Depression and Anxiety in Patients with Oropharyngeal Dysphagia Evaluated by Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

Introduction

Oropharyngeal dysphagia (OD), or difficulty swallowing, significantly impacts individuals’ quality of life and is commonly diagnosed using fiberoptic endoscopic evaluation of swallowing (FEES), which provides detailed insights into the swallowing mechanism [1]. OD can arise from diverse causes, including stroke, chronic neurological diseases, head and neck cancer or the effects of its oncological treatments, Zenker diverticulum, cervical spine abnormalities, and age-related changes, such as presbyphagia [2]. The prevalence of OD increases significantly with age and has been estimated to affect up to 40% of older adults, with even higher rates among institutionalized individuals [3].

Beyond its physical consequences, such as malnutrition, dehydration, and aspiration pneumonia, OD has a considerable psychosocial impact. Patients often experience coughing, choking, or the sensation of food sticking, leading to embarrassment, fear, and a reluctance to eat in public. These reactions can result in social withdrawal, further compromising emotional well-being. People with dysphagia often report associated anxiety and affective symptoms, as dysphagia affects health and quality of life, notably through the disruption of the social aspect of sharing meals [4,5].

Although the psychological burden of OD is increasingly recognized, the underlying mechanisms remain insufficiently understood. Prior studies have suggested that affective symptoms, particularly anxiety and depression, may not arise only as a consequence of OD but may also influence how swallowing difficulties are perceived and reported. For instance, individuals with pre-existing psychiatric conditions may report more severe subjective symptoms, even in the absence of measurable swallowing impairment [6]. Conversely, the experience of OD itself, with its social and functional limitations, can contribute to the development or worsening of emotional symptoms [7].

As the emotional burden of OD gains greater recognition, there is an increasing need to integrate psychological perspectives into clinical practice. However, despite growing awareness, much of the existing research remains centered on the physiological evaluation of swallowing, with limited emphasis on the emotional and psychological dimensions [8]. This further underscores the need for a multidisciplinary approach in both its evaluation and management [9]. To better reflect the complexity of OD, incorporating assessments of anxiety and depression into clinical evaluations can offer valuable insights. Such an approach not only enhances our understanding of how patients experience swallowing difficulties but also promotes more comprehensive, patient-centered care.

In this study, we sought to investigate the associations between OD and affective symptoms, specifically anxiety and depression, in a cohort of patients undergoing FEES. In addition, we examined the influence of sociodemographic and clinical variables on this relationship. By integrating mental health variables into the clinical evaluation of OD, we aimed to promote a more holistic and patient-centered approach to dysphagia management.

Material and Methods

ETHICAL APPROVAL, STUDY DESIGN, AND PARTICIPANTS:

Ethical approval was obtained from Gazi University on September 18, 2023 (decision No: E-77082166-604.01.02-748303). The study was conducted at the Swallowing Disorders Center, Gazi University Hospital, Department of Otorhinolaryngology. Informed consent was obtained from all patients prior to their participation.

A convenience sampling method was used to include patients who presented to the clinic with swallowing problems during the study period, and the sample size was determined by the number of eligible patients available at that time. No imputation methods were applied; cases with missing data were excluded from the relevant analyses.

Sixty-three patients who presented with OD were recruited and evaluated using FEES. A sociodemographic data form was used to collect information on age, occupation, smoking and alcohol use patterns, previous psychiatric treatments, and other relevant sociodemographic variables. Anxiety and depression levels were assessed using the Beck Anxiety Inventory (BAI) and Beck Depression Inventory (BDI), which are validated tools for measuring anxiety and depressive symptoms. The Penetration-Aspiration Scale (PAS) was used to evaluate the degree of aspiration during FEES.

At the time of inclusion, all patients were cognitively capable of completing self-report scales. Patients with neurological or chronic systemic diseases were included if they were in a stable phase of disease or on a consistent medication regimen for at least 3 months. None of the patients were in the palliative stage of care.

Exclusion criteria included age over 85 years (presbyphagia), terminal-stage disease, cognitive impairments that interfered with completion of self-report measures, and recent stroke (within the last 3 months).

SOCIODEMOGRAPHIC DATA FORM:

A sociodemographic data form, which was prepared by the researchers after reviewing the relevant literature, included questions to gather information on patients’ age, and history of psychiatric treatments, including previous diagnoses and medications used. It also collected smoking habits, alcohol use, any existing medical conditions, and regularly used medications. To improve data accuracy, information on past psychiatric diagnoses and prescribed pharmacological treatments was cross-validated using electronic medical records from the national health system database. Individuals with a recorded psychiatric diagnosis but no record of psychotropic medication use were categorized under “previous psychiatric diagnosis”, while those with documented prescriptions for psychiatric medications were classified under “psychiatric treatment”. These details aimed to identify factors that could affect swallowing function, ensuring a comprehensive evaluation of the patients.

BECK ANXIETY INVENTORY: Developed by Beck et al, the BAI inventory assesses the physical, emotional, and cognitive aspects of anxiety, as well as the fear of losing control [10]. Adapted into Turkish by Ulusoy et al, it consists of 21 items scored from 0 to 3. The total score ranges from 0 to 63 and is interpreted as follows: 0–7=minimal anxiety, 8–15=mild anxiety, 16–25=moderate anxiety, and 26–63=severe anxiety [11].

BECK DEPRESSION INVENTORY: The BDI is a self-report scale consisting of 21 items measuring somatic, emotional, cognitive, and impulsive symptoms of depression [12]. Each item is scored from 0 to 3, with total scores ranging from 0 to 63, where higher scores indicate more severe depressive symptoms. Total scores are interpreted as follows: 0–9=minimal depression, 10–16=mild depression, 17–29=moderate depression, and 30–63=severe depression. The Turkish adaptation was conducted by Hisli [13].

PENETRATION-ASPIRATION SCALE:

The PAS, developed by Rosenbek et al (1996), is an 8-point ordinal scale used to quantify the severity of airway invasion observed during swallowing, particularly in instrumental evaluations, such as videofluoroscopy or FEES. The scale ranges from 1 to 8, with a score of 1 indicating no airway invasion (normal swallowing), and a score of 8 representing silent aspiration, where material enters the airway, passes below the vocal folds, and is not expelled. Scores between 2 and 5 indicate varying degrees of penetration, while scores between 6 and 8 indicate aspiration.

In this study, the original 8-point PAS was used without modification. Each patient’s swallowing performance during FEES was scored by trained raters based on video recordings. Scores of ≥3 were considered to reflect impaired airway protection, for the purposes of group classification and statistical comparison [14].

STATISTICAL ANALYSIS:

Statistical analyses were performed using SPSS version 25. Descriptive data are presented as frequencies (n) and percentages (%). The normality of continuous variables was assessed using the Shapiro-Wilk test. As data were not normally distributed, nonparametric tests were applied. Patients were divided into 2 groups based on swallowing function assessed by FEES: group 1 (impaired swallowing, PAS ≥3) and group 2 (normal swallowing, PAS ≤2). Categorical variables were analyzed using the chi-square test or Fisher exact test, as appropriate. Continuous variables were compared between groups using the Mann-Whitney U test. The significance level was set at α=0.05.

Results

Table 1 presents the demographic and swallowing function characteristics of the study population. A total of 63 patients participated in the study, with 47.6% (n=30) women and 52.4% (n=33) men. The median age was 58.0 years (24–78). Most patients were married (86%, n=54), while 14% (n=9) were single.

FEES evaluation revealed that 62% (n=39) of patients had normal results, while 38% (n=24) had abnormal findings. Based on swallowing function, 2 groups were formed: group 1 (impaired swallowing) with PAS scores ≥3, and group 2 (normal swallowing) with PAS scores ≤2.

Comparisons of demographic, clinical, and psychiatric characteristics are presented in Table 2. Group 1 had a significantly higher median age than group 2 (P=0.041). There were significantly more men in group 1, while there were more women in group 2 (P=0.005). History of psychiatric diagnosis and psychiatric treatment were significantly more common in group 2 (P=0.013 and P=0.004, respectively). Higher levels of depressive symptoms (BDI ≥17) were observed in group 1 (P=0.044), whereas anxiety symptoms (BAI ≥16) did not differ significantly between groups (P=0.282). Regarding lifestyle factors, 41% (n=26) were smokers, and 2% (n=1) reported alcohol abuse. There was no significant difference in smoking between group 1 and group 2 (P=0.960).

The analysis of medical comorbidities showed that 17.5% (n=11) of patients had neurological diseases (eg, previous stroke, ALS), 28.6% (n=18) had cardiovascular diseases (eg, myocardial infarction, hypertension), and 4.8% (n=3) had diabetes mellitus. Other medical comorbid conditions (eg, rheumatism, asthma, osteoporosis) were present in 14.3% (n=9) of patients. Although medical comorbidities were more common in group 1, the difference was not statistically significant (P=0.082).

Discussion

In this study, we used the criterion-standard FEES method to assess swallowing function in patients with OD and, in parallel, examined how demographic, clinical, and psychological factors, particularly anxiety and depression, were associated with impaired swallowing, revealing significant intergroup differences.

FEES evaluations revealed that most patients demonstrated normal swallowing function. This outcome is partially attributable to the specific demographic and clinical profile of the sample. In routine practice at the Swallowing Disorders Center, a higher rate of swallowing impairment among individuals with OD is typically observed. However, many individuals who initially present with OD-related concerns, such as older adults or those with dementia and multiple comorbidities, can encounter challenges that hinder their ability to complete the assessment. Moreover, patients with cognitive impairments, including those with conditions such as cerebral palsy, were excluded from the study due to their inability to complete self-report instruments such as the BDI and BAI. Consequently, the inclusion of cognitively capable participants likely contributed to a lower than expected prevalence of impaired swallowing.

In our analysis, age was significantly associated with impaired swallowing function, as patients in group 1 were generally older than those in group 2. This finding aligns with previous research indicating that advancing age increases vulnerability to OD, due to age-related muscular atrophy and slower neural transmission [15,16]. Importantly, studies have shown that while OD in individuals under 60 years is often linked to identifiable causes, such as oncologic or neurologic diseases, in older adults it can arise from physiological aging itself – even in the absence of overt comorbidities [17]. These age-related functional changes may therefore explain the higher prevalence of OD observed among older individuals in our sample.

Sex differences were evident in our findings, with male patients significantly more represented in the impaired swallowing group. While several studies have reported higher OD prevalence in women [18,19], possibly due to reduced oropharyngeal muscle mass, increased comorbidity burden, and nutritional vulnerabilities, our results diverge, showing greater male prevalence in the functionally impaired group. These findings may reflect sociocultural patterns, such as delayed help-seeking behavior among men, or a clinical underrecognition of emotional symptoms in male patients with dysphagia.

A large-scale, longitudinal cohort study conducted in the United States among older adults further supports the notion that OD presents with distinct sex-related patterns. The study found that, although women were more frequently affected by new-onset swallowing difficulties, the predictive factors varied notably by sex. In men, emotional symptoms, such as anhedonia and emotional dysregulation, along with cognitive impairment, were stronger predictors of dysphagia. In contrast, for women, the presence of chronic diseases and overall health status were more prominent determinants [20]. These findings reinforce the need for sex-specific considerations in the screening, diagnosis, and management of OD.

Although lifestyle factors, such as smoking and alcohol consumption, are well-established contributors to aerodigestive tract pathology, including head and neck cancers [21,22], no significant association with OD was identified in our sample. This may be due to the limited prevalence of current smokers and individuals with alcohol-related health issues, reducing statistical power. However, previous studies suggest that these behaviors may be more prevalent and clinically consequential among older men, potentially exacerbating both the physiological risk and psychological symptoms associated with OD [20]. These sex-specific trends underscore the importance of considering lifestyle factors not only in aggregate but also within the context of sex-based behavioral patterns. Despite the limitations of our data, the strong link between these exposures and upper aerodigestive tract dysfunction in the literature calls for further research using larger, more representative cohorts to better assess their contribution to dysphagia risk.

Although our study did not identify a significant relationship between medical comorbidity burden and OD, this finding should be interpreted with caution, due to sample characteristics. Because anxiety and depression were assessed using self-report tools (BDI and BAI), we excluded patients with severe cognitive impairment or advanced medical comorbidities that could interfere with reliable questionnaire responses. As a result, individuals with a higher burden of medical comorbidity, who are often more susceptible to dysphagia, may have been underrepresented in our sample. Chronic illnesses and polypharmacy are known to increase the risk of swallowing impairment by exacerbating overall frailty and neuromuscular decline [23]. For instance, da Silva et al demonstrated that higher Charlson Comorbidity Index scores were associated with more severe swallowing impairments and an increased likelihood of nasogastric tube dependence [24].

Psychological factors, particularly depressive symptoms, appear to be associated with OD. In our study, patients in group 1 (impaired swallowing) had significantly higher BDI scores than did those in group 2 (normal swallowing). This finding aligns with a systematic review by Verdonschot et al, which analyzed 24 studies across different populations and reported a consistent association between depression and swallowing difficulties. The review also emphasized that, although the exact mechanisms remain unclear, affective symptoms can intensify the subjective experience of dysphagia. This amplification has been linked to processes similar to those observed in other functional somatic conditions, where heightened alarm sensitivity can distort symptom perception. These insights support the view that depressive symptoms not only co-occur with dysphagia but can influence how swallowing difficulties are perceived and reported [3].

Although the association between anxiety and dysphagia was less pronounced than that observed for depression, our findings suggest a potential link. BAI scores were higher among participants in group 1, with impaired swallowing, although the difference compared with group 2 did not reach statistical significance. A prospective cohort study by Verdonschot et al investigated the relationship between clinically relevant symptoms of anxiety and swallowing function using FEES-based assessments. The study showed that anxiety symptoms were associated with certain mild dysphagic features, such as piecemeal deglutition and vallecular pooling. Interestingly, the probability of presenting with anxiety decreased as the severity of these swallowing abnormalities increased [25]. While no causal relationship could be established, the findings imply that anxiety can influence how patients experience or report mild swallowing difficulties. These insights underscore the importance of assessing mental health symptoms in the clinical evaluation of OD.

Patients in group 2 had a significantly higher prevalence of psychiatric diagnoses and psychiatric pharmacological treatments. These findings can be interpreted in light of 2 distinct but interacting pathways. First, individuals with psychiatric diagnoses, particularly those with heightened health anxiety, somatization, or increased interoceptive sensitivity, may be more attuned to bodily sensations and therefore more likely to report symptoms such as dysphagia, even in the absence of measurable physiological impairment [26,27]. Second, the use of psychiatric medications, especially antipsychotics, antidepressants, and anti-dementia drugs, has been associated with an increased risk of OD, due to mechanisms such as extrapyramidal symptoms, sedation, xerostomia, and altered neuromuscular control [28]. Taken together, these findings point to an interplay between subjective symptom amplification and pharmacological mechanisms. Notably, individuals can experience OD symptoms even in the absence of observable abnormalities on objective assessments, such as FEES, suggesting a clinically meaningful impact of psychiatric status and medication-related adverse effects.

This study has several limitations that should be acknowledged. First, the relatively small sample size may have limited the statistical power to detect certain associations, particularly for lifestyle variables, such as smoking and alcohol use, and may have also influenced subgroup distributions, including sex. Second, the study was conducted in a tertiary university hospital, which may have introduced selection bias by attracting individuals with greater access to specialized care. Finally, the cross-sectional design restricts the ability to draw causal inferences between variables.

Despite these limitations, the study has notable strengths. Collaboration between an otorhinolaryngologist and a psychiatrist enabled a multidisciplinary approach, enhancing the clinical relevance and interpretive depth of the findings. The use of standardized FEES assessments provided objective and reliable evaluation of swallowing function, distinguishing this work from studies relying solely on self-report. Additionally, the incorporation of diverse demographic and clinical variables allowed for a comprehensive exploration of factors contributing to OD.

Future research should aim to replicate these findings in larger and more diverse populations, with particular attention to understudied subgroups and longitudinal designs that can better clarify causal relationships.

Conclusions

In this study, we examined the complex interplay between demographic, clinical, and psychological factors in patients with OD assessed through objective FEES evaluations. Our findings demonstrate that older age and male sex were significantly associated with impaired swallowing, while depressive symptoms showed a clear relationship with swallowing dysfunction. In contrast, anxiety levels did not significantly differ between groups, indicating that depression may play a more central role in this context.

Interestingly, individuals without objective swallowing impairment (group 2) were more likely to have a history of psychiatric diagnosis and psychiatric treatment. This may reflect the influence of heightened symptom perception and psychotropic medication use on the subjective experience of dysphagia. While FEES did not reveal functional impairment in this group, the presence of OD-like symptoms can still reflect clinically meaningful distress or medication-related adverse effects.

These findings underscore the importance of incorporating routine mental health assessment and medication history review into dysphagia evaluations. A multidisciplinary and individualized approach – integrating both a physiological assessment and psychological screening – can improve diagnostic accuracy and guide more comprehensive treatment strategies.