Reevaluating the Use of Sound Therapy for Tinnitus Management: Perspectives on Relevant Systematic Reviews

PURPOSE

Tinnitus is a highly prevalent condition that can severely reduce health functioning. In spite of extant clinical practice guidelines (CPGs), implementation of these CPGs is relatively uncommon. As a result, patients seeking professional services for tinnitus often have no assurance of receiving evidence-based care. The purpose of this tutorial was to clarify the evidence for sound therapy so that it may be included in future CPGs for tinnitus.

METHOD

"Best clinical evidence" is obtained from high-quality systematic reviews, which are generally considered the highest level of evidence. Our review of recent, comprehensive, high-quality systematic reviews of interventions for tinnitus concludes that cognitive behavioral therapy is the only effective intervention, though the strength of evidence was generally rated as low in these reviews. Although trials of sound therapy for tinnitus have been included in these reviews, they have been rated as having high risk of bias (RoB) and not included in syntheses or rated as insufficient strength of evidence.

RESULTS

Conclusions from these and other reviews have influenced recommendations made in CPGs for tinnitus. These conclusions, however, can make it appear that an intervention for tinnitus is not effective, even if the opposite is true. We contend that the strict inclusion criteria for these reviews are counterproductive and have the effect of obscuring decades of evidence demonstrating the clinical effectiveness of sound therapies for tinnitus. Ultimately, this process has resulted in many patients not receiving sound therapy, despite what should be sufficient evidence that this is an effective form of intervention.

CONCLUSION

If we rely on systematic reviews using contemporary RoB assessment criteria for studies published prior to these reporting guidelines, then we risk excluding important conclusions regarding interventions that could help patients in need.

Attention Deficit Hyperactivity Disorder in Children and Adults: A Population Survey on Public Beliefs

Objective: To investigate beliefs and attitudes of the public toward attention deficit hyperactivity disorder (ADHD) in children and adults. Method: In a representative population survey in Germany (N = 1,008) using computer-assisted telephone interviews, we asked participants about causal beliefs, illness recognition, treatment recommendations, and beliefs about ADHD, presenting an unlabelled vignette of a child or an adult with ADHD. Results: The most frequently endorsed causal beliefs for the depicted child with ADHD were "TV or Internet," "lack of parental affection," and "broken home." In comparison with the child vignette, biological causal beliefs were endorsed more often after the adult vignette. In the child vignette, 66% advised against a treatment with stimulant medication. About 90% of respondents had heard of ADHD. Of those, 20% said they believed ADHD to be not a real disease. Conclusion: Beliefs of the German public partly contradict evidence and should be considered in therapeutical and public contexts.

Sound Therapy for Tinnitus: Options for Audiologists

Purpose

Sound therapy to reduce the emotional and functional effects of tinnitus has been used by audiologists since the 1970s when Jack Vernon introduced the masking method to provide a sense of relief from tinnitus distress. Our group renamed masking sound as “soothing” sound and distinguished it from “interesting” and “background” sound, each of which has a different purpose for tinnitus sound therapy. Other methods of sound therapy have the potential to reduce the “sensation” of tinnitus, including notched noise, matched noise, desynchronization, and residual inhibition. The purpose of this article is to provide an overview of the different sound therapy approaches to serve as a resource for audiologists who often provide sound therapy to their patients with tinnitus.

Conclusion

Although, according to systematic reviews, sound therapy does not have strong evidence for treatment of tinnitus, it is nonetheless well evidenced both through abundant research and clinical utilization mostly by audiologists. It is unknown if any one form of sound therapy is superior to any other.

Are the effects of methylphenidate uncertain?

OBJECTIVES

A recent systematic review and meta-analysis of randomised controlled trials of methylphenidate (MPH) in children and adolescents by a Cochrane group, led by Storebø, raised concern around the level of evidence supporting the use of this medication for attention-deficit/hyperactivity disorder (ADHD) in children and adolescents. This led to several critical responses from a number of ADHD experts.

METHODS

This paper reviews the conclusions reached from the Storebø meta-analysis by a critical analysis of methodologies used along with drawing on extant literature.

RESULTS

The controversy raised by the Cochrane meta-analysis should lead to a balanced reflection on the research priorities and needs for the field.

CONCLUSIONS

It is hoped the controversy will ultimately lead to improve the quality of the research on the efficacy, effectiveness and tolerability of MPH for ADHD.

Risk of Bias and Quality of Evidence for Treatment of ADHD With Stimulant Medication

Storebø et al. provide a concise summary of two Cochrane reviews about benefits and harms of treatment of attention-deficit/hyperactivity disorder (ADHD) with methylphenidate: (1) a review of 185 randomized controlled trials that estimated benefits (e.g., moderate-to-large reduction in teacher-rated ADHD symptoms) and (2) a review of 260 nonrandomized trials that estimated harms (e.g., infrequent serious but frequent nonserious adverse events). They also mention (without providing much detail) additional information from the structured Cochrane method about the risk for bias in the trials reviewed (assessed as being high) and quality of evidence of the outcomes considered (rated as being very low). This led to the conclusion that "the jury is still out on benefits and harms." A similar conclusion of the first review generated an extensive debate in the literature. Some details will be summarized and discussed herein to provide context in case the recent review and the summary by Storebø et al. revive the debate.

The Cochrane Collaboration withdraws a review on methylphenidate for adults with attention deficit hyperactivity disorder

A Cochrane systematic review on immediate-release methylphenidate for adults with attention deficit hyperactivity disorder (ADHD) was withdrawn from the Cochrane Library on 26 May 2016 after substantial criticism of its methods and flawed conclusions. Retraction of scientific papers on this basis is unusual but can be necessary. We provide a summary of the criticism that led to the withdrawal. We detail the methodological flaws of the withdrawn Cochrane systematic review and general issues of bias and shortcomings of the included ADHD trials: cross-over designs compared with parallel-group designs, exclusion of participants with psychiatric comorbidity, absence of 'functional outcomes' and use of clinical outcomes with limited relevance, short trial duration and small trial populations, broken blinding caused by easily recognisable side effects, combining outcome assessments by trial investigators and participants, outcome reporting bias, poor evaluation of cardiovascular and psychiatric harms and conflicts of interest of trialists and systematic reviewers. The withdrawal of the Cochrane systematic review signals recognition of previous unreliable clinical ADHD research. We conclude that clinical trials of immediate-release methylphenidate in adults with ADHD are of very low quality. We urgently need well-conducted long-term trials free of bias to assess the benefits and harms of central stimulant treatment in adult ADHD.

Attention-Deficit/Hyperactivity Disorder

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is a common, early-onset, persistent developmental disorder of childhood and adolescence, with a prevalence of approximately 5%.

METHODS

This article is based on publications retrieved by a selective search in PubMed with an emphasis on pertinent guidelines and systematic reviews.

RESULTS

At least 75% of affected children and adolescents develop a comorbid disorder, which impedes diagnosis and treatment and worsens prognosis. The etiology of ADHD is complex and heterogeneous, involving a major genetic component and diverse neurobiological alterations. Prenatal environmental factors also seem to elevate the risk of ADHD. The mainstays of treatment are psychoeducation, behavioral therapy, and psychoactive drugs, which generally have only mild side effects, such as insomnia or decreased appetite. The indication for treatment in the individual case is based on severity, comorbidity, previous therapy attempts, and the familial, social, and educational framework conditions.

CONCLUSION

Translational research is needed to clarify the etiology of ADHD. Epidemiological studies published since 1987 do not reveal any increase in the prevalence of ADHD among children and adolescents. Improved diagnosis necessitates an evidence-based and need-adapted approach to treatment.