Open Journal of Psychiatry, 2011, 1, 40-48 OJPsych
doi:10.4236/ojpsych 2011.12007 Published Online July 2011 (http://www.SciRP.org/journal/OJPsych/).
Published Onl ine July 2011 in SciRes. http://www.sc irp.org/ journal/OJPsych
Subjective symptoms related to depression and suicidal risk in
a Japanese community: a cross-sectional study*
Shigeki Takemura1, Kouichi Yo shimasu1, Jin Fukumoto1, Hir oichi Yamamoto2, Kazuhisa Miyashita1
1Department of Hygiene, School of Medicine, Wa kay ama Medical University, Wakayama, Japan ;
2Osaka Occupational Health Service Center, Japan Industrial Safety and Health Association, Osaka, Japan.
Received 16 May 2011; revised 20 June 2011; accepted 29 June 2011 .
ABSTRACT
BACKGROUND: This cross-sectional study aimed to
assess the association between self-reported somatic
and mental symptoms and the presence of major de-
pressive disorder (MDD) and suicidal risk among
community dwellers in Japan. METHODS: From
two locations in Japan, we recruited 732 community
dwellers who underwent an annual health screening.
Basic symptoms of MDD, dysthymia, and the pres-
ence of associated suicidal risk were determined us-
ing a brief structured diagnostic psychiatric interview,
Mini International Neur opsychiatric Interview (MINI).
Information regarding self-reported somatic and
mental symptoms was obtained from a
self-administered questionnaire used in the annual
health check-up. Suicidal risk was evaluated on the
basis of six relevant questions asked in MINI. Logis-
tic regression model was used to calculate age- and
gender-adjusted odds ratios (ORs) and 95% confi-
dence intervals (CIs) for MDD. Further adjustment
fo r basic symptoms of MDD was performed to calcu-
late ORs and C Is for suicidal risk. RESULTS: A my-
riad of somatic symptoms, including headache , heavy
headedness, eye strain, and shoulder stiffness [ad-
justed OR (95% CI), 11.4 (1.22 - 107) at location 1;
5.17 (1.23 - 21.7) at location 2], were associated with
the presence of MDD. Dysmenorrhea [6.07 (1.14 -
32.3) at location 1] and dysesthesia, arthralgia, and
swelling in the extremities [2.72 (1.14 - 6.47) at loca-
tion 2] were significantly associated with an increase
in suicidal risk, independent of the presence of basic
symptoms of MDD. CONCLUSION: Several somatic
symptoms, especially pain-related ones, may serve as
possible signs of depression and suicidal risk among
community dwellers.
Keywords: Epidemiolog y; Somatic Symptoms;
Depression; Suicide; Community Dwellers
1. INTRODUCTION
More than 30,000 Japanese people die from suicide
every year, and suicide is becoming a serious public
health problem. Several epidemiological studies in
general populations have indicated personal and social
risk factors for suicide such as depression, severe an-
xiety, substance abuse, and poor interpersonal rela-
tionships including social isolation, inability to main-
tain a job, anhedonia, somatic diseases, financial prob-
lems, and personal or familial history of suicide [1-7].
Suicide is attributed to many causes including depres-
sion and other emotional disorders [8]. Mood disorders
account for 30.2% of completed suicide cases [9].
Depressive symptoms are accompanied by several
somatic symptoms such as fatigue, insomnia, nau-
sea/vomiting, back pain and so forth [10]. Among these
symp t oms, pain-related symptoms have been associated
with depression [11-15] and suicide [11,16-20]. Ac-
cording to a Japanese government survey, the preva-
lence of somatic symptoms, particularly pain-r elated
symptoms, is higher among older Japanese people.
Moreover, suicides in people aged ≥40 years account
for >70 % of all su icide cas es in Japan, with the h ighest
suicide rate in the sixth decade among men.
The relationship between somatic symptoms and de-
pression/suicidal risk can be explained with two as-
sumptions. One is that people suffering from somatic
disorders tend to develop depression or suicidal idea-
tion. The other is that those who have depression or
suicidal ideation with non-severe somatic disorders are
likely to express their mental strain as transformed so-
matic symptoms. Although several studies support both
these assumptions [21-24], we adopted the latter one
for the present study for the following reasons.
About two-thirds of patients with depression first
* This work was supported by a Grant-in-
Aid for Scientific Research
from the Japan Society for the Promotion of Science (JSPS KAKEN-
HI) 19590645.

S. Ta ke mura et al. / Open Journal of Psychiatry 1 (2011) 40-48
41
seek help from a primary care physician rather than a
psychiatrist because they develop both somatic and
mental symptoms [25]. Nevertheless, ph ysicians do not
always evaluate the risk of depression or suicide among
their patients for fear of reinvoking patients’ suicidal
ideation or making them feel guilty of thinking about
suicide, which is considered a sin in many religions
[26]. Moreover, Japanese patients feel hesitant to con-
sult a psychiatrist because compared to Westerners,
they are generally more likely to share a feeling of
stigmatization toward mental disorders or suicidal ide-
ation [27], and to suppress their emotions accordingly.
This observation was partially supported by the World
Mental Health Japan Survey, showing a lower preva-
lence of mood and anxiety disorders in Japan than in
the United States or Europe [28]. Hence, detection of
people at a high risk of depressive disorder or suicide
will be delayed in J apan.
Together with the above-mentioned situations, early
detection of mental health-related somatic symptoms
may help promote not only the secondary prevention of
depressive disorders but also the primary prevention of
suicide. However, evidence has been chiefly obtained
in clinical settings, which may not apply to community
dwellers.
The purpose of this study was to evaluate the asso ci-
ations between various mental and somatic symptoms
and MDD and suicidal risk in a Japanese community,
and to establish the key contributing elements that
would aid in detecting signs of MDD and suicidal risk
in commu nit y dw eller s a t the pr ec lin ica l stag e.
2. METHODS
2.1. Study Population
We conducted a cross-sectional study in the following
two settings.
(Location 1: Health check-up services, A City)
A private medical corporation in A City (total popu-
lation, approximately 26,000) located in the middle of
Wakayama Prefecture, provides health check-up ser-
vices for community dwellers and local company em-
ployees. Six hundred and s ev en t y-s ix p eople underwent
a health check-up at this service from January through
March 2008. Out of them, 294 people were contacted
and 280 people agreed to participate in the study.
(Location 2: B and C Towns)
B Town (total population, approximately 8000) and
C Town (total population, approximately 7000) are
both located in the middle of Wakayama Prefecture. To
de tect chronic diseases including metabolic syndrome,
these towns provide a health check-up program every
year for self-employed community dwellers and their
family me mber s each ag ed 40 - 74 years. In 2008, 3656
people aged 40 - 74 years (1809 in B Town; 1847 in C
Town) were eligible for the annual health check-up
program, and 686 (177 in B Town; 509 in C Town)
underw ent a h ealth check -up from May through August,
2008. Of these, 452 people (146 in B Town; 306 in C
Town) agreed to participate in the s tud y.
Those who underwent a health check-up were asked
to participate in the study via posters displayed at the
check-up site. Later, they were led one-by-one to the
interview room where the structured interviews were
conducted. The participants received a detailed oral and
written explanation of the study, i.e., regarding the
purpose of the study, voluntarity of participation, and
principal investigator’s contact address, from the inter-
viewers. If they agreed to participate in the study, they
gave wr i tten inf or med consent.
This study was approved by the ethics committee of
Wakayama Medica l Un iver s i ty.
2.2. Data Collection
2.2.1. Psy ch ia t ric Structu red In te rv i ew
Mini-International Neuropsychiatric Interview (MINI)
Japanese version 5.0.0 (2003) [29,30], a convenient
structured diagnostic interview for mental disorders,
was used for the interview survey. All questions in-
cluded in MINI were coded as two categories on the
basis of the respondents’ answers of yes/no. Reliability
and validity of the Japanese version of MINI is satis-
factory [31]. Nine interviewers (three at location 1 and
nine at locat ion 2), al l of who were licens ed physicians
or nurses, were enrolled as competent interviewers.
They were trained by the second author (KY), a psy-
chiatrist, for essential interview skills including didac-
tic sessions of a general interview and a review of the
instrument sections. Furthermore, the second author
checked the interviewers and corrected them as the
need arose during the interview sessions so that the
interview could be appropriately conducted.
MINI considers 17 Axis I mental disorders based on
the standard 12-month prevalence of ≥0.5% [29].
Among these 17 disorders, we chose MDD, dysthymia,
and suicidal ideation and attempts as candidate disord-
ers strongly associated with increasing suicidal risk
among community dwellers.
Basic questions essential for a diagnosis of MDD
(two questions) and dysthymia (one question) were
asked to all subjects. If their answers to the basic ques-
tions implied the possible presence of MDD or dys-
thymia, more detailed questions were asked for a final
diagnosis (seven more questions for MDD and up to
nine more questions for dysthymia).
Suicidal risk was measured on the basis of six rele-
vant items included in MINI. Of these, five items con-
sidered suicidal ideation and attempts within the pre-

S. Ta ke mura et al. / Open Journal of Psychiatry 1 (2011) 40-48
42
vious month ([1] thinking that he/she would be better
off dead, [2] thinking about self-harm, [3] thinking
about suicide, [4] planning of suicide, and [5] expe-
riences of suicide attempts), and the sixth item consi-
dered lifetime experiences of suicide attempts. Ac-
cording to the weighted value of each question, points
1, 2, 6, 10, and 10 were allotted to each response to the
former five questions, and point 4 was allotted to the
last response regarding lifetime experiences of suicide
attempts. Thus, a score of 33 was the maximum number
of points for suicidal risk. A higher score indicates the
presence of higher suicidal risk.
2.2.2. M edi cal Ex am inat ion s
Each participant at both locations was asked to com-
plete a self-administered questionnaire. This question-
naire contained items regarding lifestyle factors, the
presence or history of chronic diseases as well as their
treatment status, and self-reported somatic and mental
symptoms. The questionnaire was designed on the basis
of a questionnaire proposed by the Ministry of Health,
Labor, and Welfare, Japan [32]. Fasting blood samples
were collected for biochemical examinations such as
plasma glucose, serum LDL or HDL cholesterol, trigly-
cerides, and hemoglobin. A urine test and chest radio-
graphy were also conducted.
A checklist for the self-reported symptoms included
various somatic symptoms, such as respiratory, cardi-
ovascular, digestive, musculoskeletal, nervous, and
urogenital symptoms (21 items for location 1 and 18
items for location 2), and one mental symptom regard-
ing agitation or anxiety. Because this checklist was a
ready-made review of systems with current symptoms
developed by the health check-up service provider,
details such as precise duration or frequency and sever-
ity of th ese symptoms could not be obtained. However,
this checklist included two questions about anxie-
ty-related mental and somatic symptoms and one ques-
tion about general somatic symptoms from the Hamil-
ton Depression Rating Scale (HAM-D17) [33]. Al-
though these symptoms were mainly checked for the
secondary prevention of chronic diseases, some of them
were also considered to reflect the symptoms of soma-
toform autonomic dysfunction, which might be related
to depression. According to the corresponding res-
ponses, the status of these symptoms was simply di-
vided into presenc e or absence cat ego r ies.
These medical examinations were conducted by a
private medical corporation or a local health authority.
Psychiatric interviewers were not involved in the med-
ical examinations.
2.3. S tatistical Analysis
The frequency of subjective symptoms and
MDD/suicidal risk were calculated. Then logistic re-
gression analysis was used to calculate odds ratios
(ORs) and 95% confidence intervals (CIs). In the logis-
tic regression analysis, the dependent variables were
MDD and suicidal risk. The status of MDD was di-
vided into positive and negative c ategories on the basis
of MINI results. The status of suicidal risk was also
divided into positive and negative categories on the
basis of the total score on the corresponding questions
included in MINI. Subjects with a zero score were re-
garded as negative, and those with a score more than
zero wer e regard ed as po sitive. In the s ame mann er, the
independent variable was each subjective symptom or
mental disorders including MDD. The subjective
symptom was divided into positive or negative catego-
ries. Each subjective symptom wa s r egard ed as po sitiv e
if a subject reported the symptom.
Univar iate models wer e created to eva luate th e asso-
ciations between each symptom and MDD/s uicidal r isk.
We adjusted for gender and age in the multivariate
analysis of MDD. Age in years was div ided into t erti les
according to the distribution of age in each location.
For suicidal risk, we further adjusted for gender, age,
and the presence of loss of interest or depressed mood,
which are basic symptoms of MDD. These depres-
sion-related mental symptoms might be potential con-
founding factors regarding the association between
somatic symptoms and suicidal risk.
P values (two-sided) less than 0.05 were considered
statistically significant. All computations were per-
formed using the SAS software package, version 9.1.3
(SAS Institute Inc., Cary, NC, USA).
3. RESULTS
Table 1 shows ch arac ter istic s of th e stud y sub jec ts. The
average age was 45.4 years (range, 17 - 86) at location
1 and 62.5 years (range, 39 - 74) at location 2. The
proportion of female subjects was 46% and 60% at
locations 1 and 2, respectively. Of all symptoms, head-
ache, heavy headedness, eye strain, and shoulder stiff-
ness w ere h igh es t in frequency at both locations (26%).
Ta b le 2 illustrates the MINI results. The prevalence
of MDD was approximately 2% at both locations. The
frequency of subjects with at least one of the two basic
depressive symptoms was approximately 3% at both
locations. Only three subjects (two at location 1 and
one at location 2) were positive for dysthymia. Ap-
proximately 6% of all study subjects showed suicidal
risk.
Table 3 revea l s ag e - and gender-adjusted ORs of
MDD and dysthymia for suicidal risk. Both depressed
mood and loss of interest were significantly associated
with suicidal risks at both locations. Melancholic de-
pression and dysthymia were also strongly associated

S. Ta ke mura et al. / Open Journal of Psychiatry 1 (2011) 40-48
43
Table 1. Characteristics of the study subjects.
a. Figures denote the number of subjects (%) or the average (min.-max.).
with an increased suicidal risk, but the CI range was
wide because there were very few subjects with these
conditions. A history of MDD was insignificantly re-
lated to suicidal risk.
Tabl e 4 presents adjusted ORs of somatic factors for
MDD at locations 1 and 2. At location 1, head ache and
dysesthesia, arthralgia, and swelling in the extremities
were significantly associated with MDD in univariate
analyses. After adjusting for age and gender, only
headache remained significantly associated with MDD
in univar iate anal yses. At loc ation 2, f atigue, in somnia,
stress, abdominal pain, nausea/heartburn, headache,
palpitation/shortness of breath, vertigo/dizziness, back
pain, and dysesthesia, arthralgia, and swelling in the
extremities were associated with MDD in univariate
analyses. A heavy feeling in the stomach was also as-
sociated with MDD in age- and gender-adjusted ana-
lyses.
Table 5 demonstrates the adjusted ORs of somatic
factors for suicidal risk at locations 1 and 2. No somatic
symptom was associated with suicid al risk at location 1,
in univariate analyses, while an increase in suicidal
risk was observed among women with dysmenorr-
hea/irregular bleeding in age- and gender-adjusted
analyses. Dysesthesia, arthralgia, and swelling in the
extremities were a significant risk factor for suicidal
risk at location 2 in univariate and age- and gend-
er-adjusted analyses. Fatigue, stress, vertigo, and chest
pain were significantly associated with suicidal risk
only in univariate analyses.
4. DISCUSSION
The prevalence of MDD and suicidal risk in a Japanese
community was about 2% and 6%, respectively. We
also demonstrated the association of various pain-related
somatic symptoms with MDD and suicidal risk in a
community setting. In particular, headache, heavy
headedness, eye strain, and shoulder stiffness were as-
sociated with MDD at both lo cations. Dysmenorrhea at
location 1 and dysesthesia, arthralgia, and swelling in
the extremities at location 2 were associated with sui-
cidal risk. One of the advantages of this study is that
we evaluated mental status by administering a struc-
tured questionnaire whose reliability and validity have
been eva luated in Jap an [31]. A nother adv antage is that
we identified somatic symptoms related to MDD and
suicidal risk among community dwellers.
The presence of pain is associated with not only de-
pression [11-15] but also suicidal risk [11 ,16-20].
These findings have been confirmed in clinical and
community settings. However, to the best of our know-
ledge, this is the first study investigating the relation-
ship between a broader spectrum of somatic symptoms
and depression/suicidal risk among community dwel-
lers in J ap an .
Some previous studies in Japan have shown that a
variety of somatic symptoms are associated with de-
pression and suicidal risk. In a J apanese psychosomatic
outpatient clinic, fatigue, insomnia, nausea/vomiting
and back pain were more prevalent among outpatients
with major depression than among other outpatients
[10]. In another Japanese clinic, diarrhea, excessive
sweating and weight loss in men, and headache, dyses-
thesi a and gri ef in wome n, as we ll as sleep distu rbance,
loss of appetite, general fatigue, loss of interest and
agitation in both sexes, were significantly associated
with depression [22]. Besides, symptoms related to
depression were associated with suicidal ideation [21].
Some kinds of symptoms such as fatigue were common
to previous studies in the clinical settings and the
present study in the community setting, but others were
not. This discrepancy may reflect the temporal change
of subjective symptoms of depressive disorders. To
further investigate the temporal change of depressive
symptoms, longitudinal follow-ups wi l l be needed.
Location 1a
Location 2a
(N = 280)
(N = 452)
Gender
Men
164
(58.6)
183
(40.5)
Wome n 116 (41.4) 269 (59.5)
Age (years) 45.4 (17 - 86) 62.5 (39 - 74)
Symptoms
Fatigue
14
(5.0)
79
(17.5)
Insomnia 17 (6.1) 36 (8.0)
Stress
46
(16.4)
34
(7.5)
Abdominal pain
6
(2.1)
10
(2.2)
Heavy stomach
21
(7.5)
28
(6.2)
Nausea/heartburn
14
(5.0)
18
(4.0)
Diarrhea/constipation 49 (17.5) 38 (8.4)
Hemorrhoid
19
(6.8)
Bleeding at evacuation
11
(3.9)
5
(1.1)
Acute decrease in body
weight
1 (0.4) 10 (2.2 )
Thirst 14 (5.0) 35 (7.7)
Headache, heavy headed-
ness, eye strain, and
shoulder stiffness
73 (26.1) 116 (25.7)
Vertigo/dizziness
17
(6.1)
33
(7.3)
Palpitation/shortness of
breath 7 (2.5) 20 (4.4 )
Pain or constriction in the
chest
7 (2.5) 6 (1.3)
Back pain
39
(13.9)
98
(21.7)
Cough/sputum 17 (6.1) 39 (8.6)
Dysesthesia, arthralgia,
and swelling in the ex-
tremities
28 (10.0) 95 (21.0)
Difficulty in
urinating/hematuria 5 (1.8) 14 (3.1 )
Dysmenorrhea/irregular
bleeding (women only)
13 (11.2)
Pregnancy (women only)
3
(2.6)

S. Ta ke mura et al. / Open Journal of Psychiatry 1 (2011) 40-48
44
Table 2. The number of outcomes from the MINI
Location 1 (N = 280) Location 2 (N = 452)
Yes (%) No (%) Yes (%) No (%)
(A) Presence of MDDa 5 (1.8) 275 (98.2) 9 (2.0) 442 (98.0)
(B) 2-item MDD screening
(B1) Depre s s ed mood 5 (1.8) 275 (98.2) 7 (1.5) 445 (98.5)
(B2) Loss of interesta 5 (1.8) 275 (98.2) 9 (2.0) 442 (98.0)
(B3) (B1), (B2), or botha 8 (2.9) 272 (97.1) 13 (2.9) 438 (97.1)
(C) History of MDDa 1 (0.4) 279 (99.6) 3 (0.7) 448 (99.3)
(D) Presence of melancholic depressionab 1 (0.4) 279 (99.6) 4 (0.9) 446 (99.1)
(E)Presence of dysthymiacd 2 (0.7) 272 (99.3) 1 (0.2) 442 (99.8)
(F) Presence of suicidal risk 17 (6.1) 263 (93.9) 28 (6.2) 424 (93.8)
MDD: major depressiv e disorder . aOne subject in locatio n 2 was exclu ded because o f missing data on the basic symptoms of MDD; bOne su bject in lo cation 2
was excluded because of missing data on MDD with melancho li c featu r es ( melan cho li c dep res sio n); cFive subjects with MDD and one more subject with miss-
ing data on dysthymia i n l ocation 1 were excluded; dNine subjects with MDD in location 2 were excluded.
Table 3. Odds ratios (ORs) and 95% confidence intervals (CIs) of major depressive disorder and dysthymia for suicidal risk in the
community.
Location 1 (N = 280) Location 2 (N = 452)
Crude model Adjusted modele Crude model Adjusted modele
OR (95% CI) P OR (95% CI) P OR (95% CI) P OR (95% CI) P
(A) Presence of
MDDa 28.0 (4.32 - 181) 0.001 26.2 (3.54 - 194) 0.001 22.8 (5.73 - 90.5) 0.000 21.9 (5.24 - 91.3) 0.000
(B) 2-item MDD
screening
(B1) Depressed
mood 11.6 (1.79 - 74.5) 0.010 9.57 (1.33 - 69.1) 0.025 12.6 (2.67 - 59.4) 0.001 11.7 (2.39 - 57.2) 0.002
(B2) Loss of
interesta 28.0 (4.32 - 181) 0.001 37.5 (4.77 - 295) 0.001 38.2 (8.95 - 163) 0.000 41.6 (9.01 - 192) 0.000
(B3) (B1), (B2),
or botha 11.1 (2.40 - 51.0) 0.002 10.6 (2.09 - 54.3) 0.004 23.2 (7.15 - 75.0) 0.000 24.7 (7.12 - 85.4) 0.000
(C) History of
MDDa - - -f - - -f 7.80 (0.69 - 88.8) 0.098 6.37 (0.54 - 75.5) 0.142
(D) Presence of
melancholic
depressionab - - -f - - -f 50.5 (5.07 - 503) 0.001 43.9 (4.23 - 456) 0.002
(E) Presence of
dysthymi a cd 19.9 (1.18 - 337) 0.038 20.2 (1.01 - 402) 0.049 - - -f - - -f
MDD: major depressiv e disorder. aOne subject in l ocation 2 was excluded because of missing d ata on the basic symptoms of MDD; bOne sub ject in locat ion 2
was exclu ded b ecaus e of mis si ng dat a on MDD wi th melan ch o lic f eatu res (m elan cho li c dep res sio n); cFive subjects with MDD and one more subject with miss-
ing data on dysthymia in location 1 were excluded; dNine su bjects with MDD in location 2 were ex cluded; eAdjusted for gender and age; fThe model did not
converge because there were very few subjects with dysthymia.
In large-scale population-based studies, people with
migraine are 2.2 - 4.0 times more likely to have depres-
sion [11 ]. A significant association between severe head-
aches and suicidal ideation or behaviors has been con-
firmed among community-dwelling adults [16]. In our
study, headache, heavy headedness, eye strain, and
shoulder stiffness were significantly associated with
MDD but not with suicidal risk. This discrepancy may
be due to the small number of subjects in our study
and the relatively low suicidal risk among the study

S. Ta ke mura et al. / Open Journal of Psychiatry 1 (2011) 40-48
45
Table 4. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for major depressive disorder.
Location 1b Location 2b
OR (95% CI) P OR (95% CI) P
Women (vs. Men) 2.21 (0.36 - 13.6) 0.394 2.65 (0.54 - 13.0) 0.230
Age (years)a Tertile 1 1.00 (reference) 1.00 (reference)
Tertile 2 2.05 (0.18 - 23.1) 0.561 3.10 (0.82 - 11.8) 0.097c
Tertile 3 2.16 (0.19 - 24.4) 0.535
(Trend P = 0.545)
Symptoms
Fatigue - - -d 5.50 (1.42 - 21.3) 0.014
Insomnia 3.96 (0.38 - 41.8) 0.253 4.91 (1.11 - 21.7) 0.036
Stress 3.63 (0.57 - 23.0) 0.171 30.1 (6.31 - 143) 0.000
Abdominal pain - - -d 20.3 (3.20 - 129) 0.001
Heavy stomach 2.98 (0.29 - 30.4) 0.357 6.30 (1.16 - 34.3) 0.034
Nausea/heartburn 5.79 (0.58 - 57.9) 0.135 5.79 (1.07 - 31.4) 0.042
Diarrhea/constipation 0.97 (0.10 - 9.36) 0.976 1.28 (0.15 - 10.6) 0.821
Hemorrhoid 4.18 (0.43 - 40.9) 0.219
Bleeding at evacuation 11.0 (0.87 - 139) 0.065 - - -d
Acute decrease in body weight - - -d - - -d
Thirst - - -d 3.43 (0.64 - 18.3) 0.149
Headache, heavy headedness, eye strain, and shoulder
stiffness 11.4 (1.22 - 107) 0.033 5.17 (1.23 - 21.7) 0.025
Vertigo/dizziness 4.06 (0.37 - 44.2) 0.251 45.6 (9.56 - 217) 0.000
Palpitation/shortness of breath - - -d 12.5 (2.78 - 56.5) 0.001
Pain or constriction in the chest - - -d 11.0 (1.08 - 112) 0.043
Back pain 1.41 (0.15 - 13.1) 0.760 2.89 (0.74 - 11.2) 0.125
Cough/sputum - - -d 1.54 (0.17 - 13.7) 0.699
Dysesthesia, arthralgia, and swelling in the extremities 5.27 (0.76 - 36.4) 0.092 6.77 (1.63 - 28.1) 0.009
Difficulty in urinating/hematuria - - -d 8.68 (0.74 - 101) 0.085
Dysmenorrhea /irregular bleeding (women only) - - -d
Pregnancy (women only) - - -d
aAge in years was divided into tertiles: 17 - 40, 41 - 51, and 52 - 86 in location 1; and 39 - 61, 61 - 67, and 68 - 74 in location 2; bAdjusted for gender and age;
cTertiles 2 and 3 were combined into a single category in the multivariate model; dNot calculated because of a very small sample size.
subjects.”
On the other hand, chronic pain doubles the suicidal
risk [17]. A previous study showed an association be-
tween body pain from a duodenal ulcer and uterine ill-
ness and suicide [18]. Another study revealed that men-
strual disorders are significantly more common in female
adolescents with a smoking habit and suicidal behaviors
[19]. In our study sampl e, a significantly higher suicidal
risk was observed among women with dysmenorr-
hea/irregular bleedin g (Table 5) and those with a h istory
of mali gna nc y (data n ot sh own).
Given that dysmenorrhea is accompanied by chronic
pain and irregular bleeding among middle to elderly
women, and that it is also associated with malignancy in
the reproductive system, this result may support the ex-
istence of a relationship between dysmenorrhea and sui-
cidal risk. However, the type of malignancy was not
identified in our sample. Moreover, one of the reported
adverse effects of oral contraceptives is a suicide attempt
[20]. Further investigations on MDD and suicide should
be conducted among women, considering malignancy in
the reproductive system and oral contraceptive use.
Patients with rheumatoid arthritis, having chronic
arthralgia, are also known to have depression [12]. In a
study that was a part of a clinical trial for MDD treat
ment, the number of pain-related symptoms (including

S. Ta ke mura et al. / Open Journal of Psychiatry 1 (2011) 40-48
46
Table 5. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for suicidal risk.
Location 1b Location 2b
OR (95% CI) P OR (95% CI) P
Women (vs. Men) 3.67 (1.21 - 11.1) 0.022 1.36 (0.57 - 3.22) 0.489
Age (years)a Tertile 1 1.00 (reference) 1.00 (reference)
Tertile 2 1.59 (0.43 - 5.88) 0.491 0.83 (0.31 - 2.20) 0.705
Tertile 3 1.58 (0.42 - 5.98) 0.502 0.68 (0.24 - 1.89) 0.460
(Trend P = 0.509) (Trend P = 0.457)
Symptoms
Fatigue 1.51 (0.17 - 13.2) 0.707 1.49 (0.56 - 3.97) 0.426
Insomnia - - -c 0.76 (0.17 - 3.44) 0.719
Stress 1.45 (0.42 - 5.03) 0.561 0.85 (0.20 - 3.65) 0.831
Abdominal pain - - -c 0.50 (0.04 - 6.34) 0.594
Heavy stomach 1.22 (0.22 - 6.79) 0.820 0.21 (0.02 - 2.16) 0.188
Nausea/heartburn 0.88 (0.08 - 10.0) 0.920 0.76 (0.11 - 5.16) 0.781
Diarrhea/constipation 1.27 (0.39 - 4.18) 0.696 1.72 (0.51 - 5.81) 0.382
Hemorrhoid 0.40 (0.03 - 4.92) 0.477
Bleeding at evacuation 1.48 (0.12 - 18.1) 0.760 - - -c
Acute decrease in body weight - - -c - - -c
Thirst 0.99 (0.11 - 8.58) 0.992 1.64 (0.44 - 6.05) 0.458
Headache, heavy headedness, eye strain, and shoulder
stiffness 0.99 (0.32 - 3.12) 0.992 1.42 (0.58 - 3.47) 0.440
Vertigo/dizziness 0.51 (0.05 - 5.24) 0.574 0.93 (0.21 - 4.09) 0.926
Palpitation/shortness of breath - - -c 0.66 (0.10 - 4.36) 0.667
Pain or constriction in the chest - - -c 5.98 (0.80 - 44.6) 0.081
Back pain 0.27 (0.03 - 2.37) 0.238 1.30 (0.51 - 3.32) 0.589
Cough/sputum 1.14 (0.14 - 9.55) 0.906 1.63 (0.41 - 6.50) 0.492
Dysesthesia, arthralgia, and swelling in the extremities 1.07 (0.24 - 4.74) 0.929 2.72 (1.14 - 6.47) 0.024
Difficulty in urinating/hematuria - - -c 0.90 (0.08 - 10.6) 0.935
Dysmenorrhea /irregular bleeding (women only) 6.07 (1.14 - 32.3) 0.034
Pregnancy (women only) - - -c
aAge in years was divided into tertiles: 17 - 40, 41 - 51, and 52 - 86 in location 1; and 39 - 61, 61 - 67, and 68 - 74 in location 2; bAdjusted for gender, age, and
the presence of loss of int erest or depr essed mood, which are basic symptoms of major depressive disorder; cNot calculated because of a very small sample size.
arthralgia) experienced was moderately related to sever-
ity of depression (r = 0.35) [13]. The relationship be-
tween chronic pain and depression may apply to com-
munity dwellers in relatively better health. Although the
cause of pain in our study subjects was not specified,
identifying the symptoms may contribute to early detec-
tion of MDD and suicidal risk.
Some limitations of this study should be mentioned.
First, the prevalence of MDD and suicide was estimated
using point prevalence. The severity of depressive
symptoms fluctuates with time, which could not be de-
tected with MINI. Second, there are some difficulties
generalizing our results. Because the study subjects were
derived from a population of voluntary health check-up
receivers, many of them were probably health-oriented
and in better health. The participation rate in this study
was not sufficiently high at either location. In addition,
the prevalence of MDD in our sample was lower than
the 12-month prevalence of MDD in a previous survey
in Japan (2.9%) [34]. Third, this was a cross-sectional
study; therefore, the causality of somatic symptoms and
mental symptoms is unknown. The relationship between
headache and depression is bidirectional [35,36]. Last,
socioeconomic factors such as household income, job
status and family structure were unknown. Further in-
vestigations will be necessary with full adjustment for

S. Ta ke mura et al. / Open Journal of Psychiatry 1 (2011) 40-48
47
those factors and with longitudinal follow-ups.
In conclusion, a strong link between various somatic
symptoms, including pain-related symptoms, and MDD
and/or suicidal risk was observed among community
dwellers. Early detection of depressive symptoms in the
community or in primary care may have an impact on
the prevalence of MDD and suicide rates in Ja pan. Given
that a large proportion of patients with depression visit a
physician rather than a psychiatrist, our findings may
help physicians engaged in primary care to identify pa-
tients with MDD or suicidal risk.
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