Do you need a nexus letter for depression or anxiety due to your already service connected tinnitus? Dr. Finnerty would be happy to review your medical records and the associated scientific literature.
Sample nexus letter evidence/ scientific research related to depression and anxiety secondary to tinnitus Dr. Finnerty may use:
As noted by Baguley, et. al., “tinnitus is a common medical symptom that can be debilitating. Risk factors include hearing loss, ototoxic medication, head injury, and depression. At presentation, the possibilities of otological disease, anxiety, and depression should be considered. No effective drug treatments are available, although much research is underway into mechanisms and possible treatments. Surgical intervention for any otological pathology associated with tinnitus might be effective for that condition, but the tinnitus can persist. Available treatments include hearing aids when hearing loss is identified (even mild or unilateral), wide-band sound therapy, and counselling. Cognitive behavioural therapy (CBT) is indicated for some patients” [Baguley D, McFerran D, Hall D. Tinnitus. Lancet. 2013 Nov 9;382(9904):1600-7. doi: 10.1016/S0140-6736(13)60142-7]. Tinnitus can be described as hearing something that isn’t there (though not voices or other things which tend to be more associated with psychiatric disturbances such as psychosis or neurological diseases other than those leading to tinnitus). Tinnitus can lead to significant distress, and it is notable that cognitive behavioral therapy, a mental health treatment, is an evidence based approach for dealing with tinnitus. Tinnitus can lead to emotional distress including hypervigilance, excessive self-monitoring and attention to tinnitus sounds and sensations. It can lead to persistent worry, rumination and hopelessness about tinnitus and lead to avoidance and withdrawal from many situations. Tinnitus and the associated distress can impair functioning such as in the ability to relax, get a good night’s sleep and concentrate effectively. Veterans can have difficulties habituating to tinnitus symptoms. Tinnitus can lead to mental health symptoms which then can further worsen the distress associated with tinnitus in a vicious cycle.
There is extensive support in the research literature for a significant connection between tinnitus and anxiety and depression.
We know that “tinnitus symptoms are closely associated with anxiety, depression, shorter sleep duration, and greater workdays missed” [see Jay M. Bhatt MD Neil Bhattacharyya MD, FACS Harrison W. Lin MD (2017) Relationships between tinnitus and the prevalence of anxiety and depression; The Laryngoscope (127)2, 466-469].
Halford & Anderson noted “one hundred and twelve members of a tinnitus self-help group completed psychological and tinnitus questionnaires. In line with prior studies, we found that tinnitus was associated with elevated anxiety trait and depression” [see Halford, Jonathan & Anderson, Stewart (1991) Anxiety and depression in tinnitus sufferers; Journal of Psychosomatic Research (35)4-5, pgs 383-390].
Per Zöger, et. al., “a close association between tinnitus and psychiatric disorders has been demonstrated…” The authors note “various measures found significant correlations between the severity of tinnitus and the severity of depression and anxiety. We conclude that the severity of tinnitus is associated with psychiatric disorders, as well as with the severity of anxiety and depression in tinnitus patients…” [see Sigyn Zöger M.D. Jan Svedlund M.D., Ph.D. Kajsa-Mia Holgers M.D., Ph.D. (2006) Relationship Between Tinnitus Severity and Psychiatric Disorders. Psychosomatics, (47)4, 282-288].
We know from some research that “there is a direct correlation between duration of tinnitus and severity of stress…” and that “depression, anxiety and stress should be taken into consideration in the treatment of patients suffering from tinnitus.” [see Gomaa, M.A.M., Elmagd, M.H.A., Elbadry, M.M. et al. Depression, Anxiety and Stress Scale in patients with tinnitus and hearing loss. Eur Arch Otorhinolaryngol 271, 2177–2184 (2014)]. The estimated loudness and pitch has not been shown to be “associated with the impact, or bothersomeness, of tinnitus” per Manning, etl al. [see Manning C, Thielman EJ, Grush L, Henry JA. Perception Versus Reaction: Comparison of Tinnitus Psychoacoustic Measures and Tinnitus Functional Index Scores. Am J Audiol. 2019 Apr 22;28(1S):174-180]. Likewise, Meikle, et. al. found no correlation between rated severity and the loudness of tinnitus (obtained by a loudness balance procedure using external sounds matching the tinnitus pitch), or the type, quality, or pitch of tinnitus sound heard. However, severity ratings were highly correlated with incidence of sleep disturbance [Meikle MB, Vernon J, Johnson RM. The perceived severity of tinnitus. Some observations concerning a large population of tinnitus clinic patients. Otolaryngol Head Neck Surg. 1984 Dec;92(6):689-96]. Reactions to tinnitus leading to distress including anxiety, depression and insomnia can lead to significant impairment. It is also clear from the evidence that tinnitus can lead to mental health symptoms, and this reflects a situation where impairment and distress is likely.
Tinnitus can be linked with the research related to chronic pain [see Møller AR. Tinnitus and pain. Prog Brain Res. 2007;166:47-53]. The Veteran has experienced mental health difficulties which are also linked to pain. This is consistent with what we know about the impact of chronic pain on the development of psychological symptoms. It is well-known that chronic pain leads to depression. This is supported by the research literature. Sheng, et. al. (2017) [see The Link between Depression and Chronic Pain: Neural Mechanisms in the Brain; Neural Plasticity; 2017: 9724371] noted “chronic pain, as a stress state, is one of the critical factors for determining depression, and their coexistence tends to further aggravate the severity of both disorders.” The authors note that “In recent years, studies have found considerable overlaps between pain- and depression-induced neuroplasticity changes and neurobiological mechanism changes. Such overlaps are vital to facilitating the occurrence and development of chronic pain and chronic pain-induced depression.” The authors note that “pain and depression are closely correlated from the perspectives of both brain regions and the neurological function system, whereby chronic pain may lead to depression. One of the important causes for chronic pain leading to depression appears to be the crucial effect of common neuroplasticity changes on the occurrence and development of the two disorders in question.” Different aspects of pain negatively affect several depression outcomes. Increasing pain severity, pain that interferes with daily activities, frequent pain episodes, diffuse pain, and pain that is refractory to treatment are all associated with more depressive symptoms and more severe depression. Additionally, as pain severity worsens, other depression outcomes such as functional limitations, health-related quality of life, and work function are adversely affected. Pain with comorbid depression also appears to be additive in terms of an increased number of medical visits and higher health care costs. The prognosis of comorbid depression and pain is poor compared with the prognosis for individuals with depression without pain. Depression complicates the management of patients with pain and is associated with poorer outcomes. In patients with pain, depression is associated with more pain complaints, greater pain intensity, longer duration of pain, and greater likelihood of nonrecovery. Additive impairments in social function, work function, and functional limitations (eg, limited mobility and restricted activity) are seen when depression and pain coexist. Depression also predicts increased health care utilization, poorer adherence to treatment, worse patient satisfaction, and future episodes of pain. The combination of depression and pain is associated with worse clinical outcomes than either condition alone [see Bair, et. al. (2003) Depression and Pain comorbidity: a literature review; Archives of Internal Medicine; 163(20)2433-2445].
Research Links:
There is extensive support in the research literature for a significant connection between tinnitus and anxiety and depression; this includes, but is not limited to:
- Berthold Langguth, Verena Hund, Michael Landgrebe, and Martin Schecklmann (2017) Tinnitus Patients with Comorbid Headaches: The Influence of Headache Type and Laterality on Tinnitus Characteristics; Frontiers in Neurology, 8:440. “The main findings of this study are that tinnitus patients with comorbid headache have higher scores in TQs, a lower quality of life and more frequently comorbidities such as painful sensation to loud sounds, vertigo, neck pain, TMJ complaints, general pain, and depressive symptoms when compared with tinnitus patients without headaches. The higher impairment in quality of life in patients who suffer from both tinnitus and headache can be easily explained by a pure additive effect of both disorders on disease burden.”
- Jay M. Bhatt MD Neil Bhattacharyya MD, FACS Harrison W. Lin MD (2017) Relationships between tinnitus and the prevalence of anxiety and depression; The Laryngoscope (127)2, 466-469. “Tinnitus symptoms are closely associated with anxiety, depression, shorter sleep duration, and greater workdays missed.”
- Gomaa, M.A.M., Elmagd, M.H.A., Elbadry, M.M. et al. Depression, Anxiety and Stress Scale in patients with tinnitus and hearing loss. Eur Arch Otorhinolaryngol 271, 2177–2184 (2014). “There is a direct correlation between duration of tinnitus and severity of stress… In conclusion, depression, anxiety and stress should be taken into consideration in the treatment of patients suffering from tinnitus.”
- Halford, Jonathan & Anderson, Stewart (1991) Anxiety and depression in tinnitus sufferers; Journal of Psychosomatic Research (35)4-5, pgs 383-390. “One hundred and twelve members of a tinnitus self-help group completed psychological and tinnitus questionnaires. In line with prior studies we found that tinnitus was associated with elevated anxiety trait and depression.”
- Sigyn Zöger M.D. Jan Svedlund M.D., Ph.D. Kajsa-Mia Holgers M.D., Ph.D. (2006) Relationship Between Tinnitus Severity and Psychiatric Disorders. Psychosomatics, (47)4, 282-288. “A close association between tinnitus and psychiatric disorders has been demonstrated…” The authors note “various measures found significant correlations between the severity of tinnitus and the severity of depression and anxiety. We conclude that the severity of tinnitus is associated with psychiatric disorders, as well as with the severity of anxiety and depression in tinnitus patients…”
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