COVID-19 & HEARING CARE

Impact of COVID-19 Pandemic on Mental

Health and People with Hearing Problems
By Dany Pineault, AuD

T
he COVID-19 pandemic has resulted in an increased
prevalence of mental health problems among the
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general population.1,2 The epidemiological distribu-

tion of mental health problems provides evidence
for a psychiatric epidemic co-occurring with the COVID-19
pandemic.2A systematic review examining the general popula-
tion’s mental health status amid the pandemic found significantly
higher levels of irritability, stress, anxiety, and depression.1-3 In
an attempt to lessen the emotional burden associated with
this unprecedented hardship, studies have also shown an in-

Anthony Patrick Manieri

crease in maladaptive coping strategies such as higher tobacco,
alcohol, and cannabis consumption, increase in junk food in-
take, physical inactivity, changes in sleep routines and exces-
sive social media/news consumption.2-6
Mental health experts around the world have linked the in-
creased psychological distress to public health measures used
to mitigate the spread of the virus.1-3 Enforced lockdowns,
quarantines, restrictions in social and family gatherings, dis-
ruption of non-essential services delivery, and suspension of
cultural and sporting activities have all been identified as new
stressors and factors exacerbating mental health disorders.3,4
These restrictions combined with fear of contracting the virus,
food insecurity, permanent and temporary layoff, relationship
struggles, loneliness, boredom, and lifestyle changes (e.g.,
working from home, homeschooling) have had an enormous
impact on the psychosocial and economic well-being of the
general population.2-4
Chronic psychological distress increases the risk of devel-
oping physical and mental health conditions such as high blood
pressure, digestive problems, autoimmune diseases, sleep
disturbances, psychological disorders, and memory and con-
centration deficits. Moreover, psychological distress is also
highly associated with various hearing problems such as age-
related hearing loss, sudden idiopathic sensorineural hearing
loss, tinnitus, hyperacusis, and Ménière’s disease.7-12 Conse-
quently, the prevalence of mental health disorders is higher
among people with hearing problems than among people
without these conditions.10-12 Furthermore, several studies
suggest that severity of hearing loss, tinnitus, and hyperacusis
may also be linked to a higher risk of anxiety and depression.13
As pandemic-related psychological distress can either trigger
or aggravate hearing health problems, audiologists must gain
Dr. Pineault is an adjunct assistant professor at A.T. Still
University’s Post-Professional Doctor of Audiology pro-
gram. He also practices as a clinical audiologist at the
Canadian Hearing Services and serves as a research advi-
sor for Statistics Canada.
a better understanding of its impact on the quality of life and
treatment outcomes.1
COVID-19-RELATED PSYCHOLOGICAL
DISTRESS & HEARING PROBLEMS
Although hearing loss and tinnitus have been identified as po-
tential long-term complications of COVID-19, this article fo-
cuses on the experience of patients with pre-existing hearing
problems amid the pandemic.15-18 Recent studies have also
found an association between COVID-19 related psychologi-
cal distress and exacerbation of hearing problems such as in-
creased trouble understanding conversations in public places,
increased hearing difficulties with phone and video calls, and
worsening of tinnitus and hyperacusis.19,20 An online survey of
129 individuals with hearing loss revealed an increased level
of stress and anxiety with public health measures adopted in
response to coronavirus.19 For instance, 66 percent of re-
spondents worried about having to communicate with others
with face masks.19 Moreover, 60 percent reported that the
possibility of having to speak to people wearing face masks or
from a distance added to their anxieties about going to public
places (e.g., parks, supermarkets),19,21 and 61.5 percent re-
ported hearing worse during video calls than if the other per-
son was in the room with them. Finally, 75 percent of the
respondents worried more than usual about what to do if their
hearing aids stop working as audiology services have been
suspended or delivered remotely. In another online survey of
3,103 individuals with tinnitus from 48 countries, 40 percent
of the respondents reported that their worsening tinnitus
symptoms were related to the same public health measures.20
On the other hand, forced social isolation might have cre-
ated more favorable listening environments for some people

36 The Hearing Journal  March 2021

COVID-19 & HEARING CARE
with hearing loss. A recent study conducted by Dunn and col-
leagues found that CI users reported feeling less anxious in
their listening experiences as a result of spending more time
at home in quiet surroundings and engaging in more speech
listening on electronic devices (e.g., smartphones, TV) rather
than live conversations.22
ADVERSE EFFECTS OF CHRONIC STRESS
ON EAR-BRAIN CONNECTION
At the most basic level, stress is a hard-wire physiological reac-
tion to dangers.23,24 This primitive response is triggered by either
real or perceived threats and consists of a complex outpouring
of hormones intended to keep us out of harm’s way and main-
tain our body’s normal functional equilibrium (i.e., homeosta-
sis).22 The fight-or-flight response is beneficial if trying to escape
from the four inches claws of a grizzly bear’s but less helpful
when dealing with a deadline at work.23,25 The pervasive impact
of stress is influenced by the type, severity, and duration of
stressors. Acute stress is adaptive and necessary for short-term
survival. However, in its chronic form, stress is maladaptive and
can lead to alterations in brain structures (e.g., prefrontal cortex,
amygdala, and hippocampus) and neuronal networks.23,24
Although the deleterious effects of stress on brain health
have been investigated for over 50 years, little is known on how
it can create havoc in the auditory system.23,24,28 Chronic stress-
related health conditions such as hypertension are often listed
as an important risk factor for high-frequency sensorineural
hearing loss and tinnitus.10,11 It is hypothesized that reduced
cochlear blood supply due to cardiovascular disease may af-
fect the inner ear tissue and result in accelerated cell loss in the
stria vascularis.25 However, the pathophysiological mechanism
underlying the association between hypertension and hearing
loss remains unclear. Neuroscientists have also shown that
stress can interfere with sound processing and speech per-
ception.28 More specifically, studies have found reduced
speech recognition performance under stressed conditions
and induced state of acute anxiety.31,32 Anxiety in adults has
also been associated with poor speech recognition ability in
noisy settings.33 Finally, it is also common for tinnitus and hy-
peracusis to become worse during periods of high stress.30,34
LOOKING BEYOND THE AUDIOGRAM
As soon as patients report an increase in hearing problems or
a decrease in benefits from hearing aids, audiologists may be
quick to rule out potential changes in hearing status. Cursory
otoscopy, pure-tone and speech audiometry test procedures,
acoustic immittance measurements, supra-threshold auditory
measures, and hearing aid electroacoustic analysis immedi-
ately follow questions about changes in physical health and
medication(s). Due to appointment time restrictions, however,
clinicians often overlook questions about a decline in mental
well-being, especially when hearing test results remain un-
changed. If left unchecked, these untreated psychological co-
morbidities can amplify the distress associated with hearing
symptoms and jeopardize the efficacy of audiological man-
agement strategies. Considering the far-reaching impact of
COVID-19-related psychological distress, audiologists must
38 The Hearing Journal 
Figure 1. Clinical tools that can be used to screen levels of
stress, anxiety, depression, and sleep problems.
go beyond the traditional model of symptom(s) progression/
aggravation and screen for emotional well-being.
COMPREHENSIVE CASE HISTORY &
EMOTIONAL WELL-BEING SCREENING
Although the incidence of mental health problems most likely
increases with the severity of hearing loss, the audiogram re-
mains insensitive at predicting poor levels of mental well-being.
As the pandemic continues, a comprehensive case history is
needed to access critical information around events surrounding
a recent worsening in pre-existing hearing problems. Here are
some examples of questions that will alert clinicians about the
potential influence of COVID-19-related psychological distress:
 How different are your hearing problems now compared to
pre-COVID-19?
 Were there any new stress-related health symptoms ac-
companying recent changes in hearing or tinnitus? (e.g.,
muscle tension, sleep problem, upset stomach, concentra-
tion difficulty)
 What lifestyle changes did you need to adopt because of
public health restrictions? (e.g., working from home, home-
schooling)
 Why are these new lifestyle changes exacerbating your
hearing problems? (e.g., trouble hearing during phone or
video calls, tinnitus and/or hyperacusis became more no-
ticeable because the household is too quiet or noisy)
 What worries did the pandemic bring into your life? (e.g.,
fear of not being able to hear or follow conversations in
public places because of face masks and/or physical dis-
tancing, suspension or remote delivery of hearing service,
financial insecurity, loneliness)
 What coping strategies did you use to lessen COVID-19
emotional stress/distress?
The screening of mental health conditions is facilitated by
the administration of validated self-report measures of emo-
tional disturbances. Figure 1 shows a brief list of clinical tools
March 2021

currently available for audiologists such as the Perceived
Stress Scale (PSC), Hospital Anxiety and Depression Scale
(HADS), Patient Health Questionnaire (PSQ-9), and Insom-
nia Severity Index (ISI).35-38 These tools are easy to score and
should be given to patients prior to consultation. If a patient’s
scores are high on an anxiety and/or depression question-
naire, a referral to a mental health care professional for as-
sessment and treatment might take priority over audiological
intervention. However, clinicians should always err on the side
of caution when discussing scores obtained with these
standardized scales. Although it is within the audiologist’s
scope of practice to screen for emotional disturbances, clini-
cians are not permitted to communicate mental health diag-
noses such as anxiety and depression.
Counseling & stress MANAGEMENT
Mental illnesses are among the most common health conditions
worldwide. In Canada, statistics show one in every five adults
will struggle with a mental health problem at some point in their
lives.39 Despite public education campaigns and changing be-
liefs and attitudes toward mental illnesses, stigma, unfortunately,
persists among the general population. Mental illness-related
stigma has been identified as a significant barrier to access
treatment and receive quality care.40 The fear of being stigma-
tized often leads patients to conceal critical information about
their mental well-being to health care practitioners.
March 2021 The Hearing Journal 39
COVID-19 & HEARING CARE
While counseling patients about the impact of mental
health conditions on hearing problems, audiologists gain
from listening to their story and hardship. Be friendly, empa-
thetic, kind, non-biased, and non-prejudiced as patients do
more than listen to what you say. They also observe body
language for signs of irritability and judgment. To demystify
and normalize the experience of COVID-19-related psycho-
logical distress, audiologists must also provide education on
an array of topics including the impact of public health meas-
ures on mental well-being, the relationship between distress
and ear-brain connection, and stress management tech-
niques.
Finally, patients need to understand that stress can be use-
ful in a situation of real danger. However, chronic psychologi-
cal distress can interfere with hearing health. Thankfully, many
stress management strategies have proven to significantly
reduce the negative effects of chronic distress and improve
quality of life. Regular exercises, better sleep hygiene, limited
access to social media/news along with daily relaxation and
meditation practices (e.g., deep breathing, mindfulness, yoga)
can help build resilience and improve hearing health. Seeking
professional counseling may also be recommended for pa-
tients struggling with addiction, chronic pain, relationship
problems, and poor overall well-being. 
References for this article can be found at http://bit.ly/HJcurrent.