"Have you ever tasted gunmetal in your mouth?” asked a patient with severe, chronic tinnitus. The patient went on to describe precisely how he planned to kill himself when his tinnitus becomes unbearable. Another patient reported being “literally at the end of my rope” by the end of the year.
While there is limited data indicating no direct relationship between tinnitus and suicide, it is not uncommon to see tinnitus patients reporting suicidal thoughts in clinical practice (Jacobson. J Am Acad Audiol 2001;12:493 http://1.usa.gov/22PqjIn). This research investigated the prevalence of suicidal ideation in patients with chronic tinnitus. Findings may support development of clinical protocols and additional training in mental health for students and clinicians who are actively working with this potentially vulnerable population.
Clinical records for 218 patients seen for a tinnitus evaluation and/or consultation were reviewed. Of these, 200 qualified as subjects because they had completed the Tinnitus Reaction Questionnaire (TRQ) at the time of the initial appointment and were at least 18 years of age. The TRQ is a validated psychometric inventory used to measure tinnitus disturbance that includes a question (#24) addressing suicidal thoughts related to tinnitus: “My tinnitus has led me to think about suicide” (Wilson. J Speech Lang Hear Res 1991;34:197 http://1.usa.gov/217Khwp). Patients were instructed to respond based on “how tinnitus has affected you over the past week.” Using a 5-point Likert scale (0-4), patients rated tinnitus distress for 26 items ranging from “not at all” to “almost all of the time.” The total score was computed as the sum of all 26 items and was used to classify the level of tinnitus disturbance (maximum possible score = 104).
The mean age of patients was 59 years (range: 21-88) with a greater number of males (64%) than females (36%). The mean score on the TRQ was 43 (range: 1-102; SD=25). Thirty-two patients (16%) reported tinnitus disturbance that was not clinically significant (Figure 1). A majority of the patients (32%) reported “mild” tinnitus disturbance, while 27% reported “severe” to “profound” tinnitus disturbance.
Of the 200 patients with tinnitus included in this study, 32 (16%) reported suicidal thoughts on question #24 of the TRQ. These patients had a mean age of 61 years (range: 25-79) and were predominantly male (59%). The average total score on the TRQ was 72, which falls in the “profound” category. Nearly half of the patients with profound tinnitus disturbance reported thinking about suicide (Figure 2). However, even some patients with mild (5%) or moderate (20%) tinnitus disturbance had suicidal ideations.
The amount of time spent thinking about suicide varied in the largest group of patients reporting “a little of the time.” Twenty-five percent of patients reported thinking about suicide “a good deal of the time” or “almost all of the time” (Figure 3). Notably, two of these patients had moderate tinnitus disturbance overall. Thus, a higher TRQ score was not necessarily indicative of more time spent thinking about suicide.
When compared with other populations, patients with tinnitus were more likely to have suicidal ideation (Figure 4). One in six patients with tinnitus (16%) reported suicidal thoughts, which is four times greater than the suicidal ideation incidence among US adults in general (CDC. Suicide Facts at a Glance 2015http://1.usa.gov/217LlAk). The prevalence of suicidal ideation among patients with tinnitus was also greater than those reported for patients with other chronic health conditions including cancer, insomnia, and Parkinson's disease (Kling. SLEEP 2010http://wb.md/217L4NV; Kummer. CNS spectrums 2009;14:431 http://1.usa.gov/217M8S3; Spencer. Am J Geriatr Psychiatry 2012;20:327 http://1.usa.gov/217M1pz). Suicidal ideation in patients with tinnitus was slightly less common than among those with chronic pain (Smith. Pain 2004;111[1-2]: 201 http://1.usa.gov/217MyYD).
The prevalence of suicidal ideation is greater among patients with tinnitus compared with the general population and those with other chronic health conditions, except for chronic pain. Suicidal thoughts were even reported by patients with a mild tinnitus disturbance. These findings suggest future research to focus on identifying important warning signs and factors such as associated or concomitant conditions (e.g., depression, sleep disturbance, sound sensitivity) that could contribute to suicidal ideation among tinnitus patients. Audiologists offering tinnitus management also need to be prepared to address suicidal ideations. While mandated reporting varies from state to state, it is important for clinicians to know the applicable laws and established clinical protocols to plan (e.g., Patient Safety Plan http://bit.ly/217M2tr) and manage caring discussions about suicide, and to ensure the wellbeing of patients and clinicians alike.