Patients who have depression may visit your practice and never say that they are feeling depressed.

Typically, patients are more likely to respond with their physical symptoms when responding to the question, “What brings you here today?” In practice, these patients may share symptoms like:

• I’ve had this reoccurring backache, but have not had an injury.
• Why do I have diarrhea? I’ve not changed my diet.
• My neck and shoulders are constantly bothering me. Maybe it is why I’m not sleeping well?

As a healthcare provider, it’s essential to uncover the root of these symptoms and determine if the patient’s complaint has a physical – or mental — cause.

In his Physicians Postgraduates Press, Inc. article, “The Link Between Depression and Physical Symptoms,” Madhukar H. Trivedi, M.D. explains, “Physical symptoms are common in depression, and, in fact, vague aches and pains are often the presenting symptoms of depression.”

Trivedi goes on to add that symptoms of depression-related pain and other symptoms can include:

• Aching joints and limbs
• Back pain
• Gastrointestinal pain or distress
• Insomnia
• Poor appetite, or other changes in eating habits

According to Psychology Today: “In a study of over 25,000 patients at 15 primary care centers on five continents, Seattle researchers found that 50% of all depressed patients worldwide report multiple unexplained physical symptoms. It wasn’t that such patients were any less willing or able to express emotional distress. They readily acknowledged depressed mood when specifically asked about it.”

How depression presents itself differs from patient to patient based on numerous factors, which can include three potential sources: a patient’s unique genetic makeup, a recognized depression-related trigger, or for a reason that’s not understood (called idiopathic depression).

Why Depression & Pain are Linked

Why do depression and pain frequently present together? According to the University of Michigan Depression Center:

“Depression and chronic pain share some of the same neurotransmitters … as well as some of the same nerve pathways. Depression magnifies pain, changing the brain’s sensitivity to painful stimuli and reducing a person’s coping skills. And the constant stress of experiencing chronic pain can lead to a cascade of other medical problems linked with depression, making it still more difficult to break the cycle.”

While pain and depression may be intrinsically linked, it’s not always clear that a patient presenting with physical symptoms may be experiencing depression. In the article “Does a Depression Intervention Result in Improved Outcomes for Patients Presenting with Physical Symptoms?” published in The Journal of General Internal Medicine, researchers studied 200 patients who were eventually diagnosed with depression. The study found that it could be difficult for doctors to discern when patients are dealing with depression when they originally come to the doctor for treatment of pain.

“If you have stomach pain and there’s an ulcer, that’s an explanation for it. But often, physical ills occur for no apparent reason — and depression could be a likely cause,” said one of the study’s author Robert D. Keeley, MD, of the University of Colorado Health Sciences Center, to WebMD. “Yet unless they are specifically screened for depression, it’s hard for some doctors to pick up that it may be depression, especially in the primary care setting.”

Screening for Depression

Practitioners should screen patients for depression when they complain about pain. According to psychologist Dr. Elizabeth O’Connor, PhD, screening patients for psychological, emotional, and social distress is a critical part of modern medical practice for depression and physical wellbeing.

A simple questionnaire can give insights into a patient’s background that might otherwise go unnoticed in the exam room. The American Psychological Association suggests using either the PHQ-9 or PHQ-2 in the primary care setting. Both tests are free and available in more than 30 languages.

Creating a Treatment Plan

Treatment plans can and should vary based on the individual patient. However, as the University of Michigan Depression Center points out, “medication is commonly employed to fight both depression and pain, since they share some of the same neurotransmitters.”

Therapy can also help some patients. According to Psycom, Cognitive Behavioral Therapy can help patients manage chronic pain by addressing “anxious or negative thinking patterns and teach[ing] coping skills that reduce symptoms of both pain and depression.” Additionally, physical therapy can provide muscle relaxation, stretching exercises and low-impact cardio that may help alleviate symptoms.

Finally, for some patients, healthcare practitioners may want to consider educating patients on how diet, stress management and healthy sleep habits can play an important part of a holistic treatment plan.

Depression and physical symptoms may be linked, but they don’t have to be debilitating for your patients.