Original Article

Correlation between the Degree of Hearing Loss and the

Levels of Anxiety and Depression in Patients with Tinnitus
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Lin Zhang, Huanle Du, Huihua You

Department of Otorhinolaryngology, Head and Neck Surgery, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang, China
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Abstract
Objectives: This study aimed to explore the correlation between the degree of hearing loss (HL) and the degrees of anxiety and depression in
patients with tinnitus. Materials and Methods: This retrospective study involved the use of basic clinical data from 600 enrolled patients with
tinnitus who visited the otolaryngology clinic in Affiliated Jinhua Hospital, Zhejiang University School of Medicine from April 2020 to June
2022. The tinnitus handicap inventory (THI) scale was used to assess the tinnitus status among the participants. The pure tone audiometry
(PTA) test was used to conduct audiological assessments for all patients to determine their hearing condition. The self-rating anxiety scale
(SAS) and self-rating depression scale (SDS) were used to assess the levels of anxiety and depression among the participants, respectively. The
correlation between the HL and anxiety/depression scores from the questionnaires was tested through Pearson correlation analysis. Results:
Among the 600 enrolled patients with tinnitus, most patients had mild-to-moderate degree of tinnitus, accounting for 248 cases (41.3%) and
179 cases (29.8%), respectively. PTA results showed that a large proportion of patients with tinnitus were accompanied with HL (467 cases,
77.8%). Among them, patients with mild HL accounted for the largest proportion with a total of 241 cases (40.2%). Based on the results of
SAS and SDS test, almost half of the patients had symptoms of anxiety and depression, accounting for 52.3% (314 cases) and 48.8% (293
cases), respectively. Similarly, patients with mild anxiety and depression occupy the largest proportion, accounting for 35.8% (215 cases) and
23% (138 cases), respectively. Pearson correlation analysis showed that the degree of HL was closely related to THI/SAS/SDS scores
(P < 0.001). Conclusion: These findings indicate a strong positive correlation between the degree of HL and anxiety/depression scores in
patients with tinnitus.

Keywords: Tinnitus, Hearing loss, Anxiety, Depression, Self-rating anxiety scale, Self-rating depression scale

INTRODUCTION form the basis for the formation of tinnitus.[7] Therefore, HL

Tinnitus is a widely known heterogenous disease, which is
specifically defined as a patient producing an illusory sound
perception in the absence of a corresponding external sound
source.[1,2] It is mainly classified into subjective tinnitus and
objective tinnitus. The former is only perceived by the
patients and is the most widespread type of tinnitus.
Besides, the examiner can hear objective tinnitus, and the
patient can perceive objective tinnitus.[3] In a 35-year
demographic study among adults, the global incidence of
tinnitus varies from 5.1 to 42.7%, and it increases with noise
sensitivity and age.[4] In China, the incidence rate of tinnitus
increased obviously over the age of 50 years and stabilizes at
about 32% over the age of 70 years.[5] Tinnitus is thought to
be caused by auditory and somatosensory dysfunction. It has
been hypothesized that the imbalance can result from
cochlear lesions caused by hearing loss (HL).[6,7] HL may
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can be considered as a risk factor for tinnitus.[8]
Approximately 90% of tinnitus cases occur with underlying
HL.[9] However, some patients with tinnitus have normal
hearing by conventional audiometry, and no subjective HL or
worsening of HL occurs when new tinnitus occurs.[10]
Approximately 85 to 96% of patients with tinnitus have
Address for correspondence: Huihua You,
Department of Otorhinolaryngology, Head and Neck Surgery,
Affiliated Jinhua Hospital, Zhejiang University School of Medicine,
365 Mingyue Road, Jinhua city, Zhejiang, China.
E-mail: entyhh@163.com
Received: 15 June 2023 Revised: 25 August 2023
Accepted: 27 August 2023 Published: 28 September 2023
This is an open access journal, and articles are distributed under the terms of the
Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows
others to remix, tweak, and build upon the work non-commercially, as long as
appropriate credit is given and the new creations are licensed under the identical
terms.

For reprints contact: reprints@medknow.com

DOI: How to cite this article: Zhang L, Du H, You H. Correlation between the
10.4103/nah.nah_46_23 Degree of Hearing Loss and the Levels of Anxiety and Depression in
Patients with Tinnitus. Noise Health 2023;25:195-201.

© 2023 Noise & Health | Published by Wolters Kluwer - Medknow 195

 Zhang et al.: Correlation between hearing and the levels of anxiety and depression in patients with tinnitus
varying degrees of HL. These symptoms caused by tinnitus
can seriously affect the daily life of patients.[11]
Approximately 20% of tinnitus cases are severely
debilitating, making it difficult to perform daily activities
and causing inconvenience to patients in their daily life.[4]
Tinnitus and mood disorders have a specific association.[12]
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Patients with tinnitus as their main symptom may develop
mental comorbidities such as anxiety and depression. In the
previous studies, depression and anxiety have been identified
as the predictive factor for the chronic painful tinnitus.[13]
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Previous research has also explored the relationship between
the pain of tinnitus and depressive symptoms and shown a
significant correlation.[14] Besides, anxiety and depression
also result in a lower quality of life for patients.[15] The
anxiety prevalence rate of tinnitus patients is 24 to 42.1%, and
the anxiety prevalence rate of the general population is
7.3%.[16] In a previous study, patients with tinnitus had an
apparently higher prevalence rate of depression than the
participants without tinnitus.[7]
Limited studies have focused on the correlation between the
degree of hearing impairment and the degree of anxiety and
depression in patients with tinnitus. In the present study, the
tinnitus handicap inventory (THI) scale was used to detect the
tinnitus scores of patients with tinnitus. Pure tone audiometry
(PTA) test was used to detect the degree of HL in patients
with tinnitus. Self-rating anxiety scale (SAS) and self-rating
depression scale (SDS) were used to assess patients’ anxiety
and depression scores. The association between HL and
symptoms of psychiatric disorders was also explored to
provide supplement to the literature. In addition, it can
provide a reference for doctors to improve patients’
anxiety and depression from the perspective of improving
their hearing.
MATERIALS AND METHODS
This retrospective study included 600 patients with tinnitus as
a primary complaint who visited our otolaryngology clinic
during April 2020 to June 2022. The formula for calculating
sample size is n = (Z2 × 2)/d2, where Z is the confidence
interval, n is the sample size, d is the sampling error range,
and  is the standard deviation, usually taken as 0.5. The
inclusion criteria are as follows: (1) tinnitus as the primary
complaint of patients, with or without various types of HL; (2)
patients experiencing subjective tinnitus; (3) >18 and <65
years old[17]; (4) patients having good communication skill;
(5) written informed consent signed by patients and their
families; and (6) patients with complete clinical data. The
exclusion criteria are as follows: (1) patients who could not
cooperate with audiological and tinnitus examination
normally; (2) severe mental diseases or undergoing anti-
anxiety or depression treatment; (3) pulsatile tinnitus,
somatosounds, or objective tinnitus; (4) pregnant and
lactating women; (5) auditory nerve or traumatic brain
injury and other organic lesions; (6) patients with
incomplete clinical data; and (7) patients with the
196
incomplete clinical data. All patients were informed and
signed informed consent for this study. This study was
approved by the.
Ethics Committee of the Hospital
The general data of patients in each group were collected,
including gender, age, tinnitus side, duration of tinnitus, and
degree of the anxiety and depression. All patients completed
audiological assessment and Chinese version scales including
the THI, SAS, and SDS test. Based on whether the patient has
experienced HL, the participants were divided into two groups,
namely, the normal hearing (control) and HL group. Next,
according to the degree of the HL, the HL group was further
divided into four subgroups, namely, the mild HL (MHL)
subgroup, moderate HL (Mod HL) subgroup, severe HL
(SHL) subgroup, and profound HL (PHL) subgroup.
Measurement of Tinnitus
All patients accepted the THI test, which quantifies the
influence of tinnitus on daily life through score and
determined the severity. The study was conducted using
the Chinese–Mandarin type tinnitus disability evaluation
scale (THI-CM).[18] The THI scale was composed of three
subscales with the aims of evaluating the functional,
emotional, and catastrophic effects of tinnitus.[19] It
includes 25 questions for 100 points in total. Each
question has three choices, namely, Yes (4 points),
Occasionally (2 points), and No (0 points). Patients were
allowed to make their choice based on their own situation.
The severity of tinnitus was divided into five grades
according to the following THI scores: slight (0–16
points), mild (18–36 points), moderate (38–56 points),
severe (58–76 points), and catastrophic (78–100 points).
Audiologic Assessments
The PTA test was used to conduct audiological assessments
for all patients by using the pure tone audiometer (AD104,
Melison Medical Instrument Co Ltd, Guangzhou City,
Guangdong Province, China). The participants accepted
tests in the sound-attenuating room and needed to stay
awake during the tests. The average pure-tone hearing
threshold is the arithmetic mean of 0.5, 1, 2, and 4 Hz
hearing thresholds. The hearing threshold of the right side
was tested to calculate the pure-tone threshold in bilateral
tinnitus patients. Normal hearing was defined as a constant
frequency audiometry threshold <25 decibels (dB). HL
degree was classified according to the revised criteria of
the World Health Organization (WHO) as follows[20]:
normal (0–25 dB), mild (26–40 dB), moderate (41–60 dB),
severe (61–80 dB), and profound (>80 dB). Based on the
degree of HL, the patients were divided into four groups,
namely, the MHL, Mod HL, SHL, and PHL.
Assessment of Anxiety and Depression
The SAS developed by Zung[21] was used to assess an
individual’s anxiety degree in the last week. The SAS
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 Zhang et al.: Correlation between hearing and the levels of anxiety and depression in patients with tinnitus

consisted of 20 projects, each divided into four levels. One
point represents “no or very little time,” while four points
means “most or all of the time.” The SAS is frequently used
because of its reliability and validity.[22] The Cronbach’s
alpha between items was 0.820.[23] The SAS standard score is
the total score of each item multiplied by 1.25. The SAS
standard score ≥50 represents anxiety state. Higher scores
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For tinnitus and HL detection, the testers should be skilled in
operating the detection equipment, master the detection
method, operate according to the standard operation
method, and accurately record the test results. For the
completion of SAS and SDS scales, testers should make
patients fully understand the scoring rules of all scales and
the specific meaning of each item, and make patients give true

indicate more severe anxiety. Grading was based on the answers in the test process, so that the measurement results
following SAS scores: mild anxiety level (50–59 points), are authentic and credible.
moderate anxiety level (60–69 points), and severe anxiety
level (≥70 points). Statistical Analysis
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SDS test was conducted to assess an individual’s depressive SPSS 23.0 statistical software (IBM Corp, Armonk, NY,
behavior over the last week.[24] The SDS consisted of 20 USA) was utilized to analyses the included participants’
items, and each item was scored at four levels. One point clinical data (age). Figures 1 to 3 were made with Excel
means “no or very little time,” while four points means “most 2016 (Microsoft, DC, USA). The correction between HL and
or all of the time.” The Cronbach’s alpha between items was anxiety/depression scores from the questionnaires were tested
0.840.[23] The SDS standard score is the total score of each using Pearson correlation analysis. Continuous variables are
item multiplied by 1.25. The SDS standard score <53 presented as mean ± standard deviation (SD), while
represents no depression. Higher scores indicate more categorical variables are presented as number (n) and
severe depression. Grading was based on the following percentage (%).
SDS scores: mild depression level (53–62 points),
moderate anxiety level (63–72 points), and severe RESULTS
depression level (72 points). Patient Characteristics
Table 1 presents the patients’ general characteristics. Among
the 600 participants, 245 were female (40.8%). The patient’s
age is between 21 and 65 years with an average age of
Table 1: Patients’ Characteristics.
49.96 ± 10.11 years. Audiologic assessments results, the
Characteristics All patients n = 600 THI score, SAS, and SDS score classification were obtained.
Age (years, mean ± SD) 49.96 ± 10.11
Gender, n (%) Male 355 (59.2) Comparison of Tinnitus Status in Patients among
Female 245 (40.8) Groups with Different Degrees of Hearing Loss
Side of tinnitus, n (%) Right 135 (22.5)
Based on the data, Figure 1 shows the measurement results of
Left 205 (34.2)
tinnitus through the THI [Figure 1]. The results showed that
Bilateral 260 (43.3)
the THI rating of tinnitus in the normal group was better than
Duration of tinnitus (month) <3 months 195 (32.5)
3–6 months 68 (11.3)
the other four hearing impairment groups (MHL, Mod HL,
>6 months 337 (56.2)
SHL, PHL group). In the normal group, 131 patients (98.5%)
HL status, n (%) Control 133 (22.2) were classified under slight THI, and no patients were
Mild 241 (40.2) classified under severe or catastrophic THI. The THI
Moderate 130 (21.7) grading of tinnitus also differed among patients in
Severe 75 (12.5) different HL groups. In the MHL group, 232 patients were
Profound 21 (3.5) classified under mild THI, accounting for 96.3%. A large
THI scores, n (%) Slight 136 (22.7) percentage of patients in the Mod HL group had moderate
Mild 248 (41.3) THI (115 cases, 88.5%), 46 cases in the SHL group had
Moderate 179 (29.8) moderate THI (61.3%), and 13 cases in the PHL group had
Severe 24 (4.0) moderate THI (61.9%). In the SHL and PHL groups, more
Catastrophic 13 (2.2) patients with SHL experienced severe tinnitus, as known
SAS scores, n (%) Normal 286 (47.7) from THI results.
Mild 215 (35.8)
Moderate 87 (14.5)
Comparison of Self-rating Anxiety Scale Status in
Severe 12 (2.0)
SDS scores, n (%) Normal 307 (51.2)
Patients among Groups with Varying Degrees of
Mild 138 (23.0) Hearing Loss
Moderate 128 (21.3) Figure 2 shows the analysis of the SAS scores of each group.
Severe 27 (4.5) In the control group, 131 patients (98.5%) had normal SAS
SAS = self-rating anxiety scale, SDS = self-rating depression scale, grade and did not feel anxiety. In the MHL group, the SAS
THI = tinnitus handicap inventory. grades of normal and MHL groups were the highest,

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 Zhang et al.: Correlation between hearing and the levels of anxiety and depression in patients with tinnitus

had moderate and severe SDS grades, and no normal and

250 232
mild cases were recorded. In the SHL group, the SDS grade
200 was moderate in 57 cases, accounting for a large proportion of
76%. In the PHL group, 12 patients (57.1%) had moderate
Number of patients

150 131 SDS, and 9 patients (42.9%) had severe SDS. Similar to the
115
SAS score, the more severe the HL of patients with tinnitus,
100
the more severe the depression of patients.
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46
50 22
15 7 0 0 13 2 6
1100 5 400 0 00 00 Relationships between Hearing Loss Degree and
0
Control Mild HL Mod HL SHL PHL Anxiety/Depression/Tinnitus Levels
PTA results reflected the HL status. Normal hearing is
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Slight Mild Moderate Severe Catastrophic

defined as a constant frequency audiometry threshold
Figure 1: Comparison of tinnitus status in each hearing loss (HL) <25 dB, while values >25 dB indicate that different HL
groups. HL = hearing loss, PHL = profound HL, SHL = severe HL.
degrees occur. As shown in Table 2, the Pearson
correlation analysis exhibited a strong correlation between
HL degree and anxiety/depression levels and was remarkably
180 associated with HL and THI scores (all P values <0.001).
160 154
Based on the scatter plot, the more severe the HL, the higher
140 131 125 the SAS and SDS scores, indicating a positive correlation
Number of patients

120 between HL and the degree of anxiety and depression

100 87
[Figures 4 and 5].
80 69
60
40 DISCUSSION
20 14
2 0 0 0 0 1 4 0 0 0 6 0 1 6 This study aimed to explore the correlation of anxiety,
0 depression, and hearing impairment in patients with
Control Mild HL Mod HL SHL PHL
tinnitus. This study found a positive correlation between
Normal Mild Moderate Severe
the situation of tinnitus and HL among participants. The
Figure 2: Comparison of patients in different hearing loss (HL) groups degree of HL in patients with tinnitus is positively
and control group in terms of self-rating anxiety scale (SAS). correlated with the anxiety, depression, and tinnitus levels.
HL = hearing loss, PHL = profound HL, SHL = severe HL.

Table 2: Results of Pearson Correlation Analysis of the

including 154 (63.9%) and 87 (36.1%) cases, respectively. Hearing Loss Degree and Self-rating Anxiety Scale/Self-
Neither the control group nor the MHL group involved rating Depression/Tinnitus Handicap Inventory Scores.
moderate and severe patients with SAS grading. In the SAS Scores SDS Scores THI Scores
Mod HL group, the SAS grade was mainly mild,
PTA results Rho P value Rho P value Rho P value
accounting for 96.2% (125 cases). In the SHL and PHL
groups, the highest number of cases were classified as 0.781 <0.001 0.792 <0.001 0.808 <0.001
moderate by SAS, involving 69 (92%) and 14 cases PTA = pure tone audiometry, SAS = self-rating anxiety scale, SDS = self-
(66.7%), respectively, and no patients were classified as rating depression scale, THI = tinnitus handicap inventory.
normal based on SAS. Hence, in the present study, the
SAS scores increased with the degree of HL in patients
with tinnitus. 200
176
180
160
Comparison of Self-rating Depression Scale Status in 140 131
Patients among Groups with Different Degrees of
Number of patients

120
Hearing Loss 100
80 73
64 57 57
The SDS scores of each group were analyzed to observe the 60
depression in different HL groups. As shown in Figure 3, in 40
18 12 9
the control group, 131 patients (98.5%) had normal SDS 20 1 1 0 1 0 0 0 0 0 0 0
grades. In the MHL group, the number of patients with SDS 0
Control Mild HL Mod HL SHL PHL
grade of normal was the largest, accounting for 73% (176
Normal Mild Moderate Severe
cases), followed by mild cases (64 cases, 26.6%). In the Mod
HL group, the SDS grade was mainly mild and moderate, Figure 3: Comparison of patients in different hearing loss (HL) groups
including 73 cases (56.2%) and 57 cases (43.8%), and control group in terms of self-rating depression scale (SDS).
respectively. In both the SHL and PHL groups, patients HL = hearing loss, PHL = profound HL, SHL = severe HL.

198 Noise & Health ¦ Volume 25 ¦ Issue 118 ¦ July-September 2023

 Zhang et al.: Correlation between hearing and the levels of anxiety and depression in patients with tinnitus
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Figure 4: Correlation between the hearing loss status and anxiety
degree. PTA = pure tone audiometry, SAS = self-rating anxiety scale.
In the current study, the patients’ general characteristics
showed that most of the patients with tinnitus in our
hospital have mild-to-moderate tinnitus (71.1%), and most
of them experience HL, anxiety, and depression as well.
Among the research participants in the tinnitus population,
467 patients had symptoms of HL, accounting for 77.8%. In a
recent study among 8539 participants, Hackenberg et al.[7]
analyzed the incidence of hearing impairment in patients with
tinnitus and those without tinnitus. The incidence of mild-to-
severe hearing impairment was 51.4% in tinnitus patients and
2% in those participants without. The incidence of hearing
impairment was higher in patients with tinnitus than in those
without tinnitus. Compared with this study, all the subjects in
the current study experience tinnitus. Hence, the rate of HL in
this study increased. Previous studies have reported an
association between patients with tinnitus and HL possibly
because the risk of HL increases with age.[25-27] The results of
the study showed a strong correlation between THI score and
PTA results in patients with tinnitus, which was similar to the
previous research results of Waechter,[28] who explored the
relationship between hearing status and tinnitus disturbance
and found that THI score was positively correlated with the
average tinnitus side hearing threshold of 0.5 to 4 kHz. Aazh
et al.[29] also discussed the relationship between tinnitus
degree and pure tone hearing threshold and found that the
increase in tinnitus loudness was related to the deterioration
of PTA. In different hearing groups in our study, THI grading
also differed, and the more severe the HL, the more severe the
THI degree, which was similar to the results of previous
studies.
Tinnitus is often accompanied by emotional changes in
patients, thus affecting the quality of life of patients. In the
current study, SAS was used to quantify the anxiety levels of
the patients, and the results showed that 314 patients (52.3%)
had anxiety. Belli et al.[30] compared 90 outpatient patients
with tinnitus and normal people and observed that 18.9% of
Noise & Health ¦ Volume 25 ¦ Issue 118 ¦ July-September 2023
Figure 5: Correlation between the hearing loss status and depression
degree. PTA = pure tone audiometry, SDS = self-rating depression
scale.
patients experience anxiety disorders. The scores of anxiety
and depression in patients with tinnitus were significantly
higher than those in the normal control group. In addition, the
depressive state of patients was quantified based on the SDS,
and 293 patients (48.8%) had different degrees of depressive
mood. A recent systematic review found that the median
prevalence of depression in adults with tinnitus was 33%
(quartile range 19–49%).[31] A large study of tinnitus patients
quantified the relationship between tinnitus, anxiety, and
depression and found that 26.1% of tinnitus participants
developed symptoms of anxiety and 25.6% of tinnitus
participants developed symptoms of depression.[32]
However, a study showed that 52.2% of 1490 people with
chronic tinnitus reported depression.[33] The rate of mood
disorders in patients with tinnitus in this study was similar to
that in the present study. Taken together, anxiety/depression
symptoms are associated with patients with tinnitus to
varying degrees.[34] Anxiety, depression, and other related
symptoms already exist when tinnitus occurs. In turn,
physical and emotional exhaustion promote the patient’s
perception of tinnitus sound, which negatively affect the
processing and experience of tinnitus.[35]
The emotional effects of tinnitus are related to the discomfort
associated with HL.[11] The correlation between HL and
anxiety and depression was further explored in patients
with tinnitus. The distribution of anxiety/depression levels
differed across different HL groups. Anxiety/depression
levels increased as HL increased. Wang et al. included
393 patients with tinnitus as research objects and found
that 19.85% were diagnosed with anxiety, and multiple
logistic regression analysis showed that the degree of HL
was an independent risk factor for anxiety.[16] Improving the
hearing status of patients with HL can enhance the levels of
199
 Zhang et al.: Correlation between hearing and the levels of anxiety and depression in patients with tinnitus
anxiety, depression, and tinnitus annoyance.[36,37] Based on
Pearson correlation analysis, HL can be associated with
emotional disorders in the participants, with a strong
correlation. Therefore, patients need to improve their
lifestyle, change their mental state, relieve emotional
changes, and use drugs for tinnitus treatment. This study
has certain limitations in terms of sample size and region, and
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future studies with larger samples and more hospitals are
needed to further evaluate the clinical characteristics of
tinnitus patients. Our study was a retrospective study, and
prospective studies can be carried out in the future for the
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 02/29/2024
treatment of HL in patients with tinnitus, such as wearing
hearing aids, to explore the improvement of emotional
disorders in patients. Accordingly, these results will reveal
the correlation between hearing and emotion in patients with
tinnitus.
CONCLUSION
In conclusion, hearing impairment, anxiety, and depression
caused by tinnitus cause great distress to patients, thus
affecting the quality of life and mental health of tinnitus
patients. Based on the results, the degree of HL and anxiety/
depression scores have a close positive relationship in
patients with tinnitus.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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