By definition, rhinitis is an inflammatory alteration of the nasal mucus; which is also characterized by the presence of two or more of the following symptoms: nasal congestion, rhinorrhea, itchiness, sneezing, and daily alterations in a patients sense of smell for over an hour.1 By classifying the presence or absence of allergic sensibilization, it is possible to differentiate between allergic rhinitis (AR) and non-allergic rhinitis (NAR).2

Amongst the long evolution rhinitis, highlights the AR, disorder causing significant morbidity and disability, which affects the quality of life in social, school and workplace; causes a high economic impact as well as an increase in the consumption of alcoholic beverages and sedatives.2–6 Additionally, this disrupts sleep patterns, along with cognitive and productive capacities.3,5 Up to 43% of AR patients wake up feeling tired, this is reflected in matters such as their mood and sexual appetite, furthermore, it has been reported as a risk factor for depression and anxiety.5,7,8

The mood disorder characterized by sadness, feelings of uselessness, self-depreciation, and social isolation, are known as depression; anxiety is the feeling of restlessness or apprehension that acts as a defense mechanism and aids in managing potential danger, this appears to have an adaptive function as it produces bodily reactions that can prepare an individual for the “fight or flight” response.9

The disorder characterized by anxiety and mood changes are common in patients with chronic diseases,10–13 however, in the case of rhinitis, these side effects have not yet been researched thoroughly. For a more in-depth understanding of these associations, more clinical evidence is needed; thus far, most studies concerning anxiety and depression as possible consequences of rhinitis have been epidemiological.14–17

The objectives in this study consisted of determining the levels of anxiety and depression from a group of patients with AR and another group with NAR; thereafter, we compared our results with a group of control subjects. This was carried out in order to obtain a greater understanding of the association that rhinitis has to anxiety and depression.

This study included 241 subjects that were placed into three groups: allergic rhinitis (n=111), non-allergic rhinitis (n=34) and a control group (n=96). The mean age for each study group was approximately 30; women were the majority of the patients with any type of rhinitis while men were predominant in the control group (Table 1). Within the control group, almost 15% of the individuals smoked tobacco, and a little over 50% consumed some sort of alcoholic beverage. Over half of the participants took part in some type of physical activity at least once a week and had an average of 7h of daily sleep. Patients with AR had persistent clinical symptoms with moderate to severe levels, amongst these, the most common aeroallergen where pollens, principally, those originating from trees.

The global anxiety frequency amongst patients with AR (51/111; 45.9%) and NAR (18/34; 52.9%) was significantly higher in comparison to subjects from the control group (p<0.001). Similarly, depression frequency amongst those with AR (43/111; 38.7%) and in NAR (16/34; 47.1%) was significantly higher to that of the control group (p=0.0003). In the AR group, moderate levels of anxiety and depression were predominant; thus, within the NAR group, severe and moderate levels were predominant, respectively (Table 2).

The frequency of anxiety or depression did not differ according to the intensity and frequency of AR symptoms, Table 3.

Overall, when the AR and NAR groups were compared to the control group, there was a significantly higher frequency of anxiety: AR (OR=7.3, p<0.0001) and in NAR (OR=9.7, p<0.001). However, once stratified by sex, this association was only consistent amongst women, but not men, although amongst the latter, the association reached a significant limit. When adjusted by sex, AR and NAR maintained significant association to anxiety (Table 4). Similarly, both types of rhinitis were also associated with depression, although the level of association was much lower than that seen for anxiety (OR=2.9, p<0.001 and OR=4.1, p<0.001 for AR and NAR, respectively). Similarly, this association is not ratified in men, only women. Finally, when we weighed these groups, the association remained statistically significant after adjusting it by sex (Table 4).

Table 5 shows the risk of anxiety and depression in patients with RA and RNA adjusted by multivariate analysis. When compared to the control group, both AR and NAR were identified as risk factors for anxiety and depression. Furthermore, women presented a higher risk for anxiety and depression, because age seemed to have a week significant association to anxiety, it was taken out from the model.

Our findings highlight several noteworthy aspects: first, patients with AR and NAR had a higher prevalence for anxiety and depression than the control group. Second, our data suggests that the association that rhinitis has with anxiety and depression is specific in women. Third, rhinitis itself, and not the atopic state, is what causes alterations of psychological relevance.

Both anxiety and depression are mental health problems that appear in a higher frequency amongst individuals with diseases of prolonged evolution: chronic urticaria,10 rheumatoid arthritis,11 chronic respiratory diseases,12 cardiovascular diseases,13 however, only on a few occasions, have these been studied in chronic diseases of the nose. In our study, over a third of the tested patients with some type of rhinitis denoted the presence of anxiety or depression. These findings are consistent with previous studies, which show that subjects with AR or vasomotor rhinitis present a very high frequency of anxiety than the control group.14,19 Our study clearly illustrates a predominant occurrence of anxiety and depression in women rather than men, with both AR and NAR. Consistently, a study based on a population of adults showed that the probability of presenting symptoms for depression was greater in women that had a history of allergies14; however, it seems that the atopic state is not the only link to anxiety or depression, as this association also occurs in women affected by gastrointestinal illnesses,20,21 skin diseases22 or cardiovascular diseases,13 amongst others. The most important explanations could be found in family-life and difficult experiences during childhood, as well as a previous history of anxiety or depression, social circumstances, cultural norms and vital difficulties.23 It is necessary to carry out further studies to better understand the role that gender plays in the genesis of psychological disorders.

There are previous studies that suggest there is a link between anxiety and depression to allergies. Buske-Kirschbaum et al.24 observed that patients with atopic dermatitis or allergic rhinitis shared similarities in personality traits. More recently, in a population study Goodwin et al.15 highlighted that subjects with allergic diseases had a higher frequency of anxiety disorders and mood swings when compared to patients without allergies. This suggests that atopy is associated to psychological alterations and not to the chronic evolution of the disease. To better clarify this situation, we compared a group of patients with AR and another with NAR, whose symptoms are indistinguishable. Surprisingly, we observed that in both rhinitis groups anxiety and depression were closely associated. Patients with a diminishing or a lost sense of smell, which tend to be followed by processes of chronic nasal inflammation, have been associated to high frequencies of anxiety or depression.25,26 Another factor that often accompanies nose diseases is inflammation; the products that are released during this process could explain the origins of depression and anxiety.27

Notwithstanding, we found no association between the severity of AR to anxiety or depression. The information is inconsistent since one population study only showed association when AR was moderate to severe and persistent,28 another study carried out on adolescents with allergic rhinitis did not find any evidence of association.29 It has been proposed that the individual's attitude toward the illness is what determines the levels of allergic severity and symptoms for anxiety and depression.30

We conclude that patients with AR and NAR, particularly women, have a higher frequency of anxiety and depression when compared healthy subjects. It is likely that the cause of this association is the chronic nature of the disease and not the atopy itself.

The authors declare no conflicts of interest.