LiaisonTeam09 - Significance of Somatic Symptoms when Diagnosing Depression (Aug09)
28
Alex J Mitchell [email protected] Department of Cancer & Molecular Medicine Leicester Royal Infirmary Department of Liaison Psychiatry, Leicester General Hospital Liaison Team & Online Aug 2009 Liaison Team & Online Aug 2009 Significance of Somatic Symptoms in Depression Include or Exclude when diagnosing depression in medical Settings?
-
Upload
alex-j-mitchell -
Category
Health & Medicine
-
view
593 -
download
1
description
This is a short presentation on the significance of somatic symptoms in the diagnosis of depression. These slides question the hypothesis that somatic symptoms should always be removed when looking for depression in medical settings.
Transcript of LiaisonTeam09 - Significance of Somatic Symptoms when Diagnosing Depression (Aug09)
Alex J Mitchell [email protected]
Department of Cancer & Molecular MedicineLeicester Royal Infirmary
Department of Liaison Psychiatry, Leicester General Hospital
Liaison Team & Online Aug 2009Liaison Team & Online Aug 2009
Significance of Somatic Symptoms in DepressionInclude or Exclude when diagnosing depression in medical Settings?
Significance of Somatic Symptoms in DepressionInclude or Exclude when diagnosing depression in medical Settings?
ContextContext
Many authors have highlighted that somatic symptoms occur in both depression and physical illness. Often it has been suggested that these should be omitted when looking for comorbid depression, assuming they contaminate the clinical presentation. This assumption has not previously been examined in an evidence based way.
Further, many groups have developed scales without somatic symptoms. These include the GDS, HADS and BDI. Whilst their performance has been tested, they have not been examined relative to their performance with somatic symptoms un-excluded.
In short the diagnostic (low) significance of somatic symptoms is plausible but untested.
1. What Are Somatic Symptoms?1. What Are Somatic Symptoms?
What Are Somatic Symptoms?What Are Somatic Symptoms?
Somatic symptoms are physical (bodily) complaints that occur in physical and mental disorders, as well as in the healthy population
By Convention these might includedecreased (or change in) appetitedecreased (or change in) weightdiminished concentration (or indecisiveness)loss of energy (or fatigue)psychomotor agitationpsychomotor retardationsleep disturbance (any type)Painful physical symptoms
Importance of Somatic Symptoms in Depression1Importance of Somatic Symptoms in Depression1
Most depressed patients presenting in primary care have at least one comorbid psychiatric condition and at least one physical condition.[i] [ii]
[i] Niles BL, Mori DL, Lambert JF, et al. Depression in primary care: Comorbid disorders and related problems Journal of Clinical Psychology in Medical Settings 2005; 12(1): 71-77.
[ii] Dwight-Johnson M, Sherbourne CD, Liao D,Wells KB. Treatment Preferences Among Depressed Primary Care Patients. J Gen Intern Med. 2000; 15(8): 527–534.
At least 75% of older depressed primary care patients also have a known physical illness. [i] [ii] [iii] [iv] [v]
[i] Berardi D, Menchetti M, De Ronchi D, et al. Late-life depression in primary care: A nationwide Italian epidemiological survey. Journal of the American Geriatrics Society 2002; 50(1): 77-83.
[ii] Wells KB, Rogers W, Burnam A, Greenfield S, Ware Jr JE. How the medical comorbidity of depressed patients differs across health care settings: results from the Medical Outcomes Study. Am J Psychiatry 1991;148:1688–96.
[iii] Yates WR, Mitchell J, Rush AJ, et al. Clinical features of depressed outpatients with and without co-occurring general medical conditions in STAR*D. General HospitalPsychiatry 2004; 26(6): 421-429.
[iv] Aragones E, Pinol JL, Labad A. Depression and physical comorbidity in primary care. Journal of Psychosomatic Research 2007; 63(2): 107-111.
[v] Vuorilehto M, Melartin T, Isometsa E. Depressive disorders in primary care: recurrent, chronic, and co-morbid Psychological Medicine 2005; 35(5): 673-682.
Importance of Somatic Symptoms in Depression2Importance of Somatic Symptoms in Depression2
Importance of Somatic Symptoms in Depression3Importance of Somatic Symptoms in Depression3
Patients with physical comorbidity are less likely to have depression treatment initiated[i] and these patients may be less likely to recover from depression.[ii] [iii][iv]
[i] Nuyen J, Spreeuwenberg PM, Van Dijk L, et al. The influence of specific chronic somatic conditions on the care for co-morbid depression in general practice. Psychological Medicine 2008; 38(2): 2: 265-277.
[ii] Cole MG, Bellavance F. Depression in elderly medical inpatients: a meta-analysis of outcomes. Canadian Medical Association Journal 1997; 157:1055–60.
[iii] Oslin DW, Datton CJ, Kallan MJ, Katz IR, Edell WS, TenHave T. Association between medical comorbidity and treatment outcomes in late-life depression. J Am GeriatrSociety 2002; 50: 823-828.
[iv] Bogner, HR; Cary, MS; Bruce, ML, et al. The role of medical comorbidity in outcome of major depression in primary care - The PROSPECT study. American Journal of Geriatric Psychiatry 2005; 13(10): 861-868.
2. Somatic Symptoms in Depression Scales2. Somatic Symptoms in Depression Scales
HADS Scale (Zigmond & Snaith)
Adapted to show depression and anxiety subscales separately.
Notice the items “slowed down” and “butterflies” which are probably somatic symptoms
The following slide compared the symptom profile from 11 common approaches to depression=>
Somatic Bias in Mood Scales Slide shows somatic vs non-somatic symptoms in 11 scales/tools.
3. Phenomenology of Somatic Symptomsi - Primary Depression
3. Phenomenology of Somatic Symptomsi - Primary Depression
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
Loss
of e
nerg
yDi
min
ishe
d dr
ive
Slee
p di
stur
banc
eCo
ncen
trat
ion/
inde
cisi
onDe
pres
sed
moo
d
Anxi
ety
Dim
inis
hed
conc
entr
atio
n
Inso
mni
aDi
min
ishe
d in
tere
st/p
leas
ure
Psyc
hic
anxi
ety
Help
less
ness
Wor
thle
ssne
ssHo
pele
ssne
ssSo
mat
ic a
nxie
tyTh
ough
ts o
f dea
th
Ange
rEx
cess
ive
guilt
Psyc
hom
otor
cha
nge
Inde
cisiv
enes
sDe
crea
sed
appe
tite
Psyc
hom
otor
agi
tatio
nPs
ycho
mot
or re
tard
atio
nDe
crea
sed
wei
ght
Lack
of r
eact
ive
moo
dIn
crea
sed
appe
tite
Hype
rsom
nia
Incr
ease
d w
eigh
t
All Case ProportionDepressed ProportionNon-Depressed Proportion
n=1523
We recently examined the diagnostic significance of each symptom, when making a diagnosis of depression (Psychological Medicine 2008)
The following slide shows these sorted by ROC curve significance=>
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
Depressed Mood
Diminished drive
Diminished interest/pleasure
Loss of energy
Sleep disturbance
Diminished concentration
Sensitivity
1 - Specificity
n=1523
4. Phenomenology of Somatic Symptomsii - Comorbid Depression
4. Phenomenology of Somatic Symptomsii - Comorbid Depression
0
0.2
0.4
0.6
0.8
1
1.2
Fatig
ueInert
iaInso
mnia
Disinte
rested
in se
x
Worries
abou
t hea
lthDiss
atisfa
ction
Irrita
bility
Sadne
ssSelf
-blam
e
Distint
eres
ted in
people
Indecis
ionLo
ss A
ppeti
te
Feels
Una
ttrac
tive
Weight
Loss
Self-ha
te (se
lf-es
teem)
Crying
Hopele
ssnes
sFe
els a
failure
Guilt
Suicida
l idea
tion
Punish
ment fe
eling
s
Rate in Depressed+CADRate in CAD Alone
Data from Freedland et al (1992)
Example - Symptoms in CAD
Symptoms by frequency in comorbid depression with coronary artery disease vs CAD alone
Example - Symptoms in CAD
-0.2
0
0.2
0.4
0.6
0.8
1
1.2
Dissati
sfacti
onInert
ia
Disinter
ested i
n sexInso
mnia
Distinteres
ted in
people
Sadnes
s
Worries
about h
ealth
Feels
Unattrac
tive
Self-hate
(self
-esteem
)Indec
ision
Crying
Fatigue
Loss A
ppetiteIrr
itabilit
yFee
ls a f
ailure
Hopelessn
ess
Self-blam
e
Guilt
Suicidal idea
tion
Punishmen
t feeli
ngsWeight L
oss
Rate in Depressed+CADRate in CAD AloneDifferential
Data from Freedland et al (1992)
Symptoms by differential in comorbid depression with coronary artery disease vs CAD alone
Example – Depression in General Medicine
-0.60
-0.40
-0.20
0.00
0.20
0.40
0.60
0.80
1.00
1.20
Loss
of i
nter
est
Gui
lt
Suic
idal
thou
ghts
Lwo
moo
d
Psyc
hic
anxi
ety
Loss
insi
ght
inso
mni
a (m
iddl
e)
GI s
ympt
oms
Gen
ital s
ympt
oms
Inso
mni
a (in
itial
)
Inso
mni
a (la
te)
Hyp
ocho
ndria
sis
Ret
arda
tion
Loss
of e
nerg
y
Wei
ght L
oss
Agi
tatio
n
Som
atic
Anx
iety
Dow
nhea
rted
Bor
ed
Life
is E
mpt
y
Life
is E
xciti
ng
Feel
like
Cry
ing
Satis
fied
Wor
ry a
bout
pas
t
Feel
hel
ples
s
Hap
py
Oft
en re
stle
ss
Feel
wor
thle
ss
Bot
here
d by
Tho
ught
s
Situ
atio
n ho
pele
ss
In g
ood
spiri
ts
Avo
id s
ocia
l
Won
derf
ul to
be
aliv
e
Hop
eful
abo
ut fu
ture
Dro
pped
inte
rest
s
Mos
t peo
ple
bett
er o
ff
Pref
er to
sta
y ho
me
Enjo
y ge
ttin
g up
Ups
et o
ver l
ittle
thin
gs
Afr
aid
of s
omet
hing
bad
Wor
ry a
bout
futu
re
Full
of e
nerg
y
Min
d cl
ear
Easy
to m
ake
deci
sion
s
Trou
ble
conc
entr
atin
g
Prob
lem
s w
ith M
emor
y
Har
d to
get
sta
rted
Rate in Depressed+MedicalRate in Medical AloneDifferential
Data from Koenig (1993)
Example – Depression+ Medical vs Depression
0
0.2
0.4
0.6
0.8
1
1.2
Anhedo
nia
Appetite
decre
ase
Appetite
incre
ase
Decre
ased
activ
ity in
volve
ment
Decre
ased
sexu
al inter
est
Distinct
mood quali
tyFati
gue
Gastro
intes
tinal
symptoms
Hypers
omnia
Impair
ed co
ncentra
tion/at
tention
Insomnia
(Early
morn
ing)
Insomnia
(Middle)
Insomnia
(Ons
et)
Interpers
onal se
nsitivi
ty
Leaden
paral
ysis
Mood (an
xious)
Mood (irr
itable
)Mood (
sad)
Mood rea
ctivit
y impair
ed
Mood vari
ation b
y tim
e of d
ay
Negati
ve outlo
ok (futu
re)
Negati
ve outlo
ok (se
lf)
Panic
or phobic
symptoms
Psych
omotor agit
ation
Psych
omotor slow
ing
Somatic c
omplaint
s
Suicidal
ideatio
n
Sympath
etic ar
ousal
Weight d
ecrea
se
Weight in
creas
e
Rate in Depressed+MedicalRate in Depression Alone
Data from Yates (2005)
Example – Depression+ Medical vs Depression
-0.2
0
0.2
0.4
0.6
0.8
1
1.2
Anhedo
nia
Appetite
decre
ase
Appetite
incre
ase
Decre
ased
activ
ity in
volve
ment
Decre
ased
sexu
al inter
est
Distinct
mood quali
tyFati
gue
Gastro
intes
tinal
symptoms
Hypers
omnia
Impair
ed co
ncentra
tion/at
tention
Insomnia
(Early
morn
ing)
Insomnia
(Middle)
Insomnia
(Ons
et)
Interpers
onal se
nsitivi
ty
Leaden
paral
ysis
Mood (an
xious)
Mood (irr
itable
)Mood (
sad)
Mood rea
ctivit
y impair
ed
Mood vari
ation b
y tim
e of d
ay
Negati
ve outlo
ok (futu
re)
Negati
ve outlo
ok (se
lf)
Panic
or phobic
symptoms
Psych
omotor agit
ation
Psych
omotor slow
ing
Somatic c
omplaint
s
Suicidal
ideatio
n
Sympath
etic ar
ousal
Weight d
ecrea
se
Weight in
creas
e
Rate in Depressed+MedicalRate in Depression AloneDifferential
Data from Yates (2005)
5. Diagnostic Weight of Somatic Symptoms5. Diagnostic Weight of Somatic Symptoms
Approaches to Somatic Symptoms of DepressionApproaches to Somatic Symptoms of Depression
InclusiveUses all of the symptoms of depression, regardless of whether they may or may not be
secondary to a physical illness. This approach is used in the Schedule for Affective Disorders and Schizophrenia (SADS) and the Research Diagnostic Criteria.
ExclusiveEliminates somatic symptoms but without substitution. There is concern that this might
lower sensitivity. with an increased likelihood of missed cases (false negatives)
EtiologicAssesses the origin of each symptom and only counts a symptom of depression if it is
clearly not the result of the physical illness. This is proposed by the Structured Clinical Interview for DSM and Diagnostic Interview Schedule (DIS), as well as the DSM-III-R/IV).
SubstitutiveAssumes somatic symptoms are a contaminant and replaces these additional cognitive
symptoms. However it is not clear what specific symptoms should be substituted
Evidence Based ApproachEvidence Based Approach
Mitchell, Thombs, Coyne recently conducted a meta-analysis of the diagnostic significance of somatic symptoms in the following groups:
1. Depression with comorbid physical disease2. Depression alone3. Physical disease alone4. Healthy individuals
Co-morbid Depression vs Medical Illness Alone
Co-morbid Depression vs Medical Illness Alone
n= 4069 vs 1217
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Anxiety
(Com
orbid)
Anxiety
(Med
ical)
Concen
tratio
n (Comorb
id)
Concen
tratio
n (Med
ical)
Fatigu
e (Comorb
id)Fati
gue (
Medica
l)
Hopeles
snes
s (Comorb
id)
Hopeles
snes
s (Med
ical)
Insomnia
(any t
ype)
(Comorb
id)
Insomnia
(any t
ype)
(Med
ical)
Loss In
teres
t (Comorb
id)
Loss In
teres
t (Med
ical)
Low Mood (C
omorbid)
Low Mood (M
edical)
Retard
ation (
Comorbid)
Retard
ation (
Medica
l)
Suicide (
Comorbid)
Suicide (
Medica
l)
Weight L
oss (C
omorbid)
Weight L
oss (M
edical)
Worthles
snes
s (Comor
bid)
Worthles
snes
s (Med
ical)
Medical Illness Alone
Comorbid Depression
**
*
*
*
*
*
*
*
Co-morbid Depression vs Primary Depressions
Co-morbid Depression vs Primary Depression
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Agitatio
n (Com
orbid)
Agitatio
n (Prim
ary)
Anxiety
(Com
orbid)
Anxiety
(Prim
ary)
Appetite
(Comorb
id)
Appetite
(Prim
ary)
Concen
tratio
n (Comorb
id)
Concen
tratio
n (Prim
ary)
Fatigu
e (Comorb
id)
Fatigu
e (Prim
ary)
Guilt (
Comorbid)
Guilt (
Primar
y)
Hopeles
snes
s (Comorb
id)
Hopeles
snes
s (Prim
ary)
Insomnia
(Comor
bid)
Insomnia
(Prim
ary)
Loss In
teres
t (Comorb
id)
Loss In
teres
t (Prim
ary)
Low Mood (C
omorbid)
Low Mood (P
rimary
)
Retard
ation (
Comorbid)
Retard
ation (
Primary)
Suicide (
Comorbid)
Suicide (
Primar
y)
Weight L
oss (C
omorbid)
Weight L
oss (P
rimary
)
*
*
*
*
*
**
*
*
Comorbid Depression
Primary Depression
n=4069 vs 4982
ConclusionConclusion
Somatic symptoms are common in physical disease
Somatic symptoms are even more common in depression
Somatic symptoms are especially common in comorbid depression
Somatic symptom weighting is essentially the same in comorbid depression vs depression alone
Somatic symptom weighting is higher in comorbid depression vsphysical illness alone
Somatic symptoms retain there diagnostic importance in comorbid depressions
Message => don’t throw out somatic symptoms with good reason!
