Up to one-fourth of patients coming into the clinic with chronic rhinosinusitis symptoms (CRS) could have clinically important anxiety or depression.
Primary care physicians should consider coexisting depression and anxiety in patients with persistent symptoms of rhinosinusitis and other chronic conditions because greater awareness of mental health issues such as these, along with screening for diseases and providing appropriate treatment, may improve symptom control.
My colleagues and I discussed these points in a study published recently in the European Archives of Otorhinolaryngology. Jayani Nanayakkara, a final-year medical student in the ENT Department at Guy’s Hospital, was the lead author.
Several studies have shown that depression influences a patient’s symptoms of chronic rhinosinusitis.
One study suggested that the prevalence of depression in patients with CRS is 25%.1 Clinically depressed patients reported significantly worse pain, energy levels, and difficulty with daily activities preoperatively compared with patients with CRS who were not depressed. Even after sinus surgery, depressed patients with CRS continued to have poorer disease-specific and overall quality-of-life outcomes compared with nondepressed patients.
In another study, 31% of patients with CRS who presented for surgery screened positive for somatization, 17% were positive for anxiety, and 25% were positive for depressive disorders.2 Patients with depression also reported more severe symptoms at 6 and 12 months after surgery than those without depression.
In a third study of patients with CRS who underwent surgery, the severity of depression showed significant improvement postoperatively.3
However, all these studies were carried out in the United States. Our study is the first to look at the impact of mental health on CRS symptom score in a European population.
Impairment of quality of life drives patients to seek medical treatment. Therefore, patient-rated outcome measures are being used increasingly to supplement clinical measures of disease.
One such validated measure is the Sinonasal Outcome Test-22 (SNOT-22) questionnaire. This questionnaire contains both disease-specific (nose-specific) questions and generic quality-of-life questions. In the Guy’s Hospital study, we analyzed both the total score and the 2 domains separately.
We also used another questionnaire, a valid screening tool widely used for detecting states of depression and anxiety in the setting of a hospital medical outpatient clinic.
The results revealed a strong association between total SNOT-22 and both anxiety and depression scores. We don’t know whether having a chronic illness predisposes to depression, depression simply amplifies symptom severity, or an element of each occurs.
Having identified an association between overall scores, we then looked at the disease-specific and general domains separately. We identified a very strong association between psychological symptoms in SNOT-22 and anxiety and depression scores.
This association is likely to reflect in part that the generic aspects of the SNOT-22 are capturing the impact of the underlying anxiety and depression on quality of life. However, we also found a correlation between the disease-specific domain of the SNOT-22 and depression scores.
We speculate that underlying depression and mental health problems cause amplification in the severity of symptoms (both the psychological symptoms and the disease-specific one) that manifest as a result of biological disease processes.
Other studies have established that there is a lack of association between patient-reported subjective symptoms and objective disease severity, such as radiological severity of disease. Symptom severity probably is influenced by personal characteristics of the patient (personal values and beliefs, intrinsic personality, coexistent disease, age, and sex) and external factors (socioeconomic factors, support systems, and societal values). From our study and others, mental health also appears to play a part in this process.
Of note, about one-third of the patients with CRS had symptoms of clinical anxiety and 11% were identified as having possible clinical depression. We do not know how many of these patients had a preexisting diagnosis made by their primary care physician, but some cases are likely to go undiagnosed.
I think it is worth considering the role of underlying depression, particularly in patients in whom the symptom burden appears disproportionate to the disease load and who do not respond to appropriate treatment. Primary care physicians should consider coexisting depression and anxiety in patients with persistent symptoms of rhinosinusitis and other chronic conditions.
1. Brandsted R, Sindwani R. Impact of depression on disease-specific symptoms and quality of life in patients with chronic rhinosinusitis. Am J Rhinol. 2007;21:50-54.
2. Davis GE, Yueh B, Walker E, et al. Psychiatric distress amplifies symptoms after surgery for chronic rhinosinusitis. Otolaryngol Head Neck Surg. 2005;132:189-196.
3. Litvack JR, Mace J, Smith TL. Role of depression in outcomes of endoscopic sinus surgery. Otolaryngol Head Neck Surg. 2011;144:446-451.