Somatization and Depression

It is often seen in low to middle income countries (LMIC) that, as the living standard of the population improves, their health services have to adapt from the challenge of dealing with communicable illnesses (bowel infections like diarrhoeas, typhoid, hepatitis and amoebiasis, insect-borne diseases like malaria, dengue and chikungunya as well as droplet-borne ailments like pneumonia) to coping with chronic diseases like diabetes, heart disease and depression.

Depression is a condition that is common in the high income countries of the west. One reason for the under-diagnosis of depression in the LMIC is the stigma associated with this condition. People suffering from depression veer towards denial of their emotional problems in favour of focusing on perceived physical illness. Many patients with depression and anxiety who present to GPs complain of bodily symptoms rather than volunteering psychological symptoms. Referred to as Somatization – which is the transfer of a feeling of Unease or “Dis-Ease” of the Mind to a physical ailment of the body – this phenomenon significantly reduces the likelihood of doctors recognising depression or anxiety in these patients.

In Chinese culture, for example, the word ‘Depression’ is not in common usage and it is usual for people to complain of physical symptoms such as fatigue, headache, dizziness and pain rather than “feeling low”.

Stigmatisation of mental illness is also common in other societies. A 2004 cross-sectional research study by Ozmen, Ogel and Aker to ascertain public perceptions of depression in Istanbul, Turkey reported that a diagnosis of depression was viewed negatively – and that depressed people were viewed as ‘dangerous’. It is not unreasonable to assume that in such societies, depression is under-reported for fear of social exclusion. Even in the same country, people from different socio-economic groups may have a very different concept of depression. A 2005 study by Karasz in New York found that immigrants from European countries had a more biological and medical explanation of the symptoms of depression compared to migrants from South Asia who viewed the symptoms of depression as a response to a difficult situation, which they were likely to refer to this as “tension”.

Somatization is now recognised as a common problem in primary health care; it leads to frequent use of medical services by these patients and to frustration in both the patient and the doctor. Because their mental distress remains unrecognized and untreated, patients with somatisation are subject to long and costly investigations.

When we consult a doctor, the symptoms that we present are affected by our culture and upbringing – we all are very selective regarding what we tell the doctor! We tend to describe symptoms which we believe are relevant and culturally acceptable. Somatization is sometimes called an “idiom of distress” in cultures where psychiatric problems are associated with stigma and the expression of emotional and psychological distress is inhibited.

We need to accept that Depression is a disease, just as high blood pressure, asthma, pneumonia and dengue fever are diseases. They are all diseases that can be treated – sometimes with complete remission and at other times with therapy and/or medication that can control the disease so that the afflicted patient can lead a functionally normal life.