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Prevalence and type of functional somatic complaints in patients with first-episode depression

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Objective: To study the prevalence and type of functional somatic complaints in patients with firstepisode depression. Methods: A total of 164 patients attending the outpatient department of a general hospital psychiatric unit were evaluated using
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  © 2012 Hong Kong College of PsychiatristsEast Asian Arch Psychiatry 2012;22:146-53Original Article 146 Prevalence and Type of Functional Somatic Complaints in Patients with First-episode Depression 首發抑鬱症患者其功能性軀體化病徵的現患率和類型 S Grover, V Kumar, S Chakrabarti, P Hollikatti, P Singh, S Tyagi, P Kulhara, A Avasthi Abstract Objective: To study the prevalence and type of functional somatic complaints in patients with rst-episode depression. Methods: A total of 164 patients attending the outpatient department of a general hospital psychiatric unit were evaluated using the Patient Health Questionnaire–15 (PHQ-15) and Hamilton Depression Rating Scale (HDRS). Results:  More than half of the sample were male (n = 85; 52%) and most of the subjects were married (n = 128; 78%). The mean (standard deviation) HDRS score was 19.9 (5.4). All patients had at least 1 functional somatic complaint, and that the mean (range) number of functional somatic complaints per patient on the PHQ-15 was 8 (1-15). The most common functional somatic complaints included feeling tired or having little energy (93%); trouble sleeping (80%); nausea, gas and indigestion (68%); headache (68%); pain in arms, legs, or joints (66%); and feeling the heart racing (65%). Total PHQ-15 scores indicated the presence of moderate-to-severe severity of functional somatic complaints. Back pain, as well as pain in arms, legs, or joints, were found to be more common in females. The number and severity of functional somatic complaints did not differ signicantly in relation to other socio-demographics (locality, marital status, age, education, income) and clinical variables (duration, physical co-morbidity, and atypical features). Conclusion:  Functional somatic complaints are quite prevalent in subjects with rst-episode depression. Hence, clinicians should routinely evaluate patients with depression for these symptoms.  Key words:  Depression; Somatoform disorders 摘要目的: 檢視首發抑鬱症患者其功能性軀體化病徵的現患率和類型。 方法: 應用患者健康問卷(PHQ-15)和漢氏憂鬱量表(HDRS),對印度一所綜合醫院精神科門診部的164名患者進行評估。 結果: 在這些患者中,超過一半為男性(n = 85;52%)且大部份已婚(n = 128;78%)。HDRS平均比分為19.9(標準差5.4)。根據PHQ-15的評估,每名患者出現至少1種(介乎1至15種)功能性軀體化病徵,中位數為8種。最常見的功能性軀體化病徵包括感覺疲倦乏力(93%)、失眠(80%)、噁心有胃氣和消化不良(68%)、頭痛(68%)、胳膊、腿或關節疼痛(66%),以及心跳加速(65%)。PHQ-15總比分顯示中度至嚴重的功能性軀體化病徵。背部疼痛,以及胳膊、腿或關節疼痛在女性患者中較常見。功能性軀體化病徵的數目和嚴重程度跟社會人口統計學數據(居住環境、婚姻狀況、年齡、教育程度和收入)和臨床變數 (病程、共病和非典型病徵)沒有顯 著 相關性。 結論: 首發抑鬱症患者其功能性軀體化病徵的現患率頗為普遍。因此,臨床醫生應對抑鬱症患者的這些病徵作常規評估。 關鍵詞: 抑鬱症、心身症   Dr Sandeep Grover, MD, Department of Psychiatry, Postgraduate Institute of  Medical Education and Research, Chandigarh, India. Dr Vineet Kumar, MD, Department of Psychiatry, Postgraduate Institute of  Medical Education and Research, Chandigarh, India.Prof. Subho Chakrabarti, MD, FRCPsych, Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India. Dr Prabhakar Hollikatti, MD, Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India. Mr Pritpal Singh, MPhil, Department of Psychiatry, Postgraduate Institute of  Medical Education and Research, Chandigarh, India. Mr Shikha Tyagi, MPhil, Department of Psychiatry, Postgraduate Institute of  Medical Education and Research, Chandigarh, India.Prof. Parmanand Kulhara, MD, FRCPsych, Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India.Prof. Ajit Avasthi, MD, Department of Psychiatry, Postgraduate Institute of  Medical Education and Research, Chandigarh, India.  Functional Somatic Symptoms in DepressionEast Asian Arch Psychiatry 2012, Vol 22, No.4 147 depressed patients and reported painful FSC in 73% of those attending the psychiatric outpatient clinic; they also showed that higher severity of painful somatic symptoms was associated with increased severity of depression and poor quality of life. In a study of assessing 150 depressed patients using a self-reported 90-item Symptom Checklist, 92% reported FSC. 21  In general, studies from India focused on non-organic somatic complaints in psychiatric outpatient populations, and suggested that about 30% of patients seeking a psychiatric consultation present with FSC. 23  Many of these patients have a diagnosis of depression. 23-26  However, none of the studies specically studied patients with depression for the prevalence of FSC. Against this background, the present study aimed to evaluate the prevalence and typology of FSC in patients diagnosed with depression. Additionally, it attempted to study FSC in relation to socio-demographic and clinical correlates. Methods Setting The study was carried out in a tertiary care multispecialty teaching hospital in North India. All study patients were recruited with their written informed consent and were seen during the period of 1 March to 30 June 2010. The study was approved by the research review committee of the department. The present report is part of a larger study which evaluated the pathways to care, attitude towards psychotropic medications, prevalence and typology of FSC, aetiological attribution of depressive symptoms by patients, and treatment compliance. In this paper, data with respect to FSC are presented. Sample The sample comprised 164 consecutive patients attending the walk-in clinic of psychiatry outpatient department. To be included in the study, the patients had to be diagnosed with rst-episode depression (but excluding severe depression with psychotic symptoms) as per the ICD-10 criteria 1  and aged ≥ 18 years. Patients with co-morbid psychiatric disorder or any substance (except nicotine) dependence were excluded.  Instruments 17-Item Hamilton Depression Rating Scale The 17-item Hamilton Depression Rating Scale (HDRS) 27  was used to assess the severity of depression. Items were rated from 0 to 4 or from 0 to 2 according to intensity and frequency of symptoms over the past week. With a total score ranging from 0 to 52, scores of 0-7 indicated no depression; 8-13 mild depression; 14-18 moderate depression; 19-22 severe depression; and ≥ 23 very severe depression. This rating scale is a valid instrument with an intra-class correlation coefcient of 0.86 indicating adequate inter-observer agreement. 27 Introduction Depressive disorder is currently understood the world over by the diagnostic criteria as proposed by the ICD-10 (Mental and Behavioural Disorders) 1  and DSM-IV-TR. 2  A study from India 3  reported that a signicant proportion of patients with depression have other physical complaints, which do not nd a place in these diagnostic systems. These complaints often dominate the clinical picture and exert a crucial inuence on the perception of the illness to an extent that many patients believe their illness to be of physical srcin. This belief leads to multiple consultations with medical services resulting in misutilisation of resources, 4  wrong diagnoses, and inordinate delay before initiation of appropriate treatment. These physical complaints have been described by various terms like physical, bodily, functional or somatic complaints and somatisation. Some have attempted to operationalise such manifestations as medically unexplained somatic complaints, hypochondriacal worry, or somatic preoccupation. 5  As these somatic complaints are presumed to be a part of the depressive syndrome without any underlying physical cause, possibly a more appropriate term to describe them could be functional somatic complaint (FSC). 3  Earlier it was thought that FSC is more common in non-western populations, particularly among Asians because of the cultural disapproval for expressing strong negative emotions. 6  Some authors even considered FSC an alternative ‘idiom of distress’, prevalent in cultures where psychiatric disorders carry greater stigma. 7  However, a cross-cultural study 8  conducted by the World Health Organization (WHO) suggested that worldwide FSC is the most common clinical expression of emotional distress. It also showed that their frequency did not clearly vary according to geography or level of economic development. 8  Studies also suggested that FSC in depression is more frequently noted in women, elderly, children, and those having relatively low incomes. 9-12  Studies on patients with depression in primary care settings suggested that FSC occurs more as a rule than an exception, 13-17  and consistently showed that two-thirds or more of the depressed patients in primary health care have such complaints. 14-17  Clinic-based studies also suggested a high prevalence (73-92%) of FSC in patients with depression. 18-22  Hamilton 18  reported FSC in 80% of the sample of 260 women and 239 men suffering from major depression, and Sugahara et al 19  reported a prevalence of 77% in depressed outpatients attending the psychosomatic medicine department in a hospital of Japan. In a multicentric study from Latin America, Muñoz et al 20  evaluated 989 Address for correspondence:  Dr Sandeep Grover, Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.Tel: (91-172) 2756807; Fax: (91-172) 2744401 / 2745078; email: drsandeepg2002@yahoo.com Submitted: 28 December 2011; Accepted: 22 February 2012  S Grover, V Kumar, S Chakrabarti, et alEast Asian Arch Psychiatry 2012, Vol 22, No.4 148 Patient Health Questionnaire–15 The Patient Health Questionnaire–15 (PHQ-15) 28,29  was used to assess the prevalence and typology of FSC. It is a self-administered version of the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PRIME-MD PHQ), a diagnostic instrument for common mental disorders. The 15 somatic symptoms or symptom clusters included in PHQ-15 accounted for more than 90% of the physical complaints (excluding upper respiratory tract symptoms) reported in the outpatient setting. 30,31  Of these PHQ-15 somatic symptoms, 13 were included in the PHQ somatic symptom module, in which patients rated the severity of each symptom as 0 (not bothered at all), 1 (bothered a little), or 2 (bothered a lot). Two additional physical symptoms (‘feeling tired or having little energy’ and ‘trouble sleeping’) were contained in the PHQ depression module. The subjects were asked: “Over the last 2 weeks, how often have you been bothered by any of the following problems?” Response options were coded as 0 (not at all), 1 (several days), or 2 (more than half the days / nearly every day). Thus, the PHQ-15 total score indicated a severity ranging from 0 to 30. Based on the total score, the severity of FSC was graded as mild (0-4), moderate (5-9), and severe (≥ 10). 32  The full version of PRIME-MD PHQ was translated into Hindi using WHO methodology and has been shown to have good psychometric properties. 33  For the present study, the Hindi version was used and patients themselves rated their symptoms. In case the patients were not able to read Hindi, the scale was administered by the psychiatrist assessing the patient. Clinical Prole Sheet A study-specic clinical prole sheet was designed for recording patients’ medication status (drug-naïve or not), alcohol and other drug dependence history (as per ICD-10), sexual dysfunction prior to onset of depression, presence and type of sexual dysfunction due to depression, presence and type of atypical features of depression (weight gain, increased appetite, leaden paralysis, hypersomnia or interpersonal rejection sensitivity), as well as type of physical morbidity and treatment prescribed.  Procedure All patients diagnosed with rst-episode depression (as per ICD-10) were approached and explained the purpose of the study. Patients who fullled inclusion criteria were evaluated further. Socio-demographic data were recorded by psychiatric social workers. Recording of clinical data and rating on HDRS was performed by the psychiatrist evaluating the patient. Thereafter, the patients were requested to complete the Hindi version of the PHQ-15. Statistical Analysis Data were analysed using the Statistical Package for the Social Sciences, Windows version 14. Means and standard deviations (SDs) were calculated for continuous variables, and frequencies and percentages were calculated for discrete variables. Comparisons entailed using the Chi-square and Mann-Whitney tests. Correlations between socio-demographics, clinical variables, HDRS, and PHQ-15 were examined using the Spearman rank correlation analysis.  Results During the study period of 4 months, a total of 426 patients were diagnosed to have rst-episode depression by a qualied psychiatrist. Of these, 187 patients were excluded because of Axis 1 psychiatric co-morbidity, 13 others were diagnosed to have severe depression with psychotic symptoms, 40 refused to participate in the study, and in 22 the data available were incomplete. Thus, the nal sample entailed 164 patients. Socio-demographic Prole The mean (SD) age of the study sample was 41 (15) years. In terms of different age-groups, 91% (n = 149) were aged 18 to 64 years, the rest were ≥ 65 years. Their mean (SD) duration of education was 10 (5) years. The majority of the patients were married and inhabitants of neighbouring states. About half of the sample (52%; n = 85) were not in a paid employment. The mean (SD) monthly income of the study sample was 6148 (12,418) Indian Rupees (Table 1). Clinical Prole About one-fourth of these 164 patients had a co-morbid physical illness, hypertension being the most common (n = 27; 17%). Although abstinent at the time of the study, there was a history of alcohol or other drug dependence in a few patients (n = 10; 6%) [Table 1]. The mean (SD) duration of depression was 13 (22) months, being ≤ 6 months in 58% (n = 94), between 6 and 12 months in 21% (n = 35), and > 12 months in the remainder. Notably, 112 had never been treated with any antidepressant, while the remaining 52 had been prescribed an antidepressant by a physician or a psychiatrist. At the index assessment, prescription data were available for 124 (76%) of the patients. Escitalopram was the most commonly prescribed antidepressant (n = 62; 38%) followed by venlafaxine (n = 25; 15%).  Phenomenology of Depression The frequency of other symptoms was shown in Table 2. The mean HDRS score of the study sample was 19.9. The most common symptom was depressed mood (100%) followed by difculty in work and activities (98%), psychic anxiety (97%), and somatic anxiety (93%). About one-third of the patients (n = 58) had sexual dysfunction that started during the course of the illness. About 10% of the patients had atypical features of depression.  Prevalence and Typology of Functional Somatic Symptoms All patients reported at least 1 FSC as assessed on PHQ-15. Of these, 96% (n = 158) reported at least 3 FSCs, in whom over 75% (n = 128) had 6 to 15 FSCs. The mean (SD)  Functional Somatic Symptoms in DepressionEast Asian Arch Psychiatry 2012, Vol 22, No.4 149 naïve or those receiving antidepressant treatment in the past. Patients without any physical co-morbidity had fainting spells more frequently (χ 2  = 5.8; p = 0.02). Compared with those with any of the atypical features of depression, those without had signicantly higher prevalence of feeling tired or having little energy (χ 2  = 5.1; p = 0.02) and trouble sleeping (χ 2  = 9.3; p = 0.002). In terms of the total number and severity of FSCs, females had more FSCs (Mann-Whitney value, 2604; p = 0.02) and higher mean scores (Mann-Whitney value, 2404; p = 0.002). There was no correlation between total number of FSCs or the total PHQ-15 score and patient age, education level, or income. Also, other socio-demographic variables did not appear to inuence the total number of FSCs or the total PHQ-15 score. The total number of FSCs and total PHQ-15 scores yielded no signicant association with the presence of physical co-morbidity, atypical features of depression, and medication status (drug-naïve or not). There was also no correlation between the total number of FSCs or the total PHQ-15 score and the duration of illness. The total HDRS scores yielded a signicant positive correlation with the total number of FSCs (Spearman rank correlation coefcient, 0.245; p = 0.002) and total mean PHQ-15 scores (Spearman rank correlation coefcient 0.199; p = 0.01), but this correlation could be spurious as some items were similar in both scales. Further correlation analysis was therefore attempted after removing the somatic items from the HDRS total score. When the somatic symptoms (items 4-6), somatic anxiety (item 11), gastro-number of somatic symptoms per patient was 8 (3) and the median for the same was 8. The mean ± SD total PHQ-15 score was 11 ± 5 (range, 1-25; median = 25). In terms of severity of FSC, 12 (7%) patients had a total PHQ-15 score of 1 to 4, 60 (37%) had scores of 5 to 9, and the remainder had scores of ≥ 10. Table 3 shows the prevalence of various FSCs as assessed on the PHQ-15. The most common symptoms (present in two-thirds or more of the patients) included feeling tired or having little energy; trouble sleeping; headache; nausea, gas or indigestion; pain in the arms, legs, or joints; and feeling that heart was racing. Of these, the rst 2 led to maximum distress, and that 67% rated them as ‘leading to a lot of distress’.  Relationship of Prevalence of Functional Somatic Complaints with Different Variables Regarding socio-demographic variables, our study revealed that back pain (χ 2  = 5.7; p = 0.02) and pain in the arms, legs, or joints (χ 2  = 3.9; p = 0.05) were FSCs that were signicantly more prevalent in females. No signicant difference in the prevalence of any FSC in patients from urban versus rural background was found. Headache was signicantly more prevalent in migrant patients (χ 2  = 6.5; p = 0.01). Marital status and religion had no inuence on the prevalence of FSC. Similarly, there was no difference in the prevalence of FSC between the patients aged < 65 years and those ≥ 65 years. Concerning clinical variables, there was no difference in the prevalence of FSC between patients who were drug- Table 1. Socio-demographic and clinical prole of patients with rst-episode depression (n = 164). VariableData * Age (years)41 ± 15Gender (male)85 (52%)Marital status (married)128 (78%)Years of education10 ± 5Monthly income (in Rupees)6148 ± 12,418 (range, 0-100,000)Locality (urban)89 (54%)Migrant status (migrant)29 (18%)Religion (Hinduism)86 (52%)Presence of physical co-morbidity † 45 (27%)Duration of depressive episode (months)13 ± 22 (median = 6; mode = 2)Nicotine dependence (currently using / abstinent)7 (4%)Alcohol dependence (currently abstinent)6 (4%)Opioid dependence (currently abstinent)4 (2%)Drug-naïve status112 (68%) *  Data are shown as mean ± standard deviation or No. (%) of patients. †  Including 18 patients with hypertension, 9 had both hypertension and diabetes mellitus, 1 had diabetes mellitus, 3 had epilepsy, 2 with hypothyroidism, and 12 had other physical illnesses.  S Grover, V Kumar, S Chakrabarti, et alEast Asian Arch Psychiatry 2012, Vol 22, No.4 150 intestinal somatic symptoms (item 12), general somatic symptoms (item 13), and genital symptoms (item 14) were removed from the total HDRS score, the correlation between total HDRS scores and total number of FSCs and the total mean PHQ-15 scores was no longer evident. Furthermore, the total number of FSCs and the total mean PHQ-15 scores had no relationship with suicidal behaviour (as assessed by suicidal ideation item of the HDRS). Discussion This study attempted to determine the prevalence of FSC in patients with rst-episode depression and to study its relationship with various socio-demographic and clinical variables. The study recruited consecutive eligible adult patients (≥ 18 years) attending the outpatient clinic of a tertiary care hospital. An attempt was made to assess other symptoms of depression using standard rating scale like HDRS. Patient Health Questionnaire–15, an instrument proved to account for more than 90% of FSCs in primary care patients, was used to assess the FSCs in the present study. Our study showed that FSCs were found to be highly prevalent in depressed patients attending the psychiatry outpatient of a tertiary care hospital. All patients had at least 1 FSC, with a mean of 8 (range, 1-15) for each patient. Studies from different parts of the world assessed the prevalence of FSC using various instruments like the Table 2. Phenomenology of rst-episode depression (n = 164). HDRS item variableData Depressed mood164 (100%)Difculty in work and activities161 (98%)Anxiety (psychic)159 (97%)Anxiety (somatic)152 (93%)Insight (acknowledges being depressed and ill)150 (91%)General somatic symptoms144 (88%)Suicidal ideation 137 (84%)Insomnia (early in the night)127 (77%)Somatic symptoms (gastro-intestinal)125 (76%)Feeling of guilt122 (74%)Insomnia (middle of the night)98 (60%)Loss of weight90 (55%)Insomnia (early hours of the morning)87 (53%)Genital symptoms85 (52%)Agitation69 (42%)Retardation65 (40%)Hypochondriasis41 (25%)Mean (standard deviation) HDRS score19.9 (5.4)Severity of depression (as per HDRS cut-offs)MildModerateSevereVery severe16 (10%)49 (30%)54 (33%)45 (27%)Some form of sexual dysfunction during depression * 58 (35%)Atypical feature of depression present † 16 (10%) Abbreviation:  HDRS = Hamilton Depression Rating Scale. *  Including decreased libido (n = 50); decreased libido and premature ejaculation (n = 3); decreased libido, erectile dysfunction and  premature ejaculation (n = 3); and 1 patient each had premature ejaculation and erectile dysfunction only. †  Including 10 patients who had 1 of the 5 atypical features (weight gain, increased appetite, leaden paralysis, hypersomnia or interpersonal rejection sensitivity), and 6 patients having > 1 atypical features. In all, 7 patients had weight gain, 6 had interpersonal rejection sensitivity, 4 had increased appetite, 3 had hypersomnia, and 2 had leaden paralysis.
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