Abstract
This survey study evaluates whether there is an association between the sex of a patient with tinnitus and self-reported suicidal behavior.
Severe tinnitus has been shown to be strongly associated with depression and anxiety,1 and the only established approach to treat tinnitus is cognitive behavioral therapy.2 Our research group recently reported that the tinnitus-associated mental health burden is greater in women than in men, likely due to higher levels of anxiety and stress.3 Most of the evidence on the association of tinnitus with suicide came from case series studies, until a recent cross-sectional study reported that an increased risk of suicide attempts was associated with severe tinnitus.4 In the present study, we assessed whether this association would differ between men and women using data from a large population-based study, the Stockholm Public Health Cohort (SPHC).5
Methods
Study participants were adults from Stockholm County (Sweden) who participated in the 2010 version of the SPHC by completing a self-administered questionnaire. The study was approved by the Regional Ethical Review Board in Stockholm and informed written consent was obtained from all study participants. Tinnitus was assessed by the question “Do you have any of the following health problems or symptoms?” of which tinnitus was an option. Possible answers were “No; Yes (moderate problem); Yes (severe problem).” Patients with clinically ascertained tinnitus, diagnosed before 2010, were identified through record linkage with the National Patient register (International Statistical Classification of Diseases, Tenth Revision, code H93.1). Self-reports of suicide attempts were gathered by the question “Have you ever tried to take your own life? (Yes, more than a year ago; Yes, in the last year; Yes, in the last month; No, never).” Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) for lifetime suicide attempt were obtained using unconditional multiple logistic regression models after adjustment for a number of covariates, selected among the main known risk factors for both suicide attempts and tinnitus.
Results
Among 71 542 SPHC participants, 2404 (3.4%) reported having attempted suicide (Table 1). Overall, 16 066 (22.5%) respondents reported having any tinnitus, 1995 (2.8%) had severe tinnitus, and 1484 (2.1%) had been diagnosed with tinnitus by a specialist. In all, 19.8% (395) of severe cases of tinnitus had been diagnosed by a specialist. The number of suicide attempts was higher among participants with any tinnitus (multivariate OR, 1.15; 95% CI, 1.03-1.28) and among those with severe tinnitus (OR, 1.32; 95% CI, 1.04-1.66) (Table 2). This association was not observed for those with a formal diagnosis of tinnitus (OR, 0.92; 95% CI, 0.67-1.26). In stratified analyses, the association between severe tinnitus and suicide attempt remained statistically significant only in women (OR, 1.57; 95% CI, 1.17-2.10).
Table 1. Characteristics of Study Participants.
| Characteristic | Total No. | Attempted Suicide, No. (%) |
|---|---|---|
| Total study population | 71 542 | 2404 (3.4) |
| Sex | ||
| Men | 31 545 | 766 (2.4) |
| Women | 39 997 | 1638 (4.1) |
| Age, y | ||
| <35 | 11 094 | 578 (5.2) |
| 35-44 | 13 143 | 466 (3.6) |
| 45-54 | 13 252 | 495 (3.7) |
| 55-64 | 13 756 | 449 (3.3) |
| 65-74 | 12 681 | 311 (2.5) |
| ≥75 | 7616 | 105 (1.4) |
| Education level, ya | ||
| <10 | 26 583 | 1086 (4.1) |
| 10-15 | 24 660 | 812 (3.3) |
| ≥16 | 19 614 | 456 (2.3) |
| History of smokinga | ||
| Never smokers | 39 073 | 877 (2.2) |
| Former smokers | 23 350 | 815 (3.5) |
| Current smokers | 7848 | 648 (8.3) |
| Marijuana (ever use)a | ||
| No | 54 448 | 1573 (2.9) |
| Yes | 8862 | 637 (7.2) |
| Binge drinkinga | ||
| At least once per week | 6436 | 355 (5.5) |
| 2-3 times per month | 6276 | 242 (3.9) |
| Once per month | 6641 | 211 (3.2) |
| 1-6 times per year | 20 037 | 592 (3.0) |
| Never | 31 472 | 967 (3.1) |
| Alcohol consumption, g/da | ||
| 0 | 11 271 | 615 (5.5) |
| 1-5 | 10 081 | 332 (3.3) |
| 6-11 | 16 681 | 426 (2.6) |
| 12-21 | 17 494 | 415 (2.4) |
| ≥22 | 14 401 | 541 (3.8) |
| Health statusa | ||
| Very good | 15 239 | 224 (1.5) |
| Good | 35 927 | 837 (2.3) |
| Fair | 16 094 | 879 (5.5) |
| Bad/very bad | 3261 | 425 (13.0) |
| Depressiona | ||
| No | 61 261 | 1016 (1.7) |
| Yes | 9520 | 1291 (13.6) |
| Anxietya | ||
| No | 48 894 | 780 (1.6) |
| Yes | 21 607 | 1582 (7.3) |
| Headache/migrainea | ||
| No | 53 370 | 1329 (2.5) |
| Yes | 17 200 | 1025 (6.0) |
| Continuous tirednessa | ||
| No | 47 147 | 857 (1.8) |
| Yes | 23 183 | 1489 (6.4) |
| Difficulty sleepinga | ||
| No | 46 372 | 921 (2.0) |
| Yes | 24 103 | 1431 (5.9) |
| Hearing abilitya | ||
| No problems (without hearing aid) | 59 007 | 1852 (3.1) |
| No problems (with hearing aid) | 2872 | 92 (3.2) |
| Major difficulties | 9400 | 451 (4.8) |
Indicates that the sum does not add up to the total because of missing values.
Table 2. Association of Tinnitus With Attempted Suicide in the Study Populationa.
| Tinnitus Status | Total | Men | Women | ||||||
|---|---|---|---|---|---|---|---|---|---|
| No. | Attempted Suicide, No. (%) | OR (95% CI) | No. | Attempted Suicide, No. (%) | OR (95% CI) | No. | Attempted Suicide, No. (%) | OR (95% CI) | |
| Any | |||||||||
| No | 55 476 | 1700 (3.1) | 1 [Reference] | 23 038 | 491 (2.1) | 1 [Reference] | 32 438 | 1209 (3.7) | 1 [Reference] |
| Yes | 16 066 | 704 (4.4) | 1.15 (1.03-1.28)b | 8507 | 275 (3.2) | 1.08 (0.90-1.30) | 7559 | 429 (5.7) | 1.19 (1.03-1.36)b |
| Severe | |||||||||
| No | 55 476 | 1700 (3.1) | 1 [Reference] | 23 038 | 491 (2.1) | 1 [Reference] | 32 438 | 1209 (3.7) | 1 [Reference] |
| Yes | 1995 | 144 (7.2) | 1.32 (1.04-1.66)b | 1121 | 62 (5.5) | 0.98 (0.67-1.44) | 874 | 82 (9.4) | 1.57 (1.17-2.10)b |
| Clinically Diagnosed | |||||||||
| No | 70 058 | 2348 (3.4) | 1 [Reference] | 30 912 | 744 (2.4) | 1 [Reference] | 39 146 | 1604 (4.1) | 1 [Reference] |
| Yes | 1484 | 56 (3.8) | 0.92 (0.67-1.26) | 633 | 22 (3.5) | 0.97 (0.58-1.63) | 851 | 34 (4.0) | 0.87 (0.58-1.29) |
| Total | 71 542 | 2404 (3.4) | NA | 31 545 | 766 (2.4) | NA | 39 997 | 1638 (4.1) | NA |
Abbreviations: CI, confidence interval; NA, not available; OR, odds ratio.
Odds ratios were estimated using unconditional multiple logistic regression models after adjustment for sex (men or women), age (<35, 35-44, 45-54, 55-64, 65-74, or ≥75 years), education (<10, 10-15, or ≥16 years), smoking status (never, former, or current smoker), ever use of marijuana (yes, no, or missing data), frequency of binge drinking (5 categories), consumption of alcohol (5 categories), self-reported health status (very good, good, fair, bad, or very bad), anxiety (yes or no), headache or migraine (yes or no), continuous tiredness (yes or no), difficulty sleeping (yes or no), self-reported diagnosis of depression (yes or no), and hearing ability (no problems without hearing aid, no problems with hearing aid, or major difficulties).
Indicates statistically significant estimates.
Discussion
This study used the SPHC as a resource for population-based research on tinnitus in Sweden, where it is highly prevalent. The association between tinnitus and suicide attempts may be similar to that of chronic pain, because the 2 conditions may have similar neurological bases.6 Severe tinnitus was associated with suicide attempts in women but not in men, suggesting that different pathophysiological mechanisms may operate in each sex. Moreover, individuals who had been diagnosed with (and possibly treated for) tinnitus were not at increased risk according to the data, suggesting that medical attention may remedy impairments in quality of life among patients with tinnitus.
The cross-sectional design of our study and the use of self-reported tinnitus are possible limitations. Furthermore, we were unable to retrieve diagnoses from primary care data. Thus, clinical diagnoses and care for tinnitus may be underestimated.
Conclusions
This study shows a sex-dependent association of tinnitus with suicide attempts, with severe tinnitus associated with suicide attempts in women but not in men. Since only a fifth of the participants with severe tinnitus were diagnosed by a specialist, there is a need for increasing resources toward the management of tinnitus in clinical practice. Furthermore, additional research is needed to understand the pathophysiological differences between men and women with tinnitus.
References
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