Tinnitus & Depression as Comorbidities

Interventional Audiology in Primary Care

Author: Robert Tysoe

Audiologists know there are many causes of tinnitus, and often the cause is unknown. According to Richard Tyler, professor at the University of Iowa, the most common causes of tinnitus are noise exposure, (from shooting or machines at work), a natural part of the aging process, a head injury (e.g. from a car accident or fall), or as a side effect of medications (e.g. aspirin).

The onset of tinnitus is often accompanied by the onset of hearing loss, as research estimates that 90 percent of tinnitus sufferers have an associated hearing loss. Of course, if patients have tinnitus, they should have their hearing tested by an audiologist. Estimates of the incidence of tinnitus in the U.S. range from 30 – 50 million adults, many suffer from persistent tinnitus.

While hearing aid manufacturers have developed exciting new technology that can treat hearing loss, and simultaneously mask and improve the symptoms of tinnitus, most physicians are unaware of the role audiology plays in the identification, treatment and management of tinnitus. They need to be informed about how an audiologist can help. Audiologists provide the latest research on tinnitus and information about the benefits of the new therapeutic modalities. Thus, the physician can avoid recommending often useless tinnitus medications and prevent associated side effects associated with unregulated over-the-counter tinnitus relief products.

In addition to tinnitus, another common, yet under-appreciated comorbidity is depression. The incidence of depression in the US is approximately 10 percent of the adult population. Untreated hearing loss is strongly linked to depression, among other psychosocial disorders. The prevalence of moderate-to-severe depression was significantly higher among adults aged 18 – 69 who had self-reported hearing loss (11.4%) compared to those who reported good-to-excellent hearing (5.9%) (Chuan-Ming, 2015). Depression is among the leading causes of disability in persons 15 years and older. It affects individuals, families, businesses, and society, and is common in patients seeking care in the primary care setting. Depression is also common in postpartum and pregnant women and affects not only the woman but her child as well.

Audiologists need to know that recently the US Preventive Services Task Force (USPSTF) recommended screening for depression in the general adult population, including pregnant and postpartum women. Screening for depression should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. The Patient Health Questionnaire is a recommended screening tool that could be used by audiologists to screen their patients for depression, but only after they have developed a solid treatment and follow-up network involving the appropriate professionals.

According to Siu (2016), the USPSTF found adequate evidence that programs combining depression screening with adequate support systems in place improve clinical outcomes (i.e., reduction or remission of depression symptoms) in adults, including pregnant and postpartum women. The USPSTF found convincing evidence that treatment of adults and older adults with depression, identified through screening in primary care settings, with antidepressants, psychotherapy, or both, decreases clinical morbidity. The USPSTF also found adequate evidence that treatment with cognitive behavioral therapy (CBT) improves clinical outcomes in pregnant and postpartum women with depression.

No discussion about hearing loss, depression and tinnitus is complete without addressing patients' emotional reactions to their suffering from both co-morbidities. Feelings of annoyance, depression, anxiety and anger are common, and professional help may be required.
Poor Health Literacy is an Added Factor
The World Health Organization (WHO) reports that unipolar depression occupies first place for years lost to disability. Hearing loss is the third leading cause of years lost due to disability. Now, add in the communication challenges caused by the patient’s poor health literacy. According to Koh, et al (2015), “In the midst of rapid expansion of medical knowledge intended to benefit many, too few actually understand medical information well enough to improve their health. A landmark 2006 report notes that only about 12 % of US adults had a proficient state of health literacy whereby individuals can obtain, process, and understand the basic health information and services they need to make appropriate health decisions. As a result, despite abundant messaging from health professionals, the media, the internet, and other sources, too many patients still have difficulty with seemingly routine tasks such as taking the right medicine at the right time, properly self-managing diabetes, or correctly following hospital discharge instructions. In this increasingly complicated health environment, even the most sophisticated adult can be overwhelmed by unfamiliar medical terms, unexplained acronyms, and technical jargon. The paradox is that people are awash in knowledge they may be unable to use. These limitations are clearly hazardous to health.” Undoubtedly, untreated hearing loss, an all too common occurrence in patients suffering from tinnitus, depression and other common chronic medical conditions, has an impact on a patient’s ability to communicate effectively with their physician.

Audiologists can do something about a patient’s health literacy, the physician’s ability to engage the patient as well as the patient’s potential improvement in quality of life. The partnership between the primary care physician and the audiologist may afford the opportunity to lower the cost of care, by reducing total patient visits to the physician’s practice, a potential reduction in the risk of an emergency room visit, or a hospitalization requiring surgery.

The audiologist is able to impact the patient’s health literacy by providing the latest patient education brochures, (see the NIH website www.nidcd.nih.gov for free, quality handouts in both English and Spanish) about the disease state of hearing loss, tinnitus, and balance disorders. An informed patient will be more inclined to seek appropriate hearing care.

As a result of the audiologist providing the latest authoritative clinical research about the deaf and hard of hearing patient, the physician becomes more effective in counseling the hearing impaired patient to agree to have a hearing evaluation and a routine annual follow up.

When the treatment of hearing loss occurs earlier because of a physician’s preventive care management strategies, the patient care partnership with the audiologist may reduce the prevalence of, and the need to treat depression, which is independently associated with hearing loss, and is in and of itself a barrier to improved outcomes; The earlier the patient receives recommended hearing health care, the sooner the physician may also prevent increased isolation, reduced social connectivity, decreased sense of well-being, loss of community, early mortality, and reduced economic productivity; thus there is also the additional possibility of an improved outcome.    
Bob Tysoe is owner and marketing consultant, Hearing Healthcare Marketing Company, Portland, OR. He can be reached at [email protected].
Chuan-Ming Li, et al (2015) “Untangling the Link Between Hearing Loss and Depression”, Hearing Journal.

Koh, H, et al (2015) JAMA. Aug 6.

Siu, A (2016) JAMA. 315(4):380-387.