Correspondence
The Relation between Somatic Symptoms and Depression
N Engl J Med 2000; 342:658-659March 2, 2000
- Article
To the Editor:
The international study of somatization and depression reported by Simon et al. (Oct. 28 issue)1 raises issues that are pertinent to the practice of cross-cultural medicine in the United States. By demonstrating the similarities between cultures with respect to somatic symptoms and depression, the study suggests that these clinical manifestations cross both cultural and international boundaries and are in essence basic to the human condition. However, what if the study by Simon et al. had shown more consistent, significant international differences in somatic symptoms of depression? Would these findings influence our clinical decision making? Would we tend to treat immigrants from certain countries as “somatizers” whose symptoms had little physical basis? Studies that compare cultural attitudes and behavior may lead to a false sense of knowledge about cultures and should be applied with great caution in the clinical setting.2
Many efforts to teach doctors in training about the importance of culture in medicine have taken a categorical approach, emphasizing certain characteristics that are deemed important in the care of patients of particular cultural backgrounds.3 Although some of this information may be helpful (e.g., the incidence and prevalence of disease, specific traditions and customs, and historical perspectives), other information may lead to oversimplification and stereotyping, especially in regard to attitudes and beliefs.3 Rather than assume that patients from certain cultures act in predetermined ways (e.g., manifest depression by somatization), it is more helpful to learn how to recognize and manage the sociocultural influences on each person's health-related beliefs and behavior. When one works with diverse populations, issues related to communication, mistrust, the role of the family, the perceived role of the physician, the social context (socioeconomic status, immigration experience, and so forth), and the conceptualization of illness, among others, should be addressed and understood in the case of each patient.4
4 ReferencesAlexander R. Green, M.D.
Joseph R. Betancourt, M.D., M.P.H.
J. Emilio Carrillo, M.D., M.P.H.
Cornell Internal Medicine Associates, New York, NY 100211
Simon GE ,VonKorff M ,Piccinelli M ,Fullerton C ,Ormel J . An international study of the relation between somatic symptoms and depression. N Engl J Med 1999;341:1329-1335
Full Text | Web of Science | Medline2
Blackhall LJ ,Murphy ST ,Frank G ,Michel V ,Azen S . Ethnicity and attitudes toward patient autonomy. JAMA 1995;274:820-825
CrossRef | Web of Science | Medline3
Spector RE. Cultural diversity in health and illness. 3rd ed. Norwalk, Conn.: Appleton & Lange, 1991.
4
Carrillo JE ,Green AR ,Betancourt JR . Cross-cultural primary care:a patient-based approach. Ann Intern Med 1999;130:829-834
Web of Science | Medline
To the Editor:
In studies that involved the same population as that in the study by Simon et al., Ormel et al.1 and Gureje et al.2 reported a 2.8 percent prevalence of somatization disorder, as defined by the International Classification of Diseases, 10th Revision (ICD-10), among 14 countries. Sixty-one percent of patients with somatization disorder in these studies had coexisting psychiatric disorders. Other studies of somatization in primary care3,4 have also shown high rates of coexisting psychiatric disorders (up to 100 percent), especially depression, in patients with somatization disorder. Lenze et al.5 reported that patients with somatization disorder had at least as many mood and psychotic symptoms as those with primary diagnoses of mood or psychotic disorders, even though such disorders had not been clinically diagnosed. The exclusion of patients with somatization disorder (who are known to have depressive symptoms) from the data analysis in the study by Simon et al. was necessary to obtain unconfounded findings. The prevalence rate for major depressive disorder could be adjusted with the already available data on the prevalence of somatization disorder at each site.
Every study center in a country classified as having a lower level of development was located in one of the largest cities in the country. These cities were likely to be much more westernized than other cities in the country. This may explain why Simon et al. found no significant variation in the prevalence of somatized depression according to the economic classification of the centers. The authors might have prematurely concluded that there was no evidence of greater somatization in the non-Western countries than in the Western countries. Also, the study was conducted exclusively in primary care clinics rather than with the use of a community-based survey. The results should not be overgeneralized.
5 ReferencesChanvit Pornnoppadol, M.D.
Washington University School of Medicine, St. Louis, MO 631081
Ormel J ,Vonkorff M ,Ustan TB ,Pini S ,Korten A ,Oldehinkel T . Common mental disorders and disability across cultures: results from the WHO Collaborative Study on Psychological Problems in General Health Care. JAMA 1994;272:1741-1748
CrossRef | Web of Science | Medline2
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
Web of Science | Medline3
Fink P ,Sorensen L ,Engberg M ,Holm M ,Munk-Jorgensen P . Somatization in primary care: prevalence, health care utilization, and general practitioner recognition. Psychosomatics 1999;40:330-338
Web of Science | Medline4
Brown FW ,Golding JM ,Smith GR Jr . Psychiatric comorbidity in primary care somatization disorder. Psychosom Med 1990;52:445-451
Web of Science | Medline5
Lenze EJ ,Miller AR ,Munir ZB ,Pornnoppadol C ,North CS . Psychiatric symptoms endorsed by somatization disorder patients in a psychiatric clinic. Ann Clin Psychiatry 1999;11:73-79
Medline
Author/Editor Response
The authors reply:
To the Editor: We share Green and colleagues' concern about the influence of ethnic or cultural stereotypes on the clinical encounter. Our findings underscore the complexity of the perception and reporting of symptoms. The relation between somatic and psychological symptoms was generally similar among the study centers, whereas the problems presented to the doctors varied considerably. We should emphasize, however, that depressed patients at all centers typically presented with somatic symptoms or medical concerns. Regardless of the country or the culture, there is no substitute for careful clinical interviewing in the assessment of possible depression.
Pornnoppadol raises two questions. With regard to the coexistence of depression and somatization disorder, we have argued elsewhere1,2 that somatization disorder (i.e., the reporting of multiple somatic symptoms without medical explanation) should be viewed as a spectrum in terms of severity rather than as a distinct disorder. The diagnostic criteria of ICD-10 and the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, are based on somewhat arbitrary thresholds for identifying the extreme end of this spectrum. Abundant evidence2-4 demonstrates the strong association between unexplained somatic symptoms and other psychiatric disorders (including depression). We believe this evidence does not support attempts to distinguish between primary and secondary diagnoses. We conclude instead that “somatic and psychological distress are almost invariably intertwined.”3
We concur with Pornnoppadol's points with regard to the generalizability of our findings. Our study was limited to patients seeking care at conventional (Western) medical clinics in urban areas, and the results may not be applicable to clinics in rural areas or to patients who do not visit primary care clinics.
4 ReferencesGregory E. Simon, M.D., M.P.H.
Michael VonKorff, Sc.D.
Group Health Cooperative, Seattle, WA 981011
Katon W ,Lin E ,VonKorff M ,Russo J ,Lipscomb P ,Bush T . Somatization: a spectrum of severity. Am J Psychiatry 1991;148:34-40
Web of Science | Medline2
Simon GE ,VonKorff M . Somatization and psychiatric disorder in the NIMH Epidemiologic Catchment Area study. Am J Psychiatry 1991;148:1494-1500
Web of Science | Medline3
Simon G ,Gater R ,Kisely S ,Piccinelli M . Somatic symptoms of distress: an international primary care study. Psychosom Med 1996;58:481-488
Web of Science | Medline4
Kroenke K ,Spitzer RL ,Williams JBW , et al. Physical symptoms in primary care: predictors of psychiatric disorders and functional impairment. Arch Fam Med 1994;3:774-779
CrossRef | Medline
