Tinnitus, Depression, Anxiety, and Suicide in Recent Veterans: A Retrospective Analysis

History of Tinnitus Research at the VA National Center for Rehabilitative Auditory Research (NCRAR), 1997-2021: Studies and Key Findings

The Veterans Affairs (VA) Rehabilitation Research & Development (RR&D) National Center for Rehabilitative Auditory Research (NCRAR) was first funded by the RR&D Service in 1997 and has been funded continuously since that time. The overall purpose of the NCRAR is to "improve the quality of life of Veterans and others with hearing and balance problems through clinical research, technology development, and education that leads to better patient care" ( www.ncrar.research.va.gov ). An important component of the research conducted at the NCRAR has been a focus on clinical and rehabilitative aspects of tinnitus. Multiple investigators have received grants to conduct tinnitus research and the present article provides an overview of this research from the NCRAR's inception through 2021.

The Effect of Perceived Tinnitus Disturbance on Hope

BACKGROUND

Although there are systematic reviews of the effects of tinnitus on quality of life, the relationship of tinnitus to hopefulness has not been examined.

PURPOSE

The purpose of this study was to determine the relationship between tinnitus distress and hope by comparing the severity of tinnitus to measures of hopefulness. This was done by comparing the Tinnitus Reaction Questionnaire (TRQ) to the following hope scales: the Herth Hope Scale (HHS) and the Herth Hope Index (HHI).

METHOD

Patients seen for a tinnitus evaluation in the University of Tennessee audiology clinic completed the TRQ, HHS, and HHI scales. Investigation of relationships between tinnitus assessment using the TRQ and measurements of hope (HHS and HHI) was performed via correlation analyses using Pearson coefficients and linear regression.

RESULTS

Significant correlations were found between overall scores on the TRQ and HHS, and TRQ and HHI, indicating that greater tinnitus distress was associated with lower levels of hope. Further analyses showed the HHS and HHI Domain 1, regarding temporality and future, as significantly related to tinnitus distress.

CONCLUSION

Significant correlations between tinnitus disturbance and hope suggest that potential interventions based on hopefulness may be of benefit for individuals suffering from tinnitus.

Tinnitus, Suicide, and Suicidal Ideation: A Scoping Review of Primary Research

Tinnitus (the perception of sound in the absence of any corresponding external source) is highly prevalent and can be distressing. There are unanswered questions about how tinnitus, suicidal thoughts, and suicidal behaviours co-occur and interact. To establish the extent of scientific literature, this scoping review catalogued primary reports addressing the associations between tinnitus, suicidal ideation, attempted suicide, and death by suicide. We searched OvidSP, Medline, EMBASE, PsycINFO, CINAHL, Google Scholar, EThoS, and ProQuest for all studies and case reports on ideation and/or attempted and/or completed suicide in the context of tinnitus. Twenty-three studies were included, and data were charted according to study type. Several epidemiological and other observational studies gave evidence of risk factors and an association between suicidal ideation, suicidal behaviour, and tinnitus. However, there was no evidence of the direction of causality. Qualitative studies are indicated to explore the patient's experience and understand the dynamics of any interaction between tinnitus and suicidal thoughts and behaviours. A theory-informed model of tinnitus and suicide needs to be developed to inform the development of interventions and how tinnitus patients are supported clinically.

Vascular Factors in Patients with Midlife Sensorineural Hearing Loss and the Progression to Mild Cognitive Impairment

Background and Objectives: Midlife hearing loss (HL) has been considered as a major modifiable risk factor for a later-life progression to dementia. Our aim was to detect a link between precocious sensorineural hearing loss (SNHL) and mild cognitive impairment (MCI) and their association to putative risk factors for a common pathology. Materials and methods: In this study, a retrospective case-control study was carried out. A total of 112 patients were enrolled as following: 81 patients with bilateral SNHL and 31 subjects with normal hearing, whose ages ranged from 50 to 65 years. Both groups performed pure tone audiometry, a tinnitus handicap inventory (THI), Mini-Mental State examination (MMSE), and the Montreal Cognitive Assessment (MoCA), Hospital Anxiety and Depression Scale (HADS-A and HADS-D). Results: The mean age was 58 ± 5.2 in SNHL patients and 53.2 ± 4.8 in the control group. The mean pure tone average in the SNHL group was 40.2 ± 18.7 dB HL on the right side and 41.2 ± 17.2 dB HL on the left side, while in the control group it was 12.5 ± 2.8 dB HL on right side and 12.4 ± 3.1 dB HL on left side. About 64% of patients with SNHL exhibited comorbidities, and the most common condition was hypertension. Altered MoCA test scores were significantly related to the pure tone averages in patients with SNHL compared to the control group (p = 0.0004), while the differences in the HADS-A and HADS-D were not significant. Furthermore, a significant correlation was observed in SNHL patients between an altered MoCA test and hypercholesterolemia (p = 0.043). Conclusions: Hearing impairment and screening tests to detect MCI should be considered in the midlife in order to carry out strategies to prevent the progression to dementia. Hypertension and hypercholesterolemia are two risk factors in the development of endothelial dysfunction, oxidative stress, and vascular inflammation, and may represent the common pathology linking the inner ear and brain damage.

Tinnitus and risk of attempted suicide: A one year follow-up study

BACKGROUND

Tinnitus causes emotional stress that can be extreme, bringing on anxiety, depression, or sleep disorders. We used a nationwide, population-based database to study the risk of attempted suicide among adults with tinnitus.

METHODS

Data for this retrospective cohort study were extracted from the Taiwan National Health Insurance Research Database, on 386,055 patients with tinnitus and propensity score-matched controls. We performed Cox proportional hazards regression analysis to calculate the one-year hazard of a suicide attempt and 95 % confidence intervals (CI) following a first-time diagnosis of tinnitus.

RESULTS

The results shows that the incidence of attempted suicide was 0.253 (95 % CI = 0.237-0.269) and 0.123 (95 % CI = 0.113-0.135) for the study cohort and comparison cohort, respectively. The log-rank test suggested that the study cohort had significantly lower suicide attempt-free survival at one year than the comparison cohort (p < 0.001). Cox proportional analysis shows that the hazard ratio of attempted suicide within the one-year follow-up period was 2.04 (95 % CI = 1.83-2.28) for patients with tinnitus than those in the comparison cohort after adjusting for the patients' age, sex, monthly income, geographic region, urbanization level of the patient's residence, hyperlipidemia, diabetes, coronary heart disease, and hypertension.

LIMITATIONS

The database lacks information on socioeconomic problems, specific personal characteristics or traits, marital status, or other factors associated with attempts to commit suicide. Notably, our study addressed suicide attempts as detected from claims-based ICD codes which do not cover suicidal ideation or suicidal death.

CONCLUSIONS

We found increased likelihood of attempted suicide among patients with tinnitus.

Towards a psychological framework on time perception in patients with chronic tinnitus

Although disabling tinnitus is a chronic auditory phantom sensation, current knowledge on time perception (i.e., subjective time) in sufferers is limited and unsystematic. This theoretical analysis provides a first approach to this topic, highlighting the heterogeneity of time perception in humans as shown in various research areas. This heterogeneity is inherently related to goal attainment. Our immediate perception of time is restricted to present moment and recent past, whereas our sense of time is mostly future-oriented and represented as our past in a mental time line. The heterogeneity of time translates into a tension between anticipated changes one wants to see happen and full commitment that is required to goal attainment. Tinnitus sufferers are intensely aware of this tension in their self-perception. Their most compelling desire is that they no longer perceive tinnitus, but they get closer to this goal only by avoiding to put all their thoughts into it. Our analysis provides new perspectives on acceptance of tinnitus in relation to this time paradox. Building on the Tolerance model and the role of self-awareness in time perception, we contend that the main way for patients to gain long-term self-confidence is to engage in the present moment. Attention to this attitude is obscured in chronic sufferers by worries and ruminations associated with the ongoing presence of tinnitus. We provide arguments that time perception is a social perception, emphasizing the role of rewarding interactions in helping sufferers to overcome the feeling of being prevented from living in the moment. In the course of improvement towards acceptance, different changes in time perception are hypothesized that promote individuals' disengagement from unattainable goal (i.e., tinnitus suppression). A framework for future research is proposed, which distinguishes individuals' behaviors and associated emotions in relation to the time paradox.

The association between stress, emotional states, and tinnitus: a mini-review

Extensive literature supporting the view of tinnitus induced stress in patients is available. However, limited evidence has been produced studying the opposite, that is, does stress cause tinnitus? The hypothalamus pituitary adrenal axis, one of the main neuroendocrine systems involved in stress response, is commonly disturbed in tinnitus patients. Patients with chronic tinnitus have been shown to develop abnormal responses to psycho-social stress, where the hypothalamus pituitary adrenal axis response is weaker and delayed, suggesting chronic stress contributes to the development of chronic tinnitus. The sympathetic branch of the autonomic nervous system also plays a major role in stress response and its chronic hyperactivity seems to be involved in developing tinnitus. Psycho-social stress has been shown to share the same probability of developing tinnitus as occupational noise and contributes to worsening tinnitus. Additionally, exposure to high stress levels and occupational noise doubles the likelihood of developing tinnitus. Interestingly, short-term stress has been shown to protect the cochlea in animals, but chronic stress exposure has negative consequences. Emotional stress also worsens pre-existing tinnitus and is identified as an important indicator of tinnitus severity. Although there is limited body of literature, stress does seem to play a vital role in the development of tinnitus. This review aims to highlight the association between stress, emotional states, and the development of tinnitus while also addressing the neural and hormonal pathways involved.

Superior Semicircular Canal Dehiscence: A Case Report and Literature Review of an Otologic Condition Associated With Severe Psychiatric Disturbance and Suicide Attempt

We report the case of a man suffering from superior semicircular canal dehiscence with severe audiovestibular symptoms. The patient had a history of posttraumatic stress disorder and traumatic brain injury, and he had a presumed diagnosis of schizophrenia, with suicidal ideation. The patient was treated surgically with complete resolution of his symptoms and a retraction of his schizophrenia diagnosis. This case highlights the overlap between tinnitus and auditory hallucinations, as both result in auditory perception without an external stimulus. Ascertaining the appropriate cause of a patient's auditory symptoms is integral to providing appropriate medical and possibly surgical care.

Analysis of Clinical Characteristics and Psychoacoustic Indexes in Different TCM Syndromes of Idiopathic Tinnitus

Objective

To explore the differences in clinical characteristics and psychoacoustic indexes of various traditional Chinese medicine (TCM) syndromes in patients with idiopathic tinnitus.

Methods

312 patients with idiopathic tinnitus in our hospital from December 2017 to March 2020 were selected; divided into the wind evil invasion group (n = 61), the liver fire disturbance group (n = 69), the phlegm fire stagnation group (n = 42), the spleen and stomach weakness group (n = 48), and the kidney essence loss group (n = 92) according to the medical syndrome type and the detailed medical history; and clinical characteristics of patients in each group were compared.

Results

The kidney essence loss group's age and course of disease were older and longer than those of other syndrome groups, and the wind evil invasion group's disease course was shorter than the liver fire disturbance, phlegm fire stagnation, and spleen and stomach weakness groups (P < 0.05). The PSQI score of all patients was higher than 7 points, but there was no obvious difference between the groups (P > 0.05). The SAS score of the liver fire disturbance and the phlegm-fire stagnation groups was higher than that of the wind evil invasion, the spleen and stomach weakness, and the kidney essence loss groups, and the SDS score of the spleen and stomach weakness and the kidney essence loss groups was higher than that of the wind evil invasion, the liver fire disturbance, and the phlegm and fire stagnation groups (P < 0.05). The kidney essence loss group's total hearing loss rate (92.39%) was higher than the other syndrome groups, and the wind evil invasion group's total hearing loss rate (8.19%) was lower than the other syndrome groups (P < 0.05); the low to medium frequency tone of tinnitus's rate in the wind evil invasion group, liver fire disturbance group, and phlegm fire stagnation group was higher than the spleen and stomach weakness group and the kidney essence loss group, but the high frequency tone of tinnitus's rate was opposite. The tinnitus loudness in these groups was higher than the spleen and stomach weakness and kidney essence loss group (P < 0.05).

Conclusion

In addition to the wind evil invasion type, most tinnitus patients may have different levels of psychological disorders. So, in the treatment of idiopathic tinnitus, in addition to the disease itself, paying more attention to the psychological status of the patient is one better therapeutic method. Besides, clinical characteristics and the psychoacoustic indexes of patients with idiopathic tinnitus have a certain correlation with the TCM syndromes.

A Longitudinal Exploration of Self-Reported Hearing Loss, Tinnitus, and Posttraumatic Stress Disorder Treatment Outcomes in Australian Veterans

OBJECTIVE

Tinnitus, hearing loss, and posttraumatic stress disorder (PTSD) are common conditions among veterans. Shared underlying symptoms, such as hypervigilance and heightened sense of threat, may interfere with talk-based psychological treatments. The aim was to investigate the prevalence and risk factors for self-reported tinnitus and hearing loss among Australian treatment-seeking veterans, as well as links with PTSD symptoms and quality of life (QOL) after treatment.

METHODS

Australian veterans participating in hospital-based PTSD treatment (n = 523) completed self-report measures of subjective hearing impairment, service-related factors, PTSD symptoms, and QOL at treatment intake and discharge, as well as 3- and 9-month follow-ups. Univariate analyses of covariance modeled symptom change over time.

RESULTS

More than half of veterans on PTSD treatment self-reported doctor-diagnosed hearing loss or tinnitus, whereas 43% reported both. However, 75% reported subjective mild to moderate hearing impairment, and only 1% reported severe impairment. Service-related factors, such as longer length of service and exposure to explosions, were risk factors for having any hearing condition. After controlling for intake scores, there were no significant differences on PTSD or QOL outcomes over time between those with and without hearing conditions.

CONCLUSIONS

Although self-reported tinnitus and hearing loss are prevalent among veterans, those with severe hearing impairments are unlikely to be represented in this context. There is a need for psychological treatments that are accessible to patients with severe hearing impairments, which should be examined routinely among military members accessing psychological treatments.

Associations of Earphone Use with Tinnitus and Anxiety/Depression

Objective:

This study aimed to investigate the association of earphone use with audiologic and psychologic factors.

Materials and methods:

Korea National Health and Nutrition Examination Survey 2010–2012 data were collected for participants aged ≥12 years old with earphone use ≥1 hour/day. They were matched to a control group for age, sex, income, and education level. The relationship between earphone use and the hearing thresholds of pure-tone audiometry, tinnitus, and psychologic factors such as depression and anxiety, and other quality of life variables was analyzed using multiple logistic regression tests with complex sampling.

Results:

Among the participants, 22.9% (449/1955) of earphone users and 18.1% (355/1600) of control participants had tinnitus (P < 0.001). Earphone users showed 1.27-times higher odds for tinnitus (95% confidence interval [CI] = 1.09–1.50, P = 0.003). Moreover, 6.5% (128/1955) of earphone users and 5.0% (97/1600) of control participants had anxiety and depressive symptoms (P = 0.033). Earphone users showed 1.32-times higher odds for anxiety and depressive symptoms (95% CI = 1.14–1.52, P = 0.040). Nevertheless, the hearing thresholds were comparable between earphone users and control participants.

Conclusion:

Earphone use was associated with tinnitus and anxiety or depressive symptoms.

The evaluation of global cognitive and emotional status of older patients with chronic tinnitus

OBJECTIVES

Tinnitus is a common symptom largely impactful on quality of life, especially in the elderly. Our aim was to evaluate the efficacy of self-administered screening tests to correlate the severity of subjective perception of tinnitus with emotional disorders and the overall cognitive status.

METHODS

Patients aged ≥ 55 years with chronic tinnitus were recruited and submitted to a complete audiological evaluation; Tinnitus Handicap inventory (THI); Hospital Anxiety and Depression Scale (HADS-A and HADS-D) and Mini-Mental State Examination (MMSE). Demographic and audiological features of patients with and without cognitive impairment (MMSE score cut-off of 24/30) were analyzed in order to reveal the relationship among tinnitus, emotional disorders, and cognitive dysfunction.

RESULTS

102 patients were recruited (mean age: 70.4 ± 9.6). THI score was directly related to HADS-A score (r = .63) HADS-D score (r = .66), whereas there was no relationship between tinnitus severity and MMSE (r = .13). CI and n-CI groups did not differ in the characteristics of tinnitus (p > .05), however, hearing threshold (p = .049) and anxious depressive traits measured with HADS-A (p = .044) and HADS-D (p = .016) were significantly higher in the group with cognitive impairment. Furthermore, age ≥ 75 years (p = .002, OR = 13.8), female sex (p = .032; OR = 6.5), severe hearing loss (p = .036; OR = 2.3), and anxiety (p = .029; OR = 9.2) resulted risk factors for CI. Therefore, in CI group MMSE score was inversely related to age (r = -.84).

CONCLUSIONS

Cognitive impairment and psychiatric discomfort should be considered in tinnitus patients, related to increasing age, female sex, and severe hearing loss. Thus, self-administered questionnaires can be useful in addressing clinical approach.

Content validity of the tinnitus outcome questionnaire for sound management

Standardized instruments are often used to monitor one’s progress in tinnitus relief although they were developed to screen and diagnose tinnitus. The need for the development for a tinnitus outcome assessment tool is high in the field of audiology and otolaryngology. The purpose of this study was to develop a tinnitus outcome questionnaire for sound management (listening to sound stimuli for tinnitus relief) and assess its content validity. A total of 32 questions with six domains (Tinnitus characteristics, the impact of tinnitus, tinnitus and hearing issues, handedness, tinnitus management, and sound management outcome) were generated after closely investigating major tinnitus questionnaires used worldwide (i.e. Tinnitus Handicap Inventory and Tinnitus Handicap Questionnaire) as well as literature. Ten healthcare professionals evaluated the appropriateness of the questionnaire items on a five-point Likert scale, where 1 is strongly inappropriate and 5 is strongly appropriate. Content relevance was assessed by computing the content validity index with the cut-off value of 0.75. Each response was first weighted as follows: 1 = 0; 2 = 0.25; 3 = 0.5; 4 = 0.75; and 5 = 1.0. The weighted average was then calculated. Items with a content validity index less than 0.75 were discarded and some items were revised according to the experts’ feedback. As a result, 31 out of the 32 items had the content validity index higher than 0.75, indicating that the items are appropriate to obtain information about the six domains. Reflecting the experts’ feedback, some questions were revised to be more specific. The study provides a baseline structure regarding potential questions to be included in a tinnitus outcome questionnaire for sound management. Development and standardization of such questionnaire would be a pathway to validating tinnitus relief via sound therapy.

Transcutaneous Electrical Nerve Stimulation for Treatment of Tinnitus: A Systematic Review and Meta-analysis

OBJECTIVE

To evaluate the treatment efficacy of transcutaneous electrical nerve stimulation (TENS) in patients with tinnitus.

DATA SOURCES

PubMed, Scopus, Web of Science, and Cochrane Library were searched for the following concepts: "Transcutaneous Electric Nerve Stimulation" and "Tinnitus."

STUDY SELECTION

Inclusion: 1) double- or single-blinded randomized controlled trials; 2) double- or single-blinded randomized comparison trials; 3) prospective or retrospective observational studies; and 4) case series. Exclusion: Non-English studies, nonhuman studies, case reports (n ≤ 5), and review articles.

DATA EXTRACTION

Tinnitus Handicap Inventory (THI), the Visual Analog Scale (VAS), and perceived tinnitus suppression after treatment. Additional data collected included tinnitus laterality, duration of symptoms, location of electrode placement, time to follow-up, etiology of tinnitus, and treatment side effects.

DATA SYNTHESIS

The literature search yielded 2941 unique articles. After reviewing 118 full-text articles, 17 studies reporting on 1,215 patients were included for final analysis. Four studies provided data available for meta-analysis of pre- and posttreatment THI and VAS (Cochrane Review Manager). TENS showed significant overall reduction on THI (-7.55 [-10.93 to -4.18], p < 0.0001) and VAS (-0.65 [-0.99 to -0.30], p < 0.0002). Subjective improvement of tinnitus was pooled across 13 studies using meta-analysis of proportions (MedCalc). Tinnitus suppression occurred in 40.0% [28.9-51.7%] patients. Among those who responded, 22.2% [12.2-29.7%] experienced complete suppression and 10.2% [0.2-31.9%] experienced persistent improvement at 3 months.

CONCLUSIONS

TENS represents a safe and feasible treatment option for tinnitus and might be a worthy consideration among the spectrum of interventions developed for tinnitus.

Social Support and Tinnitus Distress: The Importance of Developing Positive Psychological Qualities in Patients with Chronic Tinnitus

INTRODUCTION

The role of social support in the relief of tinnitus distress and related mechanisms remains unclear. This study aimed to confirm a hypothesis that the influence of social support on tinnitus distress is mediated by resilience and self-esteem.

METHODS

The Social Support Rating Scale, Connor-Davidson Resilience Scale, Positive Version of Rosenberg Self-Esteem Scale, and Tinnitus Handicap Inventory were used to assess 296 patients who experience chronic subjective tinnitus. The collected data were subjected to correlational analysis, mediating effect testing, and structural equation model analysis using R 3.3.1 with the mediate and lavaan packages.

RESULTS

The result showed that social support had significant positive correlations with resilience and self-esteem, while resilience and self-esteem had significant negative correlations with tinnitus distress. Furthermore, social support indirectly affected tinnitus distress through the full mediating effects of resilience and self-esteem and could indirectly affect resilience through the partial mediating effects of self-esteem.

CONCLUSION

These results suggested that the key to social support for alleviating tinnitus distress lies in the development of patients' resilience and self-esteem. Promoting the development of positive psychological quality of tinnitus patients and improving their perception of social support may become the new approaches of clinical management of tinnitus.

Role of the caudate-putamen nucleus in sensory gating in induced tinnitus in rats

Tinnitus can be described as the conscious perception of sound without external stimulation, and it is often accompanied by anxiety, depression, and insomnia. Current clinical treatments for tinnitus are ineffective. Although recent studies have indicated that the caudate-putamen nucleus may be a sensory gating area involved in noise elimination in tinnitus, the underlying mechanisms of this disorder are yet to be determined. To investigate the potential role of the caudate-putamen nucleus in experimentally induced tinnitus, we created a rat model of tinnitus induced by intraperitoneal administration of 350 mg/kg sodium salicylate. Our results revealed that the mean spontaneous firing rate of the caudate-putamen nucleus was increased by sodium salicylate treatment, while dopamine levels were decreased. In addition, electrical stimulation of the caudate-putamen nucleus markedly reduced the spontaneous firing rate of neurons in the primary auditory cortex. These findings suggest that the caudate-putamen nucleus plays a sensory gating role in sodium salicylate-induced tinnitus. This study was approved by the Institutional Animal Care and Use Committee of Peking University Health Science Center (approval No. A2010031) on December 6, 2017.

Prevalence of Self-Reported Depression Symptoms and Perceived Anxiety Among Community-Dwelling U.S. Adults Reporting Tinnitus

Purpose

The aim of this study was to examine the relationship between tinnitus and self-reported mental health distress, namely, depression symptoms and perceived anxiety, in adults who participated in the National Health and Nutrition Examinations Survey between 2009 and 2012. A secondary aim was to determine if a history of serving in the military modified the associations between tinnitus and mental health distress.

Method

This was a cross-sectional study design of a national data set that included 5,550 U.S. community-dwelling adults ages 20 years and older, 12.7% of whom were military Veterans. Bivariable and multivariable logistic regression was used to estimate the association between tinnitus and mental health distress. All measures were based on self-report. Tinnitus and perceived anxiety were each assessed using a single question. Depression symptoms were assessed using the Patient Health Questionnaire, a validated questionnaire. Multivariable regression models were adjusted for key demographic and health factors, including self-reported hearing ability.

Results

Prevalence of tinnitus was 15%. Compared to adults without tinnitus, adults with tinnitus had a 1.8-fold increase in depression symptoms and a 1.5-fold increase in perceived anxiety after adjusting for potential confounders. Military Veteran status did not modify these observed associations.

Conclusions

Findings revealed an association between tinnitus and both depression symptoms and perceived anxiety, independent of potential confounders, among both Veterans and non-Veterans. These results suggest, on a population level, that individuals with tinnitus have a greater burden of perceived mental health distress and may benefit from interdisciplinary health care, self-help, and community-based interventions.

Supplemental Material

https://doi.org/10.23641/asha.12568475

Association between major depressive disorder and subsequent tinnitus: A population-based study

BACKGROUND

Previous studies have presented an unclear association between major depressive disorder (MDD) and tinnitus. Therefore, in this study, we aimed to demonstrate the actual association between MDD and new-onset tinnitus using a large, population-based dataset in Taiwan.

METHOD

This case-control study used the data from the National Health Insurance Database. In total, 18,365 patients with tinnitus were recruited as cases, and 18,365 propensity score-matched patients without tinnitus were identified as controls. Logistic regression models were constructed to calculate the odds ratios (ORs) and to estimate the association between prior MDD and tinnitus.

RESULTS

MDD was found in 396 (2.16%) patients with tinnitus and 228 (1.24%) controls without tinnitus. The logistic regression model indicated that prior MDD was associated with tinnitus (adjusted OR, 1.74; 95% CI, 1.47-2.05). Moreover, MDD was positively associated with tinnitus among most subgroups. Notably, a significant association between MDD and tinnitus was observed among patients with diabetes (adjusted OR, 2.05) and hyperlipidemia (adjusted OR, 1.94). Furthermore, sensitivity analyses consistently found a relationship between prior MDD and tinnitus.

LIMITATIONS

The database used in this study does not provide information regarding the lifestyle and gene factors.

CONCLUSIONS

Our results showed a positive association between prior MDD and tinnitus. In addition, MDD may be one of the risk factors for tinnitus onset. Therefore, we recommended that the clinicians should be alert about the tinnitus condition among patients with MDD and provide appropriate interventions for them.

Parental Mental Illness in Childhood as a Risk Factor for Suicidal and Self-Harm Ideations in Adults Seeking Help for Tinnitus and/or Hyperacusis

Purpose The aim of this study was to explore the relationship between parental mental illness in childhood with suicidal and self-harm ideations in adults seeking help for their tinnitus and/or hyperacusis. Method This was a retrospective, cross-sectional study. The data for 292 consecutive patients who attended a Tinnitus and Hyperacusis Therapy Specialist Clinic in the United Kingdom were included. Results Forty-six of 292 patients, or 15.75% of the patients, expressed that they have been bothered by suicidal and self-harm ideations within the last 2 weeks. Furthermore, 38.7% of the patients (113/292) reported that, while they were growing up during the first 18 years of life, their parent(s) were suffering from a mental illness. Logistic regression analysis showed a significant relationship between suicidal and self-harm ideations and the history of parental mental illness after adjusting the model for (a) tinnitus disability as measured via the Tinnitus Handicap Inventory (Newman, Jacobson, & Spitzer, 1996), (b) hyperacusis as measured via the Hyperacusis Questionnaire (Khalfa et al., 2002), (c) anxiety as measured via the Generalized Anxiety Disorder Questionnaire (Spitzer, Kroenke, Williams, & Löwe, 2006), (d) depression as measured via the Patient Health Questionnaire (Kroenke, Spitzer, & Williams, 2001), and (e) age and gender. Adjusted odds ratio was 2.5 (95% CI [1.14, 5.6], p = .022). The only other variable that was significantly related to the risk of suicidal and self-harm ideations was depression; adjusted odds ratio was 7.7 (95% CI [2.6, 26.3], p = .001). Conclusions Clinicians who offer tinnitus and hyperacusis rehabilitation should screen for suicidal and self-harm ideations among patients, especially for those with symptoms of depression and a childhood history of parental mental illness. Patients with suicidal and self-harm ideations should be referred to mental health services for further diagnosis and treatment.

Reliability and validity of the mandarin version of the tinnitus primary function questionnaire: A preliminary observational study

Tinnitus is a prevalent condition among different populations. As the nature of tinnitus is subjective, self-reported measures have been validated and utilized to assess psychometric properties of tinnitus patients. Without exception, Chinese clinicians have administered these measures to patients in mainland China after cross-cultural adaptation. However, shortcomings of these Mandarin measures limited the widespread use of them. Measures which can be fully adapted to the context of Chinese tinnitus patients are still needed. The objective of this study was to evaluate the reliability and validity of the Mandarin Tinnitus Primary Function Questionnaire (TPFQ-M) in a Chinese population.In this observational questionnaire study, we recruited 350 subjects with primary tinnitus from hearing clinics of West China Hospital and administered the TPFQ-M, Mandarin Tinnitus Handicap Inventory (THI-M), and a systematic hearing test battery.The subjects finished the TPFQ-M within 3 minutes. Exploratory and confirmatory factor analyses demonstrated that a 4-factor model was close to fit. The Cronbach alpha of TPFQ-M was 0.925, and test-retest reliability was reasonable with a 7-day test interval (ICC = 0.857, P < .001; 95% CI: 0.764-0.915). Test-retest reliabilities of subdomains were not parallel to each other, with 0.612 for Emotion, 0.766 for Sleep, 0.860 for Concentration, and 0.897 for Hearing. The convergent validity of TPFQ-M compared to the THI-M was moderate (r = 0.705, P < .001; 95% CI: 0.647-0.754).The TPFQ-M, which shows high internal consistency and good factor structure, is simple and relatively easy to administer in busy clinics. Additional in-depth research involving multiple centers in mainland China is warranted.

Tinnitus and suicide: An unresolved relation

Tinnitus is an auditory phantom sensation which can be a devastating condition for the affected person causing annoyance and discomfort. It may be associated with psychiatric conditions. Patients with highly annoying tinnitus and different comorbidities may have a higher risk of expressing suicidal behaviour and ideation. We aimed to review available reports on the prevalence of suicide and suicidal behaviour with tinnitus patients in order to collate current concepts and to identify possible alarming signs and risk factors. A comprehensive search for appropriate studies listed in PubMed, Ovid and Cochrane databases was conducted using appropriate keyword combinations. We identified 22 publications including original articles, case reports and reviews of which 10 fit our stringent search criteria. Most importantly, from the present studies it appears not feasible to univocally conclude on the co-incidence of tinnitus and suicide. This is due to methodological differences in these approaches, complex interrelations between tinnitus and other psychiatric comorbidities and confounding factors such as the inclusion of patients suffering from post-traumatic stress disorder. More concerted actions involving different medical disciplines are needed to reflect the ethiological heterogeneity of tinnitus and suicide or suicidal behaviour to test for a relationship.