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Psychological comorbidity, functional impairment common in tinnitus patients: First Lankan study

20 Jan 2022

  • Patients with tinnitus should be routinely screened for psychiatric morbidity by ENT docs/audiologists using appropriate screening tools and referrals 
  • Psychotherapy should give more weight to mindfulness and relaxation and less weight to cognitive restructuring
BY Ruwan Laknath Jayakody Psychological comorbidity and functional impairment have been found to be, according to the first-ever local study of its kind, common in patients with tinnitus. This finding was made in an original paper on the “Psychological morbidity and resilience associated with tinnitus in a Sri Lankan population” which was authored by T. Abayabandara-Herath (attached to the University of Kelaniya Medical Faculty’s Paediatrics Department) and A. Rodrigo (attached to the same Faculty’s Psychiatry Department) and published in the Sri Lanka Journal of Psychiatry 12 (2) in December 2021. Tinnitus, Abayabandara-Herath and Rodrigo explained, is a perception of sound which is unrelated to an external acoustic source and is usually described as a ringing noise. It is per A. McCormack, M. Edmondson-Jones, S. Somerset, and D. Hall’s “A systematic review of the reporting of tinnitus prevalence and severity”, a common health issue with a lifetime prevalence of 5.1% to 42.7% which according to J.J. Simpson and W.E. Davies’s “Recent advances in the pharmacological treatment of tinnitus”, adversely influences the quality of life in affected individuals, ranging from a minor irritation to severe distress, in turn leading to self harm. Abayabandara-Herath and Rodrigo noted that tinnitus often presents with impaired functioning and psychiatric illnesses. Psychiatric diseases are highly prevalent among people with tinnitus, with 77% of the population with tinnitus, according to E. Wallhäusser-Franke, W. Delb, T. Balkenhol, W. Hiller, and K. Hormann’s “Tinnitus-related distress and the personality characteristic resilience” and M. Salviati, F.S. Bersani, S. Terlizzi, C. Melcore, R. Panico, G.F. Romano, G. Valeriani, F. Macrì, G. Altissimi, F. Mazzei, V. Testugini, L. Latini, R.D. Chiaie, M. Biondi and G. Cianfrone’s “Tinnitus: Clinical experience of the psychosomatic connection”, reporting a psychiatric disorder. According to P.C. Pinto, C.M. Marcelos, M.A. Mezzasalma, F.J. Osterne, M.A.D.M.T.D. Lima and A.E. Nardi’s “Tinnitus and its association with psychiatric disorders: Systematic review”, post-traumatic stress disorder, insomnia, anxiety disorder, and depressive disorder co-occur with tinnitus, with the latter two disorders being the most common comorbidities, with such disorders both adding to and exacerbating the burden of tinnitus (S. Hébert, B. Canlon, D. Hasson, L.L.M. Hanson, H. Westerlund, and T. Theorell’s “Tinnitus severity is reduced with the reduction of depressive mood – A prospective population study in Sweden” finding emotional exhaustion to be a strong predictor of the severity of tinnitus). Therefore, the association between tinnitus and psychiatric disorders is bidirectional, per H. Bartels, S.S. Pedersen, B.F.A.M.V.D. Laan, M.J. Staal, F.W.J. Albers and B. Middel’s “The impact of Type D personality (the joint tendency towards negative affectivity and social inhibition) on the health-related quality of life in tinnitus patients is mainly mediated by anxiety and depression”. None of the available treatment options and interventions, per V. Wu, B. Cooke, S. Eitutis, M.T.W. Simpson, and J.A. Beyea’s “Approach to tinnitus management”, have been proven to consistently eliminate tinnitus. Moreover, Abayabandara-Herath and Rodrigo observed that the majority of these treatment modalities are not available in Sri Lanka. Therefore, Abayabandara-Herath and Rodrigo highlighted the importance of addressing treatable psychiatric comorbidities, which will in turn improve the severity and impact of tinnitus. On the other hand, Abayabandara-Herath and Rodrigo added that some people are resilient even in the face of debilitating illness such as tinnitus and adapt well without developing psychiatric illness. Wallhäusser-Franke et al. reported that the loudness of the tinnitus, depression, anxiety, and somatic symptoms had an inverse correlation with resilience. Abayabandara-Herath and Rodrigo, therefore, sought to study and assess the prevalence, correlates of functional impairment and psychiatric morbidity in a cohort of people with tinnitus, along with the factors associated with resilience. This was a multi-centre, cross-sectional, descriptive study conducted among Sri Lankan patients with the complaint of tinnitus. All eligible, consecutive, adult patients who attended otolaryngology (focused on the ears, nose, and throat – ENT) clinics in three large hospitals, namely the Colombo South/Kalubowila Teaching Hospital, the Kandy National Teaching Hospital, and the Matale District General Hospital, between August 2016 and April 2017, being considered for recruitment for the study. Patients with a diagnosis of mental illness prior to the onset of tinnitus were excluded. Information was gathered using a self-administered questionnaire. For the purpose of the study, Abayabandara-Herath and Rodrigo defined resilience as the absence of psychiatric illness and functional impairment. A total of 200 patients returned completed questionnaires. The majority (124 – 62%) were female. The average age of the participants was 53.6 years (Range 18 years to 75 years). The average duration of tinnitus was 2.9 years. The clinical characteristics of tinnitus are the site of tinnitus (bilateral or right ear or left ear or head), the onset of tinnitus (gradual or sudden), the type of tinnitus sound (chirping or pulsatile or roaring or whistling or other), the subjectively perceived loudness of tinnitus (minimal or mild or moderate or severe or profound), the nature of tinnitus (continuous or intermittent or predominantly at night), and associated problems (hearing loss or ear pain or vertigo/giddiness). Only 14 – 7% reported a history of severe noise exposure. A majority (51.5%) had comorbid medical conditions such as diabetes mellitus (the body does not produce enough or respond normally to insulin, causing blood sugar/glucose levels to be abnormally high), hypertension (high blood pressure), or dyslipidaemia (imbalance of lipids). In terms of the impairments associated with tinnitus, the following domains were assessed; difficulty in engaging in occupational work, difficulty in communicating with others, difficulty in sleeping, difficulty in completing daily household chores, or difficulty in engaging in entertainment activities. A majority (82.5%) reported a functional impairment in one of the domains assessed. A majority (116 – 68%) were suggestive of psychiatric cases, and 61.5% were detected to have depression. Sleep disturbance, feeling exhausted, the uncontrollable nature of the tinnitus and functional impairment were significantly associated with psychiatric comorbidity. Resilience was defined as the absence of psychiatric morbidity and functional impairment, and 12% were found to be resilient. A logistic, regression analysis demonstrated that being able to distract oneself and practicing mindfulness were significantly associated with resilience. However, being optimistic, being religious, appreciating the full context of any situation, and perceived self efficacy did not have significant associations with resilience. Per McCormack et al., the instant study too found that the majority of the patients with tinnitus were more than 50-years-old. Abayabandara-Herath and Rodrigo explained that this has a clear implication for Sri Lanka, indicating that with a rapidly ageing population, the prevalence of tinnitus will increase in the future. A majority reported significant impairment in all the functional domains that were assessed. The disability or functional impairment is higher than what has been reported in A.A. Adoga and T.J. Obindo’s “The association between tinnitus and mental illnesses”. Abayabandara-Herath and Rodrigo opined that the lack of effective treatment, the absence of patient support groups, and poor public awareness may have led to higher rates of reported disability in Sri Lanka. The prevalence of depression was almost 10 times higher than the point prevalence in the normative Sri Lankan population (H.A. Ball, S.H. Siribaddana, Y. Kovas, N. Glozier, P. McGuffin, A. Sumathipala, and M. Hotopf’s “Epidemiology and symptomatology of depression in Sri Lanka: A cross sectional population based survey in the Colombo District”). For Abayabandara-Herath and Rodrigo, the associated disability and the lack of effective treatment for tinnitus in Sri Lanka may explain the high prevalence of depression. The rate of psychological distress or depression is equivalent or higher than that of patients with lung cancers (67%) and Parkinson’s disease (48% – brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and co-ordination) in Sri Lanka, per E.B. Weeratunga, C. Senadheera, and U. Ekanayake’s “Psychological distress in cancer patients in the Southern Province of Sri Lanka” and T.B. Herath, M. Withana, C. Rodrigo, R. Gamage, and C. Gamage’s “Prevalence and associations for symptoms of depression in patients with Parkinson’s disease: A Sri Lankan experience”. The high prevalence of depression demonstrated to Abayabandara-Herath and Rodrigo, the significant psychological impact of tinnitus, which is often neglected and in turn highlights the necessity for routine mental health assessment of these patients, which is not available in Sri Lanka. Therefore, Abayabandara-Herath and Rodrigo proposed that patients with tinnitus should be routinely screened for psychiatric morbidity in Sri Lankan clinical settings which could easily be done by ENT doctors and audiologists using appropriate screening tools and referrals made when required. The high prevalence of depression may also be due to, Abayabandara-Herath and Rodrigo mentioned, patients attending the ENT clinics being in the severe end of the spectrum of tinnitus, as suggested by nearly half of the population reporting their tinnitus to be intolerable. Poor public awareness of this condition in Sri Lanka may explain, Abayabandara-Herath and Rodrigo pointed out, late presentations with severe symptoms. Abayabandara-Herath and Rodrigo, found that while sleep disturbance, feeling exhausted, the perceived loudness of tinnitus and functional impairment were significantly associated with depression, this should however be interpreted with caution, as except for the perceived loudness of the tinnitus, the other features are symptoms of depression. S. Degeest, P. Corthals, I. Dhooge and H. Keppler’s “The impact of tinnitus characteristics and associated variables on tinnitus related handicap” and J.L. Henry and P.H. Wilson’s “The psychometric properties of two measures of tinnitus complaint and handicap” have noted that a bidirectional association is seen between nocturnal tinnitus or sleep disturbances and depression. “Tinnitus may keep individuals awake at night leading to depression. Insomnia associated with depression may make tinnitus more noticeable in the night. The prevalence of depression was higher among patients with unilateral tinnitus compared with patients with bilateral tinnitus,” the study further read. Mindfulness and the ability to distract oneself were significantly associated with resilience, whereas optimism, religiosity, the ability to see the bigger picture and perceived self efficacy were not. This, Abayabandara-Herath and Rodrigo emphasised, has a direct implication on psychological treatment for tinnitus in Sri Lanka, and may suggest, they elaborated, that psychotherapy for tinnitus in Sri Lanka should give more weight to mindfulness and relaxation and less weight to aspects such as cognitive restructuring.


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