1. SOMATIC COMPLAINTS in DEPRESSION
Blok XX Psikosomatik
Universitas Tadulako
2012

2. 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
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

3. 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

4. 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

5. Depression. It’s not only a state of mind.
The symptoms of depression
Emotional Symptoms Include:
Sadness
Loss of interest or pleasure
Overwhelmed
Anxiety
Diminished ability to think or concentrate, indecisiveness
Excessive or inappropriate guilt
Physical Symptoms Include:
Vague aches and pains
Headache
Sleep disturbances
Fatigue
Back pain
Significant change in appetite 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: ,489.

6. 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 primary care, physical symptoms are often
the chief complaint in depressed patients
N = 1146 Primary care patients with major depression
Reference:
Simon GE, et al. N Engl J Med. 1999;341(18):

7. Aches/pain – a physical symptom of significance
Aches/Pain as common as anxiety among depressed patients
KEY POINTS
These data show the prevalence of pain and body aches as well as anxiety disorders among depressed patients.
Depending upon the survey, body aches and pain seem to be as prevalent among depressed patients as anxiety disorders.
DATA
Data computed using the two studies published in the Green journal.
The two studies reported pain / body aches among pure vs depressed somatic patients (somatic defined as depression with sleep disturbances and appetite changes – pure is without these two).
Adapted from
1.Silverstein B. Am J Psychiatry. 1999;156(3): Silverstein B. Am J Psychiatry. 2002;159(6):

8. 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:
Adapted from: Paykel ES, et al. Psychol Med. 1995;25:

9. Serotonin5HT and NorepinephrineNE in the brain
Limbic System
Prefrontal Cortex
Locus Ceruleus (NE Source)
Raphe Nuclei (5-HT source)
Serotonin and Norepinephrine in Depression1
Serotonin and norepinephrine are believed to be key neurotransmitters in the etiology of depression
From the raphe nuclei and locus ceruleus, 5-HT and NE, respectively, send projections up to the prefrontal cortex and limbic system where emotional depressive symptoms are thought to be mediated.
Additionally, there are also 5-HT and NE-rich tracts into the spinal cord, which are thought to modulate pain perception.
1. Adapted from Stahl SM. J Clin Psych. 2002; 63:
Cooper JR, Bloom FE. The Biochemical Basis of Neuropharmacology

10. There are at least two sides to the neurotransmitter story
Functional domains of Serotonin and Norepinephrine1-4
Serotonin (5-HT)
Norepinephrine (NE)
Depressed Mood
Anxiety
Irritability
Thought process
Sex
Appetite
Aggression
Concentration
Interest
Motivation
Vague Aches and pain
Some symptoms (e.g. appetite, attention) seem to be mediated more by one neurotransmitter than the other. Some other symptoms (e.g. anxiety) seem to be mediated by either. There are other symptoms (e.g. aches and pain) that seem to be mediated more consistently by a combination of both the neurotransmitters.
Both serotonin and norepinephrine mediate a broad spectrum of depressive symptoms
References:
Adapted from: Stahl SM. In: Essential Psychopharmacology: Neuroscientific Basis and Practical Applications: 2nd ed. Cambridge University Press 2000.
Blier P, et al. J Psychiatry Neurosci. 2001;26(1):37-43.
Doraiswamy PM. J Clin Psychiatry. 2001;62(suppl 12):30-35.
Verma S, et al. Int Rev Psychiatry. 2000;12:

11. 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 pain perception among depressed patients1-3
Imbalances of 5HT and NE may explain the presence of both emotional and physical symptoms of depression.
Descending Pathway
Descending
Pathway
Ascending
Pathway
Ascending Pathway
Adapted from References:
Stahl SM. J. Clin Psych. 2002;63:
Verma S, et al. Int Rev Psychiatry. 2000;12:
Blier P, et al. J Psychiatry Neurosci. 2001;26(1):37-43.

12. 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:

13. Response and Remission defined
Hamilton Depression Rating Scale (HAM-D): 17 Items, Total Score
HAM-D17 Scores
Depression
(Major Depressive Disorder) 15
Response
 50% reduction from baseline HAM-D score
Remission: HAM-D Score  7 7
References:
1. Frank E. Conceptualization and rationale for consensus definition terms in MDD, Arch Gen Psych. 1991; 48:

14. Treatment outcome:Effect on work & social functioning
Remitted patients virtually equaled healthy controls on functioning levels at endpoint of 12-week treatment trial (Responders & non-responders did not)
Higher Score indicates greater impairment
Normal
(n=482)
Remission (n=202)
Response
(n=122)
Nonresponse
(n=299)
Social Adjustment Scale-SR (Mean ± SD) * ** 1 2 3 5
Study in chronic depressed patients
*p.05 vs nonresponse. **p.05 vs response.
Miller IW, et al. J Clin Psychiatry. 1998;59(11):

15. 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.

16. Incomplete relief from symptoms may increase the risk of relapse2,3
Lingering emotional and physical symptoms may jeopardize achieving remission.
References:
Nierenberg AA, et al. J Clin Psychiatry. 1999:60(suppl 22):7-11.
O’Reardon JR, et al. Psychiatr Ann. 1998;28:
Lynch ME. J Psychiatry Neurosci. 2001;26(1):30-36.

17. neurotransmitter dysregulation cytokine dysregulation
5-HT
neurotransmitter dysregulation
cytokine dysregulation
Mechanisms proposed as underlying Fatigue
circadian rhythm disruption
vagal afferent activation
alterations in muscle and ATP metabolism
hypothalamic–pituitary–adrenal axis dysfunction

19. 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