Depression and anxiety are common mental health disorders, and they often co-occur with other chronic health conditions¹. In 2019, the U.S. Department of Health and Human Service, National Center for Health Statistics estimated 10.8% of adults 18 or over had symptoms of anxiety disorder or depressive disorder.² Importantly, in the case of depression, the relationship with physical diseases has been demonstrated to be temporarily bidirectional, meaning that a history of disease increases risk of subsequent depression and vice-versa³.

A growing body of literature has examined the presence of depression and anxiety in conjunction with voice disorders. Studies have shown there is a correlation between anxiety and depression and higher Voice Handicap Index-10 (VHI-10) scores⁴. Depression has been associated with a nearly 2-fold increased chance of patients reporting voice problems⁵. Additionally, patients with a history of depression and anxiety are susceptible to developing functional voice disorders^6–8.

People with dysphagia often report associated anxiety and affective symptoms, as dysphagia impacts health and quality of life, notably through the disruption of the social aspect of sharing meals⁹. However, the effects of pre-existing anxiety and/or depression on swallowing function surveys have not been investigated.

The Eating Assessment Tool – 10 (EAT-10) is a widely used validated patient reported outcome measure for dysphagia that can be utilized to document initial symptom severity and to monitor treatment response¹⁰. The purpose of this study was to evaluate the effects of pre-existing diagnosis of depression and/or anxiety on EAT-10 in subjects with normal and abnormal swallowing function on instrumental swallow evaluation (fluoroscopy, flexible endoscopic evaluation of swallowing, or esophagoscopy). We hypothesized that subjects with a diagnosis of anxiety and/or depression with normal instrumental swallow evaluation may present with higher EAT-10 scores that those without those co-occurring mental disorders.

This was a retrospective data analysis completed via a REDCap¹¹ database. All procedures performed were in accordance with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Approval was obtained from the Weill Cornell Medical College Institutional Review Board (# 22-02024665).

Overall, 290 patients met inclusion criteria. The average age of the overall cohort, Group 1 and Group 2 were 66.0 ± 18.4, 63.1 ± 19.2 and 68.8 ± 18.3 respectively. While 55% of the overall cohort was female, 63% of Group 1 and 47% of Group 2 were female. Among included patients, 60 (21%) had a diagnosis of anxiety, 49 (17%) had a diagnosis of depression and 36 (12%) had a diagnosis of both. Overall, 50% of the subject population had anxiety and/or depression, with 21% of subjects with anxiety, 17% with depression and 12% with anxiety and depression. Detailed distribution of patients according to presence of anxiety and/or depression and type dysphagia is given in Table 1.

Figure 1 displays the distribution of EAT-10 according to presence or absence of diagnosis of anxiety and/or depression. Median and mean EAT-10 scores were as follows: 15 (range, 0–40) and 16.0 (sd 11.0), no anxiety or depression; 12 (range, 1–36) and 15.7 (sd 11.5), anxiety; 14 (range, 0–40) and 16.9 (sd 11.2), depression; 15 (range, 1–40) and 17.4 (sd 11.4), anxiety and depression. No significant difference was found in comparing mean EAT-10 score across mental health status as displayed in Table 2 (p=0.85 by ANOVA test and p=0.84 by Kruskal-Wallis test). Comparison of mean EAT-10 score per absence or presence of anxiety and/or depression showed a slightly higher mean EAT-10 score in patients with anxiety and/or depression (mean 16.5 vs. 16.0), but the difference was not significant (p=0.69 by two-sample t-test) (Table 3). Of note, EAT-10 score distribution was relatively parametric and the results were near identical for both the parametric and nonparametric analyses. Kruskal-Wallis and Wilcoxon rank-sum test results were confirmatory with the t-tests and ANOVA results.

In analyzing the distribution of EAT-10 according to the mental health diagnosis and the etiology of dysphagia, we found that, in patients with normal swallowing function based on the laryngology note and instrumental swallow evaluation, the mean EAT-10 score was statistically higher in patients with anxiety and/or depression diagnosis (P=0.023). No significant difference in EAT-10 was found between each group in patients with abnormal swallow based on the laryngology note or the instrumental swallow evaluation (Table 4).

Anxiety and depression are prevalent mental health diagnoses that affect quality of life². Although the frequent co-occurrence of anxiety and affective symptoms and dysphagia has been noted before⁹, investigation of the severity of dysphagia in relation to anxiety and/or depression diagnosis has not been reported. Our study has revealed three important findings: 1) in our patients with normal swallowing function on instrumental examination, dysphagia symptoms were amplified in the presence of anxiety and/or depression; 2) anxiety/depression did not aggravate dysphagia in patients with objective findings of swallowing dysfunction in our clinic population; 3) consistent with other studies, we found high prevalence of anxiety and/or depression in patients presenting with dysphagia.

Our group has previously highlighted the importance of accurate terminology in distinguishing dysphagia and swallowing dysfunction. Dysphagia refers to the patient’s sensation of obstruction to food passage, while swallowing disorder refers to objective findings of abnormal deglutitive function observed by clinicians¹⁷. This distinction is important, as the extent of swallowing dysfunction is not necessarily commensurate with the patient’s discomfort, and patients may have dysphagia with no objective findings, or conversely, severe swallowing impairments requiring non-oral findings and minimal symptoms. Dysphagia and swallowing disorders, as distinct concepts, are measured with different tools. Dysphagia assessed with patient reported outcomes measures (PROMs), while swallowing dysfunction is assessed by instrumental examination - such as bedside swallow evaluation, flexible evaluation of swallowing, videofluoroscopy, esophagoscopy or high-resolution manometry. The importance of precise semantics is highlighted by the findings of our present study, with worsened dysphagia symptoms in the presence of anxiety/depression despite a normal instrumental exam.

Dysphagia may devastate one’s quality of life, and has been previously associated with anxiety and affective symptoms⁹. Two recent systematic reviews demonstrated that anxiety and depression are common in patients presenting with oropharyngeal dysphagia¹⁸. A preliminary study of 96 outpatient adults with dysphagia presenting to a university medical center in the Netherlands for dysphagia evaluation revealed 47% of participants demonstrated affective symptoms. Screening for affective symptoms can be particularly clinically relevant in patients with head and neck cancer and concurrent dysphagia¹⁹.

The incidence of dysphagia is expected to increase worldwide with aging populations. Gaining additional insight into mood and anxiety comorbidities in people with dysphagia will be important to further refine patient-centered multidisciplinary evaluation and treatment. Improved understanding of the relationship could contribute to a targeted multidisciplinary approach to treatment of both swallowing and mental health symptoms. Furthermore, anxiety and depression are prevalent in patients with dementia, and so is swallowing dysfunction^20,21. Unravelling the relationship between affective disorders and deglutition may bring new insights in this complex population, with currently limited options for swallowing improvement.

Our findings resonate with prior evidence of an impact of mood and anxiety disorders on pharyngeal and pharyngoesophageal sensations. For instance, the severity of globus pharyngeus has been associated with distress caused by anxiety, low mood or depression, and somatic concern²². A possible pathophysiologic explanation to these findings is the known negative effect of anxiety on esophageal motility and esophageal hyperalgesia^23,24. Thus, anxiety may play a role in higher EAT-10 scores by either heightening globus symptoms through increased hyperalgesia,^25,26 or inducing esophageal dysmotility¹⁰. Prospective studies with the inclusion of high resolution manometry may be helpful in elucidating an explanation for such findings.

Significance of anxiety and affective comorbidities in the field of laryngology have been mostly investigated in relation to dysphonia^4–8. Investigations in gastroenterology, however, have suggested that psychological factors, such as anxiety or hypervigilance, may exacerbate patients’ symptoms beyond any objective physiologic abnormalities. For instance, in patients undergoing manometry, a higher score on the Esophageal Hypervigilance and Anxiety Scale questionnaire predicted severe dysphagia better than identification of a true major motility disorder²⁷. Similarly, in patients with dysphagia due to eosinophilic esophagitis, a higher esophageal symptom-specific anxiety predicted severity of dysphagia better than objective findings on endoscopy or histology²⁸. Supportive treatments targeting the brain-gut axis such as cognitive-behavioral therapy, swallow therapy, and neuromodulators may be effective in addressing deglutitive functional disorders²⁹.

The contemporary pain literature may shed new insights on the experience of somatic discomfort in relation to affective disorders in laryngology. More specifically, the concept of nociplastic pain offers a useful framework to address chronic symptoms with no obvious organic basis, which may be exacerbated by anxiety and depression. Nociplastic pain arises from the abnormal processing of pain signals without any objective findings of tissue damage or pathology involving the somatosensory system, such as in fibromyalgia or irritable bowel syndrome^30–32. This pain category is thought to be associated with augmented sensory processing and has a high co-prevalence with psychiatric conditions. Nociplastic conditions management prioritizes non-pharmacological interventions, such as cognitive behavioral therapies, acceptance-based interventions, biofeedback and hypnotherapy, and avoidance of medication and procedural interventions which provide modest benefits³⁰. Collaboration with pain medicine specialists may shed new lights on functional disorders affecting swallowing.

Our study has several limitations. As a retrospective chart review, it was limited by the data found in the electronic medical record. For instance, the presence of globus sensation in included subjects could not be investigated. Furthermore, the battery of test for dysphagia work-up was variable across included patients. We also did not include measures of severity of anxiety and depression or history of pharmaceutical intervention and cognitive behavioral therapy, as many subjects had their psychological care at other institutions, with limited documentation available in the electronic medical record. Future studies should be prospective, include patient reported outcome measures for anxiety and depression, as well as current psychological/psychiatric management regimen, in addition to a comprehensive dysphagia work-up with esophagoscopy, high resolution manometry, and FEES or VFSS. Future studies may also consider item analysis between EAT-10 and swallowing dysfunction type. Post-surgical or post-radiation head and neck cancer treatment was not specifically investigated in the subgroup analysis, and this would be investigated in the future. Of note, there were patients in both groups (no anxiety/depression & anxiety/depression) with a history of head and neck cancer. Despite these limitations, our study highlights an area of investigative deficiency in otolaryngology and suggests for the first time that anxiety and/or depression may have an impact on patients’ experience of swallowing difficulty.

Our retrospective study suggests that pre-existing anxiety/depression may aggravate dysphagia in patients with normal swallowing function on instrumental evaluation. A similar relationship was not demonstrated in patients with objective findings of swallowing dysfunction. Prospective studies are needed to further delineate the relationship between patients’ perception of difficulty swallowing and anxiety and affective disorders.