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Mr. Smith suffers from isolation, inactivity, lack of enjoyment and negative thinking. His wife complains that lately he speaks less and with more silences. He takes longer to respond to the remarks of others, and his face is relatively devoid of animation. He gestures infrequently, and when he does communicate, she says he is likely to express negative feelings. Recently, he has been hostile and demanding. Sound familiar? Does Mr. Smith sound to you like he might have a significant hearing problem? He could, but these descriptions are cited by the Menninger Foundation1 as signs of serious depression. There are many effects of hearing loss that parallel the symptoms of depression. In fact, depressive symptoms persist among those with hearing loss regardless of their use or non-use of hearing aids.2-4 An alarming 22.1% of Americans age 18 and older suffer from some diagnosable mental disorder in a given year.5 While treatment for mental disorders does not fall within the scope of audiology practice, its effects on our patients fall directly upon usespecially when patients suffer from depression. Through aural rehabilitation we are expected to restore hope and increase a sense of inner well-being in patients who (very often unknowing to us) suffer from depression. If we look at some of the challenges or failures in our rehabilitation efforts, including hearing aid dispensing, we may find client depression as a highly influential factor. Depression is rarely considered in the process of aural rehabilitation, and even more rarely, if ever, measured by us in clinical practice. While we may interpret a depressed patients condition as an effect of hearing loss and work hard to overcome the implied obstacles, we could be working futilely to achieve the impossible without medical intervention. It is often falsely believed that depression is a natural part of aging, but this is actually a misunderstanding of the nature of depression. All of us from time to time and at all ages experience a low moment, a passing period of the blues, a dark mood or perhaps an empty feeling. This is common when attributable to the loss of a loved one, a divorce, a disappointment or any of a multitude of possibilities. When this sadness does not normally subside, nor is quelled by any standard means through enjoyments in life, it is a warning sign for depression. Major depressive disorder is the leading cause of disability in the U.S. and established market economies worldwide6, and ranks second only to ischemic heart disease in magnitude of disease burden.7 While it can develop at any age, the average age at onset is the mid-20s8, and in the U.S., about twice as many women as men are affected by depressive disorders.5 Population estimates based on the most recent U.S. Census revealed approximately 18.8-million American adults, or just under 10% of the population age 18 and over, have a depressive disorder.9 The burden of mental illness on health and productivity in the U.S. is more than the disease burden caused by all cancers.7 Based on the data provided above, it seems apparent that no dispensing professional can escape encountering patients with depressive disorders, whether we realize it or not. In fact, based on the data, almost one-in-four patients will suffer from some type of mental illness, and not fewer than 1-in-10 are likely to suffer from depression, irrespective of hearing loss. The incidence of chronic depression among those with hearing loss could be even higher because of the emotionally-charged state hearing loss can precipitate. Table 1. Criteria for a Major Depressive Episode* A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either 1) depressed mood or 2) loss of interest or pleasure. (Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations,) Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appear tearful). Note: In children and adolescents, can be irritable mood; Markedly diminished interest or pleasure in all, or almost all activities most of the day, nearly every day (as indicated by either subjective account or observation made by others); Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight. Note: In children, consider failure to make expected weight gains; Insomnia or hypersomnia nearly every day; Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down); Fatigue or loss of energy nearly every day; Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick); Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others); Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. B. The symptoms do not meet criteria for a Mixed Episode (that is, both Manic Episode and Major Depressive Episode). C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism). E. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation. *Reprinted with permission from the American Pschiatric Assn.: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington D.C.: American Pschiatric Assn., 2000: 356. If hearing loss is a condition many patients feel compelled to hide, surely mental illness remains an issue of far greater secrecy. The reasons are self-evident. However, hearing care professionals can recognize the signs of depression (Tables 1 and 2), and place themselves in a better position to assist such troubled patients. Our role should be to fundamentally recognize its presence, and consider how it will affect consultation with patients, their hearing aid orientation and ultimately their adjustment to hearing loss and hearing instruments. Table 2. Symptoms of Depression in Older Adults* IF YOUR CLIENTS FEEL... very tired, slowed down, fatigued in a persistently sad mood a change in behavior, e.g., overall withdrawal from social support, unopened mail they dont enjoy things the way they used to restless or irritable difficulty concentrating theyre sleeping more or less than usual theyre eating more or less than usual persistent headaches, stomach aches, or chronic pain nervous or empty guilty, worthless or helpless hopeless like life is not worth living like no one loves them an absence of pleasures or joy excessive crying *From NIH Publication No. 01-4593 (2001): www.nimh.nih.gov/publicat/elderlydepsuicide.cfm and www.nimh.nih.gov/publicat/over65.cfm and Patient Care Advisor, LRP Publications, 1998; 747 Dresher Rd., PO Box 980, Horsham PA 19044-0980. Background The primary audiology texts in the 1960s on the psychology of deafness10,11 never addressed issues of depression. It might seem difficult today to understand how any issues surrounding hearing loss could not have addressed this most fundamental human response to a sensory loss, but some 40 years later, current research, literature and published data remain scant. One study evaluating the long-term benefits of hearing instruments in the elderly12 showed depression present in 23% of its 192 subjects, but most subjects were men. As reported earlier, depression is twice as common in women5, so these results could be more significant when applied across both genders. Conversely, Bridges & Bentler2 studied depression in 251 normal-hearing and hearing-impaired subjects with more than twice as many women as men, but they did not separate the variable of gender. They found depression was significantly more prevalent among those with hearing loss. In a six-year longitudinal study by Wallhagen et al.13, 356 hearing-impaired men and women age 65 and older were compared to a normal-hearing control group. They found that while depression among the hearing-impaired group was present even at baseline, there was more than a three-fold greater likelihood of its presence at the six-year follow-up. In a subsequent report14 derived from the original study population of 2461 subjects but drawn from ages 50 and older (57% women, 43% men), hearing impairment was independently associated with subsequent decline in a wide variety of functional outcomes (i.e., after adjustment for co-occurring medical conditions and other baseline factors). The research revealed that individuals reporting moderate or more hearing impairment were twice as likely to be depressed as persons reporting no hearing impairment. A study by the National Council on Aging and the Hearing Industries Assn.3 also demonstrated a prevalence of depression among subjects with hearing loss. A revealing aspect was that family members consistently reported more depression in their loved ones than patients themselves admitted, which suggests that if we ask our patients if they are depressed, they may deny it. If we are to make such inquiry, the question also needs to be posed to the spouse, children of elder adults, or another close family member to derive a more objective observation. Depressive Disorders Defined Depression is characterized as a mood disorder, which according to the Diagnostic and Statistical Manual for Mental Disorders8, is divided into three general types: major depressive disorder, dysthymic disorder and bipolar disorder. They can be accompanied by many different diagnostically significant degrees and features, which is beyond the scope of this paper. In general terms, a major depressive disorder is characterized by at least two weeks of depression in conjunction with at least four additional symptoms of depression (see Table 1). Dysthymic disorder is generally a less severe but more chronic form of depression, and must be present for more days than not over at least two years. It affects approximately 5.4% of Americans age 18 and older during their lifetime, which translates to almost 11-million American adults, and about 40% of this group also meets the criteria for major depressive disorder or bipolar disorder.5 Bipolar disorder, also known as manic depression, affective or mood disorder, entails wide mood swings from depression to mania and variations between. It affects approximately 2.3-million American adults, with men and women suffering equally.9 The average age for a first manic episode is the early 20s.8 The Complexity of Diagnosis The prevalence rates of dysthymia in the elderly are statistically lower than in younger adults, but there is strong evidence to suggest that this may be a result of errors in factoring. Bellino and his group15 challenged the efficacy of some portions of the Diagnostic and Statistical Manual of Mental Disorders8 for failing to account for a number of influencing factors in older adults such as co-morbid general conditions, cognitive deterioration and disorders, and frequent adverse life events such as bereavement. While hearing loss alone is enough to cause depression, there is another consideration. Late-life depression (see Table 2) is common with multiple chronic diseases and disabilities including cancer, cardiovascular disease, neurological disorders, various metabolic disturbances, arthritis and sensory loss.16 Therefore, hearing loss may be only one of several co-occurring bases for depressionthat is, one of several medical conditions. (Authors Note: readers are referred to Goldberg40 for information on the alarming rates of depression in people with co-occurring medical conditions.) Hence, the link between depression and other medical conditions may not be well-recognized because hearing care professionals are not generally aware of all events related to the patients primary medical care. This is despite the fact that some of the characteristics of depression, as described by DiMatteo and colleagues17, include hopelessness and social isolation, both of which are factors that drive many of our patients to seek hearing helpoften motivated by family rather than by the patients themselves. When hearing care professionals see these patients, the origin of their depressed state is unknown. It is not complicated to understand that many people medically diagnosed as depressed do not welcome this information. They do not want the stigma. Furthermore, the rate of noncompliance for those accurately diagnosed and dispensed medications is disquieting. One resource has reported, In a meta-analysis of 30 years of related research literaturedepressed patients were 3 times more likely not to adhere to treatment recommendations than were patients who were not depressed.17 They go on to say that depression occurs in 25% of individuals undergoing medical treatment and that about half of all medical patients in the U.S. do not comply with treatment recommendations. This directly impacts the services of hearing care professionals, especially when providing rehabilitation services for non-compliant patients trying to endure the frustrations of hearing aid use. Worse, hearing care professionals are not likely to even know that the patient is depressed, let alone non-compliant. It should be recognized that there can be many different human reactions to the identical medical diagnosis. One person may get depressed, another may find skillful coping mechanisms (those with hearing loss are perfect examples of this variability). One person may be highly compliant with medication, another fully non-compliant. But when hearing loss co-occurs with a serious health condition, as participating practitioners, we cannot assume that we have been duly informed. Therefore, what we might observe as depression in a patient may have nothing to do with hearing loss. On the other hand, in the absence of a contributing medical condition linked to depression, the depression may well be attributed to a patients inability to cope with the stress and issues around living with hearing loss: impaired communication, diminished music appreciation, lowered self-esteem, etc. Study of etiology of depression sometimes gets murky because of the obvious variables involved (number of co-occurring conditions, duration, genetic history, environmental factors, etc.). What is known from limited published audiologic research is that depression is a serious factor worthy of consideration in our patients, and something seldom discussed in our consultations. Self-realization of hearing loss can result in depression, short-term and chronic, for some people. As one study14 has revealed, with increased hearing loss there is a probability of increased depression. However, the degree to which this depression develops into a major depressive episode remains unknown because there is no research data from which to draw. An expedient depression screening tool called the Online Depression Screening Test (ODST) can be accessed via the Internet at www.med.nyu.edu/Psych/screens/depress.html. Developed by Waguih William Ishak, MD, the 10-question test is designed to be completed in a matter of minutes, with results sent back to the individual. It should be acknowledged that this is a slippery slope for hearing care professionals, and may be best suited to clinical and hospital settings where consulting physicians, otologists, psychologists or psychiatrists are available. However, a depression screening tool like the ODST at least offers patients and their families options for addressing the possibility of depression, and provides hearing care professionals increased assurance that a depressive state will not interfere in the hearing instrument delivery or rehabilitation process. Due to the amount of time spent with their patients, dispensing professionals are in a unique position in the heath care delivery model to be able to identify depression. However, the question remains, What do we do with this information? In work environments, the hearing care professional could be a valuable asset in the recognition of depression, appropriate referral and addressing issues pertaining to hearing loss. Recommended Websites Discussing Depression in Older Adults www.aagpgpa.org www.aarp.org www.alzheimers.org www.aoa.gov * www.apa.org www.asaging.org * www.counseling.org * www.depression.org www.med.nyu.edu www.nami.org www.ndmda.org www.nih.gov/nia www.nimh.nih.gov www.nmha.org www.nmisp.org www.psychologicalscience.org * www.psychwww.com/resource/journals.htm www.CAPS4caregivers.org *Not recommended for patient viewing Special Considerations for Older Adults It is common for older adults to spend a lot of time alone. Many are divorced or widowed. It is important that solitude for elder Americans does not turn into isolation and, ultimately, depression. We know that hearing loss has the potential to drive some people into isolation, but most especially vulnerable are older adults because of coexisting health conditions: Signs of depression in elders are not just hopelessness, despair and tearsIt manifests itself in seniors as the absence of pleasure and joy.18 Unaddressed issues of hearing loss in older Americans, particularly among those who need hearing aids but who have not purchased them, has been linked to depression.3 Whats more, a survey of 667 general practitioners (GPs) revealed a danger that many elderly patients are inadequately treated for depression.19 This is not a indictment against GPs, but a realization that all health care providers may have difficulty recognizing depression in older adults in the context of multiple health problems. Unfortunately, inadequate treatment can and does lead to death in a number of cases. In a long-term study of 5201 participants, depressive symptoms in older adults were associated with a higher mortality rate (23.9%) than baseline depression scores (17.7%).20 In another study, among 1551 people who were free of heart disease, those who had a history of depression were four times more likely to have a heart attack within fourteen years than non-depressed subjects.21 Both studies are examples of the profound life-threatening impact depression can have on older adults. Additionally, older Americans are disproportionately likely to commit suicide. In fact, major depression is a significant predictor of suicide in older adults.22 Noteworthy is that 70% of elderly suicide victims had seen their physicians within 30 days of their suicide.23 This is not coincidental. They undoubtedly were searching for answers they could not find, or perhaps did not know how to ask. When they saw their physician, they may have become more aware of their problematic health, or their prior suspicions were reinforced and their hopes vanquished (i.e., realized the limits of medical help). Because many older adults face physical illnesses, as well as various social and economic difficulties, health care professionals often mistakenly conclude that depression is a normal consequence of these problemsan attitude often shared by patients themselves.24 Since hearing loss has been isolated as a variable among multiple medical conditions13-14 and showed depression as significantly more prevalent, we might consider the possibility that hearing loss could act as an emotional trigger to exacerbate the depression in some patients, or possibly even lead to suicide. We as clinicians are not likely to make the association between hearing loss and suicide because we do not measure depression, and in the absence of a patient returning, we would not necessarily be informed of the death caused from other than natural or disease-state causes. There is no question that depression combined with hearing loss and multiple co-occurring medical conditions poses very serious risks. One study showed that severity of depressive symptoms predicted subsequent decline in physical performance among 1286 persons aged 71 years and older.25 Finally, to emphasize how important it is for a patient depressed over hearing loss to discuss it with a professional, social support has been found to be more positively impacting on chronicity of major depressive illness than were severity of illness or family history.26 Hearing care professionals should not perform the role of psychiatrist, psychologist or clinical therapist. What we need to do is begin talking (social support) with our patients about their feelings regarding hearing loss. If we do not open this doorway to communication exchange, they are unlikely to ask. The therapeutic value of a discussion of their feelings, including depression, by hearing care professionals trained and confident in addressing it, goes a long way toward adjustment and healing from depression over hearing loss. Unfortunately, physicians, psychologists and therapists do not have access to the client information and knowledge of many of the facts that are revealed during the course of aural rehabilitation. Few are better positioned or more competent to address the specific feelings experienced by hearing-impaired individuals than hearing care professionals.27 For resources, there are a variety of counseling techniques offered in hearing rehabilitation texts from which we can draw.28-32 Making Referrals Approximately 80% of older adults with depression improve when they receive appropriate treatment with medication, psychotherapy or both.33 There is always the need for referral to a trained psychotherapist when indicated. Dispensing professionals are part of a comprehensive healthcare team and have professional counseling boundaries that should not be crossed. When it appears that we are delving into matters that are beyond our training or best handled by a psychotherapist, we need to accept these limits and refer. With this said, referral itself holds its own set of problems. While on an academic level referrals would seem to be straightforward, it rarely works out that way. First, patients themselves are highly resistant to the ideajust try making such a referral. Second, they do not trust that we as hearing healthcare practitioners are trained to know that such a referral is indicatedand perhaps with the hearing care fields current lack of understanding about depression, they would be right. Third, as previously discussed, since noncompliance is typically high even if we successfully make a referral, among a significant segment of patients, depression will persist. When patients are ill-equipped to handle their depression, hearing care professionals often become immobilized to help them through referral for psychotherapy or to their PCP. For a depressed patient denying the existence of depression, we should turn to accompanying family members for their direction and encouragement in such a referral. Regardless of the etiology of depression, if it is undiagnosed and untreated, significant obstacles will be encountered during hearing rehabilitation. Final Thoughts There is compelling evidence that depression affects both mind and body. Through various techniques of brain imaging, research has shown that recurrent depression can alter brain chemistry.34 Therefore, it is efficacious to identify symptoms of depression early through intake or case history forms so you can progress through the rehabilitation process at a pace that is sensitive to special needs. Keep in mind that if depression is listed on a case history checklist, many patients will not mark it for fear of stigmatization or as a result of denial of the problem itself. To more accurately document this information, it would be wiser to offer the list of symptoms for depression without identifying it as such. Also important on case history information will be co-occurring medical conditions where depression has been linked. These items provide valuable insight into a patients present state of mind, and what challenges may lay ahead for you and the patients. The most hearing care professionals can hope to accomplish toward assisting patients in resolving depression caused by hearing loss is to provide counseling services (or refer out), appropriate amplification including hearing instruments and assistive devices, and on-going care in their adjustment to hearing loss. It has been clearly identified that individuals who wear hearing instruments are less depressed than those who do not.3 By the same token, another study found that deaf and hard-of-hearing subjects rated physician-initiated discussions of depression as less important than did hearing controls35, which suggests that our challenges could be formidable should we choose to address depression related to hearing loss. Despite these implications, many patients do desire to learn more about their hearing loss to help themselves surmount barriers to communication. Appropriate materials need to be supplied. A recent study36 revealed that, when literature is provided to patients after counseling that addresses specific health complaints for which patients are being seen, they are more likely to read the material, and it is a catalyst for change. In-depth consumer educational information on hearing loss and hearing instruments are critically important ingredients in the rehabilitation process37, and have been demonstrated to significantly increase wearer satisfaction and reduce hearing aid returns.38 One concern that should be expressed is that depressive disorders appear to be occurring earlier in life in people born in recent decades compared to the past.6 Furthermore, with the aging population of the world, it is projected that by 2020 mental illness will increase its present burden on society by 50%.7 This means that our future patients with depression will be appearing in our offices at progressively younger ages, and more of our patients will be affected. It would be helpful if we could recognize the presence of depression because our rehabilitation efforts for someone suffering should be approached differently than for non-depressed patients. Through brain imaging techniques, according to the National Institute of Mental Health, "We are now at the dawn of an era when we cansee pathways in the brain that underlie emotions."39 Future hearing rehabilitation may well include brain scan observations of patients to better identify depression and other emotions that would be pertinent to both us addressing their feelings, and our patients more expedient resolution of life-limiting, and even life-threatening, barriers. Richard E. Carmen, AuD, is director of audiology services at Northern Arizona Speech and Hearing Center, and is author/editor of The Consumer Handbook on Hearing Loss & Hearing Aids, Auricle Ink Publishers, Sedona, AZ. Correspondence can be addressed to HR or Richard Carmen, AuD, Northern Arizona Speech and Hearing Center, Plaza West, Ste. 210, 2155 W. Highway 89-A, Sedona, AZ 86336; email: sprunner@sedona.net. References 1. Allen JG: Depression causes vicious cycles in relationships. The Meninniger Letter 1995;3(2):6. 2. Bridges JA & Bentler RA: Relating hearing aid use to well-being among older adults. Hear Jour 1998; 51(7):39-44. 3. Kochkin S & Rogin CM: Quantifying the obvious: The impact of hearing instruments on quality of life. Hearing Review 2000; 7(1):18,22,24,26,30,32. 4. Schmall V: Understanding and caring for older depressed adults. Hearing Review 1997; 4 (10): 48-54. 5. Reiger DA, Narrow WE, Rae DS et al: The de facto mental and addictive disorders service system. Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Arch General Psychiatry, 1993; 50(2):85-94. 6. Klerman GL & Weissman MM: Increasing rates of depression. JAMA 1989;261(15):2229-35. 7. Murray CJL & Lopez AD: The global burden of disease and injury series, Volume 1: A comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Cambridge, MA: Harvard University Press. Published by the Harvard School of Public Health on behalf of the World Health Organization and the World Bank, 1996. 8. Amer Psychiatric Assn: Diagnostic and Statistical Manual for Mental Disorders (Fourth edition, DMS-IV). Washington, DC: American Psychiatric Press, 1994. 9. Narrow WE.: One-year prevalence of depressive disorders among adults 18 and over in the U.S.: NIMH ECA prospective data. Population estimates based on the US census estimated residential population age 18 and over on July 1, 1998 (NIH publication No. 99-4584), unpublished. 10. Levine ES: The Psychology of Deafness: Techniques of appraisal for rehabilitation. New York and London: Columbia Univ Press: 1960. 11. Myklebust HR: The Psychology of Deafness (Second edition). New York and London: Grune & Stratton, 1964. 12. Mulrow CD, Tuley MR & Aguilar C: Sustained benefits of hearing aids. Jour Speech Hear Res 1992; 35: 1402-05. 13. Wallhagen MI, Strawbridge WJ & Kaplan GA: Six-year impact of hearing impairment on psychosocial and physiologic functioning. Nurse Pract 1996; 21 (9):11-12,14. 14. Strawbridge WJ, Wallhagen MI, Shema SJ, et al: Negative consequences of hearing impairment in old age: A longitudinal analysis. Gerontologist 2000; 40 (3): 320-326. 15. Bellino S, Bogetto F, Vaschetto P et al: Recognition and treatment of dysthymia in elderly patients. Drugs Aging 2000; 16(2):107-21. 16. Diagnosis and Treatment of Depression in Late Life. NIH Consensus Statement 1991; Nov 4-6; 9(3): 1-27. 17. DiMatteo MR, Lepper HS & Croghan TW: Depression is a risk factor for noncompliance with medical treatment. Arch Intern Med 2000; 160(14): 2101-07. 18. Patient Care Advisor. LRP Publications, 747 Dresher Rd., PO Box 980, Horsham PA 19044-0980, 1998. 19. Orrell M, Collins E, Shergill S et al: Management of depression in the elderly by general practitioners: I. Use of antidepressants. Fam Pract 1995;12(1):5-11. 20. Schultz R, Beach SR, Ives DG et al: Association between depression and mortality in older adults. Arch Intern Med 2000; 160(12): 1761-68. 21. Frasure-Smith N, Lesperance F & Talajic M: Depression and 18-month prognosis after myocardial infarction. Circulation 1995; 91(4): 999-1005. 22. Conwell Y, Brent D. Suicide and aging I: patterns of psychiatric diagnosis. International Psychogeriatrics 1995;7(2):149-64. 23. Conwell Y: Suicide in elderly patients. In LS Schneider, CF Reynolds III, BD Lebowitz & AJ Friedhoffs (eds) Diagnosis and Treatment of Depression in Late Life. Washington, DC: American Psychiatric Press, 1994; 397-418. 24. Lebowitz BD, Pearson JL, Schneider LS, et al: Diagnosis and treatment of depression in late life. Consensus statement update. JAMA 1997; 278(14): 1186-90. 25. Penninx BH, Guralnik JM, Ferrucci L, et al: Depressive symptoms and physical decline in community-dwelling older persons. JAMA 1998; 279(21): 1720-1726. 26. Hays JC, Krishnan KR, George LK, et al: Psychosocial and physical correlates of chronic depression. Psychiatry Res 1997; 72(3): 149-59. 27. Carmen R & Hull R: Profiles in aural rehabilitation. Hear Jour 2000; 53(5): 30,39-41. 28. Citron D: Counseling and orientation toward amplification. In M Valentes (ed) Audiology: Treatment. New York: Thieme Medical Pub: 2000. 29. Clark JG, Martin FN. Effective Counseling in Audiology. New Jersey: Prentice-Hall, 1994. 30. Maurer JF: Counseling the older adult who is hearing impaired. In RH Hulls (ed) Aural Rehabilitation: Serving Children and Adults (3rd edition), San Diego: Singular Publishing Group, 1997. 31. Murray NT: Foundation of Aural Rehabilitation. San Diego: Singular Publishing Group, 1998. 32. Sweetow RW: Counseling for Hearing Aid Fittings. San Diego: Singular Publishing Group, 1999. 33. Little JT, Reynolds CF III, Dew MA, et al: How common is resistance to treatment in recurrent, nonpsychotic geriatric depression? Amer J Psychiatry 1998; 155(8): 1038-8. 34. Sheline YI, Sanghavi M, Mintun MA, et al: Depression duration but not age predicts hippocampal volume loss in medically healthy women with recurrent major depression. Jour of Neuroscience 1999; 19(12): 5034-43. 35. Tamaskar P, Malia T, Stern C, et al: Preventive attitudes and beliefs of deaf and hard-of-hearing individuals. Arch Fam Med 2000; 9(6): 518-525. 36. Kreuter MW, Chheda SG & Bull FC: How does physician advice influence patients behavior? Evidence for a priming effect. Arch Fam Med 2000; 9(5): 426-433. 37. Carmen R (ed.): The Consumer Handbook on Hearing Loss & Hearing Aids: A Bridge to Healing. Sedona, AZ: Auricle Ink Publishers, 1998. 38. Kochkin S: Reducing hearing instrument returns with consumer education. Hearing Review 1999; 6(10): 18,20. 39. NIH Publication No. 01-4601: www.nimh.nih.gov/publicat/feel.cfm. 40. Goldberg RI: Depression in medical patients. Rhode Island Med 1993; 76: 391.

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