Content of this journal is licensed under a Abstract
Background:
Major depressive disorder (MDD) is a serious mental disorder that is common worldwide and is associated with somatic symptoms. Cognitive and behavioral problems caused by depression can negatively affect problem-solving skills, and somatic symptoms related to depression can intensify this effect. Although the relationship between depression and problem-solving skills has been investigated in the literature, the mediating role of somatic symptoms in this relationship has not been sufficiently examined. This study aims to investigate the effect of somatic symptoms on problem-solving skills in patients with depression.
Methods:
This study included 200 patients diagnosed with MDD according to Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria who applied to the psychiatry outpatient clinic of Recep Tayyip Erdogan University Training and Research Hospital between March 2021 and March 2022. The sociodemographic data form, Structured Clinical Interview for DSM-5 Disorders Clinician Version, Hamilton Depression Rating Scale, Beck Depression Inventory, Problem Solving Inventory, and Somatosensory Amplification Scale were administered to the participants. The obtained data were analyzed using the SPSS v26.0 program.
Results:
Around 111 (55.5%) of the participants had somatic symptoms, and depression levels were found to be higher in this group. Somatic symptoms were more common in women and older individuals. Participants with somatic symptoms exhibited more hasty and avoidant approaches to problem-solving skills and used thoughtful, evaluative, planned, and self-confident approaches less. In addition, it was observed that problem-solving skills improved with increasing education levels. It was determined that somatic symptoms had a mediating role in the effect of depression on problem-solving skills.
Conclusion:
This study is the first in the literature to evaluate the relationship between somatic symptoms and problem-solving skills in patients with depression. This study shows that somatic symptoms have a negative effect on problem-solving skills in depressed individuals. The presence of somatic symptoms leads to the use of less effective strategies in the problem-solving process, which can exacerbate the cognitive symptoms of depression. Approaches aimed at reducing somatic symptoms in treatment processes can strengthen the problem-solving skills of depressed individuals and improve treatment outcomes.
Main Points
Depression negatively affects individuals’ problem-solving skills.
Somatic symptoms are more common in women, the elderly, and individuals with low education levels.
Somatic symptoms play a partially mediating role in the relationship between depression and problem-solving skills.
Somatic symptoms cause individuals to adopt more hasty and avoidant approaches, while reducing the use of thoughtful, planned, and self-confident strategies.
Introduction
Major depressive disorder (MDD) is a common mental disorder affecting approximately 185 million people worldwide.1 The relationship between MDD and somatic symptoms has been a subject of research for many years. Epidemiological and clinical studies show a strong relationship between them.2 Somatic symptoms play an essential role in the clinical presentation and prognosis of MDD. These symptoms, including somatic complaints such as pain, gastrointestinal problems, and fatigue, are common in patients with MDD and are associated with higher clinical severity and poorer treatment outcomes. The presence of somatic symptoms in depression increases the risk of early relapse and suicide.3 Problem-solving skills are an essential requirement for an individual to live a healthy life and maintain their mental health. It is stated that there is a very close relationship between problem-solving skills and mental health.4 Deficits in problem-solving are a central feature of depression. Deficits in problem-solving skills are associated with increased depressive symptoms and suicidality, particularly in adolescents and young adults.5 It is thought that deficiencies in problem-solving skills have a mediating role between adverse life events and depression. In 1 study, it was found that individuals who were effective in problem solving under high-stress levels reported fewer depressive symptoms than individuals with the same stress level but ineffective problem-solving skills.6
The relationship between problem-solving skills and somatic symptoms in MDD patients is multifaceted. Research suggests that depressive symptom severity, including somatic symptoms, may mediate the relationship between poor problem-solving skills and outcomes such as suicidal ideation.7 This suggests that the presence of somatic symptoms may intensify the cognitive deficits associated with depression, thereby impairing problem-solving abilities.7 Additionally, somatic symptoms have been found to be inversely related to social cognition performance in patients with current MDD, supporting the idea that these symptoms may interfere with cognitive processes necessary for effective problem-solving.8 While it is known that depressive symptoms have negative effects on problem-solving processes, it is important to investigate the effects of somatic symptoms on individuals’ cognitive and behavioral functions. The aim of this study is to examine the effect of depression on individuals’ problem-solving skills and to determine whether somatic symptoms play a mediating role in this relationship. The study aims to contribute to the shaping of interventions in the field of mental health in this direction by revealing the importance of somatic symptoms in the interaction between depression and problem-solving skills.
Materials and Methods
Participants and Study Setting
The study included 224 consecutive patients who were diagnosed with MDD according to DSM-5 diagnostic criteria and who applied to the psychiatry outpatient clinic of Recep Tayyip Erdoğan University Training and Research Hospital with depressive complaints between March 2021 and March 2022 and who had not received any psychiatric treatment for the last 6 months. Of these, 200 patients who met the inclusion criteria and were included in the study. Inclusion criteria for the study included meeting the diagnosis of MDD, having no additional medical or neurological disease, not using psychotropic medications for at least 6 months, not having an alcohol or substance use disorder, being between the ages of 18 and 75, not having a condition that would prevent the interview or the application of the scale, and agreeing to participate in the study. All participants were informed about the study and their written consent was obtained. After being informed about the purpose and method of the study, the patients diagnosed with MDD who agreed to participate by filling out the informed consent form and met the inclusion criteria were administered the Sociodemographic Data Collection Form, Structured Clinical Interview for DSM-5 Disorders Clinician Version (SCID-5-CV), Hamilton Depression Rating Scale (HDRS), Beck Depression Inventory (BDI), Somatosensory Amplification Scale (SAS), and Problem-Solving Inventory (PSI). In this study, the psychiatric assessment of the participants was made using the Structured Clinical Interview for DSM-5 Disorders – Clinical Version (SCID-5-CV). In this process, only individuals diagnosed with MDD were included in the study. Psychiatric diagnoses other than depression (e.g., somatic symptom disorder, anxiety disorders, eating disorders, personality disorders) were systematically excluded. Using SCID-5-CV ensured that comorbid diagnoses were accurately assessed and excluded from the study. Only patients with newly diagnosed MDD were included in the study. The flow chart showing the sample selection is presented in Figure 1. Participants were classified into groups with and without somatic symptoms based on their scores from the somatic symptom-related items of the HDRS.
Figure 1.
Sample selection flow chart.
In order to examine the relationship between depression levels and PSI levels in the study, the minimum sample size required was calculated. The sample size calculation was performed using G*Power software (V. 3.1.9.2). In the power analysis, an α-error level of 0.05, 95% power (1-β), and an effect size of 0.33 (Cohen’s d) were taken into account to reach statistical significance. In line with these parameters, it was determined that the minimum sample size was N = 104 to detect the difference between the groups. The accepted effect size was based on a previous study by Fırıncık and Gürhan.9
Ethical Approval
Before starting the study, all participants were informed about the study procedures and their written consent was obtained. Ethics committee approval for the study was obtained from the Recep Tayyip Erdoğan University Non-Interventional Ethics Committee (Ethics Committee Decision Approval Date: February 25, 2021; Decision No.: 2021/38).
Data Collection Tools
Depression levels were assessed using BDI10 and HDRS.11 These scales have been shown to be valid and reliable for the Turkish population.12,13 The HDRS includes items that assess emotional and cognitive symptoms of depression, as well as somatic symptoms such as sleep disturbances, appetite changes, fatigue, and somatic pain.11 Cronbach’s α results obtained from the data for the BDI and HDRS scales are 0.85 and 0.90, respectively.
The SAS is a 10-item scale developed by Barsky et al14, and its validity and reliability have been demonstrated. Participants rate each item from 1 (Not true at all) to 5 (Extremely true). The SAS assesses sensitivity to normal bodily sensations and neutral/noxious stimuli. It was adapted into Turkish by Güleç et al15, and the Turkish version of the SAS has good internal reliability with a Cronbach’s α of 0.80. Cronbach’s α results obtained from this data for the SAS are 0.90.
The PSI is a scale developed by Heppner and Petersen16 in 1982 that evaluates individuals’ problem-solving skills. It addresses problem definition, alternative generation, decision making, and evaluation. The Likert-type scale, consisting of 35 items with a score range of 1-6, is applied without any time limitation. Some items are not included in the scoring or are reverse-scored. The lowest score is 32, and the highest score is 192. A low score indicates high problem-solving skills. It has 6 sub-dimensions, and some represent positive and some negative behaviors. The Turkish adaptation of the scale was made by Şahin et al17 in 1993, and the Cronbach’s α coefficient was determined as 0.90. Cronbach’s α results obtained from this data for the PSI are 0.90.
Statistical Analysis
Data were analyzed using the SPSS v26 (IBM SPSS Corp.; Armonk, NY, USA) package software. Descriptive statistics were presented as frequency and percentage (n(%)), mean and SD. The Kolmogorov–Smirnov test was used to assess the normality of distribution for continuous variables. For categorical variables, comparisons were made using the chi-square test or Fisher’s exact test when expected cell counts were below acceptable thresholds. For continuous variables, group comparisons were performed using the independent samples t-test. Correlations between variables were evaluated using the Pearson correlation coefficient, reported with P-values in open format to 3 decimal places. Regression and mediation analyses were conducted to examine the relationships between depression, somatic symptoms, and problem-solving skills. Statistical significance was defined as P < .05.
Results
Demographic and Clinical Data
This study examined 200 patients diagnosed with MDD. While 111 (55.5%) of the patients showed somatic symptoms, 89 (44.5%) did not. The mean age was higher in the group with somatic symptoms (42.4 ± 12.8), and this difference was statistically significant (P < .001). 133 (66.5%) participants were female, and somatic symptoms were more common in women (P = .03). According to the level of education, somatic symptoms were found to be more common in those with lower levels of education (P = .012). However, no significant relationship was found between somatic symptoms and other demographic variables such as employment status, income level, and place of residence. These findings show that somatic symptoms are related to age, gender, and level of education (Table 1).
Table 1.
Comparison of Demographic Characteristics of Participants According to Somatic Symptoms
| Variable | With Somatic Symptoms 111 (55.5) | Without Somatic Symptoms 89 (44.5) | Total 200 (100) | Statistics | P | |
|---|---|---|---|---|---|---|
| n (%) | n (%) | n (%) | ||||
| Gender | Woman | 81 (73) | 52 (58.4) | 133 (66.5) | χ² = 4.691a | .03 |
| Man | 30 (27) | 37 (41.6) | 67 (33.5) | |||
| Marital status | Single | 40 (36) | 38 (42.7) | 78 (39) | χ² = 7.783b | .051 |
| Married | 63 (56.8) | 50 (56.2) | 113 (56.5) | |||
| Divorced | 6 (5.4) | 0 (0) | 6 (3) | |||
| Widow | 2 (1.8) | 1 (0.5) | 3 (1.5) | |||
| Education level | Illiterate | 0 (0) | 0 (0) | 0 (0) | χ² = 10.899a | .012 |
| Primary education | 37 (33.3) | 19 (21.3) | 56 (28) | |||
| Secondary Education | 12 (10.8) | 9 (10.1) | 21 (10.5) | |||
| High school | 35 (31.5) | 20 (22.5) | 55 (27.5) | |||
| University | 27 (24.3) | 41 (46.1) | 68 (34) | |||
| Employment status | Public | 11 (9.9) | 12 (13.5) | 23 (11.5) | χ² = 2.796a | .593 |
| Private | 11 (9.9) | 14 (15.7) | 25 (12.5) | |||
| Self-employed | 15 (13.5) | 9 (10.1) | 24 (12) | |||
| Retired | 3 (2.7) | 3 (3.4) | 6 (3) | |||
| Unemployed | 71 (64) | 51 (57.3) | 122 (61) | |||
| Income level | Low | 26 (23.4) | 11 (12.4) | 37 (18.5) | χ² = 4.527a | .21 |
| Medium | 38 (34.2) | 32 (36) | 70 (35) | |||
| High | 36 (32.4) | 33 (37.1) | 69 (34.5) | |||
| Very high | 11 (9.9) | 13 (14.6) | 24 (12) | |||
| Place living | Countryside | 29 (26.1) | 18 (20.2) | 47 (23.5) | χ² = 0.957a | .328 |
| City | 82 (73.9) | 71 (79.8) | 153 (76.5) |
n, number.
aChi-square test for the comparison between study groups.
bFisher-freeman-halton test for the comparison between study groups.
Significance of the value in bold P < .05.
Comparison of Hamilton Depression Rating Scale, Beck Depression Inventory, Somatosensory Amplification Scale, Problem-Solving Inventory, and Related Subscales According to Somatic Symptoms
The mean HDRS score in the group with somatic symptoms was 21.76 ± 8.27 and 15.49 ± 4.82 in the group without somatic symptoms. This difference is statistically significant (P < .001), which shows that individuals with somatic symptoms have higher depression levels. Regarding BDI scores, the mean of the group with somatic symptoms was 27.58 ± 9.22 and the mean of the group without somatic symptoms was 21.77 ± 8.39 (P < .001). This reveals that somatic symptoms have a strong relationship with depression symptoms. The SAS scores measuring the level of body perception were found to be 32.43 ± 7.13 in the group with somatic symptoms and 25.43 ± 5.82 in the group without somatic symptoms (P < .001). This shows that individuals with somatic symptoms have higher somatic sensations. The general PSI score was measured as 113.85 ± 22.55 in the group with somatic symptoms and 97.54 ± 20.57 in the group without somatic symptoms, and this difference is statistically significant (P < .001). This result suggests that somatic symptoms may hurt problem-solving skills. The mean of the Hasty Approach subscale scores was found to be 27.52 ± 7.61 in the group with somatic symptoms and 31.51 ± 8.25 in the group without, and a significant difference was observed (P < .001), indicating that somatic symptoms increase the tendency to make quick and hasty decisions. The mean scores of the Thinking Approach subscale were 16.53 ± 6.24 in the group with somatic symptoms and 13.01 ± 5.75 in the group without (P < .001), indicating that individuals with somatic symptoms have a weaker tendency to think. The mean scores of the Avoidant Approach subscale were 12.92 ± 4.74 in those with somatic symptoms and 14.92 ± 4.42 in those without, indicating a significant difference (P = .003). This result shows that individuals with somatic symptoms have a lower tendency to avoid. The mean scores of the Evaluative Approach subscale were 9.07 ± 4.61 in the group with somatic symptoms and 7.49 ± 4.09 in the group without somatic symptoms (P = .012), indicating that individuals with somatic symptoms have more difficulty in making evaluations. Self-Confident Approach subscale scores were found to be 21.03 ± 6.38 for those with somatic symptoms and 18.20 ± 5.83 for those without (P = .001), indicating that individuals with somatic symptoms have more difficulty with self-confidence. Planned Approach subscale scores were found to be 13.38 ± 5.36 for those with somatic symptoms and 11.35 ± 4.61 for those without, and this difference was significant (P = .005), indicating that those with somatic symptoms have an insufficient tendency to plan (Table 2).
Table 2.
Comparison of Age, Hamilton Depression Rating Scale, Beck Depression Inventory, Somatosensory Amplification Scale, Problem Solving Inventory, and Related Subscales According to Somatic Symptoms
| Variables | With Somatic Symptoms | Without Somatic Symptoms | Statistics | P |
|---|---|---|---|---|
| Mean (SD) | Mean (SD) | |||
| Age | 42.4 (12.8) | 34.8 (12) | t = 3.625 | <.001 a |
| HDRS | 21.76 (8.27) | 15.49 (4.82) | t = 6.687 | <.001 a |
| BDI | 27.58 (9.22) | 21.77 (8.39) | t = 5.588 | <.001 a |
| SAS | 32.43 (7.13) | 25.43 (5.82) | t = 7.467 | <.001 a |
| PSI | 113.85 (22.55) | 97.54 (20.57) | t = 5.282 | <.001 a |
| PSI/HA | 27.52 (7.61) | 31.51 (8.25) | t = −3.552 | <.001 a |
| PSI/TA | 16.53 (6.24) | 13.01 (5.75) | t = 4.106 | <.001 a |
| PSI/AA | 12.92 (4.74) | 14.92 (4.42) | t = −3.061 | .003 a |
| PSI/EA | 9.07 (4.61) | 7.49 (4.09) | t = 2.527 | .012 a |
| PSI/SA | 21.03 (6.38) | 18.20 (5.83) | t = 3.233 | .001 a |
| PSI/PA | 13.38 (5.36) | 11.35 (4.61) | t = 2.831 | .005 a |
AA, avoidant attitude; BDI, Beck Depression Inventory; EA, evaluative attitude; HA, hasty attitude; HDRS, Hamilton Depression Rating Scale; PA, planning attitude; PSI, Problem Solving Inventory; SA, self-confident attitude; SAS, Somatosensory Amplification Scale; TA, thinking attitude.
aStudent’s t-test for the comparison between study groups.
Correlation of Age, Hamilton Depression Rating Scale, Beck Depression Inventory, Somatosensory Amplification Scale, Problem Solving Inventory and Related Subscale
There is a significant positive correlation between age and bodily sensations (r = 0.196, P = .005), increases as age increases, exaggeration of bodily sensations increases. Age also significantly correlates with the total problem-solving skill score (r = 0.151, P = .033). A strong positive correlation exists between BDI and HDRS (r = 0.706, P < .001), indicating that depression levels are consistent with the 2 scales. There is a positive correlation between BDI and SAS (r = 0.358, P < .001), indicating that as depression level increases, exaggeration of bodily sensations increases. The BDI is also positively correlated with the total problem solving-skill score (PSI) (r = 0.491, P < .001), indicating that individuals with high depression levels may have difficulty in problem-solving skills. There is a significant positive correlation between HDRS scores and exaggeration of bodily sensations (r = 0.385, P < .001). In addition, HDRS scores are positively correlated with the total problem solving skill score (r = 0.401, P < .001). These results show that individuals with high levels of depression exaggerate bodily sensations more and may have more problems in problem-solving skills. A significant positive correlation was found between SAS scores and PSI (r = 0.467, P < .001). A negative correlation was found between hasty approach score and BDI (r = −0.307, P < .001) and HDRS (r = −0.328, P < .001). This suggests that individuals with high levels of depression make less hasty decisions. Considerate approach score was positively correlated with BDI (r = 0.347, P < .001), HDRS (r = 0.315, P < .001), and SAS (r = 0.372, P < .001). Avoidant approach score was negatively correlated with BDI (r = −0.245, P < .001), HDRS (r = −0.207, P < .001), and SAS (r = −0.240, P < .001). The evaluative approach score was significantly positively correlated with SAS (r = 0.261, P < .001). The confident approach score was positively correlated with BDI (r = 0.380, P < .001), HDRS (r = 0.309, P < .001), and SAS (r = 0.297, P < .001). The plan approach score was positively correlated with BDI (r = 0.377, P < .01), HDRS (r = 0.235, P < .001), and SAS (r = 0.321, P < .001) (Table 3).
Table 3.
Correlations (Pearson’s r) for Study Variables
| Variables | Age | BDI | HDRS | SAS | PSI | PSI/HA | PSI/TA | PSI/AA | PSI/EA | PSI/SA | PSI/PA | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Age | r | 1 | 0.094 | 0.119 | 0.196 | 0.151* | 0.010 | 0.111 | −0.103 | 0.164* | 0.001 | 0.102 |
| P | .184 | .094 | .005 | .033 | .893 | .119 | .145 | .020 | .986 | .153 | ||
| BDI | r | 1 | 0.706 | 0.358 | 0.491 | −0.307 | 0.347 | −0.245 | 0.117 | 0.380 | 0.377 | |
| P | <.001 | <.001 | <.001 | <.001 | <.001 | <.001 | .098 | <.001 | <.001 | |||
| HDRS | r | 1 | 0.385 | 0.401 | −0.328 | 0.315 | −0.207 | 0.127 | 0.309 | 0.235 | ||
| P | <.001 | <.001 | <.001 | <.001 | .003 | .072 | <.001 | .001 | ||||
| SAS | r | 1 | 0.467 | −0.248 | 0.372 | −0.240 | 0.261 | 0.297 | 0.321 | |||
| P | <.001 | <.001 | <.001 | .001 | <.001 | <.001 | <.001 | |||||
| PSI | r | 1 | −0.538 | 0.747 | −0.471 | 0.592 | 0.634 | 0.741 | ||||
| P | <.001 | <.001 | <.001 | <.001 | <.001 | <.001 | ||||||
| PSI/HA | r | 1 | −0.179* | 0.327 | −0.075 | −0.132 | −0.123 | |||||
| P | .011 | <.001 | .293 | .062 | .082 | |||||||
| PSI/TA | r | 1 | −0.125 | 0.526 | 0.495 | 0.683 | ||||||
| P | .078 | <.001 | <.001 | <.001 | ||||||||
| PSI/AA | r | 1 | −0.217 | −0.138 | −0.224 | |||||||
| P | .002 | .052 | .001 | |||||||||
| PSI/EA | r | 1 | 0.379 | 0.529 | ||||||||
| P | <.001 | <.001 | ||||||||||
| PSI/SA | r | 1 | 0.615 | |||||||||
| P | <.001 | |||||||||||
| PSI/PA | r | 1 | ||||||||||
| P | ||||||||||||
AA, avoidant attitude; BDI, Beck Depression Inventory; EA, evaluative attitude; HA, hasty attitude; HDRS, Hamilton Depression Rating Scale; PA, planning attitude; PSI, Problem Solving Inventory; SA, self-confident attitude; SAS, Somatosensory Amplification Scale; TA, thinking attitude.
Effect of Variables on Problem-Solving Skills
Table 4 shows a multiple regression analysis assessing the impact of depression and somatic perception levels on problem-solving skills. Age, HDRS, BDI, and SAS were used as independent variables in the model. The model shows that the independent variables have a significant effect on problem solving skills in total (F(4, 195) = 25.269, P < .001). The model's explanatory power is 32.8% (Adj. R2 = 0.328), which indicates that the independent variables explain approximately one-third of the variance in PSI. The Durbin–Watson value is 1.964, indicating that there is no autocorrelation. The BDI scores significantly affect problem-solving skills (b = 0.896, P < .001). This result shows that difficulty in problem-solving skills occurs as the depression level increases. SAS significantly affects on PSI scores (b = 0.999, P < .001). This situation shows that the level of body perception negatively affects problem-solving skills. According to the results of Table 4, the most potent effects on problem-solving skills come from the BDI and SAS variables. As BDI and SAS increase, problem-solving skills decrease. Table 5 shows the the mediation analysis results testing whether SAS plays a mediating role in the relationship between BDI and PSI. In the first stage, the direct effect of BDI on PSI was analyzed. The results show that BDI is significantly related to PSI (b = 1.226, t = 7.941, P < .001). This result shows that a high level of depression leads to a weakening of problem-solving skills. In the second stage, the effect of BDI on SAS was examined. The analysis results show that BDI has a significant and positive relationship with SAS (b = 0.287, t = 5.395, P < .001). This finding shows that the level of depression causes an increase in body perception. In the last stage, the effect of SAS on PSI was examined, and it was evaluated whether it played a mediating role in the relationship between BDI and PSI. The results show that SAS has a significant effect on PSI (b = 1.037, t = 5.375, P < .001) and plays a partial mediating role in the relationship between BDI and PSI (Figure 2). This indicates that while depression affects problem-solving skills, body perception also strengthens this effect.
Table 4.
Multiple Regression Analysis of Problem-Solving Inventory
| Variables | b | SE | β | t | P | 95% CI | Tolerance | VIF | |
|---|---|---|---|---|---|---|---|---|---|
| Lower | Upper | ||||||||
| Constant | 50.599 | 6.480 | 7.809 | <.001 | 37.819 | 63.379 | |||
| Age | 0.093 | 0.106 | 0.052 | 0.876 | .382 | −0.116 | 0.301 | 0.959 | 1.042 |
| HDRS | 0.054 | 0.254 | 0.018 | 0.214 | .831 | −0.447 | 0.556 | 0.481 | 2.079 |
| BDI | 0.896 | 0.206 | 0.359 | 40.337 | <.001 | 0.488 | 1.303 | 0.493 | 2.028 |
| SAS | 0.999 | 0.200 | 0.321 | 40.988 | <.001 | 0.604 | 1.394 | 0.815 | 1.228 |
F(4, 195) = 25.269; P < .001; Adj. R2: 0.328; Durbin–Watson = 1.964.
BDI, Beck Depression Inventory; HDRS, Hamilton Depression Rating Scale; PSI, Problem Solving Inventory; SAS, Somatosensory Amplification Scale.
Table 5.
Mediator role of Somatosensory Amplification Scale in the Relationship Between Beck Depression Inventory and Problem Solving Inventory
| Predicted variable | Predictor variable | R | R2 | Radj | B | SE | Beta | t | F | P |
|---|---|---|---|---|---|---|---|---|---|---|
| PSI | BDI | 0.491 | 0.242 | 0.238 | 1.226 | 0.154 | 0.491 | 7.941 | 63.063 | <.001 |
| SAS | BDI | 0.358 | 0.128 | 0.124 | 0.287 | 0.053 | 0.358 | 5.395 | 29.109 | <.001 |
| PSI | BDI | 0.582 | 0.339 | 0.332 | 0.928 | 0.155 | 0.372 | 5.996 | 50.422 | <.001 |
| PSI | SAS | 0.582 | 0.339 | 0.332 | 1.037 | 0.193 | 0.334 | 5.375 | 50.422 | <.001 |
BDI, Beck Depression Inventory; PSI, Problem Solving Inventory; SAS, Somatosensory Amplification Scale.
Figure 2.
Mediator model analysis diagram.
Discussion
In patients with MDD, somatic symptoms were more common in older age, in women, and in those with lower levels of education. Somatic symptoms tend to increase with age. Older adults generally report more somatic symptoms. The results of this study support previous studies.18-20 Studies have shown that women report higher levels of somatic symptoms.18,21,22 Depression has a significant impact on problem-solving skills. Depressive symptoms are associated with impairments in cognitive functions such as memory, reasoning, and cognitive flexibility, which impair problem-solving abilities.23 Depression, in particular, can lead to difficulties in generating practical solutions to problems in both social and interpersonal contexts.24,25 This study found a negative relationship between depression severity and problem-solving skills. The regression analysis results are discussed in more detail to highlight the relationship between depression severity and problem-solving skills. Details of the analyses (e.g., regression models) performed to assess whether the effect of somatic symptoms was independent of depression severity are described. Studies have shown that more severe depressive symptoms are associated with more significant deficits in cognitive domains critical to problem solving. For example, a meta-analysis found significant correlations between depression severity and deficits in episodic memory, executive function, and processing speed.26 It shows that as the severity of depression increases, associated cognitive impairments become more pronounced and further impede problem-solving skills.23 Moreover, current depression severity has been found to be negatively correlated with performance in multiple cognitive domains, including verbal reasoning and working memory, which are necessary for effective problem solving.27 As depressive symptoms become more severe, perception and reporting of somatic symptoms also increase. One study found that depressive symptoms were a stronger predictor of increased somatic symptom reporting than neuroticism or negative emotionality.28 Suarez-Roca et al29 showed that patients with depression reported sensory experiences such as thermal and tactile paresthesias significantly more intensely compared to controls, and that these perceptions were positively correlated with depression severity.
In this study, problem-solving skills were found to be lower in depressed patients with somatic symptoms. As somatic symptoms increase, mental energy and motivation may also decrease. This situation may negatively affect skills such as analytical thinking, focus, flexibility, and creative solution finding, which are important in the problem-solving process. Somatization may worsen the effects of depressive symptoms on cognitive functions such as memory, reasoning, and learning, thus leading to a deterioration of problem-solving skills in individuals with depression.23 Research suggests that somatization symptoms are associated with emotional memory biases in adolescents with depressive disorders, which may affect cognitive processes critical for problem-solving.30 In particular, somatization may lead to an increased focus on negative emotional memories, which may impair the ability to generate effective solutions to problems.30 One study found that higher somatic scores were associated with lower alertness, as measured by reaction times on attention-demanding tasks.31 This suggests that somatic symptoms will negatively affect cognitive functions such as attention and concentration and therefore the problem-solving process.
Patients with somatic symptoms have been found to use negative approaches (hasty and avoidant approaches) more in the problem-solving process and positive approaches (thoughtful, evaluative, planned and self-confident approaches) less. Since somatic symptoms create a constant feeling of discomfort in the individual, the individual wants to reduce this discomfort or find a solution as soon as possible. This can lead the individual to seek quick and superficial solutions rather than analyze the problems more deeply. Somatic symptoms are associated with reduced cognitive control and impaired error awareness, which can contribute to a more impulsive and less conscious problem-solving approach.32 This is supported by findings that depressed individuals with somatic symptoms show a reduced ability to engage in sustained analytical thinking, which is necessary for effective problem solving.33 In addition, studies have shown that depressed individuals, especially those with somatic symptoms, perceive their problems more negatively and approach them more impulsively. This impulsivity in problem solving is characterized by a tendency to make quick decisions without thoroughly evaluating all possible solutions, which leads to less effective results.34 Somatic symptoms create a constant feeling of discomfort in the individual, and the individual spends energy trying to cope with these symptoms. In this case, the person tends to avoid existing problems instead of confronting them because their mental resources are limited when dealing with somatic discomfort, and they do not want to deal with a problem that creates more stress. Experiential avoidance, a coping mechanism in which individuals try to avoid negative feelings and thoughts, plays an important role in this dynamic. Studies show that individuals with high somatic symptoms often resort to experiential avoidance to manage their distress. This avoidance behavior can lead to a tendency to avoid directly confronting problems, and thus an avoidant problem-solving style can be adopted.35,36 Depressed individuals often exhibit diminished analytical thinking and problem-solving skills, which are exacerbated by the presence of somatic symptoms. This can lead to a cycle in which avoidance of emotional and cognitive challenges maintains both somatic symptoms and depressive state.37,38 Individuals with higher levels of somatic symptoms often exhibit reduced cognitive control and impaired error awareness, which may impair their ability to evaluate and select optimal solutions to problems.32
This study has some limitations. First, study’s cross-sectional nature, it is not possible to establish causality in the relationships between depression, somatic symptoms, and problem-solving skills. Longitudinal studies are needed to understand whether these relationships are linear or reciprocal. Second, the study included only individuals diagnosed with MDD, which limits its generalizability to individuals with different psychiatric disorders. In addition, the sample was taken from a specific geographical region, and it should be taken into account that cultural factors may affect the way somatic symptoms are expressed and problem-solving approaches. Therefore, the findings may differ in studies conducted with individuals from different cultural backgrounds. Finally, the study relied only on self-report measures. This situation may increase the risk of bias due to the participants’ tendency to reflect themselves positively or negatively. Additional studies that evaluate cognitive and behavioral performance with objective measures may increase the reliability of the results. This study is one of the first studies to evaluate the effect of somatic symptoms on problem solving skills in individuals diagnosed with depression. It fills an important knowledge gap in the field of mental health by examining how somatic symptoms and problem solving skills interact in individuals diagnosed with MDD. The study examines in detail how somatic symptoms of depressed individuals relate to their problem-solving abilities and how these symptoms shape problem-solving strategies. This study demonstrates that the presence of somatic symptoms in depressed individuals increases the tendency for deterioration in problem-solving skills and the use of negative strategies in the problem solving process, thus emphasizing the importance of treatment approaches targeting somatic symptoms.
The findings of the study show that somatic symptoms are frequently seen in individuals diagnosed with depression and that these symptoms negatively affect problem-solving skills. Patients with somatic symptoms exhibited more hasty and avoidant approaches in the problem-solving process and used thoughtful, evaluative, planned and self-confident strategies less. This suggests that somatic symptoms intensify the cognitive and behavioral effects of depression and weaken problem-solving skills. In addition, demographic factors such as age, gender, and education level were found to significantly affect on the severity of somatic symptoms and problem-solving skills. Somatic symptoms were found to be more common in women and older individuals; problem-solving skills increased as the level of education increased.
In conclusion, this study reveals that somatic symptoms in depressed individuals play a role in reducing problem-solving skills and that this situation should be taken into consideration during the treatment process. Strategies aimed at reducing somatic symptoms in the treatment of depression can contribute to the development of problem-solving skills and alleviate the cognitive symptoms of depression. Therefore, adopting a holistic approach focusing on somatic symptoms in individuals diagnosed with depression can increase the effectiveness of the treatment process.
Funding Statement
The authors declared that this study has received no financial support.
Footnotes
Ethics Committee Approval: The ethics committee approval of the research was obtained from Recep Tayyip Erdoğan University Non-Interventional Ethics Committee (Ethics Committee Decision Approval Date: February 25, 2021; Decision No.: 2021/38).
Informed Consent: Written informed consent was obtained from the patients who agreed to take part in the study.
Peer-review: Externally peer-reviewed.
Author Contributions: Concept – D.S., B.B.; Design – D.S., B.B.; Supervision – D.S., B.B.; Resource – D.S., B.B.; Materials – D.S., B.B.; Data Collection and/or Processing – D.S.; Analysis and/or Interpretation – D.S.; Literature Search – D.S., B.B.; Writing – D.S.; Critical Reviews – D.S., B.B.
Declaration of Interests: The authors have no conflict of interest to declare.
Data Availability Statement:
The data that support the findings of this study are available upon request from the corresponding author.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available upon request from the corresponding author.