Impact of anxiety and depression on the swallowing process among patients with neurological disorders and head and neck neoplasia: systemic review
The Egyptian Journal of Neurology, Psychiatry and Neurosurgery volume 59, Article number: 75 (2023)
Dysphagia is associated with depression and anxiety due to the severity, impact of symptoms itself or secondary to the underlying cause. This is more recognizable to brain diseases that has consequences common to the neural supply of the swallowing act and the cognition and behavior. Limited data are available to explore, quantitate and monitor these neurological outcomes. Our aim of this research to review the literature pertinent to depressive disorders, anxiety, and/or the quality of life (QoL) and psychological well-being. Search of Medline and Google Scholar databases for relevant articles had revealed a total of 1568 citations; 30 articles met the inclusion and exclusion criteria.
Data about the direct effect of dysphagia on psychiatric aspects are limited. Studies of the relationship between severity of dysphagia and depressive symptoms demonstrated that several evaluation tools are available for objective and subjective assessment. The severity and progression of dysphagia was significantly associated with increased depressive symptoms.
Dysphagia is associated with and positively correlated to depression and anxiety scores observed in Parkinson disease (PD), multiple sclerosis (MS) and stroke. Similar association is observed in patients with head and neck cancer, tongue cancer and oral cancer. A bidirectional positive correlation exists with a vicious circle that loops between dysphagia and psychological disease. Moreover, the severity of dysphagia shows correlation with depression and/or anxiety scores (Fig. 1, Graphical abstract).
Swallowing is a complex process that involves the integration of more than 30 muscles and nerves in a collective smooth action . In a three-phase sequential process the food bolus is moved from the oral cavity to the pharynx, esophagus and then to the stomach . The three phases are the oral (subdivided into oral preparatory stage and oral propulsive stage), pharyngeal and esophageal phases . Any abnormality occurring in any one of these phases is referred to as dysphagia [1, 3]. Dysphagia is a Greek term, derived from the words ‘dys’ meaning disorder and ‘phagein’ meaning eating . Dysphagia, therefore, refers to the difficulty either in the process of oral food preparation prior to swallowing or in the food passage from the oral cavity to the pharynx, esophagus and stomach [1, 3]. Dysphagia is clinically recognizable as either oropharyngeal or esophageal dysphagia . Oropharyngeal dysphagia is characterized by the difficulty to initiate a swallow, whereas esophageal dysphagia is characterized by the difficulty experienced through swallowing several seconds immediately after the initiation of a swallow as well as the sensation of food being obstructed in its passage .
Epidemiology of dysphagia
Epidemiology of dysphagia is underestimated. Its Incidence among individuals above the age 50 in several European and US populations was 16 to 22% based on survey studies in the early 1990s [6,7,8,9]. However, more recent studies explored the epidemiology of dysphagia in adults reported rather different values. In USA, the incidence of dysphagia that occur at least twice weekly was 3% in both males and females, in a population-based cohort of 7640 individuals . Furthermore, a population-based study in Iceland, revealed an estimated annual incidence of esophageal food impaction in adults to be 25 in 100,000 persons with the prevalence increases with age, particularly after the seventh decade . The prevalence was broad in different countries and geographical regions, ranging between 3 to 27% [10, 12]. Dysphagia was found to be more prevalent in the male (male-to-female ratio 1.5:1) [11, 13] and elderly populations .
Etiology of dysphagia
As the etiologies of dysphagia are diverse, they can be classified as nervous system-related causes, gastrointestinal-associated causes or causes induced by muscular, endocrinological, iatrogenic (surgical), pharmacological, mechanical, and psychogenic disturbances [14,15,16,17]. Swallowing is a vagal nerve mediated process under balance of sympathetic and parasympathetic balance, it is demonstrated that fear conditioning in humans as demonstrated by spectral heart rate variability that refers to variations in length between consecutive heart beats may add easily performed in a less invasive assessment for neurologically mediated swallowing process. Heart rate variability may serve as a biomarker of the inhibitory prefrontal–amygdala fear network [18, 19]. Neurogenic dysphagia secondary to central nervous system disorders (CNS) including upper motor and autonomic centers responsible for controlling the swallowing process or the peripheral nervous system (PNS) including neuropathies, neuromuscular junction disorders, and muscle diseases . Altered neuronal circuits in cerebral regions such as (cingulate cortex, amygdala, basal ganglia) may ultimately lead to psychopathological and functional symptomatic expressions. Among CNS disorders with gut manifestations including dysphagia is Parkinson’s disease (PD) which is the second most common neurodegenerative disorder. Other CNS disorders are neurodevelopmental process abnormalities, cerebrovascular stroke, CNS neoplasms, degenerative disorders, and multiple sclerosis . Notably, Increased expression of serotonergic genes occurs with activation of the serotonergic system and subsequently, elevated anxiety levels on animal models . Health resilience has drawn increasing attention to one of the etiological factors of illnesses from molecular to social levels. Less mitochondrial stress resilience, the disturbance of thiol homeostasis, and contemporary lifestyles may reportedly contribute to the pathogenesis of neurological and psychiatric diseases, multiple sclerosis, and mental illnesses, respectively . It is believed that the pathogenesis of several diseases related to dysphagia is mediated by tryptophan (Trp)–kynurenine (KYN) metabolic system, Tanaka and colleagues discussed the Trp–KYN metabolic system with special emphasis on its interaction with the immune system, including the tolerogenic shift towards chronic low-grade inflammation, additionally explored the linkage between chronic low-grade inflammation, KYN metabolites, and major psychiatric disorders, including depressive disorder, bipolar disorder, substance use disorder, post-traumatic stress disorder, SCZ, and autism spectrum disorder . Accelerated tryptophan metabolism is observed in conditions such as infection, inflammation, cancer, aging, neurodegenerative diseases, and psychiatric disorders . Neurodegenerative processes that take place in CNS are mediated by microglial cells that participate in acute inflammatory state that is consequently resort either to a neuronal recovery or development of a low-grade inflammation. This biological mechanism explains the underlying pathobiology of dysphagia manifested in these disorders . Analysis of levels of neurotoxic KYNs and neuroprotective KYNs revealed higher levels of neurotoxic KYNs and higher ratios of neurotoxic KYNs in neurodegenerative and psychiatric diseases, however, these levels and ratios of the neuroprotective KYNs are not clearly understood yet . Animal models showed that in high doses of KYNA (20–40 µg/2 µL) there is a significantly decreased the avoidance latency, whereas at a low dose of KYNA (0.5 µg/2 µL) significantly elevate it compared to controls, Therefore, a low dose of KYNA would enhance memory function . A major role of Neurodevelopmental pathology ought to explain the pathogenesis of other mental illnesses and neurological diseases. Schizophrenia (SCZ) has a substantial neurodevelopmental basis in the pathogenesis; likewise, bipolar disorder (BP), anxiety disorder, obsessive compulsive disorder (OCD), and Tourette syndrome are reported to have the neurodevelopmental backgrounds.It is caused by brain insults at stages of brain growth and development during late first or early second trimester as well as early postnatal period, leading to the emergence of neuropsychiatric manifestations during early life, which tend to last for lifetime. The earlier the age of onset and the higher the severity and persistence of the genetic, cognitive, sensorimotor, and psychopathological dysfunction, the greater the overall neurodevelopmental impairment . Clinical manifestations of altered KYN metabolism include impairments in memory and learning, poor planning, defects in set-shifting, adapt behavior to the environment, impaired working memory, emotional regulation, and altered executive function, which are common in neurological and psychiatric diseases that correlate with a typical cognitive pattern observed in frontal lobe dysfunction .
Movement disorders characterized by early accumulation of abnormal alpha-synuclein (α-SYN) containing inclusions (Lewy neurites) at the enteric nervous system (ENS) and at the dorsal motor nucleus of the vagus (DMV) both in PD and in incidental Lewy body disease (ILBD) [30,31,32] when compared to supranuclear palsy alpha-synucleinopathy were significantly more measurable compared to tauopathies related to progressive supranuclear palsy [33, 34].Upon studying the full thickness of the upper gastrointestinal tract of Parkinson’s postmortem findings that showed that Lewy pathology affects mucosal sensory axons in specific regions of the upper gastrointestinal tract and may be related to Parkinsonian type esophageal dysphagia . Furthermore, detection of Synucleinopathy in the pharyngeal nerves using an immunohistochemical method for phosphorylated α-synuclein, Parkinson patients with dysphagia noted to have a higher density of α-synuclein aggregates in the pharyngeal nerves [35, 36]. Among common PNS and muscle disorders with dysphagia manifestations include Guillain–Barré syndrome, myasthenia gravis, polymyositis, and facioscapulohumeral muscular dystrophy . These conditions affect the motor function of the upper gastrointestinal tract and impair swallowing . Among the common causes of dysphagia are disorders that occur in the gastrointestinal tract . Infrequently, swallowing disorder arise without a discernible abnormalities in the anatomy of the upper aerodigestive tract and/or in the swallowing physiology [13, 39,40,41]. Dysphagia is attributed to visceral conditions, most often related to gastroesophageal reflux disease (GERD) [10, 42, 43].Autoimmune syndromes may present with systemic as well as gastrointestinal symptoms and dysphagia such as Sjögren's syndrome  in whom three-quarters of the patients were reported to have it [45,46,47].Several studies have explored the relationship between GERD and dysphagia [42, 43]. In a population-based study of 926 individuals Eslick et al. reported that GERD was independently correlated with dysphagia (OR = 2.96, 95% CI: 1.76–4.98) using a regression analysis . Similarly, in a national population Argentinian residents reported that frequent GERD symptoms were connected with dysphagia (OR = 2.12, 95% CI: 1.27–3.54) . Dysphagia can also arise from surgical (iatrogenic) causes, such as laryngectomy or head and neck surgeries [48, 49]. It can be caused by cancer of the oral cavity, tongue, or head and neck region [48, 49]. It can also result from an adverse effect of certain medications such as neuroleptics, cholesterol-lowering agents and anticholinergic drugs [50,51,52]. The aging process may also be a cause for dysphagia, and is associated with increased risk of mortality and morbidity [53,54,55,56]. However, the aging process gives rise to mild abnormalities of esophageal motility, which are rarely symptomatic . Psychogenic dysphagia is a diagnosis of exclusion, detected only after thorough knowledge of patient history and full investigations . For dysphagic patient morbidity and mortality rates are attributed, in part, to the higher risk of aspiration pneumonia [58, 59] and partly ascribed to the resultant states of malnutrition and dietary deficiencies .
Psychiatric aspects of dysphagia
Dysphagia is a distressing symptom that exerts several negative consequences on the patient’s general state and health-related quality of life . Combined with the negative consequences of the original diseases and/or conditions causing dysphagia, the difficulty in swallowing itself increases the morbidity and sometimes even the mortality rates of the causative disorders [58, 59, 61, 62]. Phenotypically, anxiety, depression and cognitive changes such as dementia were demonstrated to be inter-related to each other in a form of cross talk between each other . To explain the rule of emotions and affection, emotions are noted to impact several brain executive processes, such as action inhibition. However, the complex interplay between emotional stimuli and action control is not clear. Inhibitory control measurement is done by the stop-signal task (SST) . It is demonstrated and proved by Battagalia et al. that vicarious fear learning has a remarkably affect the cognitive abilities, making a neutral image as threatening as phylogenetically innate negative stimuli and hence impact behavioral control . Moreover, it is noted by the prior author that observation of positive and negative body postures enhanced the ability to suppress an ongoing action compared to a neutral body posture. Concluding that emotional valence independent stimuli facilitate action control and explains that a trigger would increase sensory representation and/or attentional processing which promotes stop-signal processing and hence improved inhibitory performance . In fact, one-third of the major sequelae of dysphagia are their negative consequences . Dysphagic patients were reported to have high risk for depression and anxiety; however, due to the complexity of the dysphagia etiology, such psychological symptoms are generally studied more in connection with the chronic comorbidities than with the swallowing dysfunction itself. Only limited review data are available on the relationship between depression and/or anxiety, quality of life and dysphagia itself. The aim of this research was to review the published studies available in the literature that focused on the major depressive disorders, anxiety, and/or the quality of life (QoL) in dysphagic patients.
Data sources and searches
This review is performed as a systemic review of the English language literature with inclusion criteria of adult age groups with no geographical location restriction. We searched the literature between January 1980 to December 2020 for neurological and psychiatric aspects along with their impact of these disorders on swallowing and dysphagia manifestation on quality of life (QoL) in various medical conditions mainly but not exclusively for the neurological disorders which neurodegenerative, neurodemyelinating and neurovascular disorders as well as for psychiatric disorders which are depression, anxiety and stress. An advanced search was conducted using the major search engines which are PubMed, Cochrane Library, and Google Scholar wing MESH keywords of/combination ‘dysphagia’, ‘swallowing disorders’, ‘Parkinson’, ‘cancer’, multiple sclerosis’, ‘depression’, ‘anxiety’, ‘major depressive disorder’, ‘psychological’,” surgery’, Stroke’, elderly’, dementia’ and ‘quality of life’ in a variety of combinations. The inclusion was non-restrictive of the type of publication or the setting of the study whether outpatient or hospital-based studies. Exclusion criteria are studies of non-English language and pediatric population studies. Literature that discussed dysphagia related to gastrointestinal diseases, functional non-organic disorders and neoplastic disorders was excluded.
Figure 1 depicts the steps involved in the search conducted to choose the articles selected for review. First, the titles were screened, and then the abstracts of the selected articles were reviewed. The full texts of the relevant articles were then carefully read. The initial search revealed 1568 articles. After screening of the titles and elimination of the duplicates, 406 articles were selected for further assessment. After reading the abstracts of the remaining articles, 30 articles were chosen for final review for their relevance to the topic of study in the present manuscript [10, 42, 53, 54, 66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87,88] (Table 1).
Characteristics of the studies included
While all the 30 studies reviewed were observational, barring a single interventional non-randomized controlled trial , most of the observational studies (total cohort = 16) were cross-sectional [10, 43, 54, 66, 68,69,70,71, 77,78,79, 82, 83, 86,87,88,89,90,91]. Six were prospective cohort studies [53, 80,81,82], three were retrospective cohort studies [68, 69, 73], and two were case control studies [66, 79]. All the studies were exclusively inpatient, except for four; one was both mixed inpatient (hospital-based) and outpatient (community-based) , while the other three were community-based studies [10, 53, 77]. The studies included in this review evaluated dysphagia of several etiologies. The commonest etiologies were Parkinson disease assessed in six studies [70,71,72, 75, 76, 78] and old age evaluated in six studies [53, 54, 77, 88,89,90]. Dysphagia resulting from head and neck cancer was evaluated in five studies [68, 69, 79, 80, 82], while dysphagia due to oral  and tongue cancers  were evaluated in one study each. The remaining studies evaluated dysphagia in MS (total cohort = 1) , stroke (total cohort = 1) , total laryngectomy (total cohort = 1) , and anterior cervical spine surgery (total cohort = 1) . Dysphagia of different etiologies was estimated in six studies [10, 42, 67, 83, 85, 87], and medically unexplained oropharyngeal dysphagia (MUNDO) was evaluated in one study . Although most of the studies did not focus specifically on investigating the association between the psychological status and dysphagia, relevant findings were reported in their results. Only six of the studies reviewed included a specific aim in their objectives to evaluate the association between psychological status and anxiety [10, 42, 78, 83, 86, 89]. The objectives of the rest of the studies were directed mainly towards studying the prevalence of psychological dysfunction and dysphagia in certain comorbidities, and then further investigated their impact on each other in the context of their findings. The detailed findings of all the studies reviewed are described in Table 1. Quality assessment of the studies using CONSORT (Table 2) and STROBE assessment (Table 3) guidelines are performed.
Evaluation of dysphagia
A variety of methods of evaluating dysphagia were observed among the studies reviewed. The vast majority of the studies used only subjective measurement tools like questionnaires or patients’ self-reporting of swallowing problems [10, 42, 67, 70, 73,74,75,76,77,78,79,80, 82, 84, 90, 91]. Physical examination performed either by a neurologist, an otolaryngologist (ENT) or a speech and language pathologist (SLP) was used to assess the dysphagia in eight studies [53, 54, 66, 71, 88, 89]; objective evaluation adopting the modified barium swallow examination (MBS) [68, 69], fiber-optic endoscopic evaluation of swallowing (FEES) [72, 83, 85, 86] or video-fluoroscopic swallowing study (VFSS) [81, 83, 87] was used only in eight studies. The commonest questionnaires/scales for assessment of dysphagia included the Unified Parkinson Disease Rating Scale (UPDRS) adopted in three studies [70, 75, 78]; the MD Anderson Dysphagia Inventory (MDADI) employed in two studies[79, 80], the Swallowing Disturbance Questionnaire (SDQ) used in two studies [72, 76], and the Sydney Swallow Questionnaire was utilized in two studies [77, 90]. The rest of the questionnaires/scales included the Dysphagia Severity Scale (DSS) (total cohort = 1) , European Organization of Research and Treatment of Cancer Quality of Life Core Questionnaire for head and neck cancer, version 35 (EORTC QLQ H and N35) (total cohort = 1) , Self-Reporting Questionnaire of Dysphagia (total cohort = 1) , Questionnaire of Gustafson and Tibbling (total cohort = 1) , bowel disease questionnaire total cohort = 1 , Bazaz–Yoo dysphagia severity scale total cohort = 1) , and Dische morbidity recording scheme with Visual Analog Scale (VAS) total cohort = 1 .
Evaluation of psychiatric aspects and QoL related to dysphagia
The three commonest questionnaires used included the Hospital Anxiety Depression Scale (HADS) total cohort = 10) [66, 68, 69, 74, 75, 78, 82,83,84, 86], Geriatric Depression Scale (GDS) total cohort = 6) [42, 54, 71, 77, 89, 90], and Beck Depression Inventory (BDI) total cohort = 6) [72, 76, 79,80,81]. The less commonly used scales were the Depression Anxiety and Stress Scale (DASS) total cohort = 1) , Montgomery Asberg Depression Rating Scale (MARDS) total cohort = 1) , Center for Epidemiological studies-Depression (CES-D) , Trait Anxiety Inventory (TAI) , Zung anxiety and Zung Depression Scale total cohort = 2) [84, 85]. In only one study, the Diagnostic and Statistical Manual of Mental Disorders criteria, version IV (DSM-IV), was used for the diagnosis of depression ; however, two studies used the hospital files of the patients to select individuals diagnosed with depression and/or taking antidepressant medications [10, 88]. Questionnaires for assessment of the quality of life included the University of Washington Quality of Life scale (UW QoL) total cohort = 1) , World Health Organization Quality of Life-Bref (WHOQoL-Bref) total cohort = 1), and the Questionnaire of Gustafson and Tibbling total cohort = 1) .
This review aimed at assessing the association between dysphagia and psychological well-being in the earlier literature. To date, this association has not been evaluated in randomized controlled trials. All the studies reviewed were observational and only one single non-randomized clinical trial was found and reviewed. Although the absence of well-designed randomized controlled trials reduces the strength of the evidence of the results, the large majority of the observational studies which focused upon the relationship between dysphagia and the psychological status reported consistent findings. From the majority of the studies, it appeared that anxiety and/or depression were independently and positively associated with dysphagia. Further, dysphagia and the psychological state seemed to be correlated in a vicious circle which is dysphagia could increase the psychological disturbance, and the psychological disturbance could worsen the dysphagia.
Dysphagia and its association with psychological well-being
Dysphagia was reported to have a significant association with the psychological state of the patients in a number of diseases such as MS , PD , stroke , head and neck cancer , oral cancer , tongue cancer , and aging . In patients with MS, abnormal swallowing was strongly linked to a more depressed mood (p < 0.001). Both depression and dysphagia are a common occurrence in PD patients [70, 71]. Poor swallowing was observed to have some correlation with depression and anxiety, in several cross-sectional and population-based studies of PD [71, 72, 75]. Similarly, lower swallowing rates were significantly correlated with depression scores in patients with tongue cancer , while those with oral cancer having severe dysphagia demonstrated symptoms of increased anxiety and depression . Dysphagia is one of the most common complications noted in the treatment of head and neck cancer , and the depression and anxiety scores on the HADS were significantly higher in the dysphagic patients who experienced it as a treatment-induced complication, compared with patients who had no dysphagia . Concurring with this observation, Cnossen et al.  in their prospective cohort study using 67 patients with head and neck cancer, reported that dysphagia was significantly linked to anxiety and depressive symptom scores, not only at time of diagnosis but on follow-up as well. The link between dysphagia and psychological well-being was also investigated in patients who had undergone total laryngectomy. In a retrospective cohort study involving 110 patients receiving total laryngectomy, dysphagia was found to exert a negative impact on the psychological well-being, exhibited as higher rates of depression, anxiety, as well as stress .
Regardless of the etiology of swallowing, patients with oropharyngeal dysphagia expressed higher rates of anxiety and panic during eating , were less likely to enjoy eating , and exhibited markedly higher rates of depression and general anxiety scores [83, 85]. Similar findings were reported in dysphagia that accompanies aging. The prevalence of the swallowing problems among the elderly was in the 11.4–40% range in elderly living in the community [77, 89], and 52% in long-term care residents . The severity of dysphagia was seen to increase with age . In this population, dysphagia was identified to be strongly linked to depression [77, 89]. Above two-thirds of depressed elderly patients living in long-term care facilities were reported to experience swallowing problems, significantly more than their counterparts who lacking depression (p < 0.005) .
Although there were wide variations in the study designs, population studies, measurement tools and patient characteristics in the studies cited earlier, they all concurred on the fact that dysphagia is directly related to the psychological well-being of the individual. However, three out of the 30 studies reviewed failed to identify any relationship between these two parameters. The first was a cross-sectional study conducted in the Netherlands  on 15 patients with MUNOD, at the University Hospital, ENT Outpatient clinic, for dysphagia. Although depression and anxiety were widespread among those patients (42.8%), the DSS scores showed no significant difference between the patients with and those without anxiety/depression . Similarly, Kim and colleagues.in their cross-sectional study performed using 90 patients with dysphagia (regardless of etiology), reported no significant connection between dysphagia and depression, despite the high incidence of depression among the patients investigated (62.2%) . One important fact to be noted here is that the results of both the studies must be given due consideration because they both adopted objective methods for the dysphagia evaluation (that is FEES or VFSS) [86, 87]. In contrast, most of the prior studies that reported a strong relationship between dysphagia and the psychological state employed either questionnaires or self-reporting of symptoms by the patients, which possibly render them highly subjective [10, 42, 67, 70, 73, 75,76,77,78,79,80, 82, 84, 90, 91]. Depressed patients might be more likely to report organic symptoms like dysphagia, hence making the association biased. Another important argument is that the disease causing the dysphagia might be a confounding factor in this association, and the only study that addressed the link between dysphagia and the psychological state in MUNOD patients failed to identify any significant association . Therefore, caution is needed when interpreting the results, and the need for well-designed randomized controlled trials continues to account for these variables remain a priority. A third study that failed to discover a relationship between dysphagia and the psychological state was a large cross-sectional, community-based US study, conducted by Cho et al. using 3669 patients with dysphagia . It used the validated bowel disease questionnaire which included only one question regarding dysphagia, and explored the association between dysphagia and the use of antidepressant medications (prescribed in the patients’ medical records). Data from this study revealed gastroesophageal reflux disease (GERD) as the commonest etiology for the dysphagia, and antidepressants were one of the medications routinely taken by patients with dysphagia. However, their usage was not significantly unlike those who had no dysphagia . In their discussion, Cho et al. argued against the association between dysphagia and depression . They reported that despite the positive association reported between GERD and depression in previous literature , they failed to find such an association in their results. They attributed their findings to the different methods they had adopted for the evaluation of depression; they only considered the use of antidepressant medications rather than the diagnosis of depression .
The severity of dysphagia and its correlation with psychological well-being
Dysphagia was found to be associated not only with the psychological state, however the severity of the dysphagia correlates as well. In a retrospective analysis of 104 patients who received treatment for head and neck cancer, Nguyen and colleagues assessed the severity of dysphagia through a modified barium swallow examination and studied its correlation to the QoL, depression, and anxiety using the UW QoL questionnaire and HADS. They reported that the anxiety, depression, and QoL scores were significantly higher in patients experiencing moderate-to-severe dysphagia compared with those having No to mild dysphagia . Similar data were reported by Chan et al. in their study on 77 patients with head and neck cancer; they stated that the depression scores on the BDI were significantly correlated with dysphagia, assessed by the MDADI score (β = − 17.31; p = 009) . The severity of dysphagia was also reported to bear correlation to depression and/or anxiety scores in patients with PD. In a hospital and community-based, cross-sectional study using 137 PD patients, those with poorer swallowing rates evaluated by the timed swallowing test showed significantly higher depression symptoms compared with patients having better swallowing (p = 0.01) . In another cross-sectional study performed on 69 PD patients who were evaluated more objectively for dysphagia that is FEES, more severe swallowing difficulties were directly correlated with the anxiety (r = 0.472, p < 0.0001) and depression scores (r = 0.357, p < 0.003) on TAI and BDI, respectively . In fact, Hans and colleagues reported similar results in their cross-sectional study conducted on 127 patients with PD. The patients were segregated into four categories based on their BDI scores total cohort depression, mild depression, moderate depression, and severe depression) and compared in accordance to their SDQ scores, either with scores ≥ 11 or with scores < 11. Patients with mild depression were 3 times more likely to have dysphagia, and patients with moderate depression were 13 times more likely to have depression, whereas patients with severe depression were 30 times more likely to have dysphagia compared to the non-depressed patients . Another logistic regression preliminary analysis from the French COPARK cohort of 419 patients with PD showed that severe dysphagia was linked to higher depression symptom scores (p = 0.001) .
Further, in the elderly population severe dysphagia showed a strong relationship with higher depression scores. Two large studies performed on elderly patients reported a significant correlation between depression and varying grades of dysphagia. The first study, a prospective population-based one, conducted on 415 elderly individuals showed an odds ratio of 3.0 (p = 0.02) of major depression diagnosed according to DSM-IV criteria on dysphagia assessed by standardized swallowing examination . The second study, a larger cross-sectional study, conducted on 13,361 elderly individuals, in which the clinical data for both depression and dysphagia were drawn from their medical records , showed an odds ratio of 1.7.
Psychological disease as a predictor for dysphagia
To add more information to the complex association between dysphagia and the psychological state, some researchers evaluated the predictive value of psychological diseases in determining the dysphagia outcomes. In fact, Kang et al. in a prospective study of 72 patients, explored the association between the psychiatric factors and development of chronic dysphagia, immediately post-anterior cervical spine surgery. They reported that the presence of psychological disorders prior to surgery was the only significant predictor of chronic dysphagia (p = 0.005) .
Similarly, Cnossen et al. in their prospective study of patients with head and neck cancer, reported that depression showed significant association with dysphagia, at baseline, as well as on follow-up (r = 0.46; p = 0.001), suggesting that the depression raises the risk of the chronicity of dysphagia among these patients . Therefore, that depression might be considered a risk factor for poor recovery from dysphagia needs to considered during the initial evaluation of patients with dysphagia, to optimize the outcome and enhance or speed up the recovery of dysphagia.
Dysphagia as a predictor of psychological disease
Just as depression may increase the chronicity of dysphagia, dysphagia may also increase the risk of depression. In a cross-sectional study conducted on 220 PD patients from a PD registry in Germany, patients with dysphagia were found to have three times greater likelihood of developing depressive symptoms (OR 3.06). Therefore, dysphagia was a significant predictor for depressive symptoms (R2 = 0.289, p = 0.006). Concurring with this finding, Kang et al. in their non-randomized clinical trial, evaluated the effect of a bedside exercise program on 50 stroke patients with dysphagia . In their report, they stated that patients who had responded to the swallowing program and had less severe dysphagia on VFSS, showed lower depressive symptoms and higher QoL . The results of both these studies suggest that suitable treatment of dysphagia reduces the risk of depression, and vice versa. Thus, the optimized management of dysphagia in its initial stages will definitely improve the well-being and quality of life on a long-term basis.
Limitations and future research
Major limitation of the literature assessment of dysphagia that is associated with psychological disorders is lack of objective assessment and variability in relation to the magnitude of severity of anxiety and depression and its impact for the precise assessment of dysphagia in this patient group. More deep assessment is needed to investigate the impact of anxiety and depression on the underlying neurological pathologies using spectral, brain waves in conjunction with the classical methods of subjective and objective assessment.
Dysphagia is associated with and positively correlated to depression and anxiety scores observed in PD, MS and stroke. Similarly, dysphagia does correlate with oral, tongue cancer. A bidirectional positive correlation exists with a vicious circle that loops between dysphagia and psychological disease. Moreover, the severity of dysphagia shows correlation with depression and/or anxiety scores. A critical understanding of this correlation between dysphagia and the neuropsychological pathologies would ultimately improve patient outcomes, quality of life, compliance, and adherence to management plan.
Availability of data and materials
The authors confirm that the data supporting the findings of this study are available within the article [and/or] its Additional files.
Central nervous system
Peripheral nervous system
Gastroesophageal reflux disease
Quality of Life
Ears, nose and throat
Modified barium swallow
Speech, language pathologist
MD Anderson Dysphagia Inventory
Swallowing disturbance questionnaire
Visual Analog Scale
Hospital Anxiety Depression Scale
Fiberoptic endoscopic evaluation of swallowing
Video fluoroscopic swallow study
- EORTC QLQ H andN35:
European Organization of Research and Treatment of Cancer Quality of Life Core Questionnaire for head and neck cancer, version 35
Geriatric Depression Scale
Beck Depression Inventory
Depression Anxiety and Stress Scale
Montgomery Asberg Depression Rating Scale
Center for Epidemiological Studies-Depression
Trait Anxiety Inventory
Diagnostic and Statistical Manual of Mental Disorders criteria, version IV
- UW QoL:
University of Washington Quality of Life Scale
World Health Organization Quality of Life-Bref
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Khayyat, Y.M., Abdul Wahab, R.A., Natto, N.K. et al. Impact of anxiety and depression on the swallowing process among patients with neurological disorders and head and neck neoplasia: systemic review. Egypt J Neurol Psychiatry Neurosurg 59, 75 (2023). https://doi.org/10.1186/s41983-023-00674-y