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. Author manuscript; available in PMC: 2022 Jun 9.
Published in final edited form as: Aging Ment Health. 2019 Apr 4;24(8):1225–1228. doi: 10.1080/13607863.2019.1597013

Somatic and Anxiety Symptoms of Depression are Associated with Disability in Late Life Depression

Ruth T Morin 1, Craig Nelson 2, David Bickford 2, Philip S Insel 3,4, R Scott Mackin 1,2,3
PMCID: PMC9183787  NIHMSID: NIHMS1572171  PMID: 30945553

Abstract

OBJECTIVES:

To assess the relationships of somatic and anxiety symptoms of depression with functional disability in a sample of older adults with late life depression.

METHOD:

Data were analyzed from 78 older adults aged 65-88 with current major depression. Somatic and anxiety symptoms from the 24-item Hamilton Depression Rating Scale (HDRS) were summed to create variables measuring severity of these symptoms. Other symptoms of depression were also assessed using the remaining items of the HDRS. Current physical health burden was assessed using the Functional Comorbidity Index (FCI). Disability was measured with the Late Life Function and Disability Instrument (LLFDI) total limitation score. A linear regression analysis was performed to assess the association of somatic and anxiety symptoms with disability independent of other factors.

RESULTS:

The model accounted for 26.6% of variance in disability, (F(6,51) = 3.1, p = .01). Somatic (B=−1.9, p=.004) and anxiety (B=−3.7, p=.04) symptoms of depression were significantly associated with disability. Other depressive symptoms and physical illness burden were not associated with disability.

DISCUSSION:

In older adults with major depression, somatic and anxiety symptoms of depression are associated with disability. Identification and treatment to remission of these symptoms may improve functional outcomes among older depressed adults.

Keywords: late life depression, disability, somatic symptoms, anxious symptoms

Late life major depression (LLD) is a significant public health concern growing with the rapid aging of the United States population, with an estimated prevalence of between 8-16% of older adults affected by symptoms (Blazer, 2003). Though major depressive disorder (MDD) is the leading cause of disability worldwide (C. J. Murray, Lopez, & Organization, 1996), it is a fairly heterogeneous syndrome with significant variability in symptom presentation among individuals (Carragher, Adamson, Bunting, & McCann, 2009; Chen, Eaton, Gallo, & Nestadt, 2000). This variability is complicated by the significant comorbidity seen between diagnoses of depression and anxiety (Aartjan T.F. Beekman et al., 2000; Kessler et al., 2015), and overlap of symptoms needed to meet criteria for these disorders. Further, the increase in physical health problems in older age likely adds to the disability burden of physical symptoms associated with depression and anxiety (Marengoni et al., 2011).

Somatic symptoms, specifically fatigue, aches and pains, change in appetite, weight loss, psychomotor retardation and sleep problems, are a prominent part of the clinical presentation in depressed older adults, with sleep problems more frequently observed in older compared to depressed younger adults (J. Hegeman, Kok, Van der Mast, & Giltay, 2012). This symptom presentation is likely complicated in older depressed adults, given co-occurring physical health problems (J. M. Hegeman, de Waal, Comijs, Kok, & van der Mast, 2015), which negatively impact functioning and make differentiating between somatic symptoms of depression and medical illness difficult (Penninx, Leveille, Ferrucci, van Eijk, & Guralnik, 1999).

Symptoms of anxiety have also been identified as contributing to disability in late life, particularly in the presence of depression (Lenze et al., 2001). Given the significant overlap in physical symptoms with the somatic and anxiety symptoms of depression, as well as the presence of these same symptoms in many physical health disorders, disentangling the associations of these symptom clusters with disability is of clinical interest (Galatzer-Levy & Bonanno, 2014; Morin, Galatzer-Levy, Maccallum, & Bonanno, 2017; Sin, Yaffe, & Whooley, 2015). Understanding the independent contribution of somatic and anxiety symptoms of depression to disability in LLD will help to clarify risk factors for disability, and potentially lead to improved treatment outcomes (Barry, Abou, Simen, & Gill, 2012).

The current study aims to assess the association of somatic and anxiety symptoms of depression with disability, controlling for age, gender, other symptoms of depression, and current physical health problems. It is hypothesized that somatic and anxiety symptoms of depression will be related to disability independent of other factors.

METHODS

Participants and Procedures

This study used data from community-dwelling older adults with major depression who provided informed consent upon their enrollment in a study investigating cognition and disability in late life depression. The research was conducted in line with the Declaration of Helsinki for protection of human subjects, and approved by the institutional review board of the University of California, San Francisco. Inclusion criteria were age over 65, a current diagnosis of Major Depressive Disorder diagnosed using the Structured Clinical Interview (SCID; (First, Spitzer, Gibbon, & Williams, 2002)) for the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (Association & Association, 2000), with symptom severity of ≥15 on the 17-item Hamilton Depression Rating Scale (Hamilton, 1960). Diagnoses of Generalized Anxiety Disorder and simple phobias were allowed as comorbidities in the current study, however individuals with other comorbid psychiatric disorders were excluded from participation. Also excluded were those with significant current neurologic disease, such as epilepsy, Parkinson’s disease, traumatic brain injury, cortical stroke, or evidence of dementia (<25 on the Mini Mental Status Exam; (Creavin et al., 2016)), in an attempt to study late life depression in the absence of other comorbidities which might contribute to disability and other factors.

Eligible participants underwent completed measures of depression symptom severity, current physical health conditions, and disability status.

Measures

Depression Symptoms.

After initial screening for this study using the 17-item version of the Hamilton Depression Rating Scale (HDRS), current symptoms of depression were assessed at baseline using the 24-item HDRS to capture a greater range of depressive symptoms (Hamilton, 1960). Somatic symptoms of depression, specifically the items measuring general somatic symptoms (fatigue, aches and pains), gastrointestinal somatic symptoms, weight loss, psychomotor retardation, and the three items measuring sleep disturbance were summed to create a separate variable (7 items in total, with a possible score range from 0-12 on this variable). Anxiety symptoms of depression, specifically somatic anxiety and psychic anxiety, were summed to create a variable measuring these anxious depression symptoms (2 items, for a possible score range from 0-5). Finally, the remaining non-somatic, non-anxiety symptoms of depression (including low mood, anhedonia and suicidal ideation, among others), were summed to create a variable measuring severity of non-somatic and non-anxiety depressive symptoms (15 items, with a total possible score range of 0-24).

Current Physical Health.

Current burden of physical illness was measured using the physical health items on the Functional Comorbidity Index (FCI) (Groll, To, Bombardier, & Wright, 2005). This scale measures the presence or absence of a variety of physical illnesses, including heart attack, arthritis, and hearing impairment, among others. The total number of listed health problems an individual reported was used to indicate current physical health burden.

Disability.

The Late Life Function and Disability Instrument (LLFDI), a measure commonly used in geriatric research and with LLD specifically (Karp et al., 2009), was utilized as the measure of disability status in this study(Beauchamp, Schmidt, Pedersen, Bean, & Jette, 2014). Specifically, the total limitations score of the LLFDI was used as the outcome of interest. This is a self-report, measuring limitations in the patients’ participation in various activities, with a lower score indicating more disability. Examples of items on this scale are the extent to which an individual is limited in taking care of their own personal needs, participating in social activities, taking part in active recreation, and taking care of one’s own health, among others.

Data Analysis

Statistical analyses were conducted using SPSS version 20 (Nie, Hull, & Bent, 2011). Descriptive statistics, including demographic, clinical and functional characteristics of the sample were obtained. A linear regression analysis was then conducted, assessing whether somatic and anxiety symptoms of depression are significantly associated with functional disability, controlling for the effects of age, gender, other symptoms of depression, and current physical health burden, with tests of multicollinearity included in the analysis.

RESULTS

The 78 participants in the study were 76.6% female, and mean age was 71.9. Other descriptive characteristics of the sample are presented in Table 1.

Table 1.

Participant demographic characteristics and descriptive statistics (n = 78)

Variable Mean SD Range
Age 71.9 6.1 65-88
Years of Education 15.9 2.6 11-22
MMSE 28.7 1.5 25-30
HDRS-17 17.3 3.7 10-25
HDRS-24 Somatic Symptoms 5.7 2.4 0-12
HDRS-24 Anxiety Symptoms 3.3 .97 0-5
HDRS-24 Other Depressive Symptoms 14.1 3.9 6-24
Functional Comorbidity Index 2.8 1.9 0-8
LLFDI 50.9 12.6 23-80
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A linear regression analysis was conducted to assess the independent contributions of somatic and anxiety depression symptoms on disability status, while controlling for age, gender, non-somatic, non-anxiety symptoms of depression, and physical health problems (see Table 2). Overall, this model was significant at p =.01, and accounted for 26.6% of the variance in disability status (F (5, 61) = 3.08). The somatic symptom cluster (B = −1.9, p <.01) and the anxiety symptom cluster (B = −3.7, p <.05) were significantly associated with disability, while age, gender, other depression symptoms, and physical health problems were not significantly associated with disability. Tests of multicollinearity were also conducted, with values within acceptable limits to interpret the results (VIF values for depressive symptoms were 1.04-1.23).

Table 2.

Hierarchical regression analysis predicting disability

Variable Beta Standard Error p-value
Step 1.
  Age .044 .293 .881
  Gender 6.44 3.95 .109
Step 2.
  Age .046 .284 .873
  Gender 4.45 3.91 .261
  HDRS-24 Somatic −1.93 .633 .004*
  HDRS-24 Anxious −3.71 1.77 .041*
  HDRS-24 Other .475 .450 .296
  Physical Illness Burden .346 .851 .686
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Note. HDRS-24 = Hamilton Depression Rating Scale – 24 item.

Step 1 R2 Δ = .047

Step 2 R2 Δ = .219

Given the significant theoretical overlap in symptoms attributed to anxiety and somatic etiology, we attempted to further parse the two symptoms considered to be “anxiety” symptoms on the HDRS-24, particularly as one of these symptoms is explicitly called somatic anxiety. Specifically, Pearson correlations for the association of disability with psychic anxiety and with somatic anxiety were obtained. Somatic anxiety was significantly correlated with disability (r = −.26, p<.05), while psychic anxiety was not (r = −.09. p=.46). Thus, it appears the association of anxiety symptoms with disability in the linear regression performed is driven by the somatic anxiety symptom.

Based on the difference in the association of the anxious symptoms with disability, the linear regression was repeated entering psychic and somatic anxiety symptoms separately. In this regression, somatic symptoms remained independently associated with disability (B = −1.8, p<.01). Psychic anxiety (B = −2.6, p=.28) and somatic anxiety, however, were not significantly associated with disability (B = −5.03, p = .06) above and beyond other somatic depressive symptoms, though the trending of the somatic anxiety symptom appears to indicate overlap with the somatic symptoms construct, despite lack of multicollinearity between the two. As in the previous regression analysis, age, gender, other depression symptoms, and physical health burden were not significantly associated with functional limitations in this post-hoc analysis.

DISCUSSION

The present study sought to assess the association of somatic and anxiety symptom clusters of depression with disability in a sample of older adults with depression. Our results indicate that somatic and anxiety symptom clusters are independently associated with disability. Somewhat surprisingly, all other symptoms of depression were not associated with disability in this study. This raises the question of whether it is the depression syndrome that is related to disability, or specific symptoms that account for poor functional outcomes among older adults.

A post-hoc analysis of the two questions in the anxiety symptoms cluster showed that while the somatic anxiety symptom was related to disability, the ideational symptom of anxiety was not. It is worth considering whether to conceptualize somatic anxiety as another somatic symptom. There is significant theoretical overlap between the various sub-categories of depressive symptoms, particularly anxiety and somatic symptoms, which may be less distinct among older adults with physical health conditions. The attempt to distinguish these clusters and the way in which they are categorized, while seemingly promising, warrants greater investigation among older adults with depression. Further research on the overlap among these constructs as they relate to preoccupations about physical symptoms is warranted.

The lack of an independent association of current physical health burden with functional disability is somewhat surprising; however, this finding may be an attribute of the scale, which asked if various illnesses were present or absent. Although patients endorsed a mean of 2.8 physical illnesses (range 0-8), the scale does not ask about severity or functional impact of each illness, possibly underrepresenting the disabling nature of the illnesses counted as present. Further, the fact that participants in this study were community-dwelling older adults may indicate healthier and less functionally impaired sample to begin with, possibly limiting the association between physical health and disability in this particular study. Future research should include more medically ill participants to investigate this association further.

This study is limited by a small sample size and by the cross-sectional nature of the data. Additionally, though physical health problems were not associated with disability in this sample, the measure of physical health burden as a count of syndromes rather than a measure of severity may have obscured a relationship between physical health and disability, particularly in a community-dwelling sample who may have a lower illness burden. Additionally, pain status was not assessed in this study. Indeed, it has been reported that 60% of adults over age 65 experience pain secondary to a physical health problem, with implications for depression symptoms and disability (Gallagher, Verma, & Mossey, 2000). The possibility that the relationship between symptoms of depression and disability are bidirectional, or that it is functional disability which leads to these depressive symptoms, cannot be assessed using cross-sectional data, an additional limitation. Future studies with larger samples, including current pain measures, comparison samples of older adults with physical health issues and without clinical depression (Geerlings, Beekman, Deeg, & Van Tilburg, 2000; Gould, O’Hara, Goldstein, & Beaudreau, 2016), and longitudinal data will aid in the further parsing of these variables, and understanding of underlying mechanisms as well as directionality of observed relationships.

The findings of this study have implications for screening and treatment of older adults with depression. Given the association of somatic symptoms with functional impairment, educating patients about the impact of these symptoms and treating them to remission may aid in improving functional outcomes in older depressed patients. Medical providers may be less likely to attribute somatic complaints to depression, rather viewing them as a result of current physical health problems (Burroughs et al., 2006; J. Murray et al., 2006). They may miss an opportunity for intervention to address somatic depressive symptoms that may reduce functional impairment in the context of other physical health problems (Ormel, Rijsdijk, Sullivan, Van Sonderen, & Kempen, 2002). Thus, identification of symptom clusters which are associated with disability may aid in expedited assessment in primary care settings (Lyness et al., 1997; Mitchell, Vaze, & Rao, 2009), and help providers better assess for and educate patients about somatic symptoms of depression (Tylee & Gandhi, 2005).

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