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Lugo A, Trpchevska N, Liu X, et al. Sex-Specific Association of Tinnitus With Suicide Attempts. JAMA Otolaryngol Head Neck Surg. Published online May 02, 2019145(7):685–687. doi:10.1001/jamaoto.2019.0566
Severe tinnitus has been shown to be strongly associated with depression and anxiety,1 and the only established approach to treat tinnitus is cognitive behavioral therapy.2 Our research group recently reported that the tinnitus-associated mental health burden is greater in women than in men, likely due to higher levels of anxiety and stress.3 Most of the evidence on the association of tinnitus with suicide came from case series studies, until a recent cross-sectional study reported that an increased risk of suicide attempts was associated with severe tinnitus.4 In the present study, we assessed whether this association would differ between men and women using data from a large population-based study, the Stockholm Public Health Cohort (SPHC).5
Study participants were adults from Stockholm County (Sweden) who participated in the 2010 version of the SPHC by completing a self-administered questionnaire. The study was approved by the Regional Ethical Review Board in Stockholm and informed written consent was obtained from all study participants. Tinnitus was assessed by the question “Do you have any of the following health problems or symptoms?” of which tinnitus was an option. Possible answers were “No; Yes (moderate problem); Yes (severe problem).” Patients with clinically ascertained tinnitus, diagnosed before 2010, were identified through record linkage with the National Patient register (International Statistical Classification of Diseases, Tenth Revision, code H93.1). Self-reports of suicide attempts were gathered by the question “Have you ever tried to take your own life? (Yes, more than a year ago; Yes, in the last year; Yes, in the last month; No, never).” Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) for lifetime suicide attempt were obtained using unconditional multiple logistic regression models after adjustment for a number of covariates, selected among the main known risk factors for both suicide attempts and tinnitus.
Among 71 542 SPHC participants, 2404 (3.4%) reported having attempted suicide (Table 1). Overall, 16 066 (22.5%) respondents reported having any tinnitus, 1995 (2.8%) had severe tinnitus, and 1484 (2.1%) had been diagnosed with tinnitus by a specialist. In all, 19.8% (395) of severe cases of tinnitus had been diagnosed by a specialist. The number of suicide attempts was higher among participants with any tinnitus (multivariate OR, 1.15; 95% CI, 1.03-1.28) and among those with severe tinnitus (OR, 1.32; 95% CI, 1.04-1.66) (Table 2). This association was not observed for those with a formal diagnosis of tinnitus (OR, 0.92; 95% CI, 0.67-1.26). In stratified analyses, the association between severe tinnitus and suicide attempt remained statistically significant only in women (OR, 1.57; 95% CI, 1.17-2.10).
This study used the SPHC as a resource for population-based research on tinnitus in Sweden, where it is highly prevalent. The association between tinnitus and suicide attempts may be similar to that of chronic pain, because the 2 conditions may have similar neurological bases.6 Severe tinnitus was associated with suicide attempts in women but not in men, suggesting that different pathophysiological mechanisms may operate in each sex. Moreover, individuals who had been diagnosed with (and possibly treated for) tinnitus were not at increased risk according to the data, suggesting that medical attention may remedy impairments in quality of life among patients with tinnitus.
The cross-sectional design of our study and the use of self-reported tinnitus are possible limitations. Furthermore, we were unable to retrieve diagnoses from primary care data. Thus, clinical diagnoses and care for tinnitus may be underestimated.
This study shows a sex-dependent association of tinnitus with suicide attempts, with severe tinnitus associated with suicide attempts in women but not in men. Since only a fifth of the participants with severe tinnitus were diagnosed by a specialist, there is a need for increasing resources toward the management of tinnitus in clinical practice. Furthermore, additional research is needed to understand the pathophysiological differences between men and women with tinnitus.
Accepted for Publication: March 2, 2019.
Published Online: May 2, 2019. doi:10.1001/jamaoto.2019.0566
Open Access: This article is published under the JN-OA license and is free to read on the day of publication.
Corresponding Author: Christopher R. Cederroth, PhD, Department of Physiology and Pharmacology, Karolinska Institutet, 171 77 Stockholm, Sweden (firstname.lastname@example.org).
Author Contributions: Dr Cederroth had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Lugo, Trpchevska, Magnusson, Gallus, Cederroth.
Acquisition, analysis, or interpretation of data: Lugo, Liu, Biswas, Magnusson, Gallus, Cederroth.
Drafting of the manuscript: Lugo, Trpchevska, Liu, Cederroth.
Critical revision of the manuscript for important intellectual content: Lugo, Liu, Biswas, Magnusson, Gallus, Cederroth.
Statistical analysis: Lugo, Liu, Gallus.
Obtained funding: Magnusson, Gallus, Cederroth.
Administrative, technical, or material support: Magnusson.
Study supervision: Magnusson, Gallus, Cederroth.
Conflict of Interest Disclosures: Dr Cederroth reported grants from Decibel Therapeutics outside the submitted work. No other disclosures were reported.
Funding/Support: This study is partially funded by the European Union's Horizon 2020 research and innovation program under the Marie Skłodowska-Curie grant agreement, No 722046, and the GENDER-NET Plus Cofund, No GNP-182. Dr Gallus is Honorary Associate Professor of the University of Nottingham, School of Medicine, Nottingham, England.
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
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