The overlap of somatic, anxious and depressive syndromes: A population-based analysis Sebastian Kohlmann PhD a, ⁎ ,1 , Benjamin Gierk MSc a,b,1 , Anja Hilbert PhD c , Elmar Brähler PhD c , Bernd Löwe MD a a Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf and Schön Clinic Hamburg Eilbek, Germany b Department of Psychiatry – Ochsenzoll, Asklepios Clinic Hamburg, Germany c Integrated Research and Treatment Center Adiposity Diseases & Department of Medical Psychology and Medical Sociology, University of Leipzig, Germany abstract article info Article history: Received 1 March 2016 Received in revised form 1 September 2016 Accepted 7 September 2016 Available online xxxx Objective: The comorbidity of somatic, anxious and depressive syndromes occurs in half of all primary care cases. As research on this overlap of syndromes in the general population is scarce, the present study investigated the prevalence of the overlapping syndromes and their association with health care use. Method: A national general population survey was conducted between June and July 2012. Trained interviewers contacted participants face-to-face, during which, individuals reported their health care use in the previous 12 months. Somatic, anxious and depressive syndromes were assessed using the Somatic Symptom Scale–8 (SSS-8), Generalized Anxiety Disorder-2 (GAD-2) and Patient Health Questionnaire-2 (PHQ-2) respectively. Results: Out of 2510 participants, 236 (9.4%) reported somatic (5.9%), anxious (3.4%) or depressive (4.7%) syn- dromes, which were comorbid in 86 (3.4%) cases. The increase in the number of syndromes was associated with increase in health care visits (no syndrome: 3.18 visits vs. mono syndrome: 5.82 visits vs. multi syndromes: 14.16 visits, (F (2,2507) = 149.10, p b 0.00001)). Compared to each somatic (semi-partial r 2 = 3.4%), anxious (semi-partial r 2 = 0.82%) or depressive (semi-partial r 2 = 0.002%) syndrome, the syndrome overlap (semi-par- tial r 2 = 6.6%) explained the greatest part of variance of health care use ( change_in R 2= 11.2%, change_in F (3,2499) = 112.81, p b 0.001.) Conclusions: The overlap of somatic, anxious and depressive syndromes is frequent in the general population but appears to be less common compared to primary care populations. To estimate health care use in the general population the overlap of somatic, anxious and depressive syndromes should be considered. © 2016 Published by Elsevier Inc. Keywords: Depression Anxiety Somatic symptom burden Health care use Population survey Syndrome 1. Introduction Somatoform, anxiety and depressive disorders are among the most frequently occurring mental disorders in primary care and in the gener- al population [1,2]. Each of these diagnoses is associated with substan- tial health burdens and increased health care use [3,4]. In primary care settings, however, patients rarely present with a “pure” depressive, anx- iety or somatoform disorder. Instead, patients often report a combina- tion of somatic, anxious and depressive syndromes that have been described as the ‘Somatization-Anxiety-Depression Triad’ [1,5–7]. Thus far, the prevalence of the somatic, anxious and depressive (SAD) syn- dromes and their overlap has primarily been investigated in patients in primary care and mental health settings [8]. To understand the epidemiology of these highly overlapping mental health syndromes, knowledge of the ‘natural’ prevalence of the overlap of single SAD syn- dromes in the general population is vital. The prevalence of the comorbidity of the SAD syndromes has mainly been investigated in primary care patients: It is estimated that every second patient with one SAD syndrome comorbidly suffers from anoth- er of these syndromes [8]. Therefore, it is argued that in primary care pa- tients, “…there is little evidence that depression, anxiety and somatization are separated by natural boundaries” [8]. The data on the overlap of SAD syndromes in the general population are yet not avail- able; studies have investigated the prevalence rates of individual syn- dromes but have neglected the overlap of single SAD syndromes. These data, however, are crucial for objectively evaluating the overlap of single SAD syndromes at the level of the whole society and using this as the basis of comparison with clinical populations. In addition, knowledge of the overlap of single SAD syndromes is vital to determin- ing whether prevention of the three most common mental health syn- dromes should focus on each individual syndrome or on all three SAD syndromes [9]. In terms of the comorbidity of psychiatric diagnoses, Journal of Psychosomatic Research 90 (2016) 51–56 ⁎ Corresponding author at: Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany. E-mail address: s.kohlmann@uke.de (S. Kohlmann). 1 Both authors contributed equally. http://dx.doi.org/10.1016/j.jpsychores.2016.09.004 0022-3999/© 2016 Published by Elsevier Inc. Contents lists available at ScienceDirect Journal of Psychosomatic Research