---
title: "ICF-based content overlap between tinnitus distress and depression questionnaires"
id: "plos-one-21-an-icf-based-content-analysis-of-the-overlap-between-questionnaires-assessing"
canonical_url: "https://medichelpline.com/clinical-feed/plos-one-21-an-icf-based-content-analysis-of-the-overlap-between-questionnaires-assessing"
content_type: "clinical_feed_article"
specialty: "Neurology"
source_name: "PLOS ONE (Medicine)"
source_url: "https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0358644"
published_at: "2026-09-21T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# ICF-based content overlap between tinnitus distress and depression questionnaires
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-one-21-an-icf-based-content-analysis-of-the-overlap-between-questionnaires-assessing
- **Specialty:** [Neurology](https://medichelpline.com/clinical-feed/neurology.md)
- **Primary Source:** PLOS ONE (Medicine)
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0358644)
- **Published At:** 2026-09-21T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- This study used the **International Classification of Functioning, Disability and Health (ICF)** to systematically compare item content of validated self-report questionnaires for **tinnitus distress** and **depressive symptoms**. - Six tinnitus distress measures were analyzed: THI, TQ, mTQ, THQ, TRQ, and TFI. Seven depression measures were included: BDI-II, HADS-D, SDS, PHQ-9, CES-D, SCL-90-R (depression subscale), and DASS-42 (depression subscale). - Each questionnaire item was linked to the most precise ICF category using established linking rules; items could receive multiple codes or special codes (nc, pf, nd) when appropriate. - Two independent reviewers performed initial linking; disagreements and ambiguous mappings were resolved iteratively with a third reviewer (ENT specialist/epidemiologist). Several interpretive coding decisions were made and documented. - At the ICF second-level, depressive symptom questionnaires covered 14 categories, while tinnitus distress questionnaires covered 23 categories, indicating greater diversity among tinnitus measures. - Seven second-level ICF categories were shared between the two groups: **energy and drive functions**, **sleep functions**, **attention functions**, **emotional functions**, **thought functions**, **interpersonal interactions and relationships**, and **recreation and leisure**. - Overlap varied across instruments: at second-level ICF coding the TQ had the lowest overlap with depression questionnaires (11.54–26.92%), and the TRQ the highest (61.54–73.08%). - Among depression questionnaires, SDS showed the least overlap with tinnitus measures (40–60%), while the DASS-42 depression subscale showed the most overlap (85.71–100%). - A specific coding decision treated items that named tinnitus as the direct object as tinnitus-specific (b240/b2400); an alternative coding strategy recoded some of these to underlying processes to evaluate effects on overlap estimates. - The authors conclude that content overlap between tinnitus distress and depressive symptom questionnaires is nontrivial and should inform instrument selection and interpretation in clinical practice and research.
## Clinical Analysis & Structured Key Points
An ICF-based content analysis of the overlap between questionnaires assessing tinnitus distress and depressive symptoms | PLOS One Browse Subject Areas ? Click through the PLOS taxonomy to find articles in your field. For more information about PLOS Subject Areas, click here . Article Authors Metrics Comments Media Coverage Peer Review Reader Comments Figures Figures Abstract Introduction The experience of tinnitus varies considerably among individuals, particularly in terms of perceived distress. Psychological factors play a major role in this variability, and numerous studies have demonstrated a correlation between symptoms of depression and tinnitus distress. Both constructs are commonly assessed through self-report questionnaires. However, content overlap between these questionnaires can make it challenging to differentiate the constructs and interpret their relationship. Given the variation in content among questionnaires assessing tinnitus distress and depressive symptoms, a comprehensive examination of their similarities and differences is needed. This study therefore aims to systematically assess the content overlap of tinnitus distress and depressive symptom questionnaires using the International Classification of Functioning, Disability and Health (ICF) framework. Methods and analysis Six validated, multi-item, self-report questionnaires measuring tinnitus distress (THI, TQ, mTQ, THQ, TRQ, TFI) and seven validated, multi-item, self-report depressive symptom questionnaires (BDI-II, HADS-D, SDS, PHQ-9, CES-D, SCL-90-R depression subscale, DASS-42 depression subscale) were included in the content analysis. The underlying concepts of all items of these questionnaires were linked to the most specific ICF categories based on established linking rules. The overlap between the tinnitus distress and depressive symptom questionnaires was analyzed based on the assigned second-level ICF categories. Results The depressive symptom questionnaires demonstrated less diversity in ICF category coverage compared to the tinnitus distress questionnaires, with 14 versus 23 second-level ICF categories. Seven second-level categories were shared between tinnitus distress and depressive symptom questionnaires; energy and drive functions, sleep functions, attention functions, emotional functions, thought functions, interpersonal interactions and relationships, and recreation and leisure. The content analysis showed that, at the second-level ICF category, the TQ had the lowest degree of overlap with the depressive symptom questionnaires (11.54–26.92%), while the TRQ exhibited the highest (61.54–73.08%). Among the depressive symptom questionnaires, the SDS showed the least overlap with the tinnitus distress questionnaires (40–60%), whereas the DASS-42 depression subscale demonstrated the most overlap (85.71–100%). Conclusion The overlap between tinnitus distress and depressive symptom questionnaires emphasizes the importance of carefully selecting assessment tools and interpreting their results, based on specific clinical or research goals. This content analysis can guide making decisions about this selection. Citation: Fuchten D, Assouly KKS, Stegeman I, Smit AL (2026) An ICF-based content analysis of the overlap between questionnaires assessing tinnitus distress and depressive symptoms. PLoS One 21(9): e0358644. https://doi.org/10.1371/journal.pone.0358644 Editor: Bojana Bukurov, University of Belgrade: Univerzitet u Beogradu, SERBIA Received: January 7, 2026; Accepted: September 3, 2026; Published: September 21, 2026 Copyright: © 2026 Fuchten et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: All relevant data are within the manuscript and its Supporting information files. Funding: The author(s) received no specific funding for this work. Competing interests: The authors have declared that no competing interests exist. Introduction Tinnitus, the perception of sound in the absence of an external auditory stimulus [ 1 ], is a prevalent phenomenon estimated to affect around 740 million people worldwide [ 2 ]. While many people experience tinnitus, it is important to distinguish between its presence and its potential impact on individuals, as the majority of those affected do not experience significant distress from this phantom sound [ 2 , 3 ]. To address this distinction, de Ridder et al. proposed two separate terms [ 4 ]. They defined tinnitus as “the conscious awareness of a tonal or composite noise for which there is no identifiable corresponding external sound source”, while tinnitus disorder occurs when tinnitus is “associated with emotional and/or cognitive dysfunction, and/or autonomic arousal, leading to behavioral changes and functional disability” [ 4 ]. Although it is not yet fully understood why some people are severely impacted by tinnitus while others are less affected, research indicates that psychological factors play a major role in the variability of this perceived severity [ 5 , 6 ]. Among these psychological factors, depression is frequently found to be associated with the distress experienced by individuals with tinnitus [ 6 – 9 ]. Several hypotheses have been proposed to explain the link between tinnitus and depression. Some theories suggest that the impact of tinnitus can trigger depression in individuals who are prone to it, or that depression might cause a heightened focus on existing tinnitus, causing it to be perceived as more severe [ 10 ]. Other theories propose a more bidirectional relationship, shared neurobiological mechanisms, or common risk factors between tinnitus and depression [ 11 ]. Though the exact mechanism remains a topic of debate [ 8 ], the association between tinnitus and depression has consistently been observed. A systematic review by Meijers et al. (2022), which examined the relationship between tinnitus distress and depressive symptoms in observational studies, found significant positive correlations in 31 out of 33 included studies [ 9 ]. Studies examining this relationship often utilize self-report questionnaires for both tinnitus and depression assessment [ 11 ]. However, the content of these questionnaires partially overlaps, which can potentially lead to an overestimation of the correlation between depression and tinnitus [ 12 ]. For example, a study by Ooms et al. (2011) found content overlap in 15 out of 25 questions of the Tinnitus Handicap Inventory (THI) with 13 out of 21 questions of the Beck Depression Inventory (BDI) [ 12 ]. This overlap can complicate the differentiation of the two conditions and interpretation of their relationship, and may also impact treatment decisions when prioritizing interventions to reduce symptoms in clinical practice. Moreover, the overlap also poses challenges in participant selection in clinical trials. High scores on tinnitus distress measures may reflect depressive symptoms due to shared content, making it difficult to include patients who experience significant tinnitus burden but low depression levels [ 13 ]. This may inadvertently lead to the exclusion of eligible subjects, compromising the representativeness of study populations and limiting the generalizability of research findings. Understanding the overlap requires considering what these questionnaires actually measure. Tinnitus questionnaires mainly operationalize tinnitus-related distress and impact, meaning the emotional, cognitive, and functional consequences of hearing the tinnitus sound in daily life, rather than the tinnitus percept, which refers solely to the auditory sensation itself. Depression questionnaires, in turn, measure depressive symptoms rather than providing a clinical diagnosis of depression. Part of the content overlap between these questionnaires can be attributed to shared symptomatology: patients with tinnitus often report problems with sleeping, difficulty concentrating, social withdrawal, and despair, symptoms that are also indicative of depression [ 11 ]. Both tinnitus distress and depression are heterogeneous, multidimensional constructs. Depression manifests as a set of partially overlapping and sometimes opposing symptom dimensions, including somatic, cognitive, affective, and behavioral dimensions, with questionnaires differing substantially in how they weight these dimensions [ 14 ]. Similarly, tinnitus distress can manifest across different domains, with questionnaires differing in their focus. For example, the Tinnitus Reaction Questionnaire (TRQ) is designed to evaluate the psychological distress associated with tinnitus [ 15 ] and therefore places greater emphasis on emotional functions compared to other tinnitus measures [ 16 ]. Given this heterogeneity, and the fact that different instruments operationalize these constructs by placing varying emphasis on specific symptom dimensions, overlap between questionnaires should be interpreted primarily as overlap between specific measurement instruments and their item content, rather than as direct evidence of overlap between the underlying constructs. The variability in questionnaire focus underscores the need for a comprehensive examination of multiple tinnitus distress and depressive symptom questionnaires to better understand the nature and extent of their overlap. The current study aims to examine the overlap between tinnitus distress and depressive symptom questionnaires by analyzing their content based on the International Classification of Functioning, Disability and Health (ICF) framework. By using this standardized and internationally recognized framework to guide the content analysis, this study ensures a systematic examination of the items in the questionnaires. This analysis will provide a comprehensive understanding of the similarities and differences between the measures, and can guide future decisions regarding the selection of measurement tools. Methods The methods of this study are detailed in a previously published protocol [ 17 ]. For a more comprehensive description of the methodology and questionnaires used, readers are advised to consult the published protocol of our study. No ethical approval was required for this study, due to the characteristics of the study design. Questionnaires The content analysis included a selection of validated, multi-item, self-report questionnaires for assessing tinnitus distress and depressive symptoms. The included tinnitus distress questionnaires are the Tinnitus Handicap Inventory (THI), Tinnitus Questionnaire (TQ), mini Tinnitus Questionnaire (mTQ), Tinnitus Handicap Questionnaire (THQ), Tinnitus Reaction Questionnaire (TRQ) and Tinnitus Functional Index (TFI) [ 15 , 18 – 23 ]. These questionnaires have been widely utilized in both clinical practice and research in order to assess the severity of symptoms, and are recommended or referenced in multiple international clinical practice guidelines [ 24 – 31 ]. The included depressive symptom questionnaires are the Beck Depression Inventory-II (BDI-II), Hospital Anxiety and Depression Scale (HADS) depression subscale, Zung Self-Rating Depression scale (SDS), Patient Health Questionnaire-9 (PHQ-9), Center for Epidemiologic Studies Depression Scale (CES-D), Symptom Checklist-90-Revised (SCL-90-R) depression subscale and Depression Anxiety Stress Scale (DASS) depression subscale [ 32 – 38 ]. These questionnaires are commonly used in research on tinnitus based on two systematic reviews on tinnitus and depression [ 8 , 9 ]. ICF linking procedure ICF linking rules. The International Classification of Functioning, Disability and Health (ICF) framework, developed by the World Health Organization, was used to analyze the content of the tinnitus distress and depressive symptom questionnaires [ 39 ]. As illustrated in Fig 1 , the ICF is organized into two main parts; (1) functioning and disability, which includes the components body functions and structures as well as activities and participation, and (2) contextual factors, consisting of environmental and personal factors. With the exception of personal factors, each component is further categorized in levels with corresponding codes. Download: PNG larger image TIFF original image Fig 1. Hierarchical structure of the ICF Framework. https://doi.org/10.1371/journal.pone.0358644.g001 Each questionnaire item was linked to the ICF framework based on the linking rules developed and refined by Cieza et al [ 40 – 42 ]. In accordance with these rules, the main concept and, when applicable, additional concepts of each item of the questionnaires were identified, after which they were linked to the most precise ICF category. An item could only be assigned to more than one category when it contained multiple concepts. For concepts not adequately represented in the ICF framework, specific codes were assigned: ‘nc’ (not covered) for concepts absent from the ICF, ‘pf’ for personal factors not further classified in the ICF framework, and ‘nd’ (not definable) when item information was insufficient for precise ICF category linking. Further elaboration on the most recent version of the linking rules can be found in the article of Cieza et al. published in 2019 [ 42 ]. However, two steps outlined in this article, identification of the perspective and identification of the response options, were not applied in the current study. As the perspective from which an item was written and the type of response scale used do not affect what concept an item measures, these rules were not relevant for the purpose of the current analysis. Table 1 shows an example of the linking of a questionnaire item to the ICF framework. Download: PNG larger image TIFF original image Table 1. Example of linking a questionnaire item ( TFI item 2. Over the past week, how strong or loud was your tinnitus? ) to the hierarchical structure of the ICF Framework. https://doi.org/10.1371/journal.pone.0358644.t001 Consensus procedure and additional coding decisions. All items were linked by two independent reviewers (DF and KKSA), a psychologist and a biomedical researcher. Upon comparing their initial categorizations, some differences in the interpretation of specific ICF category codes were identified, which prompted discussion and revision of the coding of ambiguous or discrepant items across the questionnaires. This process of coding, comparison, and discussion was iterative in nature. Several interpretive decisions were made after discussion between the two reviewers, either to resolve different initial interpretations, or to address items whose content was inherently more complex to map onto the ICF framework. First, items in which tinnitus itself was the direct object of the concept being measured were treated as inseparable from the tinnitus experience, and were therefore linked to sensations associated with hearing and vestibular function (b240) , and more specifically to the third-level category ringing in ears or tinnitus (b2400) . For example, the item “Over the past week, how easy was it for you to ignore your tinnitus?” was categorized under this code because the concept being measured is ‘ignoring’, with tinnitus as its direct object. In contrast, the item “Over the past week, how much did your tinnitus interfere with your ability to concentrate?” was not coded in this manner, as the concept being measured is concentration, with tinnitus representing the source of the difficulty rather than its direct object. This item was therefore linked to attention functions (b140) . This approach was chosen to provide a consistent method for coding tinnitus-specific items when comparing tinnitus distress questionnaires with depressive symptom measures. The effect of this specific coding decision on the reported overlap was subsequently examined using an alternative coding strategy, described under ‘Alternative coding of b240 items’. Second, for items referring to hearing and listening contexts a distinction was made following Granberg et al. (2014) [ 43 ]. Hearing as a passive function was linked to hearing functions (b230) , whereas listening as an active and intentional process was linked to listening (d115). Items involving listening with comprehension were linked to communicating with – receiving – spoken messages (d310), and items involving bidirectional communication were linked to interpersonal interactions and relationships (d799). Third, the category temperament and personality functions (b126), defined as ‘general mental functions of constitutional disposition of the individual to react in a particular way to situations, including the set of mental characteristics that makes the individual distinct from others’, was not applied, as the definition relates to personality traits rather than psychological states [ 44 ], and the items in the questionnaires assess a change rather than a constant. Following this iterative process, a third reviewer (ALS), an ENT specialist as well as an epidemiologist, was consulted to reach consensus on items that remained unresolved after discussion between the two primary reviewers. These generally concerned two types of issues: individual items where the appropriate ICF category was unclear (e.g., whether certain hearing-related items involved comprehension) and groups of conceptually similar items across questionnaires for which a consistent coding rule was established. In addition to unresolved items, discussions with the third reviewer also included a small number of items on which the two primary reviewers had already agreed, but which were re-examined as a verification check. Several recurring themes were identified during the sessions with the third reviewer for which consistent coding decisions were made. Items related to enjoyment of life, such as life feeling full, meaningless, or not worthwhile, were coded as nc-qol . Items reflecting negative self-perception, such as feelings of insecurity, loss of confidence, or feeling like a failure, were linked to emotional functions (b152), as the third-level category confidence (b1266) under temperament and personality functions was not applied in the current study. Similarly, items regarding feeling hopeless, helpless or discouraged were also linked to emotional functions (b152). Alternative coding of b240 items. The coding decision of the b240 ( hearing and vestibular function ) items, as described above, represents a deliberate choice made for the purpose of comparing tinnitus distress and depressive symptom questionnaires. For these items, tinnitus is named as the direct object of the concept being measured (e.g., coping with tinnitus, ignoring tinnitus), and this decision means that the concept is treated as inseparable from the tinnitus experience itself. However, an alternative interpretation is possible for these items: what is measured may instead be a more general process (e.g., a general capacity for coping), which manifests here in relation to tinnitus but might not necessarily be specific to it. To assess the extent to which this alternative interpretation affects the reported overlap, an alternative coding strategy was applied in which such items were recoded, where a plausible ICF category could be identified for the underlying process in question. Items whose content could only be understood as describing the tinnitus percept itself, such as its loudness or presence, remained coded under b240 . Data analysis Content analysis was performed on the second-level codes assigned to each item of the included questionnaires. Frequencies of the assigned second-level codes per questionnaire were reported as absolute numbers and percentages. Additionally, frequencies of the assigned second-level codes for all tinnitus distress questionnaires combined and for all depressive symptom questionnaires combined were repo
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