Chronic Rhinosinusitis May Up Risk for Anxiety, Depression

Veronica Hackethal, MD

February 07, 2019

Having chronic rhinosinusitis (CRS) may increase the risk for depression and/or anxiety compared with not having the condition, according to a large database study conducted in South Korea.

The study, published online today in JAMA Otolaryngology – Head and Neck Surgery, also found that people who have both CRS and nasal polyps may have even higher risk for depression or anxiety than those without polyps.

Although other studies have found a link between CRS and increased risk for depression, this study is the first to take a nationwide look at the link between CRS and anxiety.

"[T]his study provides new insight into the effects of CRS on mental health problems. Physicians should be aware of the potential comorbidities observed in patients with CRS and provide therapy to reduce the risk of depression and anxiety in these patients," write Jon-Yeup Kim, MD, PhD, of Hallym University College of Medicine, Chuncheon, Republic of Korea, and colleagues.

CRS ranks among the most common chronic diseases. The diagnosis requires evidence of chronic sinus inflammation of at least 12 weeks' duration. Typically, the condition is classified as CRS without nasal polyps, and CRS with nasal polyps. CRS with nasal polyps usually represents a more severe form of the condition.

CRS often affects quality of life and can have negative effects on physical and emotional health. Studies have suggested that depression and anxiety represent the two most common mental health disorders among individuals with CRS. People with depression or anxiety may also have more difficulty managing CRS.

To further evaluate the links, the researchers conducted a retrospective cohort study using data from the South Korean national health insurance database. They randomly selected more than 1 million patients for whom database records were available for the period 2002 to 2013. This represents about 2.2% of the South Korean population. From those persons, they identified 16,224 adults who had CRS and matched them with 32,448 adults who did not have CRS.

Results showed that during 11 years of follow-up, individuals with CRS had 1.54 times higher risk for depression (24.2 vs 16.0 per 1000 person-years; adjusted hazard ratio [aHR], 1.54; 95% confidence interval [CI], 1.48 – 1.61) and 1.57 times increased risk for anxiety (42.2 vs 27.8 per 1000 person-years; aHR, 1.57; 95% CI, 1.52 – 1.62) compared to those without CRS.

Analyses in which adjustments were made for sex, age, residential area, household income, and comorbidities showed that the risk for depression and anxiety was higher among those who had both CRS and nasal polyps than among those with CRS who did not have nasal polyps.

Specifically, those with CRS and nasal polyps were 1.61 times more likely to be diagnosed with depression (95% CI, 1.54 – 1.69) and were 1.63 times more likely to be diagnosed with anxiety (95% CI, 1.57 – 1.69), compared with those who did not have CRS.

Among those with CRS who did not have nasal polyps, the hazard ratios for depression and anxiety were 1.41 (95% CI, 1.32 – 1.50) and 1.45 (95% CI, 1.38 – 1.52), respectively, compared with those without CRS.

The authors mentioned several limitations to their study. Notably, the analysis could not adjust for smoking, alcohol consumption, and body mass index, which could have affected results.

In a linked editorial, Edward McCould, MD, MPH, of Ochsner Clinic, New Orleans, Louisiana, notes several strengths of the study. These include the use of propensity score matching to minimize confounding by baseline factors and the fact that the analysis was restricted to individuals who were diagnosed with CRS by an otolaryngologist or with depression/anxiety by a psychiatrist.

However, he also mentions several "notable" limitations.

Although the study's large size and long duration increase the likelihood that the findings are generalizable to other populations, past studies have suggested that CRS in Asian populations may differ from CRS in individuals in Western countries. Thus, it's unclear whether the findings generalize to the North American population, according to McCould.

He also urges caution when interpreting these findings. Because of its retrospective design, the study cannot determine the causes for the association between CRS and anxiety/depression. The question may represent a chicken-or-egg scenario: does CRS cause increased risk for depression/anxiety, or do depression/anxiety amplify symptoms of CRS?

Nevertheless, he writes: "Given the current state of knowledge, the physician may choose to screen patients with newly diagnosed CRS for the presence of depression or anxiety disorders.

"As future studies continue to define the relationship between psychiatric disease and CRS, a nuanced assessment of mental health status may become increasingly important for physicians who treat sinonasal disease," he concludes.

The study was supported by a grant from the Korea Health Technology R&D Project through the Korea Health Industry Development Institute, which is funded by the Ministry of Health and Welfare, Republic of Korea, and by a grant from the Bio and Medical Technology Development Program of the National Research Foundation, which is funded by the Korean government. The authors and editorialist have disclosed no relevant financial relationships.

JAMA Otolaryngol Head Neck Surg. Published online February 7, 2019.

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