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Year : 2022  |  Volume : 38  |  Issue : 1  |  Page : 69-72

Gender differences in somatic symptoms in patients with depression: A comparative study at tertiary care center in North India

Department of Psychiatry, JLN Medical College, Ajmer, Rajasthan, India

Date of Submission02-Jun-2020
Date of Decision29-Jun-2020
Date of Acceptance08-Jul-2020
Date of Web Publication08-Sep-2021

Correspondence Address:
Dr. Parth Singh Meena
5, Department of Psychiatry, JLN Medical College, Ajmer, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijsp.ijsp_140_20

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Introduction: Women suffering from clinical depression often present with prominent somatic complaints. Epidemiological studies have found that the prevalence of somatic depression, but not pure depression, distinguished women from men. The purpose of the study is to evaluate whether somatic symptoms of depression are more prevalent in females than in males. Subjects and Methods: A cross-sectional analytic study was carried out at a tertiary level referral hospital attached to a medical college in Rajasthan by the department of psychiatry. Consecutive patients (both male and female) suffering from depression were recruited for the study, diagnosed as per the International Classification of Diseases-10. Eighty-two male and 86 female adult psychiatric outpatients with diagnosis of depressive disorder were assessed using Hamilton Depression Rating Scale (HDRS-17) and Somatic Symptom Scale-Adult (derived from Patient Health Questionnaire Physical Symptoms) to quantify the severity of depression and somatic symptoms, respectively, and compared. Data collected from the patients were analyzed using unpaired t-test and Fisher's exact test. 95% confidence interval and P ≤ 0.05 were used to indicate a significant difference between the groups. Results: No statistically significant difference was found in the severity of depression between male and female patients. Somatic symptom scores were higher in female patients, both on somatic symptom score and HAM-D. Conclusions: Higher prevalence of somatic depression was found in female patients suffering from depression.

Keywords: Depression, gender, somatic depression

How to cite this article:
Meena PS, Sharma A, Jain M. Gender differences in somatic symptoms in patients with depression: A comparative study at tertiary care center in North India. Indian J Soc Psychiatry 2022;38:69-72

How to cite this URL:
Meena PS, Sharma A, Jain M. Gender differences in somatic symptoms in patients with depression: A comparative study at tertiary care center in North India. Indian J Soc Psychiatry [serial online] 2022 [cited 2022 Aug 18];38:69-72. Available from: https://www.indjsp.org/text.asp?2022/38/1/69/325752

  Introduction Top

Somatic symptoms essentially characterize the clinical states of depression. This well-known psychopathological knowledge has not been appreciated sufficiently by the official diagnostic system of the International Classification of Diseases-10 (ICD-10) Classification of Mental and Behavioral Disorders.[1] This unmet diagnostic need is deplorable, as the main mode of presenting a depression is by reporting somatic symptoms. “Somatic symptoms” consist of various bodily sensations that a depressed person perceives as unpleasant or worrisome. Several basic physical dysfunctions, such as those of sleep, appetite, or digestion, are also to be included in the term “somatic.” From a diagnostic point of view, somatic symptoms play a significant role both in primary psychiatric disorders like depression and anxiety disorders and in somatoform disorders as well as underlying somatic diseases like musculoskeletal and connective tissue disorders. More than two-third of patients suffering from depression present with somatic symptoms.[2],[3] When somatic symptoms, particularly painful physical symptoms accompany the already debilitating psychiatric symptoms of depression, the course of the illness may be more severe translating into a higher risk of early relapse, chronicity, or suicide.[1]

Although clinically depressed women generally endorse higher levels of depression than men,[4],[5],[6] review of data from large epidemiological studies found that the prevalence of somatic depression, but not pure depression, distinguished women from men. Silverstein defined somatic depression as sleep disturbance, fatigue, and appetite disturbance for at least 2 weeks and pure depression as high levels of depression not associated with these other symptoms.[5] Using data from the National Comorbidity Survey, the study found that women reported twice the prevalence of somatic depression as compared to men.[5] In addition to these studies of interviewer obtained ratings of symptoms, another study used the Centre for Epidemiologic Studies Depression Scale (CES-D)[7] and found that somatic depression was higher in female than among male high school[8] and college students.[9] These studies provide evidence for gender differences in the expression of depression and the possibility that somatic depression might be a diagnostic category separate from major depression.[7] A study using the updated BDI-II found that a female-to-male ratio of somatic symptoms was approximately 2:1 in psychiatric outpatients diagnosed with major depressive disorder.[10] Very few studies from India have focused on somatic symptoms in patients with depression,[11],[12] although there are few studies which have focused on the prevalence of functional somatic symptoms in outpatients in general.[13],[14],[15],[16] An IPS multicentric study .aimed at understanding the typology of somatic symptoms in first-episode depression compared to the gender difference in prevalence and frequency of somatic symptoms.[17] Hence, it is important to replicate and extend these findings in an independent research using established measures of depression and using samples of clinical relevance.

  Subjects and Methods Top

The current study employed a cross-sectional-analytical study design, conducted at a tertiary level referral hospital attached to a medical college in Rajasthan, India. After getting approval from the ethics committee, psychiatry outpatients were screened for the diagnosis of depression using Depression Subsection of Mini International Neuropsychiatric Interview. The diagnosis was confirmed using diagnostic guidelines of ICD-10. Patients suffering from clinical depression as defined as having HDRS17 scores above 13 and willing to participate in the study were included in the study. Patients suffering from bipolar depression and psychotic depression and those having other comorbid psychiatric illnesses such as Obsessive Compulsive Disorder (OCD), panic disorder, Post traumatic Stress Disorder (PTSD), and serious substance abuse were excluded from the study. Patients suffering from any disorder contributing directly to painful conditions such as disorders of the musculoskeletal system, neurological disorders, connective tissue disorders, and medical conditions such as peptic ulcer disease, recurrent renal colic, and pyrexia were also excluded from the study.

Two hundred male and 200 female consecutive patients were screened out, of which 94 males and 112 females fulfilled criteria for depression. Eighty two male and 86 female patients who provided written consent were included in the study and were assessed by the trained clinical psychologist using the 17 items version of Hamilton Depression Rating Scale (HDRS17) and Somatic Symptom Scale (SSS)-Adult (derived from Patient Health Questionnaire Physical Symptoms [PHQ-15]) to measure the severity of depression and somatic symptoms, respectively. The Hamilton Depression Rating Scale is the most widely used clinician-administered depression assessment scale. Items 12 and 13 of HDRS17 represent somatic symptoms of depression. Ratings on both the items were specifically compared. Score ≥1 was considered to be indicative of somatic symptoms. Item 12 is related to the gastrointestinal system, i.e., loss of appetite, heavy feeling in the abdomen, and constipation, while Item 13 represents general somatic symptoms such as heaviness in the limbs, back or head, diffuse backache, loss of energy, and fatigability. SSS-Adult measure is an adaptation of the PHQ-15 that assesses the domain of somatic symptoms. Each item requires the individual (or informant) to rate the severity of the individual's somatic symptom during the past 7 days. Each item is rated on a 3-point Likert scale (0 = not bothered at all; 1 = bothered a little; and 2 = bothered a lot). The total score can range from 0 to 30, with higher scores indicating greater severity of somatic symptoms. Unpaired t-test and Fisher's exact test were used to analyze the data. Confidence interval 95% and P ≤ 0.05 indicated a statistically significant difference between the groups.

  Results Top

The mean age of male and female patients was 31.2 (standard deviation [S.D.] = 8.71) and 29.8 (S.D. = 7.27) years, respectively, and the difference was not statistically significant.

The mean HDRS17 score of males and female patients was 20.3 (S. D. = 7.23) and 19.6 (S. D. = 5.43), respectively. No difference was found between the severity of depression (t = 0.71, P = 0.47) [Table 1]. The mean SSS score of female patients (11.40) (S.D. = 3.29) was significantly higher than that of male patients (9.57) (S.D. = 3.45), (t = 3.52, P = 0.0005,) [Table 1]. Items 12 and 13 on HDRS17 represent somatic symptoms. About 37.8% (n = 13) of the male patients reported gastrointestinal symptoms and 40.24% (n = 33) reported general somatic symptoms, while 60.4% (n = 52) of the female patients complained of gastrointestinal symptoms and 56.9% (n = 49) reported general somatic complaints [Table 2]. Chi-square analysis of data obtained from responses on item 12 and 13 of HDRS-17 indicates that female depressed patients reported more somatic symptoms as compared to male patients and the difference was statistically significant (χ2 = 8.62, P = 0.003, for Item 12 and P = 0.04, χ2 = 4.05 for Item 13). No correlation between HDRS17 score and somatic symptoms score in male patients (r = 0.11) [Chart 1] was found, while HDRS17 scores and SSS scores of female patients showed weak correlation (r = 0.39) [Chart 2].
Table 1: Comparison of age, Hamilton Depression Rating Scale 17, and Somatic Symptom Scale scores of male and female patients

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Table 2: Somatic symptoms in male and female patients on Items 12 and 13 of Hamilton Depression Rating Scale

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  Discussion Top

The current study investigates the presence of somatic symptoms among depressed patients and whether there are gender differences in frequency and type of somatic symptoms.

The study included 168 patients of both genders suffering from depression. The groups were matched for age. A comparison of mean HDRS17 scores showed that there was no statistically significant difference in the severity of depression between the groups. Previous studies also have reported that although the overall prevalence of depression is higher in females, there is no remarkable difference in the severity of depression.[5],[16],[18]

Somatic symptoms were compared both on SSS and item 12 and 13 of HDRS17. Data analysis of scores of both the scales revealed that somatic symptoms were more prevalent in females. No correlation was observed between the severity of depression and severity of somatic symptoms among male patients, while the weak correlation was noted in case of female patients. As no gender difference was found in the severity of depression, any attribution of severity of depressive symptomatology to somatic symptoms was effectively ruled out. Female gender has been confirmed to be closely associated with somatization in many studies.[19] In a gender differential analysis of the epidemiological data of the National Comorbidity Survey, Silverstein by dividing the patients into those who met overall criteria for major depression and exhibited fatigue, appetite, and sleep disturbances (”somatic depression”) and those who met overall criteria without these somatic symptoms (”pure depression”) demonstrated gender differences only for “somatic depression” but not for “pure depression.” The higher prevalence of “somatic depression” in females was strongly associated with a high frequency of anxiety disorders. This type of “somatic depression” among female patients had its onset during early adolescence with predominantly bodily pains and aches. Wenzel et al. attributed the higher prevalence of “somatic depression” in women largely to changes in appetite.[10]

Two studies have explained the higher prevalence of somatic depression in females to reason they face in attempting to achieve occupational success.[8],[20] The results from their studies provide correlational evidence, suggesting that somatic depression is especially prevalent in women who believe that their or their mothers' accomplishments were limited because of being female. Although this pattern of results was replicated in several samples, the mechanism by which gender discrimination results specifically in somatic symptoms, rather than other depressive symptoms, remains unclear.

Psychosocial factors might account for gender differences in somatic depression, as it is possible that results could reflect gender differences in the expression of distress that has arisen through different socialization processes in men and women.[10] In both male and female, reasons for fluctuations in both mood and appetite are changes in neurotransmitter levels, such as serotonin.[21]

However, such fluctuations may be exacerbated by changes in the balance between estrogen and progesterone levels that a woman experiences at different stages of her menstrual cycle.[22] Fluctuations in hormones may account both for increases in somatic symptoms as well as perceptions of gender inequality as reported by a subset of females in the studies. It will be important to measure these biological factors in the context of these psychosocial factors; for example, Wenzel et al. attributed the higher prevalence of “somatic depression” in women largely to changes in appetite.[10] Other psychosocial factors may also play a significant role in increased frequency of somatic symptoms among females, for example, conservative societies where emotional problems are not considered as “illness” per se, and somatic symptoms such as pain and gastrointestinal upset are often seen as “hallmarks” of illness, females may find it easier to express depressive symptoms with somatic symptoms to validate their emotional and behavioral problems.

A small sample size was a limitation of this study. Although the samples were matched for age and severity of depression, they were not matched for other important covariates such as duration of index episode and the number of previous episodes.

In spite of these limitations, the results from this study have theoretical and practical implications. Depression with somatic complaints has been shown to respond less well than pure depression to antidepressant medication.[23] Gender differences in prevalence, association with gender roles and maternal depression as well as different responses to antidepressants in depression with somatic symptoms highlight the need to consider depression with and without somatic symptoms as distinct clinical entities to be treated differently.


We would like to express our special thanks of gratitude to all the patients who participated in the study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Kapfhammer HP. Somatic symptoms in depression. Dialogues Clin Neurosci 2006;8:227-39.  Back to cited text no. 1
Hamilton M. Frequency of symptoms in melancholia (depressive illness) Br J Psychiatry 1989;154:201-6.  Back to cited text no. 2
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Bebbington PE. Sex and depression. Psychol Med 1998;28:1-8.  Back to cited text no. 4
Silverstein B. Gender difference in the prevalence of clinical depression: The role played by depression associated with somatic symptoms. Am J Psychiatry 1999;156:480-2.  Back to cited text no. 5
Silverstein B. Gender differences in the prevalence of somatic versus pure depression: A replication. Am J Psychiatry 2002;159:1051-2.  Back to cited text no. 6
Radloff LS. The CES-D Scale: A self-report depression scale for research in the general population. Applied Psychol Measurement 1977;1:385-401.  Back to cited text no. 7
Silverstein B, Caceres J, Perdue L, Cimarolli V. Gender differences in depressive symptomatology: The role played by banxious somatic depressionQ associated with gender-related achievement concerns. Sex Roles 1995;33:621-36.  Back to cited text no. 8
Silverstein B, Clauson J, Perdue L, Carpman S, Cimarolli V. The association between female college students' reports of depression and their perceptions of parental attitudes regarding gender. J Applied Soc Psychol 1998;28:537-49.  Back to cited text no. 9
Wenzel A, Steer RA, Beck AT. Are there any gender differences in frequency of self-reported somatic symptoms of depression? J Affect Disord 2005;89:177-81.  Back to cited text no. 10
Chakraborty K, Avasthi A, Kumar S, Grover S. Psychological and clinical correlates of functional somatic complaints in depression. Int J Soc Psychiatry 2012;58:87-95.  Back to cited text no. 11
Grover S, Kumar V, Chakrabarti S, Hollikatti P, Singh P, Tyagi S, et al. Prevalence and type of functional somatic symptoms in patients with first episode depression. East Asian Arch Psychiatry 2012;22:146-53.  Back to cited text no. 12
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Parker G, Fletcher K, Paterson A, Anderson J, Hong M. Gender differences in depression severity and symptoms across depressive sub-types. J Affect Disord 2014;167:351-7.  Back to cited text no. 18
Kapfhammer HP. Gender differential perspective on somatoform disorders. Psychiatr Psychothérapie 2005;1:21-32.  Back to cited text no. 19
Silverstein B, Blumenthal E. Depression mixed with anxiety, somatization, and disordered eating: Relationship with gender-role-related limitations experienced by females. Sex Roles 1997;36:706-25.  Back to cited text no. 20
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  [Table 1], [Table 2]


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