Managing tinnitus: a comparison of different approaches to tinnitus management training

Long-term effects of a single psycho-educational session in chronic tinnitus patients

PURPOSE

To evaluate the effects of a single psycho-educational session on tinnitus burden in chronic tinnitus patients. The session is organized at a tertiary referral center for otologic disorders at the University Hospital Antwerp as a group session (maximum of 10-15 patients a time) lasting for approximately 3-4 h. The session focusses on different aspects of tinnitus.

METHODS

The current manuscript reports on 96 patients who completed the Tinnitus Functional Index (TFI), Visual Analogue Scale for mean loudness (VAS), Hyperacusis Questionnaire (HQ), and the Hospital Anxiety and Depression Scale (HADS) prior to treatment and at 6-month follow-up. The TFI was chosen as the primary outcome. Paired-samples T tests were performed to evaluate therapy effect at 6-month follow-up. In addition, a logistic regression model revealed baseline TFI/VAS scores and duration of tinnitus as contributing factors to a significant decrease of the TFI.

RESULTS

The TFI total score showed a significant decrease (p < 0.001) at the 6-month follow-up time point. At follow-up, 75% of patients reported their tinnitus to be under control not requiring any additional treatment. The logistic regression model showed that patients with higher baseline TFI scores, lower baseline mean VAS loudness ratings, and shorter tinnitus duration were more likely to show clinically significant improvement on the TFI scale.

CONCLUSIONS

Tinnitus Retraining Therapy or Cognitive Behavioural Therapy are effective, though very time-consuming and expensive treatments. A single psycho-educational group session was shown to be highly effective in decreasing the tinnitus burden, which increases feasibility and cost-effectiveness.

TRIAL REGISTRATION

Not applicable as this is a retrospective reporting of tinnitus outcome in the daily clinical practice, not a clinical trial.

Effect of educational counseling alone on people with tinnitus: Meta-analysis of randomized controlled trials

OBJECTIVE

To review and meta-analyze the efficacy of educational counseling alone in tinnitus.

METHODS

We collected randomized controlled trials (RCTs) adhered to PRISMA guidelines. Analyzed the effect of educational counseling alone versus other forms of therapy (psychological or combination) with RevMan 5.3.

RESULTS

In nine trials, 582 patients receiving educational counseling alone and 759 patients receiving other psychological or combination therapies. During the 3-6 months follow-up, there was no significant difference in the tinnitus recovery rate between these two groups (OR 0.62, 95% CI 0.34-1.16, P = 0.14; I² = 71%, P = 0.00, random-effects model). The tinnitus symptom severity rates were also similar during 1-12 months follow-up (mean difference, 3.59, 95% CI -0.56-7.74, P = 0.09) with heterogeneity among studies (I² = 74%, P = 0.00; random-effects model). Sensitivity analysis indicated that a single trial containing almost 40% of the patients was the cause of heterogeneity. There was no significant change in tinnitus loudness at the 3 months follow-up (OR 0.84, 95% CI 0.42-1.66, P = 0.61), with no significant heterogeneity (I² = 0%, P = 0.60).

CONCLUSION

Educational counseling alone helps to improve tinnitus and related problems, and has the same effect as other psychological or combination therapies.

PRACTICE IMPLICATIONS

The results of the current analysis may help to develop evidence-based cost-effective treatment(s) for tinnitus, which will be minimally burdensome for the patients.

Psychological Therapy for People with Tinnitus: A Scoping Review of Treatment Components

Supplemental Digital Content is available in the text.

Background:

Tinnitus is associated with depression and anxiety disorders, severely and adversely affecting the quality of life and functional health status for some people. With the dearth of clinical psychologists embedded in audiology services and the cessation of training for hearing therapists in the UK, it is left to audiologists to meet the psychological needs of many patients with tinnitus. However, there is no universally standardized training or manualized intervention specifically for audiologists across the whole UK public healthcare system and similar systems elsewhere across the world.

Objectives:

The primary aim of this scoping review was to catalog the components of psychological therapies for people with tinnitus, which have been used or tested by psychologists, so that they might inform the development of a standardized audiologist-delivered psychological intervention. Secondary aims of this article were to identify the types of psychological therapy for people with tinnitus, who were reported but not tested in any clinical trial, as well as the job roles of clinicians who delivered psychological therapy for people with tinnitus in the literature.

Design:

The authors searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; Cochrane Central Register of Controlled Trials; PubMed; EMBASE; CINAHL; LILACS; KoreaMed; IndMed; PakMediNet; CAB Abstracts; Web of Science; BIOSIS Previews; ISRCTN; ClinicalTrials.gov; IC-TRP; and Google Scholar. In addition, the authors searched the gray literature including conference abstracts, dissertations, and editorials. No records were excluded on the basis of controls used, outcomes reached, timing, setting, or study design (except for reviews—of the search results. Records were included in which a psychological therapy intervention was reported to address adults (≤18 years) tinnitus-related distress. No restrictive criteria were placed upon the term tinnitus. Records were excluded in which the intervention included biofeedback, habituation, hypnosis, or relaxation as necessary parts of the treatment.

Results:

A total of 5043 records were retrieved of which 64 were retained. Twenty-five themes of components that have been included within a psychological therapy were identified, including tinnitus education, psychoeducation, evaluation treatment rationale, treatment planning, problem-solving behavioral intervention, thought identification, thought challenging, worry time, emotions, social comparison, interpersonal skills, self-concept, lifestyle advice, acceptance and defusion, mindfulness, attention, relaxation, sleep, sound enrichment, comorbidity, treatment reflection, relapse prevention, and common therapeutic skills. The most frequently reported psychological therapies were cognitive behavioral therapy, tinnitus education, and internet-delivered cognitive behavioral therapy. No records reported that an audiologist delivered any of these psychological therapies in the context of an empirical trial in which their role was clearly delineated from that of other clinicians.

Conclusions:

Scoping review methodology does not attempt to appraise the quality of evidence or synthesize the included records. Further research should therefore determine the relative importance of these different components of psychological therapies from the perspective of the patient and the clinician.

Mining and analysis of audiology data to find significant factors associated with tinnitus masker

Objectives

The objective of this research is to find the factors associated with tinnitus masker from the literature, and by using the large amount of audiology data available from a large NHS (National Health Services, UK) hearing aid clinic. The factors evaluated were hearing impairment, age, gender, hearing aid type, mould and clinical comments.

Design

The research includes literature survey for factors associated with tinnitus masker, and performs the analysis of audiology data using statistical and data mining techniques.

Setting

This research uses a large audiology data but it also faced the problem of limited data for tinnitus.

Participants

It uses 1,316 records for tinnitus and other diagnoses, and 10,437 records of clinical comments from a hearing aid clinic.

Primary and secondary outcome measures

The research is looking for variables associated with tinnitus masker, and in future, these variables can be combined into a single model to develop a decision support system to predict about tinnitus masker for a patient.

Results

The results demonstrated that tinnitus maskers are more likely to be fit to individuals with milder forms of hearing loss, and the factors age, gender, type of hearing aid and mould were all found significantly associated with tinnitus masker. In particular, those patients having Age < =55 years were more likely to wear a tinnitus masker, as well as those with milder forms of hearing loss. ITE (in the ear) hearing aids were also found associated with tinnitus masker. A feedback on the results of association of mould with tinnitus masker from a professional audiologist of a large NHS (National Health Services, UK) was also taken to better understand them. The results were obtained with different accuracy for different techniques. For example, the chi-squared test results were obtained with 95% accuracy, for Support and Confidence only those results were retained which had more than 1% Support and 80% Confidence.

Conclusions

The variables audiograms, age, gender, hearing aid type and mould were found associated with the choice of tinnitus masker in the literature and by using statistical and data mining techniques. The further work in this research would lead to the development of a decision support system for tinnitus masker with an explanation that how that decision was obtained.

Sound therapy (masking) in the management of tinnitus in adults

BACKGROUND

This is an update of a Cochrane Review first published in The Cochrane Library in Issue 12, 2010.Tinnitus is described as the perception of sound or noise in the absence of real acoustic stimulation. Numerous management strategies have been tried for this potentially debilitating, heterogeneous symptom. External noise has been used as a management tool for tinnitus, in different capacities and with different philosophical intent, for over a century.

OBJECTIVES

To assess the effectiveness of sound-creating devices (including hearing aids) in the management of tinnitus in adults. Primary outcome measures were changes in the loudness or severity of tinnitus and/or impact on quality of life. Secondary outcome measures were change in pure-tone auditory thresholds and adverse effects of treatment. 

SEARCH METHODS

We searched the Cochrane ENT Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 8 February 2012.

SELECTION CRITERIA

Prospective randomised controlled trials recruiting adults with persistent, distressing, subjective tinnitus of any aetiology in which the management strategy included maskers, noise-generating device and/or hearing aids, used either as the sole management tool or in combination with other strategies, including counselling.

DATA COLLECTION AND ANALYSIS

Two authors independently examined the 387 search results to identify studies for inclusion in the review, of which 33 were potentially relevant. The update searches in 2012 retrieved no further potentially relevant studies. Both authors extracted data independently.

MAIN RESULTS

Six trials (553 participants) are included in this review. Studies were varied in design, with significant heterogeneity in the evaluation of subjective tinnitus perception, with different scores, scales, tests and questionnaires as well as variance in the outcome measures used to assess the improvement in tinnitus sensation/quality of life. This precluded meta-analysis of the data. There was no long-term follow-up. We assessed the risk of bias as medium in three and high in three studies. Following analysis of the data, no significant change was seen in the loudness of tinnitus or the overall severity of tinnitus following the use of sound therapy compared to other interventions such as patient education, 'relaxation techniques', 'tinnitus coping strategies', counselling, 'tinnitus retraining' and exposure to environmental sounds. No side effects or significant morbidity were reported from the use of sound-creating devices.

AUTHORS' CONCLUSIONS

The limited data from the included studies failed to show strong evidence of the efficacy of sound therapy in tinnitus management. The absence of conclusive evidence should not be interpreted as evidence of lack of effectiveness. The lack of quality research in this area, in addition to the common use of combined approaches (hearing therapy plus counselling) in the management of tinnitus are, in part, responsible for the lack of conclusive evidence. Other combined forms of management, such as tinnitus retraining therapy, have been subject to a Cochrane Review. Optimal management may involve multiple strategies.

Melatonin: Can it Stop the Ringing?

Objectives:

We sought to report the efficacy of oral melatonin as treatment for chronic tinnitus and to determine whether particular subsets of tinnitus patients have greater benefit from melatonin therapy than others.

Methods:

This was a prospective, randomized, double-blind, crossover clinical trial in an ambulatory tertiary referral otology and neurotology practice. Adults with chronic tinnitus were randomized to 3 mg melatonin or placebo nightly for 30 days followed by a 1-month washout period. Each group then crossed into the opposite treatment arm for 30 days. The tests audiometric tinnitus matching (TM), Tinnitus Severity Index (TSI), Self Rated Tinnitus (SRT), Pittsburgh Sleep Quality Index (PSQI), and Beck Depression Inventory (BDI) were administered at the outset and every 30 days thereafter to assess the effects of each intervention.

Results:

A total of 61 subjects completed the study. A significantly greater decrease in TM and SRT scores (p < 0.05) from baseline was observed after treatment with melatonin relative to the effect observed with placebo. Male gender, bilateral tinnitus, noise exposure, no prior tinnitus treatment, absence of depression and/or anxiety at baseline, and greater pretreatment TSI scores were associated with a positive response to melatonin. Absence of depression and/or anxiety at baseline, greater pretreatment TSI scores, and greater pretreatment SRT scores were found to be positively associated with greater likelihood of improvement in both tinnitus and sleep with use of melatonin (p < 0.05).

Conclusions:

Melatonin is associated with a statistically significant decrease in tinnitus intensity and improved sleep quality in patients with chronic tinnitus. Melatonin is most effective in men, those without a history of depression, those who have not undergone prior tinnitus treatments, those with more severe and bilateral tinnitus, and those with a history of noise exposure.

A randomized controlled trial of mindfulness-based cognitive therapy for treating tinnitus

We conducted a randomized clinical trial to examine the relative effectiveness of two psychological interventions for treating tinnitus. People with tinnitus were initially offered a single session of psychoeducation about tinnitus, followed 2 months later by six weekly sessions of either mindfulness or relaxation training. Results indicated benefits from psychoeducation in reducing negative emotions, rumination and psychological difficulties of living with tinnitus. These effects were maintained or enhanced by mindfulness training that also emphasized acceptance, although they were eroded in the relaxation condition over the follow-up. Mediating processes are discussed, and suggestions for refining clinical interventions for this population are offered.

KEY PRACTITIONER MESSAGE

The present results suggest that mindfulness training might constitute a useful addition to psychoeducation for interventions targeting the psychological consequences of tinnitus.

Is tinnitus an acoasm?

Tinnitus and unspecific auditory hallucinations generally known as acoasms arise from identical or at least similar cerebral structures. Both phenomena can be interpreted as signs of an over activation of neuronal networks. Several pieces of evidence to underline this hypothesis as well as its implications are discussed. It is even speculated that both clinical entities might profit from treatment strategies that are normally employed for treatment of the other.

Sound therapy (masking) in the management of tinnitus in adults

BACKGROUND

Tinnitus is described as the perception of sound or noise in the absence of real acoustic stimulation. Numerous management strategies have been tried for this potentially debilitating, heterogeneous symptom. External noise has been used as a management tool for tinnitus, in different capacities and with different philosophical intent, for over a century.

OBJECTIVES

To assess the effectiveness of sound-creating devices (including hearing aids) in the management of tinnitus in adults. Primary outcome measures were changes in the loudness or severity of tinnitus and/or impact on quality of life. Secondary outcome measures were change in pure-tone auditory thresholds and adverse effects of treatment. 

SEARCH STRATEGY

We searched the Cochrane ENT Group Trials Register; CENTRAL (2009, Issue 3); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; mRCT and additional sources for published and unpublished trials. The date of the most recent search was 11 September 2009.

SELECTION CRITERIA

Prospective randomised controlled trials recruiting adults with persistent, distressing, subjective tinnitus of any aetiology in which the management strategy included maskers, noise-generating device and/or hearing aids, used either as the sole management tool or in combination with other strategies, including counselling.

DATA COLLECTION AND ANALYSIS

Two authors independently examined the 362 search results to identify studies for inclusion in the review, of which 33 were potentially relevant. Both authors extracted data independently.

MAIN RESULTS

Six trials (553 participants) are included in this review. Studies were varied in design, with significant heterogeneity in the evaluation of subjective tinnitus perception, with different scores, scales, tests and questionnaires as well as variance in the outcome measures used to assess the improvement in tinnitus sensation/quality of life. This precluded meta-analysis of the data. There was no long-term follow up. We assessed the risk of bias as medium in three and high in three studies. No side effects or significant morbidity were reported from the use of sound-creating devices.

AUTHORS' CONCLUSIONS

The limited data from the included studies failed to show strong evidence of the efficacy of sound therapy in tinnitus management. The absence of conclusive evidence should not be interpreted as evidence of lack of effectiveness. The lack of quality research in this area, in addition to the common use of combined approaches (hearing therapy plus counselling) in the management of tinnitus are, in part, responsible for the lack of conclusive evidence. Other combined forms of management, such as Tinnitus Retraining Therapy, have been subject to a Cochrane Review. Optimal management may involve multiple strategies.

Results of TRT after eighteen months: Our experience

The aim of this study was to evaluate the efficacy of TRT in patients suffering from tinnitus. The tinnitus disorder affects about 10-15% of the population and, in one person out of a hundred, it is a disabling disorder. TRT treatment is based on Jastreboff's neurophysiological model. TRT consists of two parts: counselling, and sound therapy by means of dedicated hearing aids and sound generators. It proved to be useful to reduce the symptoms related to tinnitus. Jastreboff's structured interviews were proposed to a sample of 51 patients with tinnitus belonging to the I-II-III-IV classes according to Jastreboff. These patients were treated for 18 months. Sixty-eight percent of patients reported a reduction in the symptoms related to tinnitus, such as sleep disturbance, problems in concentration, and inability to relax. A percentage (64.7%) of patients thought that their quality of life was improved. Patients who had suffered from tinnitus for less than one year achieved significantly better results than patients who had suffered for a longer period of time. TRT is an effective tool in the treatment of tinnitus.

Use of bedside sound generators by patients with tinnitus-related sleeping difficulty: which sounds are preferred and why?

CONCLUSIONS

Most tinnitus patients who have difficulty sleeping experience some improvement in sleep after short-term use of bedside sound generators (BSSGs), although this study does not allow conclusions to be drawn as to how much other factors contribute. Many patients seem to find BSSGs helpful in reducing autonomic arousal. Further research is needed, but these findings raise the possibility that the emotional effects of sound enrichment have an important role to play in improving sleep among tinnitus patients.

OBJECTIVES

This study investigated which sounds out of the options available on BSSGs are commonly chosen by patients and the reasons behind these choices. It also aimed to provide an indication as to whether BSSGs improve sleep quality in the short term.

PATIENTS AND METHODS

A consecutive series of 39 tinnitus clinic patients who made a subjective complaint of sleep disturbance took part in the study. All participants were given a Naturecare BSSG to use at night. The Pittsburgh Sleep Quality Index (PSQI) and a semi-structured interview were used as outcome measures.

RESULTS

Among the 35 participants who attended for follow-up there was a significant improvement in PSQI scores (p=0.001). 'Brook' and 'birds' were the most popular sounds, while 'white noise' proved the least popular. Most BSSG users listened to one sound only and most said that they chose their sound because of a pleasant emotional effect. A minority gave the quality of sound or its perceived effect on tinnitus as a reason for their choice.

Joint medico-psychological consultation for patients suffering from tinnitus

Because no effective treatment against tinnitus is available, all sorts of approaches have been developed. We believe the care of tinnitus patients concerns mainly ENT medical doctors. In order to take care of such patients, we started in 1993 a joint medico-psychological consultation (JMPC) to dispense adequate care for patients and training to the ENT residents. Every patient visiting our clinic for a tinnitus consultation benefits first from a comprehensive audiological examination. Once all objective causes of tinnitus are excluded, those patients who were not able to accept their auditory disorder or who insist on focusing on the annoyance caused by the perception of their tinnitus are invited by the doctor to the JMPC. The intolerance caused by tinnitus is enhanced by psychological and social aspects. These aspects are considered and discussed during the JMPC. The patients talk about their tinnitus bringing additional information on professional, familial and relational issues. In the JMPC, the therapists try to help the patients to void the affective irritation and the internal tension they clearly demonstrate. When the patients notice that the therapists accept their distress, they usually talk more calmly about their hearing irritation and even consider it tolerable. The medical and psychological information given during the JMPC helps the patients to understand the links between tinnitus and the disturbing elements of their current life. During the JMPC, the medical residents have been able to observe how somatic complaints can lead to complaints of another nature, to distress, to aggressive or angered behaviors. They have acknowledged the way the psychologist deals with the attitudes of these patients. This learning process became mandatory to all our residents specializing in ENT. At the end of their training they should have learned how to help the patient accept the tinnitus and the irritation it causes. They should be able to help tinnitus patients to stop searching for a treatment that does not exist in the so-called specialized centers, which often do not fulfill their expectations.

Long-term effectiveness of ear-level devices for tinnitus

OBJECTIVE

This study was undertaken to assess long-term changes in tinnitus severity exhibited by patients who purchased and used ear-level devices (hearing aids or sound generators).

STUDY DESIGN AND SETTING

Patients were evaluated and treated within a comprehensive tinnitus management program. Follow-up questionnaires were mailed to patients 6 to 48 months after their initial appointment.

RESULTS

Follow-up questionnaires from 150 patients were reviewed. Fifty patients purchased and used hearing aids, 50 patients purchased and used in-the-ear sound generators for an average of 18 months after their initial appointment; 50 patients did not use ear-level devices. At follow-up, all 3 groups of patients exhibited significant reductions in Tinnitus Severity Index scores and self-rated tinnitus loudness. Patients who used ear-level devices reported greater improvement than patients who did not use hearing aids or sound generators.

CONCLUSIONS

Ear-level devices such as hearing aids or sound generators can help a significant number of patients who experience chronic tinnitus. Both types of devices reduce patients' perception of tinnitus and can facilitate habituation to the symptom. Amplification provides additional benefits of improved hearing and communication.

Does sound stimulation have additive effects on cognitive-behavioral treatment of chronic tinnitus?

Psychological and physiological habituation are major goals in the treatment of patients suffering from chronic tinnitus. This study evaluates whether sound stimulation provided by use of low level white noise generators (NG) enhances the effects of cognitive-behavioral treatment (CBT). 124 outpatients with tinnitus of >6 months received manualized group treatment and were randomly assigned to the NG/no NG conditions. Those with moderate tinnitus-related distress obtained four sessions focusing on education, while severely distressed subjects were treated according to a full 10-session CBT program. Outcome was assessed at post-treatment and at 6- and 18-month follow-up. No additive effects due to the NGs could be demonstrated. All groups improved significantly on measures of tinnitus-related distress, dysfunctional cognitions, general psychopathology, depression, hypochondriasis and psychosocial functioning. Beneficial effects of the NGs were only observed for patients with concurrent tinnitus and hyperacusis. As systematic physical stimulation of the auditory system does not further improve the effects of CBT, the importance and strength of psychological interventions are emphasized. The clinical relevance of recently developed "retraining" approaches accentuating physical stimulation should be reconsidered.

SSRI use by Tinnitus Patients: Interactions between Depression and Tinnitus Severity

Depression is often coincident with chronic tinnitus, and several studies have suggested that antidepressant medications may play a role in relieving tinnitus as well as depression. We conducted a retrospective study of the use of selective serotonin reuptake inhibitors (SSRIs) by patients at a large tinnitus clinic to assess the effects of these antidepressants on tinnitus severity. We focused on a subgroup of 30 patients with depression who had begun taking SSRI medication after the onset of their tinnitus; these patients had also been treated with psychotherapy by a mental health clinician. At a mean follow-up of 20.6 months, only 10 of the 30 patients reported that they were still experiencing major depression. Moreover, this group as a whole demonstrated a statistically significant improvement in tinnitus symptoms as reflected by a reduction in their Tinnitus Severity Index scores. We conclude that SSRIs represent one category of tools that can be used to help patients with severe tinnitus and depression. Like all antidepressant medications, SSRIs should be used in conjunction with psychotherapy to facilitate patient improvement.

Differential changes in Fos-immunoreactivity at the auditory brainstem after chronic injections of salicylate in rats

In human, salicylate-induced tinnitus sometimes occurs a few days after its administration, but the chronic effects of salicylate in animal models are not fully known. In this study, we revealed the distribution of active cells in the rat auditory brainstem by staining an activity marker Fos-protein after multiple daily injections of salicylate. Experimental animals were first given five daily doses of sodium salicylate (250 mg/kg, i.p.). On day 6 they were placed inside a sound room for 8 h before sacrifice. Immunohistochemistry showed a significant increase in the number of Fos-positive cells at the inferior colliculus (IC), particularly its central division. At the cochlear nucleus (CN), only a few Fos-stains were found at the dorsal nucleus while no Fos-stain appeared at the ventral nucleus. The scarcity of Fos-stains at the CN reflected more a lack of external sound inputs than an adaptation in Fos-expression. Since Fos-stains in CN could still be induced on day 6 following brief tonal stimulation. Results are consistent with the hypothesis that salicylate-induced tinnitus is a phantom sound perception related to overactivity of cells at the IC.

Long-term reductions in tinnitus severity

BACKGROUND: This study was undertaken to assess long-term changes in tinnitus severity exhibited by patients who completed a comprehensive tinnitus management program; to identify factors that contributed to changes in tinnitus severity within this population; to contribute to the development and refinement of effective assessment and management procedures for tinnitus. METHODS: Detailed questionnaires were mailed to 300 consecutive patients prior to their initial appointment at the Oregon Health & Science University Tinnitus Clinic. All patients were then evaluated and treated within a comprehensive tinnitus management program. Follow-up questionnaires were mailed to the same 300 patients 6 to 36 months after their initial tinnitus clinic appointment. RESULTS: One hundred ninety patients (133 males, 57 females; mean age 57 years) returned follow-up questionnaires 6 to 36 months (mean = 22 months) after their initial tinnitus clinic appointment. This group of patients exhibited significant long-term reductions in self-rated tinnitus loudness, Tinnitus Severity Index scores, tinnitus-related anxiety and prevalence of current depression. Patients who improved their sleep patterns or Beck Depression Inventory scores exhibited greater reductions of tinnitus severity scores than patients who continued to experience insomnia and depression at follow-up. CONCLUSIONS: Individualized tinnitus management programs that were designed for each patient contributed to overall reductions in tinnitus severity exhibited on follow-up questionnaires. Identification and treatment of patients experiencing anxiety, insomnia or depression are vital components of an effective tinnitus management program. Utilization of acoustic therapy also contributed to improvements exhibited by these patients.

Human factors issues in ventricular assist device recipients and their family caregivers

Ultimately, for ventricular assist devices (VADs) to be acceptable as permanent alternatives to heart transplantation, patients' and their families' satisfaction with specific features and risks of VADs must be addressed. Of 42 eligible patients who received VADs between February of 1996 and December of 1998, we interviewed 37 patients (17 Novacor, 18 Thoratec, 2 with both devices) and 20 of their primary family caregivers about device related concerns and reactions. Demographic and health related correlates of respondents' concerns were examined. Eleven patients discharged from the hospital with the VAD in place were then reinterviewed 1 month after discharge. At baseline, patients' general perceptions of the VAD were positive, although 22-52% reported specific concerns, including most often worry about infection (52%), difficulty sleeping due to the position of the driveline (52%), pain at the driveline exit site (46%), worry about device malfunction (40%), and being bothered during the day by device noise (32%). The prevalence of most concerns rose with duration of VAD support. Caregivers' perceptions did not differ significantly from patients' perceptions. Outpatients were somewhat more concerned than inpatients about device noise and risk of stroke, but were markedly less concerned about infection. Across all patients, higher levels of device related concerns were correlated with more physical functional limitations and more psychological distress, and reduced quality of life. Demographic characteristics and device type were not uniformly related to device concerns.

A review of randomized clinical trials in tinnitus

OBJECTIVES

Review reports of randomized clinical trials (RCTs) in tinnitus to identify well-established treatments, promising developments, and opportunities for improvement in this area of clinical research.

STUDY DESIGN

Literature review of RCTs (1964-1998) identified by MEDLINE and OLD MEDLINE searches and personal files.

METHODS

Studies were compared with the RCT criteria of Guyatt et al. for quality of design, performance, and analysis; "positive" results were critically examined for potential clinical relevance.

RESULTS

Sixty-nine RCTs evaluated tocainide and related drugs, carbamazepine, benzodiazepines, tricyclic antidepressants, 16 miscellaneous drugs, psychotherapy, electrical/magnetic stimulation, acupuncture, masking, biofeedback, hypnosis, and miscellaneous other nondrug treatments. No treatment can yet be considered well established in terms of providing replicable long-term reduction of tinnitus impact, in excess of placebo effects.

CONCLUSIONS

Nonspecific support and counseling are probably helpful, as are tricyclic antidepressants in severe cases. Benzodiazepines, newer antidepressants, and electrical stimulation deserve further study. Future tinnitus therapeutic research should emphasize adequate sample size, open trials before RCTs, careful choice of outcome measures, and long-term follow-up.

A meta-analytic review of psychological treatments for tinnitus

Meta-analysis is a technique of combining results from different trials in order to obtain estimates of effects across studies. Meta-analysis has, as yet, rarely been used in audiological research. The aim of this paper was to conduct a meta-analysis on psychological treatment of tinnitus. The outcomes of 18 studies, including a total of 24 samples and up to 700 subjects, were included and coded. Included were studies on cognitive/cognitive-behavioural treatment, relaxation, hypnosis, biofeedback, educational sessions and problem-solving. Effect sizes for perceived tinnitus loudness, annoyance, negative affect (e.g. depression) and sleep problems were calculated for randomized controlled studies, pre-post-treatment design studies and follow-up results. Results showed strong to moderate effects on tinnitus annoyance for controlled studies (d = 0.86), pre-post designs (d = 0.5) and at follow-up (d = 0.48). Results on tinnitus loudness were weaker and disappeared at follow-up. Lower effect sizes were also obtained for measures of negative affect and sleep problems. Exploratory analyses revealed that cognitive-behavioural treatments were more effective on ratings of annoyance in the controlled studies. It is concluded that psychological treatment for tinnitus is effective, but that aspects such as depression and sleep problems may need to be targeted in future studies.

The influence of training on tinnitus perception: an evaluation 12 months after tinnitus management training

Sixty-five subjects were reviewed 12 months after tinnitus management training, which had been comprised variously of information, relaxation training and a therapeutic noise strategy. Seventy-four per cent of subjects reported increased habituation to tinnitus (n = 48), 65% reported reduced tinnitus annoyance (n = 42), and 52% reported an increased ability to cope with tinnitus (n = 34). Twenty-five per cent of subjects reported deterioration in coping ability (n = 16), 23% reported reduced habituation to tinnitus (n = 15) and 8% reported increased tinnitus-related annoyance (n = 5). None of the management strategies were found to be significantly more effective than others in facilitating improved coping or habituation to tinnitus. Subjects who reported reduced coping and habituation to tinnitus experienced greater levels of general life stress than subjects who reported increased habituation and coping ability. The use of relaxation therapies as applied in this study did not appear to influence the level of tinnitus distress or the level of life stress. Thirty-seven per cent of subjects given long-term low-level white noise (LTWN) stimulation reported benefit. However, LTWN stimulation did not significantly alter tinnitus awareness or the minimum masking level (MML) of tinnitus. Long-term low-level white noise stimulation appeared to influence cognitive reaction to tinnitus rather than its physical perception. Subjects who initially had low ability to cope with tinnitus and preferred a more active coping style reported significantly greater benefit from LTWN stimulation than subjects whose primary approach to coping was to regulate the emotional impact of tinnitus.

A critical analysis of directive counselling as a component of tinnitus retraining therapy

Tinnitus retraining therapy (TRT) has been presented as a new approach to tinnitus management. In this paper a number of theoretical and practical problems with TRT are identified. These problems relate to the distinction between directive counselling and cognitive therapy, the adequacy of the cognitive therapy components, the nature of the outcome data which have been presented to date, the theoretical basis for the treatment, and the conceptual clarity of terms such as perception, attention and coping. The stated goal of removal of the perception of tinnitus may lead to confusion about the likely outcome of TRT for most patients. Methodological limitations in the research which has been published to date preclude any claims about the efficacy of TRT at the present time. It is suggested that randomized, controlled studies which include no-treatment and placebo conditions need to be undertaken. Studies are required in which the efficacy of the counselling and white noise components can be clearly isolated. Suggestions are made about the role of psychologists and non-psychologists in the provision of counselling and cognitive therapy services to tinnitus patients.