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* From Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY.
Correspondence to: Peter Dicpinigaitis, MD, Einstein Division/Montefiore Medical Center, 1825 Eastchester Rd, Bronx, NY 10461; e-mail: pdicpinigaitis{at}pol.net
Abstract
Study objectives: Cough is the most common complaint for which patients in the United States seek medical attention. Although the significant effect of cough on quality of life has been reported, the association of chronic cough with depressive symptomatology has not previously been investigated.
Design: Prospective, nonrandomized evaluation.
Setting: Outpatient department of academic medical center.
Patients: Representative sample of patients presenting to a specialty center seeking evaluation and treatment of chronic cough.
Interventions: Participants completed the Center for Epidemiologic Studies Depression Scale (CES-D), a 20-item self-report questionnaire designed to measure depressive symptomatology and risk for clinical depression, on initial evaluation and again after 3 months. Patients also provided subjective cough scores reflecting the severity of their cough.
Measurements and results: Of 100 patients undergoing initial evaluation, 53% scored positive (
16) on the CES-D. Mean CES-D score was 18.3 ± 13.2 (± SD). Among 81 subjects followed up at 3 months, mean CES-D score fell to 7.4 ± 10.4, and subjective cough score decreased from 10 to 4.9 ± 3.1. There was a statistically significant improvement in both cough and depression scores after 3 months (p < 0.001). Improvement in cough score correlated significantly with improvement in depression score (p = 0.003; Spearman 
= 0.323).
Conclusion: Depressive symptomatology is very common in patients with chronic cough. Physicians and other caregivers must be aware of the significant risk of clinical depression in this patient population.
Key Words: Center for Epidemiologic Studies Depression Scale • cough • depression • quality of life
Cough is the most common complaint for which patients in the United States seek medical attention.1 Although acute cough is usually transient and self-limited, chronic cough, defined as cough lasting > 8 weeks,2 causes significant morbidity and utilization of health-care resources. Multiple studies34 have documented the severe impact that chronic cough has on quality of life. To the authors’ knowledge, however, the prevalence of depression or depressive symptoms in patients with chronic cough has not been investigated. The goals of this investigation were to evaluate the prevalence of depressive symptomatology among patients with chronic cough, and to assess the effect of treatment of cough on depressive symptoms.
Materials and Methods
Between July 2004 and April 2005, patients with chronic cough presenting for their initial evaluation at the Montefiore Cough Center (Bronx, NY) completed the Center for Epidemiologic Studies Depression Scale (CES-D). The CES-D, a widely used and validated instrument, is a 20-item self-report questionnaire designed to measure depressive symptomatology.5 A score 16 reflects significant depressive symptomatology and risk for clinical depression.5 The CES-D was administered verbally by one of the investigators. Subjects granted informed consent for this study, which was approved by the Institutional Review Board of Montefiore Medical Center.
Patients were further evaluated and managed on an individual basis, according to their specific history, previous evaluation and treatment, current signs and symptoms, and the presumptive etiologies of their chronic cough. The number and frequency of subsequent visits were at the discretion of the treating physician.
Approximately 3 months after their initial visit, patients were contacted by telephone to repeat the CES-D. At that time, they were also asked to provide a subjective score describing the present severity of their cough, based on a zero to 10 scale, with a score of 10 representing the severity of their cough at the time of their initial evaluation 3 months earlier.
Changes between study entry and follow-up assessment at 3 months, and correlation between cough duration at study entry and cough score at follow-up were assessed (Wilcoxon signed-ranks test). Univariate correlations between changes in CES-D score from baseline to follow-up and between changes in CES-D score and changes in subjective cough score between study entry and follow-up assessment; cough duration at study entry and CES-D score at follow-up; cough score and CES-D score at follow-up; age and baseline CES-D and follow-up CES-D scores; as well as age and change in cough score during the study period were assessed (Spearman ). Differences in changes in CES-D score during the study period between subjects whose cough did improve and subjects whose cough did not improve; baseline and follow-up CES-D scores between male and female subjects; and changes in cough score during the study period between male and female subjects were assessed (Mann-Whitney U test). Nonparametric tests were used for all the above comparisons because of skewed variable distribution. In order to determine whether improvement in cough during the study period remained associated with depression scores at follow-up, the relationship between these variables after adjustment for gender, age at study entry, cough duration at study entry, CES-D score at study entry, and the interaction between gender and change in CES-D score during the study period was explored (linear regression with forced entry of variables into the model).
In June 2005, we performed a National Library of Medicine (PubMed) search using the term "CES-D." The search dated back to the time of the development of the CES-D (1977). Studies were sought in which the CES-D was used in other adult patient groups, so as to put the results of the present study into perspective. Studies in which the standard, 20-item form of the CES-D was used, and results provided in terms of the percentage of patients scoring positive (CES-D 16) were identified.
Results
One hundred patients (79 women, 21 men) completed the CES-D at their initial visit. Three subjects were not enrolled because of a preexistent diagnosis of depression and/or use of an antidepressant medication. The predominance of women in this study accurately reflects the overall percentage of women seen at the Montefiore Cough Center since its inception, and mirrors the experience at other subspecialty cough centers where women, who have enhanced cough reflex sensitivity compared to men,67 represent the majority of patients seeking treatment.78
Mean age of subjects was 59.5 ± 12.6 years (± SD) [median, 58.5 years; range, 35 to 82 years], and mean duration of cough was 106 ± 108 months (median, 72 months; range, 2 to 540 months). The mean CES-D score for the group as a whole was 18.3 ± 13.2 (median, 16; range, 0 to 49), with 53% scoring 16. When evaluated by gender, 53% of women and 52% of men scored positive on the CES-D scale (score 16). There was no correlation between baseline depression score and duration of cough.
Eighty-one subjects (64 women, 17 men) participated in the 3-month follow-up study; these subjects represent 81% of the original group of female participants and 81% of the original group of male participants. Sixteen subjects were unavailable for follow-up, 2 subjects declined to participate, and 1 subject died during that time interval. For the 81 subjects undergoing subsequent evaluation, mean CES-D score fell from 18.6 ± 13.4 (median, 16.0; range, 0 to 49) to 7.4 ± 10.4 (median, 4; range, 0 to 48). The CES-D score decreased in 73 of 81 subjects, remained unchanged in 5 of 81 subjects, and increased in 3 of 81 subjects. The subjective cough score, arbitrarily defined as 10 on a zero to 10 scale at the initial visit, fell to 4.9 ± 3.1 (median, 5; range, 0 to 10) after 3 months. The subjective cough score at 3 months decreased in 70 of the 81 subjects, and remained at a level of 10 in 11 subjects. Of the 81 subjects for whom follow-up data are available, 44 subjects had initially positive CES-D scores. Of this group, 42 subjects (95%) had a lower CES-D score at follow-up, and 31 subjects (70%) had CES-D scores that decreased into negative (< 16) range. Only 1 of 81 subjects had an initial negative CES-D score that on follow-up evaluation was positive (CES-D score changed from 12 to 16).
There was a statistically significant improvement in both cough (Z = – 7.34; Wilcoxon signed-ranks test; p < 0.001) and depression (Z = – 7.14; Wilcoxon signed-ranks test; p < 0.001) scores from the start of treatment to the 3-month follow-up. Improvement in cough score correlated significantly with improvement in depression score (p = 0.003; Spearman = 0.323). When adjusted for gender, age at study entry, cough duration at study entry, depression score at study entry, and possible interactions between gender and depression score, improvement in cough score still correlated significantly with depression score at follow-up (unstandardized regression coefficient ß = – 0.18; SE 0.04; 95% confidence interval, – 0.26 to – 0.10, p < 0.001; R2 for full model = 0.28). Those subjects whose cough did not improve had significantly less diminution in depression scores during the study period than those whose cough score improved (Z = – 4.00; Mann-Whitney U; p < 0.001).
There was no significant correlation between duration of cough at study entry and 3-month CES-D score. However, cough duration and 3-month cough score (Spearman = 0.227; p = 0.041), baseline and 3-month CES-D scores (Spearman = 0.581; p < 0.001), and 3-month CES-D and 3-month cough scores (Spearman 0.29, p = 0.009) were significantly and positively correlated. There was no significant gender difference in baseline and 3-month CES-D scores, and in change in cough score from baseline to 3-month follow-up. There was no significant correlation between age at study entry and baseline and 3-month CES-D score, and in change in cough score from baseline to 3-month follow-up (Spearman ).
Through a National Library of Medicine (PubMed) search, we identified 24 publications in which the percentage of CES-D scores 16 on the full 20-item CES-D scale were provided for various adult patient populations.91011121314151617181920212223242526272829303132 These data are tabulated in Table 1
in order of percentage of the study population scoring positive on the CES-D scale.
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Chronic cough can result in significant morbidity and loss of quality of life.34 Patients have a host of physical complaints, including chest and throat discomfort, sleep deprivation, nausea and/or vomiting after paroxysms of cough and, especially in women, urinary incontinence. Furthermore, many patients with chronic cough become socially isolated; fear of severe coughing in public places forces them to abandon activities such as attending movies and concerts, eating in restaurants, and participating in church functions. The patient’s suffering may be further exacerbated by the negative effects of the chronic cough on relationships with spouses, other family members, and coworkers. Many of the patients seen at our cough center had been evaluated by multiple physicians in the past, without success, thus likely contributing to their feeling of frustration and hopelessness regarding their condition.
It is perhaps not surprising, therefore, that 53% of our patients with chronic cough scored 16 on the CES-D, indicating the presence of significant depressive symptomatology. These results seem even more impressive when compared to CES-D scores of other chronic patient populations, as shown in Table 1. Although the subject population in this study was predominantly female (79%), reflecting the enhanced cough reflex sensitivity in women,67 and mirroring the experience at other subspecialty cough centers,78 the percentage of our subjects demonstrating significant depressive symptomatology was essentially identical in women (53%) and men (52%).
The 3-month follow-up data are noteworthy for a number of reasons. Firstly, the relationship of the improvement in cough score after treatment to the improvement in CES-D score supports a causal link between chronic cough and the presence of depressive symptomatology. Furthermore, as has been shown in successfully treated psychiatric patients,5 we were able to demonstrate an improvement in CES-D score with successful treatment of chronic cough. Antidepressant medications were not prescribed for any patients. It should be noted, however, that this study lacked a control group who underwent serial CES-D measurement without intervening treatment.
In summary, our study has demonstrated that depressive symptomatology is very common in patients with chronic cough. Physicians and other caregivers must be cognizant of the significant risk of clinical depression in this patient population. Furthermore, clinicians should exercise judgment in deciding whether appropriate mental health referral is necessary, regardless of the outcome of treatment for chronic cough.
Footnotes
Abbreviation: CES-D = Center for Epidemiologic Studies Depression Scale
Presented in part at the American Thoracic Society International Conference, San Diego, CA, May 23, 2005.
The authors have no conflicts of interest related to this work to disclose.
Received for publication November 4, 2005. Accepted for publication June 13, 2006.
References
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