The results of our research indicate that somatic symptoms accompanying bereavement are not direct consequences of this state but they can be traced back to the associated anxiety and depression. Furthermore, our data revealed that anxiety was a mediator between bereavement and somatic symptoms in both genders, while depression played a mediating role only in men. These data draw attention to the need to recognize anxiety and depression looming in the background of somatic symptoms. Mental health problems may be masked by somatoform disorders [21
]; therefore, clinicians need to be trained to recognize and treat more effectively the psychiatric disorders in the background of somatoform disorders [22
Among the bereaved, this is the first research measuring individual somatic symptoms with the PHQ-15 questionnaire. The results confirm former studies which pointed out the co-morbidity of depression and anxiety [10
]. Research in this field is all the more important since even today there is an ongoing professional debate about the criteria by which the diagnosis of “bereavement related disorder” may enter the DSM-V [23
]. Psychosomatic symptoms are frequent and normal reactions during the grieving period, but clinicians should assess anxiety and depression underlying these phenomena. As previous studies have pointed out, the co-morbidity of somatoform symptoms, depression, and anxiety indicates an increased difficulty of coping with bereavement [24
The strength of our study is that it is based on a national representative survey. According to a comprehensive study [12
], only one analysis has been carried out using the PHQ-15 Questionnaire on a representative sample [25
]. The limitation of the study, however, is its cross-sectional nature; thus it cannot verify causal relationships. Moreover, we analysed anxiety with only one question. Although the single question method used here is generally accepted and often used in large scale epidemiological surveys [26
], and this question shows a very strong correlation with an often used and internationally recognised anxiety scale, the reliability of single item scales is inevitably weaker than that of longer scales. Thus we could have given a more reliably and nuanced picture of a person’s anxiety level with an extended and more complex instrument. Consequently, also the stronger mediator role of anxiety should be considered as preliminary result until confirmed in other studies using multi-item anxiety scales. It is also important to bear in mind that the PHQ-15 questionnaire gives no explanation of the causes of symptoms, which means that it is inappropriate for setting up a clinical diagnosis of somatization disorder. At the same time, the questionnaire had a sensitivity of 78% and a specificity of 71% for a DSM-IV somatoform diagnosis [27
]. Finally, formation of somatic symptoms in bereavement can be affected by several other potential mediator factors (perceived social support, religious beliefs etc.) than anxiety and depression, which deserves further evaluation.
In conclusion, our research draws attention to the need to recognize anxiety and depression looming in the background of somatic disorders and provides useful data for setting up the diagnostic criteria of complicated grief.