depressive states. The results demonstrated the discriminative validity of the DSSS and the HADS.

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.

Migraine: a missing link between somatic symptoms and major depressive disorder

BACKGROUND

Research into the role of migraine in somatic symptoms of major depressive disorder (MDD) has long been neglected; hence, the aim of this study was to compare the impact of migraine and anxiety comorbidities on the somatic symptoms of patients with MDD.

METHODS

Consecutive psychiatric outpatients with MDD in a medical center were enrolled. MDD and anxiety disorders were diagnosed using the Structured Clinical Interview for DSM-IV-TR; migraine was diagnosed according to the International Classification of Headache Disorders, 2nd edition. Four scales were administered and evaluated: the Hamilton Depression Rating Scale, the Depression and Somatic Symptoms Scale, the somatization subscale of the Symptom Checklist-90-Revised, and the Hospital Anxiety and Depression Scale. Multiple linear regressions were used to find the most powerful comorbidities in predicting somatic symptoms.

RESULTS

One hundred and fifty five patients (106F, 49M) completed the study. Subjects with migraine had higher somatic, depression and anxiety severities. Panic disorder was the most important factor when predicting somatic severity among anxiety comorbidities. Migraine (R(2) change=0.28 to 0.04, p<.01) was the strongest independent factor in predicting somatic severity, even after controlling for anxiety comorbidities and demographic variables.

LIMITATIONS

This study used certain exclusion criteria when enrolling MDD outpatients, possibly introducing bias.

CONCLUSIONS

Comorbidity with migraine was found to be associated with more somatic symptoms in patients with MDD, and migraine was a strong and independent predictor for the somatic symptoms of MDD. Future studies on the somatic symptoms of MDD should therefore take migraine into consideration.

Validation of the Depression and Somatic Symptoms Scale by comparison with the Short Form 36 scale among psychiatric outpatients with major depressive disorder

BACKGROUND

The Depression and Somatic Symptoms Scale (DSSS) is a self-administered scale developed for monitoring both depression and somatic symptoms. The aims of this study were to establish the criterion-related validity of the DSSS by testing the correlation between the DSSS and the Short Form 36 (SF-36) scale and to compare the ability of the DSSS and two other scales in predicting the outcome of the SF-36.

METHODS

The study enrolled 135 outpatients with a major depressive episode, 95 of whom received treatment for 1 month. Four scales were administered and evaluated: the DSSS, the SF-36, the Hospital Anxiety and Depression Scale, and the Hamilton Depression Rating Scale. Pearson correlation was used to test correlations among scales. Multiple linear regressions were used to find the scales most effective in predicting the SF-36.

RESULTS

The three scales were significantly correlated with most of the SF-36 subscales. The depression and somatic subscales of the DSSS significantly correlated with the mental and physical subscales of the SF-36, respectively. The DSSS and the Hospital Anxiety and Depression Scale were better able to predict physical and mental subscales of the SF-36, respectively. The Hamilton Depression Rating Scale had a good ability to predict functional impairment.

CONCLUSIONS

Psychometric scales with appropriate somatic symptoms might be more compatible with both physical and mental dimensions of the SF-36. DSSS proved to be a valid scale for monitoring both depression and somatic symptoms in patients with depression. Future studies should test whether the DSSS is better at predicting the treatment and prognosis of depression than conventional scales for depression.

Precipitating or aggravating factors for headache in patients with major depressive disorder

OBJECTIVE

The aim of this study was to investigate the common precipitating or aggravating factors for headache among patients with major depressive disorder (MDD) and to compare precipitating or aggravating factors specifically for migraine with those for other headaches.

METHODS

Consecutive psychiatric outpatients with MDD in a medical center were enrolled. Headaches were diagnosed based on the International Classification of Headache Disorders, 2nd Edition. A 21-item self-report questionnaire was used to identify precipitating or aggravating factors. Subjects were divided into migraine and other-headache groups.

RESULTS

Of 122 subjects (76% female) with headache, 63 (51.6%) were diagnosed with migraine. Mental stress and depressive symptoms were the most common precipitating or aggravating factors, and 17 factors affected >50% of the subjects. Compared with other-headache groups, the migraine group was more sensitive to emotional and perceptional stimuli and to the stress of daily activities.

CONCLUSION

Treatment of depression and education of depressed patients about how to cope with mental stress might help to eliminate the negative impact of headache.