Depression Happens

Author: Victor Bray, Ph.D.

A Story. He was in his mid-60’s and he was struggling. His personal interactions and quality of life, at both home and work, had been significantly impacted by his progressive, bilateral, moderate, sensorineural hearing loss. We had been working together for about six weeks, through an initial diagnosis, hearing aid selection and fitting, check-ups and troubleshooting adjustments, and we were successfully closing out his hearing aid trial period. But while his auditory capabilities and speech understanding ability had been restored to improve daily function, he was still unhappy with life.

As we wrapped up this phase of his treatment plan and I reflected on the next steps, I decided on two actions. One, the routine action, was to recommend to him to return to see me in six months for follow-up, or sooner if problems developed. The second, and nontraditional action, was to consult with the otologist in the clinic to make the request that we refer our patient to a psychiatrist for evaluation for depression.

This was not an easy referral for me to make, as it was the first time I had ever taken a step to interject myself into a patient’s personal life with a recommendation for mental health evaluation. But, I was highly motivated to do so because I had seen a similar situation develop earlier in the year; a man of similar age, similar life situation, the same frustrations, the same unhappiness as the hearing aids were not the panacea to solve his life problems, who committed suicide. I did not want to see that happen again.

It was now six months later and he had returned for his check-up appointment. As we started our dialogue, he looked me straight in the eye, and with a bit of anger, stated ‘it was you who referred me to the psychiatrist, wasn’t it?’ I replied, ‘yes, it was me’ taking action through the otologist. He said to me ‘well, I didn’t appreciate it, but I did go see the psychiatrist and, looking back, it was the right thing for you to do and for me to get some help.’ He went on to say ‘I now recognize that I had some significant depression, which was brought to crisis in dealing with my hearing loss. I’m still in treatment with the psychiatrist, but much better now. So, thank you for making the referral. But, I still hate having to wear these damn hearing aids.’ Thus was my first encounter in holistic health care that went beyond the evaluation and treatment for hearing loss.

An Overview of Depression1,2,3
Depression happens and is all around us. It is a common, serious mental health disorder affecting more than 300 million persons worldwide and 1 in 6, or 16 million Americans. In the USA, the prevalence of major depressive episodes is 6.7% in the general population, higher among females (8.5%) than males (4.8%), and more common in younger persons 18-25 (10.9%) than persons in the age ranges 26-49 (7.4%) and 50+ (4.8%). But, in the older population the prevalence of depression increases, with estimates of 10 – 11% for persons in their 70’s and 12 – 13% for those 80 and older.4

Depression negatively affects feelings, thoughts, and actions and can lead to emotional and physical problems and a decrease in a person’s ability to function at work and at home. Depression is characterized by persistent sadness and a loss of interest in activities that are normally enjoyed, accompanied by an inability to carry out daily activities for at least two weeks. People with depression may have anxiety, reduced concentration ability, feelings of worthlessness, guilt, or hopelessness, and thoughts of self-harm or suicide.

Depression is the leading cause of disability worldwide and is a major contributor to the overall burden of disease and health care. In the USA, a little over 10% of physician visits have depression indicated in the medical record. Depression-related suicides occur at a rate of about 14 per 100,000 persons, or 45,000 per year, and suicides are the tenth leading cause of death in the USA, following heart disease, cancer, accidents, chronic lower respiratory diseases, stroke, Alzheimer’s disease, diabetes, influenza and pneumonia, and kidney disease.

Some general risk factors for depression include a personal or family history of depression; major life changes, trauma, or stress; and/or certain physical illnesses and medications. More specifically, risk factors include lifestyle and addiction behaviors of alcohol dependence and substance abuse; biological factors of chronic pain, unexplained somatic symptoms, and being nonresponsive to normally effective treatments for medical conditions; gender associations of female sex, obstetric conditions, and recent childbirth; psychological association with anxiety, hypomania, or psychosis; and life factors of recent stressful events and comorbid chronic conditions. While hearing loss is not specifically listed as a risk factor of depression, hearing loss can be considered as a chronic condition that can introduce significant stress on the individual.

Depression, itself, is a chronic disease that should be monitored, but it cannot be identified by laboratory tests or clinically useful biological markers and its pathophysiological cause is unknown. Fortunately, when identified through behavioral observations, depression is treatable with talking therapies or antidepressant medication or a combination of these. Of those persons with depression, about 44% receive both therapy and medication, 13% participate in therapy alone, 6% utilize medications, and 37% are not in treatment.

Increased Depression Associated with Hearing Loss
There have been numerous epidemiological studies examining population statistics to document depression and hearing loss in the population. Where increased rates of depression were found to be associated with hearing loss, the most frequent explanations include a sequence of events whereby hearing loss reduces speech recognition and ability to communicate, especially in difficult listening environments, which negatively impacts the person and their interpersonal relationships, leading to a declined quality of life, related to isolation, reduced social activity, a feeling of being excluded, and increased symptoms of depression.5

Strawbridge and colleagues (2000)6 examined data on almost 2,500 persons tracked in the Alameda, California database, looking for effects associated with untreated hearing loss. They found multiple, negative outcomes and negative functional status associated with hearing loss, including depression, loneliness, and altered self-esteem. They calculated adjusted odds ratios (OR) associated with moderate or greater hearing loss, of 1.39 for fair or poor physical health, 1.90 for fair or poor mental health, 1.85 for Activities in Daily Living, 1.98 for physical performance disability, and 2.05 for depression.

Gaynes and colleagues (2002)7 evaluated depression and its impact on health-related quality of life (HRQOL) across almost 10,000 persons using the USA National Health and Nutritional Examination Survey (NHANES). They found that that depression can be an independent source of suffering and disability, similar to that of arthritis, diabetes, and hypertension, that the effect of depression on HRQOL was comparable to the chronic illnesses, and that depression could interact with the chronic illnesses to amplify the negative effects of the illnesses.

Li and colleagues (2014)8 examined a sample size of over 18,000 adults using NHANES data. They found that hearing loss was one of many factors associated with depression, along with age, body mass index, cardiovascular disease, diabetes mellitus, educational level, general health status, hypertension, living alone, poverty income ratio, sex, sleep disorder, smoking, and trouble seeing (even with visual aids). They found the prevalence of moderate-to-severe depression to be 4.9% in persons with excellent hearing, 7.1% in persons with good hearing, and 11.4% in persons with hearing loss. They reported the odds ratio for depression were 1.4 for persons with good hearing, 1.7 for little trouble hearing, 2.4 for moderate trouble hearing, 1.5 for a lot of trouble hearing, and 0.6 for deafness.

Hsu and colleagues (2016)9 examined the Taiwan National Health Insurance Database (TNHID) for the presence of depression associated with hearing loss. Their analysis of over 5,000 patients with sensorineural hearing loss and 20,000 patients without hearing loss yielded a dozen comorbidities associated with hearing loss, including alcohol-related illness, anxiety, asthma, chronic artery disease, chronic kidney disease, chronic obstructive pulmonary disease, cirrhosis, diabetes mellitus, hearing loss, hyperlipidemia, hypertension, steroids, and stroke. Of particular interest to us, four of the conditions associated with depression were also associated with hearing loss: alcohol-related illness, anxiety, chronic artery disease, and stroke. Comparing the incidence of depression and hearing loss, the adjusted hazard ratio (aHR) was 1.73 and the aHR increased with patient age and was higher in women than men.

The epidemiological studies described above are not the only ones that show statistically significant correlations between hearing loss and depression. However, these studies are characteristic of many findings that come from analyses of the population data bases. In general, many of the studies report an odds ratio of around 2 when linking hearing loss and depression, indicating that the presence of hearing loss is associated with a doubling of the occurrence of depression, compared to not having hearing loss. In practical terms, if your patients are in the older age groups, where depression occurs at a rate of 10 – 15%, this may be consistent with older onset depression, occurring at twice the 5% rate of the adults over age 50.

In consideration of the general findings of these epidemiological studies, please take into account two cautions. First, while these linkages between depression and hearing loss are statistically significant, it is not necessarily because of a strong linkage between hearing loss and depression, but instead because of the very large sample sizes used, which can pick up the weak link between untreated hearing loss and depression. Second, these studies utilize correlational analysis tools and cannot be used to imply causation. As previously stated, the increased odds ratio implies a comorbidity between hearing loss and depression, where the depressive symptoms are believed by many audiologists to be a result of impaired communication and socialization. But, the increased odds ratio can also imply a comorbidity between depression and hearing loss, which could be caused by other factors, such as brain-centered, neurological degradation having a negative impact on both emotion health (e.g. depression) and sensory processing (e.g. hearing loss).

Reduced Depression Associated with Treatment for Hearing Loss
There have been epidemiological studies examining population statistics to understand depression, hearing loss, and treatment with hearing aids. With regard to the finding that use of hearing aids was correlated with reduced depression, compared to individuals with untreated hearing loss, an explanation is that treatment for hearing loss reduces depressive symptoms through improved social engagement, or another explanation is that individuals without depression may be more likely to seek treatment with hearing aids.

Mener and colleagues (2013)10 evaluated over 1,000 subjects, age in their 70’s, using the NHANES database. They found that 58.5% had hearing loss, 7.1% met the criteria for depressive disorder, and 3.9% met criterial for major depressive disorder (MDD). In examining the use of hearing aids, they reported reduced odds ratio of 0.33 for those with any depressive symptoms and 0.35 for those with symptoms of MDD. These findings were similar to those of Gopinath and colleagues (2009)11 who evaluated over 1,000 persons, age 60 and older, using the Blue Mountains (Australia) database and found hearing aid use was associated with lower odds ratio of 0.32 for depressive symptoms.

While these correlational studies are significant in their findings of hearing aid use being associated with significantly reduced rates of depression, more powerful evidence on the reduction of depression associated with treatment for hearing loss can be found in clinical trials.

Mulrow and colleagues (1990)12, with USA military veterans, fit hearing aids to almost 100 patients who were matched to a similar group of patients placed on a waiting list for treatment. At the beginning of the study, 82% of the combined treatment group and waiting group reported adverse effects of quality of life due to hearing impairment and 24% were depressed. At four months after treatment, compared to the waiting list, there were significant improvements for social and emotional function, communication function, cognitive function, and depression. In a follow-up report, Mulrow and colleagues (1992)13 reported that many of the quality of life changes, including from depression, were sustained at eight and twelve months. They concluded that several adverse effects of hearing loss on the quality of life for elderly persons, including depression, are reversible with use of hearing aids.

More recently, Choi and colleagues (2016)14, in the Johns Hopkins Medicine Studying Multiple Outcomes after Aural Rehabilitation Treatment (SMART) study, evaluated 112 participants, aged 50 or older, for effects on depression following aural rehabilitation. For the 63 participants who received hearing aids, Geriatric Depression Scale (GDS) scores were improved by 28% (a significant effect) at six months and 16% (a nonsignificant effect) at twelve months. For the 50 participants who received cochlear implants, GDS scores were improved by 31% at six months and 38% at twelve months (both significant effects). In terms of individual effects, at baseline, only five of the hearing aid recipients (8%) and eight of the cochlear implant recipients (16%) had GDS scores suggestive of depression. At twelve months post-treatment, three of the hearing aid recipients (5%) and six of the cochlear implant recipients (12%) still had GDS scores suggestive of depression.

This study highlights two important considerations when clinically applying the general conclusion that amplification may relive depressive symptoms in patients. First, while there were statistically significant effects on depression scores for the group, the vast majority of each group (92% of the hearing aid recipients and 84% of the cochlear implant recipients) did not have GDS scores indicative of depression at baseline. Second, the individuals who demonstrated the most substantial improvement in depression scores were individuals who had the highest depression scores at baseline. Thus not all persons with untreated hearing loss had GDS scores indicating depression, but for the minority who had the highest depression scores, large reductions in scores did occur for post-treatment depression.

Related to depression, Weinstein and colleagues (2016)15 evaluated 40 adults for the effect of hearing aid use for emotional loneliness and social loneliness. They found, with hearing aid usage, there was a significant change for overall loneliness and perceived emotional loneliness, particularly for those with moderate-to-severe hearing loss. Their findings urge us to remember that treatment with hearing aids is more than just restoring audibility, but should be considered as a method to improve verbal communication, restoring the possibility for social networking, thereby improving the quality of life and quality of social interactions.

Another important aspect of their findings is that hearing loss alone is not the cause of all forms of loneliness, and hearing aid use is not an all-purpose remedy for loneliness. For the group, 28% of the participants were lonely after treatment, compared to 45% of the participants pre-treatment. In terms of the number of participants, the 17% change would correspond to 7 participants, with 22 of the participants not reporting loneliness before treatment and 11 still reporting loneliness after treatment. Clinically we must remember that not all of our patients will have negative psychosocial consequences as a result of hearing loss, not all of our patients will obtain relief from psychosocial problems following treatment with amplification, but for some of our patients, hearing loss will have psychosocial consequences and the treatment we provide can have a dramatic, and positive, effect.

Depression Associated with Dual Sensory Loss
As audiologists, while we may concentrate on the auditory aspects of verbal communication and the psychosocial consequences resulting from hearing loss, we must also be aware of vision, vision impairment, and visual communication. Many of our patients with hearing impairment also have vision impairment, known as dual sensory loss (DSL). While hearing impairment is associated with increased rates of depression, vision impairment has higher rates and DSL has even higher rates (see details below). Heine and Browning (2002)16 point out that decreased vision and/or decreased hearing both can interfere with reception of speech, resulting in communication breakdown, which can result in poor psychosocial functioning, including deeper depression. Many visual factors, which audiologists normally rely on to facilitate communication, may no longer be available to the DSL patient. These factors include the inability to perform lip-reading (to pick up cues for those hard-to-hear high-frequency fricatives, which are also hard to amplify to audibility) and even the inability to see the person, resulting in the loss of non-verbal cues such as facial expressions, body posture, and gestures.

Huang and colleagues (2010)17 conducted a meta-analysis of 31 publications concerning nine chronic conditions and depression. The concluded from their investigation that there were definite risk factors, including elevated odds ratios, for increased depression in old age for five conditions: cardiac disease (OR: 1.67), hearing loss (OR: 1.71), stoke (OR: 1.87), vision loss (OR: 1.94), and chronic lung disease (OR: 2.13). It is extremely important that we recognize that hearing loss and vision loss were two of the five factors that emerged from the meta-analysis and that the odds ratio for depression and vision impairment (1.94) was stronger than for hearing impairment (1.71).

In additional investigations of DSL and depression, Armstrong and colleagues (2016)18 reported the prevalence of depression at 11.6% in their older adult population, at 17% for persons with hearing impairment, at 25% for vision impairment, and at 31% for dual sensory loss. Turunen-Tahari and colleagues (2017)19 reported rates of depression of 34% for the DSL group vs. 19% for the hearing impairment group. Cosh and colleagues (2017)20 also found that DSP posed a more significant risk for depression and loneliness than vision loss or hearing loss alone.

Some Thoughts on Clinical Guidelines for the Audiology Patient with Depression*
Many patient encounters begin with the case history and intake discussions. At this point, the clinician may choose to start collecting information on depression and comorbid conditions. Several important items to consider incorporation into the case history form are those that have been found to be comorbid with depression: alcohol-related illness, anxiety, asthma, cardiovascular disease, chronic kidney disease, chronic obstructive pulmonary disease, cirrhosis, diabetes mellitus, hyperlipidemia, hypertension, sleep disorder, smoking, steroids, stroke, and trouble seeing (even with visual aids). The presence of these items, as identified through the case history, may place your patient at increased risk of a depressive disorder, separate from the hearing loss you are treating.

As for the presence of depression, the audiologist may utilize the Patient Health Questionnaire with two questions (PHQ-2): “Over the past 2 weeks, have you felt down, depressed, hopeless?” and “Over the past 2 weeks, have you felt little interest or pleasure in doing things?” Patients who have a positive response to one or both questions can have a more complete assessment, which can be in the form of the nine question PHQ-9, as follows:

Over the past two weeks, how often have you been bothered by any of the following problems? (0 = not at all; 1 = severaldays; 2 = more than one half the days; 3 = nearly every day)
  1. Little interest or pleasure in doing things
  2. Feeling down, depressed or hopeless
  3. Trouble falling or staying asleep or sleeping to much
  4. Feeling tired or having little energy
  5. Poor appetite or overeating
  6. Feeling bad about yourself or that you are a failure or have let yourself or your family down
  7. Trouble concentrating on things, such as reading the newspaper or watching television
  8. Moving or speaking so slowly that other people have noticed, or the opposite (i.e. being so fidgety or restless that you have been moving around a lot more than usual
  9. Thoughts that you would be better off dead or hurting yourself in some way
Scoring: Items 1 through 9 are added to yield a score ranging from 0 to 27. On this scale, 0 – 4 is considered nondepressed, 5 to 9 is considered minor depression, 10 – 14 is considered mild depression, 15 – 19 is considered moderately severe depression, and 20 – 27 is conserved severe depression.21,22,23

If you, as the clinician, detect that your patient may have depressive symptoms that are (a) not resolved through your course of auditory rehabilitation, and (b) negatively impacting the quality of life of your patient, please consider referral of your patients to an appropriate mental health care provider. Remember that depression is all around us and most likely will be occurring at an elevated rate, in your patients, through many factors associated with aging. While auditory rehabilitation is an excellent course of treatment for some of your patients who have depression associated with untreated hearing loss, the amplification and therapy treatments we offer can have very limited effect on depression associated with many other life factors in our patients’ lives.    
Victor Bray, Ph.D., is Associate Professor and former dean at Osborne College of Audiology. He was previously the Director of Audiology for the Austin (Texas) Ear Clinic, the Director of Clinical Research for ReSound Corporation, the VP and Chief Audiology Officer for Sonic Innovations, and VP and Chief Audiology Officer of OtoKinetics. Dr. Bray holds a bachelor’s degree in Biochemistry, a master’s degree in Audiology, and a doctorate in Speech and Hearing Science. He has presented nationally and internationally at numerous workshops, seminars and conferences on the clinical applications of audiology.

* The comments in this section are not medical advice, but ‘food for thought’ for the audiology clinician concerning a significant issue coming through our offices on a regular, and frequent, basis. You are urged to develop awareness of depression in your patients; be alert for improvement, or lack of improvement, in the patient’s depressive symptoms during the course of auditory rehabilitation; and refer, when appropriate, to appropriate health care providers. In the development of a protocol for your clinical setting, it is highly recommended that you consult with, and seek advice from, the health care providers who will be your referral point for patients showing depressive symptoms. Also, in consultation with these professionals, the audiologist should take the opportunity and time to sensitize the mental health professionals of the relationship between hearing loss and depression, thus alerting them to the need to refer appropriate patients to you for hearing health care. For more information, see “Hearing Loss. The Silent Risk for Psychiatric Disorders in Late Life” by Blazer (2018).
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