What treatment options are available for a patient with tinnitus who is taking a Selective Serotonin Reuptake Inhibitor (SSRI)?

Managing Tinnitus in Patients Taking SSRIs

SSRIs should not be prescribed for the primary treatment of tinnitus, but if a patient is already taking an SSRI for depression or anxiety, it should be continued while implementing evidence-based tinnitus treatments like Cognitive Behavioral Therapy (CBT) and hearing aids if hearing loss is present. 1

Critical Context: SSRIs and Tinnitus Have a Complex Relationship

The relationship between SSRIs and tinnitus is bidirectional and requires careful consideration:

• SSRIs are explicitly NOT recommended by the American Academy of Otolaryngology-Head and Neck Surgery for primary tinnitus treatment due to insufficient evidence of benefit and potential for side effects 1, 2, 3

• However, SSRIs can paradoxically both help and harm: While they may improve tinnitus in depressed patients with severe symptoms 4, 5, they can also cause or worsen tinnitus as a side effect in rare cases 6

• The key distinction: SSRIs may help tinnitus indirectly by treating comorbid depression/anxiety in patients who have both conditions, but they do not treat tinnitus itself 4, 5

Evidence-Based Treatment Algorithm for Your Patient

Step 1: Assess Tinnitus Characteristics and Red Flags

Determine if imaging or urgent evaluation is needed:

• Unilateral tinnitus requires MRI with contrast to exclude vestibular schwannoma 3
• Pulsatile tinnitus requires vascular imaging (CTA or MRA) to exclude treatable vascular abnormalities 1, 2
• Bilateral, symmetric, non-pulsatile tinnitus does NOT require imaging 2

Step 2: Obtain Comprehensive Audiologic Testing

• Audiometry is mandatory for any tinnitus that is unilateral, persistent ≥6 months, or associated with hearing difficulties 1, 2
• Even mild hearing loss warrants hearing aid evaluation, as this provides significant relief 1, 3

Step 3: Screen for Psychiatric Comorbidities

• Assess for severe anxiety or depression immediately, as tinnitus patients with psychiatric comorbidities have increased suicide risk requiring prompt intervention 1, 3
• If depression/anxiety is present and already being treated with an SSRI, continue the SSRI while adding tinnitus-specific treatments 4, 5

Step 4: Implement Evidence-Based Tinnitus Treatments

Primary treatments with strong evidence:

• Cognitive Behavioral Therapy (CBT) has the strongest evidence for improving quality of life in persistent, bothersome tinnitus and should be recommended for all such patients 1, 2, 3

• Hearing aids should be recommended for any degree of hearing loss, even if mild or unilateral 1, 2, 3

• Education and counseling about tinnitus management strategies are essential for all patients with persistent tinnitus 1

• Sound therapy may provide symptomatic relief as an adjunctive option 1

Step 5: Avoid Ineffective or Harmful Treatments

Do NOT prescribe the following for tinnitus treatment:

• Antidepressants, anticonvulsants, or anxiolytics (including benzodiazepines) for primary tinnitus treatment 1, 2, 3
• Intratympanic medications due to lack of evidence 1, 2
• Dietary supplements (Ginkgo biloba, melatonin, zinc) due to lack of consistent benefit 1, 3

Special Considerations for Patients Already on SSRIs

If the SSRI Was Started Before Tinnitus Onset:

• Continue the SSRI if it's treating depression/anxiety effectively, as the benefit of treating the psychiatric condition outweighs concerns, and SSRIs may indirectly help tinnitus severity in depressed patients 4, 5
• Add CBT and hearing aids as the primary tinnitus treatments 1, 3

If Tinnitus Developed After Starting the SSRI:

• Consider whether the SSRI may be causing the tinnitus, though this is rare 6
• Evaluate the timeline: If tinnitus began shortly after SSRI initiation (within weeks), the medication may be contributory 6
• Weigh risks vs. benefits: If the SSRI is essential for treating severe depression/anxiety, continue it and treat tinnitus with CBT and hearing aids 1, 4
• If the SSRI is not essential or depression is well-controlled, consider discontinuation to see if tinnitus resolves 6

If Starting an SSRI in a Patient with Pre-existing Tinnitus:

• SSRIs may help if the patient has comorbid depression/anxiety and severe tinnitus, particularly when combined with psychotherapy 4, 5
• SSRIs should be used in conjunction with psychotherapy, not as monotherapy 4
• Monitor for worsening tinnitus as a potential side effect, though this is uncommon 6

Common Pitfalls to Avoid

• Do not prescribe SSRIs solely for tinnitus treatment without comorbid depression/anxiety, as guidelines explicitly recommend against this 1, 2, 3

• Do not overlook mild hearing loss that could benefit from hearing aid intervention, as even minimal hearing loss warrants evaluation 1, 3

• Do not delay psychiatric referral if severe anxiety or depression is present, given the increased suicide risk 1, 3

• Do not assume bilateral tinnitus is benign without proper audiologic evaluation, as 10-15% of cases have identifiable underlying causes 7, 3

• Do not forget long-term follow-up, as some patients will have underlying causes identified only after extended observation 7

Prognosis and Ongoing Management

• No cure exists for tinnitus; treatment focuses on symptom management and quality of life improvement 2
• A team approach involving otolaryngology, audiology, and mental health professionals is encouraged for optimal management 7
• Familiarity with hearing aids, hearing-assistive technology, and tinnitus management strategies is required for ongoing care 7