SSRI use by tinnitus patients: interactions between depression and tinnitus severity

Ear, Nose & Throat Journal, Feb, 2004 by Robert L. Folmer, Yong-Bing Shi

Abstract

Depression is often coincident with chronic tinnitus, and several studies have suggested that antidepressant medications may play a role in relieving tinnitus as well as depression. We conducted a retrospective study of the use of selective serotonin reuptake inhibitors (SSRIs) by patients at a large tinnitus clinic to assess the effects of these antidepressants on tinnitus severity. We focused on a subgroup of 30 patients with depression who had begun taking SSRI medication after the onset of their tinnitus; these patients had also been treated with psychotherapy by a mental health clinician. At a mean follow-up of 20.6 months, only 10 of the 30 patients reported that they were still experiencing major depression. Moreover, this group as a whole demonstrated a statistically significant improvement in tinnitus symptoms as reflected by a reduction in their Tinnitus Severity Index scores. We conclude that SSRIs represent one category of tools that can be used to help patients with severe tinnitus and depression. Like all antidepressant medications, SSRIs should be used in conjunction with psychotherapy to facilitate patient improvement.

Introduction

Because depression is often coincident with chronic tinnitus, (1-3) several studies have investigated the effectiveness of antidepressant medications in patients with tinnitus. Some success was reported with the tricyclic antidepressants amitriptyline (4) and nortriptyline, (5,6) but Mihail et al (7) found that trimipramine was not superior to placebo. In a 1999 review of tinnitus treatments, Dobie suggested that future studies should explore the use of the newer antidepressant drugs, such as the selective serotonin reuptake inhibitors (SSRIs). (8) SSRIs increase the availability of serotonin in the brain, which often leads to the desired effects of improving patients' mood and reducing anxiety and obsessive-compulsive tendencies. This class of medications includes citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, and venlafaxine.

There have been few published reports of clinicians using SSRIs to treat tinnitus patients. Shemen claimed that "a trial with low-dose fluoxetine (10 mg every day) completely abolished the tinnitus in all three patients within one week." (9) He went on to write, "Perhaps a double-blind study with fluoxetine should be undertaken in a center with a large number of patients with this symptom, given the encouraging result of this anecdotal report."

Christensen reported the case of a woman who switched antidepressant medications from imipramine to paroxetine. (10) "Within 8 weeks, this individual had a significant improvement in her mood disorder and a pronounced diminishment of panic attacks," he wrote. "Moreover, her tinnitus completely resolved after the 8 weeks of treatment of paroxetine at the maintenance dose of 30 mg [per] day."

Although reports of chronic tinnitus completely resolving after treatment with various medications are encouraging, such occurrences are rare. Consider two facts:

* Millions of people worldwide experience chronic tinnitus.

* Millions of people worldwide take SSRI medication daily.

Given these facts (and the relatively high prevalence of depression among tinnitus sufferers), it is logical to assume that thousands of tinnitus patients have taken SSRI medication. Yet few of these patients have reported that taking an SSRI stopped their perception of tinnitus. It is therefore unlikely that current SSRI medications represent a potential "cure" for most patients with chronic tinnitus. However, some patients do benefit from taking these medications, which can contribute to improvements in their overall condition.

In this article, we describe a retrospective study that we undertook for two reasons: (1) to obtain information on a large clinic population of tinnitus patients who took SSRIs and (2) to assess the effects of SSRIs on tinnitus severity.

Patients and methods

We reviewed the records of 957 consecutive patients who had been evaluated and treated in the Tinnitus Clinic at Oregon Health and Science University (OHSU) between 1996 and 2002. Detailed questionnaires had been mailed to all patients prior to their initial appointment. These questionnaires solicited information about each patient's medical, hearing, and tinnitus history. (11) Included were 12 questions that constitute the Tinnitus Severity Index, which is an efficient indicator of the negative impact that tinnitus has on patients (appendix). (12) Patients rated the loudness of their usual tinnitus on a scale of 1 (very quiet) to 10 (very loud). Patients were also asked if they had ever experienced depression or were currently experiencing depression. Information from these questionnaires was entered into a database known as the Oregon Tinnitus Data Registry. (13)

The initial Tinnitus Clinic visit had been conducted according to the following format:

* Members of the Tinnitus Management Team--an otolaryngologist, a neurophysiologist, and an audiologist--reviewed each patient's questionnaire and medical records prior to each patient encounter.