The COVID-19 pandemic has resulted in an increased prevalence of mental health problems among the general population.1,2 The epidemiological distribution of mental health problems provides evidence for a psychiatric epidemic co-occurring with the COVID-19 pandemic.2A systematic review examining the general population's mental health status amid the pandemic found significantly higher levels of irritability, stress, anxiety, and depression.1-3 In an attempt to lessen the emotional burden associated with this unprecedented hardship, studies have also shown an increase in maladaptive coping strategies such as higher tobacco, alcohol, and cannabis consumption, increase in junk food intake, physical inactivity, changes in sleep routines and excessive social media/news consumption.2-6
Mental health experts around the world have linked the increased psychological distress to public health measures used to mitigate the spread of the virus.1-3 Enforced lockdowns, quarantines, restrictions in social and family gatherings, disruption of non-essential services delivery, and suspension of cultural and sporting activities have all been identified as new stressors and factors exacerbating mental health disorders.3,4 These restrictions combined with fear of contracting the virus, food insecurity, permanent and temporary layoff, relationship struggles, loneliness, boredom, and lifestyle changes (e.g., working from home, homeschooling) have had an enormous impact on the psychosocial and economic well-being of the general population.2-4
Chronic psychological distress increases the risk of developing physical and mental health conditions such as high blood pressure, digestive problems, autoimmune diseases, sleep disturbances, psychological disorders, and memory and concentration deficits. Moreover, psychological distress is also highly associated with various hearing problems such as age-related hearing loss, sudden idiopathic sensorineural hearing loss, tinnitus, hyperacusis, and Ménière's disease.7-12 Consequently, the prevalence of mental health disorders is higher among people with hearing problems than among people without these conditions.10-12 Furthermore, several studies suggest that severity of hearing loss, tinnitus, and hyperacusis may also be linked to a higher risk of anxiety and depression.13 As pandemic-related psychological distress can either trigger or aggravate hearing health problems, audiologists must gain a better understanding of its impact on the quality of life and treatment outcomes.1
COVID-19-RELATED PSYCHOLOGICAL DISTRESS & HEARING PROBLEMS
Although hearing loss and tinnitus have been identified as potential long-term complications of COVID-19, this article focuses on the experience of patients with pre-existing hearing problems amid the pandemic.15-18 Recent studies have also found an association between COVID-19 related psychological distress and exacerbation of hearing problems such as increased trouble understanding conversations in public places, increased hearing difficulties with phone and video calls, and worsening of tinnitus and hyperacusis.19,20 An online survey of 129 individuals with hearing loss revealed an increased level of stress and anxiety with public health measures adopted in response to coronavirus.19 For instance, 66 percent of respondents worried about having to communicate with others with face masks.19 Moreover, 60 percent reported that the possibility of having to speak to people wearing face masks or from a distance added to their anxieties about going to public places (e.g., parks, supermarkets),19,21 and 61.5 percent reported hearing worse during video calls than if the other person was in the room with them. Finally, 75 percent of the respondents worried more than usual about what to do if their hearing aids stop working as audiology services have been suspended or delivered remotely. In another online survey of 3,103 individuals with tinnitus from 48 countries, 40 percent of the respondents reported that their worsening tinnitus symptoms were related to the same public health measures.20
On the other hand, forced social isolation might have created more favorable listening environments for some people with hearing loss. A recent study conducted by Dunn and colleagues found that CI users reported feeling less anxious in their listening experiences as a result of spending more time at home in quiet surroundings and engaging in more speech listening on electronic devices (e.g., smartphones, TV) rather than live conversations.22
ADVERSE EFFECTS OF CHRONIC STRESS ON EAR-BRAIN CONNECTION
At the most basic level, stress is a hard-wire physiological reaction to dangers.23,24 This primitive response is triggered by either real or perceived threats and consists of a complex outpouring of hormones intended to keep us out of harm's way and maintain our body's normal functional equilibrium (i.e., homeostasis).22 The fight-or-flight response is beneficial if trying to escape from the four inches claws of a grizzly bear's but less helpful when dealing with a deadline at work.23,25 The pervasive impact of stress is influenced by the type, severity, and duration of stressors. Acute stress is adaptive and necessary for short-term survival. However, in its chronic form, stress is maladaptive and can lead to alterations in brain structures (e.g., prefrontal cortex, amygdala, and hippocampus) and neuronal networks.23,24
Although the deleterious effects of stress on brain health have been investigated for over 50 years, little is known on how it can create havoc in the auditory system.23,24,28 Chronic stress-related health conditions such as hypertension are often listed as an important risk factor for high-frequency sensorineural hearing loss and tinnitus.10,11 It is hypothesized that reduced cochlear blood supply due to cardiovascular disease may affect the inner ear tissue and result in accelerated cell loss in the stria vascularis.25 However, the pathophysiological mechanism underlying the association between hypertension and hearing loss remains unclear. Neuroscientists have also shown that stress can interfere with sound processing and speech perception.28 More specifically, studies have found reduced speech recognition performance under stressed conditions and induced state of acute anxiety.31,32 Anxiety in adults has also been associated with poor speech recognition ability in noisy settings.33 Finally, it is also common for tinnitus and hyperacusis to become worse during periods of high stress.30,34
LOOKING BEYOND THE AUDIOGRAM
As soon as patients report an increase in hearing problems or a decrease in benefits from hearing aids, audiologists may be quick to rule out potential changes in hearing status. Cursory otoscopy, pure-tone and speech audiometry test procedures, acoustic immittance measurements, supra-threshold auditory measures, and hearing aid electroacoustic analysis immediately follow questions about changes in physical health and medication(s). Due to appointment time restrictions, however, clinicians often overlook questions about a decline in mental well-being, especially when hearing test results remain unchanged. If left unchecked, these untreated psychological comorbidities can amplify the distress associated with hearing symptoms and jeopardize the efficacy of audiological management strategies. Considering the far-reaching impact of COVID-19-related psychological distress, audiologists must go beyond the traditional model of symptom(s) progression/aggravation and screen for emotional well-being.
COMPREHENSIVE CASE HISTORY & EMOTIONAL WELL-BEING SCREENING
Although the incidence of mental health problems most likely increases with the severity of hearing loss, the audiogram remains insensitive at predicting poor levels of mental well-being. As the pandemic continues, a comprehensive case history is needed to access critical information around events surrounding a recent worsening in pre-existing hearing problems. Here are some examples of questions that will alert clinicians about the potential influence of COVID-19-related psychological distress:
- How different are your hearing problems now compared to pre-COVID-19?
- Were there any new stress-related health symptoms accompanying recent changes in hearing or tinnitus? (e.g., muscle tension, sleep problem, upset stomach, concentration difficulty)
- What lifestyle changes did you need to adopt because of public health restrictions? (e.g., working from home, homeschooling)
- Why are these new lifestyle changes exacerbating your hearing problems? (e.g., trouble hearing during phone or video calls, tinnitus and/or hyperacusis became more noticeable because the household is too quiet or noisy)
- What worries did the pandemic bring into your life? (e.g., fear of not being able to hear or follow conversations in public places because of face masks and/or physical distancing, suspension or remote delivery of hearing service, financial insecurity, loneliness)
- What coping strategies did you use to lessen COVID-19 emotional stress/distress?
The screening of mental health conditions is facilitated by the administration of validated self-report measures of emotional disturbances. Figure 1 shows a brief list of clinical tools currently available for audiologists such as the Perceived Stress Scale (PSC), Hospital Anxiety and Depression Scale (HADS), Patient Health Questionnaire (PSQ-9), and Insomnia Severity Index (ISI).35-38 These tools are easy to score and should be given to patients prior to consultation. If a patient's scores are high on an anxiety and/or depression questionnaire, a referral to a mental health care professional for assessment and treatment might take priority over audiological intervention. However, clinicians should always err on the side of caution when discussing scores obtained with these standardized scales. Although it is within the audiologist's scope of practice to screen for emotional disturbances, clinicians are not permitted to communicate mental health diagnoses such as anxiety and depression.
COUNSELING & STRESS MANAGEMENT
Mental illnesses are among the most common health conditions worldwide. In Canada, statistics show one in every five adults will struggle with a mental health problem at some point in their lives.39 Despite public education campaigns and changing beliefs and attitudes toward mental illnesses, stigma, unfortunately, persists among the general population. Mental illness-related stigma has been identified as a significant barrier to access treatment and receive quality care.40 The fear of being stigmatized often leads patients to conceal critical information about their mental well-being to health care practitioners.
While counseling patients about the impact of mental health conditions on hearing problems, audiologists gain from listening to their story and hardship. Be friendly, empathetic, kind, non-biased, and non-prejudiced as patients do more than listen to what you say. They also observe body language for signs of irritability and judgment. To demystify and normalize the experience of COVID-19-related psychological distress, audiologists must also provide education on an array of topics including the impact of public health measures on mental well-being, the relationship between distress and ear-brain connection, and stress management techniques.
Finally, patients need to understand that stress can be useful in a situation of real danger. However, chronic psychological distress can interfere with hearing health. Thankfully, many stress management strategies have proven to significantly reduce the negative effects of chronic distress and improve quality of life. Regular exercises, better sleep hygiene, limited access to social media/news along with daily relaxation and meditation practices (e.g., deep breathing, mindfulness, yoga) can help build resilience and improve hearing health. Seeking professional counseling may also be recommended for patients struggling with addiction, chronic pain, relationship problems, and poor overall well-being.
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