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Psychosomatics 49:520-529, November-December 2008
doi: 10.1176/appi.psy.49.6.520
© 2008 Academy of Psychosomatic Medicine
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Prevalence, Characteristics, and Attribution of Somatic Symptoms in Spanish Patients With Major Depressive Disorder Seeking Primary Health Care

Luis Caballero, M.D., Ph.D., Enric Aragonès, M.D., Ph.D., Javier García-Campayo, M.D., Ph.D., Fernando Rodríguez-Artalejo, M.D., Ph.D., Jose Luis Ayuso-Mateos, M.D., Ph.D., Pepa Polavieja, D.Stat., Eduardo Gómez-Utrero, M.D., Ph.D., Irene Romera, M.D., and Immaculada Gilaberte, M.D., Ph.D.

Received December 12, 2006; revised March 16, 2007; accepted March 20, 2007. From the Psychiatry Department, Hospital Puerta de Hierro, Madrid; Centro de Atención Primaria Constanté, Tarragona; the Psychiatry Dept, Hospital Miguel Servet, Zaragoza, the Dept. of Preventive Medicine and Public Health, School of Medicine, Universidad Autonóma de Madrid; the Dept. of Psychiatry. Universidad Autónoma de Madrid, Hospital Universitario de la Princesa, Madrid; and the Clinical Research Department, Lilly, SA, Madrid, Spain. Dr. Eduardo Gómez Utrero is currently affiliated with the Dept. of Neurophysiology, Hospital de Móstoles, Madrid, Spain. Send correspondence and reprint requests to Irene Romera, M.D., Clinical Research Department, Lilly, SA, Avenida de la Industria, 30, Alcobendas E-28108, Madrid, Spain. e-mail: romerai{at}lilly.com
© 2008 The Academy of Psychosomatic Medicine


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
BACKGROUND: Somatic symptoms (SS) tend to dominate clinical symptomatology in patients with depression in primary care. OBJECTIVE: The authors performed a cross-sectional nationwide epidemiological study on 1,150 primary-care patients with major depression and evaluated the prevalence of SS and physicians’ attribution of their origin. METHOD: Patients were administered the Structured Polyvalent Psychiatric Interview. RESULTS: Ninety-three percent of patients had at least one SS fully or partially attributed to depression, and 45% of patients had four to nine. Painful symptoms, despite being the most frequent, were the least often attributed to depression (fewer than 25% of patients with pain) and significantly more often attributed to a combined origin. CONCLUSION: Results suggest that primary-care physicians tend to associate pain with depression to a significantly lesser extent than any other somatic symptom (e.g., cardiopulmonary or gastrointestinal). Therefore, special attention should be given to painful symptoms in order to ensure efficient management of depression in primary care.


  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHOD
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Depressive disorders are among the most common and relevant health problems faced by primary-care physicians.1 Epidemiological studies in this setting have found prevalence of clinically relevant depressive symptoms to be as high as 20%2 and prevalence rates of major depression to be between 5% and 10%.3

Somatic symptoms (SS) tend to dominate clinical symptomatology in patients with depression in primary care,4,5 and are often not attributed to an identifiable organic origin by treating physicians.6,7 Moreover, these SS keep depression from being recognized, particularly in patients with normalizing styles of presentation,8,9 thereby leading to underdiagnosis and undertreatment of this highly relevant entity.10 Consequently, primary-care physicians often engage in a lengthy and costly search for possible underlying diseases instead of considering the diagnosis of depression.11

Among SS, pain symptoms are the most common, with an average prevalence rate of 65% among patients with major depressive disorder (MDD).12 Several studies show that these painful SS increase the burden of depression, including the degree of physical and psychological distress,13,14 associated costs,15,16 and outcomes.17–20

Understanding the relationship of SS and depression is an essential and yet incomplete step toward improving our knowledge of depressive disorders in the primary-care setting. Hence, the burden of depression-associated physical symptoms deserves further research efforts.21 We have studied this relationship in patients attending primary-care facilities who met the criteria for MDD in a large, nationwide, cross-sectional study that addresses the following questions: 1) What is the prevalence of MDD in the primary-care setting in Spain? 2) What is the prevalence of SS in primary-care patients with MDD, and to what do primary-care physicians attribute these symptoms? 3) What are the characteristics of the SS not attributed to an organic origin, and what is the prevalence rate of the Abridged Somatization Symptom Cluster (ASSC) in these primary-care patients with MDD?


  METHOD

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Study Centers and Subjects
Up to 79 primary-care centers belonging to the public healthcare system in Spain, and widely distributed across the country, actively participated. One physician with previous experience in clinical management and research on depression was designated to conduct the study at each site. Participation was proposed only to those physicians in their regular practices, so that they were aware of the patients’ background and history. The main criterion used for site selection was the ability to provide a comprehensive description of aspects of the disease. All participating physicians attended a 1-day training session before the beginning of the study to establish uniform criteria on the use of the assessment instruments and data collection.

Subjects seeking consultation with any of the participating physicians for whatever reason between April and July 2004 were screened for depressed mood. A systematic procedure based on appointment logs was used for sampling; participation was offered to every fifth patient on different days, with the aim of obtaining at least 100 screenings per site. Other criteria included being at least 18 years old and not having any condition that would impede understanding of the study or hinder participation. A signed authorization for the collection and use of clinical data in accordance with standing regulations regarding personal data protection was obtained from all subjects before their enrollment, and the study protocol was reviewed and approved by the pertinent independent ethics committees.

Study Design and Procedures
The study comprised a two-stage, cross-sectional, multicenter, epidemiological study (Figure 1). First, the validated Spanish version of the Goldberg Anxiety and Depression Scale (GADS)22,23 was used to screen for depressed mood. The cutoff point was ≥3 positive responses on the 9-item Depression scale. According to available data,23 this cutoff yields a sensitivity of 0.74 and a specificity of 0.93.


Figure 1
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FIGURE 1.  Flow Chart of the Study and Data Used to Estimate Prevalence Rates of Depressed Mood and Major Depressive Disorder


Patients who screened positive were admitted into the second stage and were given an appointment with the same physician for a single study-specific visit, in which sociodemographic parameters (gender, age, marital status, area of residence, and occupational status), data on current concomitant medications, identification of previous MDD diagnosis or the presence of another psychiatric condition, and previous healthcare resource utilization (outpatient consultation within the preceding 2 weeks or hospitalization for any reason within the last year) were collected.

We used the Mini-International Neuropsychiatric Interview (MINI)24 to establish the diagnosis of MDD according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM–IV). Subsequently, those patients who met these criteria underwent the Standardized Polyvalent Psychiatric Interview (SPPI), described by Lobo et al.25 and specifically designed for the primary-care setting, to identify and characterize their SS. This interview is made up of two parts. The first one compiles information regarding the presence of 42 somatic symptoms, including those in the following areas: gastrointestinal, painful, pseudoneurological (conversion disorder), cardiopulmonary, and gynecological-sexual (only in women). Symptoms were collected by means of a systematic checklist, including a qualitative nominal score for the attribution given for the origin of each somatic symptom in any of the following categories: "organic;" there is a medical diagnosis that explains the symptom, and the symptom is fully attributed to such medical diagnosis; "depression;" there is no medical diagnosis that could explain the symptom, and the symptom is fully attributed to the depression diagnosis; or "combined;" the origin of the SS is partly attributed to a medical diagnosis and partly to a depression diagnosis. The attribution of the origin of the SS was made by the primary-care physician on the basis of his or her clinical judgment. Second, the characteristics of the SS (in patients with SS attributed to depression or to a combined origin) are described in terms of intensity, frequency, relationship with psychological distress, persistence during leisure time, associated disability, duration, and the patient’s attribution of the symptoms’ origin by means of 5-point Likert-type categorical scales, where 0 corresponds to the least-severe category and 4 to the most-severe. The item addressing the patient’s attribution of the symptoms’ origin does not have an intrinsic order; hence, 0 refers to Completely Psychological and 4 to Completely Organic attribution.

Given that a large proportion of primary-care patients who present SS do not meet all the required criteria for DSM–IV Somatization Disorder, we used the Abridged Somatization Symptom Cluster (ASSC)26 to capture somatization phenomena. This instrument was refined from the Somatic Symptom Index developed by the same authors27 and constitutes a relevant construct for clinical research because it has been shown to be a good predictor of outcome in terms of disability and health-resource utilization.28 After completing the SPPI, patients met criteria for the ASSC if: 1) they presented at least 4 (for men) or 6 (for women) somatic symptoms; 2) the treating primary-care physician did not attribute these SS to an organic cause. Symptoms must be attributed to depression or combined-cause; and 3) the symptoms must have been present for at least for 6 months before the interview.

Depression severity was assessed both by patients, using the Spanish version of Zung’s Self-Rating Depression Scale (SDS),29,30 as well as by physicians, by means of the Clinical Global Impression Scale of Severity (CGI–S).31 The SDS is a 20-item, self-report measure of the symptoms of depression that includes statements about cognitive, somatic, psychomotor, and affective symptoms. The results of these two instruments were categorically expressed by reporting the proportion of patients scoring at each CGI–S level (1 to 7) and the categories no/irrelevant depression (SDS transformed score <50), mild depression (transformed score 50 to 59), moderate or marked depression (transformed score 60 to 69), and severe or extreme depression (transformed score ≥70), obtained after multiplying the raw total SDS score by 1.25, according to the authors’ procedure.30

Statistical Analysis
All analyses were performed using observed data. Missing values were not included. Exploratory data analysis was used to describe relevant variables with moment- and range-based measures or absolute and relative frequencies, as appropriate; 95% confidence intervals (CI) were calculated for relative frequencies and for means to estimate the values of proportions and measures in the population.

To explore the relationship of sociodemographic/clinical characteristics with the presence of the ASSC criteria, the odds of meeting criteria for the ASSC were modeled by means of logistic-regression with data collected on clinical and demographic characteristics. A Wald chi-square test was performed at baseline to discriminate variables with significant predictive ability from among the following: age, sex, area of residence, occupational status, marital status, current use of analgesics/anti-inflammatory drugs, antipsychotics, benzodiazepines, antidepressants, presence of a previous diagnosis of the current major depressive episode, presence of one or more psychiatric disorders other than depression, hospitalization within the previous year, outpatient consultation during the previous 2 weeks, and current CGI–S, and SDS global scores.

The sample size was calculated on the basis of an estimated prevalence of depression between 14% and 20% of the population seeking consultation in primary care,32 and factoring in a 20% dropout rate. Hence, it would be necessary to collect information from 10,000 potential patients from the list of appointments of primary-care physicians in order to obtain a sample of approximately 1,000 to 1,500 patients with depression. With this figure in mind, the prevalence of somatic symptoms can be estimated by means of a 95% CI with a precision of 2.2%.


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Prevalence of Major Depressive Disorder and Patient Characteristics
Of the 8,687 patients selected on the basis of their attendance at a primary healthcare facility, 8,215 (94.6%) agreed to participate and were screened with the GADS. A positive result was obtained in 1,998, corresponding to a 23.0% prevalence rate of depressed mood in the overall sample (95% CI: 22.1%–23.9%); however, 209 subjects refused to continue the study. Therefore, 1,789 entered the second stage, of whom 1,150 (64.3%) were diagnosed with MDD according to DSM–IV criteria, by use of the MINI interview, corresponding to a 14.0% prevalence rate (95% CI: 13.3%–14.8%). Figure 1 provides a summary of this process.

Clinical and demographic characteristics of patients meeting criteria for MDD are summarized in Table 1. It is worth noting that only 45.9% of patients who met the criteria for MDD in this study actually had a previous diagnosis of the current MDD episode, and, of these, only 56.3% were on antidepressant medication.


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TABLE 1. Clinical and Demographic Characteristics of Patients Meeting Criteria for Major Depressive Disorder (MDD; N=1,150)



Prevalence and Attribution of the Origin of Somatic Symptoms
The data presented in this section were obtained from the first part of the SPPI, which addressed the presence of SS; it was completed by 1,131 of the 1,150 patients with a positive MINI result. The symptoms were numerous; the mean number per patient was 8.1 (standard deviation [SD]: 4.7), with a median of 7. Figure 2 provides the relative frequencies of patients in whom each of the most common SS (those reported in at least 20% of patients) was reported in the course of the SPPI, with indication of the primary-care physician’s attribution of their origin.


Figure 2
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FIGURE 2.  Relative Frequencies of Patients in Whom Each of the Most Common Symptoms Were Reported, With Indication of the Attribution of Origin (Depression, Organic, or Combined) by the Treating Primary-Care Physicians

The sample (N=1,131) comprised those who completed the Standardized Polyvalent Psychiatric Interview (SPPI). Symptom types, as listed on the SPPI, are the following: GI: gastrointestinal; PA: pain; PS: conversion/pseudoneurological; CP: cardiopulmonary; WO: women; OT: other. Only symptoms reported in ≥20% of patients are included.


The greatest relative frequency was in the area of pain symptoms: 85.5% of patients had at least one symptom specific to the area of pain; followed by cardiopulmonary symptoms (80.6% of patients); gastrointestinal (69.4%); gynecological/sexual (present in 65.7% of the women participants); and pseudoneurological/conversion (64.2%). Regarding individual symptoms, the greatest prevalence was in back pain (present in 69.3% of patients), palpitations (57.3% of patients), limb pain (56.7%), joint pain (49.4%), and flatulence (47.6% of patients).

The attribution patterns given by the primary-care physician for the origin of the different symptom groups was uneven; whereas cardiopulmonary symptoms were attributed to depression in most patients (79.9% of patients with palpitations, 70.8% of patients with thoracic pain, and 60.9% of patients with dyspnea), and gastrointestinal symptoms in more than one-half of patients (68.5% of patients with nausea, 55.1% of patients with flatulence, and 54.0% of patients with abdominal pain), pain symptoms themselves were attributed to depression in less than one-fourth of patients (24.3% of patients with back pain, 24.3% of patients with limb pain, and 16.5% of patients with joint pain). The attribution was more variable in patients with pseudoneurological/conversion and gynecological/ sexual symptoms.

The SS most commonly attributed to depression by the primary-care physician were: loss of libido in women (82.8% of women with loss of libido), palpitations (79.9% of patients with palpitations), amnesia (74.0%), thoracic pain (70.8%), and nausea (68.5%); these were attributed to depression in more that two-thirds of patients (Figure 2).

Of the most prevalent somatic symptoms, pain symptoms were significantly attributed to combined origin more often: back pain in 44.8% of patients (95% CI: 41.2%–48.4%), limb pain in 42.5% (95% CI: 38.6%–46.4%), and joint pain in 41.6% (95% CI: 37.4%–45.8%) than any other most-prevalent SS, such as palpitations, in 13.3% of patients (95% CI: 10.7%–15.9%), flatulence in 29.2% (95% CI: 25.3%–33.1%), loss of sexual drive in 13.4% (95% CI: 10.0%–16.8%), or dizziness in 26,2% of patients (95% CI: 22.1%–30.3%).

Characteristics of Somatic Symptoms Not Attributed to an Organic Origin and Prevalence of the Abridged Somatization Symptom Cluster (ASSC)
This section reports the results obtained in the second part of the SPPI, which was completed for 1,026 patients. The prevalence of SS was evaluated according to SPPI Question 43, which excludes SS attributed to an organic origin. Therefore, only SS attributed to a psychological or combined origin were considered. With this in mind, in 954 patients (93.0%; 95% CI: 91.2%–94.5%) the primary-care physician considered that the patient had at least one SS that could not be attributed to an organic origin, whereas 7% of patients did not present such symptoms. The primary-care physician considered that there were 239 patients with ≤3 of such symptoms (23.3%), 462 with 4 to 9 (45.0%), and 126 with ≥10 SS not attributed to an organic origin (12.3%). In the remaining 127 patients (12.4%), the symptoms not attributed to an organic origin were considered to be common complaints of uncertain psychological origin.

The analysis of the characteristics of these SS not attributed to an organic cause revealed that they had persisted for more than 6 months in 52.6% of patients, were rated as moderate or severe by 56.1%, did not disappear or disappeared only occasionally during free time in 37.7%, caused intense and/or frequent incapacitation for routine activities in 38.1%, showed a moderate-to-severe increase with psychological distress in 52.8%, were present for at least several hours every day in 61.7%, and were fully or almost fully attributed by patients to a psychiatric condition in 52.2% of cases. Of note, 15.5% of the patients attributed these SS entirely to an organic origin, despite the physician’s psychological attribution.

Up to 30.4% of the subjects with MDD met criteria for the ASSC (95% CI: 27.8%–33.1%). We found clinical and demographic differences between the individuals who qualified and those who did not. In general, patients meeting the cluster definition were slightly older (mean: 57.8 [SD: 14.6] versus 52.9 [SD: 15.3] years); there were more women (83.0% versus 73.5%); there were more home-makers (42.8% versus 35.7%) or retired patients (20.5% versus 13.2%); they were taking more medications (45.7% versus 25.5% took antidepressants; 56.3% versus 40.7%, benzodiazepines; and 62.9% versus 47.2%, analgesics/anti-inflammatory drugs); they were more likely to have consulted a physician recently (60.3% versus 45.2%), and had more severe depression scores (71.2 [SD: 9.6] versus 67.1 [SD: 9.7] points on the global SDS score).

The adjusted analysis, which included 933 patients, revealed that the likelihood of meeting the ASSC criteria increases with age (the odds of qualifying increase by 1.02 per year, or, what is the same, 1.23 per decade; and, in the case of the CGI–S score, the odds increase by 1.44 per 1-point increase on the CGI–S score). Furthermore, having concomitant treatment with analgesics/anti-inflammatory drugs or antidepressants, having consulted with a physician in the preceding 2 weeks, and being a woman were also independently associated with the ASSC scores (Table 2).


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TABLE 2. Logistic-Regression Analysis: Reduced Model of the Relationship Among Criteria for the Abridged Somatization Symptom Cluster and Sociodemographic and Clinical Characteristics in Patients With Major Depressive Disorder (MDD; N=933)




  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
In this large, cross-sectional, epidemiological study, we found a 23% prevalence of depressed mood and a 14% prevalence of MDD among patients attending primary healthcare facilities in Spain, results that are consistent with those reported in previous studies.3,32–34 Nevertheless, these estimations must be considered with caution, first, because the primary site-selection criterion was not aimed at estimating prevalence, and, second, because the cutoff point chosen for screening possible cases of depression with the GADS was high, so as to decrease the number of false-positives at the expense of sensitivity. It is worth noting that a previous diagnosis of the current MDD episode was present in fewer than half of these patients (45.9%), and only 31% of depressed patients were taking anti-depressant medication. This reflects the underdiagnosis of major depression in primary care already addressed at length by other studies.9,34–36

Our findings confirm results obtained in previous studies on depression in primary care characterized by the high prevalence and large number of somatic symptoms in patients with MDD.4,10,37,38 Also, the high prevalence of pain symptoms observed in our study (more than 8 in 10 patients reported at least one painful symptom, with back pain present in more than two-thirds) is consistent with the literature available on depression in primary-care settings.39–41 Nonetheless, it is particularly striking that, in a large proportion of these patients, their pain symptoms are fully or at least partially attributed to an organic origin. Of the most prevalent somatic symptoms, back, limb, and joint pain are significantly more often attributed to a combined origin than any other somatic symptom, suggesting that pain is significantly less associated with depression by primary-care physicians. Of note, too, is the rather high, uniform proportion of patients whose cardiopulmonary and gastrointestinal symptoms were attributed to depression, on the one hand, and the heterogeneity of the attribution in patients with pseudoneurological/conversion and gynecological/sexual symptoms, on the other.

To our knowledge, our results come from the largest sample of primary-care patients with MDD in which the occurrence and factors associated with the ASSC have been investigated. The presence of numerous SS not attributed to an organic origin that persist for more than 6 months was significantly associated, among other variables, with greater analgesic use and greater number of visits to primary-care facilities, and these should cue the clinician as to the presence of depression. Also, the high use of analgesic/anti-inflammatory drugs (63.9%)—higher than the use of antidepressants (45.7%)—suggests that these patients with depression and SS are being inadequately treated.

As reported previously, the prevalence of somatization varies depending on the selected criteria of diagnosis.42 The ASSC is a less restrictive alternative than full somatization-disorder criteria, so we would expect to find higher prevalence rates with these criteria. When evaluating the prevalence of an abridged somatization symptom cluster in our study, several considerations must be made. First, the criteria used for meeting the ASSC after completing the Standardized Polyvalent Psychiatric Interview did not consider severity of somatic symptoms. Therefore, prevalence might have been overestimated. Also, patients met ASSC criteria if SS were present for at least for 6 months before the interview. This criterion might have underestimated the true prevalence if lifetime SS had been considered.

Our study shows that there are substantial differences in the causes that physicians attribute to different categories of SS. The lower attribution rate of pain to depression suggests that primary-care physicians are less likely to consider pain a purely depressive symptom, and instead attribute pain to organic or combined causes, partly because the evaluation of the origin of pain is complex, and also because pain is the most frequent cause of primary-care consultation.43 One striking finding is that more than half of the SS that the physician felt were not due to an organic cause were also considered by the patient to be attributable to a psychological cause. This high agreement rate between patients and physicians suggests that patients are not so reluctant to view their SS as having a psychological origin as previously reported.44

Also, there is much confusion and controversy regarding the terminology to be used for depression-related somatic symptoms. Many terms have been used, including "chronic painful physical conditions," "medically unexplained symptoms," and "somatized symptoms."10 This lexicon surrounding somatic symptoms and depression reflects the complicated and as-yet-incomplete understanding of the relationship between depression and concomitant SS.

Rejecting the idea that pain may be a depressive symptom may be one of the reasons for underdiagnosis of depression in primary care, likely because theoretical developments regarding the pain/depression dyad in the primary-care setting have not been generally applied in the clinical setting. To-date, studies on somatic symptoms and depression with large samples of depressed patients, particularly those addressing specifically painful symptoms, have been in the primary-care setting.12 In the recently published conceptual review of somatic disorders by Kroenke and Rosmalen38 the total symptom count in patients who present with physical complaints has a strong relationship with the likelihood of a coexisting depressive or anxiety disorder. Therefore, primary-care physicians should not dismiss the possibility of a comorbid psychiatric condition because the patient presents with pain instead of cardiopulmonary or gastrointestinal symptoms.

We have studied SS and their attribution in patients suffering psychological distress, given that we proceeded by selecting individuals meeting criteria for MDD. Hence, we have evaluated the phenomenon of symptoms at a point in their natural history in which patients met the threshold for MDD. One salient finding is the great clinical heterogeneity of patients in the primary-care setting that clearly separates them from the population studied in specialized settings where major depression has been traditionally defined and investigated.45 It is possible that these same patients would qualify for an anxiety disorder or even fail to present psychological distress at all at a different time-point, for which they might have been classified as functional somatizers under the Somatization Disorder or other Somatoform Disorder category. We propose, on the basis of our results and previous studies, that these SS fully or partially attributed to depression by the primary-care physician could be a constituent part of the depressive disorder, which could be named Primary Somatic Depressive Symptoms. However, we cannot exclude other possibilities—somatic symptoms associated with depression in any of the following ways: 1) subthreshold or established anxiety disorders comorbid with depression; 2) subthreshold or established comorbid somatoform disorder; 3) physical symptoms caused by other medical illnesses that ultimately lead to depression; or 4) functional symptoms totally unrelated to psychiatric conditions.

Several important limitations of this study must be mentioned. We have already commented on the shortcomings of prevalence estimations. Second, the current study did not have a control group of nondepressed patients for comparison of the prevalence of SS. Although the presence of SS was the norm, many patients had not received a diagnosis of MDD and were seeking health care for their physical symptoms. Whether or not, they had more SS than nondepressed patients cannot be directly ascertained. However, in the literature, there are studies showing significantly higher prevalence of such symptoms in MDD patients versus patients without MDD.46 Furthermore, patients were screened on the basis of their visiting their regular general-practitioner; thus, the results cannot be extrapolated to MDD patients not visiting their primary-care physician. And, last, cross-sectional investigation cannot address important issues such as the temporal sequence in which depressive and SS occur, the natural clustering of symptoms, or the stability of the MDD diagnosis.


  CONCLUSIONS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
In summary, our findings confirm results obtained in previous studies on depression in primary care, characterized by the underdiagnosis of MDD and the high prevalence and large number of SS in primary-care patients with MDD. However, to-date, this is the first study in a large sample of patients with MDD to show in depth primary-care physicians’ attribution of the origin of the SS associated with depression. Despite the fact that pain symptoms were the most prevalent, they were significantly less often attributed to depression than cardiopulmonary or gastrointestinal symptoms and significantly more often attributed to a combined origin. This suggests that primary-care physicians tend to associate pain with depression to a significantly lesser extent than any other somatic symptom. Special attention must be paid to painful somatic symptoms in order to ensure efficient management of depression in primary care.


  ACKNOWLEDGMENTS

 
The authors thank all the primary-care centers that participated, as well as patients who agreed to participate, provided consent for the use of part of their clinical data, and went to an additional visit to fulfill study procedures.

We acknowledge the contributions to this article made by Helena Delgado-Cohen.

This study was supported by a research grant from Eli Lilly and Company.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

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