LiaisonTeam09 - Significance of Somatic Symptoms when Diagnosing Depression (Aug09)
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LiaisonTeam09 - Significance of Somatic Symptoms when Diagnosing Depression (Aug09)

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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 ...

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.

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LiaisonTeam09 - Significance of Somatic Symptoms when Diagnosing Depression (Aug09) Presentation Transcript

  • 1. Significance of Somatic Symptoms in Depression Significance of Somatic Symptoms in Depression Include or Exclude when diagnosing depression in medical Settings? Include or Exclude when diagnosing depression in medical Settings? Alex J Mitchell ajm80@le.ac.uk 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
  • 2. Context 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.
  • 3. 1. What Are Somatic Symptoms?
  • 4. 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 include decreased (or change in) appetite decreased (or change in) weight diminished concentration (or indecisiveness) loss of energy (or fatigue) psychomotor agitation psychomotor retardation sleep disturbance (any type) Painful physical symptoms
  • 5. Importance of Somatic Symptoms in Depression1 1 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.
  • 6. Importance of Somatic Symptoms in Depression2 2 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 Hospital Psychiatry 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.
  • 7. Importance of Somatic Symptoms in Depression3 3 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 Geriatr Society 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.
  • 8. 2. Somatic Symptoms in Depression Scales
  • 9. 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=>
  • 10. Somatic Bias in Mood Scales Slide shows somatic vs non-somatic symptoms in 11 scales/tools.
  • 11. 3. Phenomenology of Somatic Symptoms i - Primary Depression
  • 12. 0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00 L os s of ene rg y Dim inis he dd r ive Sl e e pd is tu Con rba c en nc e tr at ion /i n dec is ion D ep res sed mo od Dim A nx inis iet y he dc onc ent r at ion Dim Ins o inis he m nia d in t er est /p l e asu re Ps y chi ca nx i e ty Hel p less nes s Wo r th les s nes s Hop e les s nes s Som ati c anx iety Tho ug hts of dea th A ng er Exc ess ive guil We recently examined the diagnostic significance of each symptom, Ps y t The following slide shows these sorted by ROC curve significance=> cho mo t or when making a diagnosis of depression (Psychological Medicine 2008) c ha ng e n=1523 Ind ec i siv e nes D ec s rea s ed app eti t Ps y cho e mo t or agi Ps y tati cho on mo t or ret ard atio n D ec rea s ed wei L ac g ht ko f re act ive mo od Inc rea sed app et it e Hy p erso mn ia All Case Proportion Inc rea Depressed Proportion sed we ight Non-Depressed Proportion
  • 13. 1 Depressed Mood S Diminished interest/pleasure e 0.9 Diminished drive n s Loss of energy i Sleep disturbance 0.8 t Diminished concentration i 0.7 v i t 0.6 y 0.5 0.4 0.3 0.2 0.1 1 - Specificity 0 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 n=1523
  • 14. 4. Phenomenology of Somatic Symptoms ii - Comorbid Depression
  • 15. 0 0.2 0.4 0.6 0.8 1 1.2 Fa t ig ue In er t ia D In is in so te m re ni W st a or ed rie in s se ab ou x th Data from Freedland et al (1992) D ea is lth sa tis fa ct io Irr n ita bi l it y Sa dn D es is s tin Se te lf- re bl st am ed e in pe op In le de ci Lo si ss on Fe A pp Rate in CAD Alone el s et U i te na t tr Example - Symptoms in CAD ac Rate in Depressed+CAD Se W tiv lf- ei e ha gh te tL (s os el f-e s st ee m ) C H ry op in el g es sn Fe es el s s a fa ilu re Su ic G Pu id ui lt al ni id sh ea m ti o en n tf ee l in gs Symptoms by frequency in comorbid depression with coronary artery disease vs CAD alone
  • 16. Di ss at is -0.2 0 0.2 0.4 0.6 0.8 1 1.2 fa ct Di io si n te n In re er st tia ed Di in st in se te In x re so st ed m Data from Freedland et al (1992) ni in a pe W op or le rie Sa s dn ab es Fe ou th s el Se s ea lf- Un lth ha at te tra (s ct el iv Differential f- e e st ee In m ) Rate in CAD Alone de ci si on Rate in Depressed+CAD Cr yi ng Fa Lo t ig ss ue Example - Symptoms in CAD Ap pe tit Irr e it a Fe bi el lit s y a fa Ho ilu pe re le ss ne Se ss lf- bl am Su e ic G Pu id ui al lt ni sh id ea m tio en n tf ee W lin ei gs gh tL os s Symptoms by differential in comorbid depression with coronary artery disease vs CAD alone
  • 17. -0.60 -0.40 -0.20 0.00 0.20 0.40 0.60 0.80 1.00 1.20 Loss of interest Guilt Suicidal thoughts Lwo mood Psychic anxiety Loss insight Data from Koenig (1993) insomnia (middle) GI symptoms Genital symptoms Insomnia (initial) Insomnia (late) Hypochondriasis Retardation Loss of energy Weight Loss Agitation Somatic Anxiety Downhearted Bored Life is Empty Life is Exciting Feel like Crying Satisfied Worry about past Feel helpless Happy Differential Often restless Feel worthless Bothered by Thoughts Rate in Medical Alone Situation hopeless In good spirits Rate in Depressed+Medical Avoid social Wonderful to be alive Hopeful about future Dropped interests Most people better off Prefer to stay home Enjoy getting up Upset over little things Example – Depression in General Medicine Afraid of something bad Worry about future Full of energy Mind clear Easy to make decisions Trouble concentrating Problems with Memory Hard to get started
  • 18. D A p p An ec re et h 0 0.2 0.4 0.6 0.8 1 1.2 ite e d as ed A on pp de et cr ia D ac ti ite e a ec re vity in se as cr ed inv e se ol ase D ve m Data from Yates (2005) is xu tin al e ct in nt G m te as oo res tr oi d t nt qu Im es al pa tin it ire al Fa y d sy ti co m gue nc H pt In ent y om so r a per s m tio so ni n/ m a ni (E atte a ar nt In ly io so m n m o ni rni In I a n te nso ( M g) rp m id er dl so nia e na (O ) ls ns Le e et ad nsi ) en tiv p ity M oo a ra d ly (a s M nx is oo d io M M o (ir us) oo od rit d re a va ac Mo ble ria tiv od ) N ti ity (s eg on i ad ) at by mp iv ai e tim re N ou e d Pa ega tlo of ni tiv ok da c (fu y or e o ph utl tu re Ps ob oo k ) yc ic ( ho sy sel Ps m m f) y c oto pto ho r m m a gi s So ot ta m or tio at sl n ic ow co in Su m g Sy ic pl m ida ai n pa l ts th ide et at W ic io n ei a gh ro us Rate in Depression Alone td W ec al Rate in Depressed+Medical ei re Example – Depression+ Medical vs Depression gh t i ase nc re as e
  • 19. D A p p An ec re et h -0.2 0 0.2 0.4 0.6 0.8 1 1.2 ite e d as ed A on pp de et cr ia D ac ti ite e a ec re vity in se as cr ed inv e se ol ase D xu ve m is tin al e Data from Yates (2005) ct in nt G m te as oo res tr oi d t nt qu Im es al pa tin it ire al Fa y d sy ti co m gue nc H pt In ent y om so r a per s m tio so ni n/ m a ni (E atte a ar nt In ly io so m n m o ni rni In I a n te nso (M g) rp m id er dl so nia e na (O ) ls ns Le e et ad nsi ) en tiv p ity M oo a ra d ly (a s M nx is oo d io M M o (ir us) oo od rit d re a va ac Mo ble ria tiv od ) N ti ity (s eg on i ad at by mp ) iv ai e tim re N ou e d Pa ega tlo of ni tiv ok da c (fu y or e o ph utl tu re Ps ob oo k ) yc ic ( ho sy sel Ps m m f) y c oto pto ho r m m a gi s So ot ta m or tio at sl n ic ow co in Differential Su m g Sy ic pl m ida ai n pa l ts th ide et at W ic io n ei a gh ro td us W ec al ei re Rate in Depression Alone Example – Depression+ Medical vs Depression gh t i ase Rate in Depressed+Medical nc re as e
  • 20. 5. Diagnostic Weight of Somatic Symptoms
  • 21. Approaches to Somatic Symptoms of Depression Inclusive Uses 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. Exclusive Eliminates somatic symptoms but without substitution. There is concern that this might lower sensitivity. with an increased likelihood of missed cases (false negatives) Etiologic Assesses 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). Substitutive Assumes somatic symptoms are a contaminant and replaces these additional cognitive symptoms. However it is not clear what specific symptoms should be substituted
  • 22. Evidence 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 disease 2. Depression alone 3. Physical disease alone 4. Healthy individuals
  • 23. Co-morbid Depression vs Medical Illness Alone
  • 24. A nx ie ty (C om 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 A or C nx bi on ie d) ce ty nt (M ra ed tio ic C n al on (C ) * ce om nt or ra bi tio d) n Fa (M t ig ed ue ic al (C ) * om H Fa or bi op t ig n= 4069 vs 1217 el ue d) es sn (M es ed H s ic al op (C ) In el om * so es m sn or bi ni a es d) (a s ny (M In ty ed so pe ic m al ni )( C ) a * (a om ny or Lo ty bi pe d) ss In )( te M re ed st ic al Lo (C ) * ss om In or te bi re d) Lo st w (M M ed oo ic d al ) (C * Lo om w or M bi R oo d) et d ar (M da ed tio ic n al R (C ) * et om ar or da bi t io d) n Su (M ic ed id ic e al ) (C * om Su or W ic id bi d) ei e gh (M tL ed os ic s al W (C ) * ei om gh W or Co-morbid Depression vs Medical Illness Alone or tL bi th os d) le s ss (M ne ed W ss ic al or (C ) th om le or ss ne bi ss d) (M ed ic Medical Illness Alone Comorbid Depression al )
  • 25. Co-morbid Depression vs Primary Depressions
  • 26. A gi ta tio n (C A om 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 gi ta or bi tio A n d) nx (P ie rim ty ar (C y) * om A or nx ie bi A ty d) pp (P et rim ite ar (C y) C on A pp et om or bi * n=4069 vs 4982 ce ite d) nt (P ra ri C tio m on n ar ce (C y) nt om ra or tio bi n d) Fa (P tig rim ue ar (C y) om Fa or tig bi ue d) (P G ri m ui lt ar y) (C * om H op G or el ui bi es lt d) sn (P es ri H s m op (C ar el om y) * es sn or es bi In s d) so (P m ri ni m a ar (C y) In om * so Lo m or bi ss ni In a d) te (P re ri st m Lo ar ss (C y) om In * te or re bi Lo st d) w (P M rim oo d ar y) Lo (C w om * M or R oo bi et ar d d) da (P t io rim n ar R (C y) et om ar da or Co-morbid Depression vs Primary Depression t io bi n d) Su (P ic ri id m e ar (C y) * om Su W ic or bi ei id d) gh e tL (P ri os m W s ar ei (C y) gh om tL or os bi s d) (P rim ar Primary Depression y) Comorbid Depression *
  • 27. Conclusion 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 vs physical illness alone Somatic symptoms retain there diagnostic importance in comorbid depressions Message => don’t throw out somatic symptoms with good reason!