Association of Hearing Loss With Psychological Distress and Utilization of Mental Health Services Among Adults in the United States

Key Points Question What is the association between hearing, hearing aid use, psychological distress, and utilization of mental health services? Findings In this cross-sectional study using data from 25 665 participants in the 2017 National Health Interview Survey, hearing loss was associated with increased odds of psychological distress and increased utilization of mental health services. Hearing aid use was associated with decreased odds of psychological distress. Meaning The results of this study suggest that hearing loss may be a modifiable risk factor for psychological distress.


Introduction
Psychological distress is often characterized by depression and anxiety and is ranked by the World Health Organization as the single largest contributor to global disability. 1,2 Individuals with psychological distress have increased utilization of mental health services and have overall higher mental health and non-mental health care expenditures. 3,4 While the causes of psychological distress are complex and multifactorial, recent studies suggest that hearing impairment may be a modifiable risk factor for psychological distress in older adults. 5,6 Hearing loss (HL) is prevalent in two-thirds of adults older than 70 years 7 and could contribute to psychological distress. 5 Several authors have suggested that HL also contributes to depression, possibly mediated by increased social isolation and changes in brain structure related to HL. 5,6 Importantly, the mechanisms through which HL may affect these outcomes may be modifiable via treatments (ie, hearing aids) 8,9 that remain vastly underutilized among those with HL. 10 The existing literature suggests potential associations between HL and psychological distress, but studies have been limited by small sample sizes or nongeneralizable cohorts. [11][12][13][14] Whether HL could also be associated with mental health care and medication utilization and whether these associations could be modified through the use of hearing aids also remains unknown. In the present study, we analyze data from the 2017 National Health Interview Survey (NHIS) to describe the association between HL, psychological distress, and mental health care utilization and to conduct exploratory analyses to assess the association of hearing aid use with observed outcomes.

Analytic Cohort
The NHIS is an annual cross-sectional household interview survey conducted by the National Center for Health Statistics to evaluate the health of the civilian, noninstitutionalized US population. The survey uses a stratified multistage sample design with oversampling of individuals from minority groups. We used data from the 2017 sample, which consisted of a total of 26 734 adults aged 18 years and older. 15 Our primary analytic cohort comprised 25 665 individuals with complete data on hearing, covariates, and other outcomes of interest. The NHIS was evaluated and approved by the Research Ethics Review Board of the National Center for Health Statistics. Informed consent was obtained from the respondent to participate in the household interview. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

Hearing Assessment
Sample participants were asked by interviewers to rate the quality of their hearing without a hearing aid. Responses were analytically collapsed into 3 hearing categories, as follows: no HL (response of excellent hearing), mild HL (response of good hearing), and moderate or worse HL (responses of has a little trouble hearing, has moderate trouble hearing, has a lot of trouble hearing, or deaf). Prior published research has also collapsed these latter variables into a single variable. 16 Participants were also asked if they currently used a hearing aid.
Kessler scores were used in 3 analyses, as follows: a binary cutoff of at least 13, a binary cutoff of at least 5, and as a continuous variable. Interviewers also asked participants if they saw or talked to a mental health professional in the past 12 months. A total of 974 participants (3.6%) did not have complete data on the Kessler psychological distress scale.
A random sample of respondents were also asked a series of questions as part of the Adult Functioning and Disability Supplement to the NHIS. Those selected were asked if they used medications for feelings of depression or feelings of worry, nervousness, or anxiety, which were classified as antidepressant or antianxiety medication use, respectively. Approximately half of adults were randomly selected for these questions, yielding an unweighted group of 12 723 participants (49.6%) for antidepressant medication and 12 733 participants (49.6%) for antianxiety medication, respectively. Those with missing medication data were similar to those with medication data, but were less likely to report hypertension (OR, 0.87; 95% CI, 0.81-0.94), and less likely to be African American participants than white participants (OR, 0.87; 95% CI, 0.79-0.97).

Covariates
Self-reported demographic variables include age, race (white, African American, Asian American, or other), sex, marital status (married, widowed, divorced or separated, or never married), family income (<$50 000, $50 000 to $100 000, >$100 000, or unknown), highest education achieved (<12th grade, 12th grade, 1-3 years of college, or Ն4 years of college), and self-reported health status (excellent, very good, good, fair, or poor). Participants were asked if they had smoked 100 or more cigarettes in their life. A modified Charlson Comorbidity Index was also created using self-reported health conditions, which included 1 point each for asthma, emphysema, cardiac arrest, heart disease, stroke, diabetes, ulcer, liver disease, and renal disease and 2 points for cancer. 19 Age was not included in the modified Charlson Comorbidity Index because it was included separately in the regression analyses. A total of 163 adults (0.6%) had missing data on comorbidities.

Statistical Analysis
Analyses were conducted with sample weights provided by the NHIS to be representative of the civilian noninstitutionalized US population. Multiple logistic regression models and Poisson regression models with incident rate ratios were used to evaluate the association between levels of HL and outcomes of interest. Analyses of hearing aid use and outcomes of interest were limited to individuals with moderate or worse HL. Multivariate models included age, sex, race, family income, education, marital status, self-reported health, and cardiovascular comorbidities (ie, hypertension, diabetes, heart disease, stroke, and smoking history). A separate analysis was performed using the modified Charlson Comorbidity Index instead of individual cardiovascular comorbidities. Subgroup analyses were performed using a cutoff of 5 for the Kessler 6 score to assess effect modification by age (ie, <65 years vs Ն65 years) and sex. All analyses were completed using Stata version 13 (StataCorp). Statistical significance was set at P < .05, and all tests were 2-tailed.    We next investigated whether self-reported hearing loss was also associated with indicators of mental health care utilization (medication use and mental health services). In fully adjusted models ( We performed a sensitivity analysis evaluating the raw hearing data (not collapsed in 3 groups)

Results
in an adjusted logistic regression model in all ages using the cutoff of 5 for Kessler 6 scores. We performed additional sensitivity analyses to test the robustness of our observed results. The association between mild HL and a score of at least 5 on the Kessler 6 was significantly lower among those aged 65 years and older compared with those younger than 65 years (OR, 0.70; 95% CI, 0.54-0.90), and there was not a significant difference between age groups for moderate or worse HL (OR, 0.85; 95% CI, 0.65-1.10). Sex-stratified analyses yielded qualitatively similar results for both mild HL (OR, 0.95; 95% CI, 0.78-1.14) and moderate or worse HL (OR, 0.89; 95% CI, 0.72-1.11). Finally, we performed analyses adjusting for a modified Charlson Comorbidity Index rather than adjusting for individual cardiovascular risk factors, and the results did not differ substantively from the presented results (data not shown).

Discussion
In a large nationally representative sample of US adults, we observed an association between greater self-reported HL and increased odds of psychological distress. Compared with those with no HL, Prior studies have linked HL with a number of adverse health and quality-of-life outcomes.
Individuals with impaired hearing have been found to have greater rates of cognitive decline and incident dementia. 20- 26 The evidence for an association between hearing impairment and depression is mixed. Many larger studies identified increased odds of depressive symptoms with hearing impairment [11][12][13]27,28 ; however several smaller studies did not. 29,30 Several reviews provide a comprehensive analysis and discussion of the existing literature on hearing loss and depression. 5,6,31 The present study adds to the literature demonstrating the potential association of HL with psychological distress in the largest study, to our knowledge, of a population-representative cohort of noninstitutionalized US adults.
Importantly, findings from the present study demonstrate higher utilization of mental health medications and services in adults with HL. One prior study of 5328 Hispanic adults 14  The present study found that among those with moderate or worse HL, individuals who reported using hearing aids had lower rates of psychological distress than those who did not.
Additionally, adults younger than 65 years with HL who used hearing aids were less likely to use with HL are more likely to avoid social environments because of difficulty communicating. 38,39 Several neuroimaging studies have also found decreased activation and decreased volumes in several areas of the brain, including the primary auditory cortex; superior, middle, and inferior temporal gyri; thalamus; brainstem; and parahippocampus, 40 Our results suggest that hearing impairment may be a strong risk factor for psychological distress, which is reflected in increased rates of utilization of mental health medications and services.
Further longitudinal studies and clinical trials are needed to assess the basis of this association and whether treatments for HL could potentially lower rates of psychological distress and utilization of mental health care.

Limitations
This study has limitations. Our results are from a cross-sectional analysis that limits robust causal inference. While self-reported hearing has been validated as a reliable indicator of hearing measured with criterion-standard audiometry 43,44 and the prevalence of HL in our study was comparable with prior studies of US adults that used audiometric data, 45,46 other factors associated with selfassessment of hearing could potentially confound observed associations of HL with psychological distress. We accounted for these potential confounders by adjusting for both self-reported health and cardiovascular risk factors as well as by performing additional analysis with the modified Charlson Comorbidity Index, but residual confounding is still a possibility. Furthermore, our exploratory analyses suggesting that hearing aid use among those with moderate HL may be associated with reduced odds of psychological distress must be interpreted with caution. Individuals with HL using hearing aids vs those who do not use hearing aids are likely to differ across multiple measured (eg, income, education) and unmeasured (eg, health consciousness, health behaviors, family and social status) factors that cannot be fully accounted for in our analyses and may lead to a bias toward seeing beneficial associations with hearing aid use. In contrast, hearing aid use could also be indicative of individuals who are the most severely affected by HL, which could plausibly lead to a potential bias toward seeing hearing aid use as associated with greater psychological distress. We did observe an isolated finding of hearing aid use being associated with greater odds of reporting mental health care utilization by older adults, which is of unclear significance.

Conclusions
In this study, self-reported HL was associated with psychological distress, antidepressant and antianxiety medication use, and utilization of mental health services in a nationally representative sample of US adults. Further research is warranted to determine whether hearing loss may be a modifiable risk factor for psychological distress.