Physical and Somatic Symptoms in the Diagnosis and Treatment of Depression: An Expert Interview With Maurizio Fava, MD

May 26, 2006

Editor's Note:
The interplay of physical and somatic symptoms significantly complicates the diagnosis and treatment of patients with depression. As many as two thirds of depressed patients in primary care present with somatic symptoms, including general aches and pains, insomnia, and fatigue. These patients are difficult to diagnose and treat, feel a greater disease burden than those without somatic symptoms, and rely heavily on healthcare services. Patients who present with somatic complaints are 3 times more likely to be misdiagnosed compared with patients who have no physical complaints. On behalf of Medscape, Jennifer M. Covino, MPA, spoke with Maurizio Fava, MD, Professor of Psychiatry at the Harvard Medical School, Boston, Massachusetts, about the role of physical and somatic symptoms in the diagnosis and treatment of depression and approaches that may improve results.

Medscape: Can you tell me something about the research you will be presenting at this year's American Psychiatric Association meeting regarding the relationship between physical and/or somatic symptoms and depression?

Dr. Fava: I am chairing a symposium that really focuses on these issues and the importance of a comprehensive system of assessment and treatment of physical and psychological symptoms of depression, particularly in the medically ill.

This includes information about the neurobiology of physical and somatic symptoms, and considers what the literature tells us about which mechanisms of action might provide more favorable interventions for treating these conditions. Given the significant evidence for abnormalities of the norepinephrine (NE) and serotonin (5-HT) neurotransmitter systems in depressive disorders and the modulating role of these 2 neurotransmitter systems in pain and other somatic symptoms, it has been hypothesized that antidepressants that affect NE and 5-HT neurotransmission, such as tertiary amine tricyclic antidepressants (TCAs) and serotonin norepinephrine reuptake inhibitors (SNRIs), may be more efficacious than selective serotonin reuptake inhibitors (SSRIs) for treating the somatic and physical symptoms of major depressive disorder (MDD). Although the evidence for their superiority compared with the SSRIs is still preliminary, this hypothesis certainly fits with some of the neurobiological theories about MDD with somatic symptoms.

We will also discuss the challenges associated with the diagnosis of depression in relationship to comorbid medical conditions such as ischemic heart disease, neurologic disorders, musculoskeletal disorders, renal disease, endocrine disorders, gastrointestinal conditions, cancer, HIV, pulmonary disease, organ transplantation, and reproductive system disorders, along with subsequent challenges of the treatment of comorbid medical illness.

Medscape: Will you be presenting any original and/or newly published data regarding physical and somatic symptoms in depression?

Dr. Fava: We are presenting the results of a study that is in press in the journal Psychosomatics by Dr. John Denninger from our group on the association between treatment response without remission and relatively higher levels of somatic symptoms compared with remission.

Medscape: Considering the topic of physical and somatic symptoms, as a psychiatrist, how important is the treatment of these symptoms in the overall treatment of depression?

Dr. Fava: One of the challenges that we all face in the field of psychiatry is that patients present to us with a constellation of symptoms that can be psychological, behavioral, and/or physical in nature. And yet in the way we are trained to ask questions, we tend to focus at lot more on what troubles our patients psychologically and less on what troubles them physically and somatically. In fact, if you look at the DSM-IV classification, of the 9 symptoms that constitute the criteria for MDD, 3 are physical -- fatigue and sleep and appetite disturbances -- and the others are psychological or behavioral. Therefore, in the treatment of depression, what patients expect from us is help with all of their symptoms, not just with the psychological ones, and we are often not very good at tracking the effects of our treatments on physical and somatic symptoms.

Medscape: Would you say that depression is often underdiagnosed because individuals may feel that they are suffering from another condition?

Dr. Fava: Studies have shown that somatic symptoms may be the chief complaint of depressed patients in primary care,[1,2] in that the patients who suffer from depression and are concerned with physical symptoms may be looking for physical explanations for their complaints, and may go to their primary care physicians to obtain help with these symptoms. For this reason, depression might be underdiagnosed in primary care settings. We know that it may only take a couple of questions to screen for depression in primary care and yet we also know that the systematic screening for depression is often still the exception rather than the rule. We are therefore still faced with the problem that many patients with MDD are undetected in the primary care setting.

Medscape: What are the most typical somatic and physical symptoms that you see in your practice?

Dr. Fava: In addition to the well-known physical symptoms of fatigue and appetite and sleep disturbances, in patients with depression we often see aches, pains, headaches, and muscle tension. Sometimes we may see changes in sexual function as part of depression, and sometimes we see physical symptoms in the gastrointestinal system, such as upset stomach and so forth. When people experience aches and pains in the context of depression, it's hard for them to realize that these symptoms may be secondary to depression; it's easier to try to pin down nonpsychiatric illnesses as their cause, although studies have clearly shown that successful treatment of depression is associated with significant improvements in physical symptoms, including pains and aches. In fact, our group has shown that patients who achieve remission have fewer residual symptoms (pains and aches) than those who respond but do not remit.[3] So there is a fairly linear correlation between the number of physical symptoms and the severity of depressive symptoms.

Medscape: As far as the treatment of symptoms, do you usually start with a single antidepressant, or may combination therapies be more appropriate?

Dr. Fava: First, you don't want to make the assumption that all physical symptoms are related to depression, so you still need to conduct a review of systems and look at potential contributing factors to the etiology of those symptoms. But, in the absence of obvious potential causes for physical and somatic symptoms outside depression, the simplest approach is to start antidepressant treatment. In the event that the most significant symptom is insomnia, there is evidence that starting with a hypnotic and an antidepressant may yield higher rates of response and remission than starting with antidepressant monotherapy. So it is not unreasonable to consider combination therapies from the outset when targeting depression with significant physical symptoms. Similarly, if someone has pronounced fatigue and lethargy (feeling really physically slowed down), one may consider starting an antidepressant plus psychostimulants or modafinil.[4]

Medscape: When you begin treatment with an antidepressant in a patient who has physical and somatic symptoms, and you do not see improvement in those symptoms, what is your next step?

Dr. Fava: If I see clear improvement but residual physical symptoms persist, the easiest thing to do is to add other psychotropic agents or augment the antidepressant to address the residual symptoms. In the absence of improvement, switching may be reasonable to try to target those physical symptoms.

Medscape: What about psychotherapy? Do you find that psychotherapy can be useful for augmenting an antidepressant trial?

Dr. Fava: Good evidence has shown that psychotherapy can be a helpful augmentation strategy in patients with depression.[5,6,7] The ability for psychotherapy to target physical symptoms has probably been understudied, partly because psychotherapy trials tend to focus on the effects of psychotherapy on psychological symptoms of depression more than the physical ones. However, we know that cognitive therapy, for example, can improve sleep, appetite, and other symptoms, and so it certainly is quite possible that psychotherapy would have significant effects on somatic symptoms as well.

Medscape: Cleary more research is needed, then?

Dr. Fava: Yes, absolutely.

Medscape: Looking ahead, will your group be examining the role of physical and/or somatic symptoms in depression?

Dr. Fava: Yes. We are looking at the prevalence of fatigue in college students to try to determine the correlates of fatigue, with and without depression, and see what the impact of excessive fatigue in that population may be.

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