**2. Ménière's and mental health at the population level**

In Phase I, the UK Biobank dataset was utilised to understand how Ménière's influences mental health and well-being at the population level. This study contained 1376 individuals with self-reported Ménière's and included comprehensive phenotypic data (e.g. anthropometric measures, early life, lifestyle, family history, medical history, general health and well-being and diet). The aim of this population-level research was to investigate whether people with Ménière's have different mental health and subjective well-being than individuals without the condition. The impact of disease duration on mental health and level of subjective well-being was also investigated within cases.

#### **2.1. Phase I methods**

**1. Introduction**

10 Up to Date on Meniere's Disease

tom of Ménière's [2].

well-being amongst people with Ménière's.

the role of significant others in this process.

**2. Ménière's and mental health at the population level**

at best.

Ménière's disease is a complex multifactorial disorder of the inner ear, consisting of several concurrent symptoms (e.g. aural pressure, hearing loss, tinnitus and vertigo). Patients with Ménière's range from minimally symptomatic highly functional individuals to severely affected disabled patients. Each of the main triad of Ménière's symptoms can impact on quality of life. Tinnitus may be associated with sleep disturbance, depression, irritability, reduced concentration and auditory difficulties [1]. Hearing loss can result in communication difficulties, which can cause problems in work and social life. Vertigo is known to cause anxiety and restrict physical and social activities, therefore significantly impacting on patients' health and well-being [1]. Vertigo is often considered to be the most detrimental and debilitating symp-

Research on the mental health and well-being impact of Ménière's disease is limited. Moreover, quantitative studies in this area are negatively influenced by small sample sizes (often with fewer than 500 participants), a lack of groups to compare the mental health impacts with (i.e. no control groups), and an inability to account for confounding factors. Furthermore, our understanding of how the mental health impact of Ménière's may shift over time is partial

The patient perspective of what it is like to live with this disease within the context of their day-to-day life is critically important for developing appropriate healthcare pathways and ensuring that patients are able to lead as fulfilling lives as possible [3]. While some studies have considered the adverse impact of Ménière's on quality of life, along with patients' perspectives regarding triggers and symptoms of the disease [4], there is very limited information about how patients experience and manage the disease (or not), including its triggers and symptoms in everyday life. In addition, we are currently unaware of the role that other people may play in this process [5–7] or how these issues impact on the sense of mental health and

This chapter will build upon existing research in this area, describing a comprehensive, multilayered two-phase analysis of the impact of Ménière's on patients' mental health and wellbeing. First, epidemiological analysis from the most powerful Ménière's resource currently available (the UK Biobank, www.biobank.ac.uk) will provide insights on the mental health and well-being impacts of Ménière's at a population level (Phase I). Secondly, qualitative research (Phase II) will provide deeper insights into patients' experiences of living with and negotiating the triggers and symptoms of Ménière's disease on a day-to-day basis, including

In Phase I, the UK Biobank dataset was utilised to understand how Ménière's influences mental health and well-being at the population level. This study contained 1376 individuals with self-reported Ménière's and included comprehensive phenotypic data (e.g. anthropometric

#### *2.1.1. The UK Biobank, Ménière's diagnosis and mental health*

The UK Biobank is a phenotypically rich study of over 500,000 individuals aged between 37 and 73 years in 2006–2010 [8]. All participants were interviewed by a nurse, who collated a list of health conditions for each participant. There were several options for ear/vestibular disorders, including tinnitus, vertigo, labyrinthitis, Ménière's disease, otosclerosis or a generic ear/vestibular disorder. The 1376 individuals who reported symptoms of Ménière's disease were selected. An investigation of prescribed medications and key symptom data (e.g. tinnitus and hearing loss) was utilised to validate the variable. For each individual reporting Ménière's, an age of diagnosis was also available and this was utilised to determine disease duration.

The UK Biobank incorporated extensive questions on mental health and subjective well-being. A subsection of questions asked participants to record the frequency of depressed mood, unenthusiasm, tiredness and tenseness within the 2 weeks prior to recruitment. Further questions focused on the number and duration of depression episodes over each participant's life. Participants rated their overall happiness and their satisfaction with health, work, friends and family and finances to provide a range of measures of subjective well-being. Participants were also asked to complete the Eysenck Personality Inventory (EPI) [9].

The participants also reported regular prescription medications, and use of the major antidepressant class—the selective serotonin reuptake inhibitors (SSRIs)—was monitored.

#### *2.1.2. Statistical analysis*

The mental health impact of individuals with Ménière's was compared to the whole control population of non-Ménière's sufferers. Linear regression models were utilised to investigate whether a diagnosis of Ménière's influenced the frequency of depression, tiredness, tenseness or unenthusiasm experienced in the 2 weeks prior to recruitment. Similar models were utilised to: (a) investigate how Ménière's influenced subjective well-being; (b) compare the frequency of family contact for cases and controls; and (c) examine the longest duration of depression in cases and controls.

Logistic regression models were used to investigate the odds of: (a) reporting depression; (b) reporting an episode of depression lasting over a week; and (c) utilising SSRIs in Ménière's cases compared to controls.

The role of disease duration on mental health and well-being was investigated. Individuals diagnosed for 5 or more years were compared to those diagnosed within the past 5 years.

Models were adjusted for potential confounders, including participants' age, sex, socioeconomic status, waist circumference, home location (urban versus rural as defined by the UK Biobank using the participant's postcodes and the 2001 census data) and ethnicity as covariates. Further adjustment for tinnitus severity was carried out to determine whether this symptom significantly contributed to any mental health associations. Personality is one of the biggest predictors of happiness [10] and therefore the EPI was included as a covariate in the statistical models. All analyses were conducted using STATA/SE Version 12.1 (College Station, USA). Statistical significance was denoted by *P* < 0.05 unless otherwise stated; Bonferroni correction methodology was utilised where appropriate.

#### **2.2. Phase I results**

The demographics of the 1376 Ménière's cases and controls are summarised in **Table 1**. As noted in previous studies, there was a preponderance of females (62% versus 54%). The data suggested that individuals with Ménière's had higher proportions of disability benefit than controls (5.3% versus 2.2%, *P* < 0.001) and were more likely to hold disabled badges than controls (8.7% versus 3.6%, *P* < 0.001). Ménière's cases were more likely to be unable to work


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**Table 1.** Demographics of the 1376 Ménière's sufferers and the 501,306 controls in the UK Biobank.

because of illness (7.4% versus 3.8%, *χ*<sup>2</sup> *P* < 0.001), although it should be noted that the large majority of individuals did work.

#### *2.2.1. Depression*

Models were adjusted for potential confounders, including participants' age, sex, socioeconomic status, waist circumference, home location (urban versus rural as defined by the UK Biobank using the participant's postcodes and the 2001 census data) and ethnicity as covariates. Further adjustment for tinnitus severity was carried out to determine whether this symptom significantly contributed to any mental health associations. Personality is one of the biggest predictors of happiness [10] and therefore the EPI was included as a covariate in the statistical models. All analyses were conducted using STATA/SE Version 12.1 (College Station, USA). Statistical significance was denoted by *P* < 0.05 unless otherwise stated; Bonferroni cor-

The demographics of the 1376 Ménière's cases and controls are summarised in **Table 1**. As noted in previous studies, there was a preponderance of females (62% versus 54%). The data suggested that individuals with Ménière's had higher proportions of disability benefit than controls (5.3% versus 2.2%, *P* < 0.001) and were more likely to hold disabled badges than controls (8.7% versus 3.6%, *P* < 0.001). Ménière's cases were more likely to be unable to work

**Demographics All MD sufferers All controls N** 1376 501,306

Male (%) 517 (37.6) 228,677 (45.6) Female (%) 859 (62.4) 272,629 (54.4) **Mean age at recruitment in years (95% CI)** 63.4 (63.0–63.8) 60.4 (60.4–60.5)

White 1333 (96.9) 471,525 (94.1) Mixed 7 (0.5) 2951 (0.6) Asian 14 (1.0) 9869 (2.0) Black 2 (0.1) 8065 (1.6) Chinese 2 (0.1) 1572 (0.3) Other 7 (0.5) 4554 (0.9) Missing/unknown 11 (0.8) 2770 (0.5)

Less than £18,000 351 (25.5) 96,874 (19.3) £18,000–£30,999 319 (23.2) 107,891 (21.5) £31,000–£51,999 250 (18.2) 110,546 (22.0) £52,000–£100,000 171 (12.4) 86,124 (17.2) More than £100,000 34 (2.5) 22,900 (4.6) Missing/unknown 251 (18.2) 76,971 (15.4)

rection methodology was utilised where appropriate.

**2.2. Phase I results**

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**Sex**

**Ethnicity (%)**

**Household income**

Participants with Ménière's were at higher odds of reporting:

Doctor diagnosed depression odds ratio (OR): 1.53 (95% confidence intervals (CI) 1.32, 1.70, *P* < 0.001, **Figure 1**).

A week long period of depression (OR: 1.33; 95% CI: 1.07, 1.65; *P* = 0.011).

The use of SSRIs (OR: 1.32; 95% CI: 1.01, 1.71; *P* = 0.041).

Ménière's was associated with longer durations of depression—on average this was 10 weeks longer than controls (95% CI: 5.2, 15.2, *P* < 0.001, **Figure 1**).

#### *2.2.2. Mental health impact*

Ménière's was associated with increased frequency of depression, tiredness, tenseness and unenthusiasm in the 2 weeks prior to recruitment, although adjustment for the participant's

**Figure 1.** Graphic demonstrating the association between Ménière's and (A) depression and (B) the duration of depression.

neuroticism subscale of the EPI attenuated the regression coefficients with only tiredness remaining significant (**Figure 2**).

Tinnitus, a major symptom of Meniere's, is linked to mental health. Adjustment for tinnitus severity in a subset of the population (*n* = 168,341), with a similar prevalence of Ménière's (0.25% versus 0.27%), attenuated all the mental health associations.

#### *2.2.3. Subjective well‐being*

Individuals with Ménière's had lower health satisfaction scores than controls and were on average less happy overall. However, there was no difference between cases and controls in terms of satisfaction with their family relationships, friendships and financial situation (**Figure 3**). Higher odds of having social interaction with family and friends on a daily basis (odds ratio 1.5; 95% CI: 1.3, 1.8, *P* < 0.001) or 2–4 times per week (1.2; 1.0, 1.4, *P* < 0.01) was noted for Ménière's cases when compared to controls. The frequency of social interaction predicted individual satisfaction with friends and family.

Living with Ménière's Disease: Understanding Patient Experiences of Mental Health and Well-Being in Everyday Life http://dx.doi.org/10.5772/66391 15


**Figure 2.** Change in frequency of depression, tiredness, tenseness and unenthusiasm in cases compared to controls. Adjusteda accounts for common covariates and Adjustedb includes the EPI.

**Figure 3.** Differences in well-being in cases and controls. \*Work satisfaction only asked in individuals with a job.

#### *2.2.4. Disease duration*

neuroticism subscale of the EPI attenuated the regression coefficients with only tiredness

**Figure 1.** Graphic demonstrating the association between Ménière's and (A) depression and (B) the duration of

Tinnitus, a major symptom of Meniere's, is linked to mental health. Adjustment for tinnitus severity in a subset of the population (*n* = 168,341), with a similar prevalence of Ménière's

Individuals with Ménière's had lower health satisfaction scores than controls and were on average less happy overall. However, there was no difference between cases and controls in terms of satisfaction with their family relationships, friendships and financial situation (**Figure 3**). Higher odds of having social interaction with family and friends on a daily basis (odds ratio 1.5; 95% CI: 1.3, 1.8, *P* < 0.001) or 2–4 times per week (1.2; 1.0, 1.4, *P* < 0.01) was noted for Ménière's cases when compared to controls. The frequency of social interaction

(0.25% versus 0.27%), attenuated all the mental health associations.

predicted individual satisfaction with friends and family.

remaining significant (**Figure 2**).

*2.2.3. Subjective well‐being*

depression.

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Within the Ménière's cohort, disease duration was associated with lower levels of depression in the 2 weeks prior to recruitment (*P* < 0.05). Furthermore, individuals diagnosed for more than 5 years were at lower odds of visiting a doctor about depression 0.60 (0.41, 0.90) than recently diagnosed individuals. Longer disease duration was also associated with improved health satisfaction (*P* < 0.01, **Figure 4**).

**Figure 4.** Scatter plot representing how health satisfaction within the Ménière's sufferers changes with time since diagnosis. Regression analysis indicated a significant relationship between overall health satisfaction and disease duration (*P*<0.01).
