Review article
Depression and tinnitus

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Major depressive disorder

The Diagnostic and statistical manual, 4th edition, of the American Psychiatric Association [3] lists the following criteria for MDD:

  • Depressed mood or decreased interest or pleasure in daily activities, consistently for at least 2 weeks

  • Negative effects on functioning at work, school, social activities, or other important activities

  • Unexplained by substance abuse, medical illness, bipolar disorder, psychosis, or normal bereavement

At least five of these nine symptoms should be present, nearly

Other psychiatric conditions

Our tinnitus clinic study found small numbers of patients with current alcohol abuse (10%) and anxiety disorders (15%); these percentages were not different from those seen in the hearing loss control group [2]. One report from Sweden [4], although confirming that depression was the most common psychiatric problem in their tinnitus patients (62% lifetime history), also found a rather high prevalence of anxiety disorders (45% lifetime history). Their study was limited to younger tinnitus

Tinnitus and suicide

Suicide is a serious risk for patients with MDD, especially older men who are socially isolated. Whether tinnitus is itself a risk factor for suicide over and above the presence of MDD is unclear. A recent review [6] concluded that “nowhere in the existing literature is there any evidence supporting a cause and effect relationship between tinnitus and suicide.” Nevertheless, the risk of suicide is an important reason why all patients with MDD should be offered prompt treatment.

Does tinnitus cause depression?

Because most people with tinnitus are not depressed, the answer must be either “no” or “not very often.” In the author's tinnitus clinic, about half of the depressed patients had MDD before they ever had tinnitus [7]; although tinnitus certainly did not cause the early episodes of MDD in these patients, it could have been a precipitating factor for later episodes in patients who are demonstrably susceptible to MDD. The Swedish study previously referenced [4] reported even more dramatic results:

Tricyclic antidepressants

If many (if not most) of the most severely affected tinnitus patients have MDD, it makes sense to treat their MDD, whether by drugs or psychotherapy. Early in the author's tinnitus clinic experience, good results were obtained treating depressed tinnitus patients with nortriptyline, a tricyclic antidepressant. It was decided to conduct a double-blinded randomized clinical trial using this drug. The author and colleagues advertised widely in the Seattle area and were able to enroll 92 patients

Prediction of benefit

Who should receive antidepressants? Most otolaryngologists are not skilled in detection and diagnosis of MDD, but they should at least be alert to the possibility that patients who complain bitterly of their tinnitus often have MDD. Surprisingly, in our study [8], presence of MDD was only a weak prediction of benefit from nortriptyline; the best prediction (by far) was the presence of insomnia. Perhaps this is not so surprising when one considers how important sleep disturbance is in both

Duration of benefit

Although there is stronger support for tricyclic antidepressants than for any other class of drugs in the treatment of tinnitus patients [12], almost nothing is known about benefits beyond a few months. This is an important weakness in the entire tinnitus literature; long-term benefit in excess of placebo effects has not been shown for any treatment.

Newer antidepressants

Such drugs as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil) are now widely used to treat depression and have fewer side effects than the tricyclic antidepressants. Some of the author's psychiatric colleagues have anecdotally noted good results treating patients with severe tinnitus with these drugs, but no large clinical experience has been reported. At least one clinical trial (using paroxetine) is underway in mid-2002.

Other drugs

Dozens of different drugs have been tried in treating tinnitus, and many have been tested in randomized clinical trials [12]. Based on these studies, the most promising classes of drugs seem to be antidepressants and antianxiety agents (especially benzodiazepines). Unfortunately, benzodiazepines (brand names include Valium and Xanax) carry significant risk of drug dependence.

Psychotherapy

Patients who are severely affected by tinnitus display ineffective coping strategies [2], such as overreliance on avoidance. In addition, they often harbor inappropriate beliefs about their problems. Not surprisingly, a variety of psychologic therapies have been tried, including cognitive therapy, relaxation, coping-behavioral therapy, and directive counseling. Most of these approaches have been compared with no treatment (the so-called waiting list control group) and some have been compared

Referral

Otolaryngologists, like all physicians, must be alert for signs of MDD in their patients. Patients who complain bitterly of tinnitus are at particular risk for MDD. Some otolaryngologists may choose to treat some cases of MDD themselves, typically with antidepressant drugs, but most refer these patients either to a psychiatrist or to a primary care physician.

Summary

Most patients with tinnitus are neither depressed nor seriously bothered by their tinnitus. Patients who complain bitterly of tinnitus, however, are often found to have a MDD. Treatment with tricyclic antidepressant drugs helps these patients, especially those who complain of insomnia. Other types of drugs and psychotherapy may also be helpful.

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