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. Author manuscript; available in PMC: 2023 Jul 1.
Published in final edited form as: Otol Neurotol. 2022 Jun 17;43(6):625–631. doi: 10.1097/MAO.0000000000003531

The Laterality of Age-Related Hearing Loss and Depression

Alexander Chern 1,2, Alexandria L Irace 1, Justin S Golub 1
PMCID: PMC9467465  NIHMSID: NIHMS1778786  PMID: 35709424

Abstract

Objective:

There is a known association between hearing loss (HL) and depressive symptoms. The objective was to establish if there is a stronger association with the left or right ear.

Study Design:

Cross-sectional analysis of an ongoing prospective epidemiologic cohort study

Setting:

Hispanic Community Health Study (US, multicentered)

Patients:

5,328 adults ≥50 years old

Interventions:

none

Main Outcome Measures:

The main outcome was depressive symptoms, measured by the 10-Item Center for Epidemiologic Studies Depression Scale-10 (CESD-10) and defined continuously and binarily. Subjects with CESD-10≥10 were categorized as having clinically significant depressive symptoms (CSDS). Linear and logistic regressions were performed to assess the association between depressive symptoms and hearing in each ear, controlling for hearing aid use, age, sex, educational level, study site, geographic background, cardiovascular disease, and antidepressant use.

Results:

Mean age was 58.5±6.3 years. Mean pure-tone average (PTA) was 20.3±11.7 dB (range=0–125) in the right ear and 20.3±12.4 dB (range=−2.5–120) in the left. Multivariable regression adjusting for covariates demonstrated significant associations between depressive symptoms and HL in both the left and right ear. For every 20-dB worsening in right ear PTA, there was 0.89-point increase in CESD-10 (95% confidence interval=0.59–1.2), and odds of CSDS increased 1.31 times (1.17–1.46). For every 20-dB worsening in left ear PTA, there was a 0.85-point increase in CESD-10 (0.55–1.14), and odds of CSDS increased 1.34 times (1.20–1.49).

Conclusions:

Worsening hearing in the right and left ears individually was associated with increased depressive symptoms and odds of CSDS. No ear laterality was demonstrated.

Keywords: laterality, hearing loss, presbycusis, age-related hearing loss, depression, CESD-10

Introduction

Age-related hearing loss (ARHL) is a highly prevalent and undertreated disorder of older life.1 The majority of adults greater than 70 years of age are affected by this condition;2 however, fewer than one fifth of adults with hearing loss who can benefit from amplification ultimately obtain treatment.3 A growing body of evidence has demonstrated a relationship between hearing loss (HL) and neuropsychiatric disorders of later life, including depression,4–7 cognitive decline, and dementia.8,9 Recent research has also demonstrated that this association begins earlier than previously thought, at subclinical levels of HL (i.e., HL within the normal range of hearing, or <25 dB).9–11

One potential mechanism explaining this association is that HL causes functional (i.e., activity) or structural (i.e., anatomic) changes in the brain, which then increases the risk of such neuropsychiatric conditions, such as cognitive impairment or depression. It is well-established that the right and left side of the brain are asymmetric in function and structure.12 Neuroimaging studies have demonstrated right-left asymmetries of brain function in individuals with depressive disorders.12 In addition, structural MRI studies in those with ARHL have demonstrated lateralized volume decreases among different brain regions, such as the right temporal gray matter, right hippocampus, and left entorhinal cortex.13–17 Symptoms seen in major depressive disorder have been linked to the neuronal connectivity in some of these as well as other brain regions, suggesting that functional or structural changes to these brain regions due to ARHL may contribute to developing depression.18

ARHL typically presents as a bilateral, progressive sensorineural HL that begins at higher frequencies. However, ARHL is not always perfectly symmetrical. In older adults, some asymmetry is even common. These subtle asymmetries in HL provide variability that allows laterality-based studies.19,20 Neuroimaging studies have demonstrated that HL is associated with lateralized changes in the right and left brain hemispheres.17,21–23 Indeed, other studies have shown that left and right ears demonstrate asymmetric input to the ascending auditory pathways, which likely reflects the hemispheric asymmetry of the central nervous system and possibly its processing of different types of stimuli (e.g., speech vs. tones).24–26 Moreover, each ear has stronger neuronal connections to the contralateral brain hemisphere;27 this suggests that HL in each ear may be associated with different central changes and clinical manifestations. In summary, since the brain does not symmetrically process auditory stimuli, it is possible that the input from one ear may have a more significant impact than input from the other.

Because the left temporal lobe is typically dominant for language processing, a right-ear advantage has been postulated.28 However, studies on the hearing-cognition relationship have been inconsistent, showing that either worse hearing in the left10,29 or right17 ears are more associated with cognitive impairment and related biomarkers. To our knowledge, the laterality of HL and depression has not previously been investigated. In this study, we aimed to fill this knowledge gap by measuring the effect of hearing loss laterality on depressive symptoms.

Methods

Study Cohort

The Hispanic Community Health Study/Study of Latinos is an oingoing community-based prospective epidemiologic cohort study situated at four sites (Bronx, NY; Chicago, IL; Miami, FL; and San Diego, CA). The present analysis only includes wave 1 and is cross-sectional. Most subjects who underwent this study had both pure tone audiometry and a quality-of-life assessment which included the Center for Epidemiologic Studies Depression Scale-10 (CESD-10). Testing was performed in English or Spanish based on subject preference. Although the HCHS cohort is longitudinal, only the 2008–2011 wave of data was released at the time of extraction; thus, cross-sectional analysis was performed on the 2008–2011 wave.

Adult subjects with audiometric and CESD-10 data were included. Subjects with missing records, audiometric data, covariate data, or CESD-10 results were excluded. To restrict subjects to those at risk for ARHL, subjects <50 years of age or with reported early-onset HL were also excluded.

Exposure variables

Hearing was assessed objectively using pure tone audiometry. Hearing thresholds (in dB, decibel hearing level), were measured from low frequency (500 Hz) to high frequency (8,000 Hz). Better hearing is indicated by lower hearing thresholds; worse hearing is indicated by high hearing thresholds. The primary exposure variables were right ear hearing and left ear hearing, both of which were defined as the four-frequency pure tone average (PTA) of the right and left ear, respectively. The pure tone average is defined as the mean hearing threshold (dB) at 500, 1,000, 2,000, and 4,000 Hz. HL severity was defined using the following categories: normal hearing (0 to 25 dB), mild HL (26 to 40 dB), moderate HL (41 to 55 dB), moderately-severe HL (56 to 70 dB), severe HL (71 to 90 dB), and profound HL (91 dB or worse). Since there were few participants with severe or profound HL, these categories were combined with the moderately-severe HL category. In a sensitivity analysis, we also examined degree of asymmetry as an exposure. We defined this in three ways: absolute value of the difference between the two ears, difference between the ears among those with worse left hearing, and difference between the ears among those with worse right hearing.

Outcome variable

The CESD-10 was used to assess for depressive symptoms in subjects, defined continuously and binarily. The binary outcome was employed because it was advantageous to create a set point for clinically significant depressive symptoms (CSDS); we used a set point of ≥10, which has been associated with worse health outcomes and disability in the elderly.30,31 Moreover, CESD-10≥10 has been shown to have good accuracy in predicting CSDS in comparison to the standard CESD-20 set point of ≥20.32 As such, subjects with CESD-10≥10 were categorized as having CSDS.

Covariates

Several potential confounding variables were included as covariates in our multivariable models assessing the association between HL and depressive symptoms. These included age (years), gender (man/woman), education (years), hearing aid use (yes/no), study site, geographic background, antidepressant use and cardiovascular disease (composite score from 0 to 5 where higher indicates worse disease). To avoid multicollinearity in our models, a composite cardiovascular disease score was created from several risk factors as described previously.33,34

Statistical Analysis

Continuous variables were described using means and standard deviations, while categorical variables were described using frequencies and proportions. Multivariable regressions models were created to assess the association between depressive symptoms and hearing variables, adjusting for covariates (age, sex, education, cardiovascular disease, and hearing aid use). Specifically, linear regression was employed to assess the association between continuous CESD-10 and hearing, while logistic regression was used to assess the association between binary CESD-10 (i.e., CESD-10≥10, or CSDS) and hearing. We report results according to a 20-dB change in PTA; this is equivalent to a one-category change in hearing level (i.e., normal, mild, moderate, moderately-severe, and profound). Data analysis was performed using R 3.6.3 (R Foundation for Statistical Computing) with RStudio 1.2.5033 (RStudio, Inc, Boston, MA). P-values were considered statistically significant at the p <0.05 level (two-tailed). Estimates are described using 95% confidence intervals (CI).

Results

Study Participants and Demographic Characteristics

There were originally 16,415 subjects in the included study cohort. Those with missing records (n=2,260), missing audiometric data (n=241), missing covariate data (n=358), or missing CESD-10 scores (n=36) were excluded. To restrict subjects to those at risk for ARHL, subjects <50 years of age (n=7,980) or with reported early-onset HL (212) were excluded.

Demographic characteristics are described in Table 1. After applying exclusion criteria, a total of 5,328 subjects were included for analysis, 4,517 with normal hearing (≤25 dB) and 982 with HL (>25 dB). Mean age was 58.5±6.3 years. Women comprised 61.5% of all subjects. Hearing aid use amongst subjects was 0.9% overall and 4% in those with HL. Mean education level was 10.4±4.7 years. Mean composite cardiovascular disease score was 1.7 (1.1% of all participants). Among all subjects, 553 (10.0%) used antidepressants and 1751 (32.9%) had CSDS (CESD-10>10). Mean CESD-10 score (SD) was 7.7 (6.4). Mean pure-tone average (PTA) was 20.3±11.7 dB (range=0–125) in the right ear and 20.3±12.4 dB (range=−2.5–120) in the left ear. Among all subjects, 2,209 had left ear hearing asymmetry (i.e., left ear PTA – right ear PTA > 0 dB), while 2,362 had right ear asymmetry (i.e., right ear PTA – left ear PTA > 0 dB).

Table 1.

Baseline characteristics of subjects

Total Cohort (n= 5328)
Age, yr, mean ± SD 58.5 ± 6.3
Men, no. (%) 2045 (38.4)
Hearing aid use, no. (%) 47 (0.9)
Education, yr, mean ± SD 10.4 ± 4.7
Antidepressant use, no. (%) 553 (10.0)
Composite cardiovascular disease score,1 no. (%) 1.7 (1.1)
CESD-10 score, mean ± SD 7.7(6.4)
Clinically significant depressive symptoms (CESD-10≥10), no. (%) 1751 (32.9)
Study site, no. (%)
Bronx 1296 (24.3)
Chicago 1169 (21.9)
Miami 1638 (30.7)
San Diego 1225 (23.0)
Geographic background, no. (%)
Dominican Republic 469 (8.8)
Central or South America 905 (17.0)
Cuba 1044 (19.6)
Mexico 1780 (33.4)
Puerto Rico 1029 (19.3)
Other or multiple 101 (1.9)
Better Hearing Ear (n= 5328)3 Right Ear (n=5239) Left Ear (n=5239)
Normal hearing, no. (%) 2 4387 (82.3) 4032 (77.0) 3978 (75.0)
Mild HL, no. (%) 749 (14.1) 922 (17.6) 963 (18.4)
Moderate HL, no. (%) 143 (2.7) 200 (3.8) 204 (3.9)
Moderately-severe or worse HL, no. (%) 49 (0.9) 85 (1.6) 94 (1.8)
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1

Cardiovascular disease score ranges from 0 (lowest) to 5 (highest). Points were assigned for each component (1 for coronary artery disease, 1 for hypertension, 1 for stroke; 1 for impaired glucose tolerance, 2 for diabetes).

2

Hearing loss was defined as pure tone average >25 dB.

3

The sample size for right ear and left ear is slightly largely than the total cohort because there were 89 participants that were missing right ear pure tone audiometry, as well as a separate 89 participants that were missing left ear pure tone audiometry.

Abbreviations: SD = standard deviation, % = percent, CESD-10: Center for Epidemiologic Studies Depression Scale-10; HL: hearing loss; SD, standard deviation

Among right ears, 4032 (77.0%) had normal hearing, 922 (17.6%) had mild HL, 200 (3.8%) had moderate HL, and 85 (1.6%) had moderately-severe or worse HL. Among left ears, 3978 (75.0%) had normal hearing, 963 (18.4%) had mild HL, 204 (3.9%) had moderate HL, and 94 (1.8%) had moderately-severe or worse HL. Among the better ear, 4387 (82.3%) had normal hearing, 749 (14.1%) had mild hearing loss, 143 (2.7%), and 49 (0.9%) had moderately-severe or worse hearing loss in the better hearing ear. There was no significant difference between PTA in the right ear versus left ear (p=0.83).

Multivariable Linear Regression Models

Multivariable linear regression adjusting for covariates demonstrated significant associations between depressive symptoms and HL in both the left and right ear. For every 20-dB worsening in left ear PTA, there was a 0.85-point increase in CESD-10 (95% CI: 0.55–1.14). For every 20-dB worsening in right ear PTA, there was 0.89-point increase in CESD-10 (95% CI: 0.59–1.2) (See Table 2, Figure 1, and Figure 2).

Table 2:

Multivariable regression models for depressive symptoms and laterality of hearing loss

Model Multivariable Linear Regression1 Multivariable Logistic Regression
CESD-10 Score Increase Per 20 dB Decrease in Hearing2 (95 % CI) p OR of Clinically Significant Depressive Symptoms3 Per 20 dB Decrease in Hearing (95% CI) p
Right Ear PTA 0.89 (0.59–1.2) <0.001* 1.31 (1.17–1.46) <0.001*
Left Ear PTA 0.85 (0.55–1.14) <0.001* 1.34 (1.2–1.49) <0.001*
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1

Multivariable models were conducted adjusting for covariates, including age, sex, educational level, study site, geographic background, antidepressant use, hearing aid use, and cardiovascular disease.

2

Hearing was defined by the pure tone average.

3

Clinically significant depressive symptoms were defined by CESD-10≥10.

*

Significant, p < 0.05

Abbreviations: PTA = pure tone average, CI = confidence interval, p = p-value

Figure 1:

Figure 1:

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Right ear hearing versus CESD-10 score with line of best fit from multivariable regression modeling. Depressive symptoms (measured by CESD-10; Center for Epidemiologic Studies Depression Scale, 10-Item) score versus right ear hearing (pure tone average) for each subject was depicted using a scatterplot. The regression line from multivariable analysis, adjusting for covariates (age, gender, education, cardiovascular disease, and hearing aid use), is shown (blue line) with 95% confidence interval (gray shading).

Figure 2:

Figure 2:

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Left ear hearing versus CESD-10 score with line of best fit from multivariable regression modeling. Depressive symptoms (measured by CESD-10; Center for Epidemiologic Studies Depression Scale, 10-Item) score versus left ear hearing (pure tone average) for each subject was depicted using a scatterplot. The regression line from multivariable analysis, adjusting for covariates (age, gender, education, cardiovascular disease, and hearing aid use), is shown (blue line) with 95% confidence interval (gray shading).

In a sensitivity analysis, multivariable linear regression did not demonstrate associations between depressive symptoms and degree of asymmetry between the ears, regardless of how this was defined (Supplemental Tables 1, 2, and 3).

Multivariable Logistic Regression Models

Multivariable logistic regression adjusting for covariates demonstrated significant associations between CSDS and HL in both the left and right ear. For every 20-dB worsening in right ear PTA, the odds of CSDS increased 1.31 times (95% CI: 1.17–1.46). For every 20-dB worsening in left ear PTA, the odds of CSDS increased 1.34 times (95% CI: 1.2–1.49) (See Table 2).

In a sensitivity analysis, multivariable logistic regression did not demonstrate associations between CSDS and degree of asymmetry between the ears, regardless of how this was defined (Supplemental Tables 1, 2, and 3).

Discussion

A growing body of research has demonstrated a clear association between HL and depression,4–7 which may begin with lesser levels of HL than previously thought.9–11 Prior studies have investigated the laterality of HL and its associated structural brain changes, particularly with respect to cognition.17,35 Our aim was to explore the role of laterality of HL (i.e., right and left ear differences) in the association between HL and depressive symptoms. To our knowledge, this has not previously been explored. Our study demonstrates that worse hearing in the right ear and worse hearing in the left ear were both associated with greater depressive symptoms and odds of CSDS as measured by the CESD-10. Our results show that the relative right ear versus left ear contributions to the association between ARHL and depressive symptoms are absent or too small to detect. Thus, we found no evidence to suggest auditory laterality contributing to the relationship between HL and depressive symptoms.

Our results can be explained by several hypotheses. Neuroimaging studies have shown that HL is associated with structural and functional changes in the brain.13–16,18,36,37 It is plausible that these changes (i.e., in brain regions implicated with the pathophysiology of depression) may in turn increase the risk of depressive symptoms. However, it is also possible that the differences in right ear and left ear contributions to structural or functional brain changes underlying the association between ARHL and depressive symptoms are negligible. Although both functional and structural neuroimaging studies have implicated various brain regions (e.g., amygdala,38–40 hippocampus,41–44 thalamus)45,46 and circuit abnormalities with the pathophysiology of depression47,48 these studies have demonstrated inconsistent results. Moreover, stimulation of several brain regions and neural circuits have been shown to create an antidepressant effect.49–53 Thus, the current data suggest that the neural basis of depression may be localized across many brain regions and circuits simultaneously. For example, a common molecular abnormality (e.g., neuronal receptor mutation) in various brain regions may explain this phenomenon.48 As such, the relative right ear or left ear contributions may simply manifest as structural (i.e., anatomic/volumetric) and functional (i.e., activity) changes across multiple regions throughout the brain with no strong laterality, which in turn then manifest clinically as depressive symptoms.

Whether or not there is an auditory laterality in the known association between depressive symptoms and hearing loss does not change the immediate clinical management of ARHL. Bilateral HL, whether symmetric or asymmetric, should still be treated with binaural hearing aids. Our study adds to the growing body of literature that HL may have a mechanistic relationship with depressive symptoms. Randomized controlled trials are needed to prove causality. However, even without definitive randomized controlled trial results, there is a low risk and strong theoretical benefit of employing hearing aids as a preventative strategy for depressive symptoms and other neuropsychiatric diseases of older life such as cognitive decline and dementia.54

Our study has several limitations. It is possible that auditory laterality does contribute to asymmetric structural/functional brain changes in regions associated with depressive symptoms, but these changes are not clinically detectable using a global behavioral test (i.e., CESD-10). There are other depression assessment instruments (e.g., Beck Depression Inventory Hamilton Depression Rating Scale) that were not employed for this study; these could be investigated in future studies.55 Neuroimaging, including volumetric MRI and specialized functional modalities, could also be utilized to further examine the relationship between auditory laterality and structural/functional brain changes. Regardless, depression is a clinical diagnosis and not based on neuroimaging and thus, depressive symptom inventories, such as the CESD would be needed.

Additional future studies could include whether or not frankly asymmetric HL (e.g., single-sided deafness in the left versus right ear) is more strongly associated with depression and other neuropsychiatric conditions of older life. Moreover, there is a well-established “right-ear advantage” for speech recognition; when two distinct speech stimuli are presented to both ears simultaneously, studies have shown that listeners report stimuli more correctly from the right ear compared to the left ear.56–59 Further investigation of the relative contributions of speech recognition in each ear (rather than hearing thresholds) may also elucidate any potential contributions of auditory laterality to the known association between HL and depression.

Our study was a cross-sectional analysis of a multi-centered, community-based study. Thus, causality cannot be assessed. Moreover, the majority of individuals had hearing within the normal range (82.1% with normal hearing [≤25 dB] vs. 17.9% with HL [>25 dB]) (see Table 1). In addition, the cohort was entirely Hispanic/Latino. To better generalize our results, this study should be replicated in a more diverse population across a wide spectrum of hearing. This might require oversampling individuals with greater levels of hearing loss. Although our multivariable analysis controlled for potential confounding variables, including age, gender, hearing aid use education, and cardiovascular disease, it is possible that other unknown confounders could affect the relationship between right and left ear HL with depressive symptoms.

Conclusion

Worsening hearing in both right and left ears was associated with increased depressive symptoms and odds of CSDS, adjusting for confounders. No ear laterality was demonstrated. These findings will help inform understanding of the laterality of central auditory connections.

Supplementary Material

Supplemental Table 3

Multivariable regression models for depressive symptoms and absolute hearing asymmetry1Multivariable models were conducted adjusting for covariates, including age, sex, educational level, study site, geographic background, antidepressant use, hearing aid use, and cardiovascular disease.2Hearing was defined by the pure tone average. 3Clinically significant depressive symptoms were defined by CESD-10≥10.*Significant, p < 0.05Abbreviations: PTA = pure tone average, CI = confidence interval, p = p-value

Supplemental Table 2

Multivariable regression models for depressive symptoms and right ear hearing asymmetry1Multivariable models were conducted adjusting for covariates, including age, sex, educational level, study site, geographic background, antidepressant use, hearing aid use, and cardiovascular disease.2Hearing was defined by the pure tone average. 3Clinically significant depressive symptoms were defined by CESD-10≥10.*Significant, p < 0.05Abbreviations: PTA = pure tone average, CI = confidence interval, p = p-value

Supplemental Table 1

Multivariable regression models for depressive symptoms and left ear hearing asymmetry1Multivariable models were conducted adjusting for covariates, including age, sex, educational level, study site, geographic background, antidepressant use, hearing aid use, and cardiovascular disease.2Hearing was defined by the pure tone average. 3Clinically significant depressive symptoms were defined by CESD-10≥10.*Significant, p < 0.05Abbreviations: PTA = pure tone average, CI = confidence interval, p = p-value

Acknowledgments

FINANCIAL MATERIAL & SUPPORT: None

Institutional Review Board Approval: AAAQ9546(M00Y01): Designated Not Human Subjects Research Under 45 CFR 46

Footnotes

CONFLICT(S) OF INTEREST TO DECLARE: Alexander Chern: None. Alexandria L. Irace: None. Justin S. Golub: travel expenses for industry-sponsored meetings (Cochlear, Advanced Bionics, Oticon Medical), consulting fees or honoraria (Oticon Medical, Auditory Insight, Optinose, Abbott, Decibel Therapeutics), department received unrestricted educational grants (Storz, Stryker, Acclarent, 3NT, Decibel Therapeutics).

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Associated Data

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Supplementary Materials

Supplemental Table 3

Multivariable regression models for depressive symptoms and absolute hearing asymmetry1Multivariable models were conducted adjusting for covariates, including age, sex, educational level, study site, geographic background, antidepressant use, hearing aid use, and cardiovascular disease.2Hearing was defined by the pure tone average. 3Clinically significant depressive symptoms were defined by CESD-10≥10.*Significant, p < 0.05Abbreviations: PTA = pure tone average, CI = confidence interval, p = p-value

NIHMS1778786-supplement-Supplemental_Table_3.docx (15.1KB, docx)
Supplemental Table 2

Multivariable regression models for depressive symptoms and right ear hearing asymmetry1Multivariable models were conducted adjusting for covariates, including age, sex, educational level, study site, geographic background, antidepressant use, hearing aid use, and cardiovascular disease.2Hearing was defined by the pure tone average. 3Clinically significant depressive symptoms were defined by CESD-10≥10.*Significant, p < 0.05Abbreviations: PTA = pure tone average, CI = confidence interval, p = p-value

NIHMS1778786-supplement-Supplemental_Table_2.docx (14.9KB, docx)
Supplemental Table 1

Multivariable regression models for depressive symptoms and left ear hearing asymmetry1Multivariable models were conducted adjusting for covariates, including age, sex, educational level, study site, geographic background, antidepressant use, hearing aid use, and cardiovascular disease.2Hearing was defined by the pure tone average. 3Clinically significant depressive symptoms were defined by CESD-10≥10.*Significant, p < 0.05Abbreviations: PTA = pure tone average, CI = confidence interval, p = p-value

NIHMS1778786-supplement-Supplemental_Table_1.docx (14.9KB, docx)

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