Audiologists have a significant part to play in identifying anxiety, depression, and other mental health problems in hearing health care patients and in ensuring that these patients receive the proper psychological care.
To achieve this, they need to have a network of mental health professionals to which to refer patients, or suggest that patients see their primary care physicians for further assessment and referral, according to Barbara E. Weinstein, PhD, professor of audiology and founding executive officer of Health Sciences Doctoral Programs at the Graduate Center, City University of New York, coauthor of the Hearing Handicap Inventory for the Elderly/Adults and columnist for The Hearing Journal.
Stacy Weisend, AuD, a clinical audiologist and vestibular lab coordinator at the University of Akron in Akron, OH, said it is not the role of the hearing health care professional to diagnose or treat mental health problems, but it is their duty to counsel and treat within the realm of audiology.
“We need be able to recognize signs and symptoms of depression, anxiety, and other disorders so we can properly refer patients,” she said.
DEPRESSION AND ANXIETY'S PREVALENCE
Of 18,318 individuals who participated in the National Health and Nutrition Examination Survey (NHANES), the prevalence of moderate-to-severe depression is dose dependent, with 4.9 percent of moderately to severely depressed individuals reporting excellent hearing, 7.1 percent reporting good hearing, and 11.4 percent experiencing a little trouble or greater hearing impairment, according to a recent National Institute on Deafness and Other Communication Disorders report (JAMA Otolaryngol Head Neck Surg 2014;140:293-302http://archotol.jamanetwork.com/article.aspx?articleid=1835392).
Overall, the prevalence of mental health problems in the hearing health population is largely unknown, said Dr. Weisend.
“We typically see people after they have an audiological issue, such as tinnitus, hearing loss, hyperacusis, or dizziness, and it is difficult to determine whether they have mental health problems, as many are undiagnosed or unreported,” she said. If there is a diagnosis of anxiety or depression, knowing whether it stems from a hearing problem or a preexisting condition is challenging, she said.
Most audiologists do not measure presenting mental health conditions, nor do they typically measure outcomes in these domains, said Dr. Weinstein.
“But one would speculate that among people with moderate-to-severe hearing loss there would be a considerable depression factor, given the studies demonstrating a link between depression, hearing loss, and self-rated psychosocial hearing difficulties,” she said.
Depression and anxiety seem to have a high prevalence in Dr. Weisend's patients, she said. Even though patients may not have an official diagnosis, they seem to experience—per self-report—an alteration in their mental health that has psychosocial manifestations that affect their individual thoughts and behaviors. Audiological issues, for example, can limit or sever social connections, and human beings are social by nature, she said.
When patients lose their social connections, “they lose the mirror [or] feedback that helps them calibrate and stay in line with the world.” Social pain and rejection can trigger the same neural pathways as physical pain, said Dr. Weisend, but social pain is much more easily triggered and can be relived more vividly than physical pain.
MENTAL HEALTH KNOWLEDGE NECESSARY FOR PATIENTS
The literature demonstrates a relationship between hearing loss and depression, said Dr. Weinstein. For example, the incidence of depressive symptoms is higher among persons self-reporting a hearing handicap as compared with those not reporting one, and self-reported hearing handicap is an independent predictor of depressive symptoms (J Am Geriatr Soc 2010;58(1):93-7http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2009.02615.x/abstract; Age Ageing. 2012;41(5):618-623http://ageing.oxfordjournals.org/content/41/5/618.long). Some studies,for example, show that hearing aids reduce depression (Geriatr Gerontol Int. 2012 Jul;12(3):440-445http://onlinelibrary.wiley.com/doi/10.1111/j.1447-0594.2011.00789.x/abstract;jsessionid=0A07FBB35A8D13D8FDF65DB01DA3EE69.f02t02).
A recent study reported that hearing health care patients with moderate-to-severe hearing loss may experience anxiety associated with the inability to manage their condition, as well as physiologic symptoms such as elevated blood glucose levels, said Dr. Weinstein (Disabi Rehabil 2015;37:22:2070-2075http://www.tandfonline.com/doi/full/10.3109/09638288.2014.996675). Persons with self-reported psychosocial hearing difficulties also experience fatigue, a symptom associated with reduced quality of life, depression, and compromised decision-making ability, she said, citing recent studies (Ear Hear. 2016;37(1):e1-e10http://journals.lww.com/ear-hearing/pages/articleviewer.aspx?year=2016&issue=01000&article=00014&type=abstract).
Audiologists also need to understand the grieving reactions of people who are experiencing hearing loss, said Michael A. Harvey, PhD, ABPP, a private-practice clinical psychologist with specialization in hearing loss in Framingham, MA, and a former consulting faculty member at Salus University in Elkins Park, PA. Notably, people born with moderate-to-profound hearing loss don't have the same grieving reactions as individuals who transition from normal hearing to hearing loss. “You see a lot more acute depression and anxiety as people experience a real loss, going from one state to a lesser state,” he said.
Audiologists should be aware that patients with a moderate hearing loss often experience a phenomenon called “between two worlds,” which is characterized by identifying with both the hearing and deaf communities, said Dr. Harvey. People may identify with the hearing world through their love of music, for example. When they start experiencing problems hearing in crowds or environments with background noise, however, they may begin to feel isolated and gravitate toward the deaf community, but without knowing how to sign.
Patients with hearing loss may experience a range of emotional and psychological symptoms, said Robert Sweetow, PhD, emeritus professor in the Department of Otolaryngology–Head and Neck Surgery at the University of California, San Francisco. These can include anger, denial, guilt, paranoia, embarrassment, frustration and impatience, isolation and withdrawal, sadness, depression, anxiety, loss of confidence, self-pity, and fatigue. People with hearing loss may also recognize a fundamental difference in the way others perceive them and the way in which they communicate. As a result, they often don't want to be told by an audiologist what to do or how to view their hearing loss, he said.
VALUABLE ASSESSMENT TOOLS
A variety of screeners can help audiologists identify mental health problems in their hearing health patients.
The audiogram is typically not predictive of the self-reported psychosocial effects of hearing loss in patients with age-related hearing loss, said Dr. Weinstein.
“It's important that audiologists, in addition to measuring hearing impairment, measure psychosocial patient-reported hearing difficulties when individuals receive hearing aids or other interventions and then after they have had their hearing health care solution for a while,” she said.
Dr. Weinstein suggests using a number of different patient-reported outcome measures. For example, audiologists can use the Patient Health Questionnaire-2 (PHQ-2), consisting of two questions to assess depression. If results indicate that a risk for depression is present, they can administer the longer questionnaire, the PHQ-9. “These are very common screeners for depression that correlate with audiologists’ self-rated measures of the hearing handicap inventory,” she said.
The Physician Quality Reporting System, part of Medicare reporting, allows audiologists to use mental health measures, one of which is the Hospital Anxiety and Depression Scale (HADS), said Dr. Weisend.
One challenge audiologists face is that they lack good screeners to distinguish between mental health issues and cognitive decline, said Dr. Sweetow, adding that depression, anxiety, and other mental health problems are often sequelae of cognitive problems. He suggests using tools like the Beck Depression Inventory and the State Trait Anxiety Index to assess mental health and the Six Item Cognitive Impairment Test (6CIT) to assess cognitive decline, but only if audiologists are prepared to refer patients to the necessary health professionals if these screeners suggest significant clinical problems.
Other reliable validated assessment tools for cognitive decline are available on the Alzheimer's Association website and include the General Practitioner Assessment of Cognition (GPCOG), the Memory Impairment Screen (MIS), and the Mini-CogTM. A more formal tool, and the one best utilized by audiologists—according to Dr. Sweetow—is the Montreal Cognitive Assessment, available at mocatest.org.
THE IMPORTANCE OF A COMPREHENSIVE MEDICAL HISTORY
Although assessment tools can provide useful information to audiologists about a patient's mental health, an audiologist should always obtain a thorough case history, according to Dr. Weisend.
A comprehensive medical history is also valuable because some mental health problems may trigger or exacerbate audiological conditions, said Dr. Weisend. For example, anxiety, stress, muscle tension, and some psychiatric medications can trigger tinnitus or make it worse, she said. Anxiety can also contribute to tinnitus, hyperacusis, and dizziness. Alternatively, tinnitus and hyperacusis can elicit anxiety in patients.
Asking about physical symptoms is also important, said Dr. Weisend. Patients with mental health problems, particularly depression and anxiety, may present with physical complaints, such as an upset stomach or pain that result from their mental health concerns.
ESTABLISHING EFFECTIVE COMMUNICATION
While discussing mental health problems with hearing health care patients, audiologists need to let patients know that “they are heard and understood,” said Dr. Weisend. “You want to normalize their concerns in effort to establish a good rapport.”
Audiologists also need to be competent observers of their environment and recognize that how they behave will affect the patient's behavior, responses, and outcomes, said Dr. Weisend. Even facial micro expressions, such as widening of the eyes or lip pursing, can have a significant impact, she said.
If patients are depressed, the audiologist may want to reinforce how taking the initiative to have their hearing evaluated is a positive step in their overall health, said Dr. Weinstein. The audiologist can further reassure patients that he or she can help them develop skills and strategies to better communicate and reduce the stress associated with communication breakdowns.
USING COGNITIVE BEHAVIORAL THERAPY COMPONENTS
Introducing cognitive behavioral therapy as a counseling concept to the patient is an acceptable and relatively simple practice within the professional purview of audiologists, said Dr. Sweetow.
For example, a person who is hard of hearing may express feeling paranoid because she thinks people are talking about her behind her back in social settings. Audiologists can acknowledge this feeling but then question what evidence the patient has for reaching this conclusion, said Dr. Sweetow. They can then present her with alternative reasons for why other people are talking that have nothing to do with her or her hearing loss.
Before introducing the ideas behind cognitive behavioral therapy, Dr. Sweetow said he first recommends gaining the patient's trust. “Don't act omnipotent. Before advice can be offered that is regarded as having great value, the patient must be convinced of the professional's desire to be part of the solution,” he said.
FURTHER RESEARCH IS NECESSARY
More research is needed to show how audiological interventions can positively affect patients’ health outcomes and quality of life, said Dr. Weinstein. Notably, a soon-to-be-published manuscript demonstrates that hearing aids used to improve speech understanding in noise also reduce social and emotional loneliness, which, in turn, may affect cognition, she said (Weinstein. Am J Audiol 2016; In Press).
Another study (Am J Audiol. 2015 Sep 1;24(3):307-310http://aja.pubs.asha.org/article.aspx?articleid=2405554) is investigating whether an eight-week Internet-delivered acceptance-based cognitive behavioral therapy has a positive effect on distress associated with hearing difficulties, anxiety, and depression, Dr. Weinstein said.
Although hearing loss and cognition are commonly addressed in the audiological literature, “there's a lot less going on in mental health issues. I think there's a particular need for the development of more screening measures that specifically address the hearing-impaired population,” Dr. Sweetow said.