Allergic Rhinitis: Relationships with Anxiety and Mood Syndromes

| July 31, 2011 | 0 Comments

by Randy A. Sansone, MD, and Lori A. Sansone, MD
Dr. R. Sansone is a professor in the Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education at Kettering Medical Center in Kettering, Ohio; Dr. L. Sansone is a family medicine physician (civilian) and Medical Director, Family Health Clinic, Wright-Patterson Medical Center in WPAFB, Ohio. The views and opinions expressed in this column are those of the authors and do not reflect the official policy or position of the United States Air Force, Department of Defense, or US government.

Innov Clin Neurosci. 2011;8(7):12–17

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by Randy A. Sansone, MD, and Lori A. Sansone, MD
Dr. R. Sansone is a professor in the Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education at Kettering Medical Center in Kettering, Ohio; Dr. L. Sansone is a family medicine physician (civilian) and Medical Director, Family Health Clinic, Wright-Patterson Medical Center in WPAFB, Ohio. The views and opinions expressed in this column are those of the authors and do not reflect the official policy or position of the United States Air Force, Department of Defense, or US government.

Innov Clin Neurosci. 2011;8(7):12–17

This ongoing column is dedicated to the challenging clinical interface between psychiatry and
primary care—two fields that are inexorably linked.

Funding: There was no funding for the development and writing of this article.

Financial disclosures: The authors have no conflicts of interest relevant to the content of this article.

Key words: Allergic rhinitis, anxiety, anxiety disorders, depression, mood disorders, panic disorder

Abstract: In this article, the authors examine the preponderance of publications pertaining to relationships between allergies and anxiety and mood syndromes. Through a review of the relevant articles in the PubMed and PsycINFO databases, the authors found that the majority of studies (9 of 11 studies on anxiety syndromes, 10 of 12 studies on depressive syndromes) indicate associations between allergies and anxiety/mood syndromes, despite a number of methodological variances. In addition, there appear to be a number of potential variables that mediate the relationship between allergies and these two psychiatric phenomena (e.g., allergies may heighten risk for these syndromes by triggering the immune system and cytokines; allergies may impair sleep through nasal obstruction and secondarily exacerbate psychiatric symptoms; and allergies may negatively affect cognitive functioning and contribute to psychiatric disturbance) as well as a possible shared genetic risk. The authors review and discuss these variables.

Introduction

Runny itchy nose, sneezing, and nasal congestion—sound familiar? These are the commonplace symptoms of rhinitis, which we have all experienced at some point in our lives during a cold. These are also the identical symptoms for allergic rhinitis—the focus of this edition of The Interface.

Up to 30 percent of the adult population suffers from allergies.[1] Allergic rhinitis may be classified as seasonal (i.e., symptoms occur during a specific time of the year) or perennial (i.e., symptoms occur year round).[1] Seasonal rhinitis is typically caused by identifiable outdoor allergens, such as tree, grass, and weed pollens as well as molds. Perennial rhinitis may be precipitated by dust mites, cockroaches, animal proteins, and fungi.[1] In contrast to allergic rhinitis, some forms of reactive rhinitis, such as vasomotor rhinitis, manifest as a nonallergic reaction to environmental irritants, such as tobacco smoke, vehicle fumes, changes in temperature, strong fragrances, fibers, and alcoholic beverages.

Regardless of the nature of the allergen, the symptoms of allergic rhinitis are notably discomforting. In addition to acute discomfort, however, there appears to be empirical evidence for a relationship between allergic rhinitis and specific psychiatric syndromes such as anxiety and mood disorders. In this edition of The Interface, we explore the possible relationships between allergic rhinitis and anxiety and mood disorders, which is relevant for contemplation in both psychiatric and primary care settings.

Allergic Rhinitis and Anxiety Syndromes

Through a search of the PubMed and PsycINFO databases, we encountered 11 articles with empirical findings related to anxiety symptoms in individuals with allergies.[2–12] We eliminated articles that primarily focused on some adjunctive aspect of our query as well as those with very small sample sizes. The remaining articles are summarized in Table 1.

From a scientific perspective, it is very difficult if not impractical to directly compare these data sets because of varying population types, divergent assessment methods for the confirmation of allergies, and differing study measures for the determination of anxiety symptoms/disorders. For example, the 11 samples come from five different countries, participants either self-reported allergies or underwent formal confirmatory testing, and only two studies used the same measure to assess anxiety symptoms/disorders. So, at the outset, there are a number of potential methodological quagmires in meaningfully comparing these studies. However, as an overview, despite varying methodologies, 9 of the 11 studies reported a positive association between allergies and anxiety syndromes. For example, Cuffel et al[5] examined the healthcare claims of more than 85,000 individuals and found that anxiety symptoms were 1.41 times higher in individuals with allergies versus those without allergies. Likewise, in a sample of more than 12,000 individuals, Patten and Williams[9] determined that allergic individuals evidenced a higher rate of panic disorder (odds ratio [OR]=1.7) as well as social phobia (OR=1.3).[9]

One fundamental approach to examining these data is to tally the number of participants in studies with positive results versus the number of participants in studies with negative results. In doing so, 102,068 individuals were in studies indicating a positive relationship between allergies and anxiety syndromes whereas 97 individuals were in studies indicating a negative relationship between allergies and anxiety syndromes. Thus, a very large majority of individuals (99.9%) were in studies that evidenced a decisive and positive relationship between allergy symptoms and anxiety syndromes.

We also examined studies with negative findings (i.e., those in the minority) for any potential or noteworthy confounds. In doing so, we found that researchers in the Marshall et al[6] study used the Positive Affect Negative Affect Schedule (PANAS) for the assessment of anxiety symptoms.  While negative affect may be associated with anxiety, Zevon and Tellegen found that the descriptors underlying the PANAS construct are, “being upset, distressed, hostile, irritable-angry, scared, afraid-fearful, ashamed, guilty, nervous,” and “jittery”—but there is no explicit descriptor for clinical anxiety.[13] In other words, while the Marshall study did not confirm a relationship between allergies and anxiety, the study scale used to assess anxiety was inadequate, thereby affecting the conclusions of the study. In the Kennedy study,[7] in which researchers investigated the link between allergy and panic disorder patients, the sample was atypical (i.e., the sample consisted solely of panic disorder patients). Given that panic disorder is highly comorbid with other types of anxiety syndromes, it is likely that the unusual clinical composition of this sample washed out potential findings between panic-disorder participants with and without allergies.

Allergic Rhinitis and Depressive Syndromes

In addition to studies on the association between allergies and anxiety syndromes, a number of studies have examined associations between allergies and depressive symptoms (Table 2).[3,5,7–11,14–18] After eliminating articles according to the previous exclusion criteria, we encountered 12 relevant publications in the PubMed and PsycINFO databases.

Similar to the previous group of studies on anxiety syndromes, direct comparisons of these data are compromised for exactly the same cited reasons. Explicitly, the samples come from five different countries, participants either self-reported allergies or underwent formal confirmatory testing, and the assessments for depression markedly vary across studies. In addition, the assessments for depression in these studies vary in their ability to be translated into clinical or Diagnostic and Statistical Manual for Mental Disorders (DSM) diagnoses of depression. Despite these methodological variations, 10 of 12 studies report positive relationships between allergies and depression. For example, in their data analysis of more than 85,000 individuals, Cuffel et al[5] found that a depression diagnosis was 1.7 times higher in individuals with allergies compared to those individuals without allergies.[5] Likewise, in their examination of more than 12,000 individuals, Patten and Williams9 determined that major depression was more frequent in individuals with allergies (OR=1.5) than in individuals without allergies.[9]

Using our previous tally strategy, 104,124 individuals were in studies indicating a positive relationship between allergies and depression, whereas 3,060 individuals were in studies indicating a negative relationship between allergies and depression. As before, a very large majority of individuals (97.1%) were in studies that evidenced a positive relationship between allergy symptoms and some type of depressive syndrome.

In examining the two studies with negative statistical associations between allergies and depression,[7,8] we encountered some interesting methodological issues. In the study by Kennedy et al,[7] which again investigated whether there was an association between allergies and panic disorder, the assessment of depression was undertaken with the Hamilton Anxiety Scale, which is a 14-item clinician-rated scale.[19] Only one item in this scale addresses depression, with the rater prompters being, “decreased interest in activities,” “anhedonia,” and “insomnia.” Given the nine DSM (4th edition, text revision)[20] criteria for major depression, this inquiry for mood disorder is likely to be inadequate. In the second study with purportedly negative findings (the Goodwin study),[8] there was a significantly higher prevalence of major depression among hay-fever sufferers (18.9%) compared with non-sufferers (13.4%). However, these initial differences apparently dissipated after controlling for sociodemographic differences and other mental disorders.

Variables that Might Mediate Allergies and Anxiety/Mood Syndromes

Given the strong evidence for relationships, albeit indistinct, between allergies and anxiety/mood syndromes, are there any potential mediating variables? Possible mediators might include but are not limited to 1) the effects of either syndrome on immunity and immune-related illnesses, with each possibly contributing to the presence of the other,[21] perhaps via the presence of cytokines;[22] 2) the physiological role of nasal obstruction and its impairing effects on sleep, with subsequently negative effects on psychiatric symptoms;[23,24] 3) allergy-related disturbances in cognitive functioning and their subsequent effect on psychological well-being;[25,26] and 4) a possible shared genetic risk between both allergies and depression.[27]

Conclusion

Despite stark differences in methodologies, the majority of published studies indicate some type of indistinct relationship between allergies and anxiety and mood syndromes. The strength of these associations is difficult to discern, given the present data. There may be a number of allergy-related mediating variables, such as alterations in immunity/cytokines, the effects of nasal obstruction on sleep, disturbed cognitive functioning, and genetic overlap. Regardless, current evidence indicates that individuals with allergies appear to be at a higher risk, of an unknown degree, for developing various types of anxiety and/or mood syndromes.

References
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5.    Cuffel B, Wamboldt M, Borish L, et al. Economic consequences of comorbid depression, anxiety, and allergic rhinitis. Psychosomatics. 1999;40:491–496.
6.    Marshall PS, O’Hara C, Steinberg P. Effects of seasonal allergic rhinitis on fatigue levels and mood. Psychosom Med. 2002;64:684–691.
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12.    Postolache TT, Langenberg P, Zimmerman SA, et al. Changes in severity of allergy and anxiety symptoms are positively correlated in patients with recurrent mood disorders who are exposed to seasonal peaks of aeroallergens. Int J Child Health Hum Dev. 2008;1:313–322.
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14.    Hurwitz EL, Morgenstern H. Cross-sectional associations of asthma, hay fever, and other allergies with major depression and low-back pain among adults aged 20–39 years in the United States. Am J Epidemiol. 1999;150:1107-1116.
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17.    Bavbek S, Kumbasar H, Tugcu H, Misirligil Z. Psychological status of patients with seasonal and perennial allergic rhinitis. J Investig Allergol Clin Immunol. 2002;12:204–210.
18.    Muluk NB, Oguzturk O, Koc C, Ekici A. Minnesota Multiphasic Personality Inventory profile of patients with allergic rhinitis. J Otolaryngol. 2003;32:198-202.
19.    Hamilton Anxiety Scale (HAM-A). http://www.servier.com/App_Download/Neurosciences/Echelles/HAM.pdf. Accessed on August 3, 2010.
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22.    Dunn AJ, Swiergiel AH, de Beaurepaire R. Cytokines as mediators of depression: what can we learn from animal studies? Neurosci Biobehav Rev. 2005;29:891–909.
23.    Fang BJ, Tonelli LH, Soriano J, Postolache TT. Disturbed sleep: linking allergic rhinitis, mood and suicidal behavior. Front Biosci (Schol Ed). 2010;2:30–46.
24.    Leger D, Annesi-Maesano I, Carat F, et al. Allergic rhinitis and its consequences on quality of sleep: an unexplored area. Arch Intern Med. 2006;166:1744–1748.
25.    Kremer B, den Hartog HM, Jolles J. Relationship between allergic rhinitis, disturbed cognitive functions and psychological well-being. Clin Exp Allergy. 2002;32:1310–1315.
26.    Wilken JA, Berkowitz R, Kane R. Decrements in vigilance and cognitive functioning associated with ragweed-induced allergic rhinitis. Ann Allergy Asthma Immunol. 2002;89:372–380.
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Category: Anxiety Disorders, Medical Issues, Mood Disorders, Past Articles, Primary Care, Psychiatry, Suicidality, The Interface

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