Hearing loss is a common condition. However, many adults who could benefit from amplification do not use their hearing aids even though it could help them overcome negative consequences, such as social withdrawal, loneliness, and depression. Equally concerning, hearing aid use is highly variable among young children (LSHSS. 2013;44:73 http://bit.ly/2h7Kv6N;JAAA. 2014;25:380 http://bit.ly/2h7MwQA), compromising speech and language development outcomes (Ear Hear. 2015;36:76S http://bit.ly/2h7JDiu).
How clients are coping with emotional challenges may be a contributing factor to hearing aid usage; such challenges may go undetected by audiologists. Depression and anxiety are common mental health conditions (Int J Methods Psychiar Res. 2012;21:169 http://bit.ly/2h7LEeK) and can interfere with effective health care management and treatment adherence; for example, when parents of children with hearing loss were experiencing symptoms of depression, their children wore hearing aids fewer hours per day than those with no depression (Ear Hear. 2016;37:703 http://bit.ly/2h7LvYA). Stress can also impact the physical and emotional well-being of clients with hearing loss and caregivers, and may its impact be positively influenced by social support (J Health Soc Beh. 2010;51[1suppl]:S41 http://bit.ly/2gLdH2G).
For audiologists to understand client challenges, both internal (e.g., lack of confidence, fear) and external (e.g., need for information), they need to engage clients in communication aimed at identifying underlying issues that influence client behavior. Unfortunately, research shows that audiologists may not be sufficiently focused on understanding client challenges that are related to psychosocial factors; instead, they prefer to focus on challenges that are technical in nature (AJA. 2014;23:337 http://www.ncbi.nlm.nih.gov/pubmed/25036799;Ear Hear. 2015;36:191 http://bit.ly/2gYV0K2). Paying attention to communication with the purpose of developing an effective therapeutic relationship has been shown to have significant positive effects on client adherence to treatment recommendations (Med Care. 2010;47:826 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2728700/). Client involvement in their care through shared decision making, discussion about their concerns, and exploration of how to navigate challenges can decrease misunderstandings and help clients effectively integrate new habits into their routines for more successful outcomes.
Achieving an effective therapeutic alliance includes acknowledging and engaging pertinent emotions such as depression and anxiety. Including a screening instrument may be an effective way to determine when clients are struggling with depression, anxiety, and/or stress. Our study was conducted to find out how clients felt about completing a screening and how audiologists felt about performing the screening.
SCREENING FOR DEPRESSION, ANXIETY, STRESS
From March to June 2015, clients and parents of children with hearing loss, in consecutive hearing aid and cochlear implant follow-up appointments, were invited to participate in the study. Adult clients (n=28) and parents of pediatric clients (n=24) completed a demographic form, the Depression, Anxiety and Stress Scale (DASS), and a feedback form (see Table 1 for client demographics). Ten clinicians (four clinical supervisors; six graduate student clinicians) trained in the use of the screening form and in making referrals for positive screens completed a feedback form at the end of the study. A counseling or medical referral was made when a score demonstrated mild or greater symptoms of depression, anxiety, or stress, particularly if the client perceived that the symptoms were persistent. Institutional Review Board approval from Utah State University was obtained, and participants signed informed consent. The word “clients” is used in the remainder of the article to refer to adult clients and parents of pediatric clients.
STUDY FINDINGS AND SCREENING RESULTS
We observed three main findings in this study: (1) some clients were experiencing clinical levels of depression, anxiety, and/or stress; (2) clients found the screening acceptable; and (3) clinicians had feelings of uncertainty related to managing the screening.
The DASS screening questionnaire queried how clients felt during the week prior to their appointment for depression, anxiety, and stress. The majority scored within the normal range for each component, although some reported symptoms of depression, anxiety, and/or stress were outside the range of normal (Table 2).
FEEDBACK ABOUT THE SCREENING
The majority of clients who participated completed a feedback form (n=49; 92%; Table 3), and responded positively about the screening experience. They stated benefits of the screening in response to an open-ended question, and indicated that the screening tool could help individuals with depression, anxiety, or stress by increasing overall awareness. Two clients expressed concerns: “Some weeks are more challenging than others,” “Answers vary at different times based on child, treatment, etc.,” and “I don't really want to find out that I have depression–it sounds so hard to surmount.”
All of the clinicians completed a feedback form at the completion of the study (Table 4). There was general agreement that the screening was easy to implement, not too time-consuming, and suitable for audiology practice; however, there was less agreement on the perception that including the screening was time well spent and whether the clinicians were comfortable managing the conversation with clients about the screening. Written feedback regarding benefits included helping clients who might not otherwise seek help, building stronger connections with clients, improving clinical skills, and providing more complete care. Concerns were related to client comfort, possible client reactions to the screening, clinician skills and ability, and time constraints to include the screening.
By screening for psychosocial conditions, audiologists can recognize when challenges such as depression may affect a client's daily management of hearing loss. Such challenges will be present—whether the audiologist acknowledges them or not—and have the potential of negatively influencing a client's regular use of hearing devices. It is useful to know if clinical levels of anxiety, depression, or stress are present because these will affect all aspects of life, including adherence to the treatment regime prescribed by audiologists.
It was interesting to note that client responses to the screening were highly positive, which contrasted with the clinicians’ perception; clinicians feared that clients would have an aversive reaction to the screening. Client feedback revealed that 96 percent were pleased the clinician was checking on how they were feeling, while the primary concern of audiologists was that clients would not appreciate the screening or feel it was judgmental or invasive of their privacy. The clinicians also reported a lack of comfort in managing conversations about the screening with clients. Further research is needed to explore knowledge, skills, and attitudes of practicing audiologists related to counseling, and to evaluate how audiology graduate programs approach counseling training to support clinician self-efficacy.
For providers to engage clients in discussions on hearing loss management, they first need to recognize the importance of addressing the clients’ emotional experiences. Comprehensive audiological care includes addressing client emotions as an intentional component in service delivery. A screening tool such as the DASS provides an opportunity to identify the presence of emotional challenges, and if needed, to refer clients for further specialized support.