Internet-based cognitive behaviour therapy for tinnitus patients delivered in a regular clinical setting: outcome and analysis of treatment dropout

Efficacy of Internet-Based Therapies for Tinnitus: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Tinnitus presents a major public health challenge, impacting quality of life. With conventional therapies being often time-consuming and costly, interest in Internet-based treatments, such as auditory treatments and Internet-based cognitive behavioral therapy, has grown due to their improved patient adherence. This meta-analysis aims to review existing scientific literature to assess the effectiveness of Internet-based therapies (IBTs) in treating tinnitus.

METHODS

Studies up to February 2024 using the Tinnitus Functional Index (TFI), Tinnitus Handicap Inventory (THI), or Tinnitus Reactions Questionnaire (TRQ) to monitor tinnitus before and after IBTs were searched in PubMed, Google Scholar, Web of Science, and the Cochrane Central Register of Controlled Trials. Variation of the score with time was analyzed and a comparison was made with non-IBT studies. Treatment effects were analyzed using Cohen's d model.

RESULTS

A total of 14 articles were considered, with a total of 1574 patients. Significant improvements in questionnaire scores were noted post-treatment. In the IBT group, THI and TFI decreased by 17.97 and 24.56 points, respectively (Cohen's d THI: 0.85; TFI: 0.80). In the control group, THI and TFI decreased by 13.7 and 4.25 points, respectively (Cohen's d THI: 0.55; TFI: 0.10).

CONCLUSIONS

Internet-based therapies showed reliable effectiveness, possibly due to improved patient compliance, accessibility, cost-effectiveness, and customization.

Effectiveness of Telerehabilitation Interventions for Self-management of Tinnitus: Systematic Review

BACKGROUND

Tinnitus is a highly prevalent symptom affecting 10%-20% of the adult population. Most patients with tinnitus have chronic tinnitus, which can directly or indirectly disrupt their daily life and negatively affect the health-related quality of life. Therefore, patients with tinnitus are frequently in need of costly and time-consuming treatments. As an answer, telerehabilitation interventions are on a rise to promote self-management in patients with tinnitus and reduce their dependency on in-person care.

OBJECTIVE

This systematic review aimed to provide an overview of the research concerning the effectiveness of telerehabilitation interventions for self-management of tinnitus.

METHODS

This systematic review adheres to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were eligible for inclusion if study participants were adult patients with complaints of primary subjective tinnitus and the study intervention comprised any possible telerehabilitation form for the self-management of tinnitus complaints. A search for eligible studies was conducted on PubMed, ScienceDirect, Scopus, Web of Science, and Cochrane Library. The Cochrane Risk of Bias 2 tool was used to the assess risk of bias.

RESULTS

In total, 29 articles were found eligible, and of these, 5 (17%) studied multiple telerehabilitation forms. Internet-based cognitive behavioral treatment with guidance by a psychologist or audiologist was examined in 17 studies (n=1767), internet-based cognitive behavioral treatment without guidance was examined in 4 studies (n=940), self-help manuals were examined in 1 study (n=72), technological self-help devices were examined in 2 studies (n=82), smartphone apps were examined in 8 studies (n=284), and other internet-based interventions were examined in 2 studies (n=130). These rehabilitation categories were proven to be effective in decreasing tinnitus severity and relieving tinnitus distress as measured by tinnitus questionnaires such as Tinnitus Functional Index, Tinnitus Handicap Inventory, or Tinnitus Reactions Questionnaire. However, dropout rates were often high (range 4%-71.4%). All studies reported between some concerns and high concerns of risk of bias, resulting in low to moderate certainty levels.

CONCLUSIONS

Overall, there is low to moderate quality evidence that telerehabilitation interventions effectively reduce tinnitus severity and distress. These interventions form a possible tool to improve the self-management capacities of the patient and the accessibility of tinnitus care as a replacement or an addition to in-person care. Nevertheless, barriers such as lack of time, engagement, motivation, and openness of the patient causing high dropout should be considered.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42021285450; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=285450.

The Treatment Outcome of Smart Device-Based Tinnitus Retraining Therapy: Prospective Cohort Study

BACKGROUND

Tinnitus retraining therapy (TRT) is a standard treatment for tinnitus that consists of directive counseling and sound therapy. However, it is based on face-to-face education and a time-consuming protocol. Smart device-based TRT (smart-TRT) seems to have many advantages, but the efficacy of this new treatment has been questioned.

OBJECTIVE

The aim of this study was to compare the efficacy between smart-TRT and conventional TRT (conv-TRT).

METHODS

We recruited 84 patients with tinnitus. Results were compared between 42 patients who received smart-TRT and 42 control participants who received conv-TRT. An interactive smart pad application was used for directive counseling in the smart-TRT group. The smart pad application included detailed education on ear anatomy, the neurophysiological model of tinnitus, concept of habituation, and sound therapy. The smart-TRT was bidirectional: There were 17 multiple choice questions between each lesson as an interim check. The conv-TRT group underwent traditional person-to-person counseling. The primary outcome measure was the Tinnitus Handicap Inventory (THI), and the secondary outcome measure was assessed using a visual analogue scale (VAS).

RESULTS

Both treatments had a significant treatment effect, which comparably improved during the first 2 months. The best improvements in THI were -23.3 (95% CI -33.1 to -13.4) points at 3 months and -16.8 (95% CI -30.8 to -2.8) points at 2 months in the smart-TRT group and conv-TRT group, respectively. The improvements on the VAS were also comparable: smart-TRT group: -1.2 to -3.3; conv-TRT: -0.7 to -1.7.

CONCLUSIONS

TRT based on smart devices can be an effective alternative for tinnitus patients. Considering the amount of time needed for person-to-person counseling, smart-TRT can be a cost-effective solution with similar treatment outcomes as conv-TRT.

Application of the Behavior Change Wheel Within the Context of Internet-Based Cognitive Behavioral Therapy for Tinnitus Management

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.

Prediction of treatment outcome in patients suffering from chronic tinnitus - from individual characteristics to early and long-term change

BACKGROUND AND OBJECTIVE

Despite the availability of successful treatment approaches for chronic tinnitus, it has proven difficult to predict who profits from treatment and it is still an open question if it is possible at all. We tried to overcome methodological shortcomings and to predict treatment outcome indicated by questionnaires measuring tinnitus distress.

METHODS

This is an observational, prospective cohort study. Lasso and post-selection inference methods were used to predict treatment outcome in patients suffering from chronic tinnitus (N = 747). Patients were treated for five consecutive days in an interdisciplinary setting according to guidelines.

RESULTS

Early change, i.e. a positive response after the screening day, as well as change due to treatment was predicted by several psychopathological variables, but also tinnitus-related factors. Female gender as an example was a predictor for change due to treatment. In general, therapy success both for early change and change due to treatment cannot be predicted satisfactorily as indicated by a high mean cross-validation error (for early change: 9.83, for change due to treatment: 14.40). Analyzing sub-groups separated by tinnitus severity to reduce heterogeneity did not improve the situation and for patients with high tinnitus severity no predictors at all could be reported (cross-validated error: 11.62 for the low quartile, 13.38 for the low-medium quartile, and 15.61 for the medium-high quartile).

CONCLUSION

Several psychopathological and tinnitus-related variables predicted early and long-term change. Nevertheless, also overcoming methodological shortcomings to predict treatment success did not lead to satisfactory results, but rather emphasizes the high heterogeneity of chronic tinnitus.

Internet-Delivered Psychological Treatments for Tinnitus: A Brief Historical Review

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.

Cost Effectiveness of Cognitive Behavioral Therapy for the Treatment of Subjective Tinnitus in Australia

OBJECTIVES

The aim of this study was to conduct an economic evaluation for the treatment of subjective tinnitus using different modalities of cognitive behavioral therapy (CBT) in Australia.

DESIGN

A decision tree model was used to conduct a cost-utility analysis for CBT to determine the cost effectiveness for tinnitus treatments, in terms of cost per responder and cost per quality-adjusted life-year (QALY), from a health system perspective using a 2-year time horizon. Meta-analysis was used to differentiate the levels of effectiveness between three delivery methods for CBT: individual face-to-face care (fCBT), group sessions (gCBT), and a supported internet program (iCBT). One-way sensitivity analysis and probabilistic sensitivity analysis (PSA) explored the uncertainty surrounding model inputs and outcomes. Results were presented as incremental cost-effectiveness ratios compared with no treatment, and as net monetary benefit at a $50,000 willingness-to-pay threshold.

RESULTS

Compared with no treatment, the incremental cost per responder was $700 for gCBT, $871 for iCBT, and $1380 for fCBT. The base case incremental cost-effectiveness ratio was $35,363 per QALY for fCBT, $17,935 per QALY for gCBT, and $22,321 per QALY for iCBT compared with no treatment, although there was substantial uncertainty around the QALY gain for responders. Net monetary benefit was $356 (fCBT), $555 (gCBT), and $487 (iCBT), indicating the treatments were cost effective compared with no treatment. One-way sensitivity analysis revealed the results were most sensitive to the probability of a positive response to treatment and treatment length. The PSA found the probability of being cost effective compared with no treatment for gCBT was 99.8%, iCBT 98.4%, and fCBT 71.5% at a willingness-to-pay of $50,000 per QALY, although QALY gain remained at a fixed value in the PSA.

CONCLUSIONS

CBT for tinnitus was likely to be cost effective compared with no treatment regardless of treatment modality, assuming they are not mutually exclusive. Of the interventions, gCBT was the lowest cost per responder and lowest cost per QALY. Internet CBT obtained comparable economic outcomes due to similar treatment effectiveness and cost. Group CBT and iCBT warrant greater adoption in clinical practice for the treatment of subjective tinnitus. Further research on preference-based utility measures for varying levels of tinnitus severity and the durability of treatment effect is required to enhance the quality of economic evaluation in this field.

User evaluation of a therapist-guided internet-delivered treatment program for anxiety disorders: A qualitative study

Therapist-guided internet-based cognitive behaviour therapy (ICBT) has been proposed as a potential means to increase individuals' access to quality mental health care and effective treatment. Guided ICBT aims to increase a patient's knowledge and competence to better cope with their disorder. Despite the growing evidence supporting the effects of guided ICBT, there is remarkably little research on the different factors that are important for patients to achieve effects from using such digital treatment interventions. Thus, the aim of this study was to conduct a user evaluation of a therapist-guided ICBT program using the updated DeLone and McLean (D&M) model for measuring information systems (IS) success or effectiveness. This model includes the following six dimensions: system quality, information quality, service quality, intention to use and use, user satisfaction, and net benefits (impacts or effect). Ten users of a Norwegian therapist-guided ICBT program for treating anxiety disorders named 'Assisted Self-Help' (Assistert Selvhjelp) participated in phone-based individual interviews. Data were analysed using directed content analysis. Results showed that the participants were quite satisfied with the program's system quality and information quality. However, participants suggested improvements, including in-program instruction, improved visibility of system status, more flexibility regarding automated measurement surveys, and the inclusion of more videos with patient stories. Further, the results indicated a need for improvement in the service quality of guided ICBT introduction, instruction, follow-up, guidance, and support from therapists. The results showed that user friendliness and high educational content might not be sufficient for a therapist-guided ICBT program to be perceived as effective. It might also be necessary for therapists to provide follow-up, guidance, and support that are more in line with individual patient needs. Thus, the results suggest that guided ICBT requires active participation from all involved in the process, including the therapist.

Applied tele-audiology research in clinical practice during the past decade: a scoping review

OBJECTIVE

The purpose of this scoping review was two-fold, (1) to provide information about the characteristics, type of service delivery, participant information and outcomes related to tele-audiology in clinical popluations, and (2) to describe documented facilitators and barriers to tele-audiology delivery from the perspectives of practitioners and service recipients. Knowledge of these findings can assist audiologists in considering remote service delivery options for their practices.

DESIGN

A scoping review was conducted in November 2019 to identify English-language peer-reviewed journal articles published from 1 January 2010 to 30 October 2019 related to remote clinical service delivery in audiology.

RESULTS

Thirty-six published research articles were included. Research studies were classified into four broad areas with some articles including more than one area within the scope of their article: Screening (n = 5), Diagnostic (n = 5), Intervention (n = 18), and Perspectives (n = 22).

CONCLUSION

Hearing healthcare service delivery is expanding with the changing technological landscape, providing greater opportunities and flexibility for audiologists and patients. There are clear opportunities for interdisciplinary collaboration and for collaboration with on-site local facilitators. Local facilitators, with training, can assist in connecting individuals to follow-up care, provide educational support, and needed hands-on assistance for specialised testing.

Effectiveness of Guided Internet-Based Cognitive Behavioral Therapy vs Face-to-Face Clinical Care for Treatment of Tinnitus: A Randomized Clinical Trial

Importance

Accessible clinical care is not always available to individuals with distressing tinnitus. Internet-based cognitive behavioral therapy has the potential to increase access to evidence-based services that manage tinnitus. Research comparing the effectiveness of this internet-based intervention with face-to-face care is required.

Objective

To evaluate whether an internet-based cognitive behavioral therapy intervention is at least as effective as established individualized face-to-face clinical care in reducing tinnitus distress and tinnitus-related difficulties.

Design, Setting, and Participants

A randomized, multicenter, 2-arm parallel group, noninferiority trial with 2-month follow-up was performed between October 4, 2016, and July 14, 2017. Invited to participate were 374 adults based in the United Kingdom who had been referred to their local tinnitus clinics because of bothersome tinnitus. The experimental group received the internet-based intervention online, and the active control group underwent the usual face-to-face tinnitus care at 1 of 3 UK-based National Health Service hospitals. Participants were randomly assigned (1:1) to either intervention using variable permuted block sizes of 4 and 6. Of 92 participants who were randomized (46 each in the experimental and control groups), 88 participants completed the assessment immediately after intervention and 74 participants completed the follow-up assessment.

Interventions

Participants were randomized to receive either 8 weeks of guided internet-based cognitive behavioral therapy or a mean of 2 to 3 individualized face-to-face appointments in a tinnitus clinic.

Main Outcomes and Measures

The primary outcome was a change in tinnitus distress (assessed by the Tinnitus Functional Index). Secondary assessment measures were included for insomnia, anxiety, depression, hearing disability, hyperacusis, cognitive failures, and satisfaction with life.

Results

Of 92 patients overall, 55 (60%) were men with a mean (SD) age of 52.96 (12.07) years and mean (SD) tinnitus duration of 6.54 (9.25) years. The between-group difference in the Tinnitus Functional Index scores after intervention were 5.18 (95% CI, -4.17 to 14.53) at the initial assessment and 5.52 (95% CI, -4.60 to 15.61) at follow-up; both differences were within the noninferiority margin of 13 points for the lower 95% CI. For the secondary outcomes, only outcomes for insomnia fell outside the noninferiority margin, both after intervention and at follow-up, favoring internet-based cognitive behavioral therapy.

Conclusions and Relevance

This is the first trial, to our knowledge, to compare an internet-based intervention with standard individualized face-to-face care for tinnitus. It revealed that both interventions are equally effective for reducing tinnitus distress and most tinnitus-related difficulties.

Trial Registration

ClinicalTrials.gov identifier: NCT02665975.

Internet-Based Cognitive Behavior Therapy for Stress and Anxiety among Young Japanese Adults: A Preliminary Study

In the present study, we examined the effect of an internet cognitive behavior therapy (ICBT) program on anxiety, stress, and depressive symptoms in university students. Data were analyzed for 17 participants undergoing ICBT and 11 control group participants. An ANOVA of intention-to-treat analysis and per protocol (PP) analysis indicated that the interaction between group and measurement time was significant for the state–trait anxiety inventory (STAI) scores and that idiosyncratic anxiety was significantly improved. Through the results of PP, a moderate effect size for changes in STAI scores in the intervention group was observed (d = 0.62) based on Cohen’s (1988) classifications. A large effect was also observed for improvements in idiosyncratic anxiety (d = 0.91). Based on the results of the analyses, a significant interaction was observed for the STAI scores. In the intervention group, STAI scores and individual anxiety were significantly reduced after implementing the ICBT program. It was suggested that the ICBT program may positively influence thinking about anxiety and stress from an objective viewpoint.

Review of Smart Services for Tinnitus Self-Help, Diagnostics and Treatments

In the recent years, there has been an increasing interest in the potential of internet- and smartphone-based technologies for the support of tinnitus patients. A broad spectrum of relevant approaches, some in the form of studies, others in the form of market products, have been mentioned in literature. They include auditory treatments, internet-based Cognitive Behavioral Therapy (iCBT), serious games, and questionnaires for tinnitus monitoring. The goal of this study is to highlight the role of existing internet-based and smart technologies for the advancement of tinnitus clinical practice: we consider contributions that refer to treatments and diagnostics, and we include contributions refering to self-help measures. We elaborate on the potential and challenges of such solutions and identify constraints associated to their deployment, such as the demand for familiarity with internet-based services and the need to re-design interactive services so that they fit on the small surface of a smartwatch.

Internet interventions: Past, present and future

Internet interventions have been around now for about 20 years. While the field still suffers from a scattered terminology a large number of programs and studies exist. In the present paper I present an overview of my experiences of studying internet-supported cognitive-behaviour therapy (ICBT), but also mention other approaches including the use of smartphones. The paper covers the history of ICBT, short-term effects in controlled trials for a range of conditions, long-term effects, comparisons against face-to-face therapy, effectiveness studies, prediction studies, how the treatment is perceived, critique, and finally future directions. I conclude that we have now reached a stage in which we have numerous evidence-based treatments and procedures, and increasingly internet interventions including ICBT are disseminated.

Results of an Interdisciplinary Day Care Approach for Chronic Tinnitus Treatment: A Prospective Study Introducing the Jena Interdisciplinary Treatment for Tinnitus

Objective: Considering the heterogeneity of the symptoms shown by patients suffering from chronic tinnitus, there are surprisingly few interdisciplinary treatments available, and mostly available only for inpatients. In order to provide an interdisciplinary treatment, we developed a day care concept in which each patient was treated by an ENT doctor, a cognitive behavioral therapist, a specialist for medical rehabilitation and an audiologist (Jena Interdisciplinary Treatment for Tinnitus, JITT). The aim of this study was to observe the changes of tinnitus related distress due to interdisciplinary day care treatment and to determine which factors mediate this change.

Subjects and Methods: Tinnitus annoyance was measured using the Tinnitus Questionnaire on 308 patients with chronic tinnitus. They were treated in the day care unit over five consecutive days between July 2013 and December 2014. Data were collected before treatment when screened (T0), at the beginning (T1) and at the end of the 5 day treatment (T2), as well as 20 days (T3) and 6 months after treatment (T4).

Results: Overall, tinnitus annoyance improved significantly from the screening day to the beginning of treatment, and to a much larger degree from the beginning to the end of treatment. The treatment outcome remained stable 6 months after treatment. Patients with the following symptoms displayed higher tinnitus annoyance at T0: dizziness at tinnitus onset, tinnitus sound could not be masked with background noise, tinnitus worsening during physical stress, comorbid psychiatric diagnosis, higher age and higher hearing loss. Loudness of tinnitus perceived in the right ear correlated with tinnitus annoyance significantly. Demographic, tinnitus and strain variables could only explain 12.8% of the variance of the change in tinnitus annoyance from T0 to T4. Out of 39 predictors, the only significant ones were “sick leave 6 months before treatment” and “tinnitus annoyance at T0.”

Conclusion: The newly developed JITT represents a valuable treatment for chronic tinnitus patients with improvement remaining stable for at least 6 months after treatment. Using a large number of variables did not allow predicting treatment outcome which underlines the heterogeneity of tinnitus.

High-intensity therapist-guided internet-based cognitive behavior therapy for alcohol use disorder: a pilot study

BACKGROUND

A large proportion of individuals with alcohol problems do not seek psychological treatment, but access to such treatment could potentially be increased by delivering it over the Internet. Cognitive behavior therapy (CBT) is widely recognized as one of the psychological treatments for alcohol problems for which evidence is most robust. This study evaluated a new, therapist-guided internet-based CBT program (entitled ePlus) for individuals with alcohol use disorders.

METHODS

Participants in the study (n = 13) were recruited through an alcohol self-help web site ( www.alkoholhjalpen.se ) and, after initial internet screening, were diagnostically assessed by telephone. Eligible participants were offered access to the therapist-guided 12-week program. The main outcomes were treatment usage data (module completion, treatment satisfaction) as well as glasses of alcohol consumed the preceding week, measured with the self-rated Timeline Followback (TLFB). Participant data were collected at screening (T0), immediately pre-treatment (T1), post-treatment (T2) and 3 months post-treatment (T3).

RESULTS

Most participants were active throughout the treatment and found it highly acceptable. Significant reductions in alcohol consumption with a large within-group effect size were found at the three-month follow-up. Secondary outcome measures of craving and self-efficacy, as well as depression and quality of life, also showed significant improvements with moderate to large within-group effect sizes.

CONCLUSIONS

Therapist-guided internet-based CBT may be a feasible and effective alternative for people with alcohol use disorders. In view of the high acceptability and the large within-group effect sizes found in this small pilot, a randomized controlled trial investigating treatment efficacy is warranted.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT02384278 , February 26, 2015).

Guided Internet-based versus face-to-face clinical care in the management of tinnitus: study protocol for a multi-centre randomised controlled trial

Background

Innovative strategies are required to improve access to evidence-based tinnitus interventions. A guided Internet-based cognitive behavioural therapy (iCBT) intervention for tinnitus was therefore developed for a U.K. population. Initial clinical trials indicated efficacy of iCBT at reducing tinnitus severity and associated comorbidities such as insomnia and depression. The aim of this phase III randomised controlled trial is to compare this new iCBT intervention with an established intervention, namely face-to-face clinical care for tinnitus.

Methods/design

This will be a multi-centre study undertaken across three hospitals in the East of England. The design is a randomised, two-arm, parallel-group, non-inferiority trial with a 2-month follow-up. The experimental group will receive the guided iCBT intervention, whereas the active control group will receive the usual face-to-face clinical care. An independent researcher will randomly assign participants, using a computer-generated randomisation schedule, after stratification for tinnitus severity. There will be 46 participants in each group. The primary assessment measure will be the Tinnitus Functional Index. Data analysis will establish whether non-inferiority is achieved using a pre-defined non-inferiority margin.

Discussion

This protocol outlines phase III of a clinical trial comparing a new iCBT with established face-to-face care for tinnitus. If guided iCBT for tinnitus proves to be as effective as the usual tinnitus care, it may be a viable additional management route for individuals with tinnitus. This could increase access to evidence-based effective tinnitus care and reduce the pressures on existing health care systems.

Trial registration

ClinicalTrials.gov identifier: NCT02665975. Registered on 22 January 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-1931-6) contains supplementary material, which is available to authorized users.

A randomised controlled study of mindfulness meditation versus relaxation therapy in the management of tinnitus

OBJECTIVE

Psychotherapeutic interventions have been adopted effectively in the management of tinnitus for a long time. This study compared mindfulness meditation and relaxation therapy for management of tinnitus.

METHODS

In this randomised controlled trial, patients were recruited for five sessions of mindfulness meditation or five sessions of relaxation therapy. Patients' responses were evaluated using the Tinnitus Reaction Questionnaire as a primary outcome measure, and the Hospital Anxiety and Depression Scale, visual analogue scale and a health status indicator as secondary outcome measures.

RESULTS

A total of 86 patients were recruited. Thirty-four patients completed mindfulness meditation and 27 patients completed relaxation therapy. Statistically significant improvement was seen in all outcome measures except the health status indicator in both treatment groups. The change in treatment scores was greater in the mindfulness meditation group than in the relaxation therapy group.

CONCLUSION

This study suggests that although both mindfulness meditation and relaxation therapy are effective in the management of tinnitus, mindfulness meditation is superior to relaxation therapy.

Evaluating Digital Health Interventions: Key Questions and Approaches

Digital health interventions have enormous potential as scalable tools to improve health and healthcare delivery by improving effectiveness, efficiency, accessibility, safety, and personalization. Achieving these improvements requires a cumulative knowledge base to inform development and deployment of digital health interventions. However, evaluations of digital health interventions present special challenges. This paper aims to examine these challenges and outline an evaluation strategy in terms of the research questions needed to appraise such interventions. As they are at the intersection of biomedical, behavioral, computing, and engineering research, methods drawn from all of these disciplines are required. Relevant research questions include defining the problem and the likely benefit of the digital health intervention, which in turn requires establishing the likely reach and uptake of the intervention, the causal model describing how the intervention will achieve its intended benefit, key components, and how they interact with one another, and estimating overall benefit in terms of effectiveness, cost effectiveness, and harms. Although RCTs are important for evaluation of effectiveness and cost effectiveness, they are best undertaken only when: (1) the intervention and its delivery package are stable; (2) these can be implemented with high fidelity; and (3) there is a reasonable likelihood that the overall benefits will be clinically meaningful (improved outcomes or equivalent outcomes at lower cost). Broadening the portfolio of research questions and evaluation methods will help with developing the necessary knowledge base to inform decisions on policy, practice, and research.

Development and technical functionality of an Internet-based intervention for tinnitus in the UK

PURPOSE

Creative approaches to improve access to evidence-based tinnitus treatments are required. The purpose of this study was to develop an Internet-based cognitive behavioural therapy (iCBT) intervention, for those experiencing tinnitus in the United Kingdom (UK). Furthermore, it aimed, through technical functionality testing, to identify specific aspects of the iCBT that require improving.

METHOD

An innovative iCBT intervention for treating tinnitus in the UK has been developed using a cognitive-behavioural theoretical framework. This iCBT was evaluated by two user groups during this developmental phase. Initially, five expert reviews evaluated the intervention, prior to evaluation by a group of 29 adults experiencing significant levels of tinnitus distress. Both groups evaluated iCBT in an independent measures design, using a specifically designed satisfaction outcome measure.

RESULTS

Overall, similar ratings were given by the expert reviewers and adults with tinnitus, showing a high level of satisfaction regarding the content, suitability, presentation, usability and exercises provided in the intervention. The iCBT intervention has been refined following technical functionality testing.

CONCLUSIONS

Rigorous testing of the developed iCBT intervention has been undertaken. These evaluations provide confidence that further clinical trials can commence in the UK, to assess the feasibility and effectiveness of this iCBT intervention for tinnitus.

Internet-Delivered Cognitive-Behavior Therapy for Tinnitus: A Randomized Controlled Trial

OBJECTIVES

Tinnitus has a substantially negative impact on quality of life in up to 5% of the general population. Internet-based cognitive-behavioral treatment (iCBT) has been shown to be effective in a few trials. The aim of our study was to investigate iCBT for tinnitus by using a randomized controlled trial.

METHODS

Patients with severe tinnitus-related distress were randomly assigned to therapist-guided iCBT (n = 62) or to a moderated online discussion forum (n = 62). Standardized self-report measures for tinnitus-related distress (Tinnitus Handicap Inventory, Mini-Tinnitus Questionnaire) and associated symptoms (tinnitus acceptance, anxiety, depression, and insomnia) were assessed at pretreatment and posttreatment, 6-month-, and 1-year follow-up. Clinical significance was assessed with the Reliable Change Index.

RESULTS

Multivariate analyses of variance revealed significant main effects for time, group, and interaction in favor of the iCBT group. With regard to tinnitus-related distress, the significant univariate interaction effects (time by group) were supported by large effect sizes (Tinnitus Handicap Inventory: g = 0.83, 95% confidence interval = 0.47-1.20; Mini-Tinnitus Questionnaire: g = 1.08, 95% confidence interval = 0.71-1.64). For the secondary outcomes, significant interactions with small to medium effect sizes were found. Within-group effects for the iCBT, from pretreatment to follow-up, were substantial in regard to tinnitus-related distress (1.38 ≤ d ≤ 1.81) and small to large for secondary outcomes (0.39 ≤ d ≤ 1.04).

CONCLUSIONS

Using a randomized controlled trial design, we replicated prior findings regarding positive effects of Internet-delivered CBT on tinnitus-related distress and associated symptoms. Implementing iCBT for tinnitus into regular health care will be an important next step to increase access to treatment for patients with tinnitus.

TRIAL REGISTRATION

ClinicalTrials.gov, Identifier: NCT01205919.

Understanding User Reactions and Interactions With an Internet-Based Intervention for Tinnitus Self-Management: Mixed-Methods Process Evaluation Protocol

Background

Tinnitus is a common medical symptom that can affect an individual’s emotional and functional quality of life. Psychological therapies are acknowledged as beneficial to people with tinnitus; however, such therapies are not always readily accessible. With their global reach, automated Internet-based interventions have the potential to reduce the disparity in access to psychological support that people with tinnitus currently experience. However, the evidence on the acceptability and efficacy of these interventions is lacking. Process evaluations that develop an in-depth understanding of how users experience these interventions provide an essential first step when evaluating complex psychological interventions.

Objective

To describe the protocol for a study that will explore past, current, and new users’ reactions to and interactions with the Tinnitus E-Programme, an Internet-based intervention for the self-management of tinnitus.

Methods

Two parallel mixed-methods studies will be carried out with 2 different populations. Study 1 will use an online survey to gather past and current users’ views of the program. Study 2 will recruit new program users to take part in an interview and complete a relaxation log to explore how well they were able to implement the skills they learned during the program in their everyday lives. The findings from both studies will be triangulated to develop an in-depth understanding of the program’s mechanisms of impact and identify any implementation or contextual factors that strengthen or impede its delivery and functioning.

Results

Study 1 is open for recruitment with a projected completion in June 2016 and Study 2 was completed November 2015. At the time of submission, 36 participants have been recruited to Study 1 and 12 participants have taken part in Study 2.

Conclusions

Findings will inform the optimization of the Tinnitus E-Programme and guide future evaluation work to assess the program’s effectiveness as a therapy for people with tinnitus.

The initial evaluation of an Internet-based support system for audiologists and first-time hearing aid clients

OBJECTIVES

Audiologists provide professional contact and support between appointments to clients with hearing impairment using telephone and e-mail, but more advanced and flexible technological platforms are also possible. The present study aimed to evaluate the clinical application of an Internet-based support system for audiologists and their first-time hearing aid clients.

DESIGN

An Internet-based support system developed by Månsson et al. (2013) for psychologists and their clients was adapted for audiologic purposes. Three audiologic clinics in Sweden tested the support system with their clients.

STUDY SAMPLE

Twenty-three clients managed by four audiologists used and evaluated the support system. In addition, five of the clients and all four audiologists were interviewed and their responses were analyzed using content analysis.

RESULTS

The clients and the audiologists reported positive experiences and overall satisfaction but audiologists reported that the support system did not address the needs of all clients. More positive experiences and greater satisfaction with the support system were associated with reductions on self-reported consequences of hearing loss and positive hearing aids outcomes.

CONCLUSIONS

An Internet-based support system can be used in audiologic rehabilitation. Both audiologists and clients recognized the system's potential value to offer an online support to the provision of audiologic services.

Clinician-Supported Internet-Delivered Psychological Treatment of Tinnitus

PURPOSE

Internet-delivered psychological treatments for tinnitus distress have existed for more than 15 years, and there are a slowly growing number of studies. The aim of this brief report is to review the evidence and to comment on the future potentials of Internet treatments for tinnitus.

METHOD

Studies were retrieved, and in total 6 controlled studies were included in the review with 9 different comparisons (6 in which the treatment was compared against a control group and 3 in which Internet treatment was compared against group treatment). Moreover, 2 open studies based on clinical samples in regular care were also included in the review. The outcomes for the 2 controlled sets of studies were analyzed using meta-analytic methods.

RESULTS

For the 6 studies comparing Internet treatment against a no-treatment control condition, a moderate effect size was found (Hedges's g = 0.58). The 3 studies comparing Internet treatment against face-to-face group treatments showed a small difference of Hedges's g =0.13.

CONCLUSIONS

Internet-delivered psychological treatment holds promise as a treatment alternative to other standard forms of treatment delivery, including group treatment. Larger studies are needed as well as ways to blend information technology with regular services.

The Process of Developing an Internet-Based Support System for Audiologists and First-Time Hearing Aid Clients

BACKGROUND

In audiologic practice, complementary information sources and access to the clinician between appointments improve information retention and facilitate adjustment behaviors. An Internet-based support system is a novel way to support information sharing and clinician access.

PURPOSE

This research forum article describes the process of developing an Internet-based support system for audiologists and their first-time hearing aid clients.

METHOD

The iterative development process, including revisions by 4 research audiologists and 4 clinical audiologists, is described. The final system is exemplified.

CONCLUSION

An Internet-based support system was successfully developed for audiologic practice.

The Application of Intervention Coding Methodology to Describe the Tinnitus E-Programme, an Internet-Delivered Self-Help Intervention for Tinnitus

PURPOSE

This article describes the Tinnitus E-Programme, a previously untested Internet-delivered self-help intervention for tinnitus.

METHOD

Intervention coding methodology was applied to describe the intervention components, techniques, and mode of delivery.

RESULTS

The intervention consists of 5 self-management intervention components, 5 behavior change techniques, and 3 modes of Internet delivery, which aim to promote relaxation behavior and reduce tinnitus distress.

CONCLUSIONS

The intervention coding provided a reliable method for reporting Internet-delivered self-help interventions. It will be used to facilitate our understanding of the intervention's potential mechanisms of change and will guide future evaluation work.

Internet-vs. group-delivered cognitive behavior therapy for insomnia: A randomized controlled non-inferiority trial

The aim of this study was to compare guided Internet-delivered to group-delivered cognitive behavioral therapy (CBT) for insomnia. We conducted an 8-week randomized controlled non-inferiority trial with 6-months follow-up. Participants were forty-eight adults with insomnia, recruited via media. Interventions were guided Internet-delivered CBT (ICBT) and group-delivered CBT (GCBT) for insomnia. Primary outcome measure was the Insomnia Severity Index (ISI), secondary outcome measures were sleep diary data, depressive symptoms, response- and remission rates. Both treatment groups showed significant improvements and large effect sizes for ISI (Within Cohen's d: ICBT post = 1.8, 6-months follow-up = 2.1; GCBT post = 2.1, 6-months follow-up = 2.2). Confidence interval of the difference between groups post-treatment and at FU6 indicated non-inferiority of ICBT compared to GCBT. At post-treatment, two thirds of patients in both groups were considered responders (ISI-reduction > 7p). Using diagnostic criteria, 63% (ICBT) and 75% (GCBT) were in remission. Sleep diary data showed moderate to large effect sizes. We conclude that both guided Internet-CBT and group-CBT in this study were efficacious with regard to insomnia severity, sleep parameters and depressive symptoms. The results are in line with previous research, and strengthen the evidence for guided Internet-CBT for insomnia.

TRIAL REGISTRATION

The study protocol was approved by, and registered with, the regional ethics review board in Linköping, Sweden, registration number 2010/385-31.

Internet-based guided self-help versus group cognitive behavioral therapy for chronic tinnitus: a randomized controlled trial

BACKGROUND

The aim of this randomized controlled trial was to investigate the effects of conventional face-to-face group cognitive behavioral therapy (GCBT) and an Internet-delivered guided self-help treatment (Internet-based CBT, ICBT) on tinnitus distress.

METHODS

A total of 128 adults with at least mild levels of chronic tinnitus distress were randomly assigned to GCBT (n = 43), ICBT (n = 41), or a web-based discussion forum (DF) that served as a control condition (n = 44). Standardized self-report measures [the Tinnitus Handicap Inventory (THI), Mini-Tinnitus Questionnaire (Mini-TQ), Hospital Anxiety and Depression Scale, Insomnia Severity Index and Tinnitus Acceptance Questionnaire] were completed at the pre- and post-assessments and at the 6-month follow-up.

RESULTS

Repeated-measures ANOVAs revealed significant time × group interaction effects on the primary outcomes (THI and Mini-TQ scores) in favor of both CBT interventions compared with the DF at post-assessment (0.56 ≤ g ≤ 0.93; all p ≤ 0.001). There were no significant differences between GCBT and ICBT (all p > 0.05) and the treatment effects remained stable at the 6-month follow-up.

CONCLUSIONS

This study provides evidence that ICBT might be an equally effective alternative to conventional CBT in the management of chronic tinnitus. Despite encouraging results, further research is necessary to determine the actual potential of ICBT as a viable alternative to CBT, and under which circumstances it is effective.