Screening for mental illness

There are several reports suggesting a high prevalence of psychological disturbances in patients suffering from tinnitus and hyperacusis (Pinto et al. 2014; Juris et al. 2013; Schecklmann et al. 2014; Andersson et al. 2004; Pattyn et al. 2016; Paulin et al. 2016; Aazh et al. 2016; Aazh & Allott 2016). In tinnitus and hyperacusis clinics, it is important to screen for psychological co-morbidities in order to make appropriate onward referrals to mental health services when needed (Department of Health 2009; McKenna et al. 1991). However, it is not clear whether psychological questionnaires are relevant to the problems faced by patients experiencing tinnitus and hyperacusis and whether patients seen in audiology clinics find completing such questionnaires relevant to them and applicable generally to people with tinnitus and/or hyperacusis.

In a pioneering research study, Dr. Aazh’s tinnitus team explored for each psychological questionnaire whether high scores for hyperacusis handicap are associated with an increased likelihood of an abnormal score. The results will inform audiologists in selecting the appropriate questionnaires to be used in screening for psychological co-morbidities and in deciding whether to make onward referrals.

Use of these questionnaires in tinnitus and hyperacusis clinics is to identify patients who may benefit from onward referral to mental health services and is not a replacement for psychological/psychiatric evaluation by mental health professionals.

What are the questionnaires that should be used in order to screen for mental illness among patients with tinnitus and/or hyperacusis?

The questionnaires described below assess anxiety disorders and depression which are typically prevalent among people who experience tinnitus and/or hyperacusis/misophonia-related distress (Aazh & Moore 2017). Dr. Aazh’s research shows that over 65% of the patients seeking help for tinnitus and/or hyperacusis meet the caseness criteria for at least one psychological test. The caseness refers to the recommended cut-off score by the UK mental health system for abnormal psychological symptoms (IAPT 2011). For details of the study population and statistical analysis see the paper published in International Journal of Audiology.

GAD-7 (Generalised Anxiety Disorder)

This is a 7-item questionnaire for assessment of anxiety symptoms (Spitzer et al. 2006). Patients are asked how often during the last 2 weeks they had been bothered by each symptom. Response options are not at all (0), several days (1), more than half the days (2), and nearly every day (3). The total score ranges from 0 to 21. Cronbach’s alpha for the GAD-7 is 0.92 and its test-retest reliability (intraclass correlation) is r=0.83 (Spitzer et al. 2006). A score of 10 or above is suggested as indicating anxiety disorder (Spitzer et al. 2006). However, the recommended cut-off score for general anxiety in the UK mental health system is a score of 8 or above (IAPT 2011). This is referred to as meeting “caseness”.

SHAI (short version of Health Anxiety Inventory)

Health anxiety is excessive fear of having a serious illness based on the misinterpretation of bodily sensations (American Psychiatric Association 2000). The SHAI has 18 items. Each item consists of four statements in which the individual is instructed to select the statement that best describes their feelings over the past two weeks. Item scores are weighted 0–3 and are summed to obtain a total score between 0 and 54. Cronbach’s alpha for this questionnaire is between 0.74 and 0.96 (Alberts et al. 2013). Test-retest reliability was found to be good (r = 0.87) (Olatunji et al. 2011). A score of 27 or above indicates the likely presence of health anxiety (Alberts et al. 2013). However, a less conservative score of 18 or above was suggested by Rode et al. (2006). The score that is used in mental health services in the UK to indicate caseness is 18 or above (IAPT 2011).

MINI-SPIN (mini version of Social Phobia Inventory)

The Mini-SPIN (Connor et al. 2001) is the short version of the SPIN (Connor et al. 2000) questionnaire, which is designed to assess social anxiety disorder. Cronbach’s alpha for the SPIN is 0.94 and its test-retest reliability is r=0.89 (Connor et al. 2000). Unlike the 17-item full version used in the IAPT, the Mini-SPIN consists of only 3 items. Each item has 5 possible answers with scores from 0 to 4. The total score is between 0 and 12. Total scores of 6 or higher on the Mini-SPIN indicate possible problems with social anxiety (Weeks et al. 2007). The recommended cut-off for caseness for social phobia in the UK mental health system is a score of 19 or above on the full version of the SPIN (IAPT 2011). Scores of 6 or higher on the Mini-SPIN indicate possible problems with social anxiety (Connor et al. 2001).

OCI-R (revised version of Obsessive Compulsive Inventory)

The OCI–R (Foa et al. 2002) is the short version of the OCI (Foa et al. 1998) and is a self-report questionnaire to assess symptoms of obsessive compulsive disorder (OCD). While the full version used in the IAPT contains 42 items, the OCI-R contains only 18 items. Items are rated on 5-point Likert-type scale (0-4) giving total scores between 0 and 72. Patients are instructed to circle the number that best describes how much that experience has distressed or bothered them during the past month. This questionnaire has 6 subscales: Checking, Washing, Obsessing, Mental Neutralizing, Ordering, and Hoarding (Foa et al. 2002). Cronbach’s alpha for the total score is 0.81 and test-retest reliability is 0.82, both of which are good (Foa et al. 2002). The recommended cut-off for caseness for OCD in the UK mental health system is scores of 40 or above on the full version of the OCI (IAPT 2011). Scores of 21 or above indicate the likely presence of OCD for the OCI-R (Foa et al. 2002).

PDSS-SR (Panic Disorder Severity Scale-self report)

This is a 7-item questionnaire for assessment of panic disorder. Each item has 5 possible answers weighted from 0 to 4 (0= none, higher ratings reflecting more severe symptoms). Patients are instructed to choose the answer that best reflects how they have felt over the past week. For this questionnaire, a panic attack is defined as a sudden rush of fear or discomfort accompanied by at least four of the following panic symptoms: rapid or pounding heartbeat, chest pain or discomfort, chills or hot flushes, sweating, nausea, fear of losing control or going crazy, trembling or shaking, dizziness or faintness, breathlessness, feelings of unreality, fear of dying, feeling of choking, numbness or tingling. The total score is between 0 and 28. Cronbach’s alpha for this questionnaire is 0.92 and it has good test-retest reliability (r = 0.81) (Houck et al. 2002). Yamamoto et al. (2004) suggested that total scores up to 10 correspond to mild, 11-15 to moderate, and 16 or above to severepanicdisorder. Furukawa et al. (2009) suggested a cut off score of 8 to identify people with panic disorder. The recommended cut-off for caseness in the UK mental health system is a score of 8 or above (IAPT 2011).

PHQ-9 (Patient Health Questionnaire)

This is a 9-item questionnaire for assessment of depression. The total score ranges from 0 to 27. A score less than 5 indicates no depression, while 5-9 indicates mild depression, 10-14 indicates moderate depression, 15-19 indicates moderately severe depression, and a score over 19 indicates severe depression (Kroenke et al. 2001). Cronbach’s alpha for the PHQ-9 is 0.89 and its test-retest reliability is r=0.84 (Kroenke et al. 2001). The recommended cut-off for caseness for depression in the UK mental health system is a score of 10 or above (IAPT 2011).

PSWQ-A (Penn State Worry Questionnaire-abbreviated version)

The PSWQ-A (Hopko et al. 2003) is a short version of the PSWQ used for assessment of generalised anxiety disorder. The full version used in the IAPT has 16 items while the PSWQ-A contains only 8 items. Each item has 5 possible answers with scores from 1 (not at all typical of me) to 5 (very typical of me). The total score for the PSWQ-A is between 8 and 40. Cronbach’s alpha was 0.89 and test-retest reliability was r=0.87 (Crittendon & Hopko 2006). The recommended cut-off for caseness for generalised anxiety disorder in the UK mental health system is a score of 45 or above on the full version of the PSWQ (IAPT 2011). A score of 23 or more on the PSWQ-A indicates the presence of generalised anxiety disorder (Wuthrich et al. 2014).

How to decide on the choice of psychological questionnaires based on levels of tinnitus and hyperacusis handicap?

Audiologists who are specialised in tinnitus and hyperacusis rehabilitation typically measure tinnitus handicap via Tinnitus Handicap Inventory (THI; Newman et al. 1996) and hyperacusis via Hyperacusis Questionnaire (HQ; Khalfa et al. 2002). In this section we describe how to select appropriate questionnaires for screening of psychological disorders based on the scores on THI and HQ.

Over 20% of patients with moderate tinnitus handicap (THI scores ³36/100) and over 30% of patient with hyperacusis (HQ scores ³26) had abnormal scores for the GAD-7, SHAI, Mini-SPIN, OCI-R, PDSS-SR, PSWQ-A, and PHQ-9. Therefore, application of these questionnaires may be useful in the assessment of such patients, as they might need a referral to mental health services.

However, due to the time constraints in audiology clinics, audiologists may have to limit the number of questionnaires uses. The outcome of our risk ratio analysis maybe used to select appropriate questionnaires based on the patient’s initial THI or HQ scores. Patients with THI scores ³ 36 are at higher risk of abnormal scores on the GAD-7, SHAI, or PHQ-9. Hence, application of these questionnaires is recommended for such patients. Patients with HQ scores ³ 26 are at higher risk of abnormal scores on the SHAI, Mini-SPIN, PDSS-SR, PHQ-9, and PSWQ-A. The value of the PDSS-SR remains in some doubt.

The table below shows outcomes of multinomial logistic regression models assessing the relative risk ratios (RRR) of abnormal scores on the psychological questionnaires based on tinnitus handicap category as measured via the THI and on hyperacusis handicap as measured via the HQ. Significant p values are indicated in bold font.

References

Aazh, H., & Allott, R. (2016). Cognitive behavioural therapy in management of hyperacusis: a narrative review and clinical implementation. Auditory and Vestibular Research, 25, 63-74.

Aazh, H., & Moore, B. C. J. (2017). Usefulness of self-report questionnaires for psychological assessment of patients with tinnitus and hyperacusis and patients’ views of the questionnaires. International Journal of Audiology, 56, 489-498.

Aazh, H., Moore, B. C. J., Lammaing, K., et al. (2016). Tinnitus and hyperacusis therapy in a UK National Health Service audiology department: Patients’ evaluations of the effectiveness of treatments. International Journal of Audiology, 55, 514-522.

Alberts, N. M., Hadjistavropoulos, H. D., Jones, S. L., et al. (2013). The Short Health Anxiety Inventory: a systematic review and meta-analysis. J Anxiety Disord, 27, 68-78.

American Psychiatric Association (2000). Treatment Works: Major Depressive Disorder: a Patient and Family Guide. American Psychiatric Pub.

Andersson, G., Carlbring, P., Kaldo, V., et al. (2004). Screening of psychiatric disorders via the Internet. A pilot study with tinnitus patients. Nord J Psychiatry, 58, 287-91.

Connor, K. M., Davidson, J. R., Churchill, L. E., et al. (2000). Psychometric properties of the Social Phobia Inventory (SPIN). New self-rating scale. Br J Psychiatry, 176, 379-86.

Connor, K. M., Kobak, K. A., Churchill, L. E., et al. (2001). Mini-SPIN: A brief screening assessment for generalized social anxiety disorder. Depress Anxiety, 14, 137-40.

Crittendon, J., & Hopko, D. R. (2006). Assessing worry in older and younger adults: Psychometric properties of an abbreviated Penn State Worry Questionnaire (PSWQ-A). J Anxiety Disord, 20, 1036-54.

Department of Health (2009). Provision of Services for Adults with Tinnitus: A Good Practice Guide. London UK Department of Health.

Foa, E. B., Huppert, J. D., Leiberg, S., et al. (2002). The Obsessive-Compulsive Inventory: development and validation of a short version. Psychol Assess, 14, 485-96.

Foa, E. B., Kozak, M. J., Salkovskis, P. M., et al. (1998). The validation of a new obsessive–compulsive disorder scale: The Obsessive–Compulsive Inventory. Psychological Assessment, 10, 206.

Furukawa, T. A., Katherine Shear, M., Barlow, D. H., et al. (2009). Evidence-based guidelines for interpretation of the Panic Disorder Severity Scale. Depress Anxiety, 26, 922-9.

Hopko, D. R., Stanley, M. A., Reas, D. L., et al. (2003). Assessing worry in older adults: confirmatory factor analysis of the Penn State Worry Questionnaire and psychometric properties of an abbreviated model. Psychol Assess, 15, 173-83.

Houck, P. R., Spiegel, D. A., Shear, M. K., et al. (2002). Reliability of the self-report version of the panic disorder severity scale. Depress Anxiety, 15, 183-5.

IAPT (2011). The IAPT Data Handbook: Guidance on recording and monitoring outcomes to support local evidence-based practice In D. o. Health (Ed.), UK: IAPT National Programme Team

Juris, L., Andersson, G., Larsen, H. C., et al. (2013). Psychiatric comorbidity and personality traits in patients with hyperacusis. Int J Audiol, 52, 230-5.

Khalfa, S., Dubal, S., Veuillet, E., et al. (2002). Psychometric normalization of a hyperacusis questionnaire. ORL J Otorhinolaryngol Relat Spec, 64, 436-42.

Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med, 16, 606-13.

McKenna, L., Hallam, R. S., & Hinchcliffe, R. (1991). The prevalence of psychological disturbance in neuro-otology outpatients. Clinical Otolaryngology & Allied Sciences 16, 452-456.

Newman, C. W., Jacobson, G. P., & Spitzer, J. B. (1996). Development of the Tinnitus Handicap Inventory. Arch Otolaryngol Head Neck Surg, 122, 143-8.

Olatunji, B. O., Etzel, E. N., Tomarken, A. J., et al. (2011). The effects of safety behaviors on health anxiety: an experimental investigation. Behav Res Ther, 49, 719-28.

Pattyn, T., Van Den Eede, F., Vanneste, S., et al. (2016). Tinnitus and anxiety disorders: A review. Hear Res, 333, 255-265.

Paulin, J., Andersson, L., & Nordin, S. (2016). Characteristics of hyperacusis in the general population. Noise Health, 18, 178-84.

Pinto, P. C., Marcelos, C. M., Mezzasalma, M. A., et al. (2014). Tinnitus and its association with psychiatric disorders: systematic review. J Laryngol Otol, 128, 660-4.

Rode, S., Salkovskis, P., Dowd, H., et al. (2006). Health anxiety levels in chronic pain clinic attenders. J Psychosom Res, 60, 155-61.

Schecklmann, M., Landgrebe, M., Langguth, B., et al. (2014). Phenotypic characteristics of hyperacusis in tinnitus. PLoS One, 9, e86944.

Spitzer, R. L., Kroenke, K., Williams, J. B., et al. (2006). A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med, 166, 1092-7.

Weeks, J. W., Spokas, M. E., & Heimberg, R. G. (2007). Psychometric evaluation of the mini-social phobia inventory (Mini-SPIN) in a treatment-seeking sample. Depress Anxiety, 24, 382-91.

Wuthrich, V. M., Johnco, C., & Knight, A. (2014). Comparison of the Penn State Worry Questionnaire (PSWQ) and abbreviated version (PSWQ-A) in a clinical and non-clinical population of older adults. J Anxiety Disord, 28, 657-63.

Yamamoto, I., Nakano, Y., Watanabe, N., et al. (2004). Cross-cultural evaluation of the Panic Disorder Severity Scale in Japan. Depress Anxiety, 20, 17-22.