The prevalence of anxiety and depression in bronchiectasis patients and their association with disease severity: a cross-sectional study

Bronchiectasis is a chronic lung disease characterized by recurrent respiratory symptoms. Several studies demonstrated that psychological comorbidities are common in patients with bronchiectasis. The aim of this study is to investigate the prevalence of anxiety and depression in bronchiectasis patients and assess their association with disease severity. In this cross-sectional study, we included patients diagnosed with bronchiectasis. The study was conducted using an interviewer-administered questionnaire via phone calls and data collected from the electronic medical records at JUH. The questionnaire included patients’ demographics and disease characteristics. Anxiety and depression were assessed using GAD7 and PHQ9 respectively. Bronchiectasis disease severity was assessed using BSI and FACED score. The total number of included patients was 133. Moreover, 53.4% of the participants were females while the rest were males (46.6%). PHQ9 demonstrated that 65.4% of the patients had depression. Regarding anxiety, GAD7 scale showed that 54.1% of the patients had anxiety. Pearson correlation showed that bronchiectasis severity index was significantly associated only with PHQ9 depression scores (r = 0.212, P value = 0.014). The prevalence of depression and anxiety is high among patients with bronchiectasis. We believe that patients affected with bronchiectasis should be screened for depression to improve their quality of life.


Ethical approval
This study was authorized by the International Review Board (IRB) Committee of the University of Jordan Hospital and the faculty of medicine.The IRB number was 10/2023/534.Moreover, before completing the questionnaire, a written informed consent was taken from the patient after describing the aims of the study.All the performed methods were conducted in accordance with the relevant guidelines and regulations including the Declaration of Helsinki.

Data analysis
Categorical variables were presented as counts and percentages while the continuous variables were interpreted as mean, standard deviation and range.The correlations between bronchiectasis severity scores and depression and anxiety scales was tested using Pearson Correlation Coefficient.Chi-square test was used to assess difference in anxiety and depression between patients with other comorbidities and patients without.Any test with a P value < 0.05 was considered significant.The data analysis was done using IBM-SPSS v.25.

Characteristics of the included patients
The total number of included patients was 133.Moreover, 53.4% of the participants were females while the rest were males (46.6%).The mean age of the participants was 50.43 ± 15.14.Around half of the patients had university-based education.Additionally, 13.5% of the patients were smokers.Only 0.8% of the patients had history of TB and 7.5% of the patients complained of hemoptysis.Furthermore, 75.9% of the patients had diabetes and 34.6% of them had hypertension.Also, 12.8% of the patients had cardiovascular diseases and 6.0% of them had chronic lung disease.The mean disease duration among the patients was 11.68 ± 12.65.Table 1 describes the characteristics of the included patients.

Bronchiectasis disease severity
According to BSI assessment, 29.3% of the patients had severe bronchiectasis (Fig. 1).On the other hand, FACED assessment showed that only 4.5% of the patients had severe bronchiectasis (Fig. 2).The mean BSI and FACED scores were 6.41 ± 3.77 and 1.90 ± 1.24, respectively (Table 1
Of them, 28.0% had mild depression, 21.2% had moderate depression, 8.3% had moderately severe depression and 8.3% had severe depression (Fig. 4).Regarding anxiety, GAD7 scale showed that 54.1% of the patients had anxiety (Fig. 5).Severity scales revealed that 24.8% had mild anxiety, 22.6% had moderate anxiety and 6.8% had severe anxiety (Fig. 6).The mean GAD7 score was 6.10 ± 5.07 (Table 1).Patients with other lung diseases had      higher depression and anxiety prevalence compared to patients without other lung diseases but the difference between the two groups was not statistically significant (P value > 0.050) (Table 2).In addition, no comorbidity was associated with depression or anxiety (P value > 0.050) (Table 3).

Correlations between bronchiectasis severity scales and anxiety and depression scales
Pearson correlation showed that bronchiectasis severity index was significantly associated only with PHQ9 depression scores (r = 0.212, P value = 0.014).No significant correlation was found between FACED score and PHQ9 depression score or GAD7 anxiety score (P value > 0.0) (Table 4).

Discussion
Anxiety and depression are common comorbidities in patients with chronic diseases including chronic airway lung diseases 12 .Notably, anxiety and depressive symptoms are often overlooked by physicians and have been associated with worse adherence to treatment and overall increased morbidity in patients with chronic airway lung diseases [13][14][15] .
The findings in this study are consistent with the findings of previous studies done on this topic that anxiety and depression are common among patients with bronchiectasis.Our study demonstrated that the prevalence of depression in bronchiectasis patients is 65.4% and that of anxiety is 54.1%.However, those numbers are higher than those reported by other studies.Olveira et al. 1 reported a prevalence of 20% and 38% for depression and anxiety, respectively.On the other hand, a Korean study done on outpatients with chronic airway lung diseases had a depression prevalence of 55% in patients with bronchiectasis, similar to that of COPD patients, and anxiety prevalence of 39% which was higher than that in patients with COPD or asthma 16 .A Turkish cross-sectional study, which only included non-cystic fibrosis bronchiectasis patients, reported a prevalence of 41% and 30% for depression and anxiety, respectively 4 .A study by Girón Moreno et al. 17 conducted in Spain reported a depression rate of 34% among non-cystic fibrosis bronchiectasis patients and 55% for anxiety.
The discordance in the prevalence rates of anxiety and depression may be due to differences in patients' characteristics, differences in methodologies and the use of different screening questionnaires for depression and anxiety.Patients in this study had higher mean age than some previous studies, the aforementioned Olveira et al. study presented increasing of depression and anxiety in relation to increasing age.Although the questionnaires used to assess the psychological status are validated screening tools, they might overestimate the rates of anxiety and depression 18 .Furthermore, bronchiectasis patients frequently suffer from fatigue, sleep disturbances and reduced appetite which are incorporated into the screening tools for psychological status may have consequently resulted in falsely elevated rates of depression and anxiety.Approximately 75.9% of the participants in this study have diabetes which has been linked to high prevalence of comorbid depression and anxiety 19,20 .However, there may also be social factors contributing to the high prevalence of anxiety and depression in patients in this study compared to the studies from other countries.
Bekir et al. 4 reported no association between anxiety and depression rates and bronchiectasis disease severity assessed with BSI and FACED.This is consistent with the Chinese cross-sectional study where they suggested that anxiety and depression in bronchiectasis patients might have originated from other mechanisms unrelated to the disease severity 5 .No significant association was found between anxiety and disease severity scores (BSI and FACED) in the present study.However, this study demonstrated that depression scores was associated with disease severity only when assessed by BSI but not FACED.This finding is consistent with the finding of a Korean multicenter cohort which found a significant association between depression, assessed by PHQ9, and disease severity assessed by BSI and EFACED but reported no association with FACED score, hence they suggested exacerbation to be a significant factor associated with depression 3 .The differences in the association between the two scores can be explained by the fact that each of these scores consider different aspects as BSI score includes factors that FACED does not such as BMI, number of exacerbations in the last year and pseudomonas colonization.
This study includes some limitations that should be noted.First, it was conducted in a single tertiary hospital that usually receives severe and advanced patients compared to all affected patients.Second, the small number of patients recruited can be considered as a limitation as well which might impact the generalizability of our findings.In addition to that, the psychological and social status of the patients were examined for the patients' present status but the development of it over time was not examined.Finally, disease activity was reported by the patients and no specific biomarkers or measures were used to evaluate it.

Conclusion
This study showed that the prevalence of depression (65.4%) and anxiety (54.1%) is high among patients affected with bronchiectasis.Disease severity index is significantly associated with depression but not anxiety.This associations can lead to much worse clinical consequences that can affect the progress of the disease.We believe that patients affected with bronchiectasis should be screened for depression to improve their quality of life.

Table 1 .
Characteristics of the included patients.

Table 2 .
Difference in depression and anxiety prevalence between patients with other lung diseases in addition to bronchiectasis and patients without.
VariableResponse Patients with lung diseases Patients without lung diseases P value

Table 3 .
Investigating the comorbidities associated with depression.

Table 4 .
Correlations between bronchiectasis severity scales and anxiety and depression scales.*P value < 0.05.