Internet-Based Audiologist-Guided Cognitive Behavioral Therapy for Tinnitus: Randomized Controlled Trial

Abstract

Background: Tinnitus is a symptom that can be very distressing owing to hearing sounds not related to any external sound source. Managing tinnitus is notoriously difficult, and access to evidence-based care is limited. Cognitive behavioral therapy (CBT) is a tinnitus management strategy with the most evidence of effectiveness but is rarely offered to those distressed by tinnitus. The provision of internet-based CBT for tinnitus overcomes accessibility barriers; however, it is not currently readily available in the United States.

Objective: The aim of this study is to investigate the efficacy of internet-based CBT compared with that of weekly monitoring for the management of tinnitus in reducing tinnitus distress; reducing tinnitus-related comorbidities, including tinnitus cognitions, insomnia, anxiety, and depression; and assessing the stability of the intervention effects 2 months after the intervention.

Methods: A 2-arm randomized clinical trial comparing audiologist-guided internet-based CBT (n=79) to a weekly monitoring group (n=79) with a 2-month follow-up assessed the efficacy of internet-based CBT. Eligible participants included adults seeking help for tinnitus. Recruitment was conducted on the web using an open-access website. Participants were randomized via 1:1 allocation, but blinding was not possible. The study was undertaken by English or Spanish speakers on the web. The primary outcome was a change in tinnitus distress as measured using the Tinnitus Functional Index. Secondary outcome measures included anxiety, depression, insomnia, tinnitus cognition, hearing-related difficulties, and quality of life.

Results: Internet-based CBT led to a greater reduction in tinnitus distress (mean 36.57, SD 22) compared with that in weekly monitoring (mean 46.31, SD 20.63; effect size: Cohen d=0.46, 95% CI 0.14-0.77) using an intention-to-treat analysis. For the secondary outcomes, there was a greater reduction in negative tinnitus cognition and insomnia. The results remained stable over the 2-month follow-up period. No important adverse events were observed. Further, 16% (10/158) of participants withdrew, with low overall compliance rates for questionnaire completion of 72.3% (107/148) at T1, 61% (91/148) at T2, and 42% (62/148) at T3.

Conclusions: This study is the first to evaluate and indicate the efficacy of audiologist-delivered internet-based CBT in reducing tinnitus distress in a US population. It was also the first study to offer internet-based CBT in Spanish to accommodate the large Hispanic population in the United States. The results have been encouraging, and further work is indicated in view of making such an intervention applicable to a wider population. Further work is required to improve compliance and attract more Spanish speakers.

Trial registration: ClinicalTrials.gov NCT04004260; https://clinicaltrials.gov/ct2/show/NCT04004260.

Keywords: cognitive behavioral therapy; eHealth; internet intervention; randomized controlled trial; teleaudiology; telehealth; tinnitus; web-based intervention.

Figure 1

The CONSORT (Consolidated Standards of Reporting Trials) flow diagram. ICBT: internet-based cognitive behavioral therapy.

Figure 2

Intervention engagement.

Figure 3

Change in tinnitus severity among groups over time. T1: only the experimental group had the intervention; T2: after the intervention for the control group and 2-month follow-up for the experimental group; T3: the comparison of the 2-month follow-up for both groups.

Figure 4

(A) Magnitude of Tinnitus Functional Index score changes between T0 and T1 after the experimental group underwent internet-based cognitive behavioral therapy. The control group was monitored weekly. (B) The magnitude of these changes between T0 and T3 at the 2-month follow-up after both groups completed the full intervention.

Figure 5

Weekly monitoring between the experimental and control group between T0 and T1. THI-S: Tinnitus Handicap Inventory–Screening; TQQ: Tinnitus Qualities Questionnaire.