Eur Arch Otorhinolaryngol DOI 10.1007/s00405-014-3138-8
Otology
Hungarian adaptation of the Tinnitus Handicap Inventory: reliability and validity Beata Bencsik · László Tamás · Krisztina Trimmel · Adrienne Stauder
Received: 23 April 2014 / Accepted: 6 June 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract The objective of this study was to determine the reliability and validity of the Hungarian version of the original Tinnitus Handicap Inventory (THI). In the study design the original THI (THI-US) was translated into Hungarian by three independent investigators. The final Hungarian version (THI-HUN) was constructed on the basis of these Hungarian interpretations and then administered to 72 patients suffering from chronic tinnitus. Construct validity was assessed using short version of Beck’s Depression Inventory (BDI), Perceived Stress Scale (PSS4 version), Visual Analogue Scale (VAS) (loudness, annoyance and pitch of tinnitus), pure tone audiometry and tinnitometry. The 72 participants were 43 women and 29 men. Their mean age was 49.86 years with a mean tinnitus duration of 4.16 years. In the results THI-HUN and its subscales showed good internal consistency reliabilities (α = 0.95– 0.74), with significant correlation between THI-HUN total score and subscales and the BDI, PSS4 and VAS annoyance. There was a high or moderate correlation between THI-HUN total score and VAS loudness, tinnitus duration, hearing loss and subjective perception of tinnitus loudness. The VAS pitch of tinnitus, the subjective perception of tinnitus pitch, age, gender and level of education did not show B. Bencsik (*) · L. Tamás Department of Otorhinolaryngology and Head and Neck Surgery, Semmelweis University, Szigony Street 36, Budapest 1083, Hungary e-mail: [email protected] K. Trimmel Faculty of Medicine, Semmelweis University, Üllo˝i Road 26, Budapest 1085, Hungary A. Stauder Institute of Behavioural Sciences, Semmelweis University, Nagyvárad Square 4, Budapest 1089, Hungary
any correlation with THI-HUN total score. The test–retest reliability was high (r = 0.97). We conclude that a valid and reliable THI-HUN questionnaire was constructed. Keywords Questionnaires · Quality of life · Tinnitus · Validity
Introduction Tinnitus as a phantom auditory perception is a very common symptom. Results of neuroscientific research from the last 20 years yielded some theories about the pathophysiology of tinnitus, but the whole mechanism is still unknown. Although there are no standadized questionnaires available for the evaluation of tinnitus prevalence [1], some studies found that prevalence of tinnitus in general population can reach up to 10–15 % [2], with a predominance among the elderly [3]. Tinnitus is primarily a subjective disorder. Self-report tinnitus questionnaires are commonly used tools for assessing the impact of tinnitus on the patient’s everyday life. Of these, Tinnitus Handicap Inventory [4] is one of the most commonly used test method for the evaluation of tinnitus patients. It has been translated and validated into a wide range of languages, including Danish [5], Spanish [6], Korean [7], Brazilian Portuguese [8], Turkish [9], Italian [10], Chinese/Cantonese [11], Singapore [12], French [13], Persian [14], Hebrew [15] and Chinese (Mandarin) [16]. Several studies have demonstrated the relationship between tinnitus and certain psychiatric disorders, such as depression or anxiety. Based on the evaluation of 224 subjects, Zöger et al. [17] found a significant correlation between the severity of tinnitus and depression; for anxiety, this correlation was significant only in the high-risk population.
13
Until now, no tinnitus-specific questionnaire has been avaliable in Hungarian. Therefore, the aim of our study was to validate our Hungarian adaptation of the THI (THIHUN) for the evaluation of Hungarian-speaking tinnitus patients and for its satisfactory application in clinical/ research environments.
Materials and methods Translation procedure The Tinnitus Handicap Inventory (THI) [4] consists of 25 items grouped into three subscales: a functional subscale (THI—functional, 12 items), an emotional subscale (THI— emotional, 8 items) and a catastrophic subscale (THI— catastrophic, 5 items). Each item offers three potential answers: “yes” = 4 points, “sometimes” = 2 points, and “no” = 0 point. The THI score may vary between 0 and 100, specifying different ranges of an index score, namely, light (0–16), mild (18–36), moderate (38–56), severe (58– 76) and catastrophic (78–100) handicap. Cronbach’s alpha of the original THI is 0.93. Firstly we asked the author (C.W. Newman) of the original version (THI-US) to permit us to have the THI translated into Hungarian and validate the test approved by him. Then, three independent translations were made from English into Hungarian by professional translators with an excellent knowledge of both languages. These three Hungarian translations was integrated into a single, optimized version that was then back-translated into English by a native English-speaking translator who was not aware of the original English version. Then, the original THI and the back-translated THI were compared by the professional English translator. The final Hungarian version (THI-HUN) was then considered to be suitable for validation. Study method In our study, the final version of the THI-HUN was administered to 72 patients with chronic idiopathic tinnitus. All of them were assessed as outpatients at the Department of Otorhinolaryngology and Head and Neck Surgery of Semmelweis University. The following inclusion criteria were used: minimum age of 18 years, peresence of tinnitus as a leading symptom; mono- or bilateral, continuous tinnitus experienced at least for 3 months prior to the enrollment. Patients treated with severe psychiatric disease; persons with mental incapacity or those not understanding or speaking Hungarian were excluded. At Visit 1, an otoscopic evaluation was performed and medical history data were collected. Patients were asked to complete self-report questionnaires: in addition to
13
Eur Arch Otorhinolaryngol
THI-HUN, a 9-item short version of Beck’s Depression Inventory (BDI), Perceived Stress Scale (PSS4) and Visual Analogue Scale (VAS) (loudness, annoyance and pitch of tinnitus). Each patient underwent pure tone audiometry (air and bone conduction) and tympanometry and their subjective perception of pitch and loudness of tinnitus was determined. 2 weeks after the completion of the first THI-HUN, subjects were asked to complete THI-HUN test again at home (test–retest stability) without receiving any additional treatment meanwhile or being aware of the previous test results. All participants were fully informed about the aim of study and the test procedure and gave their approval to participation in the study by signing the written informed consent. The study design was approved by the Ethics Committee of Semmelweis University of Budapest (Nr.: 9/2013). Perceived Stress Scale (PSS) Perceived stress scale, or PSS, is one of the most widely used tool for the measurement of stress level [18] with a reliability demonstrated in large subject samples [19]. The original version of the questionnaire (PSS14) consists of 14 items to be scored at a 5-point Likert scale (0–4). Total score is a global indicator of percieved stress; higher score suggests more frequent stress situations. Two short versions have been developed with 10 (PSS10) and 4 (PSS4) items, respectively. In our study, validated Hungarian version of PSS4 [20] was administered to the study population that shows a strong correlation with PSS14 (r = 0.93), with a good internal consistency (Cronbach alpha: 0.79) and excellent test–retest reliability (r = 0.90). Short version of Beck’s Depression Inventory (BDI) One of the most popular self-measuring tool for revealing mood disorders or depression is Beck’s Depression Inventory (BDI) involving 21 items [21]. Its 13-item and 7-item short versions are used for screening purposes [22, 23]. Short 9-item Hungarian adaptation of this measuring tool was tested on a large sample by a Hungarian team of researchers. Their results confirmed the reliability and validity of the test, Cronbach alpha: 0.81 [24]. The test includes questions on a wide range of depression symptoms. For the assessment, 4-point Likert scale is applied where higher scores suggest the presence of more depression symptoms. Test evaluation: 0–9 normal, 10–18 mild, 19–25 moderate, >25 severe depression. For the calculation of standard (not short) BDI value, the total score of short test should be multiplied by 2.2. In our study, the short, 9-item version of BDI scale was used.
Eur Arch Otorhinolaryngol Table 1 Means and SDs for right and left air-conduction thresholds (dB HL) for subject sample (n = 72)
HL hearing level
Frequency (Hz) Right ear Mean (dB) SD (dB) Left ear Mean (dB) SD (dB)
125
250
500
1,000
2,000
4,000
8,000
20.08 12.94
18.19 13.75
17.57 14.99
18.26 15.45
20.24 18.99
30.56 22.10
36.39 24.87
18.69
17.08
18.19
19.24
20.97
32.22
39.44
13.21
14.38
18.04
15.42
16.52
19.06
23.95
Visual Analogue Scale Visual Analogue Scale (VAS) scales ranged from 0 (corresponding to the absence of tinnitus) to 100 (corresponding to the maximal imaginable loudness, annoyance and pitch of tinnitus). Patients reported the actually perceived loudness, annoyance and pitch of tinnitus on a scale ranging from 0 to 100. Data analysis SPSS version 20.0 was used for all statistical analyses.
of hearing levels of all patients on both ears as well as mean values and SDs of frequency/(kiloHertz (kHz)/and loudness/ decibel (dB)/of tinnitus can be seen in Table 2. In 19 cases we could not measure the frequency and loudness of tinnitus. In Table 3 response rate for 25 questions of THI was calculated for the Hungarian (THI-HUN) and the original (THIUS) version. In the last coloumn, the item–total correlation is given for the Hungarian and the original version. Table 3 Endorsement rates and item–total correlations of the Hungarian translation (THI-HUN) and the original version of the Tinnitus Handicap Inventory (THI-US) Item
Table 2 Hearing levels and psychoacoustics of tinnitus in study subjects (n = 72) Range
Mean ± SD
Tinnitus loudness (dB), n = 53
0–100 0–100 10–95
23.08 ± 19.30 23.76 ± 19.25 39.9 ± 19.43
Tinnitus pitch (kHz), n = 53
0.125–9.929
3.329 ± 2.775
Hearing threshold right (dB HL) Hearing threshold left (dB HL)
Hearing threshold ranged from 0.125 to 8 kHz
Item–total correlation
Yes
Sometimes
No
1F 2F 3E 4F 5C 6E 7F 8C
24 (24) 35 (35) 42 (20) 13 (18) 26 (17) 39 (17) 51 (24) 72 (60)
36 (49) 24 (35) 35 (38) 32 (25) 32 (25) 28 (26) 26 (38) 17 (20)
40 (27) 42 (30) 24 (42) 56 (57) 42 (58) 33 (57) 22 (38) 11 (20)
0.71 (0.70) 0.40 (0.22) 0.71 (0.54) 0.51 (0.64) 0.76 (0.54) 0.62 (0.63) 0.64 (0.48) 0.40 (0.55)
9F 10E 11C 12F 13F 14F 15F 16E 17E 18F 19C
25 (8) 44 (29) 28 (14) 19 (12) 19 (10) 26 (22) 25 (20) 25 (25) 24 (26) 25 (15) 64 (63)
24 (29) 21 (37) 21 (23) 35 (26) 29 (32) 28 (32) 22 (29) 36 (38) 21 (20) 35 (42) 18 (18)
51 (63) 35 (34) 51 (63) 46 (62) 51 (58) 46 (46) 53 (51) 39 (37) 56 (54) 40 (43) 18 (19)
0.71 (0.61) 0.67 (0.77) 0.58 (0.48) 0.74 (0.69) 0.60 (0.56) 0.78 (0.69) 0.51 (0.48) 0.80 (0.76) 0.74 (0.53) 0.76 (0.69) 0.30 (0.48)
20F 21E 22E 23C 24F
28 (18) 28 (18) 25 (25) 21 (11) 50 (43)
24 (23) 33 (26) 32 (28) 36 (40) 29 (25)
49 (59) 39 (56) 43 (49) 43 (49) 21 (32)
0.63 (0.58) 0.73 (0.63) 0.72 (0.54) 0.71 (0.59) 0.48 (0.49)
25E
28 (16)
18 (20)
54 (64)
0.74 (0.47)
Results 72 patients [43 (60 %) female and 29 (40 %) male] were included in the study. They suffered from chronic idiopathic tinnitus with a mean duration of 4.16 years, standard deviation (SD): 5.19, min.: 0.25, max.: 35 years. Mean age was 49.86 years (SD: 14.34, min.: 20, max.: 79 years). 35 of them had unilateral (13 right, 22 left) tinnitus, while 37 subjects percieved this symptom on both ears or in the head. Educational profile of patients was the following: 29 had academic degree, 42 had secondary education degree and 1 patient had a primary education degree. All patients underwent a normal otoscopic examination. Tympanometry showed normal middle ear pressure for all patients. Air conduction hearing threshold was defined as the degree of hearing impairment. Frequency distribution of air conduction hearing threshold values measured on the right and left ear is presented in Table 1. Mean values and SDs
Endorsement rates (%)
Data of the original (THI-US) version are listed in parentheses F functional subscale, E emotional subscale, C catastrophic subscale
13
Eur Arch Otorhinolaryngol
Table 4 Reliability coefficients (Cronbach’s alpha) of the Hungarian translation of the THI (THI-HUN) and the original version (THI-US) THI-HUN (Cronbach alpha)
THI-US (Cronbach alpha)
THI-HUN (Item–total)
THI-US (Item–total)
THI total (25 items) Functional (12 items) Emotional (8 items)
0.95 0.9 0.9
0.93 0.86 0.87
0.30–0.80 0.46–0.76 0.62–0.82
0.22–0.77 0.27–0.76 0.56–0.82
Catastrophic (5 items)
0.74
0.68
0.31–0.63
0.42–0.48
Table 5 Mean scores (±SD) and range of scores of the total THI scale and subscales of the Hungarian translation (THI-HUN) and the original version (THI-US)
THI-HUN (mean, n = 72) THI-US (mean, n = 66) THI-HUN (range, n = 72) THI-US (range, n = 66)
THI total
Functional
Emotional
Catastrophic
46.6 ± 27.2
20.8 ± 13.2
14.7 ± 10.3
11.1 ± 5.4
24.4 ± 20.5
11.0 ± 9.7
8.2 ± 8.4
6.1 ± 4.5
2–96
0–44
0–32
0–20
0–92
0–44
0–32
0–18
The internal consistency reliability coefficients (Cronbach’s alpha) were calculated for the THI-HUN total scale and the three subscales separately. The Cronbach’s alpha coefficients of the THI-HUN compared with the THI-US and the range of item–total correlations of them are given in Table 4. The reliability coefficients of the THI-HUN were higher than the original version, ranging from 0.74 to 0.95. The ranges of item–total correlation for the THI total and subscales of the THI-HUN were generally higher than those of the THIUS. As seen in Table 5, mean scores of the Hungarian version were generally higher than those of the original version on theTHI total scale and on the subscales as well. The score ranges of the THI-HUN were comparable to those of the THI-US. The correlations among the total scale and subscales of the THI-HUN—except the catastrophic subscale—were higher than those in the original THI-US version, as seen in Table 6. The Cronbach’s alpha coefficients of the Hungarian and of the other translations are given in Table 7. The construct validity was tested by comparing the THI-HUN scores (total and subscales) with the tinnitus severity measures Visual Analogue Scale, the short 9-item version Beck’s Depression Inventory scores, 4-item Perceived Stress Scale scores, hearing loss, tinnitus duration, tinnitus pitch and loudness and age. The correlation coefficients are summarized in Table 8, showing moderate to strong correlation (r = 0.273−0.735) of the THI scores with the symptom scores, except VAS pitch and tinnitus subjectively rated pitch judgements. There was
13
Table 6 Pearson’s product–moment correlations among THI total and subscales of the Hungarian (THI-HUN) and the original (THIUS) version THI total
Functional Emotional Catastrophic
THI total HUN 1.00 (1.00) – – – (US) Functional HUN 0.96 (0.92) 1.00 (1.00) – – (US) Emotional HUN 0.96 (0.93) 0.87 (0.75) 1.00 (1.00) – (US) Catastrophic HUN (US)
0.85 (0.89) 0.71 (0.65) 0.80 (0.78) 1.00 (1.00)
no significant correlation between THI scores and age, gender (independent samples test, p = 0.095) or level of education (ANOVA, p = 0.086). 48 of the 72 patients (67 %) returned the completed THIHUN retest questionnaire. Mean duration between the completion of the test and retest questionnaires was 16 days, SD: 6 days. Test–retest correlation is given in Table 9. We found a high test–retest correlation both for total scores and subscales, p = 0.000. Based on the total THI-HUN scores, 11 patients (15 %) showed no handicap, 21 (29 %) mild handicap, 12 (17 %) moderate handicap and 28 (39 %) severe handicap.
Discussion The internal consistency of the THI-HUN is comparable to the original THI-US version and to the other versions. The Cronbach’s alpha of the THI-HUN total is the highest (α = 0.95) of all (Table 7). The functional, emotional, catastrophic sub-scales show the same results, the Hungarian version has a high or the highest Cronbach’s alpha value (α = 0.9, 0.9, 0.74). The range of item–total correlations for the THI total and sub-scales of the THI-HUN were higher than those of the THI-US (Table 4). Items 2, 8 and 19 had a relatively low correlation coefficient (Table 3). For item 2 (Does the loudness of your tinnitus make it difficult for you to hear people?), also a low item–total correlation was found with the US, Danish, Korean, Turkish, Hebrew and Chinese versions [4, 5, 7, 9, 15, 16]. Tinnitus is not likely to
Eur Arch Otorhinolaryngol Table 7 Cronbach’s alpha coefficient of the Hungarian THI and other versions HUN
US
DK
S
K
BP
T
I
CC
H
CM
THI total (25 items) Functional (12 items) Emotional (8 items)
0.95 0.90 0.90
0.93 0.86 0.87
0.93 0.85 0.88
0.93 0.85 0.85
0.90 0.91 0.83
0.93 N/A N/A
0.89 0.78 0.75
0.92 0.85 0.86
0.94 0.89 0.89
0.93 0.85 0.90
0.93 0.85 0.87
Catastrophic (5 items)
0.74
0.68
0.74
0.42
0.73
N/A
0.80
0.63
0.64
0.74
0.78
HUN Hungarian, US United States, DK Danish, S Spanish, K Korean, BP Brazilian Portuguese, T Turkish, I Italian, CC Chinese Cantonese, H Hebrew, CM Chinese–Mandarin, N/A not available
disturb speech perception in all tinnitus patients [5]. Item 8 (Do you feel as though you cannot escape your tinnitus?) showed a low item–total correlation in the Hebrew version (r = 0.17) [15]. The correlation coefficient was also low for item 19 (Do you feel that you have no control over your tinnitus?) of the Danish adaptation (r = 0.29) [5]. When assessing the correlation among the age, gender, tinnitus duration, degree of hearing impairment and THI-HUN scores, the following relationship was observed (Table 8). For gender and education level no significant correlation was found with THI-HUN total and subscale scores. Regarding the age, there was a very weak but significant correlation with emotional subscale (r = 0.296) but not with THI-HUN total, functional and catastrophic subscales. When using the original version, no significant correlation was revealed for age, gender or the degree of Table 8 Pearson’s product–moment correlations THI total VAS loudness0.273* right VAS loudness-left 0.495** VAS annoyance0.441** right VAS annoyance0.735** left VAS pitch-rigth −0.079 VAS pitch-left 0.137 Beck total 0.645** PSS4 total 0.546** Hearing loss-right 0.377** (dB) 0.300* Hearing loss-left (dB) Duration of tin0.277* nitus (years) Age (years) 0.225 Tinnitus rating 0.362** loudness (dB) Tinnitus rating pitch (Hz)
0.021
* p 0.05). In the THI-US low corrrelation was observed between the THI (total and subscales) and the subjectively rated tinnitus pitch (r = 0.06–0.18) and loudness (r = 0.2–0.24). On the other hand, we found a relatively high correlation (r = 0.23–0.36) between THIHUN scores and subjective perception of tinnitus loudness, while no correlation between the THI-HUN scores and subjective perception of tinnitus pitch (r = 0.01–0.03) was observed. Our study confirmed the validity and reliability of the Hungarian translation of the THI. THI-HUN is the first questionnaire in Hungarian that can be used to quantify the impact of tinnitus on everyday life and to measure tinnitusevoked distress. This is a self-report questionnaire, which can be used both in busy clinical practice and in clinical studies. A further advantage is that it allows international comparisons through the THI versions in other languages. Conflict of interest The authors declare that they have no conflict of interest.
Appendix The THI-HUN is available on the following website: htt p://semmelweis.hu/fulorrgegeszet/kutatasi-teruletek/ tinnitus-handicap-inventory-kerdoiv.
References 1. Henry JA, Dennis KC, Schechter MA (2005) General review of tinnitus: prevalence, mechanisms, effects and management. J Speech Lang Hear Res 48:1204–1235 2. Holgers KM, Barrenas ML, Svedlung J, Zöger S (2003) Clinical evaluation of tinnitus: a review. Audiological Medicine 2:101–106 3. Hoffman HJ, Reed GW (2004) Epidemiology of tinnitus. In: Snow JB Jr (ed) Tinnitus: theory and management. BC Decker, Lewiston, pp 16–41 4. Newman CW, Jacobson GP, Spitzer JB (1996) Development of the Tinnitus Handicap Inventory. Arch Otolaryngol Head Neck Surg 122:143–148 5. Zachariae R, Mirz F, Johansen LV, Andersen SE, Bjerring P et al (2000) Reliability and validity of a Danish adaptation of the Tinnitus Handicap Inventory. Scand Audiol 29:37–43 6. Baguley D, Norman M (2001) Tinnitus Handicap Inventory. J Am Acad Audiol 12:379–380 7. Kim JH, Lee SY, Kim CH, Lim SL, Shin JN et al (2002) Reliability and validity of a Korean adaptation of the Tinnitus Handicap Inventory. Korean J Otolaryngol-Head Neck Surg 45:328–334
13
Eur Arch Otorhinolaryngol 8. Schmidt LP, Teixeira VN, Dall’Igna C, Dallagnol D, Smith MM (2006) Brazilian Portuguese language version of the “Tinnitus Handicap Inventory”: validity and reproducibility. Braz J Otorhinol 72:808–810 9. Aksoy S, Firat Y, Alpar R (2007) The Tinnitus Handicap Inventory: a study of validity and reliability. Int Tinnitus J 13:94–98 10. Monzani D, Genovese E, Marrara A, Gherpelli C, Pingani L et al (2008) Validity of the Italian adaptation of the Tinnitus Handicap Inventory: focus on quality of life and psychological distress in tinnitus-sufferers. Acta Otorhinolaryngol Ital 28:126–134 11. Kam AC, Cheung AP, Chan PY, Leung EK, Wong TK et al (2009) Psychometric properties of the Chinese (Cantonese) Tinnitus Handicap Inventory. Clin Otolaryngol 34:309–315 12. Lim JJ, Lu PK, Koh DS, Eng SP (2010) Impact of tinnitus as measured by the Tinnitus Handicap Inventory among tinnitus sufferers in Singapore. Singapore Med J 51:551–557 13. Ghulyan-Bedikian V, Paolino M, Giorgetti-D’Esclercs F, Paolino F (2010) Psychometric properties of a French adaptation of the Tinnitus Handicap Inventory. Encephale 36:390–396 14. Mahmoudian S, Shahmiri E, Rouzbahani M, Jafari Z, Keyhani MR et al (2011) Persian language version of the “Tinnitus Handicap Inventory”: translation, standardization, validity and reliability. Int Tinnitus J 16:93–103 15. Oron Y, Shushan S, Kreitler S, Roth YA (2011) Hebrew adaptation of the tinnitus handicap inventory. Int J Aud 50:426–430 16. Zhaoli M, Yun Z, Shixi L, Kai W, Xiudan K et al (2012) Reliability and validity of the Chinese (Mandarin) Tinnitus Handicap Inventory. Clin Exp Otorhinolaryngol 5:10–16 17. Zöger S, Svedlund J, Holgers KM (2006) Relationship between tinnitus severity and psychiatric disorders. Psychosomatics 47:282–288 18. Cohen S, Kamarck T, Mermelstein R (1983) A global measure of perceived stress. J Health Soc Behav 24:385–396 19. Cohen S, Williamson GM (1988) Perceived stress in a probability sample of the United States. In: Spacapan S, Oskamp S (eds) The social psychology of health. Sage, Newbury Park, pp 31–67 20. Stauder A, Konkoly TB (2006) Characteristics of the Hungarian version of the Perceived Stress Scale (PSS). Mentálhigiéné és Pszichoszomatika 7:203–216 21. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J (1961) An inventory for measuring depression. Arch Gen Psychiatry 4:561–571 22. Beck AT, Beck RW (1972) Screening depressed patients in family practice: a rapid technique. Postgrad Med 52:81–85 23. Beck AT, Guth D, Steer RA, Ball R (1997) Screening for major depression disorders in medical inpatients the Beck Depression Inventory for primary care. Behav Res Ther 35:785–791 24. Rózsa S, Szádóczky E, Füredi J (2001) Experiences with the shortened version of the Beck Depression Scale in Hungary. Psychiatria Hungarica 16:379–394 25. Prestes R, Gil D (2009) Impact of tinnitus on quality of life, loudness and pitch match, and high-frequency audiometry. Int Tinnitus J 15:134–138 26. Figueiredo RR, Azevedo AA, Oliveira Pde M (2009) Correlation analysis of the visual-analogue scale and the Tinnitus Handicap Inventory in tinnitus patients. Braz J Otorhinolaryngol 75:76–79 27. Kuk F, Tyler RS, Russel D, Jordan H (1990) The psychometric properties of a tinnitus handicap questionnaire. Ear Hear 11:434–442 28. Crocetti A, Forti S, Ambrosetti U, Bo LD (2009) Questionnaires to evaluate anxiety and depressive levels in tinnitus patients. Otolaryngol Head Neck Surg 140:403–405
Otology
Hungarian adaptation of the Tinnitus Handicap Inventory: reliability and validity Beata Bencsik · László Tamás · Krisztina Trimmel · Adrienne Stauder
Received: 23 April 2014 / Accepted: 6 June 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract The objective of this study was to determine the reliability and validity of the Hungarian version of the original Tinnitus Handicap Inventory (THI). In the study design the original THI (THI-US) was translated into Hungarian by three independent investigators. The final Hungarian version (THI-HUN) was constructed on the basis of these Hungarian interpretations and then administered to 72 patients suffering from chronic tinnitus. Construct validity was assessed using short version of Beck’s Depression Inventory (BDI), Perceived Stress Scale (PSS4 version), Visual Analogue Scale (VAS) (loudness, annoyance and pitch of tinnitus), pure tone audiometry and tinnitometry. The 72 participants were 43 women and 29 men. Their mean age was 49.86 years with a mean tinnitus duration of 4.16 years. In the results THI-HUN and its subscales showed good internal consistency reliabilities (α = 0.95– 0.74), with significant correlation between THI-HUN total score and subscales and the BDI, PSS4 and VAS annoyance. There was a high or moderate correlation between THI-HUN total score and VAS loudness, tinnitus duration, hearing loss and subjective perception of tinnitus loudness. The VAS pitch of tinnitus, the subjective perception of tinnitus pitch, age, gender and level of education did not show B. Bencsik (*) · L. Tamás Department of Otorhinolaryngology and Head and Neck Surgery, Semmelweis University, Szigony Street 36, Budapest 1083, Hungary e-mail: [email protected] K. Trimmel Faculty of Medicine, Semmelweis University, Üllo˝i Road 26, Budapest 1085, Hungary A. Stauder Institute of Behavioural Sciences, Semmelweis University, Nagyvárad Square 4, Budapest 1089, Hungary
any correlation with THI-HUN total score. The test–retest reliability was high (r = 0.97). We conclude that a valid and reliable THI-HUN questionnaire was constructed. Keywords Questionnaires · Quality of life · Tinnitus · Validity
Introduction Tinnitus as a phantom auditory perception is a very common symptom. Results of neuroscientific research from the last 20 years yielded some theories about the pathophysiology of tinnitus, but the whole mechanism is still unknown. Although there are no standadized questionnaires available for the evaluation of tinnitus prevalence [1], some studies found that prevalence of tinnitus in general population can reach up to 10–15 % [2], with a predominance among the elderly [3]. Tinnitus is primarily a subjective disorder. Self-report tinnitus questionnaires are commonly used tools for assessing the impact of tinnitus on the patient’s everyday life. Of these, Tinnitus Handicap Inventory [4] is one of the most commonly used test method for the evaluation of tinnitus patients. It has been translated and validated into a wide range of languages, including Danish [5], Spanish [6], Korean [7], Brazilian Portuguese [8], Turkish [9], Italian [10], Chinese/Cantonese [11], Singapore [12], French [13], Persian [14], Hebrew [15] and Chinese (Mandarin) [16]. Several studies have demonstrated the relationship between tinnitus and certain psychiatric disorders, such as depression or anxiety. Based on the evaluation of 224 subjects, Zöger et al. [17] found a significant correlation between the severity of tinnitus and depression; for anxiety, this correlation was significant only in the high-risk population.
13
Until now, no tinnitus-specific questionnaire has been avaliable in Hungarian. Therefore, the aim of our study was to validate our Hungarian adaptation of the THI (THIHUN) for the evaluation of Hungarian-speaking tinnitus patients and for its satisfactory application in clinical/ research environments.
Materials and methods Translation procedure The Tinnitus Handicap Inventory (THI) [4] consists of 25 items grouped into three subscales: a functional subscale (THI—functional, 12 items), an emotional subscale (THI— emotional, 8 items) and a catastrophic subscale (THI— catastrophic, 5 items). Each item offers three potential answers: “yes” = 4 points, “sometimes” = 2 points, and “no” = 0 point. The THI score may vary between 0 and 100, specifying different ranges of an index score, namely, light (0–16), mild (18–36), moderate (38–56), severe (58– 76) and catastrophic (78–100) handicap. Cronbach’s alpha of the original THI is 0.93. Firstly we asked the author (C.W. Newman) of the original version (THI-US) to permit us to have the THI translated into Hungarian and validate the test approved by him. Then, three independent translations were made from English into Hungarian by professional translators with an excellent knowledge of both languages. These three Hungarian translations was integrated into a single, optimized version that was then back-translated into English by a native English-speaking translator who was not aware of the original English version. Then, the original THI and the back-translated THI were compared by the professional English translator. The final Hungarian version (THI-HUN) was then considered to be suitable for validation. Study method In our study, the final version of the THI-HUN was administered to 72 patients with chronic idiopathic tinnitus. All of them were assessed as outpatients at the Department of Otorhinolaryngology and Head and Neck Surgery of Semmelweis University. The following inclusion criteria were used: minimum age of 18 years, peresence of tinnitus as a leading symptom; mono- or bilateral, continuous tinnitus experienced at least for 3 months prior to the enrollment. Patients treated with severe psychiatric disease; persons with mental incapacity or those not understanding or speaking Hungarian were excluded. At Visit 1, an otoscopic evaluation was performed and medical history data were collected. Patients were asked to complete self-report questionnaires: in addition to
13
Eur Arch Otorhinolaryngol
THI-HUN, a 9-item short version of Beck’s Depression Inventory (BDI), Perceived Stress Scale (PSS4) and Visual Analogue Scale (VAS) (loudness, annoyance and pitch of tinnitus). Each patient underwent pure tone audiometry (air and bone conduction) and tympanometry and their subjective perception of pitch and loudness of tinnitus was determined. 2 weeks after the completion of the first THI-HUN, subjects were asked to complete THI-HUN test again at home (test–retest stability) without receiving any additional treatment meanwhile or being aware of the previous test results. All participants were fully informed about the aim of study and the test procedure and gave their approval to participation in the study by signing the written informed consent. The study design was approved by the Ethics Committee of Semmelweis University of Budapest (Nr.: 9/2013). Perceived Stress Scale (PSS) Perceived stress scale, or PSS, is one of the most widely used tool for the measurement of stress level [18] with a reliability demonstrated in large subject samples [19]. The original version of the questionnaire (PSS14) consists of 14 items to be scored at a 5-point Likert scale (0–4). Total score is a global indicator of percieved stress; higher score suggests more frequent stress situations. Two short versions have been developed with 10 (PSS10) and 4 (PSS4) items, respectively. In our study, validated Hungarian version of PSS4 [20] was administered to the study population that shows a strong correlation with PSS14 (r = 0.93), with a good internal consistency (Cronbach alpha: 0.79) and excellent test–retest reliability (r = 0.90). Short version of Beck’s Depression Inventory (BDI) One of the most popular self-measuring tool for revealing mood disorders or depression is Beck’s Depression Inventory (BDI) involving 21 items [21]. Its 13-item and 7-item short versions are used for screening purposes [22, 23]. Short 9-item Hungarian adaptation of this measuring tool was tested on a large sample by a Hungarian team of researchers. Their results confirmed the reliability and validity of the test, Cronbach alpha: 0.81 [24]. The test includes questions on a wide range of depression symptoms. For the assessment, 4-point Likert scale is applied where higher scores suggest the presence of more depression symptoms. Test evaluation: 0–9 normal, 10–18 mild, 19–25 moderate, >25 severe depression. For the calculation of standard (not short) BDI value, the total score of short test should be multiplied by 2.2. In our study, the short, 9-item version of BDI scale was used.
Eur Arch Otorhinolaryngol Table 1 Means and SDs for right and left air-conduction thresholds (dB HL) for subject sample (n = 72)
HL hearing level
Frequency (Hz) Right ear Mean (dB) SD (dB) Left ear Mean (dB) SD (dB)
125
250
500
1,000
2,000
4,000
8,000
20.08 12.94
18.19 13.75
17.57 14.99
18.26 15.45
20.24 18.99
30.56 22.10
36.39 24.87
18.69
17.08
18.19
19.24
20.97
32.22
39.44
13.21
14.38
18.04
15.42
16.52
19.06
23.95
Visual Analogue Scale Visual Analogue Scale (VAS) scales ranged from 0 (corresponding to the absence of tinnitus) to 100 (corresponding to the maximal imaginable loudness, annoyance and pitch of tinnitus). Patients reported the actually perceived loudness, annoyance and pitch of tinnitus on a scale ranging from 0 to 100. Data analysis SPSS version 20.0 was used for all statistical analyses.
of hearing levels of all patients on both ears as well as mean values and SDs of frequency/(kiloHertz (kHz)/and loudness/ decibel (dB)/of tinnitus can be seen in Table 2. In 19 cases we could not measure the frequency and loudness of tinnitus. In Table 3 response rate for 25 questions of THI was calculated for the Hungarian (THI-HUN) and the original (THIUS) version. In the last coloumn, the item–total correlation is given for the Hungarian and the original version. Table 3 Endorsement rates and item–total correlations of the Hungarian translation (THI-HUN) and the original version of the Tinnitus Handicap Inventory (THI-US) Item
Table 2 Hearing levels and psychoacoustics of tinnitus in study subjects (n = 72) Range
Mean ± SD
Tinnitus loudness (dB), n = 53
0–100 0–100 10–95
23.08 ± 19.30 23.76 ± 19.25 39.9 ± 19.43
Tinnitus pitch (kHz), n = 53
0.125–9.929
3.329 ± 2.775
Hearing threshold right (dB HL) Hearing threshold left (dB HL)
Hearing threshold ranged from 0.125 to 8 kHz
Item–total correlation
Yes
Sometimes
No
1F 2F 3E 4F 5C 6E 7F 8C
24 (24) 35 (35) 42 (20) 13 (18) 26 (17) 39 (17) 51 (24) 72 (60)
36 (49) 24 (35) 35 (38) 32 (25) 32 (25) 28 (26) 26 (38) 17 (20)
40 (27) 42 (30) 24 (42) 56 (57) 42 (58) 33 (57) 22 (38) 11 (20)
0.71 (0.70) 0.40 (0.22) 0.71 (0.54) 0.51 (0.64) 0.76 (0.54) 0.62 (0.63) 0.64 (0.48) 0.40 (0.55)
9F 10E 11C 12F 13F 14F 15F 16E 17E 18F 19C
25 (8) 44 (29) 28 (14) 19 (12) 19 (10) 26 (22) 25 (20) 25 (25) 24 (26) 25 (15) 64 (63)
24 (29) 21 (37) 21 (23) 35 (26) 29 (32) 28 (32) 22 (29) 36 (38) 21 (20) 35 (42) 18 (18)
51 (63) 35 (34) 51 (63) 46 (62) 51 (58) 46 (46) 53 (51) 39 (37) 56 (54) 40 (43) 18 (19)
0.71 (0.61) 0.67 (0.77) 0.58 (0.48) 0.74 (0.69) 0.60 (0.56) 0.78 (0.69) 0.51 (0.48) 0.80 (0.76) 0.74 (0.53) 0.76 (0.69) 0.30 (0.48)
20F 21E 22E 23C 24F
28 (18) 28 (18) 25 (25) 21 (11) 50 (43)
24 (23) 33 (26) 32 (28) 36 (40) 29 (25)
49 (59) 39 (56) 43 (49) 43 (49) 21 (32)
0.63 (0.58) 0.73 (0.63) 0.72 (0.54) 0.71 (0.59) 0.48 (0.49)
25E
28 (16)
18 (20)
54 (64)
0.74 (0.47)
Results 72 patients [43 (60 %) female and 29 (40 %) male] were included in the study. They suffered from chronic idiopathic tinnitus with a mean duration of 4.16 years, standard deviation (SD): 5.19, min.: 0.25, max.: 35 years. Mean age was 49.86 years (SD: 14.34, min.: 20, max.: 79 years). 35 of them had unilateral (13 right, 22 left) tinnitus, while 37 subjects percieved this symptom on both ears or in the head. Educational profile of patients was the following: 29 had academic degree, 42 had secondary education degree and 1 patient had a primary education degree. All patients underwent a normal otoscopic examination. Tympanometry showed normal middle ear pressure for all patients. Air conduction hearing threshold was defined as the degree of hearing impairment. Frequency distribution of air conduction hearing threshold values measured on the right and left ear is presented in Table 1. Mean values and SDs
Endorsement rates (%)
Data of the original (THI-US) version are listed in parentheses F functional subscale, E emotional subscale, C catastrophic subscale
13
Eur Arch Otorhinolaryngol
Table 4 Reliability coefficients (Cronbach’s alpha) of the Hungarian translation of the THI (THI-HUN) and the original version (THI-US) THI-HUN (Cronbach alpha)
THI-US (Cronbach alpha)
THI-HUN (Item–total)
THI-US (Item–total)
THI total (25 items) Functional (12 items) Emotional (8 items)
0.95 0.9 0.9
0.93 0.86 0.87
0.30–0.80 0.46–0.76 0.62–0.82
0.22–0.77 0.27–0.76 0.56–0.82
Catastrophic (5 items)
0.74
0.68
0.31–0.63
0.42–0.48
Table 5 Mean scores (±SD) and range of scores of the total THI scale and subscales of the Hungarian translation (THI-HUN) and the original version (THI-US)
THI-HUN (mean, n = 72) THI-US (mean, n = 66) THI-HUN (range, n = 72) THI-US (range, n = 66)
THI total
Functional
Emotional
Catastrophic
46.6 ± 27.2
20.8 ± 13.2
14.7 ± 10.3
11.1 ± 5.4
24.4 ± 20.5
11.0 ± 9.7
8.2 ± 8.4
6.1 ± 4.5
2–96
0–44
0–32
0–20
0–92
0–44
0–32
0–18
The internal consistency reliability coefficients (Cronbach’s alpha) were calculated for the THI-HUN total scale and the three subscales separately. The Cronbach’s alpha coefficients of the THI-HUN compared with the THI-US and the range of item–total correlations of them are given in Table 4. The reliability coefficients of the THI-HUN were higher than the original version, ranging from 0.74 to 0.95. The ranges of item–total correlation for the THI total and subscales of the THI-HUN were generally higher than those of the THIUS. As seen in Table 5, mean scores of the Hungarian version were generally higher than those of the original version on theTHI total scale and on the subscales as well. The score ranges of the THI-HUN were comparable to those of the THI-US. The correlations among the total scale and subscales of the THI-HUN—except the catastrophic subscale—were higher than those in the original THI-US version, as seen in Table 6. The Cronbach’s alpha coefficients of the Hungarian and of the other translations are given in Table 7. The construct validity was tested by comparing the THI-HUN scores (total and subscales) with the tinnitus severity measures Visual Analogue Scale, the short 9-item version Beck’s Depression Inventory scores, 4-item Perceived Stress Scale scores, hearing loss, tinnitus duration, tinnitus pitch and loudness and age. The correlation coefficients are summarized in Table 8, showing moderate to strong correlation (r = 0.273−0.735) of the THI scores with the symptom scores, except VAS pitch and tinnitus subjectively rated pitch judgements. There was
13
Table 6 Pearson’s product–moment correlations among THI total and subscales of the Hungarian (THI-HUN) and the original (THIUS) version THI total
Functional Emotional Catastrophic
THI total HUN 1.00 (1.00) – – – (US) Functional HUN 0.96 (0.92) 1.00 (1.00) – – (US) Emotional HUN 0.96 (0.93) 0.87 (0.75) 1.00 (1.00) – (US) Catastrophic HUN (US)
0.85 (0.89) 0.71 (0.65) 0.80 (0.78) 1.00 (1.00)
no significant correlation between THI scores and age, gender (independent samples test, p = 0.095) or level of education (ANOVA, p = 0.086). 48 of the 72 patients (67 %) returned the completed THIHUN retest questionnaire. Mean duration between the completion of the test and retest questionnaires was 16 days, SD: 6 days. Test–retest correlation is given in Table 9. We found a high test–retest correlation both for total scores and subscales, p = 0.000. Based on the total THI-HUN scores, 11 patients (15 %) showed no handicap, 21 (29 %) mild handicap, 12 (17 %) moderate handicap and 28 (39 %) severe handicap.
Discussion The internal consistency of the THI-HUN is comparable to the original THI-US version and to the other versions. The Cronbach’s alpha of the THI-HUN total is the highest (α = 0.95) of all (Table 7). The functional, emotional, catastrophic sub-scales show the same results, the Hungarian version has a high or the highest Cronbach’s alpha value (α = 0.9, 0.9, 0.74). The range of item–total correlations for the THI total and sub-scales of the THI-HUN were higher than those of the THI-US (Table 4). Items 2, 8 and 19 had a relatively low correlation coefficient (Table 3). For item 2 (Does the loudness of your tinnitus make it difficult for you to hear people?), also a low item–total correlation was found with the US, Danish, Korean, Turkish, Hebrew and Chinese versions [4, 5, 7, 9, 15, 16]. Tinnitus is not likely to
Eur Arch Otorhinolaryngol Table 7 Cronbach’s alpha coefficient of the Hungarian THI and other versions HUN
US
DK
S
K
BP
T
I
CC
H
CM
THI total (25 items) Functional (12 items) Emotional (8 items)
0.95 0.90 0.90
0.93 0.86 0.87
0.93 0.85 0.88
0.93 0.85 0.85
0.90 0.91 0.83
0.93 N/A N/A
0.89 0.78 0.75
0.92 0.85 0.86
0.94 0.89 0.89
0.93 0.85 0.90
0.93 0.85 0.87
Catastrophic (5 items)
0.74
0.68
0.74
0.42
0.73
N/A
0.80
0.63
0.64
0.74
0.78
HUN Hungarian, US United States, DK Danish, S Spanish, K Korean, BP Brazilian Portuguese, T Turkish, I Italian, CC Chinese Cantonese, H Hebrew, CM Chinese–Mandarin, N/A not available
disturb speech perception in all tinnitus patients [5]. Item 8 (Do you feel as though you cannot escape your tinnitus?) showed a low item–total correlation in the Hebrew version (r = 0.17) [15]. The correlation coefficient was also low for item 19 (Do you feel that you have no control over your tinnitus?) of the Danish adaptation (r = 0.29) [5]. When assessing the correlation among the age, gender, tinnitus duration, degree of hearing impairment and THI-HUN scores, the following relationship was observed (Table 8). For gender and education level no significant correlation was found with THI-HUN total and subscale scores. Regarding the age, there was a very weak but significant correlation with emotional subscale (r = 0.296) but not with THI-HUN total, functional and catastrophic subscales. When using the original version, no significant correlation was revealed for age, gender or the degree of Table 8 Pearson’s product–moment correlations THI total VAS loudness0.273* right VAS loudness-left 0.495** VAS annoyance0.441** right VAS annoyance0.735** left VAS pitch-rigth −0.079 VAS pitch-left 0.137 Beck total 0.645** PSS4 total 0.546** Hearing loss-right 0.377** (dB) 0.300* Hearing loss-left (dB) Duration of tin0.277* nitus (years) Age (years) 0.225 Tinnitus rating 0.362** loudness (dB) Tinnitus rating pitch (Hz)
0.021
* p 0.05). In the THI-US low corrrelation was observed between the THI (total and subscales) and the subjectively rated tinnitus pitch (r = 0.06–0.18) and loudness (r = 0.2–0.24). On the other hand, we found a relatively high correlation (r = 0.23–0.36) between THIHUN scores and subjective perception of tinnitus loudness, while no correlation between the THI-HUN scores and subjective perception of tinnitus pitch (r = 0.01–0.03) was observed. Our study confirmed the validity and reliability of the Hungarian translation of the THI. THI-HUN is the first questionnaire in Hungarian that can be used to quantify the impact of tinnitus on everyday life and to measure tinnitusevoked distress. This is a self-report questionnaire, which can be used both in busy clinical practice and in clinical studies. A further advantage is that it allows international comparisons through the THI versions in other languages. Conflict of interest The authors declare that they have no conflict of interest.
Appendix The THI-HUN is available on the following website: htt p://semmelweis.hu/fulorrgegeszet/kutatasi-teruletek/ tinnitus-handicap-inventory-kerdoiv.
References 1. Henry JA, Dennis KC, Schechter MA (2005) General review of tinnitus: prevalence, mechanisms, effects and management. J Speech Lang Hear Res 48:1204–1235 2. Holgers KM, Barrenas ML, Svedlung J, Zöger S (2003) Clinical evaluation of tinnitus: a review. Audiological Medicine 2:101–106 3. Hoffman HJ, Reed GW (2004) Epidemiology of tinnitus. In: Snow JB Jr (ed) Tinnitus: theory and management. BC Decker, Lewiston, pp 16–41 4. Newman CW, Jacobson GP, Spitzer JB (1996) Development of the Tinnitus Handicap Inventory. Arch Otolaryngol Head Neck Surg 122:143–148 5. Zachariae R, Mirz F, Johansen LV, Andersen SE, Bjerring P et al (2000) Reliability and validity of a Danish adaptation of the Tinnitus Handicap Inventory. Scand Audiol 29:37–43 6. Baguley D, Norman M (2001) Tinnitus Handicap Inventory. J Am Acad Audiol 12:379–380 7. Kim JH, Lee SY, Kim CH, Lim SL, Shin JN et al (2002) Reliability and validity of a Korean adaptation of the Tinnitus Handicap Inventory. Korean J Otolaryngol-Head Neck Surg 45:328–334
13
Eur Arch Otorhinolaryngol 8. Schmidt LP, Teixeira VN, Dall’Igna C, Dallagnol D, Smith MM (2006) Brazilian Portuguese language version of the “Tinnitus Handicap Inventory”: validity and reproducibility. Braz J Otorhinol 72:808–810 9. Aksoy S, Firat Y, Alpar R (2007) The Tinnitus Handicap Inventory: a study of validity and reliability. Int Tinnitus J 13:94–98 10. Monzani D, Genovese E, Marrara A, Gherpelli C, Pingani L et al (2008) Validity of the Italian adaptation of the Tinnitus Handicap Inventory: focus on quality of life and psychological distress in tinnitus-sufferers. Acta Otorhinolaryngol Ital 28:126–134 11. Kam AC, Cheung AP, Chan PY, Leung EK, Wong TK et al (2009) Psychometric properties of the Chinese (Cantonese) Tinnitus Handicap Inventory. Clin Otolaryngol 34:309–315 12. Lim JJ, Lu PK, Koh DS, Eng SP (2010) Impact of tinnitus as measured by the Tinnitus Handicap Inventory among tinnitus sufferers in Singapore. Singapore Med J 51:551–557 13. Ghulyan-Bedikian V, Paolino M, Giorgetti-D’Esclercs F, Paolino F (2010) Psychometric properties of a French adaptation of the Tinnitus Handicap Inventory. Encephale 36:390–396 14. Mahmoudian S, Shahmiri E, Rouzbahani M, Jafari Z, Keyhani MR et al (2011) Persian language version of the “Tinnitus Handicap Inventory”: translation, standardization, validity and reliability. Int Tinnitus J 16:93–103 15. Oron Y, Shushan S, Kreitler S, Roth YA (2011) Hebrew adaptation of the tinnitus handicap inventory. Int J Aud 50:426–430 16. Zhaoli M, Yun Z, Shixi L, Kai W, Xiudan K et al (2012) Reliability and validity of the Chinese (Mandarin) Tinnitus Handicap Inventory. Clin Exp Otorhinolaryngol 5:10–16 17. Zöger S, Svedlund J, Holgers KM (2006) Relationship between tinnitus severity and psychiatric disorders. Psychosomatics 47:282–288 18. Cohen S, Kamarck T, Mermelstein R (1983) A global measure of perceived stress. J Health Soc Behav 24:385–396 19. Cohen S, Williamson GM (1988) Perceived stress in a probability sample of the United States. In: Spacapan S, Oskamp S (eds) The social psychology of health. Sage, Newbury Park, pp 31–67 20. Stauder A, Konkoly TB (2006) Characteristics of the Hungarian version of the Perceived Stress Scale (PSS). Mentálhigiéné és Pszichoszomatika 7:203–216 21. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J (1961) An inventory for measuring depression. Arch Gen Psychiatry 4:561–571 22. Beck AT, Beck RW (1972) Screening depressed patients in family practice: a rapid technique. Postgrad Med 52:81–85 23. Beck AT, Guth D, Steer RA, Ball R (1997) Screening for major depression disorders in medical inpatients the Beck Depression Inventory for primary care. Behav Res Ther 35:785–791 24. Rózsa S, Szádóczky E, Füredi J (2001) Experiences with the shortened version of the Beck Depression Scale in Hungary. Psychiatria Hungarica 16:379–394 25. Prestes R, Gil D (2009) Impact of tinnitus on quality of life, loudness and pitch match, and high-frequency audiometry. Int Tinnitus J 15:134–138 26. Figueiredo RR, Azevedo AA, Oliveira Pde M (2009) Correlation analysis of the visual-analogue scale and the Tinnitus Handicap Inventory in tinnitus patients. Braz J Otorhinolaryngol 75:76–79 27. Kuk F, Tyler RS, Russel D, Jordan H (1990) The psychometric properties of a tinnitus handicap questionnaire. Ear Hear 11:434–442 28. Crocetti A, Forti S, Ambrosetti U, Bo LD (2009) Questionnaires to evaluate anxiety and depressive levels in tinnitus patients. Otolaryngol Head Neck Surg 140:403–405
