Explore This IssueApril 2014
Early in his career, William Lydiatt, MD, a head and neck surgeon, noticed that some of his patients seemed depressed, while others seemed happier, and that his patients’ moods didn’t necessarily correspond with the severity of their disease or degree of treatment-related disability.
“Some of my patients had undergone chemoradiation, had intact larynxes, and, overall, looked and functioned pretty normally. Others had total laryngectomies and were speaking with an electrolarynx, and they seemed happier. I wondered, ‘Is there a difference, or is it just my imagination?’” said Dr. Lydiatt, currently director of head and neck surgery at the University of Nebraska Medical Center in Omaha. “I wanted to know why some people seemingly didn’t do as well as others.”
Dr. Lydiatt’s curiosity spurred him to study the link between mental health and head and neck cancer. What he found was sobering. Published depression rates for patients with head and neck cancer range from 15% to 50% (Clin Adv Hematol Oncol. 2009;7:397-403). The suicide rate for head and neck cancer patients is three to four times that of the general public (JAMA Otolaryngol Head Neck Surg. 2013;139:678-686; JAMA. 2006;296:1716-1717). Depression is not related to the severity of disease or to treatment modality, making it difficult to predict which patients will suffer from depression. Yet, depression has profound effects on patients’ lives and may affect their survival, because patients who feel hopeless and depressed may make different treatment decisions than patients who feel a sense of well-being. Depressed patients also take more treatment breaks (Clin Adv Hematol Oncol. 2009;7:397-403).
These issues are not restricted to head and neck cancer. Jeremiah Alt, MD, PhD, assistant professor of the otolaryngology-rhinology and skull base surgery program at the University of Utah, estimates that approximately 30% of patients with chronic sinusitis have depression, while up to 78% percent have reduced sleep quality that significantly impacts their overall quality of life. A 2014 study of depression in adults with hearing loss found that 11.4% of individuals with difficulty hearing also had moderate or severe depression, compared with 4.9% of individuals with excellent hearing (JAMA Otolaryngol Head Neck Surg. [Published online March 6, 2014.] doi:10.1001/jamaoto.2014.42.). People with un- or under-treated allergies have a higher incidence of depression than people who don’t have allergies. And patients with sleep apnea who have excessive daytime sleepiness are also prone to depression (PLoS One. 2010; 5:e10211). Anxiety and depression are also commonly seen in patients with tinnitus and sinus and voice difficulties.
But despite the fact that depression and anxiety often accompany otolaryngologic disorders, few otolaryngologists regularly assess their patients for mental health problems or include mental health interventions in treatment plans. “Right now, the standard of care is ‘Do nothing,’” said Luke Buchmann, MD, assistant professor of otolaryngology-head and neck surgery at the University of Utah in Salt Lake City.
Ignoring mental health issues puts both patients and physicians at a disadvantage; appropriate treatment of mental health concerns may improve patient health and quality of life. “The whole key is to heal the patient, not necessarily cure the disease,” Dr. Lydiatt said. “Curing the disease may well heal them, but it’s also possible to be cured but not healed or healed and not cured. The key is trying to understand what a particular patient needs to be healed.”
The Link Between Mental Health and Otolaryngology
Depression and anxiety can be caused or exacerbated by an otolaryngologic condition or treatment modality. And depression and anxiety can play a role in the development—or worsening—of an otolaryngologic condition.
According to The National Institute of Mental Health (NIMH), nearly one in five U.S. adults has experienced an anxiety disorder within the last 12 months. Nearly 7% of U.S. adults have experienced a depressive disorder in the last 12 months. Only about half of all people with depression or anxiety are receiving treatment and, in many cases, treatment is sub-par. (According to NIMH, only about 20% of people with depression are receiving minimally adequate treatment.)
In other words, many otolaryngology patients have concurrent—and possibly untreated—mental health issues. Patients with a personal or family history of anxiety or depression are more likely to experience clinically significant anxiety or depression, especially during periods of stress, such as when dealing with an otolaryngologic disorder.
There is a growing body of evidence that suggests a physiological link between some otolaryngologic conditions and depression. “Evidence is accumulating to illuminate the possibility that the dysfunctional central behaviors that patients with chronic sinus disease complain of, including sleep loss, fatigue, and depression, may be due to the underlying mechanism of the disease itself,” Dr. Alt said, “such that depression and sleep loss may be related to the underlying inflammatory component of the disease. We’re finding that the same immune mediators and cytokines that are found locally during inflammation are also found in the brain and are known to alter behavior.” These inflammatory mediators, also called cytokines, Dr. Alt said, may trigger changes in the brain that cause depression, anxiety, and sleep and cognition problems. The fact that cytokines act in the brain to induce physiological adaptations may begin to help explain the pathophysiology of chronic sinus disease and how to treat the pathologies it is commonly associated with, including depression, fatigue, impaired cognition, and memory and sleep disturbance.
Untangling cause and effect, though, can be very difficult. “We have shown that patients with sinus disease and depression have significantly worse sleep quality (88%) compared with patients with no depression,” said Dr. Alt. This is consistent with previous investigations, which have established a strong correlation between sleep dysfunction and depression, with depressed patients reporting diminished sleep quality, he added. “This is most likely a two-way street,” he said. “The relationship between disease severity, depression, and poor sleep is most likely bidirectional; disability predicts worse sleep and depression, which may then be a predictor of worse disease severity and quality of life.”
Stigma Still Stings
Unfortunately, many patients and physicians avoid discussing mental health problems. “There are still a lot of people who believe that depression is kind of a weakness,” Dr. Lydiatt said.
“From a generational perspective, it’s only been relatively recently that it’s OK to talk about depression and mental health,” Dr. Buchmann said. He’s noticed that his older patients, in particular, are hesitant to consider depression. “I’ve had patients tell me, ‘I’m just weak. I can’t deal with this.’”
That kind of mindset may hinder patients’ health. Depression and anxiety are highly treatable conditions, but treatment hinges on appropriate diagnosis and treatment. Dr. Buchmann often experiences resistance when he suggests or refers patients for treatment of possible mental health conditions. “If I tell a patient, ‘You’ve got a heart problem. I need to send you to a cardiologist or start you on some medication,’ they’re all for it. “But if I say, ‘Hey, I don’t think your brain is working right; we need to maybe put you on some medicine,’ patients will say, ‘I don’t want to do that.’ We have to do a better job of demystifying mental health issues. We have to help patients understand that the brain is an organ, just like the heart and kidney.”
But many otolaryngologists don’t feel qualified to address patients’ mental health issues. Time is an ever-present limitation, as is lack of knowledge of mental health conditions. Those concerns, though, shouldn’t stop physicians from providing the care patients need. “You have to treat the whole patient,” Dr. Buchmann said.
Managing Mental Health
No one expects otolaryngologists to become mental health experts, but developing a series of strategies to manage patients’ mental health conditions can optimize their physical health and emotional well-being, while allowing you to efficiently manage your time.
A variety of tools are available to help healthcare providers screen patients for depression, anxiety, and other mental health issues. Screening your patients, on admission and periodically during treatment, can help you determine which patients are doing fine and which may benefit from additional intervention.
A formalized screening process is necessary because it’s impossible to screen patients just by looking at their history, said Christine Gourin, MD, MPH, associate professor of otolaryngology at Johns Hopkins University in Baltimore. “Not everybody with depression will have it recorded in their medical record, and many patients don’t talk about it either.” Talking to patients and observing their mood and affect can be helpful but should not replace the use of a validated screening tool.
The next step is to “figure out what to do when someone screens positive,” said Stacey Ishman, MD, MPH, surgical director for the Upper Airway Center at Cincinnati Children’s Hospital Medical Center. “That may be something as simple as sending them to the ER to be taken care of urgently if someone is really having difficulty or experiencing suicidal ideation. People who score above the positive threshold but are not urgent may need to see a social worker or receive a referral to a mental health provider.”
Establishing an algorithm and relationships with mental health professionals will help you effectively manage patients’ mental health needs without taking too much time away from otolaryngologic treatment. “Having relationships with mental health providers, programs, and hospitals that can serve patients’ needs is so important,” said Lawrence Miller, PsyD, director of integration and wellness for Rogers Partners in Behavioral Health, LLC, in Milwaukee, Wis. “Getting a person from referral to treatment can be a challenge.” Pre-established relationships and easy availability of mental health increase the probability of patients receiving necessary mental health assessment and treatment. “Research has shown that on average, 40% to 50% of patients will follow through on a referral to a health provider,” Dr. Miller said. “If the provider is on site, that can increase to 80% or 90%.”
Maximizing otolaryngologic treatment may help ease patients’ distress. Both continuous positive airway pressure and surgical intervention have been shown to reverse some depression in patients with sleep apnea, Dr. Ishman said. Appropriate treatment of sinus disease can also ease depression and anxiety; the same holds true for allergies.
“I tell my patients that we have to first take care of the underlying inflammatory disease process. If that takes care of the mental health problem, it’s a win-win situation,” Dr. Alt said. “If not, at least we can check that box off and move toward further treatment.”
In some cases, treatment with antidepressant medication can ease—or even prevent—depression. A randomized, double-blind, placebo-controlled clinical trial found that the prophylactic use of antidepressants significantly reduced the incidence of depression in head and neck cancer patients without a history of depression. Of the 148 patients studied, 24.6% of patients in the placebo group developed depression while undergoing cancer treatment. Just 10% of patients treated with escitalopram developed depression (JAMA Otolaryngol Head Neck Surg. 2013;139:678-686). Interestingly, the patients who received escitalopram also reported a statistically better quality of life three months after stopping the drug.
“This is level one evidence that we can prevent depression in head and neck cancer patients undergoing treatment,” said Dr. Lydiatt, lead author of the study.
Yet many otolaryngologists are uncomfortable with the idea of prescribing antidepressants to their patients. Additional studies are needed to help physicians better understand the effectiveness of antidepressants in both the treatment and prevention of depression, as well as which patients might benefit most from treatment.
In the meantime, “you have to decide at what level you’re comfortable participating in patients’ mental healthcare,” Dr. Lydiatt said. If you’re interested in diagnosing and treating patients, you need to have tools to assess and measure depression and mental health, and you need to be familiar with common mental health medications.”
“If you’re not comfortable handling mental health conditions, spend a little time developing a plan,” Dr. Lydiatt said. With a plan in place, managing mental health conditions in otolaryngology patients does not take much time, Dr. Lydiatt said. “In fact, I would argue that the time spent up front is more than repaid down the road. Your goal should be to help your patients be well, not just cured.”
Jennifer L.W. Fink is a freelance medical writer based in Wisconsin.