A glimpse into the psychological status of E.N.T inpatients in China: A cross-sectional survey of three hospitals in different regions

Introduction

Somatic diseases are often accompanied by psychological disorders. Up to 50% of general medical and surgical inpatients have symptoms indicative of psychological distress or disturbance, including depression, anxiety, and substance abuse,^1-3 and an increasing number of studies have begun to focus on the relationship between psychiatric presentations and physical diseases. Patients with otorhinolaryngological diseases may be more susceptible to mental illness. Postolache et al⁴ demonstrated a state-level relationship, rather than only a trait-level relationship, between changes in allergy symptom scores and changes in depression scores in patients with recurrent mood disorders exposed to seasonal peaks in aeroallergens. Head and neck cancer patients exhibit the highest rates of major depressive disorder among all oncology patients; fifteen to fifty percent of these cancer patients experience major depressive disorder, which typically emerges during the course of treatment with peak symptoms occurring 2–3 months after diagnosis.⁵ Depression may be more common in chronic rhinosinusitis than previously recognized.⁶ Additionally, an increase in tinnitus annoyance was positively correlated with the severity of anxiety and depression in normal-hearing patients.⁷

Nevertheless, to date, it remains unclear whether E.N.T diseases result in a higher prevalence of mental health impairments or co-occurring psychiatric disorders amplify the subjective symptom scores of quality of life. Patients with common E.N.T diseases are more likely to show comorbidity with psychiatric disorders. Psychological interventions for this patient group are highly important for both patients and doctors. To properly manage patients with both E.N.T diseases and concurrent mental illness, these patients must first be identified. Therefore, obtaining a global understanding of the psychological status of E.N.T patients in China in a real-world inpatient setting and current social environment is urgent. The objective of this study was to determine whether E.N.T inpatients have a higher prevalence of mental illness than the general population and whether certain diseases are more likely to be associated with mental illness than other diseases using a cross-sectional survey in three different hospitals in different cities in China.

Materials and methods

Results

Demographic characteristics

In total, 476 inpatients from E.N.T departments who met the inclusion criteria were included in the survey, including 439 patients who completed the questionnaire without missing data in the final data analysis, which resulted in a response rate of 92.2%. The control group consisted of 209 inpatients from the general surgery department who also participated in the survey, including 184 inpatients who completed the questionnaire, which resulted in a response rate of 88.0%. Finally, 84 of the 93 (90.3%) inpatients from the department of respiration completed the questionnaire without missing data. Descriptions of the study subjects are shown in Table 1. The mean age of the 707 participants at the time of the interview was 47.0 ± 15.9 years, including 373 males (52.8%) and 334 females (47.2%). Fig. 1 displays the distribution of various diseases in the E.N.T departments from the three hospitals at the time of the interview. ND, LP and OD accounted for the majority of inpatients in the E.N.T departments at each hospital.

Table 1. Demographic characteristics of the study sample (n = 707).

Department	Hospital	Total cases (n)	Cases included (%)	Cases with complete data	Proportion of complete data (%)	Age (y,  ± s)	Gender Male/Female
E.N.T	Chaoyang	245	219 (89.4)	207	94.5	41.7 ± 13.2	122/85 (1.44)
	Shanyi	182	166 (91.2)	148	89.2	49.7 ± 17.1	82/66 (1.24)
	Heze	101	91 (90.1)	84	92.3	42.2 ± 13.8	45/39 (1.15)
General Surgery	Chaoyang	63	52 (82.5)	46	88.5	45.2 ± 16.8	18/28 (0.64)
	Shanyi	133	113 (85.0)	98	86.7	55.2 ± 15.4	34/64 (0.53)
	Heze	49	44 (89.8)	40	90.9	46.3 ± 17.1	20/20 (1.00)
Respiration	Chaoyang	35	29 (82.9)	27	93.1	53.9 ± 13.6	18/9 (2.00)
	Shanyi	42	35 (83.3)	32	91.4	61.2 ± 20.1	18/14 (1.29)
	Heze	35	29 (82.9)	25	86.2	54.2 ± 13.4	16/9 (1.78)
Total 1		528	476 (90.2)	439	92.2	42.3 ± 13.8	249/190 (1.31)
Total 2		245	209 (84.2)	184	88.0	50.6 ± 16.7	72/112 (0.64)
Total 3		112	93 (83.1)	84	90.3	55.8 ± 15.5	52/32 (1.63)
Total 4		885	778 (88.0)	707	90.9	47.0 ± 15.9	373/334 (1.12)

• Total 1: E.N.T Department; Total 2: General Surgery Department; Total 3: Respiration Department; Total 4: Three Departments.

Factor analyses of the SCL-90

The patients in the E.N.T department of the Heze Hospital had a high prevalence of psychiatric distress in all ten domains of the SCL-90, followed by Shanyi Hospital. The subscale dimensions of O–C and hostility were the most common psychiatric symptoms in the E.N.T inpatients (Fig. 2). The prevalence of the psychiatric symptoms of SOM, hostility and paranoid ideation were higher in the patients with ND and OD than that others. Psychoticism was common in the patients with LP (Fig. 3).

Consistent with results of the SDS and SAS, depression was more common than anxiety in the E.N.T patients. However, the percentages of individuals with depression (60/439) and anxiety (25/439) screened by SCL-90 factor analysis were significantly lower than those evaluated by the SDS (349/439, 13.7% vs. 79.5%, P < 0.001) and SAS (72/439, 5.7% vs. 16.4%, P < 0.001).

Discussion

To the best of our knowledge, this study is the first to address the psychological status of E.N.T patients in three Chinese cities in a nearly real-world inpatient setting and social environment. The patients enrolled in the study accounted for 88.0% of all E.N.T inpatients during the study period.

Our results show that the prevalence of both anxiety and depression is more common in E.N.T patients than that in the general Chinese population. The prevalence of depression was nearly eight times greater than that of anxiety (81.7% vs. 9.2%). Furthermore, the patients in the E.N.T departments had a higher prevalence of anxiety and depression than those in the departments of general surgery but similar rates to the patients in the departments of respiration. Although 18.7% of the E.N.T patients were in psychiatric distress, they had lower clinical scores on the SCL-90 assessment than the general Chinese population. Furthermore, the patients with OD showed the highest prevalence of anxiety, followed by patients with benign tumors and LP. The only two severely anxious patients suffered from ND. More than one-third of the patients with OSA, malignant tumors and OD suffered from serious depression in the E.N.T group according to the SDS analysis. Moreover, the data show that the psychiatric symptoms of SOM, hostility and paranoid ideation are more common in patients with nasal and OD. Psychoticism is common in patients with LP. Therefore, patients with different E.N.T diseases experience different mental illnesses. There are significant differences in the prevalence of abnormal of SAS and SCL-90 scores in the E.N.T inpatients among different hospitals.

Despite the differences in methodologies, most published studies indicate some type of indistinct relationship between E.N.T-related diseases and mood syndromes.

Recently, an investigation of 117 Chinese patients with CRS demonstrated that the SAS and SDS scores (39.4 ± 11.6, 54.1 ± 11.0) were significantly higher than average,¹⁵ which is consistent with our results. Another study showed that psychiatric distress was prevalent in ninety-five patients awaiting surgery for CRS who were assessed using the psychiatric distress questionnaire (BSI and PHQ); 17% of these patients tested positive for anxiety, and 25% of these patients tested positive for depressive disorders.¹⁶ In a Chronic Rhinosinusitis Epidemiology Study (CRES), patients with CRS visiting E.N.T outpatient clinics at 30 centers across the United Kingdom showed significantly higher mental health morbidity than controls across the mental health and emotional well-being domains of the SF-36 (QoL – quality of life tool) and SNOT-22 (a nasal symptom score), particularly those with CRSsNPs.¹⁷ Although it remains controversial whether anxiety and depression can influence a patient's subjective symptom scores in chronic rhinosinusitis,^{16, 18, 19} anxiety and depression are prevalent in patients with CRS despite a number of methodological variances. A literature review by Sansoneet al. ²⁰ found that most published studies indicate that individuals with allergies, which is another common nasal disease, appear to be at a higher risk of an unknown degree for developing various types of anxiety or mood syndromes. The most common symptoms, such as a runny nose, sneezing, and nasal congestion, contribute to the same mental conditions as those in patients with CRS and AR. Hence, in this study, we classified all types of ND into one subgroup for the analysis, although most patients with AR do not require hospitalization. The same grouping strategy was used during the data analysis. However, there is one study that provided a different result.²¹ Notably, patients who are waitlisted for ESS did not demonstrate any significant level of psychiatric distress.

Hearing impairments, tinnitus and dizziness, which are most common symptoms of OD, are recognized causes of emotional and psychological disturbances worldwide. A systematic review by Theunissen²² reported that the literature consistently demonstrates that hearing-impaired children and adolescents are more prone than their normally hearing peers to develop depression, aggression, oppositional defiant disorder and psychopathy. In a survey of 544 patients experiencing dizziness as measured by the Beck Depression Inventory (BDI) and the Spielberger State-Trait Anxiety Inventory (STAI), the prevalence of high depression and anxiety scores were 11% and 18%, respectively. Bhatt⁷ found that 26.1% of the 21.4 million adult tinnitus sufferers reported problems with anxiety in the preceding 12 months, while 25.6% showed signs of depression. Those reporting tinnitus symptoms as a “big” or “very big” problem were more likely to concurrently report anxiety and depressive symptoms. The inpatients surveyed in the study with different OD are at risk of developing mental problems.

Studies investigating the relationship between psychopathological problems and common pathologies of the pharynx and larynx are scarce. Pooled data analyzed from 160 patients with muscle tension dysphonia,²³ benign vocal fold lesions, paradoxical vocal fold movement disorder, or glottal insufficiency indicated that 25.0%, 36.9%, and 31.2% of the patients showed elevated stress, anxiety, and depression scores, respectively. Tang et al ²⁴ reported that anxiety (39.8%), depression (31.2%) and sleep disorders (23.7%) were significantly more common in individuals with globus sensation, which is one of the common symptoms of throat and pharyngeal illness, that in healthy controls. In this study, we found that anxiety and depression are common in inpatients with LP, even though most of these diseases are vocal fold-related diseases.

Surprisingly, our data show that patients with benign tumors are more susceptible to mental issues than those with malignant tumors (SAS: 9/48, 18.8% vs. 1/13 7.7%; SDS: 41/48, 85.4% vs. 10/13, 77.8%). Patients with benign and malignant tumors face similar situations, such as fears of the unknown, malignant transformation, mortality, possible side effects, complications induced by treatment, and concerns regarding the long-term effects of the tumor and treatment on their quality of life. Psychological distress is, therefore, common in patients with cancer or benign tumors, and depression and anxiety are highly typical.^{25, 26} William et al.⁵ found that the prevalence of depression in head and neck cancer patients ranges from 15% to 50%. Despite the small sample size, our results suggest that the psychological comorbidities of patients with tumors, regardless of malignancy, should be given increased attention.

Several studies have highlighted the association between OSA and depression and anxiety with a rate of 17%–41%.^27-30 Because of the overlap in symptoms between the two conditions, such as insomnia, fatigue, decreased libido, irritability, weight changes, and cognitive difficulties, the assessment of depression in OSA is challenging, and it is difficult to find a reliable method to identify depression and anxiety in the presence of OSA. Different questionnaires have varying proportions of shared symptoms, including the SAS and SDS used in this study, which might increase the prevalence of depression in OSA.³¹ Moreover, structural and functional brain alterations have been found in anxious OSA subjects.³² More studies should be performed to clarify the possible pathophysiological mechanisms that could explain how obstructive sleep apnea can cause or worsen depression.

Based on the discussion thus far, psychological comorbidities are common among nearly all types of illnesses found in patients admitted to E.N.T departments. In addition, these mental issues exist broadly among those with otorhinolaryngologic diseases. It is important to provide a framework for subsequent investigations aiming to elucidate the scope, type and extent of the different types of E.N.T disorders. The results of our study are consistent with previous investigations. A multitude of factors might cause depression and anxiety in this group, such as sex, age, and socio-economic status. Hospitalization by itself is one of the most important factors. Previous studies have described a high prevalence of psychiatric comorbidity among general medical and surgical patients based on various assessment tools.³³ In our study, the prevalence of psychological distress or disturbance was also high in the respiratory department and general surgery department. Booth et al² reported that almost half (46.6%) of 1007 medical and surgical inpatients met the lifetime criteria for at least one diagnostic mental disorder, including 9.0 percent who showed signs of major depression or dysthymia, which is consistent with other reports.^{1, 34} Somatic illnesses and their consequences evoke strong emotions. These emotions may affect the course of the illness and the treatment efficacy through their physiological components. Since the presence of these conditions has been found to be associated with increased costs, length of stay and excess utilization of general medical services,^35-37 investigations of mental status on a large scale are warranted.

In addition to the common factors, the psychological state is significantly affected by the special symptoms induced by diseases, which might result in a different prevalence and type of psychological distress among various diseases. Our study revealed that patients with E.N.T diseases more frequently suffer from comorbid psychiatric illnesses than the patients in the control groups. This phenomenon may be attributed to the part of the body affected by the E.N.T diseases. For example, the most basic aspects of one's humanity, including the ability to speak, eat, breathe, and appear in public, may all be affected by laryngeal diseases or its treatment. Another reason maybe the interaction between the somatic symptoms and mental states. For instance, the common symptoms of nasal illness, such as obstruction, increase the risk of developing mental health problems. However, excessive anxiety and depression might exacerbate the subjective sensation of nasal discomfort.

Our study also highlighted that some differences in mental disorders are present between different type of diseases and different hospitals, which suggests that mental problems are more common and complicated in these specialized medical settings. For example, the psychiatric symptoms of SOM, hostility and paranoid ideation are more common in patients with ND and OD. It is of great importance to clarify the possible factors that increase the risk of hostility and paranoid ideation in this specific population. Different mechanisms may contribute to the situations of each disease, which suggests that attention should be paid to both the universality and particularity of the specific mental disorder experienced by the individual patient.

Although E.N.T doctors tend to be familiar with common co-occurring psychiatric disorders in certain E.N.T diseases, they are not always adept at diagnosing and treating concurrent mental illness. Thus, an understanding of this relationship and consideration of this situation during clinical training are essential. Our study provides a global scope of the psychological status of Chinese E.N.T patients in a nearly real-world inpatient setting and social environment, which has great positive implications for future research endeavors.

Another finding of the study is that the proportion of patients with anxiety and depression as identified by the SCL-90 (5.7% and 13.7%, respectively) was much lower than that found in patients screened with the SAS and SDS, which suggests that the SCL-90 does not sufficiently reflect these two common mental illnesses. However, the SCL-90 is best able to identify mental illnesses other than anxiety and depression. For instance, the analysis of the SCL-90 demonstrated that hostility is common in E.N.T inpatients. This knowledge is essential for targeted screenings and interventions. Notably, this does not imply that more is better because it is not easy for subjects to complete more than one questionnaire with high quality at one time. Thus, it is crucial to have reliable, simple, and sustainable methods for symptom monitoring that can be readily incorporated into daily medical practice.

The VAS has been found useful for assessing patients' subjective experiences or perceptions of a variety of clinical phenomena.^38-40 In the present study, the severity of diseases evaluated by the VAS score was significantly positively correlated with the severity of anxiety symptoms and the SCL-90 score but not depression. Patient-based symptom severity scoring systems may be influenced by external factors, such as the patient's age, expectations, culture, and physical and mental capabilities; it is, therefore, perhaps not surprising that there is a correlation between the severity of the disease and its symptoms. Although the VAS is a simple and rapid evaluation of the overall disease severity in a primary care and specialist setting, its accuracy and reliability should be further evaluated in screening mental disturbances in E.N.T inpatients.

Since the association between psychiatric comorbidity and specific diagnoses is known, we did not limit the study to certain medical conditions. The decision to include all possible diagnoses without strict inclusion and exclusion criteria was made to mimic a real clinical setting to ensure that the prevalence estimates are more generalizable. Accordingly, one must be cautious when interpreting the results with respect to a particular subgroup because of the limited sample size. Notably, consistent with most prospective studies investigating psychiatric comorbidity in general medical or surgical inpatients, the prevalence relied on mental health symptoms rather than on psychiatric diagnoses, which might result in an overestimate of the presence of mental illnesses. There is no current information regarding the mechanisms underlying the increased prevalence of psychiatric disorders in this specific population. Further studies should evaluate the specific role of these conditions in selected categories of E.N.T disorders in susceptible individuals.

In summary, to the best of our knowledge, this study is the first to systematically investigate the specificity of the relationships among psychiatric distress, anxiety and depression and each of the major disorders in Otolaryngology within a single study sample. Our work underscores that the successful treatment of patients with E.N.T diseases should involve medical, social, and psychological interventions. Increased knowledge regarding this relationship might significantly improve diagnostic accuracy and treatment outcomes for both otolaryngology illness and concurrent mental disturbances.

Conclusion

In summary, this study has shown that psychological distress, particularly anxiety and depression, are widespread in patients with otolaryngological diseases. This study highlights the importance of identifying and treating co-occurring psychiatric disorders in this high risk and clinically challenging group of patients.

Ethical approval

All procedures performed in the studies involving human participants were in accordance with the ethical standards of the hospitals' research committee (2015 LL128) and the 1964 Helsinki Declaration and its subsequent amendments.

Authors' contributions

TJ designed the experiment, analyzed and interpreted the patient data, and was a major contributor in writing the manuscript. LL, HF, HR and TC performed the investigation in different hospitals. ZS collected, analyzed and interpreted the patient data. All authors read and approved the final manuscript.

Funding

This study was funded by The Key Research and Development Program Funding of Shanxi Province (201603D121039).

Conflicts of interest

The authors declare that they have no conflicts of interest.