Cochrane Review: Cognitive Behavioural Therapy for Tinnitus

Cognitive behavioural therapy for tinnitus

Background
Tinnitus affects up to 21% of the adult population with an estimated 1% to 3% experiencing severe problems. Cognitive behavioural therapy (CBT) is a collection of psychological treatments based on the cognitive and behavioural traditions in psychology and often used to treat people suffering from tinnitus.

Objectives
To assess the effects and safety of CBT for tinnitus in adults.

Search methods
The Cochrane ENT Information Specialist searched the ENT Trials Register; CENTRAL (2019, Issue 11); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 25 November 2019.

Selection criteria
Randomised controlled trials (RCTs) of CBT versus no intervention, audiological care, tinnitus retraining therapy or any other active treatment in adult participants with tinnitus.

Data collection and analysis
We used the standard methodological procedures expected by Cochrane. Our primary outcomes were the impact of tinnitus on disease‐specific quality of life and serious adverse effects. Our secondary outcomes were: depression, anxiety, general health‐related quality of life, negatively biased interpretations of tinnitus and other adverse effects. We used GRADE to assess the certainty of evidence for each outcome.

Main results
We included 28 studies (mostly from Europe) with a total of 2733 participants. All participants had had tinnitus for at least three months and their average age ranged from 43 to 70 years. The duration of the CBT ranged from 3 to 22 weeks and it was mostly conducted in hospitals or online.
There were four comparisons and we were interested in outcomes at end of treatment, and 6 and 12 months follow‐up. The results below only refer to outcomes at end of treatment due to an absence of evidence at the other follow‐up time points.

Spoiler

CBT versus no intervention/wait list control
Fourteen studies compared CBT with no intervention/wait list control. For the primary outcome, CBT may reduce the impact of tinnitus on quality of life at treatment end (standardised mean difference (SMD) ‐0.56, 95% confidence interval (CI) ‐0.83 to ‐0.30; 10 studies; 537 participants; low certainty). Re‐expressed as a score on the Tinnitus Handicap Inventory (THI; range 0 to 100) this is equivalent to a score 10.91 points lower in the CBT group, with an estimated minimal clinically important difference (MCID) for this scale being 7 points. Seven studies, rated as moderate certainty, either reported or informed us via personal communication about serious adverse effects. CBT probably results in little or no difference in adverse effects: six studies reported none and in one study one participant in the CBT condition worsened (risk ratio (RR) 3.00, 95% CI 0.13 to 69.87). For the secondary outcomes, CBT may result in a slight reduction in depression (SMD ‐0.34, 95% CI‐0.60 to ‐0.08; 8 studies; 502 participants; low certainty). However, we are uncertain whether CBT reduces anxiety, improves health‐related quality of life or reduces negatively biased interpretations of tinnitus (all very low certainty). From seven studies, no other adverse effects were reported (moderate certainty).

CBT versus audiological care
Three studies compared CBT with audiological care. CBT probably reduces the impact of tinnitus on quality of life when compared with audiological care as measured by the THI (range 0 to 100; mean difference (MD) ‐5.65, 95% CI ‐9.79 to ‐1.50; 3 studies; 444 participants) (moderate certainty; MCID = 7 points). No serious adverse effects occurred in the two included studies reporting these, thus risk ratios were not calculated (moderate certainty). The evidence suggests that CBT may slightly reduce depression but may result in little or no difference in anxiety or health‐related quality of life (all low certainty) when compared with audiological care. CBT may reduce negatively biased interpretations of tinnitus when compared with audiological care (low certainty). No other adverse effects were reported for either group (moderate certainty).

CBT versus tinnitus retraining therapy (TRT)
One study compared CBT with TRT (including bilateral sound generators as per TRT protocol). CBT may reduce the impact of tinnitus on quality of life as measured by the THI when compared with TRT (range 0 to 100) (MD ‐15.79, 95% CI ‐27.91 to ‐3.67; 1 study; 42 participants; low certainty). For serious adverse effects three participants deteriorated during the study: one in the CBT (n = 22) and two in the TRT group (n = 20) (RR 0.45, 95% CI 0.04 to 4.64; low certainty). We are uncertain whether CBT reduces depression and anxiety or improves health‐related quality of life (low certainty). CBT may reduce negatively biased interpretations of tinnitus. No data were available for other adverse effects.

CBT versus other active control
Sixteen studies compared CBT with another active control (e.g. relaxation, information, Internet‐based discussion forums). CBT may reduce the impact of tinnitus on quality of life when compared with other active treatments (SMD ‐0.30, 95% CI ‐0.55 to ‐0.05; 12 studies; 966 participants; low certainty). Re‐expressed as a THI score this is equivalent to 5.84 points lower in the CBT group than the other active control group (MCID = 7 points). One study reported that three participants deteriorated: one in the CBT and two in the information only group (RR 1.70, 95% CI 0.16 to 18.36; low certainty). CBT may reduce depression and anxiety (both low certainty). We are uncertain whether CBT improves health‐related quality of life compared with other control. CBT probably reduces negatively biased interpretations of tinnitus compared with other treatments. No data were available for other adverse effects.

Authors' conclusions
CBT may be effective in reducing the negative impact that tinnitus can have on quality of life. There is, however, an absence of evidence at 6 or 12 months follow‐up. There is also some evidence that adverse effects may be rare in adults with tinnitus receiving CBT, but this could be further investigated. CBT for tinnitus may have small additional benefit in reducing symptoms of depression although uncertainty remains due to concerns about the quality of the evidence. Overall, there is limited evidence for CBT for tinnitus improving anxiety, health‐related quality of life or negatively biased interpretations of tinnitus.

Plain Language Summary

Spoiler

What is the aim of this review?
The aim of this Cochrane Review was to find out if cognitive behavioural therapy (CBT) is effective for tinnitus. Cochrane researchers collected and analysed all relevant studies to answer this question.

Key messages
There is some low‐ to moderate‐certainty evidence that CBT may reduce the negative impact that tinnitus can have on quality of life at the end of treatment, with few or no adverse effects (although further research on this is needed).

What was studied in the review?
Tinnitus is the perception of sound in the ear or head without any outside source. It is often described as a ringing, hissing, buzzing or whooshing sound. Tinnitus is mostly managed with education and/or counselling, relaxation therapy, tinnitus retraining therapy and ear‐level sound generators or hearing aids. CBT is a form of talking therapy that aims to change the patient's emotional and/or behavioural response to their tinnitus. This review looked at studies of CBT for adults who had had tinnitus for at least three months. Participants in the control groups either received no intervention, audiological (hearing) care, tinnitus retraining therapy or another type of treatment. The review authors studied the effect of CBT on tinnitus‐related quality of life, adverse effects, depression, anxiety, general quality of life and negatively biased interpretations of tinnitus.

What are the main results of the review?
We found 28 relevant studies, mostly from Europe, with a total of 2733 participants. The participants receiving CBT had treatment for between three and 22 weeks (mostly in clinics or online).

When CBT was compared to no intervention there was low‐certainty evidence that CBT may reduce the negative impact of tinnitus on quality of life at the end of treatment. It is not known whether this effect persists in the longer term (six or 12 months). There were few or no adverse effects (only one adverse effect was reported in one participant among seven studies). CBT may also slightly reduce depression (low‐certainty evidence) and may reduce anxiety, although this finding is very uncertain. It is also uncertain whether CBT improves general quality of life or negatively biased interpretations of tinnitus.

Compared to audiological care, tinnitus retraining therapy and other types of treatment, there were findings that CBT probably reduces the negative impact of tinnitus on quality of life. The certainty of this evidence ranged from moderate to low. Where reported, there were few adverse effects and no significant differences between the groups. For depression, anxiety and general quality of life the results were more mixed and the evidence less certain. There is moderate‐certainty evidence that CBT may reduce negatively biased interpretations of tinnitus compared to other types of treatment, but compared to audiological care and tinnitus retraining therapy the evidence is less certain.

How up to date is this review?
The review authors searched for studies that had been published up to November 2019.

 

It's just so weird to find three of the same actors strongly recommending CBT in the European guidelines for tinnitus and then saying the effects of CBT on tinnitus are sparse in this study.

(I recommend you to read the European guidelines though, I think it's quite a good paper minus the part on CBT)

Great find @Autumnly!

 

I think it's great! They're not blindly praising CBT for tinnitus and even concluded that there is "limited evidence for CBT for tinnitus improving anxiety, health‐related quality of life or negatively biased interpretations of tinnitus".

But it makes you wonder why they gave CBT a "strong recommendation" in the European guideline, even going as far as saying "There is high-level evidence for the effectiveness and safety of CBT for tinnitus. Recommendation is based on systematic review and one further RCT."

Oh, I read it and while there are interesting and informative parts, I think it's overall more harmful than helpful to severe sufferers.

I saw it on Twitter this morning but @Hazel had also alerted me to it yesterday and encouraged me to post it.

 

Yeah I figured you did, it was more a collective you

Yeah it was my initial thought but in the history of the Cochrane paper they published the protocol to assess the effect of CBT back in 2017. So the study was kind of in parallell to the European guideline. Just... weird, but a positive progression!

 

Quite interesting, though in my personal case the CBT concepts definitely helped during the onset of tinnitus. Still, I'm glad to see that these researchers check results later and are willing to correct earlier findings if necessary. Honest self-reflection is a highly required skill when one is investigating treatments that affect millions of patients.

 

They may be justifying more grants to "clear up these results". Or something, yeah, that is strange. Regardless these same 3 seem to be obsessed with CBT studies.