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When Depression and Hearing Loss Collide

Reprinted with permission from The Hearing Review and Medical World Communications, Los Angeles, March 2001 (v. 8, no. 3), pgs. 74-79. All rights reserved.

WHO IS AFFECTED?

An alarming 22.1 percent of Americans ages 18 and older suffer from some diagnosable mental disorder in a given year [1], including depression. "Major depressive disorder," a medical illness, is the leading cause of disability in the United States and established market economies worldwide [2] and ranks second only to ischemic heart disease in magnitude of disease burden [3].

While depression can develop at any age, the average age at onset is the mid-20s [4], and in the US, about twice as many women as men are affected by depressive disorders [1]. Population estimates based on the most recent US Census revealed approximately 18.8 million American adults, or just under 10 percent of the population age 18 and over, have a depressive disorder [5]. The burden of mental illness on health and productivity in the US is more than the disease burden caused by all cancers [3].

All of us from time to time, and at all ages, experience a low moment, a passing period of the blues, a dark mood, or perhaps an empty feeling. This is common when attributable to the loss of a loved one, a divorce, disappointment or any of a multitude of possibilities. When this sadness does not subside, nor is quelled by any standard means through enjoyments in life, it is a warning sign of depression.

As we age, our circle of friends narrows. Older adults especially find that friends and family members pass on and personal health problems restrict activities that were once routine and added to the social enjoyment of life. Research indicates that as health problems increase, the risk of depression increases. While it is common to develop health problems as we age, it appears that we have grown accustomed to expect depression as part of the process. However, the fact is depression is not a natural part of aging. Depression often can, and indeed does cause more rapid deterioration in health, as you will see.

Depression can stand alone as an illness, or be a result of a wide range of health problems. Table 1 (below) shows a variety of diseases with the percentage of depression associated with each condition. Hearing loss is notably missing. This is because there is not adequate data in research studies from which to draw. What we do know, however, is that hearing loss causes depression in many people. In addition, while hearing aids do act to reduce depression for many, the remaining communication struggles can make depression a perpetual problem.

To further complicate the matter, hearing loss may be only one of several "co-occurring" bases for depressionthat is, simultaneously-occurring medical conditions. Hence, the link between depression and other medical conditions, may not be well recognized by you or your physician.

SYMPTOMS

There are many symptoms of depression. Table 2 (below) reveals most of them. You will note that three characteristics; hopelessness, social isolation and an absence of pleasures or joys in life, are factors often found in hard of hearing people. Of course, when these conditions arise, they do so in many varying degrees of impact.

The data provided above is drawn from the general population. The prevalence among those with hearing loss suffering from some degree of chronic depression could be even higher because of the emotionally charged state that hearing loss can precipitate. Furthermore, if hearing loss is a condition many feel compelled to hide, surely "mental illness" remains a stigma for even greater secrecy. The reasons are self-evident.

TYPES OF DEPRESSION

Depression is a mood disorder and is a highly complex issue. Nonetheless, some generalities can be described and addressed. Depression can be divided into three general types: major depressive disorder, dysthymic disorder and bipolar disorder. These can separated into many different degrees and diagnostically significant features, which are beyond the scope of this article.

Major depressive disorder is characterized by at least two weeks of depression in conjunction with several additional symptoms of depression (see Table 2).

Dysthymic disorder is generally a less severe but more chronic form of depression, and must be present for "more days than not" over at least two years. There is some evidence that suggests it is more common in younger than older adults. Approximately 5.4 percent of Americans age 18 and older are affected during their lifetime, which translates to almost 11 million American adults [1]. About 40 percent of this group also meets the criteria for major depressive disorder or bipolar disorder.

Bipolar disorder, also known as manic depression, is characterized by wide mood swings from depression to mania and variations between. Approximately 2.3 million American adults are affected [5]. The average age for a first manic episode is in the early 20s, and men and women are affected equally [4].

RATES OF NONCOMPLIANCE

The rate of noncompliance for those diagnosed with depression and dispensed medications is alarming. One resource reported that depressed patients are 3 times more likely not to adhere to treatment recommendations than were non-depressed patients. Depression occurs in 25 percent of individuals undergoing medical treatment, and about half of all medical patients in the US do not comply with treatment recommendations [6].

Depression is a serious factor worthy of consideration, and something seldom discussed in medical/audiologic consultations. There is evidence to show that with increased hearing loss there is a probability of increased depression. However, the degree to which this depression develops into a major depressive episode remains unknown

There can be many different human reactions to a single identical medical diagnosis. One person may get depressed, another may seek and find skillful coping mechanisms. One person may be highly compliant with medication, another fully noncompliant. However, when hearing loss co-occurs with a serious health condition, a persons ability to cope with the stresses and issues around living with hearing loss can become greatly challenged (impaired communication, diminished music appreciation, lowered self-esteem, and so forth). Concluding that depression is linked to hearing loss is only valid when other life circumstances (such as the death of a loved one) or co-occurring medical conditions (such as cancer) can be ruled out.

The Internet can be an enlightening resource for anyone suffering from depression. Table 3 lists many good websites for exploration. However, please keep in mind, you need to know the source of the information. If you expect guidance from any website, look for the credentials of "the experts" and the source of the website itself. You should ask yourself if the source is credible and reliable. Is the information factual? Are they trying to sell you something? These and other questions will help you determine the validity of what you read on the Internet.

Some websites offer screening tools and tests for depression. One worthwhile such site is http://www.med.nyu.edu/Psych/screens/depres.html.. The results are made available to you as quickly as you submit it for scoring. The NYU website offers a good option for addressing depression, and reassurance that a depressive state will be quickly discovered.

THE NEED FOR DIAGNOSIS

It is common for older adults to spend a lot of time alone. Many are divorced or widowed. It is important that solitude for elder Americans does not turn into isolation, and ultimately depression. We know that hearing loss has the potential to drive some people into isolation, but the most vulnerable are older adults, due to coexisting health conditions.

A survey of 667 general practitioners has revealed that many seniors are inadequately treated for depression [7]. This suggests that many health care providers may have difficulty recognizing depression in older adults in the context of multiple health problems. Unfortunately, inadequate treatment can and does lead to death in a number of cases.

In one long-term study of 5201 participants, depressive symptoms in older adults were associated with a greater risk of death [8]. In another study, among 1551 people who were free of heart disease, those who had a history of depression were four times more likely to have a heart attack within fourteen years than subjects not depressed [9]. Both studies are examples of the profound life-threatening impact depression can have on older adults.

Another factor needs to be recognized: older Americans are disproportionately more likely to commit suicide. In fact, major depression is a significant predictor of suicide in older adults. It is common for most suicide victims to be seen by their physicians within thirty days of their suicide. This is not coincidental. They undoubtedly were searching for answers they could not find: perhaps they did not know how to ask for help; when they saw their physician they may have become more aware of their problematic health; or their prior knowledge was reinforced, and their hopes vanquished (that is, realizing the limits of medical help).

CONCLUSIONS

There is no question that depression combined with hearing loss and multiple co-existing medical conditions poses very serious risks. There is ample evidence that the more serious the depression, the greater the risk to declining health. In one study of 1286 persons age 71 years and older, severity of depressive symptoms predicted subsequent decline in physical performance [10].

To emphasize how important it is for patients depressed over hearing loss to discuss it with an audiologist, a physician, their family, counselor or therapist, one study has discovered that social support has been found to be more positively impacting on major depressive illness than were severity of illness or family history.


Depressive disorders appear to be occurring earlier in life. With the aging population of the world, it is projected that by 2020, mental illness will increase its present burden on society by 50 percent [3].

There is compelling evidence that depression affects both mind and body. Research has shown through various techniques of brain imaging, that recurrent depression can alter brain chemistry. Therefore, it is efficacious to identify symptoms of depression early. Through brain imaging techniques, according to the National Institute of Mental Health, "We are now at the dawn of an era when we cansee pathways in the brain that underlie emotions."

RECOMMENDATION

We need to begin "talking" with others (social support) about feelings of depression over hearing loss. Depression co-existing with hearing loss is a common occurrence. Once one finds resources, friends and professionals to turn to, treatment is 80 percent effective [11]. If you do not open this doorway to communication exchange, it is unlikely to be opened for you. The therapeutic value of a discussion of your feelings including depression, by audiologists trained and confident in addressing it, goes a long way toward adjustment and healing from depression over hearing loss. You should also feel comfortable requesting a referral for therapy if you feel you could benefit.

Editors NOTE: Dr. Richard Carmen is an audiologist in Sedona, Arizona. He has authored many articles on the emotional impact of hearing loss. His book, "The Consumer Handbook on Hearing loss & Hearing Aids: A Bridge to Healing" is recognized by his peers as a definitive patient and professional guide on these topics. The book was published in 1998 by Auricle ink Publishers.

ACKNOWLEDGMENTS:

Parts of this article were previously published in the Hearing Review, Vol 8, No 3, pp 74-79, March, 2001.

Additionally, a previous version of this article was published in, and is used with permission from, Hearing Health magazine.http://www.hearinghealthmag.com.

We are grateful to both publishers and the author for allowing us to re-edit and re-publish this article in the current format. ---Editor

REFERENCES

1. Reiger DA, Narrow WE, Rae DS, et al. The de facto mental and addictive disorders service system. Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry, 1993;50(2):85-94.

2. Klerman GL, Weissman MM. Increasing rates of depression. JAMA, 1989;261(15):2229-35.

3. Murray CJL, Lopez AD, eds. The global burden of disease and injury series, volume 1: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Cambridge, MA: Published by the Harvard School of Public Health on behalf of the World Health Organization and the World Bank, Harvard University Press, 1996.

4. Amer Psychiatric Assn. Diagnostic and Statistical Manual for Mental Disorders, fourth edition (DMS-IV). Washington, DC: American Psychiatric Press, 1994.

5. In NIH publication No. 99-4584: Narrow WE. One-year prevalence of depressive disorders among adults 18 and over in the U.S.: NIMH ECA prospective data. Population estimates based on the US census estimated residential population age 18 and over on July 1, 1998: unpublished.

6. DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment. Arch Intern Med 2000;160(14):2101-07.

7. Orrell M, Collins E, Shergill S, et al. Management of depression in the elderly by general practitioners: I. Use of antidepressants. Fam Pract 1995;12(1):5-11.

8. Schultz R, Beach SR, Ives DG, et al. Association between depression and mortality in older adults. Arch Intern Med 2000;160(12):1761-68.

9. Frasure-Smith N, Lesperance F, Talajic M. Depression and 18-month prognosis after myocardial infarction. Circulation 1995;91(4):999-1005.

10. Penninx BH, Guralnik JM, Ferrucci L, et al. Depressive symptoms and physical decline in community-dwelling older persons. JAMA 1998;279(21):1720-1726.

11. Little JT, Reynolds CF III, Dew MA, et al. How common is resistance to treatment in recurrent, nonpsychotic geriatric depression? Amer J of Psychiatry 1998;155(8):1038-8.

Opinions, facts and thoughts expressed in this article are those of the author(s) only. These opinions, facts and thoughts may or may not relate to you as a consumer, and/or patient. Therefore, we strongly urge you to seek the advice and opinion of your licensed hearing healthcare provider to determine how this article may/may not relate to you and your specific needs. Only after obtaining your case history and performing a physical examination, can a licensed health care provider can make specific recommendations for you.

Reprinted with permission from the Fall 2001 issue of Hearing Health magazine. For more information about Hearing Health: http://www.hearinghealthmag.com

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