Abstract
Objective:
To assess relations between tinnitus and suicidality, measured by suicidal ideation and suicide attempts.
Data Sources:
CINAHL, Cochrane Library, PubMed, PsycINFO, and SCOPUS databases were searched from inception through June 14, 2024.
Review Methods:
Observational studies related to suicidality in tinnitus patients at least 18 years old were included. Case reports and studies on objective or pulsatile tinnitus were excluded. Two authors extracted data, and disagreements were resolved with a third party if needed. The risk of bias was assessed according to the Risk Of Bias In Non-randomized Studies of Exposure for cohort studies and the Joanna Briggs Institute critical appraisal checklist for cross-sectional studies. Random effects meta-analyses (single means, proportions, and relative risks (RR)) were used for primary analysis.
Results:
Nine studies (n = 912,013) pertaining to suicidality and tinnitus in an adult population were included. The tinnitus group experienced a significantly higher prevalence of suicidal ideation (19.5% [95% CI: 12.9%—27.1%] versus 9.9% [95% CI: 7.1%–13.2%]) and suicide attempts (1.9% [95% CI: 0.1%—5.7%] versus 0.9% [95% CI: 0.0%–3.9%]) than the control population (p < 0.0001). The tinnitus group had a significantly (p < 0.001) higher risk of suicidal ideation (RR = 2.1, 95% CI: 1.6–2.8) and suicide attempts (RR = 1.8, 95% CI: 1.3–2.4) than the control group.
Conclusion:
Nearly one in five people with tinnitus will experience suicidal ideation, and nearly 2% will attempt suicide. Thus, otolaryngologists should be mindful of the increased risk of suicidality in patients with tinnitus.
Keywords: meta-analysis, quality of life, systematic review, tinnitus
1 |. Introduction
Tinnitus is defined as the perception of sound without a corresponding auditory source. It affects 8%–25.3% of people in the U.S. and up to 30% of people worldwide, with its impact ranging from mild annoyance to a debilitating condition with significant physical and psychiatric consequences [1]. Treatment typically focuses on rehabilitating underlying hearing loss and reducing distress through masking, habituation, and behavioral-based therapies such as Cognitive Behavioral Therapy (CBT) or Acceptance and Commitment Therapy (ACT) [2–5]. While newer treatments, including multi-modality stimulation, have shown promise for improving tinnitus burden for some patients, there is no reliable cure [6].
Tinnitus comorbidities are many and varied and include conditions such as anxiety, depression, insomnia, and excessive day-time drowsiness, all of which reduce a patient’s health-related quality of life [7]. Many individuals with tinnitus report a sense of hopelessness regarding their condition. Hopelessness and helplessness are well-known contributors to suicidality, and medical conditions perceived as incurable further elevate suicide risk [8]. This risk is magnified by chronicity, work disability, and withdrawal from previously enjoyed social activities, which are well-established consequences of both hearing impairment and tinnitus [9].
Suicide is a leading cause of death across the lifespan, and for every person who dies by suicide, many more attempt suicide [10]. Suicidality, a complex and multi-faceted concept, encompasses suicidal ideation, suicide attempts, and death by suicide. Suicidal ideation—the passive or active thought of ending one’s own life—is a leading risk factor for death by suicide and often precedes suicide attempts [10]. For this reason, understanding the prevalence of all forms of suicidality in those with tinnitus is essential.
Many features of tinnitus, including its chronicity, severity, and associated disability, align with established suicide risk factors. However, whether tinnitus acts as a risk factor for suicidality remains unclear. In this systematic review and meta-analysis, we aim to quantify the association between tinnitus and suicidality by examining the prevalence and strength of this relationship for suicidal ideation and suicide attempts.
2 |. Methods
2.1 |. Data Collection and Selection
This study is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [11]. Our PICO question was whether adults with tinnitus experience increased suicidality compared to adults without tinnitus, and we hypothesized that adults with tinnitus will experience increased suicidality. Prior to conducting our search, we registered our review protocol on PROSPERO (CRD42024557200). PubMed (National Library of Medicine—National Institutes of Health), Scopus (Elsevier), CINAHL Complete (EBSCOhost), PsycINFO (American Psychological Association), and Cochrane Library (Wiley) databases were searched from inception through June 13, 2024 by authors L. R.M. and M.K.S. Specific search strategies were used for each database with a combination of medical subject headings and the following key words: tinnitus, suicide, mental health, anxiety, depression, self-harm, and mental illness. An example of a complete search strategy is provided in the (Data S1). Reference lists of relevant articles were also searched. References were uploaded to Covidence (Veritas Health Innovation Ltd. Melbourne, Australia). Authors L.R.M. and M.K.S. independently reviewed the titles and abstracts for relevance and screened full texts for inclusion, along with any disagreements resolved through discussion.
2.2 |. Selection Criteria
Observational studies with the primary objective of examining suicidality and mental illness in patients at least 18 years old with tinnitus were included. Non-English language papers, studies of nonhuman subjects, abstracts, and unpublished studies were excluded. Case studies and case reports were excluded.
We excluded studies on objective or pulsatile tinnitus, since these distinct subtypes of tinnitus have etiologies and treatments that differ from the subjective non-pulsatile tinnitus that is the focus of this review. We also excluded studies that combined data from adult and pediatric populations without stratifying outcomes based on age.
2.3 |. Data Extraction
Study and cohort characteristics were extracted. Mental health outcomes, including the prevalence of depression, suicidal ideation, and suicide attempts, were also extracted. All data extraction was performed by authors L.R.M. and M.K.S., and conflicts were resolved by discussion and a third author (S.A.N.) if needed. The level of evidence for each selected article was evaluated using the Oxford Centre for Evidence-Based Medicine criteria [12].
2.4 |. Quality Assessment
The risk of bias was assessed according to the Risk Of Bias In Non-randomized Studies—of Exposure (ROBINS-E) [13] for cohort studies and the Joanna Briggs Institute (JBI) critical appraisal checklist for cross-sectional studies [14]. Each aspect of the risk of bias for ROBINS-E was assigned a grade of low, unclear, or high. The JBI cross-sectional checklist has 8 questions and was scored out of 8. Each question in the JBI was given a score of “1” for “yes” and “0” for “no,” “not applicable,” or “unclear.” A score of 4 or higher on the checklist was considered at low risk for bias. One author (M.K.S.) performed a risk assessment on all studies included in the meta-analysis while another author (L.R.M.) checked their work for accuracy. Disagreements were resolved by way of a third author (S.A.N.). Risk of bias items included the following: inclusion criteria, selection bias, measure of exposure, confounding factors, validity and reliability of outcome measures, appropriate statistical analysis, and other criteria.
2.5 |. Statistical Analysis
Data were quantitatively synthesized to generate pooled estimates of cohort characteristics, prevalence of suicidality, and risk ratios (RR) for suicidal ideation and suicide attempts among patients who endorse tinnitus compared to patients without tinnitus. Pooled estimates were modeled with a fixed effects model when there was low inter-study variability (I2 < 50%) and a random effects model otherwise. Each measure (mean, proportion [%], risk ratio [RR] and 95% confidence interval [CI]) was weighted according to the number of patients affected.
Analyses were conducted using Cochrane Review Manager (RevMan) version 5.4 (The Cochrane Collaboration 2020, United Kingdom) and MedCalc 22.017 (MedCalc Software, Ostend, Belgium).
3 |. Results
3.1 |. Study Characteristics
After duplicates were removed, 7780 titles and abstracts were screened for inclusion. Of those studies, 186 underwent full-text review, and nine were ultimately included for analysis (Figure 1) [7, 15–22].
FIGURE 1 |.
Flowchart depicting study attrition through screening and eligibility assessments. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
The included studies were published between 1983 and 2023 and comprised 912,013 people, of which 414,631 had tinnitus. The tinnitus population was 48.2% male, with an average age of 59.6 years (range: 19–88 years). The control population was 45.2% male, with an average age of 54.3 years. The studies represented a diverse range of countries, with one from the United States [17], four from South Korea [5, 18, 20, 21], two from Sweden [16, 19], one from Taiwan [15], and one from England [22]. All nine studies included patients at least 18 years old with subjective tinnitus. A summary of study characteristics is provided in Table 1. Only one study reported the average duration of tinnitus [16], and none of the included studies reported whether participants received specific treatments for tinnitus.
TABLE 1 |.
Characteristics of included studies and patient cohorts.
| Study (year) | Country | Oxford level of evidence | Tinnitus patients (n) | Males (n) | Patient age (mean (SD); years) | Method of assessing depression | Method of assessing suicidal ideation | Method of assessing suicide attempts |
|---|---|---|---|---|---|---|---|---|
| Cheng et al. (2023) [15] | Taiwan | 3 | 386,055 | 180,545 | 50.3 (15.7) | — | — | ICD-9 or ICD-10 codes |
| Erlandsson and Persson (2006) [16] | Sweden | 3 | 70 | 45 | 49 | — | Item 9 on BDI | Self-reported; unspecified time period |
| Fox-Thomas (2016) [17] | United States | 4 | 200 | 128 | 59 | — | Item 24 on TRQ | — |
| Joo et al. (2015) [15] | South Korea | 4 | 426 | 223 | 66.8 (0.9) | CIDI-SF | Self-reported prevalence over 1 year | — |
| Han et al. (2019) [18] | South Korea | 4 | 6391 | 2495 | — | CIDI-SF | Self-reported prevalence over 1 year | — |
| Lugo et al. (2019) [19] | Sweden | 4 | 16,066 | 8507 | — | — | — | Self-reported; unspecified time period |
| Park et al. (2022) [20] | South Korea | 4 | 1402 | 571 | 69.5 (0.2) | CIDI-SF | Self-reported prevalence over 1 year | — |
| Seo et al. (2016) [21] | South Korea | 4 | 3949 | — | 48.3 (0.4) | CIDI-SF | Self-reported prevalence over 1 year | Self-reported; unspecified time period |
| Tyler and Baker (1983) [22] | England | 3 | 72 | 22 | 63 (7.4) | — | Self-reported; unspecified time period | — |
Abbreviations: BDI, Beck Depression Inventory; CIDI-SF, Composite International Diagnostic Interview–Short Form; ICD, international classification of diseases; TRQ, Tinnitus Reaction Questionnaire.
3.2 |. Quality Assessment
Based on the Oxford Level of Evidence criteria, the three cohort studies are level 3 evidence [15, 16, 22]. The remaining six studies, all cross-sectional, are level 4 evidence [7, 17–21]. Critical appraisal of non-randomized studies (Figure 2) indicated an overall acceptably low risk of bias. JBI appraisal of the cross-sectional studies showed that all studies had a score of 5 or higher, suggesting good quality and low risk of publication bias (Figure 3).
FIGURE 2 |.
Risk of bias assessment. Proportions of studies assigned to each risk category for individual bias items are presented, as assessed using the ROBINS-E tool. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
FIGURE 3 |.
Risk of bias summary for all studies assessed with the JBI Critical Appraisal Tool. “Yes,” “No,” and “Unclear” are responses to the questions listed in the bottom half of the figure for each study. The overall score is the sum of the number of “Yes” responses. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
3.3 |. Incidence Rate of Suicidality Among Patients With Tinnitus
A large cohort study of veterans treated at the Veterans Health Administration (VHA) could not be included in the current meta-analysis since its results were reported as incidence rate ratios with insufficient data to pool with other studies [23]. Among the 116,358 veterans with a recorded diagnosis of tinnitus, 21% had comorbid depression, 8% had anxiety, and another 17% had both depression and anxiety. Among all patients who received health care at the VA, the death rate due to suicide was 32.0 per 100,000 person-years, compared to 26.9 for patients with tinnitus. Patients with tinnitus were further stratified based on comorbid mental health conditions, and the suicide rate per 100,000 person-years was 24.5 with anxiety, 40.9 with depression, 39.5 with depression and anxiety, and 15.9 with no mental health comorbidities.
3.4 |. Prevalence of Suicidality Stratified by Tinnitus Severity
Three studies reported the prevalence of suicidal ideation stratified by tinnitus severity [17, 19, 21]. Fox-Thomas (2016) reported suicidal ideation across TRQ categories. The prevalence of suicidal ideation over the past week was 0%, 0%, 5%, 20%, 39%, and 49% for not significant, significant, mild, moderate, severe, and profound, respectively [17]. Among the total population of people with tinnitus, Lugo et al. (2019) found a suicide attempt rate of 4.4% for any tinnitus compared to 3.1% for no tinnitus, 3.4% for clinically diagnosed tinnitus, and 7.2% for severe tinnitus [19]. Seo et al. (2016) asked patients to rank their tinnitus severity on a Likert scale with the following options: “not annoying; annoying; irritating; severely annoying and causes sleep problems.” When comparing patients with tinnitus who had attempted suicide to those who reported suicidal ideation with no history of suicide attempts, Seo et al. (2016) found a higher prevalence of self-reported severely annoying (6.0% vs. 1.7%) and irritating (11.8% vs. 10.3%) tinnitus among those who had attempted suicide [21].
3.5 |. Prevalence of Suicidality Stratified by Sex
Three studies included data on the prevalence of suicidality by sex [17–19]. In Fox-Thomas (2016), 18.0% of females expressed suicidal ideation, compared to 14.8% of males [17]. In Lugo et al. (2019), there was a higher prevalence of suicide attempts among women compared to men for all patients with tinnitus (5.7% vs. 3.2%), those with clinically diagnosed tinnitus (4.0% vs. 3.5%), and those with severe tinnitus (9.4% vs. 5.5%) [19]. In addition, Han et al. (2019) found that female sex was a shared risk factor among tinnitus, depressive mood, and suicidal ideation (p < 0.05) [18].
3.6 |. Measures of Depression and Suicidality
Four studies used modified versions of the World Health Organization (WHO) Composite International Diagnostic Interview-Short Form (CIDI-SF), a validated screening instrument for 12-month prevalence of depression [7, 18, 20, 21]. Three studies assessed suicidal ideation by asking participants whether they had considered suicide in the past 12 months [7, 18, 20]. One study asked patients an open-ended question about their negative experiences with tinnitus [22]. One study administered the Beck Depression Inventory (BDI) [16], and another used the Tinnitus Reaction Questionnaire (TRQ) [17], both of which have a question related to suicidal ideation. Three studies collected self-reported data on suicide attempts [16, 19, 21], and one study determined the history of suicide attempts using ICD codes (Table 1) [15].
3.7 |. Meta-Analysis of Association Between Tinnitus and Depression
Patients with tinnitus experienced a significantly higher 12-month prevalence of depression (14.5% [95% CI: 5.3%–27.2%] vs. 7.2% [95% CI: 2.7%–13.6%]) than the control group (p < 0.0001). As demonstrated in Figure S1, patients with tinnitus had a significantly higher risk of developing depression than the control population (RR = 2.3, 95% CI: 1.3–4.0).
3.8 |. Meta-Analysis of Association Between Tinnitus and Suicidality
The prevalence of suicidal ideation was reported by seven studies (Figure 4) [7, 16–18, 20–22]. Among patients with tinnitus (pooled n = 8489), 19.5% (95% CI: 12.9%–27.1%) reported suicidal ideation. This was significantly different (Δ: 9.6%; 95% CI: 8.7%–10.5%; p < 0.0001) than the control population (n = 55,851), which had a 9.9% (95% CI: 7.1%–13.2%) prevalence of suicidal ideation (RR = 2.1, 95% CI: 1.6–2.8). Since the prevalence of suicidal ideation among patients with tinnitus was reported over different time periods, subgroup analyses were conducted. Among the four studies that reported one-year prevalence [7, 18, 20, 21], the prevalence of suicidal ideation was 18.8% (95% CI: 13.9%–24.2%). One study found a 30% (21 of 70) two-week prevalence of suicidal ideation [16], and another study found a one-week prevalence of 16.0% (32 of 200) [17]. Another study that did not specify the time period found a prevalence of 7% (5 of 72) [22]. Estimates of the prevalence of suicide attempts were pooled from three studies [15, 16, 19]. Patients with tinnitus (pooled n = 406,140) reported a 1.9% (95% CI: 0.1%–5.7%) prevalence of attempts, compared to 0.9% (95% CI: 0.0%–3.9%) in the non-tinnitus pooled controls (RR = 1.8, 95% CI: 1.3–2.4).
FIGURE 4 |.
Forest plot of risk ratio for suicidal ideation and suicide attempts among patients with tinnitus compared to the control population. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
4 |. Discussion
This systematic review and meta-analysis revealed that patients with tinnitus experienced a higher 12-month prevalence of depression (14.5% vs. 7.2%), suicidal ideation (19.5% vs. 9.9%), and suicide attempts (1.9% vs. 0.9%) than those without tinnitus. The tinnitus group was twice as likely as those without tinnitus to report suicidal ideation (RR = 2.1) and suicide attempts (RR = 1.8). In addition, there was a dose–response relationship between tinnitus severity and the prevalence of suicidal ideation among studies that reported a measure of tinnitus severity.
The present study addresses several limitations of the available evidence on the association between tinnitus and suicidality. Our findings support the conclusions of Tailor et al. [24] who described six studies on the association between tinnitus and suicidal ideation. Our study also expands existing knowledge by assessing the related concepts of suicide attempts and death by suicide. In addition, a recent scoping review described findings from 23 studies, including case reports, and found an association between suicidal ideation, suicidal behavior, and tinnitus. However, they included some studies with a high potential for information bias because the study population included patients who reported symptoms of tinnitus, hyperacusis, and/or hearing loss [25]. Our systematic review includes more recently published studies, reports risk ratios and comparisons of meta-proportions, excludes studies with a high potential for confounding bias, and assesses suicide attempts in addition to suicidal ideation.
Our meta-analysis found a 19.5% prevalence of suicidal ideation and a 1.9% prevalence of suicide attempts among patients with tinnitus. In comparison, the one-year prevalence of suicidal ideation and suicide attempts was 5.2% and 0.6%, respectively, in the United States in 2022 [26]. In addition, the trend in suicidality by sex among patients with tinnitus is similar to national data comparing women to men in terms of suicidal ideation (4.5% vs. 4.1%) and suicide attempts (0.6% vs. 0.5%) [27]. The prevalence of suicidal ideation among people with tinnitus is also higher than that of other chronic conditions, such as migraine and inflammatory bowel disease, with rates of 15.5% and 17.3%, but lower than that of Parkinson disease, with a rate of 22.2% [28–30]. Other auditory symptoms, including hyperacusis and hearing loss, have also been shown to be associated with suicidality. One study of 150 patients with tinnitus or hyperacusis found that 13% of patients expressed suicidal or self-harm ideation over the past two weeks [31]. Another study of people with hearing symptoms of tinnitus, muffled sounds, distortion, hyperacusis, or hearing loss found that 31.0% endorsed thoughts about suicide within the past year [32].
In contrast to our meta-analysis findings, Martz et al. found a lower rate of suicide among patients with tinnitus compared to those without. Although these findings are counterintuitive, Martz et al. hypothesize that coping skills acquired from experiencing tinnitus could translate to stress management in other aspects of life. They postulate that cognitive and emotional processes that predispose patients to anxiety and depression also put them at risk for tinnitus-related annoyance, hence increasing their risk for suicide [23]. However, it is important to consider that their results may have been impacted by their data on the cause of death. For example, unintentional injury, which includes accidents (vehicular and falls), comprised 39.8% of total deaths, and some of these could have been suicides. In addition, patients with tinnitus may have experienced lower suicide rates since they were seeking care, assuming that their care helped them learn effective coping strategies [23].
We observed heterogeneity among the prevalence estimates for suicidal ideation and suicide attempts, which could have been due to different methods of measurement among studies. Although three studies asked about suicidal ideation over the past year, one study used the TRQ, which assesses suicidal ideation over the past week, and another used the BDI, which assesses suicidal ideation over the past two weeks. In addition, two studies collected self-reported data on suicide attempts, while two studies used ICD codes to determine the history of suicide attempts. The self-reported data may underestimate the prevalence of suicide attempts, given that only 45.9% of people with suicidal ideation or behavior have ever disclosed it [33]. These variations in measurement tools and reporting methods likely contribute to inconsistencies in observed outcomes across studies and the heterogeneity of the results.
This work has important clinical implications. Since patients may not disclose their distress unless prompted, it is important to screen for hearing loss and tinnitus in patients experiencing psychological distress. Referring these patients to an audiologist or otolaryngologist could potentially improve not only their hearing symptoms but also their psychological well-being.
4.1 |. Limitations and Future Work
Among the studies included, there was variability in terms of the tinnitus population, comorbidities, measurement of suicidality, and control population. The studies took place in five different countries, and the largest subset of our data comes from Taiwan and South Korea, which have among the highest suicide rates, with 16.4 and 28.6 per 100,000 persons respectively, compared to the global average of 9.2 per 100,000 persons [34–36]. In addition, two studies sampled from a specialist tinnitus clinic, and one study sampled from a tinnitus self-help organization, which may have elicited more responses from people who are highly disturbed by their tinnitus and exhibit more help-seeking behavior. Thus, these populations may have introduced sampling and response bias. In addition, many studies did not adjust for the presence or severity of depression or other mental health conditions when reporting the prevalence of suicidality, which may have introduced confounding bias. Furthermore, there are several known demographic risk factors associated with suicidality, such as age, sex, socioeconomic status, and urbanization that we were unable to account for in our meta-analysis given the data reported in the included studies.
Future investigations of patients with tinnitus could use standardized, validated tools to assess the presence of tinnitus and the prevalence of suicidality. Moreover, all studies in this review used a single question to elicit the presence of suicidal ideation or suicide attempts, which cannot effectively characterize the spectrum of thoughts and behaviors and the fluctuating nature of suicidality. There is also a need for more data on the relations between mental health comorbidities, demographic risk factors, and suicidality in patients with tinnitus to guide preventive efforts and clinical decision-making.
5 |. Conclusion
Tinnitus can negatively impact patients’ mental health and quality of life. Our study has identified that nearly one in five people with tinnitus will experience suicidal ideation, and nearly 2% will attempt suicide. The higher rates of depression and suicidality in patients with tinnitus necessitate collaboration between mental health and hearing professionals. Given that suicidality is multifactorial and complex, mental health professionals should be mindful of underlying physical conditions such as tinnitus that could contribute. In addition, audiologists and otolaryngologists should screen for psychological distress and suicidality among patients with tinnitus. To improve the collaboration of mental health and hearing professionals caring for this population, we recommend that future research assess risk factors for suicidality among patients with tinnitus.
Supplementary Material
Supporting Information
Additional supporting information can be found online in the Supporting Information section.
Acknowledgments
The authors have nothing to report.
Funding:
This work was supported (in part) by NIH grant T32 DC014435.
This work will be presented as a poster at The Triological Society 2025 Combined Sections Meeting from January 23–25, 2025 in Orlando, Florida.
Footnotes
Conflicts of Interest
The authors declare no conflicts of interest.
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