A 50-year-old woman requests removal of a growth on her nose that began as a small bump approximately 2 years ago and has slowly enlarged. The patient has no history of skin cancer, warts, or similar lesions elsewhere on the body and has no family history of genodermatoses. The lesion has never bled. Physical examination reveals a 0.4 cm dome-shaped, smooth, firm, flesh-colored papule of her right nares.
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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
"
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 depressed9and 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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Meet Daniel Crawford, DNP, ARNP, CPNP-PC, CNE, FAANP, Associate Dean for Graduate Practice Programs and Associate Professor at the University of Iowa College of Nursing, in Iowa City. He is president-elect of the National Association of Pediatric Nurse Practitioners (NAPNAP), which recently help their 2024 annual meeting in Denver, Colorado. Dr Crawford also maintains a clinical practice at the University of Iowa Stead Family Children’s Hospital, Division of Pediatric Neurology. The Clinical Advisor met with Dr Crawford to discuss the challenges facing the field of pediatric nurse practitioners.
Q: What do you see as the biggest challenge facing pediatric nurse practitioners in 2024?
Dr Crawford: The biggest challenges facing NAPNAP are tied to the biggest challenges facing pediatric health care. From NAPNAP’s origins over 50 years ago, pediatric nurse practitioners (PNP) have had a unique mission to meet the needs of underserved and rural populations by delivering the highest quality of health care possible. To deliver high-quality health care that is equitably available continues to be an important challenge and I believe that PNPs serve a unique role in meeting that demand in our communities.
Daniel Crawford, DNP
We are now recognized as providing quality, efficiency, and advocacy for our patients. We are seeing new roles, new ideas, and new ways that we're contributing to make a difference and move the needle on quality health outcomes for children.
My goal as NAPNAP president will be to combine these. Over the past year, I was able to co-lead our strategic planning task force. In creating a strategic plan, we realized where we are and where we need to be as an organization. We saw that there was a lot that we had to envision, which took us back to re-writing our mission statement and vision for the organization.
The vision statement says: “All infants, children, adolescents, and young adults receive equitable, high-quality pediatric health care.” Our mission is “to optimize the health and wellbeing of all infants, children, adolescents, and young adults, and empower our community of pediatric experts.”
My goal is to transition towards this new strategic plan and work with our staff and our leadership to continue to do the things we're doing well, but also areas that maybe we need to allocate our time, effort, and resources to advance what we hope to be in the future as an organization.
"
My graduate program can admit twice the number of NPs but we lack the [Federal] funding to pay for extra trainers.
Q: It has been estimated that 77 million Americans are living without a primary care clinician. What can be done to increase the number of primary care providers?
Dr Crawford: The shortage [of primary care providers] cuts across all types of patients, including pediatric patients. In my state of Iowa, a significant amount of primary care services are provided by nurse practitioners and we are not the only state where that is the case.
There is not enough training capacity for nurse practitioners to meet the demand. There are a lot of plans underway and things that are being developed and designed to hopefully address this moving forward. We continue to turn out high-quality graduates in PNP programs across the country, and we know that our physician counterparts continue to do the same, but at the end of the day, there is still a shortage.
Q: What do you think contributes to this shortage? Is it a lack of federal funding for education?
Dr Crawford: We need to fix the Federal allocations for health care training so that we can increase the number of NPs in our programs but unfortunately things move slowly . When you look at pediatrics in particular, we know there is a shortfall in PNPs and this is a missed opportunity. My graduate program can admit twice the number of NPs but we lack the funding to pay for extra trainers; we don’t have the Federal funding needed for NP education.
We are also thinking about the undergraduate pipeline. We engage students early on their nursing pathway by meeting with incoming freshmen. I am presenting to high school students who have been admitted to the College of Nursing to discuss what an advanced practice nursing career looks like. This includes what the educational pathway looks like beyond nursing school, and what kind of things are going to help support them in that process. We encourage undergraduate students who are curious about graduate degrees to start building a mentorship relationship in nursing school.
We must realize the geographic diversity of our nurse practitioner programs and our institutions that are representative of the populations we serve. A school in Chicago will have a different makeup from a school in Iowa, which is a predominantly rural state.
Our student cohorts should be reflective of the communities in which they serve. There's a body of evidence that shows that outcomes are better when providers reflect their patient population. In Iowa, nurse practitioners who are from rural communities return to their communities at a high rate after graduation. We can graduate somebody to go back to that community and establish a pediatric primary care practice and become an individual who is uniquely positioned to affect the lives of the children in that community. At the end of the day, we are about providing high-quality pediatric outcomes for all children.
Q: How did you become a pediatric nurse practitioner specializing in epilepsy?
Dr. Crawford: After nursing school, I knew what I liked and what I did not like. I joined a practice and we created a pretty unique model that I would say rivals some of the fellowship models for transition to practice with nurse practitioners. I knew I liked neurology. I knew I liked the people in the practice, and I knew that this model sounded like a really good way for me to continue to grow professionally. I spent my first few years of practice in general neurology seeing the full spectrum of neurologic disorders.
Sometimes life throws you unexpected curveballs and around that time my daughter was diagnosed with epilepsy. I was then the parent with a child with epilepsy and I got to experience what that experience looks like from the parent side. That enabled me as a PNP to not only better meet the needs of the child with epilepsy but also the family. We know that the family unit is an important part of the overall health of the child. It was an opportunity to reflect and to grow in ways that I never anticipated professionally. Thankfully, my daughter's treatment was effective and she outgrew her seizures.
Q: You recently were named the new Associate Dean for Graduate Practice Programs. How do you balance your administrative/academic work with your clinical work?
Dr Crawford: When I was offered this position, I said that I would only take it as long as I could keep my practice. My practice and clinic hours are such an important part of me. My administrative role involves a lot of meetings and strategies about a lot of complicated topics. When I go to the clinic every Thursday morning, it's my time to spend with kids, play games, and have fun. I get to work with families on managing their child’s epilepsy and just see how life is going for them.
Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by deficits in social communication/interaction and restricted, repetitive behaviors, interests, and activities that cause significant impairment in functioning.1,2 The terminology and diagnostic criteria of ASD have changed several times since the disorder was first described in 1943, which has made it challenging to standardize research and identification.3 Yet in recent years, the prevalence of ASD has been markedly increasing, and the demographics of those diagnosed with ASD has been changing.1 Understanding the basic facts about ASD and the latest statistics and trends is essential for identifying patients early and providing them with optimal care.
Causes of Autism Spectrum Disorder
Although researchers have not identified a single, unifying cause of ASD, it is believed to result from a combination of genetic and environmental factors that affect the developing brain.4,5
Limited evidence suggests individuals with ASD have anatomical changes in the layers of their cortex. Patients with ASD exhibit differences in limbic areas involved in fear and emotional regulation, such as the amygdala. The brains of individuals with ASD frequently have “overgrowth” of their cortical areas and increased cerebral spinal fluid. They also have changes in the balance of excitatory and inhibitory neurotransmission and signs of abnormal cellular differentiation.4 Extensive evidence has demonstrated thatthe measles, mumps and rubella vaccine and other childhood vaccines do not cause ASD.5
Risk Factors for ASD
Many risk factors are associated with developing ASD. Older maternal and paternal age have each been associated with an increased risk of ASD.4
The use of certain medications during pregnancy has also been associated with the risk of having a child with ASD. Maternal antidepressant use — specifically selective serotonin reuptake inhibitors — during the second or third trimester has been associated with an increased risk of ASD, even after adjusting for maternal depression.6 Prenatal use of thalidomide and valproic acid also have been linked to an increased risk of ASD in offspring.4 Conversely, taking prenatal folic acid while also taking an antiepileptic medication might decrease the risk of ASD.4
Genetics may play a role in ASD risk. Siblings of a person with ASD have a higher chance of developing the disorder.4 One monozygotic twin have a higher chance of developing ASD if the other twin has it. Several chromosome-linked disorders, including Fragile-X and Down syndrome, have also been associated with the occurrence of ASD.4,7
What Are the Most Common Signs?
The current American Psychiatric Association diagnostic criteria for ASD are published in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision.2 Those criteria include 2 primary categories of symptoms: deficits in social communication/social interaction, and restricted, repetitive patterns of behavior, interests, or activities.2
Many people with ASD have atypical social behaviors. They may have impaired verbal and nonverbal communication, as well as difficulty making friends and maintaining relationships.2,7 Individuals with ASD tend to avoid eye contact and have difficulty interpreting normal social cues.7 They have trouble understanding implications or hidden meanings and engaging in the back-and-forth of a conversation.
Repetitive behaviors commonly exhibited by people with ASD include the following2:
Repetitive motor movements or speech (such as body rocking, arm or hand flapping, repeating words just spoken by another person); and
Insisting on sameness, inflexibly adhering to routine, or performing ritualized patterns of behavior (such as having difficulty with transitions, having rigid thinking patterns, needing to eat the same food each day).
Behaviors associated with ASD also may include a strong preoccupation with minute details or obsessions with certain topics or objects, such as a type of toy. Lining up objects in a specific manner or order can be a characteristic behavior of ASD.2,8
Individuals with ASD may be hyperreactive or hyporeactive to sensory input. They may be uncomfortable or upset by certain sounds. They may also display high sensitivity to certain types of visual or tactile stimuli, such as textures, lights, or movement.2,8
For an individual to receive an ASD diagnosis, their symptoms need to significantly impair their functioning. This could include their ability to focus at school, communicate with others, or hold a job and live independently.2,8
Comorbid Conditions
Autism spectrum disorder can co-occur with many other conditions, particularly neurological or psychiatric conditions.4 Approximately 37% of children with ASD also have an intellectual disability.9 Psychiatric disorders such as anxiety disorders, attention deficit/hyperactivity disorder, mood disorders, disruptive behavior disorders, and obsessive-compulsive disorder are also highly comorbid with ASD.4 Most adults with ASD have at least 1 comorbid psychiatric condition.10 Other common comorbidities include seizures, sleep disorders, gastrointestinal problems, and immune dysfunction.4,11
When Is Autism Spectrum Disorder Diagnosed?
Autism spectrum disorder is usually diagnosed during childhood, generally during the first 2 years of life.7 Social deficits typically are noticeable in the toddler years, and parents may recognize that their children miss developmental milestones. Early diagnosis is critical for the implementation of early interventions, including psychological and behavioral therapies.7 Earlier ASD diagnoses are associated with improved quality of life compared to those in whom the diagnosis is delayed.12
A person's sex may play a role in the age of diagnosis. A study that compared the age at diagnosis of ASD in 208 people found that males were more likely to be diagnosed before they were age 18 years, and females were more likely to be diagnosed in adulthood.12
In the United States, early diagnosis of ASD may be improving. According to the Centers for Disease Control and Prevention (CDC), in 2020, children born in 2016 were 1.6 times as likely as children born in 2012 to be identified as having ASD by age 4.9
Autism Spectrum Disorder Statistics
Autism spectrum disorder is an increasingly common condition. The CDC's Autism and Developmental Disabilities Monitoring (ADDM) Network published its most recent surveillance report in 2023; it focused on data from 2020.1,13 The ADDM Network found approximately 1 in 36 children in the United States was estimated to have ASD.1,13 This prevalence has increased steadily over the last 20+ years. The estimated prevalence of ASD was 1 in 150 children in 2000, and 1 in 44 in 2018.1,13
The World Health Organization estimates that worldwide, approximately 1 in 100 people have ASD.5 This is not likely to be accurate, however, because many low-income countries have limitations with consistent reporting methods. In developing countries, there also may be less overall awareness of ASD and access to consistent medical care.5
Autism spectrum disorder affects people of all racial and ethnic groups.13 In the ADDM Network report, the estimated prevalence of ASD in 2020 was highest among Hispanic (3.3%) and Asian/Pacific Islander (3.2%) children, were followed by Black (2.9%), American Indian (2.7%), and White (2.4%) children.1,14 Children of 2 or more races had the lowest incidence of ASD (2.3%).1,14 These data differ from previous estimates, in which the prevalence was highest among White children.9
In the ADDM Network report, the prevalence of ASD also varied by geographic location. Of 11 state sites included in the report (Arizona, Arkansas, California, Georgia, Maryland, Minnesota, Missouri, New Jersey, Tennessee, Utah, and Wisconsin), the overall prevalence was highest in California (4.5%), while the estimated prevalence was lowest in Maryland (2.3%).1,9
The prevalence of ASD varies greatly by sex. In the United States, boys are about 4 times more likely than girls to receive a diagnosis of ASD.1,9 However, 2020 was the first time the ADDM Network estimated that the prevalence in girls was greater than 1%.
Author Bio
Hannah Actor-Engel, PhD, earned a BS in Neural Science at New York University and her PhD in Neuroscience at the University of Colorado. She is a multidisciplinary neuroscientist who is passionate about scientific communication and improving global health through biomedical research.
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