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Depression in elderly patients with hearing loss: current perspectives

Authors Cosh S , Helmer C, Delcourt C, Robins TG , Tully PJ

Received 25 May 2019

Accepted for publication 31 July 2019

Published 14 August 2019 Volume 2019:14 Pages 1471—1480


Checked for plagiarism Yes

Review by Single anonymous peer review

Peer reviewer comments 2

Editor who approved publication: Dr Richard Walker

Suzanne Cosh,1 Catherine Helmer,2 Cecile Delcourt,2 Tamara G Robins,3 Phillip J Tully4

1School of Psychology, University of New England, Armidale, NSW 2351, Australia; 2Bordeaux Population Health Research Center, University Bordeaux, Inserm, Team LEHA, UMR 1219, Bordeaux F-33000, France; 3School of Psychology, The University of Adelaide, Adelaide, SA 5005, Australia; 4Discipline of Medicine, Freemason’s Foundation Centre for Men’s Health, The University of Adelaide, Adelaide, SA 5005, Australia

Abstract: Hearing loss (HL) is highly common in older adulthood, constituting the third most prevalent chronic health condition in this population. In addition to posing a substantial burden to disease and negatively impacting quality of life, an emerging literature highlights that HL is associated with unipolar depression including among older adults. This review outlines evidence examining the HL and depression relationship as well as clinical implications for assessment and treatment of comorbid depression and HL. Although prevalence estimates of comorbid depression in HL vary, as many as 1 in 5 experience clinically relevant depression symptoms. Both cross-sectional and longitudinal studies indicate that HL is related to increased unipolar depression symptoms, although the strength of the association varies between studies. A range of methodological variations, such as inclusion age, severity of HL and assessment of depression, likely underpin this heterogeneity. Overall, however, the evidence clearly points to an association of HL with clinically relevant depression symptoms. The association with the diagnosis of major depression disorder remains less clear and under-researched. HL is also associated with a range of other poor mental health outcomes in older adults, including anxiety and suicidal ideation, and predicts poorer cognitive functioning. Accordingly, assessment and treatment of comorbid depression in HL is pertinent to promote mental well-being among older adults. Currently, evidence regarding best practice for treating depression in HL remains scant. Preliminary evidence indicates that audiological rehabilitation, including use of hearing aids, as well as community-based hearing interventions can also improve mental health. Psychological intervention that enhances communication skills and addresses coping strategies might also be beneficial for this population. Additionally, evidence suggests that online interventions are feasible and may circumvent communication difficulties in therapy associated with HL. Due to poor help-seeking among this population, an enhanced focus on specific and targeted assessment and treatment is likely necessary to ensure reduced mental health burden among older adults with HL.

Keywords: sensory loss, hearing impairment, mental wellbeing, treatment, intervention, aging

Hearing loss (HL) is common in older adulthood with as many as one-third of adults aged over 65 reporting HL.1 Prevalence of HL continues to increase with age and constitutes the third most prevalent chronic health condition in older adulthood.2 Age-related HL typically results from pathologic changes associated with aging, with loss of hair cells at the basilar membrane resulting in loss of high-frequency hearing.3 HL in older adults results in increased disability,4 risk of incident morbidity,5 frailty and poorer self-rated health.6 Consequently, HL among older adults poses a substantial burden to disease.7,8 HL also confers poorer psychosocial outcomes, including lower levels of happiness and self-efficacy,9,10 impaired relationship functioning and poorer emotional vitality9 and is related to poor psychological well-being, including presence of comorbid unipolar depression. Consequently, HL in older adults significantly impinges upon quality of life.11,12

HL and depression

Within the older adult population with HL, prevalence estimates of comorbid unipolar depression remain varied, but suggest that up to 1 in 5 older adults with HL report a clinically relevant level of depression symptoms that would necessitate treatment,13 and a further 22% experience the onset of incident depression symptoms over time.14 An emerging body of research further indicates that HL increases the risk of experiencing depression. In a recent meta-analysis of 35 studies (N=147,148), HL increased odds of depression including over time.15 However, the certainty of evidence was deemed low, due to few studies adjusting for covariates. Furthermore, a high degree of heterogeneity regarding the strength of the association was observed and not all studies have corroborated the HL–depression association, suggesting that there may be further nuances to this relationship.

A cross-sectional association between HL and depression among older adults has been consistently observed.13,16 Longitudinal studies remain less clear, however, with some mixed findings. HL was shown to be associated with an increased incidence of depression over 12 years, relative to matched controls, in a recent Taiwanese study.17 Likewise, elevated depression symptoms have also been observed over time in those with HL.18,19 Conversely, a Norwegian study highlighted a cross-sectional relationship, yet this was no longer significant at 6-year follow-up.20 Similarly, several Dutch studies have failed to find evidence of a longitudinal relationship between HL and depression.2123

Differences in study methodology may contribute to the variation in findings. For instance, a relationship between HL and depression was demonstrated in adults of all ages,24,25 yet the strength of association reduces into older age.17 Relatedly, a recent study of the oldest old showed no relationship between HL and depression.26 In the extant literature, varied inclusion ages (ranging from 50 and up) were used and this variation likely influences the observed results.

Hearing assessment in the literature

Further methodological variations likely to impact on findings include the assessment of HL, with some studies indicating differential results depending on whether HL is self-reported or measured.16 It should be noted that in Lawrence et al15 meta-analysis, sensitivity analyses indicated no difference in depression outcome for self-reported or measured HL. However, while both self-report and measured HL might be associated with depression, patterns of association can vary depending on assessment method.25 Mixed HL thresholds have also been used in the literature. While depression symptoms were observed both in mild and in severe self-reported HL,14 several large-scale studies have indicated that severity of HL is associated with increased depression risk,27,28 indicating a graded relationship between HL and depression. Accordingly, strengths of relationships and risk estimates of comorbid HL and depression can vary based on HL assessment methods.

Depression assessment in the literature

Assessment of depression varies substantially between studies and different depression measures have been shown to yield different findings. For example, a higher prevalence of comorbid depression was observed when depression was assessed using the Centre for Epidemiology Studies Depression-10 Scale compared with the Mental Health Index.13 Accordingly, mixed results may partly reflect variations in depression assessment.

Additional differences include analysis of depression either as a continuous variable representing symptom severity or as a categorical variable, dichotomizing depression into the presence or absence of clinically relevant symptoms. Analysis of depression as a continuous variable has yielded mixed longitudinal findings.1821 Conversely, studies that have categorized depression have reported that HL predicts increased odds of elevated depression symptoms over time.6,14 These collective findings may indicate that HL predicts the presence of clinically significant depression symptoms, yet may less directly impinge on symptom severity.

Furthermore, the majority of current research has focused on exploring depression symptoms, with diagnosis of major depression disorder (MDD) less common. A recent study assessed both diagnosis of MDD and elevated depression symptomatology14 and found that HL was associated with increased odds of elevated depression symptoms both at baseline and over 12 years, but not with MDD over follow-up. Although there is some evidence of an association of HL with MDD in adults of all ages,17,29 in older adults, HL appears to be related to the presence of depression symptoms that may not meet the full diagnosis for MDD. Presence of subthreshold depression may reflect patterns of mental health in aging more broadly, with subthreshold mental disorders common in older adults.30

A recent trend in depression research has shifted away from classifying depression as a single construct and, rather, uses an approach focusing on dimensions of depression symptoms.31 Early dimensional research has indicated that HL is also related to interpersonal problems at baseline (S Cosh, personal communication, May, 2019). HL is also associated with somatic symptoms, and this pattern parallels the tendency for older adults to report somatic depression symptoms more so than cognitive-affective symptoms. Different depression measures differentially assess different symptom types, which may further explain heterogeneity in HL–depression findings.

Conclusions regarding the HL–depression relationship

While there remain some variations to date, taken together, the extant literature clearly points to an association of HL in older adults with the presence of depression symptoms both cross-sectionally and over time, and this is observed with both measured and self-reported HL. However, differences in study methods portend varied prevalence rates and strengths of association between HL and depression. Ongoing research would valuably explore measured HL along with a diagnosis of MDD and subthreshold depression symptoms in order to paint a clearer picture of comorbid depression prevalence in older adults with HL.

Adjustment to depression in older adults with HL

Despite the growing body of evidence examining HL and depression, longer-term adjustment has been less commonly explored. A number of studies have shown that depression symptoms remain elevated over time.6,18,19 Yet, several studies have shown only cross-sectional relationships with depression, indicating that symptoms may subside over time.20,32 Arguably, older adults with HL might be able to adapt and modify communication styles, thereby mitigating potential isolation and loneliness outcomes which might contribute to depression symptoms. In the study by Chou,32 only half of the sample with sensory loss and depression continued to report persistent depression after 2 years. However, such studies have not assessed depression treatment as a covariate for change in symptoms. Currently, it remains unclear if or when adjustment occurs for older adults with HL. Further assessment of symptom trajectories over the longer term is needed to gain a greater understanding about possible adjustment.

Possible mechanisms of the HL–depression relationship

A range of possible mechanisms for depression in HL have been proposed, although ongoing research remains needed to paint a clearer picture and resolve equivocal findings. A reduction in activities of daily living observed in older adults with HL,33 partly due to impairments in communication, is a suggested contributing factor for poorer mental health outcomes.32 However, recent results showed that adjustment for functional ability did not attenuate HL–depression associations.6,14 Further possibilities include the low levels of help-seeking commonly observed in the population with HL,34 which might further contribute to or exacerbate depression symptoms. Additionally, engagement in mentally stimulating activities was shown to attenuate HL’s association with depression,19 suggesting that disengagement in activities post-HL may contribute to depression.

A well-researched mechanism pertains to communication difficulties, stemming from HL, which may pose challenges to social and relationship functioning.19,35 Relationship difficulties have been observed in HL. For example, a recent study reported that adults who were deaf were notably more likely to have conflict in key relationships, compared with those without HL.36 In support of this proposed mechanism, intervention studies to improve communication strategies have resulted in decreased anxiety and depression symptoms in adults with HL.37

Additional consequences of communication barriers, such as loneliness and social isolation, have further been suggested to contribute to depression onset, with lack of social support a known predictor of depression.38 Loneliness and social isolation among older adults with HL have been well documented.23,39 These may partly be due to difficulty following a conversation, leading to increased feelings of isolation.40 Furthermore, with a lack of social support, it has been argued that HL can then develop into a chronic stressor, thereby leading to or exacerbating depression symptoms.41 It has been observed that the association between HL and depression is attenuated when adjusted for social engagement.19 However, adjustment for social activities and number of friends did not attenuate the HL–depression relationship in another study,20 although assessment of social isolation was limited. However, adjustment to communication limitations might mitigate isolation as a pathway to depression. Currently, the extent to which isolation and loneliness contribute to depression onset remains unclear, and this may be subject to notable variation between individuals.

Although less explored, biological explanations may further explain the comorbidity of depression and HL. Shared biological disease processes have been purported to explain comorbid depression and physical health conditions when somatic symptoms of depression are dominant.42 Given the stronger association of HL to somatic symptoms (S Cosh, personal communication, May, 2019), a shared biological process may be a plausible explanation; however, dedicated research is needed to evidence this.

Recently, patterns of diminished prefrontal cortex activity have been observed in neuroimaging studies of older adults with HL and with depression, suggesting a possible shared neuropathological pathway.43 Moreover, reduced activity in the limbic system – responsible for both emotion and behavior – has been observed in those with HL. In particular, diminished limbic and auditory activity has been observed in response to emotional and auditory stimuli.43 These findings point to the possibility that neurological change or degeneration might explain both HL and depression. While these findings are highly promising, further evidence is needed to further understand the neuropathology of depression in HL.

HL and suicide risk

HL may also increase suicide risk, although research remains in the nascent stages. As many as 10% of older adults with HL reported suicidal ideation in a French study, and this prevalence was higher in those with severe HL and those with comorbid vision and HL.44 Increased risk for suicidal ideation continued to be observed over 5 years for both mild and severe HL. Notably, these results remained significant after adjustment for depression symptoms, indicating that suicide ideation may be experienced regardless of depression severity. The reasons for increased suicidality in this population are not currently clear, although an increased perception of the self as a burden45 and loneliness46 are associated with greater suicidal ideation in the elderly and may be particularly prominent in this population.47 Whether HL increases suicide risk or likelihood of attempts, however, remains unclear and this area requires further examination.

Dual sensory loss (DSL)

The population of older adults with HL are vulnerable to even poorer mental health outcomes in the event of the onset of a secondary sensory loss. A number of longitudinal studies have suggested that those with DSL – vision loss and HL – experience a greater severity of their depression symptoms than observed in single sensory losses,20,35 including in the oldest old.26 As many as one in four adults over 70 have vision loss,48 thus, a sizeable proportion of older adults are susceptible to dual losses and the resultant worsening in depression symptom severity. Given that depression severity impinges on the quality of life and treatment outcome,30 DSL is a necessary consideration when assessing and treating older adults.

HL and other mental health outcomes

While the majority of the literature has focused on depression, an increased prevalence of a range of psychiatric disorders is associated with HL.40 Most notably, an emerging literature indicates that HL is also associated with anxiety cross-sectionally.20,49,50 Given the high rates of comorbid depression and anxiety and that older adults with comorbid depression and anxiety typically have poorer outcomes,51 comorbid psychiatric conditions are necessary to consider when working with this population. Additionally, increased anxiety, especially in relation to social settings and interactions, might result in the avoidance of feared social and interpersonal situations, which might worsen social isolation and potentiate poorer depression outcome.

Anxiety disorder–specific studies remain rare, although HL was not shown to be associated with diagnosis of Generalized Anxiety Disorder.50 However, agoraphobia and social phobia are more prevalent among older adults with vision loss,52 and similar patterns of association might be noted in HL due to communication barriers impinging on social functioning. Further anxiety disorder–specific research would allow for a clearer understanding of the mental health needs of older adults with HL.

It should also be noted that some evidence points toward a prospective association of anxiety with HL. Having a lifetime history of Generalized Anxiety Disorder predicted slightly greater odds of HL onset50 and higher rates of past anxiety were reported by adults with sensorineural HL compared with those with no HL.53 Further evidence is needed to confirm this relationship and to better understand the possible underlying mechanisms. It also remains unclear whether HL onset increases risk of experiencing anxiety, especially in those without a history of anxiety, or whether the observed cross-sectional associations between HL and anxiety are a reflection of preexisting anxiety that predated the HL onset.

There is also strong emerging evidence that HL is related to poor cognitive outcomes. HL is associated with impaired cognitive function, including poorer episodic memory,54 accelerated cognitive decline55 and also incident dementia.56,57 The extent to which depression and HL may interact to increase the risk for dementia onset is not clear and has not yet been thoroughly examined. However, extant research indicates that comorbid depression and HL may heighten the risk of incident dementia. Such risk may be explained by shared neurobiological patterns, such as impairment of the central auditory function43 or reduced speech perception resulting in reduced brain volume for auditory and cognitive processing.58 Likewise, impairments in social communication from HL and social withdrawal as part of depression might further amplify the role of social isolation in dementia onset.

Clinical implications: assessment

A renewed focus on assessment and identification of both HL and depression among healthcare professionals is needed. Primary care physicians may be best placed to identify both HL and depression in the first instance,59 although health professionals would benefit from an increased understanding of HL, depression, and their interrelationship, in order to aid identification.40 Currently, screening of asymptomatic older adults for HL is not part of routine geriatric assessment guidelines.60 Yet, given the low levels of awareness of many older adults regarding their own HL,61 older adults may be less likely to seek help for HL symptoms, thus increased screening for HL in the older adult population may promote better hearing health, which may in turn also enhance psychosocial well-being.62 The role of HL in accelerating cognitive decline further underscores the need for early identification and screening of possible hearing deficits.

Further awareness of the potential impact of HL on psychosocial functioning among health professionals may facilitate identification of depression symptoms for further assessment and/or treatment. Despite expressing a desire for mental health treatment, a lack of referrals has been reported by those with severe HL,63 suggesting an increased need for assessment and referral in this population. To achieve this, further training for audiologists to understand and identify psychosocial difficulties associated with HL, as well as increased confidence in discussing mental health with patients, would be valuable.64 Further, when referred for comprehensive mental health assessment, depression assessment should be sensitive to subthreshold depression symptoms, commonly observed in HL, given the continued distress levels and deleterious outcomes observed.65 Additionally, many commonly used depression screening tools do not assess suicide risk. Given that HL confers increased odds for experiencing suicidal ideation,44 consideration and assessment of suicide risk may also be beneficial. Upskilling of non-mental health professionals may be needed to facilitate observation of risk and appropriate referral.

Clinical implications: intervention

To date, there is a minimal examination of best practice for the treatment of comorbid depression and HL, especially within the older adult population. A dual approach of managing HL in addition to psychotherapeutic interventions is likely the best approach.40 However, ongoing research to guide clinical intervention in this area is needed.

Treatment of HL

Audiological rehabilitation including use of hearing aids (which amplify weak sounds) are common treatments for HL. Auditory rehabilitation, training and use of hearing aids have shown to improve hearing, including the cortical and subcortical processing of speech, and associated cognitive function.66,67 Relatedly, use of hearing aids and auditory rehabilitation has been reported to mitigate depression symptoms.6870 A recent study showed that a 6-month auditory training program and 3 months of hearing aid use conferred a moderate to large effect on depression symptom reduction.70 Further, an intervention study documented improved depression and psychosocial well-being within 3 months of hearing aid use.71 However, findings regarding hearing aids are mixed, and in a recent meta-analysis, hearing aid use showed no effect on depression outcome,15 although the authors suggested caution in the interpretation of this finding. Indeed, much of the literature conflates hearing aid ownership with hearing aid use and this lack of distinction may contribute to equivocal findings. It has been widely observed that many owners do not actively use their aids.72 Additionally, not all users manage their aids or use appropriate and up-to-date corrections. This may, in part, be due to financial reasons,73 reluctance to seek help from health care providers74 and anxiety, which impairs HL management.75 Certainly, studies that monitor hearing aid use tend to produce the most promising results for hearing aids in reducing associated depression.

Cochlear implants are another HL intervention that may have subsequent benefit for mental well-being, although evidence for this also remains mixed. While cochlear implants have been shown to increase health-related quality of life, reduction in anxiety and depression symptoms was not observed 12 months postsurgery.76 Conversely, an observational study was indicative of improvement in depression symptoms over 12 months following cochlear implant,77 with improvements in anxiety and quality of life in addition to depression also observed.69 The longer-term benefit of cochlear implants requires ongoing assessment in older adults but may be a fruitful means of intervention.

Community-based interventions

More recently, community-based interventions to promote hearing health have been piloted. These interventions typically aim to overcome the financial burden associated with hearing aids and other HL treatments. The HEARS study, a recent pilot of a community-based program, showed promising results for depression symptoms.78 In further support of such interventions, a recently piloted community-based intervention of health education, socialization and group auditory rehabilitation showed improvements in social and emotional loneliness and hearing-related quality of life.79 These types of interventions might assist in overcoming barriers to auditory rehabilitation, such as cost. Subsequent randomized controlled trials (RCTs) to ascertain efficacy and cost-effectiveness will be valuable for guiding future intervention and clinical practice.

Psychotherapeutic interventions

Psychotherapeutic interventions for mood are also needed, including for subthreshold depression, and it has been argued that this is required early in HL rehabilitation.80 Currently used psychotropic medications are not known to have ototoxic effects and thus do not appear to be contraindicated for comorbid depression.40 However, there is a dearth of research that specifically examines interventions for older adults with comorbid HL and depression, especially psychological intervention.

Communication barriers observed in HL likely have substantial implications for the conduct and effectiveness of traditional psychological “talk therapies”. The extent to which communication barriers impinge upon treatment has not been empirically explored, yet may provide invaluable information to guide subsequent intervention. However, one study examining the use of cognitive behavioral therapy (CBT) in adults of all ages with HL in the workforce has shown some preliminary support for CBT. Although depression symptoms remained unchanged, reductions in anxiety and use of avoidant communication were observed.81 Ongoing study, especially in an older adult population, to corroborate such findings is needed.

Moreover, addressing communication barriers and modifying communication strategies might prove a beneficial first stage of psychological intervention, with such training shown to reduce psychological distress in older adults with HL.37 Online and web-based interventions that bypass or limit direct conversation might also be of value for depression treatment in HL. A recent pilot of an 8-week online Acceptance and Commitment Therapy intervention showed promising results,82 finding evidence of feasibility for an internet-based delivery in this population and improvement in symptoms. Thus, this approach may be of promise although ongoing large-scale RCTs are needed to better guide clinical practice.

Within the vision loss literature, acceptance of the loss has been shown to facilitate adjustment.83 Promoting acceptance in HL might likewise be a fruitful focus of clinical intervention. Moreover, enhancing instrumental and social coping is associated with reduced depression in the vision loss population,83 while ruminative and catastrophizing coping are associated with elevated depression and anxiety symptomatology in adults with HL.84 Thus, intervention targeting upskilling of adaptive coping strategies, especially in order to facilitate coping with and accepting the loss, may also be a valuable guide in clinical approaches to working with an HL population.

Furthermore, depression treatment efficacy can be improved by tailoring interventions specifically to the presenting depression symptom dimensions.85 Accordingly, a targeted focus on somatic symptoms of depression might be particularly indicated for older adults with HL. This may be especially critical given that somatic symptoms have been reported to portend an increased risk of suicidal ideation86 in a population already likely to be at elevated suicide risk.44

Help-seeking and engagement with health care

Help-seeking among those with HL is typically low.34,87 Consequently, direct and targeted intervention may be necessary to engage those with HL and depression in the requisite treatment and interventions. Motivational interviewing post-HL screen is being trialed in response to low uptake of audiological rehabilitation.87 Such an approach might also yield beneficial outcomes for engaging older adults with comorbid depression into mental health treatment; however, this remains to be empirically tested.

Summary and conclusion

HL increases the likelihood of experiencing clinically relevant depression symptoms in the older adult population both cross-sectionally and over time, although the impact on symptom severity and MDD is less clear. Heterogeneity in the strengths of association and prevalence rates of comorbid HL and depression have been reported to date, likely due to variations in study methodology, such as inclusion age and depression assessment. Moreover, specific subgroups, including those with severe HL, DSL and younger adults are more susceptible to poorer mental health outcomes over time. Possible shared aging and neuropathological pathways might explain the association between HL and depression, alongside psychosocial factors such as isolation and loneliness. However, mechanisms of the HL–depression relationship remain under-researched and increased understanding is needed.

Increased awareness of HL as well as its psychosocial implications among healthcare professionals may aid identification of HL and depression, thereby facilitating timely intervention. To date, limited evidence regarding intervention for this group exists. This is an important area requiring future examination and trials in order to guide practice. Audiological rehabilitation and corrective devices (e.g. hearing aid, cochlear implant), alongside novel treatments still being developed, may be beneficial for both hearing and depression, where adherence is strong. Community-based interventions show early promise, although ongoing examination is needed to establish effectiveness for both hearing and mental health. Given the communication barriers observed in HL, communication skills training or internet-based psychological therapies may be useful modes of intervention, although further evidence is needed. Ongoing dimensional research might also guide psychological intervention. How to best promote help-seeking or tailor interventions to increase uptake requires ongoing consideration in order to facilitate appropriate support for this population. Given that HL poses a substantial risk to psychosocial health and well-being of older adults, assessment and focused intervention is needed in this population to improve quality of life and reduce mental health burden.


Dr Cecile Delcourt reports personal fees from Allergan, Bausch+Lomb, grants and personal fees from Laboratoires Théa, Novartis, European Union, Agence Nationale de la Recherche, and International Research and Scholarly Exchange Program (IRESP), outside the submitted work. The authors report no other conflicts of interest in this work.


1. WHO. Mortality and Budren of Diseases. Geneva: World Health Organisation; 2012.

2. Yueh B, Shapiro N, MacLean CH, Shekelle PG. Screening and management of adult hearing loss in primary care: scientific review. JAMA. 2003;289(15):1976–1985. doi:10.1001/jama.289.15.1976

3. Patel R, McKinnon BJ. Hearing loss in the elderly. Clin Geriatr Med. 2018;34(2):163–174. doi:10.1016/j.cger.2018.01.001

4. Armstrong TW, Surya S, Elliott TR, Brossart DF, Burdine JN. Depression and health-related quality of life among persons with sensory disabilities in a health professional shortage area. Rehabil Psychol. 2016;61(3):240–250. doi:10.1037/rep0000083

5. Deal JA, Reed NS, Kravetz AD, et al. Incident hearing loss and comorbidity: A longitudinal administrative claims study. JAMA Otolaryngol Head Neck Surg. 2019;145(1):36–43. doi:10.1001/jamaoto.2018.2876

6. Yu A, Liljas AEM. The relationship between self-reported sensory impairments and psychosocial health in older adults: a 4-year follow-up study using the english longitudinal study of ageing. Public Health. 2019;169:140–148. doi:10.1016/j.puhe.2019.01.018

7. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med. 2006;3(11):e442. doi:10.1371/journal.pmed.0030442

8. Wittchen HU, Jacobi F, Rehm J, et al. The size and burden of mental disorders and other disorders of the brain in Europe 2010. Eur Neuropsychopharmacol. 2011;21(9):655–679. doi:10.1016/j.euroneuro.2011.07.018

9. Contrera KJ, Betz J, Deal JA, et al. Association of hearing impairment and emotional vitality in older adults. J Gerontol B Psychol Sci Soc Sci. 2016;71(3):400–404.

10. Kramer SE, Kapteyn TS, Kuik DJ, Deeg DJ. The association of hearing impairment and chronic diseases with psychosocial health status in older age. J Aging Health. 2002;14(1):122–137. doi:10.1177/089826430201400107

11. Tsimpida D, Kaitelidou D, Galanis P. Determinants of health-related quality of life (HRQoL) among deaf and hard of hearing adults in Greece: a cross-sectional study. Arch Public Health. 2018;76(1):55. doi:10.1186/s13690-018-0304-2

12. Eisele M, Kaduszkiewicz H, Konig HH, et al. Determinants of health-related quality of life in older primary care patients: results of the longitudinal observational AgeCoDe Study. Br J Gen Pract. 2015;65(640):e716–e723. doi:10.3399/bjgp15X687337

13. Gopinath B, Wang JJ, Schneider J, et al. Depressive symptoms in older adults with hearing impairments: the blue mountains study. J Am Geriatr Soc. 2009;57(7):1306–1308. doi:10.1111/j.1532-5415.2009.02317.x

14. Cosh S, Carriere I, Daien V, et al. The relationship between hearing loss in older adults and depression over 12 years: findings from the Three-City prospective cohort study. Int J Geriatr Psychiatry. 2018;33(12):1654–1661. doi:10.1002/gps.4968

15. Lawrence BJ, Jayakody DMP, Bennett RJ, et al. Hearing loss and depression in older adults: a systematic review and meta-analysis. Gerontologist. 2019. doi:10.1093/geront/gnz009

16. Lee AT, Tong MC, Yuen KC, Tang PS, Vanhasselt CA. Hearing impairment and depressive symptoms in an older chinese population. J Otolaryngol Head Neck Surg. 2010;39(5):498–503.

17. Hsu WT, Hsu CC, Wen MH, et al. Increased risk of depression in patients with acquired sensory hearing loss: A 12-year follow-up study. Medicine. 2016;95(44):e5312. doi:10.1097/MD.0000000000004864

18. Brewster KK, Ciarleglio A, Brown PJ, et al. Age-related hearing loss and its association with depression in later life. Am J Geriatr Psychiatry. 2018;26(7):788–796. doi:10.1016/j.jagp.2018.04.003

19. Kiely KM, Anstey KJ, Luszcz MA. Dual sensory loss and depressive symptoms: the importance of hearing, daily functioning, and activity engagement. Front Hum Neurosci. 2013;7:837. doi:10.3389/fnhum.2013.00837

20. Cosh S, von Hanno T, Helmer C, Bertelsen G, Delcourt C, Schirmer H. The association amongst visual, hearing, and dual sensory loss with depression and anxiety over 6 years: the Tromso study. Int J Geriatr Psychiatry. 2018;33(4):598–605. doi:10.1002/gps.4827

21. Stam M, Smit JH, Twisk JW, et al. Change in psychosocial health status over 5 years in relation to adults’ hearing ability in noise. Ear Hear. 2016;37(6):680–689. doi:10.1097/AUD.0000000000000332

22. Pronk M, Deeg DJ, Smits C, et al. Hearing loss in older persons: does the rate of decline affect psychosocial health? J Aging Health. 2014;26(5):703–723. doi:10.1177/0898264314529329

23. Pronk M, Deeg DJ, Smits C, et al. Prospective effects of hearing status on loneliness and depression in older persons: identification of subgroups. Int J Audiol. 2011;50(12):887–896. doi:10.3109/14992027.2011.599871

24. Ciesla K, Lewandowska M, Skarzynski H. Health-related quality of life and mental distress in patients with partial deafness: preliminary findings. Eur Arch Otorhinolaryngol. 2016;273(3):767–776. doi:10.1007/s00405-015-3713-7

25. Li CM, Zhang X, Hoffman HJ, Cotch MF, Themann CL, Wilson MR. Hearing impairment associated with depression in US adults, National health and nutrition examination survey 2005–2010. JAMA Otolaryngol Head Neck Surg. 2014;140(4):293–302. doi:10.1001/jamaoto.2014.42

26. Cimarolli VR, Jopp DS, Boerner K, Minahan J. Depressive symptoms in the oldest-old: the role of sensory impairments. Arch Gerontol Geriatr. 2018;78:249–254. doi:10.1016/j.archger.2018.07.009

27. Keidser G, Seeto M, Rudner M, Hygge S, Ronnberg J. On the relationship between functional hearing and depression. Int J Audiol. 2015;54(10):653–664. doi:10.3109/14992027.2015.1046503

28. Kim SY, Kim HJ, Park EK, Joe J, Sim S, Choi HG. Severe hearing impairment and risk of depression: a national cohort study. PLoS One. 2017;12(6):e0179973. doi:10.1371/journal.pone.0179973

29. Tseng CC, Hu LY, Liu ME, Yang AC, Shen CC, Tsai SJ. Risk of depressive disorders following sudden sensorineural hearing loss: a nationwide population-based retrospective cohort study. J Affect Disord. 2016;197:94–99. doi:10.1016/j.jad.2016.03.020

30. Blazer DG. Depression in late life: review and commentary. J Gerontol. 2003;58A(3):249–265.

31. Basso M, Combs D, Purdie R, Candilis P, Bornstein R. Neuropsychological correlates of symptom dimensions in inpatients with major depressive disorder. Psychiatry Res. 2013;207(1–2):61–67. doi:10.1016/j.psychres.2013.01.018

32. Chou KL. Combined effect of vision and hearing impairment on depression in older adults: evidence from the english longitudinal study of ageing. J Affect Disord. 2008;106(1–2):191–196. doi:10.1016/j.jad.2007.05.028

33. Gopinath B, Schneider J, McMahon CM, Teber E, Leeder SR, Mitchell P. Severity of age-related hearing loss is associated with impaired activities of daily living. Age Ageing. 2012;41(2):195–200. doi:10.1093/ageing/afr155

34. Sheppard K, Badger T. The lived experience of depression among culturally deaf adults. J Psychiatr Ment Health Nurs. 2010;17(9):783–789. doi:10.1111/j.1365-2850.2010.01606.x

35. McDonnall MC. The effects of developing a dual sensory loss on depression in older adults: a longitudinal study. J Aging Health. 2009;21(8):1179–1199. doi:10.1177/0898264309350077

36. Hovaldt HB, Lund R, Lehane CM, Dammeyer J. Relational strain in close social relations among older adults with dual sensory loss. Br J Vis Impair. 2019. 0264619619833421. doi:10.1177/0264619619833421

37. Oberg M, Bohn T, Larsson U. Short- and long-term effects of the modified Swedish version of the Active Communication Education (ACE) program for adults with hearing loss. J Am Acad Audiol. 2014;25(9):848–858. doi:10.3766/jaaa.25.9.7

38. Pennix BWJH, Leveille S, Ferrucci L, van Eijk JT, Guralnik JM. Exploring the effect of depression on physical disability: longitudinal evidence from the established populations for epidemiologic studies of the elderly. Am J Public Health. 1999;89(9):1346–1352. doi:10.2105/AJPH.89.9.1346

39. Schneider J, Gopinath B, McMahon C, et al. Prevalence and 5-year incidence of dual sensory impairment in an older Australian population. Ann Epidemiol. 2012;22(4):295–301. doi:10.1016/j.annepidem.2012.02.004

40. Blazer DG, Tucci DL. Hearing loss and psychiatric disorders: a review. Psychol Med. 2019;49(6):891–897. doi:10.1017/S0033291718003409

41. West JS. Hearing impairment, social support, and depressive symptoms among U.S. adults: A test of the stress process paradigm. Soc Sci Med. 2017;192:94–101. doi:10.1016/j.socscimed.2017.09.031

42. Anderson G, Berk M, Maes M. Biological phenotypes underpin the physio-somatic symptoms of somatization, depression, and chronic fatigue syndrome. Acta Psychiatr Scand. 2014;129(2):83–97. doi:10.1111/acps.12182

43. Rutherford BR, Brewster K, Golub JS, Kim AH, Roose SP. Sensation and psychiatry: linking age-related hearing loss to late-life depression and cognitive decline. Am J Psychiatry. 2018;175(3):215–224. doi:10.1176/appi.ajp.2017.17040423

44. Cosh S, Carriere I, Daien V, Tzourio C, Delcourt C, Helmer C. Sensory loss and suicide ideation in older adults: findings from the Three-City cohort study. Int Psychogeriatr. 2019;31(1):139–145. doi:10.1017/S104161021800056X.

45. Cukrowicz KC, Cheavens JS, Van Orden KA, Ragain RM, Cook RL. Perceived burdensomeness and suicide ideation in older adults. Psychol Aging. 2011;26(2):331–338. doi:10.1037/a0021836

46. Stickley A, Koyanagi A. Loneliness, common mental disorders and suicidal behavior: findings from a general population survey. J Affect Disord. 2016;197:81–87. doi:10.1016/j.jad.2016.02.054

47. Pronk M, Deeg DJ, Kramer SE. Hearing status in older persons: a significant determinant of depression and loneliness? Results from the Longitudinal Aging Study Amsterdam. Am J Audiol. 2013;22(2):316–320. doi:10.1044/1059-0889(2013/12-0069)

48. Stevens G, White R, Flaxman S. Global prevalence of vision impairment and blindness: magnitude and temporal trends, 1990–2010. Ophthalmology. 2013;120:2377–2384. doi:10.1016/j.ophtha.2013.05.025

49. Contrera KJ, Betz J, Deal J, et al. Association of hearing impairment and anxiety in older adults. J Aging Health. 2017;29(1):172–184. doi:10.1177/0898264316634571

50. Cosh S, Nael V, Carriere I, et al. Bidirectional associations of vision and hearing loss with anxiety: prospective findings from the Three-City Study. Age and Ageing. 2018;47(4):582–589. doi:10.1093/ageing/afy062.

51. Pennix BWJH. Depression and anxiety: their insidious dance. Lancet Psychiatry. 2015;2(6):479–480. doi:10.1016/S2215-0366(15)00118-2

52. van der Aa HP, Comijs HC, Penninx BW, van Rens GH, van Nispen RM. Major depressive and anxiety disorders in visually impaired older adults. Invest Ophthalmol Vis Sci. 2015;56(2):849–854. doi:10.1167/iovs.14-15848

53. Chung SD, Hung SH, Lin HC, Sheu JJ. Association between sudden sensorineural hearing loss and anxiety disorder: a population-based study. Eur Arch Otorhinolaryngol. 2015;272(10):2673–2678. doi:10.1007/s00405-014-3235-8

54. Maharani A, Dawes P, Nazroo J, Tampubolon G, Pendleton N. Longitudinal relationship between hearing aid use and cognitive function in older Americans. J Am Geriatr Soc. 2018;66(6):1130–1136. doi:10.1111/jgs.15363

55. Lin FR, Yaffe K, Xia J, et al. Hearing loss and cognitive decline in older adults. JAMA Intern Med. 2013;173(4):293–299. doi:10.1001/jamainternmed.2013.1868

56. Dawes P, Emsley R, Cruickshanks KJ, et al. Hearing loss and cognition: the role of hearing AIDS, social isolation and depression. PLoS One. 2015;10(3):e0119616. doi:10.1371/journal.pone.0119616

57. Lin FR, Albert M. Hearing loss and dementia - who is listening? Aging Ment Health. 2014;18(6):671–673. doi:10.1080/13607863.2014.915924

58. Rudner M, Seeto M, Keidser G, Johnson B, Rönnberg J. Poorer speech reception threshold in noise is associated with lower brain volume in auditory and cognitive processing regions. J Speech Lang Hear Res. 2019;62(4S):1117–1130. doi:10.1044/2018_JSLHR-H-ASCC7-18-0142

59. Blazer DG. Hearing loss: the silent risk for psychiatric disorders in late life. Psychiatr Clin North Am. 2018;41(1):19–27. doi:10.1016/j.psc.2017.10.002

60. Tatum PE, Talebreza S, Ross JS. Geriatric assessment: an office-based approach. Am Fam Physician. 2018;97(12):776–784.

61. Vaccaro R, Zaccaria D, Colombo M, Abbondanza S, Guaita A. Adverse effect of self-reported hearing disability in elderly Italians: results from the InveCe.Ab study. Maturitas. 2019;121:35–40. doi:10.1016/j.maturitas.2018.12.009

62. Davis A, Smith P. Adult hearing screening: health policy issues–what happens next? Am J Audiol. 2013;22(1):167–170. doi:10.1044/1059-0889(2013/12-0062)

63. Hallam R, Ashton P, Sherbourne K, Gailey L. Acquired profound hearing loss: mental health and other characteristics of a large sample. Int J Audiol. 2006;45(12):715–723. doi:10.1080/14992020600957335

64. Ekberg K, Grenness C, Hickson L. Addressing patients’ psychosocial concerns regarding hearing aids within audiology appointments for older adults. Am J Audiol. 2014;23(3):337–350. doi:10.1044/2014_AJA-14-0011

65. Chachamovich E, Fleck M, Laidlaw K, Power M. Impact of major depression and subsyndromal symptoms on quality of life and attitudes toward aging in an international sample of older adults. Gerontologist. 2008;48(5):593–602. doi:10.1093/geront/48.5.593

66. Karawani H, Jenkins K, Anderson S. Restoration of sensory input may improve cognitive and neural function. Neuropsychologia. 2018;114:203–213. doi:10.1016/j.neuropsychologia.2018.04.041

67. Karawani H, Jenkins K, Anderson S. Neural and behavioral changes after the use of hearing aids. Clin Neurophysiol. 2018;129(6):1254–1267. doi:10.1016/j.clinph.2018.03.024

68. Castiglione A, Benatti A, Velardita C, et al. Aging, cognitive decline and hearing loss: effects of auditory rehabilitation and training with hearing aids and cochlear implants on cognitive function and depression among older adults. Audiol Neurootol. 2016;21(Suppl 1):21–28. doi:10.1159/000448350

69. Manrique-Huarte R, Calavia D, Huarte Irujo A, Giron L, Manrique-Rodriguez M. Treatment for hearing loss among the elderly: auditory outcomes and impact on quality of life. Audiol Neurootol. 2016;21(Suppl 1):29–35. doi:10.1159/000448352

70. Nkyekyer J, Meyer D, Pipingas A, Reed NS. The cognitive and psychosocial effects of auditory training and hearing aids in adults with hearing loss. Clin Interv Aging. 2019;14:123–135. doi:10.2147/CIA.S183905

71. Acar B, Yurekli MF, Babademez MA, Karabulut H, Karasen RM. Effects of hearing aids on cognitive functions and depressive signs in elderly people. Arch Gerontol Geriatr. 2011;52(3):250–252. doi:10.1016/j.archger.2010.04.013

72. Wallhagen MI, Reed NS. Implications of hearing care policy for nurses. J Gerontol Nurs. 2018;44(9):9–14. doi:10.3928/00989134-20180808-04

73. McCormack A, Fortnum H. Why do people fitted with hearing aids not wear them? Int J Audiol. 2013;52(5):360–368. doi:10.3109/14992027.2013.769066

74. Bennett RJ, Laplante-Levesque A, Eikelboom RH. How do hearing aid owners respond to hearing aid problems?. Ear Hear. 2019;40(1):77–87. doi:10.1097/AUD.0000000000000595

75. Hogan A, O’Loughlin K, Miller P, Kendig H. The health impact of a hearing disability on older people in Australia. J Aging Health. 2009;21(8):1098–1111. doi:10.1177/0898264309347821

76. Ketterer MC, Knopke S, Haussler SM, et al. Asymmetric hearing loss and the benefit of cochlear implantation regarding speech perception, tinnitus burden and psychological comorbidities: a prospective follow-up study. Eur Arch Otorhinolaryngol. 2018;275(11):2683–2693. doi:10.1007/s00405-018-5135-9

77. Choi JS, Betz J, Li L, et al. Association of using hearing aids or cochlear implants with changes in depressive symptoms in older adults. JAMA Otolaryngol Head Neck Surg. 2016;142(7):652–657. doi:10.1001/jamaoto.2016.0700

78. Nieman CL, Marrone N, Mamo SK, et al. The baltimore hears pilot study: an affordable, accessible, community-delivered hearing care intervention. Gerontologist. 2017;57(6):1173–1186. doi:10.1093/geront/gnw153

79. Jones CA, Siever J, Knuff K, et al. Walk, talk and listen: a pilot randomised controlled trial targeting functional fitness and loneliness in older adults with hearing loss. BMJ Open. 2019;9(4):e026169. doi:10.1136/bmjopen-2018-026169

80. Carlsson PI, Hjaldahl J, Magnuson A, et al. Severe to profound hearing impairment: quality of life, psychosocial consequences and audiological rehabilitation. Disabil Rehabil. 2015;37(20):1849–1856. doi:10.3109/09638288.2014.982833

81. Williams KC, Falkum E, Martinsen EW. A cognitive therapy program for hearing-impaired employees suffering from mental distress. Int J Audiol. 2015;54(4):227–233. doi:10.3109/14992027.2014.958621

82. Molander P, Hesser H, Weineland S, et al. Internet-based acceptance and commitment therapy for psychological distress experienced by people with hearing problems: a pilot randomized controlled trial. Cogn Behav Ther. 2018;47(2):169–184. doi:10.1080/16506073.2017.1365929

83. Senra H, Barbosa F, Ferreira P, et al. Psychologic adjustment to irreversible vision loss in adults: a systematic review. Ophthalmology. 2015;122(4):851–861. doi:10.1016/j.ophtha.2014.10.022

84. Garnefski N, Kraaij V. Cognitive coping and goal adjustment are associated with symptoms of depression and anxiety in people with acquired hearing loss. Int J Audiol. 2012;51(7):545–550. doi:10.3109/14992027.2012.675628

85. Soskin DP, Carl JR, Alpert J, Fava M. Antidepressant effects on emotional temperament: toward a biobehavioral research paradigm for major depressive disorder. CNS Neurosci Ther. 2012;18(6):441–451. doi:10.1111/j.1755-5949.2012.00318.x

86. Fang X, Zhang C, Wu Z, et al. The association between somatic symptoms and suicidal ideation in Chinese first-episode major depressive disorder. J Affect Disord. 2019;245:17–21. doi:10.1016/j.jad.2018.10.110

87. Weineland SM, Andersson G, Lunner T, et al. Bridging the gap between hearing screening and successful rehabilitation: research protocol of a randomized controlled trial of motivational interviewing via internet. Am J Audiol. 2015;24(3):302–306. doi:10.1044/2015_AJA-15-0012

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