do medically unexplained somatic symptoms predict depression in older chinese?

RESEARCH ARTICLE

Do medically unexplained somatic symptoms predict
depression in older Chinese?
Doris S.F. Yuy and Diana T.F. Leez

The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, New Territories, Hong KongCorrespondence to: Doris S.F. Yu, E-mail: [email protected]

yAssociate Professor.

zDirector/Chair Professor of Nursing.

Copyr

Objective: To identify the pattern of somatic presentation of depression among older Chinese byexamining the association between medically unexplained somatic symptoms and depression.

Subjects:The population comprised 1433 Chinese 65 years or older recruited from 11 older communitycentres distributed across the three main territory regions of Hong Kong.

Method:Data were collected between January and December 2008, with a response rate of 72.3%. Data onsocio-demographic background, medical profile and somatic symptoms were collected. The MentalHealth Inventory (five-item) was used for depression screening. Medically unexplained somaticsymptoms were defined as those not explained by any known medical pathology.

Results: The prevalence of depression among older Chinese was 16.5%. They reported more frequentlythan did the non-depressed six medically unexplained somatic symptoms. After being adjusted for age,living arrangements, social support, financial strain, major stressful life events and chronic illness,depression was found to be significantly associated with all medically unexplained somatic symptoms(odds ratio: 1.667–2.268). Indeed, depressed older people were more likely to have multiple symptomsthan were the non-depressed, the odds ratio increasing from 2.64 (95%CI: 1.884–3.717) for two co-existing symptoms to 4.521 (95%CI: 1.872–10.917) for six symptoms.

Conclusion: Older Chinese with depression were more likely to have multiple medically unexplainedsomatic symptoms, particularly fatigue, insomnia, loss of appetite and gastro-intestinal problems. Healthcare professionals need to be aware of this pattern of somatization and take active steps to rule out anyunderlying psychological etiology. Copyright # 2011 John Wiley & Sons, Ltd.

Key words: depression; medically unexplained somatic symptoms; older Chinese; somatizationHistory: Received 24 July 2010; Accepted 4 January 2011; Published online 16 April 2011 in Wiley Online Library(wileyonlinelibrary.com).DOI: 10.1002/gps.2692

Introduction

Depression is a global public health problem amongthe older population, with a reported prevalencerate of 8.6–33.1% among people 65 years or older(Castro-Costa et al., 2007; McDougall et al., 2007;Pirkis et al., 2009). Older people with depressionnot only participate less in role fulfillment and socialactivities, but also experience a more rapid deteriora-tion in mobility and cognitive functions (Chan et al.,

ight # 2011 John Wiley & Sons, Ltd.

2009). Indeed, late-life depression also complicatesthe disease course of common chronic illnesses amongolder people and leads to a higher risk of morbidityand mortality (Chuan et al., 2008).Though late-life depression is detrimental to the

well-being of older people, this mental health problemcommonly goes unrecognized and undertreated ingerontological care (Luppa et al., 2008). One reasonmay be related to the varied symptomology ofdepression among older people. Instead of older

Int J Geriatr Psychiatry 2012; 27: 119–126.

120 D. S. F. Yu and D. T. F. Lee

people presenting the emotional suffering associatedwith depression, substantial evidence indicates theyhave an increased tendency to somatize theiremotional symptoms (Feder et al., 2001; Drayeret al., 2005; Menchetti et al., 2006).Somatization is a pattern of behaviours in which an

individual presents with a set of somatic symptoms.Instead of indicating the presence of a medicalpathology, such physical complaints represent a copingresponse to psychological distress (Kleinman, 1986).Previous studies have consistently shown that soma-tization is very common among older people withdepression in Caucasian populations (Feder et al.,2001; Drayer et al., 2005; Menchetti et al., 2006). Asample of outpatients with medically unexplainedsymptoms was found to be more than twice as likely tohave a psychiatric disorder than those withoutsymptoms (Feder et al., 2001). Other studies examin-ing somatic symptoms in patients with mental healthproblems have identified similar findings (Feder et al.,2001; Menchetti et al., 2006). Independent of medicalillness, older people with mental health problems had afivefold risk of being frequent users of primary medicalservices for somatic symptoms compared with normalcounterparts (Menchetti et al., 2006). Another studyalso found that depression independently predictedsomatization in older people attending psychiatricservices after controlling for age, gender and medicalcomorbidities (Drayer et al., 2005).Cultural differences in expression of emotion have

been recognized (Kirmayer, 2001). Some ethnics groupsuch as South-Asians are most likely to somatize theiremotional experience. Bhui (2001) found that ascompared with British patients, patients in Punjab whovisited the doctor were more likely to have depressedmood. People in North India were found to very likelyto describe depression with somatic metaphors such as‘pressure on the mind’ and ‘sinking heart’, andassociated their mood problems with aches, painand weakness (Bhugar and Mastrogianni, 2004). As forthe Chinese population, under the influence of thecultural ideologies of emotional calmness, a self-restrained demeanour and adaptive strategies, theexpression of affective symptoms is regarded as lessacceptable (Kleinman, 1986). Somatization may alsobe a more relevant problem among the Chinese olderpopulation. A few studies in this area have focused onthe somatic presentation of depressed Chinese adults(Parker et al., 2001) or older people (Da Canhotaand Piterman, 2001). It was found that over 50% ofolder Chinese first seeking medical consultation fordepression was somatic presenters (Da Canhotaand Piterman, 2001). Compared with the Caucasian

Copyright # 2011 John Wiley & Sons, Ltd.

population, somatic symptoms were a more commonreason for Chinese adults to seek psychiatric servicesfor their mental health problems (Parker et al., 2001).But these studies did not control for the influence ofphysical morbidities and social characteristics onsomatic symptoms in the older population. Another,better-controlled, study examined ethnic differences insomatic symptoms among depressed older people inChinese, Indian and Malaysian populations (Soh et al.,2009). Because this study used the Chinese participantsas the reference group, it provided no information onthe extent to which depressed older Chinese weremore likely to report somatic symptoms comparedwith the non-depressed. The study neverthelessidentified various somatic symptoms, including sleepdisturbance, dizziness, weakness, loss of appetite andbodily pain, as being more prevalent among depressedChinese.Early recognition of depression among older people

is of the utmost importance in ensuring prompttreatment for this devastating mental health problem.Although some evidence suggests the somatizationof mental health problems among older Chinese,current knowledge is inadequate for informing healthcare professionals of its pattern of presentation. Inparticular, there has been no well-controlled study to(i) identify those somatic symptoms independentlyassociated with depression, and (ii) examine whetherthe coexistence of multiple symptoms is the morecommon form of somatization of depression amongolder Chinese. Because age-related physical changesmay cause more somatic discomfort in older people,such information would be important for facilitatingearly recognition of depression in this particular cohortof the population. This study was intended to addresssuch gaps in the literature.

Method

Participants and procedure

This was a descriptive correlational study. Data werecollected between January and December 2008 in11 older community centres located in the three mainterritory regions in Hong Kong. A conveniencesample of community-dwelling people 65 years orolder, cognitive intact (i.e. had a score � 21/22 on theMini-Mental State Examination), and were membersof the older community centres, were recruited. A teamof 10 research nurses who had received training on datacollection were involved in collecting the data. Theyscreened the subject’s eligibility while the older people


Somatic presentation of depression in older Chinese 121

attended regular meetings of the centres by administer-ing the Mini-Mental State Examination. A total of 1433out of 1982 eligible older people participated in the study(72.3%). After obtaining written consent, the researchnurses conducted depression screening for all partici-pants and collected data about their socio-demographicprofile, medical health history and somatic symptomsthrough individual face-to-face interview. The studywas approved by the Survey and Behavioural EthicsCommittee of the Chinese University of Hong Kong.

Measures

Depression

Depression was screened using the five-item RandMental Health Inventory (Chinese version; MHI-5).This inventory is part of the 36-item Short Form (SF-36) Health Survey, which assesses how frequently therespondent experiences five particular mood states(Ware et al., 2000). The response set is a six-point scale.The raw score is transformed into a range of 0–100,with a higher score representing better mental health. Aprevious study showed that a cut-off point of 59/60gave the optimal sensitivity (78.7%) and specificity(72.1) to identify the presence of major depression incommunity-dwelling older people (Friedman et al.,2005). The MHI-5 is reliable (r¼ 0.83) and is in goodcorrelation with the Zung Self-rating Depression Scale(Yamazaki et al., 2005) and the General HealthQuestionnaire (Kelly et al., 2008).

Somatic symptoms and medical profile

Two exhaustive lists of somatic symptoms (in theprevious month) andmedical diseases relevant to olderpeople were developed by reviewing the literature andthe health statistics of older people in Hong Kong(Department of Health, HKSAR, 2004). The contentof the lists were endorsed by two academicians whohad expertise in geriatric nursing. Any participantconditions not included in the lists would bedocumented. Any identified somatic symptoms notrelated to a known medical pathology would beregarded as medically unexplained somatic symptoms.

Socio-demographic profile

Demographic data including age, gender, maritalstatus, education level and living arrangements were


also collected. The social profile focused on charac-teristics that have been found to be related to non-specific somatic symptoms, including perceived finan-cial strain, major stressful life events in the past6 months and social support (Okamoto & Tanaka,2004; Verhaak et al., 2006). Question for assessingperceived financial strain asked the participantswhether they had adequate money to cover dailyexpenses. A ‘1–5’ response set including ‘morethan enough,’ ‘enough,’ ‘just enough,’ ‘insufficient’and ‘very insufficient’ was used, with higher scoresrepresenting more perceived financial strain. Anexhaustive list of major life stressful events whichwere relevant to Chinese older people in HongKong (including death of spouse, close friend orother family members; discord with spouse or in-laws;serious illness or injury; changes in financial situation;hospitalization and moving) was developed fromliterature review for data collection. Social supportwas assessed by the 20-item Medical Outcomes StudySocial Support Survey (Chinese version; MOS-SSS-C)(Yu et al., 2004). The MOS-SSS-C measures theperceived adequacy of social support. The responseset is a 5-point Likert scale, with higher scoresrepresenting better perceived social support. Goodinternal consistency (Cronbach’s a¼ 0.98), test-retest reliability (r¼ 0.84) and construct validity wasreported (Yu et al., 2004).

Data analysis

The PASW was used for all statistical analyses.Descriptive statistics were used to summarize theMHI-5 score, medically unexplained somatic symp-toms and the medical and socio-demographic profilesof the participants. Binary logistic regression analysiswas used to examine the association of each non-specific somatic symptom with depression as well asthe socio-demographic and medical profile of olderpeople. An odds ratio with a 95% confidence intervalwas used to describe the strength of the association.Hierarchical logistic regression analysis was thenconducted to examine the independent relationshipbetween depression and each non-specific somaticsymptom after controlling for the related socio-demographic and medical profile variables. Hosmer-Lemeshow tests were used to test the data-model fit(Tabachnick and Fidell, 1996). The adjusted odds ratiowith a 95% confidence interval of having a particularnon-specific somatic symptom in depressed olderpeople in relation to their non-depressed counterpartswas computed. The same statistical procedures were



conducted to examine the independent relationshipbetween depression and the number of coexistingmedically unexplained somatic symptoms (i.e. two tosix symptoms or more). Criteria for entry and removalwere based on the likelihood ratio test with enter andremove limits set at p� 0.05 and p� 0.10, respectively(Tabachnick and Fidell, 1996). The level of significancewas set at 5%.

Results

Table 1 summarizes the socio-demographic andclinical profiles of the subjects. The sample had amean age of 75.6 (SD¼ 7.2) years and comprised72.8% women; fewer than 50% of participants had a

Table 1 Characteristics of the sample

Characteristics Values

Age 75.6�7.2Female gender 1043 (72.8%)With spouse 651 (45.4%)Living with family 978 (68.2%)Perceived adequacy of daily expenseMore than enough 33 (2.3%)Enough 507 (35.4%)Just enough 681 (47.5%)Insufficient 190 (13.3%)Very insufficient 22 (1.5%)

Number of major stressful life event 0.9� 1.1Serious illness/ injury 196 (13.7%)Discord with spouse 163 (11.4%)Discord with in-laws 75 (5.2%)Changes in financial situation 59 (4.1%)Stay in hospital 291 (20.3%)Moving house 73 (5.1%)Death of spouse 24 (1.7%)Death of other family members 173 (12.1%)Death of close friends 227 (15.8%)

Perceived social support(MOS-SSS-C score)

51.22� 23.84

Number of major chronic illness 2.0� 1.40 174 (12.1%)1-2 771 (53.8%)> /¼3 488 (34.1%)

Medically unexplainedsomatic symptomsLoss of appetite 249 (17.4%)Fatigue 697 (48.6%)Recurrent stomache 234 (16.3%)Recurrent headache 307 (21.4%)Dizziness 392 (27.4%)Insomnia 691 (48.2%)

Number of medicallyunexplained somatic symptoms1 352 (24.6%)2 290 (24.6%)3 210 (14.7%)4 129 (9%)5 72 (5%)6 22 (1.5%)


spouse. Fewer than 40% had enough money for dailyexpenses, and perceived social support was fair.Hospitalization and the death of close friends werethe more common stressful life events. Among theparticipants, 34.1% had more than three chronicillnesses. Over 50% reported more than two non-specific somatic symptoms, with fatigue and insomniaas the most common complaints. By using the MHI-5,16.5% of the older people were diagnosed as havingmajor depression.Table 2 shows the difference in the prevalence of

various medically unexplained somatic symptomsbetween the depressed and non-depressed participants.All symptoms were found to have a significantly higherprevalence among the depressed. In particular, fatigueand insomnia affected around 70% of the depressedparticipants.Table 3 lists the odds ratios of the associations

between each medically unexplained somatic symptomand depression adjusted for the socio-demographicand medical profile variables. Among these variables,participants who were female, perceived more financialstrain, experienced more recent stressful life events andhad more chronic illnesses had a significantly higherrisk of reporting medically unexplained somaticsymptoms (odds ratio¼ 1.045–1.751), whereas thepresence of a spouse, living with family, and bettersocial support demonstrated protective effects on mostsymptoms (odds ratio¼ 0.625–0.994). Compared withall these socio-demographic and medical variables,depression demonstrated a greater association with allmedically unexplained somatic symptoms. In a logisticregression model adjusted for the significant socio-demographic and medical confounders, the effect ofdepression in association with all unexplained somaticsymptoms remained significant (odds ratio: 1.667–2.268). In particular, participants with depression hadmore than twice the risk of experiencing loss of appetite,fatigue, gastro-intestinal problems and insomnia.Table 4 lists the odds ratios of the association

between the number of coexisting medically unex-plained somatic symptoms and depression. The oddsratio for depressed older participants reportingmultiple symptoms compared with the non-depressedincreased with the number of coexisting symptoms.After adjusting for the effects of significant socio-demographic and medical confounders, the oddsof reporting two to three coexisting medicallyunexplained symptoms was 2.5 times higher forparticipants with depression than for the non-depressed (OR¼ 2.58–26.4, p< 0.001). This odds ratioincreased to 4.52 (p< 0.001) for six coexistingsymptoms.


Table 2 Prevalence of medically unexplained somatic symptoms in depressed and non-depressed participants

Unexplainedsomatic symptoms

Depressed participants(MHI-5�59) (n¼236)

Non-depressed participants(MHI-5>59) (n¼1197)

Significance

Loss of appetite 78 (33.1%) 171 (14.3%) < 0.001Fatigue 171 (72.5%) 529 (44.2%) < 0.001Recurrent stomache 74 (31.4%) 160 (13.4%) < 0.001Recurrent headache 78 (33.1%) 229 (19.1%) < 0.001Dizziness 100 (42.4%) 292 (24.4%) < 0.001Insomnia 162 (68.6%) 529 (44.2%) < 0.001


Discussion

This study investigated the associations of depressionwith six medically unexplained somatic symptomsincluding loss of appetite, fatigue, insomnia, recurrentgastro-intestinal problems, recurrent headache anddizziness. The prevalence of all six medically unex-plained somatic symptoms among depressed olderChinese was significantly higher than among the non-depressed. Such findings were in line with thosereported for the Caucasian population in whomdepression was more prevalent among those reportedunexplained physical symptoms (Feder et al., 2001;Drayer et al., 2005; Menchetti et al., 2006). Inour study, depression also showed an independent

Table 3 Odd ratios of association between medically unexplained somatic sympand medical profile variables (N¼ 1433)

symp

Loss ofappetite

Fatigue Stom

Age 1.029**(1.010–1.049)

1.013(0.998–1.02)

0.(0.964

Female 1.029*(1.010–1.049)

1.196(0.947–1.511)

1.(0.959

Spouse 0.669**(0.505–0.886)

0.917(0.745–1.130)

0(0.595

Living with family 0.625**(0.471–0.829)

0.906(0.725–1.131)

0.6(0.491

Social support(MOS-SSS-C)

0.987**(0.981–0.993)

0.991***(0.987–0.996)

0.9(0.985

Perceived insufficientdaily expense

1.364**(1.143–1.628)

1.343***(1.170–1.541)

1.40(1.171

Number ofstressful life events

1.216***(1.080–1.368)

1.248***(1.125–1.384)

1.27(1.124

Number ofchronic illness

1.294**(1.175–1.425)

1.411***(1.301–1.529)

1.18(1.071

Depression 2.962***(2.161–4.06)

3.356***(2.467–4.564)

2.96(2.147

Depression(adjusted odd ratio)

2.264***(1.628–3.187)

2.628***(1.396–3.642)

2.37(1.671

*p< 0.05.

**p< 0.01.

***p< 0.001.


relationship with all six symptoms after adjustingfor the effects of the socio-demographic and medicalcharacteristics of older Chinese. Because all sixsymptoms had stronger associations with depressionthan with the number of chronic illnesses, the presenceof the medically unexplained somatic symptomswas quite likely attributable to depression. Suchsymptommanifestation may be a form of somatizationof depression among older Chinese. Similar to thosereported for South Asians and Malaysians, Chineseolder people with depression may be more likely toreport somatic symptoms rather than verbalize theirnegative emotional experience (Bhugar and Mastro-gianni, 2004). Indeed, the strong association betweendepression and somatic symptoms as identified in the

toms and depression after adjusting for the effects of socio-demographic

Non-specific somatictoms (odd ratios/95%CI)

ache Headache Dizziness Insomnia

983–1.003)

0.978(0.961–1.00)

1.012(0.996–1.029)

1.007(0.993–1.022)

335–1.859)

1.751***(1.282–2.391)

1.385*(1.055–1.817)

1.603***(1.265–2.030)

.79–1.051)

0.811(0.628–1.047)

0.708**(0.559–0.897)

0.697***(0.565–0.859)

56**–0.876)

0.749*(0.575–0.976)

0.745*(0.582–0.952)

0.719**(0.575–0.898)

91**–0.997)

0.994*(0.989–0.999)

0.994*(0.989–0.999)

0.989***(0.985–0.993)

2***–1.681)

1.284**(1.090–1.513)

1.223**(1.051–1.423)

1.314***(1.145–1.508)

1***–1.438)

1.10(0.989–1.223)

1.255***(1.127–1.399)

1.123*(1.018–1.239)

2***–1.305)

1.249***(1.142–1.366)

1.346***(1.237–1.466)

1.347***(1.244–1.458)

1***–4.083)

2.087***(1.535–2.837)

2.279***(1.705–3.045)

2.764***(2.053–3.723)

0***–3.351)

1.667**(1.194–2.328)

1.683***(1.297–2.183)

2.138***(1.559–2.932)


Table 4 Odd ratios of association between number of medically unexplained somatic symptoms and depression, after adjusting for the effects of socio-demographic and medical profile variables (N¼ 1433)

Number of non-specific somatic symptoms (odd ratios/95%CI)

�2 �3 � 4 � 5 �6

Age 1.012(0.998–1.027)

1.006(0.99–1.022)

0.996(0.977–1.016)

1.002(0.973–1.031)

1.030(0.971–1.011)

Female 1.461*(1.156–1.840)

1.385(1.065–1.80)

1.928***(1.335–2.783)

2.231**(1.249–3.986)

2.394(0.704–8.134)

Spouse 0.750*(0.609–0.924)

0.688***(0.547–0.865)

0.655**(0.488–0.880)

0.731(0.476–1.123)

0.683(0.285–1.637)

Living with family 0.768*(0.614–0.96)

0.654***(0.516–0.829)

0.571***(0.426–0.765)

0.579*(0.379–0.884)

0.668(0.283–1.573)

Social support (MOS-SSS-C) 0.988***(0.983–0.992)

0.989***(0.984–0.994)

0.987***(0.981–0.993)

0.991*(0.982–1.00)

0.991(0.974–1.009)

Perceived insufficientdaily expense

1.449***(1.260–1.666)

1.432***(1.234–1.662)

1.477***(1.228–1.777)

1.575***(1.209–2.053)

2.259**(1.352–3.774)

Number of stressful life events 3.428***(2.482–4.735)

1.276***(1.147–1.420)

1.409***(1.273–1.559)

1.131(0.977–1.309)

1.133(0.883–1.454)

Number of chronic illness 1.455***(1.341–1.579)

1.507***(1.383–1.642)

1.409***(1.273–1.559)

1.334***(1.157–1.538)

1.424*(1.080–1.878)

Depression 3.770***(2.741–5.861)

3.466**(2.601–4.619)

4.096***(2.974–5.641)

4.767***(3.088–7.359)

6.539***(2.714–14.893)

Depression(adjusted odd ratio)

2.646***(1.884–3.717)

2.582***(1.887–3.533)

3.158***(2.229–4.474)

3.921***(2.439–6.302)

4.521***(1.872–10.917)

*p< 0.05.

**p< 0.01.

***p< 0.001.


current Chinese older sample has also been reportedfor the South Asians (Soh et al., 2009).Another typical feature of somatization of depres-

sion in older Chinese is multiple symptoms. Comparedwith non-depressed older Chinese, the depressed weremore than twice as likely to report two to threecoexisting symptoms and almost five times more likelyto report five to six such symptoms. Earlier studieshave identified similar findings for the Caucasian adultpopulation. Depressed older people are three timesmore likely to complain of more than three coexistingunexplained symptoms than are the non-depressed(Simon et al., 1999). Another study also found that thelikelihood of a mood disorder increased with thenumber of somatic symptoms in the adult population(Kroenke et al., 1994). Presenting with multiplesymptoms appears to be an important and universalfeature in signalling the presence of depression amongpeople of different ethnicity and age groups.Among the six unexplained somatic symptoms,

fatigue affected more than 70% of the depressed olderChinese and demonstrated the greatest independentassociation with depression. But this somatic experi-ence has received the least attention in previous studiesinvestigating the somatization of depression indifferent populations (Da Canhota and Piterman,2001; Feder et al., 2001; Drayer et al., 2005; Menchettiet al., 2006; Soh et al., 2009). The reason may be that,


unlike other somatic symptoms, fatigue is a hetero-geneous phenomenon involving a combination ofphysiological, physical and psychosocial manifes-tations (Yu et al., 2010). But by defining fatigue asa purely somatic experience, characterized by thepresence of muscle pain or tired muscles after activity,the need to sleep longer, poor sleep and prolongedtiredness after activity, older people with psychologicaldisorders were found to have eight times the risk ofhaving fatigue (Wijeratne et al., 2007). Fatigue alsodemonstrated a greater relationship with concomitantdepression than with disease severity in patients withchronic illnesses (Wijeratne et al., 2007). As a result,health care professionals need to be more aware of thefatigue experience of older people. This is especiallytrue since the vague nature of fatigue may hinder themfrom making a complaint or they may just consider itas a normal consequence of aging (Yu et al., 2010).Extra attention needs to be given to identifying theunderlying etiology and possible psychological ante-cedents.Depression is associated with very detrimental

health consequences in older people (Chan et al.,2009; Chuan et al., 2008). Early detection and prompttreatment of this mental health problem are highlyprioritized agendas in gerontological care. Health careprofessionals need to pay more attention to the patternof somatization as identified in the current study for


Key Points

� Older Chinese with depression weremore likely tohave multiple medically unexplained somaticsymptoms.

� Fatigue is the somatic symptom demonstratinggreatest independent association with depressionamong older Chinese people.

� Health care professionals need to pay moreattention to the pattern of somatization amongChinese older people and take active steps to ruleout any underlying psychological etiology.


older Chinese. Those who report multiple unexplainedsomatic symptoms, particularly fatigue, insomnia andgastro-intestinal problems, must be given attention.Our findings support use of the ‘exclusion diagnosticapproach’ to rule out depression among older people.This approach advocates the importance of ruling outsymptoms of depression once patients have presentedwith somatic symptoms not readily explained by theknown pathology (Mulsant & Ganguli, 1999). Thismethod could prevent wasted time for medicalworkups and delayed treatment for late-life depression.Indeed, because Chinese cultural values may hinderolder Chinese from disclosing their emotions (Klein-man, 1986; Kirmayer, 2001), more proactive methodscould be used to screen for depression among olderpeople who manifest possible patterns of somatization.This could be done by encouraging them to describetheir general mood state and then asking more specificquestions to screen for other psychological andcognitive symptoms of depression. Indeed, a numberof brief screening tools for depression such as the five-item geriatric depression scale (Weeks et al., 2004) andfive-item mental health inventory (Ware et al., 2000)are valid and sensitive for pursuing the same purpose.According to the literacy level of older people, the pen-and-pencil method could be used to complete thesescales to avoid causing embarrassment to older peoplewhile disclosing their emotions. Even in face-to-faceadministration, the brief closed-ended questions inthese scales would be easy for older Chinese, whogenerally have a limited vocabulary to describe theiremotions (Kleinman, 1986), to respond to.Several methodological issues are worth considering

in interpreting the findings of this study. First, thestudy used dichotomous questions to elicit thepresence of somatic symptoms among older Chinese.Information about symptom severity was not con-sidered in identifying the symptoms most associatedwith depression. Second, the use of a cross-sectionalstudy design gave no information about whether thesomatic symptoms were antecedents or consequencesof depression among older Chinese. The study cannotpreclude the chance that it was the medicallyunexplained somatic symptoms that caused thedepression. Although this study controlled for theconfounding effects of medical and socio-demographiccharacteristics on somatic symptoms, older peoplewith depression commonly have concomitant anxiety(Beekman et al., 2000). The influence of the latterpsychological problem on the presentation of somaticsymptoms cannot be precluded. Finally, the over-representation of female participants in the samplemay also limit the generalizability of the study findings.


This study adds evidence to suggest that depressionamong older Chinese presents somatically. Multiplesymptoms, particularly medically unexplained fatigue,insomnia and gastro-intestinal problems, may link to apositive screen for depression. Although age-relatedphysical changes may cause more somatic discomfortin older people, health care professionals need to beaware of possible somatization among this cohort ofthe population and take more active steps to assess thepsychological health of suspected cases.

Conflict of interest

None declared.

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do medically unexplained somatic symptoms predict depression in older chinese?

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