Does Managing Patients With Chronic Rhinosinusitis Improve Their Depression Score? Prospective Study

To the Editor,

We are writing this letter regarding the article recently published in your esteemed journal, titled Does managing patients with chronic rhinosinusitis improve their depression score? Prospective study by Almofada et al ¹ In the article, the authors measured the level of depression using the Patient Health Questionnaire-9 (PHQ-9) and correlated it with the Sinonasal Outcome Test (SNOT-22) to assess whether surgical intervention improved patients’ symptoms, quality of life (QOL), and depression. The study was conducted with great care in following up with patients and analyzing the data. They concluded that treating chronic rhinosinusitis (CRS) in patients who suffer from concurrent depression improves their QOL as well. However, the field of psychiatry is vast, and the aspects in which one can look at this problem are not as simple or straightforward as portrayed. These aspects introduce the need for a more uniform patient selection, elimination of confounding factors, and a more rigorous data analysis to accurately address the study question.

The authors collected demographic details of the patients during the initial data collection phase. Two of these are of particular interest: gender and the presence of nasal polyps. Although the authors did not account for these variables, a meta-analysis by Fan et al reported the female gender and the absence of nasal polyps in CRS as potential risk factors for depression in such patients. ² This means that these patients could skew the results of the study and portray an inaccurate picture. Furthermore, the authors mention 20 patients with different comorbidities, that is, diabetes mellitus (DM), asthma, and cystic fibrosis. However, we were surprised that these were not excluded from the study, considering chronic diseases like these are risk factors for depression by themselves. The study by Bădescu et al explores the relationship between DM and depression in great detail. ³ Thus, excluding such patients from the study will help obtain more accurate results.

When we mentioned multiple aspects to consider, we were alluding to several factors in the psychological makeup of a person that could modify the variables under study. One of these is the pain catastrophizing score of a person. The study by Kazi et al clearly investigates this relationship, showing a worse QOL reported in people with a higher catastrophizing score. ⁴ Catastrophic thinking by the patient can muddy the results of self-reported questionnaires such as the PHQ-9 and SNOT-22. Another psychological aspect that can alter the results is the attachment style of the patient. The study by Epperson et al concluded that a younger age and conscientiousness were associated with avoidance of activity in CRS patients and that emotional and personality traits were strongly associated with this. ⁵ Avoidance of activity is a major symptom of depressive disorder. Adjusting for these confounding factors in the data analysis would greatly improve the overall efficacy of the study.

In conclusion, this study examines the improvement in depression in CRS patients concisely and clearly. However, consideration of the factors mentioned above in future studies will help isolate the effect of treatment more comprehensively. This will paint a more accurate and complete picture of the relationship between CRS and depression and improve the generalizability of the results.