Association Between Mental Health Symptoms and Chronic Rhinosinusitis With Nasal Polyps

Association Between Mental Health Symptoms and Chronic Rhinosinusitis With Nasal Polyps | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 24 February 2025 V1 Latest version Share on Association Between Mental Health Symptoms and Chronic Rhinosinusitis With Nasal Polyps Authors : Jianrong Ge 0009-0009-7902-4171 , Yinfen Zhang , Qiao Shi , Lu Liu , Chunxiao Sun , Peiju Zhou , and ji liu [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.174037877.71403076/v1 305 views 149 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Objectives: It is still not quite clear whether mental health symptoms could be further identified correlations among the endotype, severity and health-related quality of life (HRQOL) impairment of chronic rhinosinusitis with nasal polyps (CRSwNP). Design: Prospective cross-sectional study. Setting: One tertiary care academic hospital. Methods: Patients with CRSwNP completed prospective measurements, including calculating body mass index (BMI), identifying eosinophilic CRSwNP (eCRSwNP), assessing Lund-Mackay score (LMS), 22-item Sino-Nasal Outcomes Test (SNOT-22), 14-item Perceived Stress Scale (PSS-14), as well as Hospital Anxiety and Depression Scale (HADS). Results: Of 91 patients with CRSwNP were enrolled, including 57 males (62.64%) and 34 females (37.36%), with a mean (SD) age of 46.31 (14.41) years. The scores of SNOT-22 were correlated with both the scores of anxiety ( r = 0.348; p = 0.001) and depression scale ( r = 0.217; p = 0.039). Patients younger than 60 years old (OR, 4.798; 95% CI, 1.288-17.874; p = 0.0194) and highly educated (OR, 4.726; 95% CI, 1.689-13.224; p = 0.0031) experienced more stress. Patients with marital status (OR, 0.101; 95% CI, 0.026-0.398; p = 0.0011) had less anxiety, while normal weight (OR, 0.242; 95% CI, 0.076-0.775; p = 0.016) and short history (OR, 0.216; 95% CI, 0.063-0.742; p = 0.0150) had less depression. Conclusion: Anxiety and depression symptoms were prevalent, while stress was more prevalent in CRSwNP. Anxiety and depression were correlated with HRQOL impairment. Moreover, young and highly educated patients had more stress. Marriage reduced anxiety. Patients with normal weight and short history had less depression. not-yet-known not-yet-known not-yet-known unknown Association Between Mental Health Symptoms and Chronic Rhinosinusitis With Nasal Polyps Running title: Stress, Anxiety and Depression in CRSwNP ABSTRACT Objectives: It is still not quite clear whether mental health symptoms could be further identified correlations among the endotype, severity and health-related quality of life (HRQOL) impairment of chronic rhinosinusitis with nasal polyps (CRSwNP). Design: Prospective cross-sectional study. Setting: One tertiary care academic hospital. Methods: Patients with CRSwNP completed prospective measurements, including calculating body mass index (BMI), identifying eosinophilic CRSwNP (eCRSwNP), assessing Lund-Mackay score (LMS), 22-item Sino-Nasal Outcomes Test (SNOT-22), 14-item Perceived Stress Scale (PSS-14), as well as Hospital Anxiety and Depression Scale (HADS). Results: Of 91 patients with CRSwNP were enrolled, including 57 males (62.64%) and 34 females (37.36%), with a mean (SD) age of 46.31 (14.41) years. The scores of SNOT-22 were correlated with both the scores of anxiety ( r = 0.348; p = 0.001) and depression scale ( r = 0.217; p = 0.039). Patients younger than 60 years old (OR, 4.798; 95% CI, 1.288-17.874; p = 0.0194) and highly educated (OR, 4.726; 95% CI, 1.689-13.224; p = 0.0031) experienced more stress. Patients with marital status (OR, 0.101; 95% CI, 0.026-0.398; p = 0.0011) had less anxiety, while normal weight (OR, 0.242; 95% CI, 0.076-0.775; p = 0.016) and short history (OR, 0.216; 95% CI, 0.063-0.742; p = 0.0150) had less depression. Conclusion: Anxiety and depression symptoms were prevalent, while stress was more prevalent in CRSwNP. Anxiety and depression were correlated with HRQOL impairment. Moreover, young and highly educated patients had more stress. Marriage reduced anxiety. Patients with normal weight and short history had less depression. (2487 words) Keywords: chronic rhinosinusitis with nasal polyps; mental health symptoms; stress; anxiety; depression Summary • Anxiety and depression symptoms were prevalent, while stress was more prevalent in CRSwNP. • Anxiety and depression were correlated with HRQOL impairment. • Meanwhile, LMS was not related to any mental health symptom. • Moreover, young and highly educated patients had more stress. Marriage reduced anxiety. Patients with normal weight and short history had less depression. • Of note, there was no significant correlation between condition endotypes and mental health symptoms. 1 | Introduction Chronic rhinosinusitis (CRS) is a common nose and paranasal sinuses disease that refers to a chronic inflammation of the mucosa for more than 12 weeks (1-3) . The main symptoms include nasal congestion, discharge, facial pain or pressure, and hyposmia or anosmia, simultaneously prone to accompanied by mental health symptoms, such as anxiety and depression, affecting work, study, and interaction (1-3) . These physiological and psychological symptoms cause a impaired health-related quality of life (HRQOL) and pose a substantial global health and economic burden (1-3) . The prevalence of anxiety and depression in the CRS population are approximately 16.1%-41.6% and 20.9%-29.6%, respectively (4) . Patients with CRS are 1.4-1.6 times higher than those without CRS (5) . As a heterogeneous group of conditions with differing pathophysiologies, CRS can be described as 2 phenotypes: disease with nasal polyps (CRSwNP) and disease without nasal polyps (CRSsNP) based on nasal endoscopic findings (1-3) . It is well known that the prevalence of anxiety and depression in CRSsNP are slightly higher than those in CRSwNP (5) . However, many studies referring to mental health symptoms mainly focus on CRSsNP (6) , due to the lower prevalence of CRSwNP compared to CRSsNP (1,3) . Furthermore, it is still not quite clear whether mental health symptoms could be further identified correlations among the endotype, severity and HRQOL impairment of CRSwNP. Therefore, we aimed to investigate the association between mental health symptoms and CRSwNP, involving the endotype, severity and HRQOL impairment in the present study, and then wished to provide appropriate preventions and decisions for CRSwNP patients to reduce the burden of physiological and psychological disorders. 2 | Materials and methods 2.1 | Study Population The flow diagram of study enrollment and participation was shown in Figure 1. We consecutively recruited 91 patients of CRSwNP who underwent endoscopic sinus surgery (ESS) in the ward setting from February 11, 2023 to February 29, 2024. Patient data, such as age, gender, height, weight, education, marital status, smoking and residence were recorded in detail, as well as clinical history, recurrence, allergic and chronic comorbidities. All participants had enough literacy and provided written informed consent. The study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline to ensure comprehensive and transparent reporting of our study. 2.2 | Assessment of BMI and category BMI was calculated by weight in kilograms divided by height in square meters, and then, categorized into 4 groups according to Chinese standard as previously described: underweight (BMI < 18.5 kg/m 2 ), normal weight (18.5 ≤ BMI < 24 kg/m 2 ), overweight (24 ≤ BMI < 28 kg/m 2 ), and obesity (BMI ≥ 28 kg/m 2 ) (7) . 2.3 | Prospective assessment of clinical outcomes We prospectively measured the endotype, severity, HRQOL, and self-reported mental health symptoms of CRSwNP patients when presurgical. Each measurement was evaluated by a single experienced otolaryngologist, respectively. They were unaware of each other, and also undisturbed by each other. 2.3.1 | Diagnosis of CRSwNP and endotype All CRSwNP cases were diagnosed by trained otolaryngologists using sinus endoscopy, surveys of medical histories and CT findings (1-3) . Endotype was based on the presence or absence of a type 2 inflammatory reaction. Clinically, CRSwNP patients were further classified into eosinophilic (eCRSwNP) and non-eosinophilic (neCRSwNP) based on the number of eosinophils in nasal polyps after ESS (3) . Of note, participants, whose nasal polyp tissue eosinophil count per high power field (HPF) (× 400 magnification) was 10 or higher by standard hematoxylin and eosinstaining, were defined as eCRSwNP, otherwise as neCRSwNP. Compared to neCRSwNP, the symptoms of eCRSwNP were often more severe and difficult to be controlled, furthermore, with a higher recurrence rate (3) . 2.3.2 | Severity The assessment of disease severity was based on objective sinus CT scans and quantifiable Lund Mackay score (LMS) (1-3,8) . LMS was most commonly used and validated scoring system of sinus inflammatory change, with higher scores indicating higher severity. Total LMS of 5 or more had an excellent positive predictive value, strongly indicating true disease (3) . 2.3.3 | HRQOL Impairment The assessment of HRQOL was based on subjective 22-item Sino-Nasal Outcomes Test (SNOT-22) (1-3,9) . SNOT-22 was the most widely used and validated disease specific instrument in multiple languages, with higher numbers indicating worse consequences. Total SNOT-22 score of 20 or more were consistent with at least moderate severity of condition (2,3) . 2.3.4 | Stress The assessment of stress symptom was based on the validated Chinese version of 14-item Perceived Stress Scale (PSS-14) (10-12) . PSS-14 was a tool used to assess the level of perceived stress in an individual’s life, including disease-related chronic stress. The higher the score, the higher the stress level. Four ranges were defined: 0 to 14, normal; 15 to 28, mild; 29 to 42, moderate; and 43 to 56, severe. 2.3.5 | Anxiety and Depression The assessment of anxiety and depression symptom was based on the validated Chinese version of Hospital Anxiety and Depression Scale (HADS) (4,13,14) . HADS was originally developed to capture clinically significant states of anxiety and depression in a nonpsychiatric hospital setting as a screening tool, with 7 items indicating anxiety and 7 items indicating depression. Four ranges were defined: 0 to 7, normal; 8 to 10, mild; 11 to 14, moderate; and 15 to 21, severe. 2.4 | Statistical analysis Data of age and BMI, were normally distributed, displayed as mean ± standard deviation (SD); history, was non normally distributed, displayed as median and interquartile range (IQR). Meanwhile, the scores of LMS, SNOT-22, PSS-14 and HADS, also showed non normal distribution, analyzed using the Spearman’s rank correlation and Chi-squared test. Variables, such as gender, age, BMI, education, marital status, smoking, residence, history, recurrence, allergic and chronic comorbidities, were performed as binary variables in the logistic regression model, as well as endotype. Statistical significance was defined as a two-tailed p < 0.05. All statistical analyses were conducted using SAS version 9.4. not-yet-known not-yet-known not-yet-known unknown 3 | Results 3.1 | Population characteristics A total of 91 patients with CRSwNP were enrolled in the study, included 57 men (62.64%) and 34 women (37.36%), with a mean (SD) age of 46.31 (14.41) years, . Overall, 52.75% of patients (48 cases) experienced high school education at least; 87.91% (80 cases) were married; 28.57% (26 cases) were previous or current smokers; 61.54% (56 cases) lived in urban areas; a median (IQR) history of 24 (4-96) months; 25.27% (23 cases) had recurrence; 28.57% (26 cases) comorbided with allergic diseases, such as allergic rhinitis (AR), conjunctivitis, dermatitis, or asthma; 32.97% (30 cases) comorbided with chronic diseases, such as hypertension, diabetes or chronic obstructive pulmonary disease. The proportion of eCRSwNP was 30.77% (28 cases) (Table 1). 3.2 | Clinical outcomes Of 91 patients, the median (IQR) LMS score was 10 (7-18) (range, 1 to 24), the proportion of LMS ≥ 5 was 86.81% (79 cases). The median (IQR) SNOT-22 score was 23 (15-31) (range, 1 to 73), the proportion of SNOT-22 ≥ 20 was 64.84% (59 cases) (eTable 1 in the Supplement). Of all mental health symptoms, the overall prevalence of stress: 63.74% (58 cases), with 54.95% (50 cases) mild, 8.79% (8 cases) moderate, and no severe cases; anxiety: 20.88% (19 cases), with 15.38% (14 cases) mild and 5.49% (5 cases) moderate to severe cases; depression: 21.98% (20 cases), with 16.48% (15 cases) mild and 5.49% (5 cases) moderate to severe cases (eTable 1 in the Supplement and Figure 2). Interestingly, 10.99% (10 cases) were coexisting with anxiety and depression, 8.79% (8 cases) simultaneously experienced stress, anxiety and depression, while 24.18% (22 cases) had no symptoms at all. 3.3 | Correlation of LMS and SNOT-22 with mental health symptoms Using the Spearman’s rank correlation, there was no correlation between LMS scores and mental health symptoms; and scores of SNOT-22 were correlated with both scores of anxiety ( r = 0.348; p = 0.001) and depression scale ( r = 0.217; p = 0.039); but not for stress (eTable 2 in the Supplement and Figure 3). Using the Chi-squared test, the proportion of LMS ≥ 5 showed no significant difference in stress, anxiety and depression, respectively; the proportion of STOT-22 ≥ 20 also showed no significant difference in stress and depression, respectively, but significantly had more anxiety (28.81% vs 6.25%, p = 0.012) (Table 2). 3.4 | Risk Factors Among Stress, Anxiety and Depression Groups 3.4.1 | Variables The inflammatory microenvironment in CRSwNP was complex and heterogeneous. We combined variables such as age, gender, BMI, education, marital status, smoking, residence, history, recurrence, allergic and chronic comorbidities, as well as endotype, and further analyzed the association of mental health symptom groups with CRSwNP, using logistic regression analysis. 3.4.2 | Stress Using univariate analysis, variables, such as age < 60 years ( p = 0.0006), high school and above ( p < 0.0001), married ( p = 0.0771), and chronic comorbidities ( p = 0.0587) were performed in multivariate analysis. After adjustment, patients with age < 60 years (OR, 4.798; 95% CI, 1.288-17.874; p = 0.0194) and high school and above (OR, 4.726; 95% CI, 1.689-13.24; p = 0.0031) experienced more stress. There was no significant correlation between endotype and stress (eTable 3 in the Supplement). 3.4.3 | Anxiety Patients with marital status (OR, 0.101; 95% CI, 0.026-0.398; p = 0.0011) had less anxiety. There was also no significant correlation between endotype and anxiety (eTable 4 in the Supplement). 3.4.4 | Depression After univariate analysis, variables, such as normal weight ( p = 0.0292), urban ( p = 0.0900), and history ≤ 12 months ( p = 0.0253) were included in multivariate analysis. Patients with normal weight (OR, 0.242; 95% CI, 0.076-0.775; p = 0.016) and history ≤ 12 months (OR, 0.216; 95% CI, 0.063-0.742; p = 0.0150) had less depression. Similarly, no significant difference was showed between endotype and depression (eTable 5 in the Supplement). 4 | Discussion In present study, we prospectively assessed eosinophil infiltration, LMS, SNOT-22, PSS-14, and HADS of 91 patients with CRSwNP, and investigated the correlation of mental health symptoms with endotype, severity and HRQOL impairment. So far, there are still few reports on the mental health issues related to CRSwNP only. As is known to all, sudden stress events often catch us off guard, especially negative events, which can cause a series of physiological and psychological stress reactions. There also are some chronic stress events, such as CRSwNP symptoms (nasal congestion, discharge, and olfactory dysfunction), which are persistent and difficult to control, leading accumulated pressures from small to large. Inadaptation to stress could alter brain function and peripheral physiology, and promote the development of psychological disorders frequently in CRSwNP (15,16) , such as anxiety (4,5) and depression (4,5) . Regarding the overall prevalence of mental health symptoms in our CRSwNP cases, stress was widely present, accounting for 63.74%; anxiety and depression were relatively low, accounting for 20.88% and 21.98% respectively, but significantly higher than the 5%-10% of the general population (4) . By comparison, our data was consistent with previous studies (4,5,11,14) ; the prevalence of anxiety and depression were even very close to those of AR (17) and asthma (18) . In fact, a challenge in understanding CRSwNP, covered the impact on patients is the lack of correlation between objective measurements of severity noted by healthcare providers and subjective impairment of HRQOL experienced by patients, such as LMS and SNOT-22 (1,3) . In order to control the measurement bias, we simultaneously collected and analyzed data on LMS and SNOT-22, and identified CRSwNP cases with higher severity (LMS ≥ 5) and more impaired HRQOL (SNOT-22 ≥ 20) (1-3) . Interestingly, we found that SNOT-22 was associated with anxiety and depression, while LMS was not associated with any mental health symptoms. To our knowledge, it is HRQOL impairment, not LMS, that is the primary reason for treating CRSwNP (1) . SNOT-22 includes a psychological subdomain that overlaps with HADS; anxiety and depression may amplify HRQOL impairment (1) . These could explain the association of anxiety and depression with SNOT-22, but not LMS. Clinically, eCRSwNP is characterized by type 2 inflammatory response, typically presented mixed infiltration of eosinophils and mast cells in nasal mucosal tissue, as well as increased productions of IL-4, IL-5, and IL-13 (1-3) . The prevalence of eCRSwNP was as high as 80% in Western countries (1-3) , while in this study it was only 30.77%, which was consistent with Asian countries including China (19) . In addition, eCRSwNP was not associated with mental health symptoms and might be attributed to similarity of LMS, prone to involving multiple sinuses, but not directly promoting HRQOL impairment. Moreover, we also found that young and highly educated patients faced more stress, which had been confirmed in previous studies and might be related to many sources, such as economics, employment, scientific research, and social interactions (11,12) . Patients in marital status experienced less anxiety, which could be attributed to intimacy and support between spouses (20) . Recently, epidemiological evidence on the relationship between dietary patterns and mental health issues has been increasing. The risk of depression would be reduced by a healthy diet such as the Mediterranean diet, but increased by Western dietary patterns (WDP) (21) . These could explain why patients with normal weight experienced less depression. Additionally, many evidences also suggested that there was a specific major depression subtype, inflammatory cytokine-associated depression (ICAD) (22) . The high expressions of IL-6 and TNF-α in the nasal mucosa of CRSwNP patients could directly or indirectly affect the brain, leading to an increased risk of depression and worsening as the condition progressed (23) , even providing some basis for patients with a short history experienced less depression. The pathophysiologic mechanisms were similar to those observed in AR (17) and asthma (18) . Given that depression is associated with premature mortality from suicide (24) , our research can contribute to early identification and intervention of these high-risk patients. To our knowledge, this is the first study to reveal the association between mental health symptoms and eCRSwNP or neCRSwNP with several advantages. Firstly, it includes a prospective study design with an internal control group, making data collection comprehensively and comparing results accurately between mental health symptom groups. Secondly, combining the authoritative LMS with the validated SNOT-22, it is possible to better measure both subjective and objective burden of disease. Finally, the use of a mental health assessment method that combines stress, anxiety, and depression, is more comprehensive than previous studies. However, this study also has many limitations, including possible selection bias, as our data was obtained from CRSwNP patients in a single center. Some patients had tenacious symptoms or postoperative recurrence, which might amplify symptoms of stress, anxiety, and depression. Another limitation is just a cross-sectional research, which makes it difficult to explore the bidirectional risk of mental health symptoms for patients with CRSwNP (25) . 5 | Conclusion Our findings demonstrated that anxiety and depression symptoms were prevalent, while stress was more prevalent in CRSwNP. Anxiety and depression were correlated with HRQOL impairment. Moreover, young and highly educated patients had more stress. Marriage reduced anxiety. Patients with normal weight and short history had less depression. Further research is needed to confirm whether the endotype of this condition is related to mental health symptoms. References 1. Bachert C, Marple B, Schlosser RJ, Hopkins C, Schleimer RP, Lambrecht BN, et al. Adult chronic rhinosinusitis. Nat Rev Dis Primers . 2020 Oct 29;6(1):86. doi: 10.1038/s41572-020-00218-1. PMID: 33122665. 2. Hopkins C. Chronic Rhinosinusitis with Nasal Polyps. N Engl J Med . 2019 Jul 4;381(1):55-63. doi: 10.1056/NEJMcp1800215. 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Population characteristics of CRSwNP (N=91) Table 2. Mental health symptom groups in CRSwNP (N=91) Figure 1. Flowchart of study enrollment and participation Figure 2. Prevalence of mental health symptoms Figure 3. Degree of correlation ( r ) between LMS, SNOT-22 and mental health symptoms eTable 1. Clinical outcomes of CRSwNP (N=91) eTable 2. Degree of correlation ( r ) between LMS, SNOT-22 and mental health symptoms (N=91) eTable 3. Risk factors of stress group in CRSwNP (N=91) eTable 4. Risk factors of anxiety group in CRSwNP (N=91) eTable 5. Risk factors of depression group in CRSwNP (N=91) Supplementary Material File (supplementary tables.docx) Download 44.61 KB File (tables.docx) Download 22.84 KB Information & Authors Information Version history V1 Version 1 24 February 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Authors Affiliations Jianrong Ge 0009-0009-7902-4171 First Affiliated Hospital of Soochow University View all articles by this author Yinfen Zhang First People's Hospital of Changshu City View all articles by this author Qiao Shi First Affiliated Hospital of Soochow University View all articles by this author Lu Liu First Affiliated Hospital of Soochow University View all articles by this author Chunxiao Sun First Affiliated Hospital of Soochow University View all articles by this author Peiju Zhou First Affiliated Hospital of Soochow University View all articles by this author ji liu [email protected] First Affiliated Hospital of Soochow University View all articles by this author Metrics & Citations Metrics Article Usage 305 views 149 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Jianrong Ge, Yinfen Zhang, Qiao Shi, et al. Association Between Mental Health Symptoms and Chronic Rhinosinusitis With Nasal Polyps. Authorea . 24 February 2025. 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