Positive results from an internet-based cognitive behavioral therapy treatment for tinnitus persisted over a 6-year period, based on a new follow-up study. 

Tinnitus, the experience of chronic ringing in the ears, affects millions of individuals worldwide and can be an economic burden as well as a disabling and distressing condition, but data on the sustainability of treatments are limited, corresponding author Eldre Beukes, PhD, told Medscape Medical News. 

"While cognitive behavioral therapy for tinnitus has demonstrated strong short-term benefits, there has been very limited evidence on whether these effects persist beyond 1 year," said Beukes, associate professor at Anglia Ruskin University, United Kingdom. 

To help close this knowledge gap, the researchers assessed the sustainability of benefits from a previous nonrandomized trial involving an internet-delivered cognitive behavioral therapy (ICBT) intervention.

In the study, published in JAMA Otolaryngology-Head & Neck Surgery, the researchers reviewed follow-up data from 49 of 139 adult patients in the original ICBT study. 

The participants were adults with significant tinnitus who undertook an online intervention, with follow-up at 1, 4, 5, and 6 years to assess tinnitus distress and symptoms including anxiety, depression, insomnia, cognitive failures, satisfaction with life, and hearing disability.

The original ICBT intervention consisted of 21 modules presented over a 2-month period. The primary outcome was reduction in tinnitus distress. Secondary outcomes included reduced anxiety, depression, insomnia, cognitive failures, hyperacusis, hearing disability, and increased life satisfaction. 

The median age of the participants was 54 years, with 18 women and 31 men. In the original study, 73 individuals participated in the intervention and 73 controls undertook the same intervention 2 months later. Tinnitus distress was measured using the Tinnitus Functional Index (TFI), a 25-item questionnaire to assess tinnitus severity and its impact on a patient's life over the past week. 

Overall, the ICBT intervention was associated with significant improvement from baseline over the 6-year period; the within-group effect size for Cohen d = 1.00 (95% CI, 0.80-1.32) at 6 years after the intervention. A clinically significant improvement was measured in 19 of the 49 participants (39%) based on the Reliable Change Index (RCI) score improvement of 23.86 points (95% CI, 7.96-39.76). In addition, 27 of 49 participants (55%) met the criteria for a minimal clinically important difference (MCID) of 14 points (95% CI, 1.9-29.9).

On further analysis, the researchers found persistent treatment effects on measures of tinnitus distress, as well as anxiety, depression, insomnia, and satisfaction with life, but not for the auditory-related effects of hearing disability and hyperacusis. 

Encouraging Results and Implications

The sustained reductions in tinnitus distress and related outcomes over 6 years were encouraging, though not entirely unexpected, said Beukes. 

"The stability of treatment effects suggests that those with tinnitus continue to apply the cognitive and behavioral strategies learned through ICBT long after completing the program," she said. 

However, the lack of durability in improvement for auditory-specific outcomes was somewhat unexpected, she said. "This finding suggests that while ICBT is effective for managing tinnitus-related distress and emotional symptoms, additional or complementary interventions may be needed to address underlying auditory difficulties," she added. 

"Primary care clinicians should be aware that effective, evidence-based treatments for tinnitus are available and their benefits can be long-lasting," said Beukes. "ICBT represents a practical, accessible option that can significantly reduce tinnitus-related distress, as well as associated symptoms such as anxiety, depression, and insomnia," she emphasized. In addition, the online delivery of the intervention can help overcome treatment barriers for patients without access to specialist services, she noted. 

Looking ahead, more research is needed to focus on optimizing and scaling ICBT interventions, Beukes said. Research priorities should include development of shorter, more targeted programs that retain effectiveness and expansion of access to such programs through digital platforms and multilingual adaptations, she said. 

Promising Implications for Patient Care 

Traditionally, sound therapy and CBT have been used to treat tinnitus, but long-term data are not available often for the various treatment modalities," said Hamid Djalilian, MD, professor of otolaryngology at the University of California Irvine and chief medical advisor of the NeuroMed Tinnitus Clinic. The current study fills this gap with useful data on long-term outcomes of ICBT for tinnitus, said Djalilian, who was not involved in the study.

The study findings followed those of previous studies by the current authors, and also by Djalilian and colleagues, which have shown short-term improvement in tinnitus, associated psychological factors, and other quality-of life-measures after ICBT, Djalilian said.

"A plateauing of response is expected in the long term, with some regression over time," he noted. However, ICBT provides the tools the patient needs to reduce stress and anxiety, Djalilian added. "ICBT also teaches patients to not view tinnitus as a threatening signal that can trigger the fight-or-flight response, further increasing stress and worsening tinnitus," he said. "With time, patients learn the tools necessary to perform these routines in their life, which helps control tinnitus severity."

The current understanding of what causes tinnitus is central sensitization, also known as atypical migraine, which makes the brain pay attention to the sound, Djalilian told Medscape Medical News. "What activates central sensitization is a combination of stress, poor sleep, and dietary factors. The ICBT developed by the authors primarily addresses the stress component of central sensitization," he said. "In addition, medical treatment of central sensitization/atypical migraine helps synergistically in improving tinnitus when combined with ICBT and other tools available."

Although the current study effectively showed that the long-term benefits of ICBT are maintained, the results were limited in part by the late distribution of the questionnaires and a smaller follow-up group than the original cohort responding at the different time points, Djalilian said. "This can cause a confounding effect as potentially more happy patients responded at the later time points, as was pointed out by the authors," he said. 

The study received no outside funding. Beukes had no financial conflicts to disclose. Djalilian disclosed serving as an advisor and holding equity in Elinava Technologies and Finally Quiet.