Seasonal Allergies Often Accompanied by Mental Health and Sleep Disorders
Now that spring in the air, so is allergic rhinitis, with many affected patients streaming into clinician offices for relief. Yet for some patients, that need for relief goes beyond alleviating sneezes, itchy eyes, and stuffed noses. A growing body of research indicates a significant connection between allergies and mental health,1 especially among women.2
Not only do allergies potentially worsen mood disorders, but the stress and anxiety from mood disorders can, in turn, amp up allergic responses. “Depression in and of itself is thought to be a pro-inflammatory state,” says David Gudis, MD, chief of the division of rhinology and anterior skull base surgery at New York-Presbyterian/Columbia University Irving Medical Center, New York City. “If your inflammatory mechanisms are already firing, and then you throw an allergic reaction on top of it, you’re propelling that allergic reaction to an even greater degree. Dealing with these challenges can deplete your resilience, leaving you less equipped to handle the ways in which allergies might worsen your condition.”
Seasonal allergies, in particular, have been linked to generalized anxiety.1 This is “no surprise to most practicing allergists,” says Ron Saff, MD, a practicing allergist and assistant professor of medicine at Florida State University College of Medicine in Tallahassee, FL. Allergy season typically worsens allergy-related conditions, such as asthma and urticaria, he notes, which adds to patients’ stress levels. “Many patients usually do well with their allergic rhinitis symptoms throughout the rest of the year, but when the spring rolls around and the trees start pollinating, they come in with sneezing and runny noses and watery eyes, and many of them just don’t feel well. It seems like I see more of everything in the spring,” says Dr Saff.
Clinicians and patients alike need to be more aware of the potential for connection between seasonal allergies and mental health, so that patients’ needs can be fully addressed, Drs Saff and Gudis both stress. This is especially true given that allergy seasons are not only starting earlier but are also lasting longer and hitting harder; a 2020 study highlighted a 21% rise in pollen levels across North America between 1990 and 2018.3
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Not only do allergies potentially worsen mood disorders, but the stress and anxiety from mood disorders can, in turn, amp up allergic responses.
Inflammatory Response as a Common Denominator
“For at least 75 years, doctors have identified and written about the association between depression and anxiety and allergic rhinitis,” says Dr Gudis. “It’s been studied in different ways, using different scientific methodologies of investigation around the world. The reason that’s important is that allergens are different in different parts of the world — meaning this is not unique to a reaction to a specific allergen. It’s related more to the cascade of the inflammatory pathways that occur in the body during the allergic reaction.”4
Research delving into how our bodies react to allergens, such as tree pollen, shows a complex inflammatory response that transcends the initial point of contact. Upon encountering tree pollen, for instance, the nasal membranes react to these perceived microscopic invaders, fueling a reaction that travels through the airways and spreads through the body and brain.5
At the heart of this inflammatory response are cytokines, crucial chemical messengers that orchestrate the response.6 Pro-inflammatory cytokines can penetrate the central nervous system (CNS) and interact with critical neurological processes, thus influencing important brain functions, including how brain cells communicate, hormone regulation, and behaviors associated with mental health conditions like depression and anxiety.7
Allergy Symptoms and Mood
In severe allergic rhinitis, many of the physical symptoms that cause physical misery can also have a major effect on a patient’s mood. “Any illness or disorder, if it detracts from the enjoyment of the world around us, is a psychological stressor, and allergic rhinitis8 is no different,” says Dr Gudis. “Basically, the whole middle of their head is inflamed, impacting memory, attention, and fatigue,” Dr Gudis adds.
The nasal congestion of allergic rhinitis in itself can have a major impact on mood, he stresses. “We don’t even realize it but our sense of smell helps us connect to people around us,” Dr Gudis says. “When people have olfactory dysfunction, as a result of their noses being swollen and inflamed, they are more likely to feel depressed9 and isolated,” he says.
This relationship was underlined by a 2016 study revealing a strong link between compromised olfactory function and depression.10 Of note, people who are depressed frequently have a diminished sense of smell compared to those who aren’t depressed. Moreover, individuals with a weaker sense of smell tend to be more prone to depression, especially if they’ve completely lost their ability to smell.
Allergies, Sleep Quality, and Mental Health
A growing body of research points to how inflammation from seasonal allergies can disrupt sleep,11 a major factor connecting allergic suffering to mood disorders, adds Dr Gudis.
A 2020 meta-analysis on the association between allergic rhinitis and sleep patterns found that although there is not a significant difference in sleep duration between people with and without allergic rhinitis, the condition was linked to poorer sleep quality, increased sleep disturbances, longer sleep latency, heightened usage of sleep medications, and lower sleep efficiency.11 Moreover, hay fever sufferers experience other sleep ailments, including insomnia, restless sleep, and obstructive sleep apnea, alongside daytime dysfunction, such as difficulty waking up and daytime sleepiness.
“When people have allergic rhinitis, one thing they experience is sleep dysfunction,” says Dr Gudis. “Allergic rhinitis, fundamentally, is defined by its underlying mechanism — its pathophysiology.” The inflammatory cytokines involved can disrupt normal and healthy sleep and increase fatigue, he explains.
“There’s a shorter sleep duration… [and] a disruption of the normal sleep function and architecture.” Adequate sleep is critical to mental health, notes Dr Gudis, adding that research indicates that poor sleep “exacerbates symptoms of depression and anxiety.”
Allergy Medications and Mental Health
Some commonly used allergy medications can potentially worsen mental health conditions as well, says Dr Saff. While allergists are well-aware of this, patients and primary care providers often are not.
Older-generation decongestants present in antihistamines like those found in doxylamine or diphenhydramine can induce sedation12 and a feeling of disorientation. Pseudoephedrine and phenylephrine can cause anxiety, nervousness and insomnia13 without effectively treating allergic rhinitis.
Additionally, research suggests a connection between anticholinergics12 — such as Benadryl — and an increased risk of dementia in older adults.
“Benadryl [diphenhydramine] is frequently utilized in the emergency department,” says Saff. “And patients are frequently sent home on Benadryl, so I think there’s certainly a lack of knowledge about the side effects of first-generation antihistamines.”
Additionally, Dr Saff notes that many patients resort to self-medication with these drugs before seeing him, often reporting adverse effects like drowsiness or ineffectiveness.
Dr Saff recommends that patients who wish to self-medicate use over-the-counter nasal steroids and antihistamines as safer alternatives, citing their minimal systemic absorption14 and fewer side effects. A protocol can be started before allergy season15 for more effective symptom management. Allergy eye drops also provide targeted relief without the systemic side effects associated with oral medications.16
Second-generation antihistamines in pill form, such as cetirizine, fexofenadine, and loratadine, are still a good choice for many, says Dr Gudis, as they cause less drowsiness than the first-generation drugs and last longer. Allegra is considered the least sedating of this group.17
Moreover, decongestants like oxymetazoline are useful for symptom relief but can have a rebound effect over a prolonged time. After a few days of using decongestants, the blood vessels in the nose become less responsive to the medication, reducing their effectiveness.
For patients seeking a medication-free option, Dr Saff suggests nasal irrigation — a time-tested, research-backed method using a saline solution to clear nasal passages.18 He recommends intranasal sodium chloride products over traditional neti pots for their ease of use and effectiveness.
Discussing the Allergy-Mental Health Connection With Patients
Many patients suffering with allergies who are also experiencing mood disorders may not be aware that the 2 problems could be connected, said Dr Gudis. “Patients might not realize they should mention changes in their mood to their ear nose and throat specialist, allergist, or pulmonologist,” he notes. Given that, clinicians seeing allergy patients may want to open up this line of communication.
Dr Saff agrees. Although it is commonly assumed that depression screening is the responsibility of primary care providers, many patients — especially those without a regular primary care physician or detailed medical records — might miss crucial mental health screenings.
The US Preventive Services Task Force (USPSTF) mental health screening recommendations are useful guidelines for identifying and addressing depression, says Dr Saff, who advocates for their broader use across specialties. Dr Saff says he employs a holistic approach for those struggling with anxiety and depression, recommending reading materials, counseling, and exercise. When appropriate, he may also prescribe medications such as selective serotonin reuptake inhibitors.18
As a practicing allergist in a college town, Dr. Saff often sees students who are under stress, separated from their usual support networks, and who don’t have a local primary care physician. Getting an appointment with a mental health professional sometimes can take months for these students, he notes. “They need help and I’m happy to offer them the medication,” he adds. “Many take me up on the offer.” When they do, he has them come back for reassessment after a month. Many students will instead choose to contact their primary care physician in their hometown, consult another provider, or to just live with the stress. “It’s always the patient’s choice,” says Dr Saff.
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