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Rodriguez CR, Piccirillo JF, Rodebaugh TL. Acceptability of Cognitive Behavioral Therapy for Tinnitus: A Study With Veterans and Nonveterans. Am J Audiol 2023; 32:593-603. [PMID: 37566882 PMCID: PMC10558150 DOI: 10.1044/2023_aja-23-00020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/18/2023] [Accepted: 05/25/2023] [Indexed: 08/13/2023] Open
Abstract
PURPOSE Cognitive behavioral therapy (CBT) is a gold standard yet underutilized treatment for tinnitus, and tinnitus is especially highly prevalent among veterans. The aims of this study were twofold: to determine (a) if CBT for tinnitus is underutilized because participants find it less acceptable than other behavioral treatments for tinnitus and (b) if veterans and nonveterans rate behavioral treatments for tinnitus differently. METHOD This cross-sectional study was conducted online with a sample of 277 adults in the United States who self-reported at least some level of bothersome tinnitus in the past week. The sample for this study consisted of 129 veterans and 148 nonveterans. Participants read descriptions of CBT, tinnitus retraining therapy (TRT), and mindfulness-based stress reduction (MBSR). For each treatment, presented to them in random order, they provided credibility, expectancy, and acceptability ratings. RESULTS Among 277 participants, 147 (53.07%) reporting gender were women, 216 (77.98%) reporting race/ethnicity were White, and 129 (46.57%) were veterans of any branch of the U.S. Armed Forces. Veteran ratings of credibility, expectancy, and acceptability were significantly lower than nonveteran ratings across treatments. There were differences in credibility, expectancy, and acceptability ratings across treatments, and post hoc testing revealed that TRT was consistently rated higher than CBT or MBSR. CONCLUSIONS Despite strong research support, CBT was rated as less acceptable than a different, less widely empirically supported treatment. Veterans' ratings of acceptability were lower than those of nonveterans across all treatments.
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Affiliation(s)
- Chavez R. Rodriguez
- Department of Psychiatry, University of Michigan, Ann Arbor
- Addiction Center, University of Michigan, Ann Arbor
| | - Jay F. Piccirillo
- Clinical Outcomes Research Office, Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine in St. Louis, MO
| | - Thomas L. Rodebaugh
- Department of Psychological & Brain Sciences, Washington University in St. Louis, MO
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Rodrigo H, Beukes EW, Andersson G, Manchaiah V. Predicting the Outcomes of Internet-Based Cognitive Behavioral Therapy for Tinnitus: Applications of Artificial Neural Network and Support Vector Machine. Am J Audiol 2022; 31:1167-1177. [PMID: 36215687 PMCID: PMC9907438 DOI: 10.1044/2022_aja-21-00270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/16/2022] [Accepted: 06/23/2022] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Internet-based cognitive behavioral therapy (ICBT) has been found to be effective for tinnitus management, although there is limited understanding about who will benefit the most from ICBT. Traditional statistical models have largely failed to identify the nonlinear associations and hence find strong predictors of success with ICBT. This study aimed at examining the use of an artificial neural network (ANN) and support vector machine (SVM) to identify variables associated with treatment success in ICBT for tinnitus. METHOD The study involved a secondary analysis of data from 228 individuals who had completed ICBT in previous intervention studies. A 13-point reduction in Tinnitus Functional Index (TFI) was defined as a successful outcome. There were 33 predictor variables, including demographic, tinnitus, hearing-related and treatment-related variables, and clinical factors (anxiety, depression, insomnia, hyperacusis, hearing disability, cognitive function, and life satisfaction). Predictive models using ANN and SVM were developed and evaluated for classification accuracy. SHapley Additive exPlanations (SHAP) analysis was used to identify the relative predictor variable importance using the best predictive model for a successful treatment outcome. RESULTS The best predictive model was achieved with the ANN with an average area under the receiver operating characteristic value of 0.73 ± 0.03. The SHAP analysis revealed that having a higher education level and a greater baseline tinnitus severity were the most critical factors that influence treatment outcome positively. CONCLUSIONS Predictive models such as ANN and SVM help predict ICBT treatment outcomes and identify predictors of outcome. However, further work is needed to examine predictors that were not considered in this study as well as to improve the predictive power of these models. SUPPLEMENTAL MATERIAL https://doi.org/10.23641/asha.21266487.
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Affiliation(s)
- Hansapani Rodrigo
- School of Mathematical and Statistical Sciences, University of Texas Rio Grande Valley, Edinburg
- Virtual Hearing Lab, Collaborative initiative between Lamar University, Beaumont, TX, and University of Pretoria, South Africa
| | - Eldré W. Beukes
- Virtual Hearing Lab, Collaborative initiative between Lamar University, Beaumont, TX, and University of Pretoria, South Africa
- Vision and Hearing Sciences Research Centre, School of Psychology and Sport Science, Anglia Ruskin University, Cambridge, United Kingdom
| | - Gerhard Andersson
- Department of Behavioral Sciences and Learning, Department of Biomedical and Clinical Sciences, Linköping University, Sweden
- Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institute, Stockholm, Sweden
| | - Vinaya Manchaiah
- Virtual Hearing Lab, Collaborative initiative between Lamar University, Beaumont, TX, and University of Pretoria, South Africa
- Department of Otolaryngology–Head and Neck Surgery, University of Colorado School of Medicine, Aurora
- UCHealth Hearing and Balance, University of Colorado Hospital, Aurora
- Department of Speech-Language Pathology and Audiology, University of Pretoria, South Africa
- Department of Speech and Hearing, School of Allied Health Sciences, Manipal, India
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Beukes EW, Andersson G, Manchaiah V. Long-term efficacy of audiologist-guided Internet-based cognitive behaviour therapy for tinnitus in the United States: A repeated-measures design. Internet Interv 2022; 30:100583. [PMID: 36353148 PMCID: PMC9637888 DOI: 10.1016/j.invent.2022.100583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/19/2022] [Accepted: 10/26/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES This study investigated the long-term outcomes 1-year after undertaking an Internet-based cognitive behavioural therapy (ICBT) for tinnitus distress in a US population. Secondary aims were to identify the effects on additional difficulties associate with tinnitus and any unwanted events related to ICBT for tinnitus. METHODS A repeated-measures design with 4 time points was used. Participants previously undertaking two randomized ICBT efficacy trials for tinnitus in the US were invited to participate. Of the 200 invited, 132 (66 %) completed the 1-year follow-up questionnaire. The primary outcome was a change in tinnitus distress from baseline at one year post-intervention, as assessed by the Tinnitus Functional Index. Secondary assessment measures were included for anxiety, depression, insomnia, hearing disability, hyperacusis, tinnitus cognitions and health-related quality of life. RESULTS Undertaking ICBT for tinnitus led to significant improvements 1-year post-intervention for tinnitus severity, with a large effect size (d = 1.06; CI: 0.80 to 1.32). Medium effects were found for anxiety (d = 0.54; CI: 0.29 to 0.79), depression (d = 0.46; CI: 0.21 to 0.70), insomnia (d = 0.47; CI: 0.22 to 0.72), and tinnitus cognitions (d = 0.43, CI: 0.18 to 0.68). Small effect sizes were found for hearing disability, hyperacusis and health-related quality of life. Adverse events related to the intervention were only reported by 1 participant. CONCLUSIONS The benefits of audiologist-guided ICBT for tinnitus and tinnitus-related difficulties were maintained 1-year post-intervention with very few adverse events reported. Ways of disseminate evidence-based easily accessible interventions to the general population with bothersome tinnitus should be sought.
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Affiliation(s)
- Eldré W. Beukes
- Vision and Hearing Sciences Research Centre, Anglia Ruskin University, Cambridge, UK,Virtual Hearing Lab, Collaborative Initiative between University of Colorado School of Medicine and University of Pretoria, Aurora, CO, USA,Corresponding author at: Department of Vision and Hearing Sciences, Anglia Ruskin University, Cambridge, UK.
| | - Gerhard Andersson
- Department of Behavioral Sciences and Learning, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden,Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Vinaya Manchaiah
- Virtual Hearing Lab, Collaborative Initiative between University of Colorado School of Medicine and University of Pretoria, Aurora, CO, USA,Department of Otolaryngology–Head and Neck Surgery, University of Colorado School of Medicine, Aurora, CO, USA,UC Health Hearing and Balance, University of Colorado Hospital, Aurora, CO, USA,Department of Speech-Language Pathology and Audiology, University of Pretoria, Gauteng, South Africa,Department of Speech and Hearing, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, India
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Beukes EW, Manchaiah V, Andersson G, Maidment DW. Application of the Behavior Change Wheel Within the Context of Internet-Based Cognitive Behavioral Therapy for Tinnitus Management. Am J Audiol 2022; 31:433-444. [PMID: 35436419 DOI: 10.1044/2022_aja-21-00160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Although experiencing tinnitus can lead to many difficulties, these can be reduced by using techniques derived from cognitive behavioral therapy. Internet-based cognitive behavioral therapy (ICBT) has been developed to provide an accessible intervention. The aim of this study was to describe how ICBT can facilitate tinnitus management by identifying the active ingredients of the intervention from the perspective of health behavior change. METHOD The ICBT intervention was evaluated using the Behavior Change Wheel in eight steps across the following three stages: (1) understanding the behavior, (2) identifying intervention options, and (3) identifying content and implementation options. RESULTS Target behaviors identified to reduce tinnitus distress, as well as additional problems associated with tinnitus, included goal setting, an increased understanding of tinnitus, encouraging deep breathing and progressive muscle relaxation, identifying and restructuring unhelpful thoughts, engaging in positive imagery, and reducing avoidance behaviors. ICBT provided the required components for individuals to be physically and psychologically capable of adapting to tinnitus, providing social and environmental opportunities to manage hearing loss through practice and training, and facilitated automatic and reflective motivation. CONCLUSION Understanding ICBT in the context of the Behavior Change Wheel has helped identify how its effectiveness can be improved and can be used for future tinnitus intervention planning. SUPPLEMENTAL MATERIAL https://doi.org/10.23641/asha.19555213.
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Affiliation(s)
- Eldré W. Beukes
- Vision and Hearing Sciences Research Group, School of Psychology and Sports Sciences, Anglia Ruskin University, Cambridge, United Kingdom
- Virtual Hearing Lab, Collaborative Initiative between University of Colorado School of Medicine and University of Pretoria, Aurora
| | - Vinaya Manchaiah
- Virtual Hearing Lab, Collaborative Initiative between University of Colorado School of Medicine and University of Pretoria, Aurora
- Department of Otolaryngology–Head and Neck Surgery, University of Colorado School of Medicine, Aurora
- UCHealth Hearing and Balance, University of Colorado Hospital, Aurora
- Department of Speech-Language Pathology and Audiology, University of Pretoria, Gauteng, South Africa
- Department of Speech and Hearing, Manipal College of Health Professions, Manipal Academy of Higher Education, India
| | - Gerhard Andersson
- Department of Behavioral Sciences and Learning, Linköping University, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Sweden
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Sweden
| | - David W. Maidment
- School of Sport, Exercise and Health Sciences, Loughborough University, United Kingdom
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Andersson G. Internet-Delivered Psychological Treatments for Tinnitus: A Brief Historical Review. Am J Audiol 2022; 31:1013-1018. [PMID: 35442718 DOI: 10.1044/2022_aja-21-00245] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES Internet-delivered psychological treatments were developed more than 20 years ago, and tinnitus was among the first target conditions. The aim of this review article is to describe the history of Internet treatments for tinnitus and to comment on the evidence base. Challenges for future research and implementations will be mentioned. METHOD A narrative historical review was conducted. FINDINGS There are now several studies including controlled trials on Internet interventions based on cognitive behavior therapy (ICBT) for tinnitus. Effects in controlled trials are moderate to large with regard to tinnitus annoyance. While the treatment format now exists in four languages, there is a large treatment versus demand gap as very few clients with tinnitus receive ICBT. There is a lack of research on related conditions with the exception of hearing loss. However, there is substantial support for Internet interventions for comorbid conditions such as insomnia and depression but not specifically in association with tinnitus. CONCLUSIONS ICBT is a promising treatment approach for tinnitus and will hopefully increase access to evidence-based treatment to reduce tinnitus distress. More research is needed for related conditions such as hyperacusis and larger trials on tinnitus.
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Affiliation(s)
- Gerhard Andersson
- Department of Behavioural Sciences and Learning, Linköping University, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Sweden
- Division of Psychiatry, Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
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W Beukes E, Andersson G, Fagelson M, Manchaiah V. Internet-Based Audiologist-Guided Cognitive Behavioral Therapy for Tinnitus: Randomized Controlled Trial. J Med Internet Res 2022; 24:e27584. [PMID: 35156936 PMCID: PMC8887633 DOI: 10.2196/27584] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 03/29/2021] [Accepted: 10/05/2021] [Indexed: 12/11/2022] Open
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
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Affiliation(s)
- Eldré W Beukes
- Vision and Hearing Research Centre, Anglia Ruskin University, Cambridge, United Kingdom.,Virtual Hearing Lab, Collaborative Initiative Between University of Colorado School of Medicine and University of Pretoria, Aurora, CO, United States
| | - Gerhard Andersson
- Department of Behavioral Sciences and Learning, Linköping University, Linköping, Sweden
| | - Marc Fagelson
- Department of Audiology and Speech-Language Pathology, East Tennessee State University, Johnson City, TN, United States.,Auditory Vestibular Research Enhancement Award Program, Audiological Rehabilitation Laboratory, Veterans Affairs Medical Center, Mountain Home, TN, United States
| | - Vinaya Manchaiah
- Virtual Hearing Lab, Collaborative Initiative Between University of Colorado School of Medicine and University of Pretoria, Aurora, CO, United States.,Department of Speech-Language Pathology and Audiology, University of Pretoria, Pretoria, South Africa.,Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine, Aurora, CO, United States.,UCHealth Hearing and Balance, University of Colorado Hospital, Aurora, CO, United States.,Department of Speech and Hearing, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, India
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Manchaiah V, Brazelton A, Rodrigo H, Beukes EW, Fagelson MA, Andersson G, Trivedi MV. Medication Use Reported by Individuals With Tinnitus Who Are Seeking Internet-Based Psychological Interventions. Am J Audiol 2021; 30:1088-1095. [PMID: 34706212 DOI: 10.1044/2021_aja-21-00062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE This study examined medication use by individuals with tinnitus who were seeking help for their tinnitus by means of a psychological intervention. METHOD This study used a cross-sectional survey design and included individuals with tinnitus enrolled in an Internet-based cognitive behavioral therapy trial (n = 439). Study participants provided demographic details, completed various structured questionnaires and provided details about the medications used. The self-reported medications were classified using the United States Pharmacopeial Medicare Model Guidelines v7.0. RESULTS Current medication use was reported by 67% (n = 293) of the study participants. Those currently using medication were older; had consulted their primary care physician, had greater tinnitus severity, depression, anxiety, and insomnia when compared with those not reporting any current medication use. The top 10 medication used included cardiovascular agents (n = 162; 55.3%), antidepressants (n = 80; 27.3%), electrolytes/minerals/metals/vitamins (n = 70; 23.9%), respiratory tract/pulmonary agents (n = 62; 21.2%), anxiolytics (n = 59; 20.1%), hormonal agents/stimulant/replacement/modifying (thyroid; n = 45; 15.4%), gastrointestinal agents (n = 43; 14.7%), analgesics (n = 33; 11.3%), blood glucose regulators (n = 32; 10.9%), and anticonvulsants (n = 26; 8.87%). Some associations between type of medication used and demographic or tinnitus-related variables were noted especially for the cardiovascular agents, electrolytes/minerals/metals/vitamins, and anxiolytics. CONCLUSIONS This exploratory study indicated a large percentage of patients using medication and a range of medications. Further studies are required to assess the effects of such medications on the tinnitus percept and concurrent medication moderate treatment effects.
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Affiliation(s)
- Vinaya Manchaiah
- Department of Speech and Hearing Sciences, Lamar University, Beaumont, TX
- Virtual Hearing Lab, Lamar University, Beaumont, TX
- Department of Speech-Language Pathology and Audiology, University of Pretoria, South Africa
- Department of Speech and Hearing, School of Allied Health Sciences, Manipal Academy of Higher Education, India
| | - Alicia Brazelton
- Department of Pharmacy Practice and Translational Research, College of Pharmacy, University of Houston, TX
| | - Hansapani Rodrigo
- School of Mathematical and Statistical Sciences, The University of Texas Rio Grande Valley, Edinburg, TX
| | - Eldré W. Beukes
- Department of Speech and Hearing Sciences, Lamar University, Beaumont, TX
- Vision and Hearing Sciences Research Group and School of Psychology and Sport Science, Anglia Ruskin University, Cambridge, United Kingdom
| | - Marc A. Fagelson
- Department of Audiology and Speech-Language Pathology, East Tennessee State University, Johnson City
- Audiologic Rehabilitation Laboratory, Auditory Vestibular Research Enhancement Award Program, Veterans Affairs Medical Center, Mountain Home, TN
| | - Gerhard Andersson
- Department of Behavioural Sciences and Learning and Department of Biomedical and Clinical Sciences, Linköping University, Sweden
- Department of Clinical Neuroscience and Division of Psychiatry, Karolinska Institute, Stockholm, Sweden
| | - Meghana V. Trivedi
- Department of Pharmacy Practice and Translational Research, College of Pharmacy, University of Houston, TX
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Beukes EW, Andersson G, Manchaiah V. Patient Uptake, Experiences, and Process Evaluation of a Randomized Controlled Trial of Internet-Based Cognitive Behavioral Therapy for Tinnitus in the United States. Front Med (Lausanne) 2021; 8:771646. [PMID: 34869490 PMCID: PMC8635963 DOI: 10.3389/fmed.2021.771646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 10/04/2021] [Indexed: 11/21/2022] Open
Abstract
Introduction: An internet-based cognitive behavioral therapy (ICBT) offers a way to increase access to evidence-based tinnitus care. To increase the accessibility of this intervention, the materials were translated into Spanish to reach Spanish as well as English speakers. A clinical trial indicated favorable outcomes of ICBT for tinnitus for the population of the United States. In view of later dissemination, a way to increase the applicability of this intervention is required. Such understanding is best obtained by considering the perspectives and experiences of participants of an intervention. This study aimed to identify the processes that could facilitate or hinder the clinical implementation of ICBT in the United States. Methods: This study evaluated the processes regarding enrolment, allocation, intervention delivery, the outcomes obtained, and the trial implementation. The study sample consisted of 158 participants who were randomly assigned to the experimental and control group. Results: Although the recruitment was sufficient for English speakers, recruiting the Spanish participants and participants belonging to ethnic minority groups was difficult despite using a wide range of recruitment strategies. The allocation processes were effective in successfully randomizing the groups. The intervention was delivered as planned, but not all the participants chose to engage with the materials provided. Compliance for completing the outcome measures was low. The personal and intervention factors were identified as barriers for the implementation whereas the facilitators included the support received, being empowering, the accessibility of the intervention, and its structure. Conclusion: An understanding regarding the factors contributing to the outcomes obtained, the barriers and facilitators of the results, engagement, and compliance were obtained. These insights will be helpful in preparing for the future dissemination of such interventions. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT04004260. Registered on 2 July 2019.
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Affiliation(s)
- Eldre W. Beukes
- Department of Speech and Hearing Sciences, Lamar University, Beaumont, TX, United States
- Vision and Hearing Sciences Research Centre, School of Psychology and Sport Sciences, Anglia Ruskin University, Cambridge, United Kingdom
- Virtual Hearing Lab, a Collaborative Initiative Between Lamar University, Beaumont, TX, United States, and the University of Pretoria, Pretoria, South Africa
| | - Gerhard Andersson
- Department of Behavioral Sciences and Learning, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Division of Psychiatry, Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Vinaya Manchaiah
- Department of Speech and Hearing Sciences, Lamar University, Beaumont, TX, United States
- Virtual Hearing Lab, a Collaborative Initiative Between Lamar University, Beaumont, TX, United States, and the University of Pretoria, Pretoria, South Africa
- Department of Speech-Language Pathology and Audiology, University of Pretoria, Pretoria, South Africa
- Department of Speech and Hearing, School of Allied Health Sciences, Manipal Academy of Higher Education, Manipal, India
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Rodrigo H, Beukes EW, Andersson G, Manchaiah V. Exploratory Data Mining Techniques (Decision Tree Models) for Examining the Impact of Internet-Based Cognitive Behavioral Therapy for Tinnitus: Machine Learning Approach. J Med Internet Res 2021; 23:e28999. [PMID: 34726612 PMCID: PMC8596228 DOI: 10.2196/28999] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 08/29/2021] [Accepted: 09/12/2021] [Indexed: 01/07/2023] Open
Abstract
Background There is huge variability in the way that individuals with tinnitus respond to interventions. These experiential variations, together with a range of associated etiologies, contribute to tinnitus being a highly heterogeneous condition. Despite this heterogeneity, a “one size fits all” approach is taken when making management recommendations. Although there are various management approaches, not all are equally effective. Psychological approaches such as cognitive behavioral therapy have the most evidence base. Managing tinnitus is challenging due to the significant variations in tinnitus experiences and treatment successes. Tailored interventions based on individual tinnitus profiles may improve outcomes. Predictive models of treatment success are, however, lacking. Objective This study aimed to use exploratory data mining techniques (ie, decision tree models) to identify the variables associated with the treatment success of internet-based cognitive behavioral therapy (ICBT) for tinnitus. Methods Individuals (N=228) who underwent ICBT in 3 separate clinical trials were included in this analysis. The primary outcome variable was a reduction of 13 points in tinnitus severity, which was measured by using the Tinnitus Functional Index following the intervention. The predictor variables included demographic characteristics, tinnitus and hearing-related variables, and clinical factors (ie, anxiety, depression, insomnia, hyperacusis, hearing disability, cognitive function, and life satisfaction). Analyses were undertaken by using various exploratory machine learning algorithms to identify the most influencing variables. In total, 6 decision tree models were implemented, namely the classification and regression tree (CART), C5.0, GB, XGBoost, AdaBoost algorithm and random forest models. The Shapley additive explanations framework was applied to the two optimal decision tree models to determine relative predictor importance. Results Among the six decision tree models, the CART (accuracy: mean 70.7%, SD 2.4%; sensitivity: mean 74%, SD 5.5%; specificity: mean 64%, SD 3.7%; area under the receiver operating characteristic curve [AUC]: mean 0.69, SD 0.001) and gradient boosting (accuracy: mean 71.8%, SD 1.5%; sensitivity: mean 78.3%, SD 2.8%; specificity: 58.7%, SD 4.2%; AUC: mean 0.68, SD 0.02) models were found to be the best predictive models. Although the other models had acceptable accuracy (range 56.3%-66.7%) and sensitivity (range 68.6%-77.9%), they all had relatively weak specificity (range 31.1%-50%) and AUCs (range 0.52-0.62). A higher education level was the most influencing factor for ICBT outcomes. The CART decision tree model identified 3 participant groups who had at least an 85% success probability following the undertaking of ICBT. Conclusions Decision tree models, especially the CART and gradient boosting models, appeared to be promising in predicting ICBT outcomes. Their predictive power may be improved by using larger sample sizes and including a wider range of predictive factors in future studies.
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Affiliation(s)
- Hansapani Rodrigo
- School of Mathematical and Statistical Sciences, University of Texas Rio Grande Valley, Edinburgh, TX, United States.,Virtual Hearing Lab, Beaumont, TX, United States
| | - Eldré W Beukes
- Virtual Hearing Lab, Beaumont, TX, United States.,Department of Speech and Hearing Sciences, Lamar University, Beaumont, TX, United States.,Department of Vision and Hearing Sciences, School of Psychology and Sport Science, Anglia Ruskin University, Cambridge, United Kingdom
| | - Gerhard Andersson
- Department of Behavioral Sciences and Learning, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institute, Stockholm, Sweden
| | - Vinaya Manchaiah
- Virtual Hearing Lab, Beaumont, TX, United States.,Department of Speech and Hearing Sciences, Lamar University, Beaumont, TX, United States.,Department of Speech and Hearing, School of Allied Health Sciences, Manipal Academy of Higher Education, Karnataka, India.,Department of Speech-Language Pathology and Audiology, University of Pretoria, Gauteng, South Africa
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Beukes EW, Munzo MF, Andersson G, Manchaiah V. Internet-based cognitive behavioural therapy for tinnitus in Spanish: a global feasibility trial. Int J Audiol 2021; 61:632-641. [PMID: 34553654 DOI: 10.1080/14992027.2021.1971780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Internet-based cognitive behavioural therapy (ICBT) for tinnitus is an evidence-based intervention, but only available in a few languages. To increase accessibility, ICBT was translated into Spanish. This study's objective was to determine the feasibility of ICBT for Spanish speakers. DESIGN A single-group pre-test post-test design was used. Compliance, engagement, acceptance and outcome feasibility were measured. STUDY SAMPLE Forty-six Spanish speakers with tinnitus were screened. There were 32 participants meeting the eligibility criteria, with a mean age of 47 (±11) years. Of these 91% were Hispanic or Latino with 66% living in Spain and 34% living in South America. RESULTS Outcome feasibility was established, as a large pre- and post-test within-group effect size of d = 0.90 was found for tinnitus severity. Large pre- and post-test effect sizes were also present for the secondary outcomes of anxiety and depression with a medium effect for insomnia, health-related quality of life, and tinnitus cognitions. Intervention engagement and compliance were not optimal although no participants withdrew. Intervention acceptance rates indicated scope for improvement. CONCLUSIONS ICBT for Spanish communities appears to be feasible. A randomised controlled trial is required to further investigate the effects and identify ways of improving engagement and attracting Spanish speakers from different countries.
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Affiliation(s)
- Eldré W Beukes
- Department of Speech and Hearing Sciences, Lamar University, Beaumont, TX, USA.,Vision and Hearing Sciences Research Group, School of Psychology & Sports Science, Anglia Ruskin University, Cambridge, UK
| | - Maria F Munzo
- Department of Speech and Hearing Sciences, Lamar University, Beaumont, TX, USA
| | - Gerhard Andersson
- Department of Behavioral Sciences and Learning, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institute, Stockholm, Sweden
| | - Vinaya Manchaiah
- Department of Speech and Hearing Sciences, Lamar University, Beaumont, TX, USA.,Department of Speech and Hearing, School of Allied Health Sciences, Manipal Academy of Higher Education, Manipal, India
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11
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Beukes EW, Andersson G, Fagelson M, Manchaiah V. Audiologist-Supported Internet-Based Cognitive Behavioral Therapy for Tinnitus in the United States: A Pilot Trial. Am J Audiol 2021; 30:717-729. [PMID: 34432984 DOI: 10.1044/2021_aja-20-00222] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Patients often report that living with a condition such as tinnitus can be debilitating, worrying, and frustrating. Efficient ways to foster management strategies for individuals with tinnitus and promoting tinnitus self-efficacy are needed. Internet-based cognitive behavioral therapy (ICBT) for tinnitus shows promise as an evidence-based intervention in Europe, but is not available in the United States. The aim of this pilot study was to evaluate the feasibility of an ICBT intervention for tinnitus in the United States. Method This study reports the Phase 1 trial intended to support implementation of a larger randomized clinical trial (RCT) comparing ICBT to a weekly monitoring group. As a pilot study, a single-group pretest-posttest design was used to determine outcome potential, recruitment strategy, retention, and adherence rates of ICBT for tinnitus. The primary outcome was a change in tinnitus distress. Secondary outcome measures included measures of anxiety, depression, insomnia, tinnitus cognitions, hearing-related difficulties, and quality of life. Results Of the 42 screened participants, nine did not meet the inclusion criteria and six withdrew. There were 27 participants who completed the intervention, with a mean age of 55.48 (± 9.9) years. Feasibility was established, as a large pretest-posttest effect size of d = 1.6 was found for tinnitus severity. Large pretest-posttest effect sizes were also found for tinnitus cognitions and hearing-related effects, and a medium effect was found for insomnia and quality of life. Treatment adherence varied with a retention rate of 85% (n = 23) at post-intervention assessment and 67% (n = 18) for the follow-up assessment. Conclusions This pilot study supported the feasibility of ICBT for tinnitus in the United States. Ways of improving intervention retention and recruitment rates need to be explored in future ICBT studies. Protocol refinements that were identified will be implemented prior to further RCTs to investigate the efficacy of ICBT for tinnitus in the United States. Supplemental Material https://doi.org/10.23641/asha.15501135.
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Affiliation(s)
- Eldré W. Beukes
- Department of Speech and Hearing Sciences, Lamar University, Beaumont, TX
- Vision and Hearing Sciences Research Centre, Anglia Ruskin University, Cambridge, United Kingdom
| | - Gerhard Andersson
- Department of Behavioural Sciences and Learning, Department of Biomedical and Clinical Sciences, Linköping University, Sweden
- Division of Psychiatry, Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Marc Fagelson
- Department of Audiology and Speech-Language Pathology, East Tennessee State University, Johnson City
- Audiological Rehabilitation Laboratory, Auditory Vestibular Research Enhancement Award Program, Veterans Affairs Medical Center, Mountain Home, TN
| | - Vinaya Manchaiah
- Department of Speech and Hearing Sciences, Lamar University, Beaumont, TX
- School of Allied Health Sciences, Department of Speech and Hearing, Manipal University, Karnataka, India
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12
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Beukes EW, Andersson G, Fagelson MA, Manchaiah V. Dismantling internet-based cognitive behavioral therapy for tinnitus. The contribution of applied relaxation: A randomized controlled trial. Internet Interv 2021; 25:100402. [PMID: 34040997 PMCID: PMC8141772 DOI: 10.1016/j.invent.2021.100402] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 05/04/2021] [Accepted: 05/04/2021] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Internet-based cognitive behavioral therapy (ICBT) for tinnitus is an evidence-based intervention. The components of ICBT for tinnitus have, however, not been dismantled and thus the effectiveness of the different therapeutic components is unknown. It is, furthermore, not known if heterogeneous tinnitus subgroups respond differently to ICBT. AIMS This dismantling study aimed to explore the contribution of applied relaxation within ICBT for reducing tinnitus distress and comorbidities associated with tinnitus. A secondary aim was to assess whether outcomes varied for three tinnitus subgroups, namely those with significant tinnitus severity, those with low tinnitus severity, and those with significant depression. METHODS A parallel randomized controlled trial design (n = 126) was used to compare audiologist-guided applied relaxation with the full ICBT intervention. Recruitment was online and via the intervention platform. Assessments were completed at four-time points including a 2-month follow-up period. The primary outcome was tinnitus severity as measured by the Tinnitus Functional Index. Secondary outcomes were included for anxiety, depression, insomnia, negative tinnitus cognitions, health-related quality of life, hearing disability, and hyperacusis. Treatment engagement variables including the number of logins, number of modules opened, and the number of messages sent. Both an intention-to-treat analysis and completer's only analysis were undertaken. RESULTS Engagement was low which compromised results as the full intervention was undertaken by few participants. Both the ICBT and applied relaxation resulted in large reduction of tinnitus severity (within-group effect sizes d = 0.87 and 0.68, respectively for completers only analysis), which were maintained, or further improved at follow-up. These reductions in tinnitus distress were greater for the ICBT group, with a small effect size differences (between-group d = 0.15 in favor of ICBT for completers only analysis). Tinnitus distress decreased the most at post-intervention for those with significant depression at baseline. Both ICBT and applied relaxation contributed to significant reductions on most secondary outcome measures, with no group differences, except for a greater reduction of hyperacusis in the ICBT group. CONCLUSION Due to poor compliance partly attributed to the COVID-19 pandemic results were compromised. Further studies employing strategies to improve compliance and engagement are required. The intervention's effectiveness increased with initial level of tinnitus distress; those with the highest scores at intake experienced the most substantial changes on the outcome measures. This may suggest tailoring of interventions according to tinnitus severity. Larger samples are needed to confirm this.
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Key Words
- Applied relaxation
- CBT, Cognitive Behavioral Therapy
- CONSORT, Consolidated Standards of Reporting Trials
- Cognitive behavioral therapy
- Digital therapeutics
- GAD-7, Generalized Anxiety Disorder
- HHIA-S, Hearing Handicap Inventory for Adults - Screening
- ICBT, Internet-based Cognitive Behavioral Therapy Intervention
- ISI, Insomnia Severity Index
- Internet intervention
- PHQ-9, Patient Health Questionnaire
- RCI, Reliable Change Index
- TFI, Tinnitus Functional Index
- Telehealth
- Tinnitus
- US, United States
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Affiliation(s)
- Eldré W. Beukes
- Department of Speech and Hearing Sciences, Lamar University, Beaumont, TX, USA
- Vision and Hearing Sciences Research Group, School of Psychology and Sports Sciences, Anglia Ruskin University, Cambridge, United Kingdom
| | - Gerhard Andersson
- Department of Behavioral Sciences and Learning, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institute, Stockholm, Sweden
| | - Marc A. Fagelson
- Department of Audiology and Speech-Language Pathology, East Tennessee State University, Johnson City, TN, USA
- Audiological Rehabilitation Laboratory, Auditory Vestibular Research Enhancement Award Program, Veterans Affairs Medical Center, Mountain Home, TN, USA
| | - Vinaya Manchaiah
- Department of Speech and Hearing Sciences, Lamar University, Beaumont, TX, USA
- Department of Speech and Hearing, School of Allied Health Sciences, Manipal University, Manipal, Karnataka, India
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13
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Rodrigo H, Beukes EW, Andersson G, Manchaiah V. Internet-based cognitive-behavioural therapy for tinnitus: secondary analysis to examine predictors of outcomes. BMJ Open 2021; 11:e049384. [PMID: 34417217 PMCID: PMC8381319 DOI: 10.1136/bmjopen-2021-049384] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES The current study examined predictors of outcomes of internet-based cognitive-behavioural therapy (ICBT) for individuals with tinnitus. DESIGN Secondary analysis of intervention studies. SETTING Internet-based guided tinnitus intervention provided in the UK. PARTICIPANTS 228 individuals who underwent ICBT. INTERVENTIONS ICBT. PRIMARY AND SECONDARY OUTCOME MEASURES The key predictor variables included demographic, tinnitus, hearing-related and treatment-related variables as well as clinical factors (eg, anxiety, depression, insomnia), which can have an impact on the treatment outcome. A 13-point reduction in Tinnitus Functional Index (TFI) scores has been defined as a successful outcome. RESULTS Of the 228 subjects who were included in the study, 65% had a successful ICBT outcome. As per the univariate analysis, participants with a master's degree or above had the highest odds of having a larger reduction in tinnitus severity (OR 3.47; 95% CI 1.32 to 12.51), compared with the participants who had education only up to high school or less. Additionally, the baseline tinnitus severity was found to be a significant variable (OR 2.65; 95% CI 1.50 to 4.67) contributing to a successful outcome with the intervention. Both linear and logistic regression models have identified education level and baseline tinnitus severity to be significant predictor variables contributing to a reduction in tinnitus severity post-ICBT. As per the linear regression model, participants who had received disability allowance had shown a 25.3-point lower TFI reduction compared with those who did not experience a decrease in their workload due to tinnitus after adjusting for baseline tinnitus severity and their education level. CONCLUSIONS Predictors of intervention outcome can be used as a means of triaging patients to the most suited form of treatment to achieve optimal outcomes and to make healthcare savings. Future studies should consider including a heterogeneous group of participants as well as other predictor variables not included in the current study.ClinicalTrial.gov Registration: NCT02370810 (completed); NCT02665975 (completed).
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Affiliation(s)
- Hansapani Rodrigo
- School of Mathematical and Statistical Sciences, The University of Texas Rio Grande Valley, Edinburg, Texas, USA
| | - Eldré W Beukes
- Department of Speech and Hearing Sciences, Lamar University, Beaumont, Texas, USA
- Department of Vision and Hearing Sciences, Anglia Ruskin University, Chelmsford, UK
| | - Gerhard Andersson
- Department of Behavioral Sciences and Learning, Linköping University, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institute, Stockholm, Sweden
| | - Vinaya Manchaiah
- Department of Speech and Hearing Sciences, Lamar University, Beaumont, Texas, USA
- Department of Speech and Hearing, School of Allied Health Sciences, Manipal University, Manipal, Karnataka, India
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14
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Beukes EW, Lourenco MPCG, Biot L, Andersson G, Kaldo V, Manchaiah V, Jacquemin L. Suggestions for shaping tinnitus service provision in Western Europe: Lessons from the COVID-19 pandemic. Int J Clin Pract 2021; 75:e14196. [PMID: 33837639 PMCID: PMC8250123 DOI: 10.1111/ijcp.14196] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 03/27/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Tinnitus severity has been exacerbated because of the COVID-19 pandemic and those with tinnitus require additional support. Such support should be informed by patient preferences and needs. The objective of this study was to gather information from individuals with tinnitus living in Europe to inform stakeholders of the (a) support they needed in relation to changes associated with the COVID-19 pandemic and (b) suggestions regarding tinnitus care for the future. METHODS A cross-sectional mixed method study design was used using closed and open-ended questions via an online survey. Data were gathered from 710 adults experiencing tinnitus in Western Europe, with the majority living in The Netherlands, Belgium and Sweden. Data were analysed using qualitative content analysis and descriptive statistics. RESULTS Those with tinnitus indicated the following support needs during the pandemic (a) support for tinnitus, (b) support for hearing-related difficulties, (c) social support and (d) pandemic-related support. Five directions for future tinnitus care were provided, namely, (a) need for understanding professional support and access to multidisciplinary experts, (b) greater range of therapies and resources, (c) access to more information about tinnitus, (d) prioritising tinnitus research and (e) more support for hearing protection and hearing loss prevention. CONCLUSIONS The findings point to the need for accessible (remote), patient-centred, suitable and evidence-based tinnitus care. Insights from the current study can be used by various stakeholders including clinical practitioners and tinnitus support services to ensure those with tinnitus have access to the help and support required in order to reduce service provision insufficiencies.
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Affiliation(s)
- Eldré W. Beukes
- Department of Speech and Hearing SciencesLamar UniversityBeaumontTXUSA
- Department of Vision and Hearing SciencesAnglia Ruskin UniversityCambridgeUK
| | - Matheus P. C. G. Lourenco
- Experimental Health PsychologyMaastricht UniversityMaastrichtThe Netherlands
- Research Group Health PsychologyKU Leuven UniversityLeuvenBelgium
| | - Lana Biot
- Faculty of BiomedicalPharmaceuticals and Veterinary SciencesUniversity of AntwerpAntwerpBelgium
| | - Gerhard Andersson
- Department of Behavioral Sciences and LearningDepartment of Biomedical and Clinical SciencesLinköping UniversityLinköpingSweden
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
| | - Viktor Kaldo
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
- Department of PsychologyFaculty of Health and Life SciencesLinnaeus UniversityVäxjöSweden
| | - Vinaya Manchaiah
- Department of Speech and Hearing SciencesLamar UniversityBeaumontTXUSA
- Department of Speech and HearingSchool of Allied Health SciencesManipal UniversityManipalKarnatakaIndia
| | - Laure Jacquemin
- Department of Translational NeurosciencesFaculty of Medicine and Health SciencesUniversity of AntwerpWilrijkBelgium
- Department of Otorhinolaryngology and Head and Neck SurgeryAntwerp University HospitalEdegemBelgium
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15
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Beukes EW, Onozuka J, Brazell TP, Manchaiah V. Coping With Tinnitus During the COVID-19 Pandemic. Am J Audiol 2021; 30:385-393. [PMID: 33979227 DOI: 10.1044/2021_aja-20-00188] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Purpose The COVID-19 pandemic disrupted normal operations of health care services, broad sectors of the economy, and the ability to socialize freely. For those with tinnitus, such changes can be factors in exacerbating tinnitus. The purpose of this study was to determine tinnitus help-seeking behavior, which resources individuals utilized to cope during the pandemic, and what additional support is desired. Method An exploratory cross-sectional study design including 1,522 adults with tinnitus living in North America (Canada and the United States) was used. Data were collected through an online survey distributed by the American Tinnitus Association via e-mail. Free text from open-ended questions was analyzed using the automated content analysis. The responses to the structured questionnaire were analyzed using descriptive and nonparametric statistics. Results Significantly less tinnitus support was sought during the pandemic, and very few respondents utilized tinnitus support networks during the pandemic at the time the survey was conducted. Nonetheless, seeking support during the pandemic was significantly associated with significantly less tinnitus distress. The most frequently utilized resources for coping during the pandemic were contacting family and friends, spending time outdoors or in nature, relaxation, and exercise. Such tools for coping were associated with significantly less tinnitus distress. The support requested and advice provided by participants to health care services had overlap. The main support needs related to managing tinnitus included addressing hearing loss, providing peer support, finding cures, and accessing trained and understanding health care providers to help. The advice for professionals related to tinnitus management included the need for cures, personalized support, addressing hearing loss, targeting the tinnitus percept, and providing more information about the condition. Conclusions These findings provide suggestions on how to better support those with tinnitus at a time when health care is undergoing rapid changes. Findings can be used by stakeholders, clinical practitioners, and tinnitus support services to devise ways to work more effectively together to improve access to patient-driven, suitable, accessible, and evidence-based support. Supplemental Material https://doi.org/10.23641/asha.14558514.
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Affiliation(s)
- Eldré W. Beukes
- Department of Speech and Hearing Sciences, Lamar University, Beaumont, TX
- Department of Vision and Hearing Sciences, Anglia Ruskin University, Cambridge, United Kingdom
| | - Joy Onozuka
- American Tinnitus Association, Washington, DC
| | | | - Vinaya Manchaiah
- Department of Speech and Hearing Sciences, Lamar University, Beaumont, TX
- Department of Speech and Hearing, School of Allied Health Sciences, Manipal University, Karnataka, India
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