Brief communication

Mental distress and quality of life in the hardof hearing

Fellinger J, Holzinger D, Gerich J, Goldberg D. Mental distress andquality of life in the hard of hearing.

Objective: This study aims to compare levels of psychological distressand the quality of life in the hard of hearing with levels reported by thesigning deaf, and the hearing population.Method: A total of 373 members of the Hard of Hearing Associationcompleted the brief WHO’s Quality of Life, 12-item General HealthQuestionnaire and Brief Symptom Inventory, and provided detailsabout their initial and current deafness.Results: The hard of hearing have worse social relationships than thesigning deaf, and are disadvantaged relative to the hearing in all areasmeasured. Quality of life is related to the level of satisfaction with thehearing achieved by hearing aids.Conclusion: General psychiatrists need to be aware that patients whoare hard of hearing may be even more isolated than deaf people in asigning community. Hard of hearing patients with unsatisfactoryhearing aids can be greatly assisted by cochlear implants.

J. Fellinger1, D. Holzinger1,J. Gerich2, D. Goldberg3

1Health Centre for the Deaf, Hospital St John of God,Linz, 2Department of Sociology, Unit for Empirical SocialResearch, Johannes Kepler University, Linz, Austria and3Institute of Psychiatry, King's College, London UK

Key words: deafness; quality of life; hard of hearingpersons; psychological stress

Johannes Fellinger, Health Centre for the Deaf, HospitalSt John of God, Bischofstrasse 11, 4021 Linz, Austria.E-mail: johannes.fellinger@bblinz.at

Accepted for publication November 10, 2006

Significant outcomes

• When interviewing patients who have difficulty communicating, or who may be relying on lip-reading, clinicians should be aware of the high impact such difficulties have on both quality of lifeand emotional distress.

• Many of those with lesser degrees of hearing loss will benefit from a hearing aid, provided that itenables them to communicate in a satisfactory way.

• Those with more profound hearing loss appear to benefit from a cochlear implant.

Limitations

• These results are limited by being self-report measures on standardized questionnaires, and becausethe respondents were recruited at meetings of the hard of hearing association, and may therefore notbe representative of all those who are hard of hearing.

• Only 39.3% of the questionnaires originally distributed were returned, and young people were under-represented in those returning the questionnaires.

Introduction

It has been our experience that the hard of hearingtend to have more restricted social lives than thosewith complete prelingual deafness, as the latter are

part of a supportive deaf culture using signlanguage, while those that are hard of hearingmay be cut off from others by their disability, andstruggle to survive in a culture of those withnormal hearing. In previous papers (1, 2), when a

Acta Psychiatr Scand 2007: 115: 243–245All rights reservedDOI: 10.1111/j.1600-0447.2006.00976.x

Copyright � 2007 The AuthorsJournal Compilation � 2007 Blackwell Munksgaard

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group of signing deaf people were compared withthe hearing, they reported higher levels of psycho-logical distress but rated their social lives as equallysatisfying.

Aims of the study

The present study aims to test the hypothesis thatthose who are hard of hearing experience moreproblems with their social relationships than theprelingually signing deaf.

Material and methods

After a preliminary announcement of the purposesof the study, 950 questionnaires were distributedboth to existing members of the hard of hearingassociation and to casual visitors to the meetingswho had hearing impairment. Participants comple-ted a questionnaire concerned with details of theirhearing problems and demographic information,followed by the 12-item General Health Question-naire (GHQ) (3), the Brief Symptom Inventory(BSI) (4) and the WHO’s Quality of Life (WHO-QOL)measure (5). The prelingually deaf groupwereselected from the Association of the Deaf in UpperAustria, with approaches made to every deaf club inthe region (1, 2). The results obtained were com-paredwith the normative data for the questionnairesin German-speaking populations (6–8) weightedaccording to the bivariate distribution of age and sexin the normal population.

Results

The 373 questionnaires from the hard of hearinggroup represented 39.3% of those originally dis-tributed. Cronbach’s alpha was between 0.76 and0.84 for the WHO-QOL, 0.88 for the GHQ, 0.83–0.88 for the BSI scale. It can be seen from Table 1that the hard of hearing are disadvantaged relativeto the hearing population in terms of GHQ scoreand in all four areas of the WHO-QOL. Thesigning deaf have similar scores for social relation-

ships with the hearing population, but the hard ofhearing have significantly worse social relation-ships than the other two groups. The hard ofhearing and the signing deaf are similar in terms ofthe psychological and environmental subscale. Thestatistical comparisons between �A� and �B� aredirectly comparable with the age and sex of thegeneral population sample by a weighting proce-dure, while that for �B� vs. �C� is carried out bymultiple linear regression controlling for age andsex in both populations.The hard of hearing were significantly more

distressed than the hearing population on theGHQ and all subscales of the BSI. However,when compared with the signing deaf they wereintermediate between the other two groups andsignificantly less distressed for the GHQ, theanxiety and the somatization subscale of the BSI;but were equally handicapped for the subscales forparanoid ideation, interpersonal sensitivity anddepression (see Table 2).Within the hard of hearing group, satisfaction

with the level of hearing achieved correlatessignificantly with all measures of emotional distressand quality of life.When satisfaction is related to severity of initial

deafness, it stays at a level of about two-thirds for thefirst three groups of severity of initial deafness (mild-to-severe). However, in the profoundly deaf, over60% of those with conventional hearing aids aredissatisfied, whereas only 10% of the profoundlydeaf with cochlear implants are dissatisfied (seeTable 3).

Discussion

Our response rate is comparable with thoseachieved by others (9, 10) and contains a fullrange of auditory disabilities. If corrections aremade for biased sampling by age and gender, ourfindings are unchanged. Previously published datashows a reduced quality of life in those with partialhearing loss (11–13), as well as higher GHQ scores(9). Our findings on cochlear implants confirm

Table 1. Mean (SD) for the WHO-Quality of Life (WHO-QOL) BREF domain scores for the general German population, the hard of hearing and the signing deaf

WHO-QOLscale

A: hearing (general population)(n ¼ 2048–2055)

B: hard of hearing(n ¼ 369–371)

C: signing deaf(n ¼ 228–232) A vs. B

B vs. CBeta, P-value A vs. C

Physical 76.92 (17.68) 71.68 (18.49) 68.13 (14.38) P < 0.001 0.13; P < 0.004 P < 0.001Psychological 74.02 (15.68) 63.83 (18.60) 64.16 (17.17) P < 0.001 0.02; P ¼ 0.630 NS P < 0.001Social 71.83 (18.52) 62.15 (23.47) 70.19 (18.06) P < 0.001 )0.12; P < 0.009 P ¼ 0.428 NSEnvironment 70.38 (14.17) 68.09 (16.29) 67.68 (14.51) P < 0.001 )0.02; P ¼ 0.628 NS P < 0.05

Domain scores scaled at a range from 0 to 100, higher scores correspond with higher quality of life. Mean values and SD are unweighted. The P-value indicates thesignificance (two-tailed) of the t-statistic based on Student's t-test for the weighted data. Beta is the standardized partial regression coefficient for the hard of hearing vs. thesigning deaf. The P-value is the corresponding significance for Betas deviation from zero. (NS ¼ not significant).

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others showing significant improvements in qualityof life and social participation (14). Not only initialseverity of deafness, but satisfaction with currentlevel of hearing achieved, determine both quality oflife and emotional distress in the hard of hearing.We confirmed our clinical impression that althoughhard of hearing compared with prelingually deafhave only a partial handicap, BSI scores onparanoid ideation, depression, interpersonal sensi-tivity and QOL scores on psychological and envi-ronmental wellbeing of both groups arecomparable. Especially those with partial hearingloss show greater levels of dissatisfaction with theirsocial lives than the hearing and prelingually deaf.Those with prelingual deafness can achieve satisfy-ing social relationships by the use of sign languagewithin the deaf community, but those who are hardof hearing may lead relatively restricted social lives.

Acknowledgements

H. Neuhold, President of the Hard of Hearing Association ofAustria, co-ordinated the survey and made it possible. C. Beiteland B. Mitterhumer kindly assisted with some of the dataanalyses.

References

1. Fellinger J, Holzinger D, Dobner U et al. An innovative andreliable way of measuring Health-related quality of life andmental distress in the deaf community. Soc PsychiatryPsychiatr Epidemiol 2005;40:245–250.

2. Fellinger J, Holzinger D, Dobner U et al. Mental distressand quality of life in a deaf population. Soc PsychiatryPsychiatr Epidemiol 2005;40/9:737–742.

3. Goldberg DP, Williams PA. User’s guide to the GHQ.Windsor: NFER Nelson, 1988.

4. Derogatis LR, Spencer PM. Brief Symptom Inventory:administration, scoring and procedures manual I. Balti-more, MD: Clinical Psychometric Research, 1982.

5. WHO-QOL Group. Development of the World HealthOrganization WHOQOL BREF quality of life assessment.Psychol Med 1998;28:551–558.

6. Katschnig H, Ladinser E, Scherer M et al. OsterreichischerPsychiatriebericht 2001: Teil 1, Daten zur psychiatrischenund psychosozialen Versorgung der osterreichischen Bev-olkerung. Wien: Bundesministerium fur Soziale Sicherheitund Generationen, 2001.

7. Angermeyer MC, Kilian R, Matschinger H. Whoqol-100 undWhoqol-Bref. Handbuch fur die deutschsprachige Versionder WHO Instrumente zur Erfassung der Lebensqualitat.Gottingen: Hogrete Veilag, 2000.

8. Franke HG. BSI-Brief Symptom Inventory von DerogatisLR (Kurzform der SCL-90-R)-Deutsche Version, Manual.Gottingen: Beltz Test GmbH, 2000.

9. De Graaf R, Bilj R. Determinants of mental distress inadults with a severe audiotory impairment: differencesbetween prelingual and postlingual deafness. PsychosomMed 2002;64:61–70.

10. Tambs K. Moderate effects of hearing loss on mentalhealth and subjective well-being: results from the Nord-Trondelag hearing loss study. Psychosom Med 2004;66:776–782.

11. Espmark A, Rosenhall U, Erlandsson S et al. The two facesof Presbyacucis: hearing impairment and psychosocialconsequences. Int J Audiol 2002;41:125–135.

12. Ringhall A, Grimby A. Severe-profound hearing impair-ment and health-related quality of life among post-lingualdeafened Swedish adults. Scand Audiol 2000;29:266–275.

13. Carabellese C, Appollonio I, Rozzini R et al. Sensoryimpairment and quality of life in a community elderlypopulation. J Am Geriatr Soc 1993;41:401–407.

14. Hawthorne G, Hogan A, Giles E et al. Evaluating thehealth-related quality of life effects of cochlear implants: aprospective study of an adult cochlear implant program.Int J Audiol 2004;43:183–192.

Table 3. Self-rated satisfaction with the current level of hearing achieved usinghearing aids against self-rated initial severity of deafness

Initial severity ofdeafness (self-rated)

Satisfaction with current level of �aided�hearing

Satisfied/very satisfied

Less satisfied/not satisfied Total

Mild 11 (64.7) 6 (35.3) 17Moderate 62 (69.7) 27 (30.3) 89Severe 90 (67.2) 44 (32.8) 134Profound

Without cochlear implant 22 (39.3) 34 (60.7) 56With cochlear implant 45 (90.0) 5 (10.0) 50

Total 230 116 346

The profoundly deaf have been subdivided into those with and without cochlearimplants. Values given are number of cases and line percentages (in parentheses);v2 ¼ 16.10, P ¼ 0.001. In 27 cases, there was insufficient information on theseitems.

Table 2. Mean (SD) for the Brief Symptom Inventory (BSI) for the hearing general German population compared with the hard of hearing and the signing deaf

BSIA: hearing

(general population) (n ¼ 600)B: hard of hearing

(n ¼ 373–379)C: signing deaf(n ¼ 232–234) A vs. B

B vs. CBeta, P A vs. C

Anxiety 0.34 (0.34) 0.80 (0.79) 0.98 (0.70) P < 0.001 )0.13; P < 0.005 P < 0.001Somatization 0.20 (0.32) 0.68 (0.70) 0.81 (0.67) P < 0.001 )0.13; P < 0.005 P < 0.001Paranoid ideation 0.34 (0.20) 0.96 (0.90) 1.10 (0.77) P < 0.001 )0.04; P ¼ 0.442 P < 0.001Depression 0.28 (0.37) 0.83 (0.88) 0.87 (0.69) P < 0.001 )0.06; P ¼ 0.169 P < 0.001Interpersonal sensitivity 0.42 (0.43) 1.18 (0.98) 1.16 (0.79) P < 0.001 0.01; P ¼ 0.809 P < 0.001

Higher scores correspond to more mental health complaints. Mean and SD are unweighted. The P-value indicatesthe significance (two-tailed) of the t-statistic based on Student's t-test for the weighted data. Beta is thestandardized partial regression coefficient for the hard of hearing vs. the signing deaf. The P-value is thecorresponding significance for Betas deviation from zero. (NS ¼ not significant).

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