7Antidepressants (for distress and comorbidity)

FWhat antidepressants can and cannot do

It is tempting to reach for a tablet when a patient is suffering, and antidepressants are among the most commonly prescribed drugs for people with troublesome tinnitus. But it is vital to separate two questions: does the drug make the perceived sound quieter, and does it make the person feel better? For antidepressants the honest answer is that they do little for the first and can sometimes help with the second.

Depression, anxiety and insomnia travel with bothersome tinnitus far more often than with mild tinnitus. When these comorbidities are present and significant, treating them is good medicine in its own right — and a calmer, better-rested patient often reports that the tinnitus bothers them less, even though its measured loudness has not changed [2014].

TTricyclics: amitriptyline and nortriptyline

Tricyclic antidepressants (TCAs) were among the first drugs studied for tinnitus. Their proposed rationale is modulation of serotonergic and noradrenergic pathways that influence both auditory processing and the limbic circuitry that gives tinnitus its emotional charge. Older trials in patients with co-existing depression reported reductions in tinnitus-related disability, but the benefit tracks the mood improvement rather than a direct silencing of the sound [2013].

The practical limit is tolerability. Anticholinergic effects (dry mouth, constipation, urinary retention), sedation, postural hypotension and — importantly — cardiac conduction effects with overdose risk all constrain routine use. Nortriptyline is often preferred over amitriptyline for a somewhat gentler side-effect profile, and a low bedtime dose can double as help for sleep.

TSSRIs and SNRIs: the evidence

Selective serotonin reuptake inhibitors (such as sertraline) and serotonin–noradrenaline reuptake inhibitors (such as venlafaxine) are the modern workhorses for the anxiety and depression that accompany tinnitus. They are generally better tolerated than TCAs and are first-line for the mood disorder itself.

The pivotal evidence on whether they treat tinnitus comes from the Cochrane review by Baldo and colleagues, which pooled the randomised trials of antidepressants for tinnitus and found the studies few, small and at risk of bias, with no convincing evidence that antidepressants reduce tinnitus loudness or severity [2012]. A paradoxical wrinkle is that SSRIs are themselves occasionally reported to trigger or worsen tinnitus, so any change after starting one should be reviewed rather than ignored.

CPrescribing honestly

The clinical takeaway is to prescribe an antidepressant for a diagnosis it actually treats. If a patient screens positive for a depressive or anxiety disorder, treat that disorder on its own merits and explain that any easing of the tinnitus is a welcome secondary effect, not the primary aim [2013].

Set expectations explicitly: the goal is to reduce distress, improve sleep and restore function, not to switch the sound off. Choose the agent by comorbidity and side-effect fit, start low, review at 4 to 6 weeks, and avoid prescribing an antidepressant to a non-depressed patient purely in the hope of suppressing the percept — the evidence does not support it [2012].