A clinical analysis of the presentation of depression in Pakistan

Abstract

Background Major depressive disorder is a leading cause of disability worldwide, yet its clinical presentation varies substantially across cultural contexts. In many low- and middle-income settings, including Pakistan, depression is frequently expressed through somatic rather than psychological symptoms, contributing to under-recognition in general medical settings. Aims To estimate the prevalence of depression among patients attending a tertiary care medical clinic in Pakistan, and to characterise the somatic and psychological symptom patterns associated with depression severity. Method We conducted a cross-sectional study of 356 adult patients recruited from a general medicine out-patient clinic in Lahore, Pakistan. Depression and anxiety were assessed using Patient Health Questionnaire 9 (PHQ-9) and Generalised Anxiety Disorder 7 scales. For patient encounters with missing PHQ-9 scores, symptom-based prediction using a random forest model was applied. Clinical notes were analysed using natural language processing to extract somatic and psychological symptoms. Logistic regression models were used to identify predictors of moderate-to-severe depression. Results Sixty-three per cent of participants met the criteria for moderate-to-severe depression, with 42.4% having comorbid anxiety and depression. Psychological symptoms such as low mood and anhedonia were rarely documented, whereas somatic complaints predominated across all severity levels. Epigastric pain (odds ratio 2.31–2.50) and anxiety (odds ratio 5.87–5.95) were found to be strong predictors of moderate-to-severe depression, whereas male gender was associated with lower likelihood (odds ratio approximately 0.54). Constipation showed a borderline association with depression severity, whereas diarrhoea did not. Conclusions Depression in this clinical setting is predominantly expressed through somatic symptoms, particularly gastrointestinal complaints and pain syndromes. In general medical clinics in Pakistan, routine depression screening should be implemented for patients presenting with unexplained somatic symptoms.