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Can tinnitus be helped with antidepressants?

Last updated: May 2011

Tinnitus, commonly described as "ringing in the ears," is the perception of sound when there's no external noise. It might sound like buzzing, clicking, hissing, or roaring in one or both ears. If tinnitus is loud or doesn't go away, it can make it difficult to hear, concentrate, sleep, and cause significant emotional distress.

In fact, tinnitus is sometimes the first sign of hearing loss in older people and those who work in noisy environments. It could also be a side effect of medication or a result of excessive ear wax. Or it might be caused by an infection or an underlying health problem such as high blood pressure, a brain tumor, or thyroid abnormalities. The first step is to see a doctor for a diagnosis and to determine if there's a solution to eliminate the noise. But there's no cure for more than 95 percent of tinnitus sufferers, and no drug has been approved to treat the condition. When doctors prescribe medication for tinnitus it's an off-label use, meaning that the drugs have been approved by the Food and Drug Administration for other conditions. (Doctors can legally prescribe any medication they deem appropriate to treat a patient's condition.)

At the same time, tinnitus patients are often depressed. In one study, 60 percent of the participants had major depression compared with 7 percent of a control group with general hearing loss. In addition, depressed tinnitus patients report more severe tinnitus and related disability than people without the condition. Experts think that tinnitus might trigger depression, which in turn worsens the way tinnitus is experienced. By treating the depression, antidepressants might reduce tinnitus symptoms indirectly. But tinnitus patients without depression might also benefit from the drugs because they inhibit certain neurotransmitters in the auditory pathways of the brain that might affect the tinnitus directly.

What is the evidence for the use of antidepressants for tinnitus?

Two types of antidepressants have been studied most often for the off-label use in the treatment of tinnitus: selective serotonin reuptake inhibitors (SSRIs), such as paroxetine (Paxil and generic) and sertraline (Zoloft and generic), and tricyclic antidepressants (TCAs), such as amitriptyline (Elavil and generic). A few small studies have also evaluated another antidepressant, trazodone (Desyrel and generic).

A Cochrane review of six antidepressant trials found only one of sufficient quality. In that study, tinnitus patients without depression who took conventional doses of paroxetine had no significant improvement in tinnitus frequency, intensity, or psychological distress. But some subjects who received higher doses may have benefited.

The other trials—four with TCAs and one with trazodone—suffered from large dropout rates or a failure to separate the effects of the drugs on tinnitus from their effects on depression and anxiety. All the TCA trials suggested there was some improvement in tinnitus, while the trazodone trial reported insignificant improvements in tinnitus intensity and quality of life. The Cochrane review did not find enough evidence to determine that the antidepressants used in those studies improved tinnitus.

In a subsequent trial, patients who received sertraline reported decreased tinnitus severity and loudness compared with those who received a placebo. The authors estimated that some of the effect might be explained by improvements in the patients' depression and anxiety. In general, studies suggest that antidepressants are more effective for severe tinnitus patients who are depressed or anxious than for those who are not.

What are the risks and warnings?

SSRIs antidepressants are considered to have better tolerability and safety than TCAs. But both classes of antidepressants are associated with the following risks:

Suicidal thinking. Although this risk applies to children, adolescents, and young adults, talk with your doctor if you are thinking about harming yourself, no matter what your age.

Drowsiness. Don't drive a car or operate machinery until you know how the medication affects you. Avoid drinking alcohol, which can increase the medicine's sedative effects.

Drug interactions.
Don't use a monoamine oxidase inhibitor (MAOI), which is another type of antidepressant, while you're taking an SSRI or TCA. Because antidepressants interact with many other drugs, tell your doctor about all prescription and over-the-counter medicine and supplements you are taking.

Unknown effects on the fetus. Tell your doctor if you are pregnant or planning to become pregnant. And do not use at all if you are nursing.

Withdrawal symptoms.
If you want to stop taking an antidepressant talk with your doctor, who can minimize this risk by reducing your dose gradually.

Tinnitus. Ironically, this might occur as a side effect of antidepressants depending upon the patient, drug, and dose. (This can happen with many medications.) The condition often improves during treatment, after a dose adjustment, or within a few weeks of discontinuing the drug.

Additional side effects. SSRIs might cause a loss of libido and an inability to reach orgasm. Talk with your doctor if you experience a change in sexual desire or performance during treatment. Other SSRI side effects include diarrhea, nausea, headaches, dry mouth, insomnia, and weight gain.

TCAs are associated with arrhythmias, heart attacks, and strokes. They should be used with caution if you have a history of cardiovascular disease. TCAs might cause confusion, constipation, blurred vision, dry mouth, sedation, and difficulty passing urine, especially in older people. Weight gain has also been reported.

What other options can you try?

See your doctor. He or she might detect a treatable cause for your tinnitus, such as impacted ear wax. Review with the doctor all of your prescription and over-the-counter medication and supplements: More than 200 drugs can cause tinnitus, including aspirin and other NSAIDs (ibuprofen, naproxen, etc). Your doctor might refer you to an otolaryngologist, also known as an ear, nose, and throat specialist, for further evaluation.

Make lifestyle changes. Lessen the severity of tinnitus by avoiding loud noise or using earplugs. It may help to eliminate stimulants such as coffee, tea, cola, alcohol, and tobacco. Control your blood pressure, consume less sodium, exercise daily, and get adequate rest.

Get counseling. Cognitive behavioral therapy can reduce tinnitus annoyance and, when combined with antidepressants, might be an effective treatment for tinnitus-related depression and anxiety. Relaxation exercises and meditation might also relieve distress.

Mask the noise. A competing sound—such as a ticking clock, radio static, a whirring fan or classical music—can make tinnitus less noticeable. CDs that play calming sounds are available through the American Tinnitus Association. Other sound generators include wearable ear devices and tabletop machines to help you sleep.

Consider a hearing aid. That might quiet tinnitus if you also have hearing loss. But the American Academy of Otolaryngology recommends a thorough trial before buying a hearing aid if your primary purpose is tinnitus relief.

Get dental treatment for TMJ.
(temporomandibular joint disorder), since tinnitus can be a symptom of that condition.

Bottom line. There's no compelling evidence to recommend the off-label use of antidepressants as a treatment for tinnitus. But the drugs might reduce symptoms in people with accompanying depression, anxiety and/or sleep disturbance. Our advice: Consider the use of an antidepressant for severe tinnitus only after contributing causes have been addressed and other therapies have been investigated. And make sure the drug's risks and benefits have been thoroughly explained to you.

This off-label drug use report is made possible through a collaboration between Consumer Reports Best Buy Drugs and the American Society of Health-System Pharmacists. This is the 23rd in a series based on professional reports prepared by ASHP.

These materials were made possible by a grant from the state Attorney General Consumer and Prescriber Education Grant Program, which is funded by a multistate settlement of consumer fraud claims regarding the marketing of the prescription drug Neurontin (gabapentin).
   

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