Depression occurs due to abnormal regulation of the brain, increasing physical as well as the psychological burden of symptoms [2]. Clinicians must not inevitably assume that depressive disorders are an independent entity in patients with chronic disease, as they may be interlinked, thus requiring a more comprehensive management strategy. Psychiatric or psychological comorbidities can modify symptom perception in chronic disease, due to the negative impact on the central nervous system through the hypothalamic-pituitary-adrenal axis releasing cytokines and leading to chronic inflammation [16]. Depression is considerably underdiagnosed in primary healthcare and general hospital setups; 73.5% of patients with major depressive disorders present with somatic, not psychiatric, symptoms, this is referred to as masked depression [3]. Even in non-surgical conditions, depressive disorders predict poor outcomes [2]. Higher levels of depression are linked to exaggerated pain perception and mood changes, which is the result of abnormal activity of the anterior cingulate cortex and insula, as identified by functional magnetic resonance imaging scanning [17].

In the present study, patients were equally distributed across all age groups. The younger population had lower scores (mean PHQ-9 score of 4.68 and 5.89 in 21–30 years and 31–40 years age groups respectively), whereas the highest severity of depressive symptoms (mean PHQ-9 score of 6.07) was noted in patients with the age range of 41–50 years. This finding suggests that middle-aged individuals may be more vulnerable to depression due to health concerns, increasing professional responsibilities, and family problems. The pressures of establishing a career, raising a family, and managing financial obligations may contribute to enhanced stress levels and ensuing depressive symptoms. Litvack and co-authors found 25% of the patients to have depression at an age averaging 46.7 years [1]. A study by Cheng and co-authors to correlate depression and dizziness revealed slightly higher scores in the younger population compared to the elderly (6.74 ± 5.31 vs. 6.19 ± 4.28 respectively); however, it was not statistically significant [18].

A slight male preponderance (54%) was noted in the current study. However, the severity of depressive disorder was detected to be higher in women than in men (mean PHQ-9 score of 5.76 vs. 4.41 respectively). There exists a social stigma toward seeking mental healthcare; lack of family support and hormonal alterations add to the increased disease burden in women. Three cases of MDD were seen in men, two cases were noted in women, while other depressive disorder was seen in three men and eight women. This is comparable to the results of Mace et al.; subjects with depression were more likely to be females than patients not having depression (p-value 0.002). Occurrence of depression is almost twice as common in women, and in people with comorbidities (14–75%) than in the general population [2].

The majority of the patients in the present study were housewives (31%), followed by students and labourers (13% each). The severity of depressive symptoms was noted to be the highest in the unemployed, followed by skilled professionals and housewives (mean PHQ-9 scores of 7, 6.86, and 5.65 respectively). Two cases each of MDD were noted in the skilled professionals, housewives, and below-clerk categories. Four of the seven cases of other depressive disorder were seen in housewives. Monetary disconcertment, lifestyle factors, stress, lack of socialisation, and caregiving responsibilities contribute to the manifestation of depressive disorders in these patients. Nevertheless, statistical significance was not noted between occupation and depressive disorder or severity of depressive symptoms (p-value 0.58 and 0.6 respectively).

Most of the patients in our study (38%) presented within six months of the onset of otolaryngology symptoms; four patients with other depressive disorder belong to this category. Two cases of MDD were noted in patients with symptoms between 7 and 12 months and 13–60 months each. Nonetheless, the severity of symptoms was highest in patients who presented between 7 and 12 months of onset of otolaryngology symptoms (mean PHQ-9 score of 6.62), followed by patients who presented beyond 5 years of onset of symptoms (mean PHQ-9 score of 6.33). Statistical significance was found in correlating the duration of symptoms with the severity of depressive symptoms (p-value 0.005). Depressive disorders in longstanding illnesses may be due to increased consumption of healthcare resources, increased physician visits, missed days of work, and greater use of antibiotics [1].

In our study, minimal to mild depression was seen in 80% of the subjects, which compared well with Litvack et al., who found only 25% of patients with moderate or severe depression as per the PHQ-9 survey [1]. Nanayakkara concluded that mental health is associated with a patient’s subjective symptom scores [19]. Independent t-test was used to correlate PHQ-9 score in patients with mild depression, MDD, and other depressive disorder, and was of statistical significance (p = 0.022).

Patients with hidden depressive disorder and somatic symptoms often visit physicians instead of a psychiatrist, thus utilizing greater healthcare resources [3]. Somatic symptoms unelucidated by physical examination are described as medically unexplained symptoms (MUS), which comprise giddiness, and tinnitus. MUS are frequent, with varied presenting features, accounting for up to 45% of all general practice consultations, and without a clear diagnosis at 3 months in as high as 50% of patients [20]. Goto found MUS in 9.2% (90/983) of the patients visiting the otolaryngology department; 5.0% (49/983) had MUS with depression, while 4.2% (41/983) had MUS without depression [3]. MUS may be classified (a) based on DSM-IV criteria, (b) those without a DSM-IV diagnosis, or (c) medical MUS syndromes [21]. In this study, nine patients (18%) had no significant otolaryngology disease, indicating that their symptoms were merely a result of underlying mood disorders. Tinnitus, giddiness, and throat irritation were the commonest MUS in these patients (3 cases each). Three of the nine patients (6% of all cases included in the study) were found to have primary depression; secondary depression was noted in fifteen (30%) patients. Although comorbid depressive disorders are probably bidirectional and have a worse prognosis, it is challenging to determine the causality [22]. It is unclear whether presenting symptoms contribute to depression or vice versa [17]. Identifying underlying depression in such patients impacts patient management; emphasis on symptom management, mood stabilisation, behavioural interventions, and lifestyle modifications may be required in addition to integrated team approach, pharmacotherapy, and psychotherapy.

Wang and co-authors performed a systematic review and meta-analysis to estimate the prevalence of depression and depressive symptoms in outpatients; they found the highest prevalence of depressive disorders and symptoms in otolaryngology patients (53%), followed by dermatology and neurology (39% and 35%) respectively [23]. The occurrence of depressive disorder was noted to be 36% in the present study. Chronic otitis media was the most frequent otolaryngology diagnosis in the present study (26%). However, only 1 of the 26 patients (0.04%) had major depressive disorder. Allergic rhinitis was the next most common otolaryngology disorder (15%); none of these patients were found to have depression. A possible cause of disparity between the sinonasal symptoms and the actual infection is the existence of psychiatric comorbidities, which may alter clinical presentation [16]. Neuroticism (emotional instability) can stimulate somatic sensations like nasal obstruction and correlates well with tiredness, depression, and autonomic pupillary disturbances [24]. Nanayakkara found a significant association between sinonasal symptoms and depression score (p = 0.02) [19]. The severity of depression symptoms was the greatest in patients with chronic tonsillitis, followed by sensorineural hearing loss and deviated nasal septum (PHQ-9 scores of 7.33, 6.25, and 6.14 respectively). Brewster found that age-related hearing loss was associated with a greater likelihood (1.63 times) of having depressive symptoms compared to a healthy population, and it was statistically significant [25]. Litvack and co-authors concluded that patients with depressive disorders have a worse quality of life, even while other indicators of the severity of the disease may be similar; an increase in pain perception, oropharyngeal and CRS symptoms, lethargy, difficulty in daily chores and occupation has been reported [1]. Interestingly, three of the four patients with colloid goitre were found to have depression (one case of MDD and two cases of other depressive disorder). Mood disorders are known to have a greater prevalence in thyroid dysfunction [26]; nevertheless, all four patients were clinically euthyroid. Chandra in his study concluded that a greater rate of depression is seen in chronic otolaryngology disorders (10-14%) compared to that in a similar age group among the general population (7.3%). This was the maximum in patients with inner ear pathology, and sleep apnoea [27]. Our study encompasses a variety of chronic otolaryngology conditions, while a lot of previous studies have focused exclusively on individual otolaryngology diseases. However, the small number of subjects included in the study is a limitation. Further research is required to assess the complex association of depression and otolaryngologic conditions and symptoms in larger populations, to evaluate the temporal and causal relationship and the efficacy of integrated mental health interventions in otolaryngology practice.

Patients with inexplicable complaints are habitually subjected to multiple diagnostic tests and interventions, which may not reveal organic disease, and might be considered pointless in retrospect, except that they eliminate known medical conditions. The price of somatisation to healthcare services is high. Additionally, the impact on a patient’s quality of life can be grave. Socioeconomic status, literacy, culture, and childhood experiences, all affect the degree to which emotional suffering is expressed as physical symptoms [14]. The association between otolaryngology conditions and psychology is snowballing swiftly due to greater awareness among populations. Patients browse for disease-related information and become uneasy and distressed; some patients become over-anxious about mild symptoms such as nasal stuffiness or discharge, a lump in the throat perceived as cancer. Understanding the patient psyche and reassurance goes a long way in allaying suffering, along with medical or surgical treatment [28]. Chronic otolaryngology patients should be screened for depressive disorder, and offered education, counselling and integrated treatment approaches, including cognitive behavioural therapy, stress reduction techniques, to improve quality of life and overall wellbeing [14].