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Chronic Cough Severity Appears Worse in Patients With Anxiety and Depression


Researchers addressed the link between mental health conditions and chronic cough severity to help physicians personalize their treatment plans.

Patients with chronic cough who have prior diagnoses of anxiety and depression self-reported more severe symptoms using the Cough Severity Index (CSI) than those with neither condition, according to findings of a study published in Ear, Nose & Throat Journal.1

Researchers studied the link between depression and anxiety with patient-reported outcome measures (PROMs) to understand their perceived cough severity and help physicians create more individualized and successful treatment plans.

“Understanding patients’ unique needs and the impact of coexisting mental health conditions is important in providing interdisciplinary care for patients with chronic conditions such as cough,” the authors wrote.

To conduct this retrospective cohort study, researchers utilized a population of 141 patients with chronic cough identified by the report of an International Classification of Diseases, Tenth Revision (ICD-10) code (Cough R05.3) at their initial presentation to a laryngology clinic in 2019. Researchers used the CSI score as the primary outcome measure and the Reflux Severity Index (RSI), Glottal Function Index (GFI), and Voice-Related Quality of Life (VRQOL) as secondary outcome measures.

Researchers sorted patients into 4 categories based on ICD-10 codes, physician notes, and problem lists: those having both anxiety and depression, anxiety only, depression only, or neither. Their PROM scores were collected by physicians and compared using Kruskal Wallis and Mann-Whitney U tests for post hoc analysis.

Of the study population, 27 had both anxiety and depression (19%), 81 had neither anxiety nor depression (57%), 21 had anxiety only (15%), and 12 had depression only (9%). The median age was 64 years, with ages ranging from 20 to 85 years. Additionally, 101 of the patients were female (72%), and 123 were White (87%). Most of the population were never smokers (71%), 35 were former smokers (25%), and 5 were current smokers (4%).

CSI scores were lowest in those with anxiety only (median [range], 23 [0-40]) and those with no anxiety or depression (19 [1-38]). Conversely, patients with depression only (26.5 [0-40]) and those with both anxiety and depression (26 [5-39]) had the highest CSI scores.

After controlling for sex and smoking status in robust regression analysis, researchers found that only patients with depression and anxiety had statistically significant different CSI scores from those with neither (difference, 4.70; 95% CI, 0.54-8.87; P = .027).

RSI scores followed trends similar to CSI scores. In comparison, VRQOL scores were lowest among patients with neither condition and patients with depression only and higher for patients with both anxiety and depression and those with anxiety only. As for GFI scores, there was no difference in their distribution among the 4 groups (P = .151).

These findings show that those with anxiety and depression have more severe chronic cough symptoms, but the researchers urged physicians not to let mental health conditions dictate their treatment.

“Mental health is one component of a patient’s symptomatology but should not deter a provider from completing a thorough workup,” the authors wrote. “By understanding patients’ mental health background, however, care providers may be able to more holistically understand and treat patients’ concerns.”

Based on data found in the international Chronic Cough Registry,2 the female majority and age range of patients in this study indicate that the findings may be generalizable as this study’s sample reflects the global chronic cough population. Despite this, the researchers pointed out several study limitations. First, the data may be affected by COVID-19 because chronic cough is a lingering symptom. Also, each physician determined chronic cough subjectively, so their criteria may vary and result in different diagnoses. Finally, a limitation that calls for future research is the small sample size.

“The small sample size of 141 patients is from 1 year of first-time clinic appointments; further data including more patients are necessary to corroborate findings,” the authors wrote.


1. Hari G, Naunheim M, Kallogjeri D, Huston M. Anxiety and depression diagnoses and the Cough Severity Index: a retrospective study. Ear Nose Throat J. Published online June 14, 2023. doi:10.1177/01455613231180336

2. Moric AH, Jakes AD, Faruqi S, et al. A worldwide survey of chronic cough: a manifestation of enhanced somatosensory response. Eur Respir J. 2014;44(5):1149-1155. doi:10.1183/09031936.00217813

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