Association between the Hospital Anxiety and Depression Scale and Swallowing Function in Dysphagic Patients in Japan

Dysphagia affects 2.3 %-16 % of the general population and increases with age. It can lead to malnutrition, weight loss, aspiration pneumonia, and emotional symptoms such as anxiety and depression. Mental health disorders impact appetite and muscle mass, further worsening dysphagia. Additionally, cultural and economic factors influence anxiety and depression, which can either result from or contribute to dysphagia. Studies on the relationship between anxiety, depression, and swallowing function using FEES are limited in Asian populations. The Hospital Anxiety and Depression Scale (HADS) is a useful tool for assessing mood disorders. Therefore, in this study, we aimed to investigate the associations among anxiety, depression, and swallowing function in Japanese patients with dysphagia using HADS.

Data on age; sex; HADS; Eating Assessment Tool-10 (EAT-10); Functional Oral Intake Scale (FOIS); tongue pressure; Hyodo score, a scoring system for evaluating the swallowing function determined by flexible endoscopic evaluation of swallowing (FEES); and videofluoroscopic dysphagia scale (VDS), assessed by videofluoroscopic swallowing study, were collected and analyzed from medical records. Hyodo score consists of four parameters: (1) salivary pooling in the vallecula and piriform sinuses; (2) glottal closure reflex or cough reflex induced by touching the epiglottis or arytenoid; (3) swallowing reflex induced by colored water; and (4) extent of pharyngeal clearance after colored water is swallowed. The Mann-Whitney U test, Fisher's exact test, and multiple logistic regression analyses were used to estimate associations between HADS and swallowing function.

No significant relationships were observed between the EAT-10, FOIS, and VDS with HADS scores. Patients with depression were associated with a significantly higher percentage of anorexia complaints (p = 0.047). Lower tongue pressure was observed in patients with depression than in patients without depression (p = 0.002). Patients with anxiety had better swallowing function, as assessed by the Hyodo score (p = 0.047). Fluid clearance, a component of the Hyodo score, was significantly better in patients with anxiety (p = 0.03) even after propensity score matching adjusted for the effects of age, sex, and fluid clearance.

In patients with anxiety, swallowing function assessed by FEES was favorable, whereas a higher proportion of patients with depression reported decreased appetite, and lower tongue pressure. This discrepancy between subjective dysphagia and FEES findings suggests that patients with anxiety may underestimate their swallowing function.