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Suicide, Self-harm Considerations in Holistic Audiological Care

Schwartzer, Sarah BA; Parker, Mark PhD

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doi: 10.1097/01.HJ.0000558448.44657.d4
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A recent article1 by Hashir Aazh, PhD, and Brian C. J. Moore, PhD, DrHC, entitled “Thoughts about Suicide and Self-Harm in Patients with Tinnitus and Hyperacusis,” provides a pertinent look at an issue that plagues patients who suffer from tinnitus and/or hyperacusis, where these patients are more likely to experience suicidal and self-harmful ideations. Patients who went to the National Health Service (NHS) clinics in the United Kingdom seeking treatment for their tinnitus and/or hyperacusis were asked, “Over the last two weeks, how often have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way?” This question is from the 9-item Patient Health Questionnaire (PHQ-9). The answer options were “not at all” (0 points), “several days” (1 point), “more than half the days” (2 points), and “nearly every day” (3 points).

hearing loss, mental health, tinnitus

Of the 150 people who responded, a statistically significant number indicated that they had suicidal or self-harmful ideations within the past two weeks. These suicidal and self-harmful ideations (or “negative thoughts”) correlated strongly with scores on the anxiety and depression subscales of the Hospital Anxiety and Depression Scale (HADS), and significant relationships were found between their scores on the PHQ-9, Tinnitus Handicap Inventory (THI) questionnaire, Hyperacusis Questionnaire (HQ), and Visual Analog Scale (VAS) regarding the effects of tinnitus on daily life. Similarities in responses and correlations between results from mental health office surveys and audiologic surveys brought up an important issue that clinicians need to address when evaluating patients with these conditions: Patients with tinnitus and/or hyperacusis are at a much higher risk for suicidal and self-harmful ideations, as well as anxiety and depression.


Overall, the study got a 37 percent response rate on the PHQ-9 question included in NHS tinnitus/hyperacusis management intake appointments. Of these individuals, 12.7 percent of the tinnitus/hyperacusis patients reported having negative thoughts over the past two weeks. There were no significant differences between the scores of responders and nonresponders in the other surveys and questionnaires included in the intake packet (THI, HQ, HADS, VAS) except in the scores on tinnitus loudness perception. The negative thoughts group averaged 6.5 points on a scale of one to 10, which was a statistically significant higher score than that of the nonresponders (6 points). This result suggests a statistically significant link between how loud individuals perceived their tinnitus and how likely they were to have had ideations of suicide and/or self-harm in the past two weeks.

The authors found statistically significant direct relationships between negative thoughts and the participants’ scores on the THI and HQ. Those with more severe scores on the THI were more likely to have had negative thoughts within the past two weeks. A statistically significant relationship was also found between the effect of tinnitus on quality of life and negative thoughts. The more an individual rated their tinnitus as detrimental to their overall quality of life, the more likely they were to have had negative thoughts in the past two weeks.


Scores on the depression subscale of the HADS correlated with the reported presence of suicidal and/or self-harm ideations over the past two weeks. The r values found for the depression and anxiety subscales were 0.31 and 0.35, respectively, indicating a strong and statistically significant correlation (p values of 0.001 and <0.001). Additionally, the authors found direct relationships between audiological questionnaires (e.g., THI and HQ) and depression/self-harm screeners (e.g., the question from the PHQ-9).


Audiologists should be aware of the possibility that their patients with tinnitus and/or hyperacusis may have negative thoughts or other mental illnesses on top of their audiological disorders. Assisting these patients by providing resources, phone numbers, and people to reach out to will ensure that audiologists are providing holistic care and in turn help patients trust their audiologists.

In the clinic, the HADS and/or the PHQ-9 can be inserted in the patient intake packet along with the THI and HQ for the patient to complete before the appointment, time permitting. These questionnaires are short and easy to score, and would give clinicians useful information about the emotional and mental states of patients before seeing them. Therefore, if the scores warrant intervention and clinicians need to think of other professionals such as a psychologist and/or social work resource in the area to refer to, the clinician can think through the appointment, make the necessary calls, and ensure that the patient does not leave the clinic unsupported.

Implementing a depression and/or anxiety screener within a tinnitus/hyperacusis evaluation or management session could help facilitate appropriate referrals to mental health services. While patients with hearing loss have been reported to often experience loneliness and depression due to isolation, patients with tinnitus and/or hyperacusis are at higher risk and have a higher prevalence of having suicidal or self-harm ideations and dangerous mental states,1 which is something audiologists need to be aware of. By checking in on patients’ emotional well-being while managing their tinnitus/hyperacusis in the clinic, audiologists can also organize interdisciplinary and holistic care for their patients outside of the clinic.


1. Aazh, H. and Moore, B. (2018). Thoughts about Suicide and Self-Harm in Patients with Tinnitus and Hyperacusis. Journal of the American Academy of Audiology, 29(3), pp. 255-261.
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