Dismantling internet-based cognitive behavioral therapy for tinnitus. The contribution of applied relaxation: A randomized controlled trial

Development and Psychometric Validation of Tinnitus Qualities and Impact Questionnaire

Background: To develop and validate the Tinnitus Qualities and Impact Questionnaire (TQIQ), a new tool for evaluating the perceived qualities of tinnitus sound. Method: The study was part of two clinical trials on internet-based tinnitus interventions, using cross-sectional (n = 380) and pretest-posttest data (n = 280). Participants completed various questionnaires online, including the newly developed TQIQ and measures of tinnitus severity (Tinnitus Functional Index; TFI), anxiety (Generalized Anxiety Disorder 7; GAD-7), depression (Patient Health Questionnaire 9; PHQ-9), insomnia (Insomnia Severity Index; ISI), and health-related quality of life (EQ-5D-5L Visual Analog Scale; VAS). The psychometric properties of the TQIQ were assessed, including construct validity, internal consistency reliability, floor and ceiling effects, interpretability, and responsiveness to treatment. Results: Exploratory factor analysis resulted in two factors that accounted for 57% of the variance-internal and external tinnitus qualities. Overall, 92% convergent validity predictions were confirmed; TQIQ total scores strongly (≥0.6) or moderately (0.30 to 0.59) correlated with the TFI, GAD-7, PHQ-9, and ISI. The known-groups validity prediction was confirmed as individuals with an overall TFI score > 50 (severe) obtained significantly higher TQIQ scores. All internal consistency reliability statistics were within the required range (Cronbach's α > 0.8). Floor and ceiling effects were negligible. ROC established clinically important cut-off scores, enhancing the interpretability of tinnitus severity classification. Finally, 89% convergent validity predictions were confirmed; TQIQ and TFI change scores were moderately correlated, indicating good responsiveness of the former to treatment. Conclusions: The TQIQ has adequate psychometric properties, providing a standardized measure for the assessment of characteristics of tinnitus sound in clinical practice.

Changes in Perceived Tinnitus Sound Qualities Following Internet-Based Cognitive Behavioral Therapy for Tinnitus

Background: To examine the changes in perceived tinnitus sound qualities following internet-based cognitive behavioral therapy (ICBT) for tinnitus. Method: This study was embedded within several clinical trials evaluating the efficacy of ICBT and used a quasi-experimental design (N = 152). Participants completed a series of online questionnaires, including measures of tinnitus sound qualities (Tinnitus Qualities and Impact Questionnaire; TQIQ), tinnitus severity (Tinnitus Functional Index; TFI), anxiety (Generalized Anxiety Disorder-7; GAD-7), depression (Patient Health Questionnaire-9; PHQ-9), insomnia (Insomnia Severity Index; ISI), and health-related quality of life (EQ-5D-5L Visual Analog Scale; VAS). Data were analyzed using a range of parametric and non-parametric statistics, and Cohen's d effect sizes were reported. Results: There were no significant differences between the intervention and control groups in sociodemographic and clinical variables at baseline except for anxiety and depression symptoms, which were higher in the intervention group. A statistically significant reduction in tinnitus severity, anxiety, depression, and insomnia was noted post-intervention, with small-to-moderate effect sizes. Statistically significant improvements were also noted for the TQIQ (overall and all subscales) following ICBT compared to the no-intervention group (p ≤ 0.028), all with small-to-large effect sizes, except for the loud sounds subscale and for participants with a TQIQ < 38 at baseline, or "mild" perceived qualities of tinnitus (p ≥ 0.136). A significantly greater proportion of participants in the intervention group had minimum clinically important differences (38%) on the TQIQ compared to the no-intervention group (9%). Conclusions: ICBT can lead to changes in the perceived qualities of tinnitus sound in addition to reducing tinnitus severity and other aspects, such as anxiety, depression, and insomnia. While these findings are preliminary, they highlight that tinnitus distress and perception may be related. However, the study has several limitations including a lack of audiological variables and objective measures. For this reason, the study results must be viewed with caution and must be treated as preliminary.

Do the effects of internet-delivered cognitive-behavioral therapy (i-CBT) last after a year and beyond? A meta-analysis of 154 randomized controlled trials (RCTs)

Although the short-term efficacy of internet-delivered cognitive-behavioral therapy (i-CBT) is well-established, its long-term efficacy remains understudied. Robust variance estimation meta-analysis was thus conducted across guided and self-guided i-CBT, synthesizing data from 154 randomized controlled trials (N = 45,335) with ≥ 12-month follow-ups. For binary outcomes, guided (52.3% vs. 38.6%; log-risk ratio [LOG-RR] = 1.15 95% confidence interval [1.04, 1.26]) yielded higher remission, reliable improvement, and response rates, and lower suboptimal treatment outcome rates (9.3% vs. 10.8%; LOG-RR = 0.63 [0.45, 0.80]) than treatment-as-usual, active controls, and waitlists at ≥12 months. Insufficient studies precluded testing the efficacy between self-guided i-CBT and controls for binary outcomes. For baseline-to-12-month dimensional outcomes, guided i-CBT produced greater reductions in anxiety, depressive, post-traumatic stress disorder (PTSD) symptoms, and repetitive negative thinking (Hedge's g = -1.86 to -0.31), and self-guided i-CBT yielded stronger reductions in depressive symptoms (g = -0.51) than all controls. For outcome scores aggregated at ≥ 12-month follow-ups, guided i-CBT alleviated anxiety, depression, distress, insomnia, PTSD symptoms, role impairment, emotion regulation, and quality of life (g = -0.31 to 0.26), and self-guided i-CBT yielded lower anxiety and depressive symptoms (g = -0.16 to -0.09) than all controls. No significant differences in efficacy emerged between guided and self-guided i-CBT when sufficient studies existed for a meta-analysis. There was no evidence for publication bias. Long-term efficacy was similar to short-term efficacy for most outcomes. Implementing scalable i-CBTs should entail transparency about their long-term benefits and drawbacks.

The Indirect Effect of an Internet-Based Intervention on Third-Party Disability for Significant Others of Individuals with Tinnitus

BACKGROUND

This study aimed to investigate whether Internet-based cognitive behavioural therapy intervention (ICBT) for individuals with tinnitus had an indirect effect on the third-party disability noticed by significant others (SOs).

METHODS

Significant Others Questionnaire (CTSOQ). Individuals with tinnitus completed standardized self-reported outcome measures for tinnitus severity, anxiety, depression, insomnia, hearing-related quality of life, tinnitus cognitions, hearing disability, and hyperacusis.

RESULTS

In total, 194 pairs of individuals with tinnitus and their SOs participated. The impact of third-party disability experienced by SOs was significantly reduced after individuals with tinnitus undertook the ICBT intervention (d = 0.41). This reduced SOs with severe difficulties from 52% to 35%. The remaining impact was mild for 30% and moderate for 35%. SOs with higher baseline difficulties and SOs who were partners (e.g., spouses) were less likely to notice indirect benefits from intervention undertaken by their family members. There was a moderate positive correlation between the post-intervention CTSOQs and the clinical variables of tinnitus severity and depression.

CONCLUSIONS

Third-party disability may be reduced as an indirect effect of individuals with tinnitus undertaking ICBT. Including SOs of individuals with tinnitus within the rehabilitation process may add additional benefits, and such involvement should be encouraged.

Individuals with Tinnitus Report More Positive Experiences following Internet-Based Cognitive Behavioral Therapy

BACKGROUND

This study aimed to examine whether individuals with chronic tinnitus report more positive experiences following internet-based cognitive behavioral therapy (CBT).

METHODS

A mixed-methods design was used, nested in clinical trials evaluating internet interventions for tinnitus. Participants (n = 164) completed online questionnaires (both structured and open-ended) providing demographic information as well as health variables (e.g., tinnitus distress, anxiety, depression, insomnia). An open-ended question listing positive effects or outcomes related to having tinnitus was also included. Responses to the open-ended questions were analyzed using qualitative content analysis.

RESULTS

Of the 164 eligible participants, 32.3% (n = 53) provided at least 1 positive experience both at pre- and post-intervention, with 9.1% (n = 19) providing positive experiences only at pre-intervention, 49 (29.9%) providing positive experiences only at post-intervention, and 28.7% (n = 47) of the participants did not provide any positive experiences on either measurement occasion. Significantly more positive experiences were reported following the intervention in the overall sample (p < 0.0001, paired sample t-test). In addition, participants who reported positive experiences in both pre- and post-intervention also reported more positive experiences following intervention (p = 0.008, paired sample t-test).

CONCLUSIONS

Internet-based CBT can help individuals with tinnitus to think more positively by changing unhelpful thought patterns. Open-ended questions can supplement structured questionnaires to measure treatment outcomes.

The positive side of living with tinnitus: a cross-sectional study

OBJECTIVE

The aim of the current study was to examine the presence of positive experiences reported by individuals with tinnitus in the United States.

DESIGN

The study used a cross-sectional survey design. The data were analysed using qualitative (content analysis) and quantitative (t-test or Chi-square test) analyses.

STUDY SAMPLE

Study participants were individuals participating in clinical trials involving Internet-based cognitive behavioural therapy (ICBT) for tinnitus. A total of 439 respondents, 211 (48.1%) male and 228 (51.9%) female responded, and data were collected via an online questionnaire.

RESULTS

Of the 439 participants, 164 (i.e. 37.4%) reported at least one positive experience. Younger participants and those with lower hearing disability were more likely to report positive experiences. The responses were categorised into six categories: Outlook (n = 139), Personal development (n = 42), Treatment-related (n = 42), Coping (n = 29), Support (n = 19), and Disease-specific (n = 19).

CONCLUSIONS

The ability of individuals with chronic tinnitus to identify positive experiences may give insights regarding acceptance and coping with tinnitus as well as the temperament of individuals reporting positive experiences. Considering these variables may help when planning individualised rehabilitation programs.

The Current State of Evidence Regarding Audiologist-Provided Cognitive Behavioural Therapy for the Management of Tinnitus: A Scoping Review

BACKGROUND

Cognitive behavioural therapy (CBT) for tinnitus management is effective and widely recommended by national and international practice guidelines. However, all the evidence for CBT so far has come from Psychologist-led programs, and the potential role of Audiologists in providing CBT for tinnitus remains an important consideration.

OBJECTIVES

This study sets out to systematically map the body of literature relating to Audiologist-provided CBT for tinnitus, in order to summarise the current state of evidence and determine directions for future research.

ELIGIBILITY CRITERIA

Sources were eligible for inclusion if they addressed the concept of Audiologist-provided CBT. No restrictions were imposed on the date of publication. Only sources published in English were included.

SOURCES OF EVIDENCE

A wide range of primary and secondary literature sources were sought.

CHARTING METHODS

Data from included sources were charted systematically using a pre-designed data charting form.

RESULTS

Of the 267 identified sources, 30 were included in this review. This included both primary and secondary literature sources. Primary sources were compared and showed variation across Audiologist-provided CBT programs both in terms of procedural details and from a research standpoint.

CONCLUSIONS

A growing body of evidence has addressed the concept of Audiologist-provided CBT. Directions for future research include further primary research with an increased focus on face-to-face Audiologist-provided CBT, and a comparison of the outcomes of Audiologist-provided vs. Psychologist-provided CBT.

Reply to Aldè et al. Comment on "Manchaiah et al. Social Representations of "Tinnitus" and "Health" among Individuals with Tinnitus Seeking Online Psychological Interventions. Audiol. Res. 2023, 13, 207-220"

We would like to thank Dr. Aldè and his colleuage's for their thoughtful comments [...].

Ecological momentary assessment and applied relaxation: Results of a randomized indicated preventive trial in individuals at increased risk for mental disorders

Applied Relaxation (AR) is an established behavioral mental health intervention, but its efficacy in real life contexts remains unclear. Using randomized controlled trial data, we examined whether AR can effectively reduce mental health problems in daily life. A sample of 277 adults with increased psychopathological symptoms but without 12-month DSM-5 mental disorders at study entry was randomly assigned to an intervention group receiving AR training (n = 139) and an assessment-only control group (n = 138). Ecological momentary assessments were used to assess psychological outcomes in daily life over a period of seven days at baseline, post, and 12-month follow-up, respectively. Multilevel analyses indicated that all psychopathological symptoms decreased more in the intervention group than in the control group from baseline to post (range β = -0.31 for DASS-depression to β = -0.06 for PROMIS-anger). However, from post to follow-up, psychopathological symptoms decreased more in the control group than in the intervention group, so that only the intervention effects for PROMIS-depression (β = -0.10) and PROMIS-anger (β = -0.09) remained until follow-up. Moreover, positive affect (β = 0.19), internal control beliefs (β = 0.15), favorable coping (β = 0.60), and unfavorable coping (β = -0.41) improved more in the intervention group than in the control group, and these effects were mostly maintained in the long term. Some effects were stronger among women, older individuals, and individuals with higher initial symptoms. These findings suggest that AR can effectively reduce mental health problems in daily life. Trial registration. The trial has been registered at ClinicalTrials.gov (NCT03311529).

Third-Party Disability for Significant Others of Individuals with Tinnitus: A Cross-Sectional Survey Design

There is currently increasing awareness of third-party disability, defined as the disability and functioning of a significant other (SO) due to a health condition of one of their family members. The effects of third-party disability on the SOs of individuals with tinnitus has received little attention. To address this knowledge gap, this study investigated third-party disability in the significant others (SOs) of individuals with tinnitus. A cross-sectional survey design included 194 pairs of individuals from the USA with tinnitus and their significant others. The SO sample completed the Consequences of Tinnitus on Significant Others Questionnaire (CTSOQ). Individuals with tinnitus completed standardized self-reported outcome measures for tinnitus severity, anxiety, depression, insomnia, hearing-related quality of life, tinnitus cognitions, hearing disability, and hyperacusis. The CTSOQ showed that 34 (18%) of the SOs were mildly impacted, 59 (30%) were significantly impacted, and 101 (52%) were severely impact. The clinical variables of tinnitus severity, anxiety, and hyperacusis in individuals with tinnitus were the best predictors of the impact of tinnitus on SOs. These results show that the SOs of individuals with tinnitus may experience third-party disability. The effect of the individual's tinnitus on their SO may be greater when the individual with tinnitus has a higher level of tinnitus severity, anxiety, and hyperacusis.

Social Representations of "Tinnitus" and "Health" among Individuals with Tinnitus Seeking Online Psychological Interventions

(1) Objective: Social representations theory (SRT) is a body of theory within social psychology concerned with how individuals, groups, and communities collectively make sense of socially relevant or problematic issues, ideas, and practices. SRT has been increasingly sued in the area of health and disability. The current study examined the social representations of "tinnitus" and "health" among individuals with tinnitus who are seeking online psychological interventions. (2) Materials/Method: The data were gathered using a free association task about their "tinnitus" and "health" from 399 individuals with tinnitus. The data were analyzed using both qualitative and quantitative analyses methods. (3) Results: The responses resulted in 39 and 30 categories respectively, for "tinnitus" and "health". The most commonly occurring categories for tinnitus included: descriptions of tinnitus (18%), annoying (13.5%), persistent (8%), and distracting (5%). The most commonly occurring categories for health included: content (12%), conditions (8%), active (7%), take control (6%), and overweight (5%). The responses to tinnitus had predominantly negative connotations (i.e., 76.9%) whereas a larger proportion of responses toward their health was related to positive connotations (i.e., 46.4%). These frequently occurring items were also dominant in similarities analysis. Prototypical analysis of tinnitus responses identified categories horrible and bothersome to be key items in the central zone. The categories in central zone of health responses included: content, active, healthy, grateful, and overweight. (4) Conclusions: Individuals with tinnitus have very negative view of their tinnitus impacting their psychological status. Tinnitus management should focus on reducing the negative associations toward their tinnitus and strengthen the positive aspects related to their general health.

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.

Long-term efficacy of audiologist-guided Internet-based cognitive behaviour therapy for tinnitus in the United States: A repeated-measures design

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.

Race/Ethnicity, Gender, and Socioeconomic Status Representation in U.S.-Based Randomized Controlled Trials of Tinnitus: A Systematic Review

PURPOSE

The purpose of this study was to investigate if peer-reviewed randomized controlled trials (RCTs) for the management/treatment of tinnitus conducted in the United States include diverse participants in terms of gender, race/ethnicity, education, occupation, and income.

METHOD

We performed a comprehensive and systematic literature search via PubMed, Web of Science, Clinical-Trials.gov, and the Cochrane Central Register of Controlled Trials. Our goal was to identify prospective RCTs of tinnitus intervention conducted in the United States from January 1994 to September 2021 and published in peer-reviewed journals.

RESULTS

A total of 2,584 studies were retrieved. Thirty-two peer-reviewed articles met all inclusion criteria. Of the included studies, approximately 96% reported participants' gender. Approximately 15% studies reported race/ethnicity information in alignment with the U.S. Census Bureau. However, an underrepresentation of both females and people of color was evident across studies. Reporting of socioeconomic status information of participants was also scarce, with only 25% studies reporting education and/or occupation of participants and 0% reporting income levels.

CONCLUSIONS

This study indicates underrepresentation and underreporting of diverse participant pools in tinnitus research. Reasons for such underrepresentation are explored. Additionally, this systematic review indicates that recent research in tinnitus portrays an optimistic trend in terms of reporting and recruitment of diverse participant groups. Sustainable strategies for including diverse research participants are essential for hearing health care equity. Research and strategies to promote this goal are discussed.

Experiential Characteristics among Individuals with Tinnitus Seeking Online Psychological Interventions: A Cluster Analysis

OBJECTIVE

This study was designed to gain insights regarding patterns of social representations (values, ideas, beliefs) of tinnitus and their relation to demographic and clinical factors.

METHOD

A cross-sectional survey design was used including 399 adults seeking help and reporting interest in internet-based cognitive behavior therapy for tinnitus. Data were collected using a free association task and analysis used qualitative (content analysis) and quantitative (cluster analysis and chi-square analysis) using the Iramuteq software.

RESULTS

The social representations identified the negative impact of tinnitus and included the way it sounded (descriptions of the way tinnitus sounds (18%), annoyance (13.5%), and persistence (8%)). Four clusters were identified representing four levels of tinnitus severity, namely debilitating tinnitus (24%), distressing tinnitus (10%), annoying tinnitus (46%), and accepting tinnitus (20%). Cluster identity was associated with demographic and clinical variables.

DISCUSSION

The identified clusters represented tinnitus severity experience in four stages, ranging from debilitating tinnitus to acceptance of tinnitus. These findings are important for clinical practice where tinnitus descriptions can indicate the stage of the tinnitus experience and which intervention pathway may be most appropriate.

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.

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.

The Effects of Tinnitus on Significant Others

Although chronic conditions could cause third-party disability for significant others (SOs), little is known regarding the impact of tinnitus on SO. This study aimed to identify the effects of tinnitus on SOs. SOs of individuals with tinnitus were invited to participate in this study. SOs completed three open-ended questions focusing on the effects of tinnitus. Individuals with tinnitus completed the Tinnitus Functional Index as a self-reported measure of tinnitus severity. A mixed-methods analysis approach was undertaken. Of the 156 SOs responding, 127 (85%) reported that tinnitus impacted them. The impact surrounded sound adjustments, activity limitations, additional demands, emotional toll, and helplessness. Tinnitus negatively affected the relationship for 92 (58%) due to communication frustrations and growing apart. When asked if tinnitus had any positive effects, 64 (47%) SOs reported positive lifestyle adaptions, personal development, health awareness, and a changed outlook. There was no association between the level of tinnitus severity and SOs reporting that tinnitus had an impact on them individually, their relationships, or those reporting positive experiences. The study highlighted the third-party disability many SOs of individuals with tinnitus experience. The results indicate that SOs may benefit from a shared intervention to help mitigate the negative effects through a better understanding of tinnitus.

Examining the consequences of tinnitus using the multidimensional perspective

BACKGROUND

Tinnitus is one of the most frequent chronic conditions in adults with wide range of consequences.

AIMS/OBJECTIVES

The aim of the current study was to determine the problems and life effects reported by individuals with tinnitus using the International Classification of Functioning, Disability and Health (ICF) framework.

MATERIAL AND METHODS

The study used a cross-sectional survey design. A total of 344 individuals with tinnitus completed a series of questionnaires. The responses to open-ended questions were linked to ICF categories.

RESULTS

Activity limitations and participation restrictions were most dominant consequence of tinnitus followed by effect on the body function with limited emphasis on the contextual factors. Frequently reported responses to body function involved emotional functions (b152), attention function (b140), and sleep functions (b134). Commonly reported responses to activity limitations and participation restrictions were recreation and leisure (d920), conversation (d350), communicating with-receiving-spoken messages (d310), listening (d115), and remunerative employment (d850). Sound intensity (e2500) and sound quality (e2501) were the frequently reported responses to environmental factors. Coping styles, past and present experiences, and lifestyle were the most frequently occurring personal factors.

CONCLUSIONS AND SIGNIFICANCE

The study highlighted some key influencing factors of tinnitus in different ICF domains which can be helpful in rehabilitation planning.

Development and psychometric validation of a questionnaire assessing the impact of tinnitus on significant others

INTRODUCTION

Despite evidence showing that tinnitus can have a detrimental impact on significant others (SOs), no standardized self-reported measure is currently available that specifically assesses the presence of third-party disability for tinnitus. The aim of this study was to develop and assess the psychometric properties of a newly developed self-reported measure for SOs of tinnitus and assess how scores could be meaningfully interpreted.

METHODS

The research consisted of two phases. During Phase I, the Consequences of Tinnitus on Significant Others Questionnaire (CTSOQ) was developed using the The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidance. Phase II included the assessment of psychometric properties of the CTSOQ including the construct validity, internal consistency, interpretability, and responsiveness. Pairs of 194 individuals with tinnitus and their SOs completed a series of online questionnaires. SOs completed the CTSOQ measure while individuals with tinnitus completed measures related to tinnitus distress, anxiety, depression, insomnia, and quality of life.

RESULTS

A 25 item CTSOQ was developed using a formative model. The questionnaire validation process indicated good psychometric properties with an internal consistency of 0.93 and inter-item correlation of 0.60. Support was found for the construct and discriminative validity of the measure. Floor and ceiling effects were negligible. Scores can be meaningfully interpreted to indicate mild, significant, or severe effect of tinnitus on SOs. The questionnaire was also found to be responsive to treatment-related changes.

CONCLUSIONS

The CTSOQ was found to have sufficient measurement properties suggesting that it is a suitable measure of third-party disability for SOs of individuals with tinnitus. Further research should be initiated to measure face validity and what scores reflect clinically meaningful change.

Medication Use Reported by Individuals With Tinnitus Who Are Seeking Internet-Based Psychological Interventions

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.

Patient Uptake, Experiences, and Process Evaluation of a Randomized Controlled Trial of Internet-Based Cognitive Behavioral Therapy for Tinnitus in the United States

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.

Exploratory Data Mining Techniques (Decision Tree Models) for Examining the Impact of Internet-Based Cognitive Behavioral Therapy for Tinnitus: Machine Learning Approach

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.

Internet-based cognitive behavioural therapy for tinnitus in Spanish: a global feasibility trial

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.

The Impact of COVID-19 and the Pandemic on Tinnitus: A Systematic Review

This review aimed to systematically review what has been published regarding tinnitus during the coronavirus disease 2019 (COVID-19) pandemic up to March 2021 by performing both narrative and quantitative meta-analyses. Of the 181 records identified, 33 met the inclusion criteria, which generally had a fair risk of overall bias. In the included, 28 studies focused on the impact of the COVID-19 virus on tinnitus and 5 studies focused on the impact of the pandemic on tinnitus. From the studies identifying the impact of COVID-19 on tinnitus, there were 17 cross-sectional studies (n = 8913) and 11 case series or case report studies (n = 35). There were 2 cross-sectional studies (n = 3232) and 3 pre-post-test design studies (n = 326) focusing on the impact of the pandemic on tinnitus. No consistent patterns were found regarding the presentation of the tinnitus or additional factors that could have tinnitus developing in the disease impact studies. For the pandemic impact studies, the associated stress and anxiety of the pandemic were consistently suggested to contribute to tinnitus experiences. The pooled estimated prevalence of tinnitus post COVID-19 was 8% (CI: 5 to 13%). Medical professionals should be aware that tinnitus might be more problematic following the pandemic or after having COVID-19.