Correlation between anxiety and score for allergic rhinitis

Introduction

Allergic rhinitis (AR) is an atopic disorder affecting around 400 million people worldwide. It is caused by reactions brought on by immunoglobulin E (IgE) due to inhaled allergens. Before the age of 20 years, the occurrence of some symptoms peaks, and between the ages of 20 and 40 years, they gradually decrease (1). After the age of 40 years, the symptoms gradually disappear. The upper respiratory tract was once assumed to be the exclusive location of AR. Previous studies have shown that AR is a systemic respiratory disease involving the upper and lower respiratory tract and often appears with asthma (2).

The prevalence of AR has yet to be acknowledged in Indonesia. Nevertheless, empirical evidence gathered from multiple hospitals indicates that the incidence rate ranges from 10% to 26%. Its prevalence has risen over the past few decades, primarily due to the different stimuli that present a challenge, including irritants, allergens, infections, pollen, and air pollution. The allergy causes sneezing, rhinorrhea, nasal congestion, and itching (3). Although AR is not life-threatening, it can impact the patient’s ability to rest and work (4,5). Furthermore, research has indicated that chronic diseases, such as chronic respiratory conditions, can seriously affect people’s quality of life and impair their daily lives. Consequently, a correlation between AR and a higher risk of psychiatric disorders may exist. Additionally, anxiety and depression have been associated with a higher risk of allergy-related conditions (6).

Several studies have established and proven an association between allergies and psychological disorders. According to research by Patten et al., AR patients have greater rates of major depression [odds ratio (OR) =1.5], panic disorder, and social phobia than healthy people (OR of 1.7 and 1.3, respectively) (7). Cuffel et al. achieved similar findings, who studied 850,000 people and found that anxiety symptoms were 1.4 times more common in AR patients (8,9). This study aimed to investigate the correlation between anxiety and recurrence of AR. We present this article in accordance with the STROBE reporting checklist (available at https://jxym.amegroups.com/article/view/10.21037/jxym-23-22/rc).

Methods

This study followed AR patients in the ENT Department between February and April 2023. The present study employed a cross-sectional design to assess anxiety levels utilizing the Hamilton Rating Scale for Anxiety (HARS) questionnaire and evaluate AR recurrence using the Indonesian Score for Allergic Rhinitis (SFAR) questionnaire. Both questionnaires were sent to participants through the use of Google Forms. The metrics from the questionnaire were then categorized based on the results. The HARS has a total score range of 0–56, with scores 14 indicating no anxiety, scores 14–20 indicating mild anxiety, scores 21–27 indicating moderate anxiety, scores 28–41 indicating severe anxiety, and scores >41 indicating panic. There are 13 questions in the SFAR questionnaire. When the patient receives an SFAR score of at least 7, it will be decided whether or not the AR diagnosis is suspected. Inclusion criteria were male and female patients without psychopharmacologic or allergology treatment or psychotherapy. All patients underwent a clinical examination consistent with the diagnosis of allergic disorders and a hypersensitivity skin test to reveal hypersensitivity to environmental antigens. The statistical analysis used in this study was linear regression analysis. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the Health Research Ethics Committee of the Faculty of Medicine and Health Sciences, Universitas Muhammadiyah Yogyakarta (Approval No. 115/EC-KEPK FKIK UMY/II/2023) on February 7, 2023. The Declaration of Ethics applies until February 7, 2024. Informed consent was obtained from all individual participants.

Results

The research findings are primary data originating from the answers to questionnaires by respondents. The study sample consisted of 52 patients, with a mean age of 34 years (range, 18–57 years) and a gender distribution of 18 males (34%) and 34 females (66%). The characteristics of the respondents have been listed in Table 1.

According to Made et al., the results of the total nasal symptoms score (TNSS) questionnaire measurements allow for the classification of symptoms into three categories: mild [<7], moderate [7–10], and severe [>11] (10). Based on the data shown in Table 2, it can be observed that most male patients fall into the SFAR ≥7 group, comprising 64.7% of the male patient group. The SFAR ≥7 group showed a higher prevalence among female patients, including 83.3% of the female population. Furthermore, 21 male patients (61.8%) with no previous history of anxiety reported experiencing mild anxiety. A total of 7 patients, which represents 20.6% of the sample, reported experiencing moderate anxiety. In contrast, three individuals, representing 8.8% of the sample, said the same. Among the female patients, 14 exhibited not having previous occurrences of anxiety. In contrast, four individuals had a history of mild anxiety. This study did not find any reports of panic among the patients.

The findings of the hypothesis test, which aimed to investigate the effect of anxiety level on SFAR score, are displayed in Table 3. The study’s results show a significant association between anxiety and SFAR, as indicated by the overall statistical significance level of less than 0.05 observed in both male and female participants. The SFAR score exhibits a positive correlation with the level of anxiety score. A small rise of 1% in anxiety levels among male patients is anticipated to substantially affect 21.2% of the SFAR. Among the female population, even a small rise of 1% in anxiety levels is associated with an increase of 19.3% in the severity of SFAR.

Discussion

This study examined the relationship between patient anxiety levels and the frequency of AR recurrence. The present study employed the Indonesian version of the SFAR questionnaire to determine the frequency of AR recurrence. In contrast, the HARS questionnaire was utilized to assess the level of anxiety displayed by the participants. In this study, it was observed that 56% of the participants were in the age range of 16 to 35 years, while the remaining 44% belonged to the age group of 36 to 65 years. This finding is consistent with other research, which indicates that individuals of all ages can be affected by AR (11). Seasonal AR appears more common in pediatric groups, while chronic rhinitis is more common in adults (12).

In this study, female respondents contributed 66% of the total. Another study conducted by Made [2021] also involved 50 patients with AR, where most of the patients with AR were female (54.1%) (10). In other studies, Susanti et al. [2016] also obtained the same thing where AR patients are female, totaling 37 of 49 patients (75.51%) (13). Similar findings were also found in the study by Devi et al. [2019] which found that the most affected gender was female (83.3%) and male (16.7%) out of 42 total cases (14).

In patients with chronic diseases such as chronic urticaria, rheumatoid arthritis, chronic respiratory diseases, and cardiovascular diseases, anxiety is the most prevalent mental health disorder, yet research on anxiety disorder topic is uncommon in chronic diseases of the nose (15). Patients who lose or have their sense of smell, frequently accompanied by persistent nasal inflammatory processes, have been linked to high rates of psychological factors such as anxiety (16). Evidence related to psychological aspects of the manifestation of atopic disorders, including AR, is growing. Through neuroendocrine and immunologic changes, psychological factors may directly impact and play a significant role in the genesis and severity of atopic disorders (17-19).

In this cross-sectional study, we aimed to investigate the correlation between anxiety and AR. We also discovered that patients with AR had much higher anxiety levels than healthy people (20). The SFAR is one of the questionnaires that can be used to determine the value of the prevalence of AR in a population. The SFAR questionnaire has been used in France and six African countries, resulting in better sensitivity in diagnosing AR. SFAR uses a scoring system based on quantitative and subjective symptoms to measure the quality of life of AR patients. The questionnaire takes a short time to complete, and the content is easy to understand. After the respondent has completed the questionnaire, the score can be immediately calculated and recorded. A person is suspected of having AR if a score ≥7 is found (21).

The findings of this study indicate that both questionnaires can identify the beginning of AR. When AR reoccurs, individuals and their families can promptly recognize the symptoms and seek consultation from a doctor to receive early medical intervention. Several studies have shown that the diagnosis closely aligns with the gold standard method when validated by the skin prick test (22). Non-specialized people can utilize the SFAR questionnaire when the medical examination is unavailable due to its significant specificity and sensitivity (14,23).

Research conducted by Naiboho et al. [2017] stated that the sensitivity value of SFAR is 80%, indicating its ability to identify positive cases accurately. Similarly, the specificity of SFAR is 83.3%, reflecting its capacity to identify negative cases correctly (21). This shows how SFAR can be employed as a measuring device to identify the initial signs of recurrence of AR.

Although the outcomes of this study provide evidence of a correlation between anxiety levels and AR, there are some limitations to this study. First, this study was single-center, so the sample still needs to be expanded. Further prospective multicenter studies should also be executed to verify our outcomes. Secondly, although we have identified a correlation between anxiety and AR, there are still several factors that we have not examined, such as psychiatric medication history. So, future studies are expected to explore more patient-related information, including the history of these medications.

Conclusions

The effect of the anxiety score on recurrent AR is assessed in this study. According to the findings, screening for AR with a HARS score has been associated with an increased risk of recurrence. The utilization of SFAR and HARS questionnaires in individuals diagnosed with AR promotes the identification of symptoms, which allows for quick implementation of suitable medications.

Acknowledgments

We would like to thank all of the staff of the Department of Otorhinolaryngology, Head and Neck Surgery, Faculty of Medicine and Health Sciences, University of Muhammadiyah Yogyakarta, Indonesia, for the support.

Funding: The study received grant funding from the Faculty of Medicine and Health Sciences, Universitas Muhammadiyah Yogyakarta (No. 85.1/A.3-111/FKIK-UMY/II/2023), awarded on February 1, 2023.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jxym.amegroups.com/article/view/10.21037/jxym-23-22/rc

Data Sharing Statement: Available at https://jxym.amegroups.com/article/view/10.21037/jxym-23-22/dss

Peer Review File: Available at https://jxym.amegroups.com/article/view/10.21037/jxym-23-22/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jxym.amegroups.com/article/view/10.21037/jxym-23-22/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the Health Research Ethics Committee of the Faculty of Medicine and Health Sciences, Universitas Muhammadiyah Yogyakarta (Approval No. 115/EC-KEPK FKIK UMY/II/2023) on February 7, 2023. The Declaration of Ethics applies until February 7, 2024. Informed consent was obtained from all individual participants.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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