Psychiatric Medications That Can Cause Tinnitus
Antidepressants, particularly SSRIs and SNRIs, can paradoxically cause tinnitus as a side effect, despite sometimes being used to treat tinnitus in depressed patients. 1
Key Offending Psychiatric Medications
SSRIs (Selective Serotonin Reuptake Inhibitors)
- Sertraline has documented cases of causing bilateral tinnitus even at low doses (50 mg), with complete resolution after discontinuation 2
- Fluoxetine (Prozac) and other SSRIs can induce tinnitus through serotonergic effects on auditory processing 3
- The mechanism involves complex interactions between serotonergic, glutamatergic, and GABAergic neurotransmitter systems in cochlear input processing 2
- Prior use of salicylates (aspirin) may create a "priming effect" that increases susceptibility to SSRI-induced tinnitus 2
SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)
- Duloxetine shows the strongest association with tinnitus among all psychiatric medications (ROR 11.99,95% CI 11.38-12.63) in FDA adverse event data 4
- Venlafaxine (Effexor) and desvenlafaxine can cause tinnitus, with venlafaxine carrying additional concerns about suicide risk and overdose fatalities 1, 5
- SNRIs may cause sustained hypertension and increased blood pressure, which can contribute to pulsatile tinnitus 1
Tricyclic Antidepressants
- This older class of antidepressants can cause tinnitus, though evidence is limited by methodological concerns in studies 6
- Antimuscarinic mechanisms appear important in tinnitus development with tricyclics 3
Atypical Antidepressants
- Trazodone has been studied but shows unclear effects on tinnitus intensity 6
Critical Clinical Guidance
When Antidepressants Are Contraindicated
The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends AGAINST routinely using antidepressants for treating persistent, bothersome tinnitus, specifically noting that antidepressants may worsen tinnitus. 1
Risk Factors for Drug-Induced Tinnitus
- Female sex (59.1% of tinnitus adverse events occur in women) 4
- Concomitant use of salicylates (aspirin) may prime the auditory system for SSRI-induced tinnitus 2
- Combining multiple serotonergic agents (e.g., SSRI + trazodone + antipsychotic) increases risk through additive serotonergic effects 5, 7
Common Concomitant Ototoxic Effects
When tinnitus develops from psychiatric medications, watch for:
Management Algorithm
If Tinnitus Develops on Psychiatric Medication:
Verify medication adherence to rule out SSRI discontinuation syndrome, which can cause paresthesias and sensory disturbances within 24-48 hours of missed doses 7
Rule out serotonin syndrome if patient is on multiple serotonergic agents—look for mental status changes, neuromuscular hyperactivity, and autonomic instability 5, 7
Consider medication discontinuation if tinnitus is bothersome, as symptoms typically resolve completely after stopping the offending agent 2
Taper slowly over 10-14 days to minimize withdrawal symptoms including dizziness, nausea, headache, and sensory disturbances 5
Avoid switching to another antidepressant in the same class, as the mechanism is likely class-related through serotonergic effects 3, 2
Important Caveats
- Depression with tinnitus requires careful assessment: Patients with tinnitus and severe anxiety or depression require prompt intervention, as suicide has been reported in this population 1
- The paradox: While antidepressants can cause tinnitus, some depressed patients with pre-existing tinnitus may benefit from SSRIs when combined with psychotherapy, particularly if depression is severe 8
- No specific antidepressant is safer: There is currently no indication that one specific antidepressant type is more or less likely to cause tinnitus 3
- Dose matters: Higher doses may increase risk, though tinnitus can occur even at low doses (e.g., sertraline 50 mg) 2