Depression and Physical Symptoms

The relationship between depression and physical symptoms is an area that is being studied worldwide. The truth is: depression has many features that are intensely physical in nature. Many people with depression feel pain or other physical symptoms including: headaches, back pain, muscle aches and joint pain, chest pain, digestive problems, exhaustion and fatigue, sleeping problems, change in appetite or weight, and dizziness or lightheadedness.¹

According to Petros Skapinakis, MD, MPH, PhD, a lecturer of Psychiatry in the University of Ioannina Medical School in Greece,² "Many of these symptoms and signs are similar to symptoms seen in diseases which are known to have an identifiable physical cause.... It can therefore be difficult for both patients and doctors to be certain whether a physical symptom is representative of depression, or suggests an entirely different disorder requiring different treatment."

Kurt Kroenke, MD,³ Professor of Medicine at the Indiana University School of Medicine, Indianapolis, Indiana reveals some interesting global statistics—of 400 million clinic visits per year for primary care, half are for pain, 30 percent are for respiratory complaints, and only 20 percent are for something else.

"The top three complaints," he said, "are back pain, knee or hip pain, and abdominal pain. One third of the time, physical symptoms are medically unexplained. This number goes up dramatically in patients with comorbid psychiatric disorders: it is almost two-thirds for patients with depression and almost half for patients with an anxiety disorder."

"Because it is sometimes considered unacceptable to be psychologically ill," explains Dr. Skapinakis, "physical symptoms are often used as substitutes for psychological ones. Many cultures express mood changes in concrete body terms, including descriptions of pain, for example. Many patients feel that doctors are trained to respond to bodily complaints and hence present these unconsciously to their doctors.

"It is well known that common physical complaints can have a psychological contribution. Headaches, for instance, can be made worse by the increase in muscular tension of the neck and scalp muscles which are a physical accompaniment of a state of anxiety."

The actual number of physical symptoms is also related directly to both the likelihood of them being medically unexplained and the likelihood for psychiatric comorbidities. Even in specialty clinics, this becomes an issue: approximately half of the patients seen in either gastroenterology or neurology clinics have medically unexplained symptoms.

One study Dr. Kroenke cited looked at how patients that visited primary care clinics were recognized (or not) as having depression. Those patients who showed symptoms of depression were recognized 90 percent of the time, but those depressed patients who complained of physical or bodily ailments were only recognized 50 percent of the time, and if they were diagnosed with a medical (physical) disorder they were only recognized 20 percent of the time.³

Pain and Depression

Studies show that approximately 60 percent of depressed patients have pain and 30 percent of pain patients have depression. Pain symptoms make depression and anxiety disorders considerably more likely, particularly if the symptoms are unexplained. Dr. Kroenke states that physical and psychological symptoms can be both the cause and the consequence of each other.

High-Risk Groups

John Greden, MD,⁸ Chairman of the Department of Psychiatry at the University of Michigan, Ann Arbor, Michigan has found there are people who are at higher risk of experiencing physical pain and depression. It is important that we screen "high-risk ages and groups, such as late adolescence and early adults, women in reproductive years, adults with medical problems, and people with family histories of depression," he said.

"The first group, patients aged fifteen to twenty-four years, are important because this is where under-diagnosis often appears as a function of depression being explained away to the developmental stresses involved with that age group," he states. And it is important to screen women for depression during pregnancy, as well as older adults and medically ill patients.

Pain Management

Although antidepressants can be used to treat pain conditions, they all are not equally effective. Tricyclic antidepressants (TCAs) are somewhat more effective than selective serotonin reuptake inhibitors (SSRIs). Data shows that the more severe the pain condition is, the less likely the patient is to respond to treatment.⁴

John Greden, MD,⁸ Chairman of the Department of Psychiatry at the University of Michigan, Ann Arbor, Michigan says that new treatment approaches must emphasize earlier detection, earlier intervention, achievement of remission, prevention of progression, and integration of neurosciences and behavioral sciences. To do this, psychiatrists must partner with primary care and special care colleagues, screen patients earlier, educate the public better, develop new treatments for remission for patients with physical symptoms, and counteract stigma.

In some cases, treating your depression—with therapy or medicine or both—will resolve your physical symptoms. But, be sure to tell your health-care provider about any physical symptoms. Don't assume they will go away on their own. For example, your doctor may suggest an anti-anxiety medicine if you have insomnia. Those drugs help you relax and may allow you to sleep better.

Since pain and depression go together, sometimes easing your physical pain may help with your depression. Some antidepressants, such as Cymbalta and Effexor, may help with chronic pain too. Other treatments can help with painful symptoms. Certain types of focused therapy, like cognitive behavioral therapy, can teach you ways to cope better with the pain.¹

References

1. www.webmd.com/content/Article/106/108345.htm
2. Skapinakis, Petros, MD, MPH, PhD, lecturer of Psychiatry in the University of Ioannina Medical School, Greece. "Physical symptoms of Depression." 19 Nov 2006.
3. Kroenke K. Underdetection and inadequate treatment of physical symptoms of depression: the real barriers to remission. Program and abstracts of the American Psychiatric Association 2004 Annual Meeting; May 1-6, 2004; New York, NY. Symposium 19A.
4. Bijl D, van Marwijk HW, de Haan M, van Tilburg W, Beekman AJ. Effectiveness of disease management programmes for recognition, diagnosis and treatment of depression in primary care. Eur J Gen Pract. 2004;10:6-12. Abstract
5. Gureje O, Simon GE, Ustun TB, Goldberg DP. Somatization in cross-cultural perspective: a World Health Organization study in primary care. Am J Psychiatry. 1997;154:989-995. Abstract
6. Tumlin TR, Kvaal S. Psychotherapeutic issues encountered in the psychotherapy of chronic pain patients. Curr Pain Headache Rep. 2004;8:125-129. Abstract
7. Zubieta J. Neurochemical systems interfacing physical and emotional stressors. Program and abstracts of the American Psychiatric Association 2004 Annual Meeting; May 1-6, 2004; New York, NY. Symposium 19A.
8. McEwen BS. Stress effects on the hippocampus: relevance to depression. Program and abstracts of the American Psychiatric Association 2004 Annual Meeting; May 1-6, 2004; New York, NY. Symposium 19C.
9. Burt VK. Gender considerations in the treatment of physical symptoms of depression. Program and abstracts of the American Psychiatric Association 2004 Annual Meeting; May 1-6, 2004; New York, NY. Symposium 19D.
10. Greden JF. Best practices for achieving remission in depression with physical symptoms: current and future trends. Program and abstracts of the American Psychiatric Association 2004 Annual Meeting; May 1-6, 2004; New York, NY. Symposium 19E.

* Reprinted with permission from Medscape
http://www.medscape.com/viewarticle/480898 © 2004, Medscape.